Nutrition for Nausea

and Vomiting during

Pregnancy
SOFIE RIFAYANI KRISNADI

Nausea Vomiting in Pregnancy (NVP)

Nausea with or without vomiting;
Occurs in 50-90% of all pregnancies

Symptoms occur at 5-6 wks GA, peak at 9 wks,

Ablate by 16 to 18 wks; 20% continues for the entire pregnancy
32% during late pregnancy

Symptoms can occur any time of day80% persist throughout the day ,
usually worst in the morning ( morning sickness)
Mild, self limited, not disturb the patients health or fetuss

Hyperemesis Gravidarum
Persistent vomiting accompanied by weight loss exceeding 5% of body weight

Dehydration, ketonuria unrelated to other causes;

Onset usually 4 to 10 wks GA
Affects 1-4 in 200 (0.5-2%)pregnancies
Can persist until delivery; symptoms tend to improve in last half of pregnancy
Can be Life threatening to fetus and mother

Risk Factors
Primigravida , Young women, Houseworks

Obesity, Multiple/molar pregnancy, History of motion sickness,

Eating disorder
History of NVP/HEG, Sensitive to OCs
Psychiatric issues (stress, emotional tension,fear to be a parent,
excessive bond to mother

Female fetus

(Mylonas et al, 2007)

Pathophysiology
o Not fully understood, multifactorial
o Correlated with increasing hormone hCG /others (thyroid,
progesterone, estrogen, adrenal hormones)
o Change in smooth muscle (GI) relaxation/ contraction pattern
o Nutrition deficiencies
o Psychologic, Genetic

o Helicobacter pylori infection

Characteristics of the Stimulus for NVP

Elaborated by placenta, not fetus
Onset within 4 weeks of last menstrual period in some patients
Fully manifest by 10 weeks gestation
May persist until delivery of placenta
Rapid improvement with removal of placenta
More common with female fetus / placenta
Diminished in older women and multiparas
Diminished with smoking

Evaluating the Pregnant Patient with NV

1. Physical findings suggestive of nausea and vomiting due to other causes
2. Neurologic findings
3. Laboratory tests
Serum amylase level
Serum liver enzyme levels
Serum thyroid stimulating hormone (TSH) level

4. Ultrasound results
Multiple gestation
Molar gestation

Differential Diagnosis NVP

Nutrition During Pregnancy

Most pregnant women need 2,200-2,900 calories
Energy Requirements
No different than non- pregnant women until the
2nd trimester
340 kcal in the 2nd trimester
452 kcal in the 3rd trimester

Variety of foods
Choose nutrient-dense foods/ limit energy-dense
foods
www.mypryamid.gov

Table
Nutrient Requirements During Pregnancy

Nutrient

RDA/DRI

Key Considerations

Protein

0.81.0 gm/kg protein/d + 10 gm

protein/d per fetus using prepregnancy weight

Individuals who are protein deficient at conception,

a goal of 1.2 1.7 gm/kg protein/d is ideal

Carbohydrate

50%60% total calories

For gestational diabetes, CHO content may need to be

decreased to as low as 40% calories

Fat

30% total calories

There is no established DRI for essential fatty acids during

pregnancy, however it has been suggested intake should
be at least 4.5%6% of total calorie intake

Fluid

30 mL/kg

With nausea and vomiting, pregnant woman will need

additional fluids to account for fluid losses with emesis

Folate

600 micrograms/d

With 400 micrograms coming from supplements or synthetic

folic acid found in fortified foods

Iron

27 milligrams/d

Center for Disease Control and Prevention recommends all

pregnant woman initiate iron supplementation of 30 mg/d
at the first prenatal visit

Calcium

1000 milligrams/d for woman aged

19 to 50 years

1300 milligrams/d for women 18 years or younger

KILOCALORIES AND NUTRIENT INTAKES OF PREGNANT

WOMEN WITH AND WITHOUT NVP

(LINDSETH G.ET AL.,2008)

Nutrient Effects in Nausea of Pregnancy

Saturated fat intake before pregnancy increase the risk of HEG (Signorello,1998)
Protein predominant meals reduce nausea and gastric dysrithmic activity
(compare to carbohydrate, fat or noncaloric meals)
Meals consistency did not affect symptom responses (Jednak, 1999)
Prophylaxis Vit.B6 reduce NVP (Niebyl,2002)
Rates of NVP correlated with high intake of macronutrient (Kcal, carbohydrate,
protein,fat sugar, meat, milk and egg) (Pepper,2006)
NVP increase with low intake of cereals and pulses (Pepper,2006)
Prenatal vitamins worsen nausea because of the iron content,large size and side effects
(Einarson, 2007)

Management Considerations with NVP

Mild to
Moderate NVP
(not interfering with work or
lifestyle)

Moderate NVP (interfering

with work or lifestyle)

Severe NVP
(significant weight loss and
dehydration)

Supportive measures
(eg, dietary, lifestyle,
reassurance)

Consider pharmacologic
treatment options

Hospitalization
(eg, fluid replacement,
nutritional supplementation, IV
medications)

 Outpatient Treatment
Extensive dietary advice:
Foods should be rich in carbohydrates and low in fat , Cold and dry foods is better

Should be consumed in many small meals (6-8 X or more).

