ACOG

PRACTICE
BULLETIN
CLINICAL MANAGEMENT GUIDELINES FOR
OBSTETRICIANGYNECOLOGISTS
NUMBER 52, APRIL 2004

Nausea and Vomiting of

This Practice Bulletin was Pregnancy
developed by the ACOG Com- Nausea and vomiting of pregnancy is a common condition that affects the
mittee on Practice Bulletins health of both the pregnant woman and her fetus. It can diminish the womans
Obstetrics with the assistance quality of life and also contributes significantly to health care costs and time
of T. Murphy Goodwin, MD.
lost from work (1). Because morning sickness is common in early preg-
The information is designed to
nancy, the presence of nausea and vomiting of pregnancy may be minimized by
aid practitioners in making
decisions about appropriate health care providers and by pregnant women (1) and, thus, undertreated. One
obstetric and gynecologic care. investigator found that fewer than 50% of women who called a nausea and
These guidelines should not be vomiting of pregnancy hotline and who subsequently terminated their pregnan-
construed as dictating an exclu- cies because of severe nausea and vomiting of pregnancy had been offered any
sive course of treatment or pro- sort of antiemetic therapy (2, 3). Of those offered treatment, 90% were offered
cedure. Variations in practice regimens that were not likely to be effective. Furthermore, some women do not
may be warranted based on the seek treatment because of concerns about safety (4). Yet, once symptoms of nau-
needs of the individual patient, sea and vomiting of pregnancy progress, treatment can become more difficult;
resources, and limitations treatment in the early stages may prevent more serious complications, includ-
unique to the institution or type ing hospitalization (5). Mild cases of nausea and vomiting of pregnancy may be
of practice.
resolved with lifestyle and dietary changes, and safe and effective treatments
Reaffirmed 2011 are available for more severe cases. The womans perception of the severity of
her symptoms plays a critical role in the decision of whether, when, and how to
treat nausea and vomiting of pregnancy. In addition, nausea and vomiting of
pregnancy should be distinguished from nausea and vomiting related to other
causes. The purpose of this document is to review the best available evidence
about the diagnosis and management of nausea and vomiting of pregnancy.

Definition and Incidence

Nausea and vomiting of pregnancy is a common condition that affects 7085%
of pregnant women (6). Fifty percent of pregnant women have both nausea and
vomiting, 25% have nausea only, and 25% are unaffected (7, 8). One study has
attempted to categorize nausea and vomiting of preg-
nancy into degrees of severity by assessing the duration Differential Diagnosis of Nausea and
of nausea and vomiting each day (from less than 1 hour Vomiting of Pregnancy
in mild cases to more than 6 hours in severe cases) and
the amount of vomiting and retching per day (up to twice Gastrointestinal Conditions
for mild and moderate nausea and vomiting of preg- Gastroenteritis
nancy; more than 5 times in severe cases) (1). However, Gastroparesis
although these categories recognize nausea and vomiting
of pregnancy as a continuum, they may not be clinically
Achalasia
useful. The womans perception of the severity of her Biliary tract disease
symptoms and her desire for treatment are more likely to Hepatitis
influence clinical decision making. Intestinal obstruction
From an epidemiologic perspective, hyperemesis
gravidarum appears to represent the extreme end of the
Peptic ulcer disease
spectrum of nausea and vomiting of pregnancy (9). The Pancreatitis
incidence of hyperemesis gravidarum is approximately Appendicitis
0.52% of pregnancies. The reported incidence varies
because of different diagnostic criteria and ethnic varia- Genitourinary Tract Conditions
tion in study populations. There is no single accepted Pyelonephritis
definition of hyperemesis gravidarum; it is a clinical Uremia
diagnosis of exclusion based on a typical presentation in Ovarian torsion
the absence of other diseases that could explain the find-
ings (10). The most commonly cited criteria include per-
Kidney stones
sistent vomiting not related to other causes, a measure of Degenerating uterine leiomyoma
acute starvation (usually large ketonuria), and some dis- Metabolic Disease
crete measure of weight loss, most often at least 5% of
prepregnancy weight (11). Electrolyte, thyroid, and liver
Diabetic ketoacidosis
abnormalities also may be present. Hyperemesis gravi- Porphyria
darum is the most common indication for admission to Addisons disease
the hospital during the first part of pregnancy and is sec- Hyperthyroidism
ond only to preterm labor as the most common reason for
hospitalization during pregnancy (12, 13). Neurologic Disorders
Pseudotumor cerebri
Vestibular lesions
Differential Diagnosis Migraines
The timing of the onset of nausea and vomiting is impor- Tumors of the central nervous system
tant: symptoms of nausea and vomiting of pregnancy
Miscellaneous
manifest before 9 weeks of gestation in virtually all
affected women. When a patient experiences nausea and Drug toxicity or intolerance
vomiting for the first time after 9 weeks of gestation, Psychologic
other conditions should be carefully considered in the
Pregnancy-Related Conditions
differential diagnosis (see box). A history of a chronic
condition associated with nausea and vomiting that pre- Acute fatty liver of pregnancy
dates pregnancy should be sought (eg, cholelithiasis or Preeclampsia
diabetic autonomic dysfunction). Rare cases of hyper-
Modified from Goodwin TM. Hyperemesis gravidarum. Clin Obstet
emesis gravidarum related to a mendelian disorder of Gynecol 1998;41:597605.
hormone-receptor interaction (14) and mitochondrial dis-
orders (15) suggest that at least some portion of hyper-
emesis is caused by discrete disease states unmasked or of the nausea and vomiting. Abdominal pain is not a
exacerbated in pregnancy. prominent characteristic of nausea and vomiting of preg-
A number of physical findings point to conditions nancy; abdominal pain or tenderness other than mild epi-
other than nausea and vomiting of pregnancy as the cause gastric discomfort after retching is not seen with nausea

