36 CLINICAL FOCUS
36 CLINICAL FOCUS
19 SEPTEMBER 2025 ausdoc. com. au
| THE | WOMEN’ S AND MEN’ S HEALTH SPECIAL
Therapy Update
Antenatal nausea
and vomiting
Women’ s health
Associate Professor Sandra Lowe AM is a senior obstetric physician at the Royal Hospital for Women, Sydney and Clinical Associate Professor, school of clinical medicine, UNSW Sydney Medicine and Health, Sydney, NSW.
Dr Kate Steinweg is a GP Registrar in Sydney, NSW.
Nausea and vomiting of pregnancy and hyperemesis gravidarum can be overwhelming for women both physically and psychologically.
NEED TO KNOW
It is essential to clarify the severity of nausea and vomiting in pregnancy( NVP) and hyperemesis gravidarum, using a standardised screening tool and assess the nutritional and functional impact of symptoms. This information forms the basis of any risk assessment and treatment plan.
Management of gastric dysmotility including GORD and constipation is a critical part of treating NVP, alongside antiemetic therapies.
Supporting women to cope with the physiological, psychological and practical stress of NVP is part of a holistic treatment plan. This may include altered work arrangements, or leave from work, and facilitating arrangements for regular access to outpatient IV fluids.
NAUSEA and vomiting are among the commonest complaints of early pregnancy and management most often falls to the GP. Even though there is no onesize-fits-all approach, many women feel that they are given generic advice without full appreciation of their experience.
It is important for clinicians to recognise that this condition, even in milder forms, can be overwhelming for women both physically and psychologically. It should never be considered best practice to dismiss nausea and vomiting of pregnancy( NVP) as a benign nuisance to be endured. The reluctance of health professionals to recognise and treat NVP can itself worsen a woman’ s physical and mental health. 1-4 There are many medication options, some of which are off-label, but nonetheless recommended by national guidelines. This article aims to empower GPs with the confidence to prescribe promptly and safely for holistic symptom control. 5 General supportive measures, particularly around managing family and work responsibilities, as well as mental health, are also needed.
Assessing severity
The Pregnancy-Unique Quantification of Emesis( PUQE) scoring index( see table 1) is a quick and simple three-question tool that can be utilised in general practice to establish and monitor symptom severity. 6 The PUQE score assesses frequency of nausea, vomiting and also dry retching. The latter is an important symptom often missed in history taking. Additionally, it is important to ask about the ability to tolerate oral intake of both food and fluids, any functional concerns including the ability to work and care for family and, very importantly, impacts on mood.
Hyperemesis gravidarum( HG) is a form
Table 1. Motherisk PUQE-24 scoring system
Total score: mild ≤6; moderate 7-12; severe ≥13( scores in brackets)
of severe NVP and is defined by the following features on history: symptoms start in early pregnancy, before 16 weeks’ gestation, inability to eat and / or drink normally, and strong limitations to daily activities. 7
Some women with HG may have signs of dehydration, electrolyte abnormalities and / or weight loss but these are not required to define HG, which is a clinical diagnosis. Symptoms will improve by 20 weeks of gestation for most women with NVP or HG, but a small number will continue to have symptoms into the third trimester. It is important, therefore, to be aware that ongoing therapy may be required.
Impacts on maternal and fetal health
Mild to moderate NVP has little impact on pregnancy outcomes and generally
resolves by 12-16 weeks’ gestation. Uncontrolled HG is associated with increased maternal and fetal adverse events including Wernicke’ s encephalopathy( B1 deficiency), bleeding( vitamin K deficiency), acute kidney injury and oesophageal rupture. HG may also cause placental dysfunction, leading to an increased risk of low birthweight, preterm delivery, preterm pre-eclampsia and placental abruption. 8-14 A large Norwegian study showed that inadequate weight gain in the first trimester, and failure to achieve pre-pregnancy weight by week 13-18, were found to be independent predictors of risk of having a small for gestational age infant. 15 Apart from the physical effects of NVP
1. In the last 24 hours, for how long have you felt nauseated or sick to your stomach? and HG, constant nausea or vomiting is highly unpleasant and distressing and reduces a woman’ s quality of life. 16-18 It impairs her ability to function, affects her relationships and can be impoverishing if the woman is unable to work in addition to having to attend frequent medical appointments for management.
Investigations
Patients with mild to moderate NVP( PUQE ≤12), where symptoms are not suspicious for HG or another diagnosis, do not need investigation. In more severe or persistent cases, investigations are targeted towards excluding multiple pregnancy or gestational trophoblastic disease( by obstetric ultrasound) and excluding other causes of nausea and vomiting. 5 Although HG is associated with an increased incidence of gestational thyrotoxicosis, TSH should
It is important to ask about the ability to tolerate oral intake of both food and fluids.
Not at all( 1) 1 hour or less( 2) 2-3 hours( 3) 4-6 hours( 4) More than 6 hours( 5) 2. In the last 24 hours, have you vomited or thrown up? I did not throw up( 1) 1-2( 2) 3-4( 3) 5-6( 4) 7 or more times( 5) 3. In the last 24 hours, how many times have you had retching or dry heaves without throwing up? None( 1) 1-2( 2) 3-4( 3) 5-6( 4) 7 or more times( 5) PUQE = Pregnancy-Unique Quantification of Emesis only be measured in women with HG or NVP that is refractory to treatment, or in those with milder symptoms who have signs and / or symptoms of thyrotoxicosis. 5 Ketonuria is not reliably associated with either the diagnosis or severity of HG and there is no benefit in serial urinalysis. 19
Management
One of the most well-intentioned mistakes in managing NVP in the community is a focus on antiemetic monotherapy which targets nausea and vomiting only, without considering the associated gastric dysmotility. Nausea, GORD and constipation form a vicious cycle in pregnancy and cannot be managed in isolation. Also often overlooked is the importance of timing medication to match the timing of an individual’ s symptoms. For example, if morning symptoms predominate, focus on adequate bedtime medication and ensure morning medications are taken immediately on waking. Focusing treatment when it is most needed may in turn allow a reduction in medication use, and hence potentially reduce both medication load and side effects.
Most of the medication options used for NVP do not increase the risk of congenital malformation above the background rate, which was 3.1 % in 2002-03. 20 Specific counselling is required if ondansetron or corticosteroids are required in the first trimester( see table 2).
Principles of holistic management
Setting expectations Even with optimal pharmacological therapy, it is rare to eliminate nausea completely. Part of the treatment plan involves setting goals around what would be an acceptable level of symptom control and quality of life for the patient.
Non-pharmacological measures Cease any unnecessary supplements including iron, which can aggravate nausea and worsen constipation. If possible, continue folate( at least 400μg per day) and iodine( 150μg per day) until 12 weeks’ gestation. Appetite may vary; it is often increased in NVP but reduced with HG. Advise patients to eat and drink whatever they feel they can manage, whenever they can. Small, frequent meals are often better tolerated.
Pharmacological interventions Depending on initial severity, a stepwise approach to antiemetics is appropriate( see table 2). Multiple antiemetics, with staggered dosing, may be needed with regular review( 1-2 weekly) and adjustment as symptoms fluctuate. Women with persistent symptoms should be on a regular schedule of medication, rather than dosing‘ as needed’.
Management of associated gastric dysmotility These strategies address associated GORD and constipation. All women with significant vomiting will benefit from acid suppression therapy, even in the absence of typical reflux symptoms. 21 H2 antagonists and PPIs are both acceptable options, and in refractory cases, may be needed in