Chew and swallow your food very slowly
Eat a small snack before sleep at night will prevent morning sickness.

Eat 2-3 saltine crackers or dry toast before getting out of bed
Do not et high fat foods (fried food, heavy sauces, rich desserts)
Lie down after eating with head raised on 1-2 pillows

Outpatient Treatment
Fluids:
Fluid intake prevent dehydration.
Use your nausea-free intervals to their best advantage alternately with solids if you
cannot take
both at the same time.
Drink any nonalcoholic fluid you like, avoid soft drinks and not more than a total of
three cups
of coffee or tea per day.
Many women find lemonade or fruit drinks very acceptable.
Water is excellent, if necessary as ice cubes or frozen fluids.
Drink plenty of fluid, in small frequent quantities between meals

Outpatient Treatment
Odours: If odours bother you eat cold food and hopefully your family will agree to do the same.
Naturally you will avoid all odours and tastes that make your NVP worse.
Your sensitive nose is possibly your worst enemy at present.

The smell of cooking, especially fatty foods, coffee, tea, cigarette smoke, or perfume are the
most common items stated by NVP suffers to make their symptoms worse.
Normal odours can become unpleasantly nauseous. So, you may need to get extra help from
your family and friends.

Rest adequately since nausea tends to worsen when a woman is tired.

Get plenty of fresh air and avoid warm places, as this can aggravate the nausea.

Patient education
Reminding yourself as often as necessary that:
This condition is not your fault.
You have not done anything to cause NVP or HG.

There is nothing you could have done to prevent the onset of NVP or HG.
Keeping a daily diary of your symptoms may enable you to be prepared to eat.
Most importantly, drink at those nausea-free times.

Sometimes you may even feel hungry, but the hunger is often quickly followed by the onset of
nausea.
Either feeling hunger or a nausea-free interval gives you a chance to eat straightaway.
If you cannot face a meal, keep nibbling your favourite food, especially when nausea threate

First-line therapy for NVP

not associated with teratogenicity,
with proven effectiveness
Pyridoxine (Vit. B6). 10-25 mg TID. Few side effects. Preg. Category: A

Ginger root. 250 mg QID. Few to no side effects.

Preg. Category: not rated
Antihistamines - more sedating. Preg. Category: B
Diphenhydramine(Benadryl) 25-50 mg po Q 4-8 hrs.
Meclizine (Antivert) 25 mg po Q 4-6 hrs.
Dimenhydrinate (Dramamine) 50-100 mg po Q 4-6 hrs.

Metoclopramide (Reglan) 5-10 mg po TID. Category: B

Doxylamine (Unisom) 25 mg po QD. Category: none, but comprehensive

review has shown safe.
Descript. of preg
drug categories

Second-line choices for NVP:

considered safe but clinically unproven, Category B or C
Anti-emetics
Chlorpromazine (Thorazine): 10-25 mg po BID to TID.
Prochlorperazine (Compazine): 5-10 mg po TID to QID.
Promethazine (Phenergan): 12.5 to 25 mg po Q 4-6 hrs.
Trimethobenzamide (Tigan): 250 mg po TID to QID.
Ondansetron (Zofran): 8 mg po BID to TID.
Category B, very expensive, only studied with hyperemesis

Steroids
Methylprednisolone (Medrol) 16 mg po TID then taper.
Could be a small teratogenic risk. Only studied with hyperemesis.

Algorithm for diagnosis of hyperemesis

gravidarum, according to Mylonas-2007
GOT, Glutamatoxalacetate transaminase;
GPT, Glutamatpyruvate transaminase

Initial Treatment of Severe NVP/HEG

Hospitalization

Intravenous fluids, electrolytes,

and multivitamins

Intravenous antiemetics / antinauseants

Enteral or parenteral nutrition for severe cases

Gradual reintroduction of PO fluids and solid foods
Psychological support

Inpatient procedure in hyperemesis

gravidarum, adapted from Mylonas2007

INTRAVENOUS FLUID, ELECTROLYT AND

MULTIVITAMINS
- Normal saline or Ringer Lactate 1000 ml + Glucose 5% 1000 ml
+ Multivitamins (Thiamine-B1; Pyridoxine-B6 and Vit. C

+ Antiemetics (metoclopramide, ondancentron)

- Amino acid

NUTRITIONAL THERAPY
Nutrition is the most important issues for women with HG.

Pregnant women require a variety of nutrients both for their own healing and for the
normal development of their unborn child.