2 ACOG Practice Bulletin No. 52

and vomiting of pregnancy. Fever is not present in nau- Hormones
sea and vomiting of pregnancy but is characteristic of
many other diseases associated with nausea and vomit- Human Chorionic Gonadotropin
ing. Headache is not characteristic of nausea and vomit- Because of the close temporal relationship between peak
ing of pregnancy. An abnormal neurologic examination human chorionic gonadotropin (hCG) concentrations and
suggests a primary neurologic disorder as the cause of peak symptoms of nausea and vomiting of pregnancy,
the nausea and vomiting, although it may rarely be hCG has been considered a likely candidate for the eme-
encountered as a consequence of severe nausea and togenic stimulus arising from the placenta. A role for
vomiting of pregnancy (eg, thiamine-deficient enceph- hCG also is suggested by the fact that almost all studies
alopathy or central pontine myelinolysis). Although of thyroid hormones in pregnancy show an association
biochemical hyperthyroidism may be seen with hyper- between transient hyperthyroidism and nausea and vom-
emesis gravidarum, goiter is not found with nausea and iting of pregnancy. It has been shown conclusively that
vomiting of pregnancy. If a goiter is present, primary hCG is the thyroid stimulator of pregnancy (21); because
thyroid disease should be suspected. hyperthyroidism itself rarely causes vomiting, this find-
ing has focused attention back on hCG and its relation-
ship to nausea and vomiting of pregnancy. Among the
Etiology and Risk Factors many studies comparing nonthyroidal hormone concen-
trations in women with and without vomiting, only hCG
The etiology of nausea and vomiting of pregnancy is and estradiol have been found to have an association.
unknown. Various theories have been proposed, includ- The failure of some studies to show an association of
ing a psychologic predisposition (16), evolutionary nausea and vomiting of pregnancy with hCG may be
adaptation (17), and hormonal stimulus. The question of related to the varying biologic activity of different hCG
whether certain personality types or specific psycholog- isoforms as well as variation in the susceptibility of the
ic disorders predispose to hyperemesis gravidarum has individual woman to any emetogenic stimulus. The
been raised in the literature for many years. Two general extent of the hCG stimulus may be modified by placen-
hypotheses have been proposed to explain nausea and tal conditions that increase its concentration (eg, multi-
vomiting of pregnancy as a manifestation of psycho- ple gestation, molar gestation) and by hormone-receptor
pathology: 1) psychoanalytic theories describing hyper- interactions modifying the effect of the hormone.
emesis gravidarum as a conversion or somatization
disorder and 2) inability of the woman to respond to Estrogen
excessive life stress. There have been no controlled stud- Another hormone known to influence nausea and vomit-
ies to support these hypotheses. ing of pregnancy is estrogen. Nausea and vomiting of
A recent review of psychologic theories proposed to pregnancy is more common when estradiol levels are
explain the etiology of nausea and vomiting of preg- increased and less common when estradiol levels are
nancy concluded that the evidence that nausea and vom- decreased (22, 23). Cigarette smoking is associated with
iting of pregnancy is caused by a conversion disorder or lower levels of both hCG and estradiol (24), and numer-
an abnormal response to stress is questionable at best ous studies have shown that smokers are less likely to
(18). It is likely that the concept that nausea and vomit- have hyperemesis gravidarum. Estrogens in the com-
ing of pregnancy reflects a psychologic disorder has bined oral contraceptive pill were shown to induce nau-
impeded progress toward a greater understanding of the sea and vomiting in a dose-related fashion (25). Women
true etiology of the condition (19). with nausea and vomiting after estrogen exposure were
It also has been posited that nausea and vomiting of more likely to have nausea and vomiting of pregnancy
pregnancy is an evolutionary adaptation that developed than women who did not demonstrate such sensitivity to
to protect the woman and her fetus from foods that might estrogens (26).
be potentially dangerous (20). This theory may explain
the temporary aversions to tastes and smells that preg- Risk Factors
nant women experience. Proponents of the adaptation Women with increased placental mass (eg, advanced
theory suggest nausea and vomiting of pregnancy is a molar gestation, multiple gestation) are at risk for hyper-
healthy, protective response to pregnancy. Clinical appli- emesis gravidarum. Other risk factors include family his-
cation of this theory, however, may lead to undertreat- tory (genetics) or a history of hyperemesis gravidarum in
ment of women whose quality of life is diminished by a previous pregnancy. One study found that approxi-
nausea and vomiting of pregnancy. mately two thirds of women who described their vomit-

ACOG Practice Bulletin No. 52 3

ing as severe in one pregnancy had similar symptoms in Numerous studies have documented a lower rate of
the next pregnancy; one half of women who described miscarriage among women with nausea and vomiting of
their symptoms as mild in one pregnancy found that the pregnancy and hyperemesis gravidarum when compared
symptoms worsened in the next (7). Daughters and sis- with controls. This result is thought to be related to robust
ters of women who had hyperemesis gravidarum are placental synthesis in a healthy pregnancy rather than a
more likely to have the same problem, as are women car- protective effect of vomiting. It is unlikely that hyper-
rying a female fetus (27). Other risk factors include a emesis gravidarum is associated with a significantly
history of motion sickness or migraines (26). increased risk of malformations in offspring (50). Little
is known about the long-term health of children or
women after pregnancies complicated by hyperemesis
Maternal Effects of Nausea gravidarum. Although some cases of fetal death are still
reported, they are very rare and usually are limited to
and Vomiting of Pregnancy cases of extreme hyperemesis gravidarum. It is appropri-
Until 60 years ago, nausea and vomiting of pregnancy ate to reassure patients that the presence of nausea and
was an important cause of maternal mortality. In the vomiting of pregnancy and even hyperemesis gravidarum
1930s in the United States, 7 deaths were reported among most often portends well for pregnancy outcome.
85 women with severe vomiting (28). Although death from
nausea and vomiting of pregnancy is reported rarely today,
significant morbidity, such as Wernickes encephalopathy, Clinical Considerations and
splenic avulsion, esophageal rupture, pneumothorax, and Recommendations
acute tubular necrosis, have been reported in recent
years (2936). Thirty-three cases of Wernickes enceph- Many studies mix patients with hyperemesis gravidarum
alopathy (caused by a vitamin B1 deficiency) related to and those with other degrees of nausea and vomiting of
hyperemesis gravidarum have been reported in the past pregnancy. Because it is likely that hyperemesis gravi-
20 years. It often is associated with maternal death or per- darum is part of the continuum of nausea and vomiting of
manent neurological disability (2931). In addition to pregnancy and because evidence indicates that failure to
increased hospital admissions (37, 38), some women treat early manifestations of nausea and vomiting of
experience significant psychosocial morbidity caused by pregnancy increases the likelihood of hospital admission
nausea and vomiting of pregnancy, resulting in preg- for hyperemesis gravidarum (37, 38), the following dis-
nancy termination. cussion focuses on treatment for all stages of nausea and
A number of reversible responses to subacute dis- vomiting of pregnancy.
ease states have been described in nausea and vomiting of
pregnancy, including depression, somatization, and

Are nonpharmacologic therapies effective

hypochondriasis (16). Poor support by their partners was for the treatment of nausea and vomiting of
reported by 85% of women who called a hotline for nau-
sea and vomiting of pregnancy (3). pregnancy?
Treatment of nausea and vomiting of pregnancy begins
with prevention. Two studies found that women who
Fetal Effects of Nausea and were taking a multivitamin at the time of conception
were less likely to need medical attention for vomiting
Vomiting of Pregnancy (51, 52). Therefore, it is reasonable to advise women with
The effect of maternal vomiting on the embryo and fetus a history of nausea and vomiting or hyperemesis gravi-
depends on the severity of the condition. With mild or darum in a previous pregnancy to take a multivitamin at
moderate vomiting, there is little apparent effect on preg- the time of the next conception.
nancy outcome. The outcome most frequently examined The womans perception of the severity of her symp-
is the incidence of low birth weight (LBW). Seven stud- toms and her desire for treatment are influential in clini-
ies have identified no increase in LBW with nausea and cal decision making. Common recommendations to
vomiting of pregnancy (9, 10, 3943). Three of these alleviate initial signs of nausea and vomiting of preg-
studies found a higher incidence of LBW among women nancy include rest and avoidance of sensory stimuli that
who did not have nausea and vomiting of pregnancy may provoke symptoms. Frequent, small meals often are
(4143). Among women with hyperemesis gravidarum, recommended. Obstetriciangynecologists often suggest
however, a higher incidence of LBW has been reported avoiding spicy or fatty foods; eliminating pills with iron;
(4449). and eating bland or dry foods, high-protein snacks, and

4 ACOG Practice Bulletin No. 52

crackers in the morning before arising (53). However, ing of pregnancy diminished considerably, and hospital-
there is little published evidence regarding the efficacy of ization rates for nausea and vomiting of pregnancy
dietary changes for prevention or treatment of nausea and increased (38).
vomiting of pregnancy. A small study showed that pro- Figure 1 depicts a hierarchy of therapeutic interven-
tein meals were more likely to alleviate nausea and vom- tions that balances safety and efficacy. Despite the fact
iting of pregnancy than carbohydrate or fatty meals (54). that the combination of doxylamine and vitamin B6 is no
A study comparing powdered ginger capsules, longer commercially available in the United States, it
250 mg, with placebo in 27 women with hyperemesis remains among the first-line therapies. Individual com-
gravidarum found the ginger reduced episodes of vomit- pounding pharmacies in many communities will make up
ing (55). Another study using a similar ginger regimen in the combination of 10 mg of pyridoxine and 10 mg of
70 women with nausea and vomiting of pregnancy of doxylamine on request. The only randomized, placebo-
varying severity found significant improvement in nausea controlled trials have shown a 70% reduction in nausea
and vomiting (56). and vomiting (6163). Several casecontrol and cohort
Pressure or electrical stimulation at the P6 (or studies involving more than 170,000 exposures have
Neguian) point on the inside of the wrist has been stud- found the combination to be safe with regard to fetal
ied for nausea and vomiting of pregnancy with conflict- effects (64).
ing results. The preponderance of the literature does Many other conventional antiemetics have been
show a benefit, but many of the studies had significant described in the literature for treatment of nausea and
methodologic flaws, and the 2 largest, best-designed vomiting of pregnancy (Table 1). Data that suggest safe-
studies showed no benefit over sham stimulation (57). ty and efficacy are available on several classes of these
Interestingly, the findings in both of these studies were medications. The safety of antihistamine H1 receptor
consistent with a large placebo effect. A randomized, blockers (eg, doxylamine) is supported by a review of
controlled trial of acustimulation with a commercial tran- more than 200,000 first-trimester exposures (65).
scutaneous electrical stimulation device for varying Phenothiazines were identified as a possible cause of
degrees of nausea and vomiting of pregnancy found that malformations in one study (66), but the aggregate of
acustimulation improved nausea and vomiting symptoms studies attest to their safety (67). Three studies attest to
in the first trimester (58). the safety of trimethobenzamide (6870).
Medications for which there are some safety data but

Are pharmacologic therapies effective no conclusive evidence of efficacy include anticholiner-

for treatment of nausea and vomiting of gics and metoclopramide. Additionally, evidence is limit-
pregnancy? ed on the safety or efficacy of the 5-hydroxytryptamine 3
inhibitors (eg, ondansetron) for nausea and vomiting of
Effective pharmacologic therapy is available, but agree- pregnancy; however, because of their effectiveness in
ment on the appropriate timing of antiemetic therapy has reducing chemotherapy-induced emesis, their use
changed in recent years. Two randomized controlled tri- appears to be increasing. Although the evidence is not
als have evaluated pyridoxine (vitamin B6) for treatment strong, doses of droperidol greater than 25 mg were asso-
of varying degrees of severity of nausea and vomiting of ciated with a prolonged Q-T interval that in some cases
pregnancy. One compared pyridoxine, 25 mg every has led to the potentially fatal arrhythmia torsades de
8 hours, with placebo and found a significant reduction in pointes. This drug should be used with caution.
severe vomiting but minimal effect on mild vomiting Several case series in the past 10 years have sug-
(59). A larger study (n = 342) used pyridoxine, 10 mg gested a benefit of corticosteroids in the treatment of
every 8 hours, and found a reduction in both nausea and hyperemesis gravidarum. A randomized trial comparing
vomiting compared with placebo (60). When the combi- methylprednisolone (16 mg, 3 times per day for 3 days,
nation of vitamin B6, 10 mg, plus doxylamine, 10 mg, followed by a 2-week taper) with oral promethazine
was available in the United States from 1958 to 1983, it showed equal rates of improvement among hospitalized
is estimated that 2530% of all pregnant women received patients; however, readmission to the hospital within
this agent. Analysis of hospital admissions during this 2 weeks of discharge occurred significantly less fre-
period suggests that the ready availability of vitamin B6 quently in those taking steroids (71). In contrast, a later
and doxylamine for the treatment of the spectrum of nau- randomized controlled trial of intravenous methylpred-
sea and vomiting of pregnancy was associated with fewer nisolone followed by a tapered dose of an oral prednisone
hospital admissions for hyperemesis gravidarum (38). among women hospitalized for hyperemesis gravidarum
After the combination was removed from the U.S. mar- found the use of corticosteroids did not reduce the need
ket in 1983, use of antiemetics to treat nausea and vomit- for rehospitalization (72).