The baby's requirements for minerals, vitamins, and other nutrients come first and
are taken from the mother's bones, organs, tissues, and other storage areas.
This can leave the mother depleted very quickly, which can take months, or even
years, to correct.

NUTRITIONAL THERAPY
Also needed to form the placenta,

To increase the size of the uterus and breast tissue

To create amniotic fluid.
To support new mother's blood ( increases by 2550%) which need
more fluids, iron, B12, folic acid, zinc and copper, calcium,
magnesium, and proteins
Storage levels of most nutrients must be obtained from the diet as well.

PARENTERAL/ INTRAVENOUS
NUTRITIONAL THERAPY
Parenteral nutrition (PN) is sterile intravenous
solution of protein, dextrose and fat in
combination with electrolytes, vitamins, trace
elements and water.

Total Parenteral Nutrition (TPN), highly

recommended if a woman loses over 5% of
her body weight (pre-conception)

ENTERAL NUTRITION IN HEG

EN allows the infusion of nutrients and fluid without the associated cephalic

phase (visual cues, food aromas and flavors) that stimulates salivary and
gastric secretions,which may play a role in inducing nausea and vomiting in HEG.
If a woman with HEG has not responded to dietary manipulation and oral

antiemetics, EN should be considered.

EN, ideally via the gastric route, is anapproach that has been shown to offer
significant relief from nausea and vomiting, prevent hospitalization and lead to positive
fetal outcomes

PROGNOSIS/ OUTCOME
NVP usually improve (18-20 weeks of pregnancy)
13% persisted beyond 20 weeks' gestation
NVP reduced risk of miscarriage (6 studies, 14,564 women; OR 0.36, 95% CI 0.32 to 0.42)

No association with perinatal mortality.

Although death from HEG is rare, morbidities, including Wernicke's encephalopathy, splenic
avulsion, oesophageal rupture, pneumothorax, and acute tubular necrosis, have been reported.

Complication
Babies of mothers who are malnourished because of NVP, will also run the risk of suffering from
these diseases when they grow up.
Increase glucose intolerance, disease of lifestyle, heart disease, DM, obesity, hypertension
(Roseboom et al, 2006)
Increase coronary disease, altered clotting, raise lipids, obesity
Increase breast cancer, obstructive airway disease
Increase schizophrenia, antisocial personality (Kyle& Pritchard,2006)
Multigeneration effect (Stein & Lumey, 2000)

Increase Gallblader disease, Liver dysfunction, muscle pain, renal failure, retinal hemorrhage
(Fejzo e al., 2009)

CONCLUSIONS
Preconception diet is important (Folat, Piridoxine, Low fat)
The first choice in NVP treatment generally involves changes in diet or
lifestyle.

Early treatment of NVP might decrease the risk of HG.

Pyridoxine and metoclopramide (category A) are first-line in treatment of HG
followed by prochlorperazine (category C), prednisolone (category A),
promethazine (category C) and ondansetron (category B1).3
When the nausea and vomiting is very severe and the patient is unable to
tolerate oral fluids, she has to hospitalized and intravenous fluids, medications
or/and enteral/ parenteral nutrition should be started.

REFERENCES
1.

Latva-Pukkila U et al, 2010. Dietary and clinical impacts of nausea and vomiting during
pregnancy. J of Human Nutr & Dietetics, Vol 23, Issue 1:69-77

2.

Noel M. Lee, M.D. Nausea and Vomiting of Pregnancy.Gastroenterol Clin North Am. 2011
June; 40(2):309-38.

3.

Gill SK, Maltepe C and Koren G. The effectiveness of discontinuing iron-containing prenatal
multivitamins on reducing the severity of nausea and vomiting of pregnancy. Journal of
Obstetrics and Gynaecology, January 2009; 29(1): 1316

4.

Ioanis Mylonas, Andrea Gingaimaier, Franz Kainer.Dtsch Arztebl 2007; 104(25): A 1821-6

5.

Jednak MA, Shadigian EM, Kim,SM., et al., Protei meals reduce nausea and gastric slow wave
dysrhytmic activity in first trimester pregnancy. Am J Physiol. 277/Gastrointest.Liver Physiol
40: G855-61,1999)

6.

Niebyl JR, Goodwin TM. Overview of nausea and vomiting of pregnancy with an emphasis on
vitamins. AJOG 2002, May;186:S253-5.

REFERENCES
7. Signorello LB, Harlow BL, Wang S, Erick MA. Saturated Fat intake and the Risk of Severe
Hyperemesis Gravidarum. (Epidemiology 1998;9:636-40)
8. Einarson A, Boskovic CMR, Koren G.nTreatment of nausea and vomiting in pregnancy
An updated algorithm. Canadian Family Physician. Vol 53: december 2007 , 2109-2111.
9. Pepper GV, Roberts C. Rates of nausea and vomiting in pregnancy and dietary characteristics
across populations. Proc.R.Soc. B(2006) 273, 2675-79