ACOG Practice Bulletin No. 52 5

 Pharmacologic treatment of nausea and vomiting of pregnancy* (if no improvement, proceed to the next step)

Monotherapy: Vitamin B6 , 1025 mg, 3 or 4 times per day

Add: Doxylamine, 12.5 mg, 3 or 4 times per day

Adjust schedule and dose according to severity of patients symptoms

Add: Promethazine, 12.525 mg every 4 hours, orally or rectally

Or
Dimenhydrinate, 50100 mg every 46 hours, orally or rectally (not to exceed 400 mg per day; not to exceed 200 mg per
day if patient also is taking doxylamine)

No dehydration Dehydration

Add any of the following Intravenous fluid replacement

(presented here in alphabetical order):
Metoclopramide, 510 mg every
8 hours, intramuscularly or orally
Or Add any of the following (presented here in alphabetical order):
Promethazine, 12.525 mg every 4 hours, Dimenhydrinate, 50 mg (in 50 mL saline, over 20 min) every
intramuscularly, orally, or rectally 46 hours, intravenously
Or Or
Trimethobenzamide, 200 mg every Metoclopramide, 510 mg every 8 hours, intravenously
68 hours, rectally Or
Promethazine, 12.525 mg every 4 hours, intravenously

Add: Methylprednisolone, 16 mg every 8 hours, orally or intravenously,

for 3 days. Taper over 2 weeks to lowest effective dose.
If beneficial, limit total duration of use to 6 weeks.
Or
Ondansetron, 8 mg, over 15 minutes, every 12 hours, intravenously

*This algorithm assumes other causes of nausea and vomiting have been ruled out. At any step, consider parenteral nutrition if
dehydration or persistent weight loss is noted. Alternative therapies may be added at any time during the sequence depend-
ing on patient acceptance and clinician familiarity; consider P6 acupressure with wrist bands or acustimulation or ginger cap-
sules, 250 mg 4 times daily.
In the United States, doxylamine is available as the active ingredient in some over-the-counter sleep aids; one half of a scored
25-mg tablet can be used to provide a 12.5-mg dose of doxylamine.

Thiamine, intravenously, 100 mg daily for 23 days (followed by intravenous multivitamins), is recommended for every woman
who requires intravenous hydration and has vomited for more than 3 weeks. No study has compared different fluid replace-
ments for nausea and vomiting of pregnancy.

Corticosteroids appear to increase risk for oral clefts in the first 10 weeks of gestation.

Safety, particularly in the first trimester of pregnancy, not yet determined; less effect on nausea.

Figure 1. Pharmacologic treatment of nausea and vomiting of pregnancy. (Adapted from Levichek
Z, Atanackovic G, Oepkes D, Maltepe C, Einarson A, Magee L, et al. Nausea and vomiting of preg-
nancy. Evidence-based treatment algorithm. Can Fam Physician 2002;48:2678, 277.)

6 ACOG Practice Bulletin No. 52

Table 1. Summary of Drugs Used to Treat Nausea and Vomiting of Pregnancy

Agent Randomized Controlled Trial* Comments on Efficacy Comments on Safety

H1 blockers Effective in reducing nausea and No increased risk of malformations
vomiting of pregnancy
Doxylamine
Dimenhydrinate
Cetirizine
Meclizine
Buclizine
Hydroxyzine
Diphenhydramine
Anticholinergics No effectiveness trials for nausea and No increased risk of malformations
vomiting of pregnancy
Scopolamine
Dopamine Antagonists
Benzamides
Trimethobenzamide Effective in reducing nausea and No known malformations
vomiting of pregnancy
Metoclopramide No trials regarding efficacy No known malformations
Butyrophenones
Droperidol One study of limited power identified no
known malformations
Maternal risk of prolonged Q-T interval
Haloperidol
Phenothiazines
Promethazine Effective in reducing nausea and Bulk of evidence indicates no terato-
vomiting of pregnancy genicity (isolated case report discounted
in meta-analysis)
Prochlorperazine
Chlorpromazine
Perphenazine
Benzodiazepines
Diazepam
5-Hydroxytryptamine 3
receptor agonists
Ondansetron One trial found equal effectiveness to No malformations noted
promethazine
Steroids Pooled results do not suggest benefit in
decreasing nausea and vomiting of
pregnancy
Adrenocorticotropic hormone
Corticosteroids Small increased risks of clefts
*The drug has been evaluated in at least 1 randomized, controlled trial.

Rumeau-Rouquette C, Goujard J, Huel G. Possible teratogenic effect of phenothiazines in human beings. Teratology 1977;15:5764.
Data from Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy (Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK:
John Wiley & Sons, Ltd.; and Magee LA, Mazzotta P, Koren G. Evidence-based view of safety and effectiveness of pharmacologic therapy for nausea and vomiting of
pregnancy (NVP). Am J Obstet Gynecol 2002;186:S25661.

Three recent studies have confirmed an association Corticosteroids may be considered as a last resort in
between oral clefts and methylprednisolone use in the patients who will require enteral or parenteral nutrition
first trimester (7375). The teratogenic effect is weak, because of weight loss. The most commonly described
probably accounting for no more than 1 or 2 cases per regimen is methylprednisolone, 48 mg daily for 3 days,
1,000 treated women (76). Nevertheless, in view of this given orally or intravenously. Patients who do not
probable association, corticosteroid use for hyperemesis respond within 3 days are not likely to respond, and
gravidarum should be used with caution and avoided treatment should be stopped. For those who do respond,
before 10 weeks of gestation. the dose may be tapered over a period of 2 weeks. For

ACOG Practice Bulletin No. 52 7

recurrent vomiting, the tapered dose may be stopped and may identify a predisposing factor, such as multiple ges-
the patient continued on the effective dose for up to 6 tation or molar gestation.
weeks. To limit serious maternal side effects, corticos-

teroids should not be continued beyond this period for When is enteral or parenteral nutrition
the treatment of hyperemesis gravidarum (77). recommended?
The principal criterion for introducing additional nutri-

Is there a role for laboratory or radiologic

tional strategies is persistent weight loss. Serious compli-
assessment in the diagnosis of hyperemesis cations of hyperemesis gravidarum for the woman and
gravidarum? fetus arise in the group of women who cannot maintain
Most patients with nausea and vomiting of pregnancy do their weight despite antiemetic therapy. Intravenous
not require laboratory evaluation, but in those with nau- hydration should be used for the patient who cannot toler-
sea and vomiting of pregnancy that is severe, prolonged, ate oral liquids for a prolonged period or if clinical signs
or extended, laboratory assessment may help in the dif- of dehydration are present. Correction of ketosis and vita-
ferential diagnosis of hyperemesis gravidarum and to min deficiency should be strongly considered. Dextrose
assess the severity of the condition. Common laboratory and vitamins, especially thiamine, should be included in
abnormalities in hyperemesis gravidarum include the therapy when prolonged vomiting is present.
increased liver enzymes (usually <300 U/L), serum No randomized trials compare enteral with par-
bilirubin (<4 mg/dL), and serum amylase or lipase con- enteral nutrition in women with nausea and vomiting of
centrations (up to 5 times greater than normal levels). pregnancy who continue to lose weight despite antiemet-
Primary hepatitis as a cause of nausea and vomiting of ic therapy. Several case reports and a small series (83)
pregnancy results in increased liver enzyme levels, often suggest that enteral tube feeding is well tolerated in
in the thousands; bilirubin concentrations usually are pregnancy. Because life-threatening complications of
greatly increased as well. Acute pancreatitis may cause parenteral nutrition have been described (35, 36, 84), it
vomiting and elevated amylase concentrations, but is reasonable to attempt enteral tube feeding initially.
serum amylase concentrations usually are 510 times Peripheral parenteral nutrition using a high-lipid formu-
greater than the elevations associated with nausea and la can be used for patients whose calorie requirements
vomiting of pregnancy. A hypochloremic metabolic
are not great and those whose length of treatment is
alkalosis can be seen with severe vomiting of any cause.
anticipated to be no more than several days. For women
Serum concentrations of hCG are not helpful in deter-
who need longer-term support and who cannot tolerate
mining whether vomiting is caused by hyperemesis
gravidarum. Urinalysis may show elevated specific grav- enteral tube feedings, the use of total parenteral nutrition
ity or ketonuria or both. Patients with persistent hyper- has been described for hyperemesis gravidarum in case
emesis gravidarum that is unresponsive to standard reports and 2 small series (35, 85). A peripherally insert-
therapy may have an ulcer; treatment with antibiotics ed central catheter can be used to avoid some of the com-
and H2 receptor antagonists is safe (78, 79) and has been plications of central access (86), but it is still associated
reported to be beneficial in case reports (80). with significant morbidity (87).
Up to 70% of patients with hyperemesis gravidarum

will have suppressed thyroid-stimulating hormone levels When is hospitalization indicated?

or elevated free thyroxine concentrations (81). For the No controlled trials compare hospitalization with outpa-
patient who has no history of hyperthyroidism before tient management of hyperemesis gravidarum. When a
pregnancy and no goiter, the hyperthyroidism of hyper- woman cannot tolerate liquids without vomiting and has
emesis gravidarum can be expected to resolve by not responded to outpatient management, hospitalization
20 weeks of gestation without specific antithyroid ther- for evaluation and treatment is recommended. After the
apy. Hyperthyroidism itself rarely may present with patient has been hospitalized on one occasion and a
significant vomiting (82), but in the patient who has no workup for other causes of severe vomiting has been
goiter, thyroid tests are not needed routinely to clarify undertaken, intravenous hydration, nutritional support,
the differential diagnosis. To confirm the diagnosis of and modification of antiemetic therapy often can be
hyperthyroidism in the setting of nausea and vomiting of accomplished at home. Nevertheless, the option of hos-
pregnancy, measurement of free thyroxine and free tri- pitalization for observation and further assessment
iodothyronine concentrations should be obtained. should be preserved for patients who experience a
An ultrasound evaluation may be useful in cases of change in vital signs or a change in affect or who con-
severe presumed nausea and vomiting of pregnancy. It tinue to lose weight.

8 ACOG Practice Bulletin No. 52



Is there a role for psychotherapy in Treatment of severe nausea and vomiting of preg-
treatment? nancy or hyperemesis gravidarum with methylpred-
nisolone may be efficacious in refractory cases;
There is little evidence for a therapeutic effect of tradi- however, the risk profile of methylprednisolone sug-
tional psychotherapy in hyperemesis gravidarum. No gests it should be a treatment of last resort.
controlled trials have evaluated behavioral therapy in
nausea and vomiting of pregnancy, but there are data to The following recommendations are based primar-
indicate that delayed and anticipatory nausea and vomit- ily on consensus and expert opinion (Level C):
ing after chemotherapy is diminished by systematic

desensitization (88) and relaxation therapy (89). Intravenous hydration should be used for the patient
It has been suggested that hypnotized women with who cannot tolerate oral liquids for a prolonged
severe nausea and vomiting of pregnancy are more easi- period or if clinical signs of dehydration are present.
ly influenced by suggestion than controls, and at least Correction of ketosis and vitamin deficiency should
one controlled study supports this hypothesis (90). In a be strongly considered. Dextrose and vitamins,
limited number of studies, all lacking controls, hypnosis especially thiamine, should be included in the ther-
has been shown to decrease vomiting in patients under- apy when prolonged vomiting is present.

going chemotherapy (91, 92) and those with hypereme- Enteral or parenteral nutrition should be initiated for
sis gravidarum (93, 94). any patient who cannot maintain her weight because
of vomiting.

Summary of
Recommendations References
1. Attard CL, Kohli MA, Coleman S, Bradley C, Hux M,
The following recommendations are based on Atanackovic G, et al. The burden of illness of severe nau-
good and consistent scientific evidence (Level A): sea and vomiting of pregnancy in the United States. Am J
Obstet Gynecol 2002;186:S2207. (Level II-2)

Taking a multivitamin at the time of conception may

2. Mazzota P, Magee L, Koren G. Therapeutic abortions due
decrease the severity of nausea and vomiting of to severe morning sickness. Unacceptable combination.
pregnancy. Can Fam Physician 1997;43:10557. (Level III)

Treatment of nausea and vomiting of pregnancy 3. Mazzotta P, Stewart D, Atanackovic G, Koren G, Magee
with vitamin B6 or vitamin B6 plus doxylamine is LA. Psychosocial morbidity among women with nausea
safe and effective and should be considered first-line and vomiting of pregnancy: prevalence and association
pharmacotherapy. with anti-emetic therapy. J Psychosom Obstet Gynaecol
2000;21:12936. (Level II-3)

In patients with hyperemesis gravidarum who also

4. OBrien B, Naber S. Nausea and vomiting during preg-
have suppressed thyroid-stimulating hormone levels,
nancy: effects on the quality of womens lives. Birth
treatment of hyperthyroidism should not be under- 1992;19:13843. (Level III)
taken without evidence of intrinsic thyroid disease
5. Brent R. Medical, social, and legal implications of treat-
(including goiter and/or thyroid autoantibodies).
ing nausea and vomiting of pregnancy. Am J Obstet
Gynecol 2002;186:S2626. (Level III)
The following recommendations are based on lim-
6. Jewell D, Young G. Interventions for nausea and vomiting
ited or inconsistent scientific evidence (Level B):
in early pregnancy (Cochrane Review). In: The Cochrane
Library, Issue 4, 2003. Chichester, UK: John Wiley &

Treatment of nausea and vomiting of pregnancy

Sons, Ltd. (Meta-analysis)
with ginger has shown beneficial effects and can be
considered as a nonpharmacologic option. 7. Gadsby R, Barnie-Adshead AM, Jagger C. A prospective
study of nausea and vomiting during pregnancy [pub-

In refractory cases of nausea and vomiting of preg- lished erratum appears in Br J Gen Pract 1993;43:325]. Br
nancy, the following medications have been shown J Gen Pract 1993;43:2458. (Level II-2)
to be safe and efficacious in pregnancy: antihis-
8. Vellacott ID, Cooke EJ, James CE. Nausea and vomiting
tamine H1 receptor blockers, phenothiazines, and in early pregnancy. Int J Gynaecol Obstet 1988;27:5762.
benzamides. (Level II-2)

Early treatment of nausea and vomiting of preg- 9. Klebanoff MA, Koslowe PA, Kaslow R, Rhoads GG.
nancy is recommended to prevent progression to Epidemiology of vomiting in early pregnancy. Obstet
hyperemesis gravidarum. Gynecol 1985;66:6126. (Level II-2)

ACOG Practice Bulletin No. 52 9

10. Gadsby R, Barnie-Adshead AM, Jagger C. Pregnancy gation of the side effects attributed to oral contraceptives.
nausea related to womens obstetric and personal histo- Fertil Steril 1971;22:60923. (Level I)
ries. Gynecol Obstet Invest 1997;43:10811. (Level II-2) 26. Whitehead SA, Andrews PL, Chamberlain GV. Character-
11. Goodwin TM, Montoro M, Mestman JH. Transient hyper- isation of nausea and vomiting in early pregnancy: a sur-
thyroidism and hyperemesis gravidarum: clinical aspects. vey of 1,000 women. J Obstet Gynaecol 1992;12:3649.
Am J Obstet Gynecol 1992;167:64852. (Level II-2) (Level II-2)
12. Adams MM, Harlass FE, Sarno AP, Read JA, Rawlings 27. Basso O, Olsen J. Sex ratio and twinning in women with
JS. Antenatal hospitalization among enlisted service- hyperemesis or pre-eclampsia. Epidemiology 2001;12:
women, 19871990. Obstet Gynecol 1994;84:359. 7479. (Level II-2)
(Level II-3) 28. Reid DE, Teel HM. The treatment of the vomiting of early
13. Gazmararian JA, Petersen R, Jamieson DJ, Schild L, pregnancy. N Engl J Med 1938;218:10913. (Level III)
Adams MM, Deshpande AD, et al. Hospitalizations dur- 29. Togay-Isikay C, Yigit A, Mutluer N. Wernickes enceph-
ing pregnancy among managed care enrollees. Obstet alopathy due to hyperemesis gravidarum: an under-recog-
Gynecol 2002;100:94100. (Level II-2) nised condition. Aust N Z J Obstet Gynecol 2001;41:
14. Rodien P, Bremont C, Sanson ML, Parma J, Van Sande J, 4536. (Level III)
Costagliola S, et al. Familial gestational hyperthyroidism 30. Spruill SC, Kuller JA. Hyperemesis gravidarum compli-
caused by a mutant thyrotropin receptor hypersensitive to cated by Wernickes encephalopathy. Obstet Gynecol
human chorionic gonadotropin. N Engl J Med 1998;339: 2002;99:8757. (Level III)
18236. (Level III) 31. Kim YH, Lee SJ, Rah SH, Lee JH. Wernickes enceph-
15. Innes AM, Seargeant LE, Balachandra K, Roe CR, alopathy in hyperemesis gravidarum. Can J Ophthalmol
Wanders RJ, Ruiter JP, et al. Hepatic carnitine palmitoyl- 2002;37:378. (Level III)
transferase I deficiency presenting as maternal illness in 32. Eroglu A, Kurkcuoglu C, Karaoglanoglu N, Tekinbas C,
pregnancy. Pediatr Res 2000;47:435. (Level III) Cesur M. Spontaneous esophageal rupture following
16. Simpson SW, Goodwin TM, Robins SB, Rizzo AA, severe vomiting in pregnancy. Dis Esophagus 2002;15:
Howes RA, Buckwalter DK, et al. Psychological factors 2423. (Level III)
and hyperemesis gravidarum. J Women Health Gend 33. Liang SG, Ooka F, Santo A, Kaibara M. Pneumomedi-
Based Med 2001;10:4717. (Level II-2) astinum following esophageal rupture associated with
17. Flaxman SM, Sherman PW. Morning sickness: a mecha- hyperemesis gravidarum. J Obstet Gynaecol Res 2002;
nism for protecting mother and embryo. Q Rev Biol 2000; 28:1725. (Level III)
75:11348. (Level III) 34. Nguyen N, Deitel M, Lacy E. Splenic avulsion in a preg-
18. Buckwalter JG, Simpson SW. Psychological factors in the nant patient with vomiting. Can J Surg 1995;38:4645.
etiology and treatment of severe nausea and vomiting in (Level III)
pregnancy. Am J Obstet Gynecol 2002;186:S210 4. 35. Russo-Stieglitz KE, Levine AB, Wagner BA, Armenti VT.
(Level III) Pregnancy outcome in patients requiring parenteral nutri-
19. Bogen JT. Neurosis: a Ms-diagnosis. Perspect Biol Med tion. J Matern Fetal Med 1999;8:1647. (Level III)
1994;37:26374. (Level III) 36. Katz VL, Farmer R, York J, Wilson JD. Mycobacterium
20. Sherman PW, Flaxman SM. Nausea and vomiting of preg- chelonae sepsis associated with long-term use of an intra-
nancy in an evolutionary perspective. Am J Obstet venous catheter for treatment of hyperemesis gravidarum:
Gynecol 2002;186:S1907. (Level III) a case report. J Reprod Med 2000;45:5814. (Level III)
21. Yoshimura M, Hershman JM. Thyrotropic action of 37. Lamm SH. The epidemiological assessment of the safety
human chorionic gonadotropin. Thyroid 1995;5:42534. and efficacy of Bendectin. In: Koren G, Bishai R, editors.
(Level III) Nausea and vomiting of pregnancy: state of the art 2000.
Toronto: Motherisk; 2000. p. 1003. (Level III)
22. Bernstein L, Pike MC, Lobo RA, Depue RH, Ross RK,
Henderson BE. Cigarette smoking in pregnancy results in 38. Neutel CI, Johansen HL. Measuring drug effectiveness by
marked decrease in maternal hCG and oestradiol levels. default: the case of Bendectin. Can J Public Health 1995;
Br J Obstet Gynaecol 1989;96:926. (Level II-2) 86:6670. (Level III)
23. Depue RH, Bernstein L, Ross RK, Judd HL, Henderson 39. Jarnfelt-Samsioe A, Eriksson B, Waldenstrom J, Samsioe
BE. Hyperemesis gravidarum in relation to estradiol lev- G. Some new aspects on emesis gravidarum. Relations to
els, pregnancy outcome, and other maternal factors: a clinical data, serum electrolytes, total protein and creati-
seroepidemiologic study. Am J Obstet Gynecol 1987;156: nine. Gynecol Obstet Invest 1985;19:17486. (Level II-2)
113741. (Level II-2) 40. Weigel MM, Weigel RM. Nausea and vomiting of early
24. Goodwin TM. Nausea and vomiting of pregnancy: an pregnancy and pregnancy outcome: an epidemiological
obstetric syndrome. Am J Obstet Gynecol 2002;186: study. Br J Obstet Gynaecol 1989;96:130411. (Level II-2)
S1849. (Level III) 41. Brandes JM. First-trimester nausea and vomiting as relat-
25. Goldzieher JW, Moses LE, Averkin E, Scheel C, Taber ed to outcome of pregnancy. Obstet Gynecol 1967;30:
BZ. A placebo-controlled double-blind crossover investi- 42731. (Level II-2)

10 ACOG Practice Bulletin No. 52

42. Little RE. Maternal alcohol and tobacco use and nausea 57. Roscoe JA, Matteson SE. Acupressure and acustimulation
and vomiting during pregnancy: relation to infant birth- bands for control of nausea: a brief review. Am J Obstet
weight. Acta Obstet Gynecol Scand 1980;59:4957. Gynecol 2002;186:S2447. (Level III)
(Level II-3)
58. Rosen T, de Veciana M, Miller HS, Stewart L, Rebarber A,
43. Tierson FD, Olsen CL, Hook EB. Nausea and vomiting of Slotnick RN. A randomized controlled trial of nerve stim-
pregnancy and association with pregnancy outcome [pub- ulation for relief of nausea and vomiting in pregnancy.
lished erratum appears in Am J Obstet Gynecol 1989; Obstet Gynecol 2003;102:12935. (Level I)
160:5189]. Am J Obstet Gynecol 1986;155:101722.
59. Sahakian V, Rouse D, Sipes S, Rose N, Niebyl J. Vitamin
(Level II-2)
B6 is effective therapy for nausea and vomiting of preg-
44. Chin RK, Lao TT. Low birth weight and hyperemesis nancy: a randomized, double-blind placebo-controlled
gravidarum. Eur J Obstet Gynecol Reprod Biol 1988;28: study. Obstet Gynecol 1991;78:336. (Level I)
17983. (Level II-2)
60. Vutyavanich T, Wongtra-ngan S, Ruangsri R. Pyridoxine
45. Godsey RK, Newman RB. Hyperemesis gravidarum. A for nausea and vomiting of pregnancy: a randomized,
comparison of single and multiple admissions. J Reprod double-blind, placebo-controlled trial. Am J Obstet
Med 1991;36:28790. (Level II-3) Gynecol 1995;173:8814. (Level I)
46. Gross S, Librach C, Cecutti A. Maternal weight loss as- 61. Geiger CJ, Fahrenbach DM, Healey FJ. Bendectin in the
sociated with hyperemesis gravidarum: a predictor of treatment of nausea and vomiting in pregnancy. Obstet
fetal outcome. Am J Obstet Gynecol 1989;160:9069. Gynecol 1959;14:68890. (Level II-1)
(Level II-3)
62. Wheatley D. Treatment of pregnancy sickness. Br J Obstet
47. Kallen B. Hyperemesis during pregnancy and delivery
Gynaecol 1977;84:4447. (Level II-1)
outcome: a registry study. Eur J Obstet Gynecol Reprod
Biol 1987;26:291302. (Level II-2) 63. McGuinness BW, Binns DT. Debendox in pregnancy
sickness. J R Coll Gen Pract 1971;21:5003. (Level II-3)
48. OBrien B, Zhou Q. Variables related to nausea and
vomiting during pregnancy. Birth 1995;22:93100. 64. McKeigue PM, Lamm SH, Linn S, Kutcher JS. Bendectin
(Level II-2) and birth defects: I. A meta-analysis of the epidemiologic
49. Vilming B, Nesheim BI. Hyperemesis gravidarum in a studies. Teratology 1994;50:2737. (Meta-analysis)
contemporary population in Oslo. Acta Obstet Gynecol 65. Seto A, Einarson T, Koren G. Pregnancy outcome follow-
Scand 2000;79:6403. (Level II-2) ing first trimester exposure to antihistamines: meta-analy-
50. Boneva RS, Moore CA, Botto L, Wong LY, Erickson JD. sis. Am J Perinatol 1997;14:11924. (Meta-analysis)
Nausea during pregnancy and congenital heart defects: a 66. Rumeau-Rouquette C, Goujard J, Huel G. Possible terato-
population-based case-control study. Am J Epidemiol genic effect of phenothiazines in human beings. Teratology
1999;149:71725. (Level II-2)
1977;15:5764. (Level II-2)
51. Czeizel AE, Dudas I, Fritz G, Tecsoi A, Hanck A,
Kunovits G. The effect of periconceptional multivitamin- 67. Magee LA, Mazzotta P, Koren G. Evidence-based view of
mineral supplementation on vertigo, nausea and vomiting safety and effectiveness of pharmacologic therapy for
in the first trimester of pregnancy. Arch Gynecol Obstet nausea and vomiting of pregnancy (NVP). Am J Obstet
1992;251:1815. (Level I) Gynecol 2002;186:S25661. (Level III)
52. Emelianova S, Mazzotta P, Einarson A, Koren G. 68. Aselton P, Jick H, Milunsky A, Hunter JR, Stergachis A.
Prevalence and severity of nausea and vomiting of preg- First-trimester drug use and congenital disorders. Obstet
nancy and effect of vitamin supplementation. Clin Invest Gynecol 1985;65:4515. (Level II-2)
Med 1999;22:10610. (Level II-2) 69. Heinonen OP, Slone D, Shapiro S. Birth defects and drugs
53. Power ML, Holzman GB, Schulkin J. A survey on the in pregnancy. Littleton (MA): Publishing Sciences Group;
management of nausea and vomiting in pregnancy by 1977. (Level III)
obstetrician/gynecologists. Prim Care Update Ob Gyns 70. Mitchell AA, Schwingl PJ, Rosenberg L, Louik C,
2001;8:6972. (Level III) Shapiro S. Birth defects in relation to Bendectin use in
54. Jednak MA, Shadigian EM, Kim MS, Woods ML, Hooper pregnancy. II. Pyloric stenosis. Am J Obstet Gynecol
FG, Owyang C, et al. Protein meals reduce nausea and 1983;147:73742. (Level II-2)
gastric slow wave dysrhythmic activity in first trimester 71. Safari HR, Fassett MJ, Souter IC, Alsulyman OM,
pregnancy. Am J Physiol 1999;277:G85561. (Level II-3) Goodwin TM. The efficacy of methylprednisolone in the
55. Fischer-Rasmussen W, Kjaer SK, Dahl C, Asping U. Gin- treatment of hyperemesis gravidarum: a randomized, dou-
ger treatment of hyperemesis gravidarum. Eur J Obstet ble-blind, controlled study. Am J Obstet Gynecol 1998;
Gynecol Reprod Biol 1991;38:1924. (Level II-2) 179:9214. (Level I)
56. Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nau- 72. Yost NP, McIntire DD, Wians FH Jr, Ramin SM, Balko
sea and vomiting in pregnancy: randomized, double- JA, Leveno KJ. A randomized, placebo-controlled trial of
masked, placebo-controlled trial. Obstet Gynecol 2001; corticosteroids for hyperemesis due to pregnancy. Obstet
97:57782. (Level I) Gynecol 2003;102:12504. (Level I)

ACOG Practice Bulletin No. 52 11

73. Carmichael SL, Shaw GM. Maternal corticosteroid use 84. Greenspoon JS, Masaki DI, Kurz CR. Cardiac tamponade
and risk of selected congenital anomalies. Am J Med in pregnancy during central hyperalimentation. Obstet
Genet 1999;86:2424. (Level II-2) Gynecol 1989;73:4656. (Level III)
74. Park-Wyllie L, Mazzotta P, Pastuszak A, Moretti ME, 85. Zibell-Frisk D, Jen KL, Rick J. Use of parenteral nutrition
Beique L, Hunnisett L, et al. Birth defects after maternal to maintain adequate nutritional status in hyperemesis
exposure to corticosteroids: prospective cohort study and gravidarum. J Perinatol 1990;10:3905. (Level II-2)
meta-analysis of epidemiological studies. Teratology
2000;62:38592. (Meta-analysis) 86. Ogura JM, Francois KG, Perlow JH, Elliott JP.
75. Rodriguez-Pinilla E, Martinez-Frias ML. Corticosteroids Complications associated with peripherally inserted cen-
during pregnancy and oral clefts: a case-control study. tral catheter use during pregnancy. Am J Obstet Gynecol
Teratology 1998;58:25. (Level II-2) 2003;188:12235. (Level III)
76. Shepard TH, Brent RL, Friedman JM, Jones KL, Miller 87. Greenspoon JS, Rosen DJ, Ault M. Use of peripherally
RK, Moore CA, et al. Update on new developments in the inserted central catheter for parenteral nutrition during
study of human teratogens. Teratology 2002;65:15361. pregnancy. Obstet Gynecol 1993;81:8314. (Level III)
(Level III)
88. Morrow GR, Asbury R, Hammon S, Dobkin P, Caruso L,
77. Chan GC, Wilson AM. Complications of the use of corti- Pandya K, et al. Comparing the effectiveness of behav-
costeroids for the treatment of hyperemesis gravidarum ioral treatment for chemotherapy-induced nausea and
[Letter]. Br J Obstet Gynaecol 1995;102:5078; author vomiting when administered by oncologists, oncology
reply 5089. (Level III) nurses, and clinical psychologists. Health Psychol 1992;
78. Kallen BA. Use of omeprazole during pregnancyno 11:2506. (Level I)
hazard demonstrated in 955 infants exposed during preg-
89. Burish TG, Jenkins RA. Effectiveness of biofeedback and
nancy. Eur J Obstet Gynecol Reprod Biol 2001;96:638.
(Level II-2) relaxation training in reducing the side effects of cancer
chemotherapy. Health Psychol 1992;11:1723. (Level I)
79. Ruigomez A, Garcia Rodriguez LA, Cattaruzzi C,
Troncon MG, Agostinis L, Wallander MA, et al. Use of 90. Apfel RJ, Kelly SF, Frankel FH. The role of hypnotizabil-
cimetidine, omeprazole, and ranitidine in pregnant ity in the pathogenesis and treatment of nausea and vom-
women and pregnancy outcomes. Am J Epidemiol iting of pregnancy. J Psychosom Obstet Gynaecol 1986;5:
1999;150:47681. (Level II-2) 17986. (Level II-3)
80. Jacoby EB, Porter KB. Helicobacter pylori infection and 91. Torem MS. Hypnotherapeutic techniques in the treatment
persistent hyperemesis gravidarum. Am J Perinatol 1999; of hyperemesis gravidarum. Am J Clin Hypn 1994;37:
16:858. (Level III) 111. (Level III)
81. Goodwin TM, Montoro M, Mestman JH, Pekary AE, 92. Smith BJ. Management of the patient with hyperemesis
Hershman JM. The role of chorionic gonadotropin in tran- gravidarum in family therapy with hypnotherapy as an
sient hyperthyroidism of hyperemesis gravidarum. J Clin adjunct. J N Y State Nurses Assoc 1982;13:1726.
Endocrinol Metab 1992;75:13337. (Level II-2) (Level III)
82. Rosenthal FD, Jones C, Lewis SI. Thyrotoxic vomiting. 93. Simon EP, Schwartz J. Medical hypnosis for hyperemesis
Br Med J 1976;2:20911. (Level III) gravidarum. Birth 1999;26:24854. (Level III)
83. Hsu JJ, Clark-Glena R, Nelson DK, Kim CH. Nasogastric 94. Fuchs K, Paldi E, Abramovici H, Peretz BA. Treatment of
enteral feeding in the management of hyperemesis gravi- hyperemesis gravidarum by hypnosis. Int J Clin Exp Hypn
darum. Obstet Gynecol 1996;88:3436. (Level III) 1980;28:31323. (Level III)

ACOG Practice Bulletin No. 52 12

 The MEDLINE database, the Cochrane Library, and
ACOGs own internal resources and documents were used
to conduct a literature search to locate relevant articles pub-
lished between January 1985 and December 2003. The
search was restricted to articles published in the English
language. Priority was given to articles reporting results of
original research, although review articles and commentar-
ies also were consulted. Abstracts of research presented at
symposia and scientific conferences were not considered
adequate for inclusion in this document. Guidelines pub-
lished by organizations or institutions such as the National
Institutes of Health and the American College of Obstetri-
cians and Gynecologists were reviewed, and additional
studies were located by reviewing bibliographies of identi-
fied articles. When reliable research was not available,
expert opinions from obstetriciangynecologists were used.
Studies were reviewed and evaluated for quality according
to the method outlined by the U.S. Preventive Services Task
Force:
I Evidence obtained from at least 1 properly designed
randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
casecontrol analytic studies, preferably from more
than 1 center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncon-
trolled experiments also could be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following categories:
Level ARecommendations are based on good and consis-
tent scientific evidence.
Level BRecommendations are based on limited or incon-
sistent scientific evidence.
Level CRecommendations are based primarily on con-
sensus and expert opinion.

Copyright April 2004 by the American College of Obstetricians and

Gynecologists. All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in any form or
by any means, electronic, mechanical, photocopying, recording, or oth-
erwise, without prior written permission from the publisher.
Requests for authorization to make photocopies should be directed to
Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA
01923, (978) 750-8400.
ISSN 1099-3630
The American College of Obstetricians and Gynecologists
409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920

Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 52.

American College of Obstetricians and Gynecologists. Obstet Gynecol
2004;103:80315

13 ACOG Practice Bulletin No. 52