What is morning sickness

Morning sickness is the nausea and/or vomiting that is associated with early pregnancy. Morning sickness is an unpleasant condition, but morning sickness doesn’t put your baby at any increased risk and usually clears up by weeks 14 to 20 of pregnancy. For most women, morning sickness (nausea and/or vomiting) improves or disappears completely by around week 12 – 14, although for some women it can last longer.

During early pregnancy, nausea, vomiting and tiredness are common symptoms. Around half of all pregnant women experience vomiting, and more than 80% of women (80 out of 100) experience nausea in the first 12 weeks.

The term “morning sickness” is misleading because “morning sickness” can affect you at any time of the day or night, and some women feel sick all day long.

With morning sickness, some women are sick (vomit) and some have a feeling of sickness (nausea) without being sick.

People sometimes consider morning sickness a minor inconvenience of pregnancy, but for some women it can have a significant adverse effect on their day-to-day activities and quality of life.

It’s thought hormonal changes in the first 12 weeks of pregnancy are probably one of the causes of morning sickness.

Symptoms should ease as your pregnancy progresses. In some women, symptoms disappear by the third month of pregnancy. However, some women experience nausea and vomiting for longer than this, and about 1 woman in 10 continues to feel sick after week 20.

Furthermore, some women may get a very severe form of morning sickness (nausea and/or vomiting) called hyperemesis gravidarum, which can be very serious. Pregnant women with hyperemesis gravidarum might be sick many times a day and be unable to keep food or drink down, which can have a negative effect on their daily life. This excessive nausea and vomiting is known as hyperemesis gravidarum and often needs hospital treatment. Exactly how many pregnant women get hyperemesis gravidarum is not known as some cases may go unreported, but it’s thought to be around 1 in every 100.

If you are being sick frequently and can’t keep food down, tell your midwife or doctor, or contact the hospital as soon as possible. There is a risk you may become dehydrated, and your midwife or doctor can make sure you get the right treatment. Hyperemesis gravidarum needs specialist treatment, sometimes in hospital.

Hyperemesis gravidarum is much worse than the normal nausea and vomiting of pregnancy (“morning sickness”).

Signs and symptoms of hyperemesis gravidarum include:

• Prolonged and severe nausea and vomiting – some women report being sick up to 50 times a day
• Dehydration – not having enough fluids in your body because you can’t keep drinks down; if you’re drinking less than 500ml a day, you need to seek help
  ketosis – a serious condition that results in the build-up of acidic chemicals in the blood and urine; ketones are produced when your body breaks down fat, rather than glucose, for energy
• Weight loss
• Low blood pressure (hypotension) when standing

Unlike regular pregnancy sickness, hyperemesis gravidarum may not get better by 14 weeks. It may not clear up completely until the baby is born, although some symptoms may improve at around 20 weeks.

See your doctor or midwife if you have severe nausea and vomiting, ideally before you start suffering from dehydration and weight loss.

There are other conditions that can cause nausea and vomiting, and your doctor will need to rule these out first. For example, urinary tract infections (UTIs) can also cause nausea and vomiting. A urinary tract infection is an infection that usually affects the bladder but can spread to the kidneys.

If you have any pain when passing urine or you pass any blood, you may have a urine infection and this will need treatment. Drink plenty of water to dilute your urine and reduce pain. You should see your doctor within 24 hours.

When morning sickness is at its worst during the early hormonal surges – typically between eight and ten weeks- you may find it difficult to retain any liquids and you may need to be hospitalized for rehydration by IV (intravenous) fluids. If you are unable to keep down fluids, don’t delay in asking for treatment. Speak to your doctor, midwife or go to your nearest emergency room.

Morning sickness complications

Usually, morning sickness doesn’t cause complications for mother or baby.

However, if you’re underweight before pregnancy and morning sickness prevents you from gaining a healthy amount of weight during pregnancy, your baby may be born underweight. Rarely, frequent vomiting may lead to tears in the tube that connects the mouth to the stomach (esophagus).

Morning sickness prevention

There’s no proven way to prevent morning sickness. Before conception, however, it may help to take prenatal vitamins. Several older studies suggest that women who take multivitamins at the time of conception and during early pregnancy are less likely to experience severe morning sickness. The folic acid in prenatal vitamins also helps prevent neural tube defects, such as spina bifida.

What causes morning sickness

What causes morning sickness isn’t clear, but the hormonal changes of pregnancy are thought to play a role. Rarely, severe or persistent nausea or vomiting may be caused by a medical condition unrelated to pregnancy — such as thyroid or liver disease.

Risk factors for morning sickness

Morning sickness can affect anyone who’s pregnant, but a number of different factors may mean you are more likely to have nausea and vomiting in pregnancy.

These include:

• nausea and vomiting in a previous pregnancy
• a family history of nausea and vomiting in pregnancy, or morning sickness
• a history of motion sickness – for example, in a car
• a history of nausea while using contraceptives that contain estrogen
• you experienced nausea or vomiting from motion sickness, migraines, certain smells or tastes, or exposure to estrogen (in birth control pills, for example) before pregnancy
• obesity – where you have a body mass index (BMI) of 30 or more
• stress
• multiple pregnancies, such as twins or triplets
• first pregnancy.

Morning sickness symptoms

Morning sickness is characterized by nausea with or without vomiting. It is most common during the first trimester, sometimes beginning as early as two weeks after conception.

Morning sickness diagnosis

Morning sickness is typically diagnosed based on your signs and symptoms. If your pregnancy care provider suspects hyperemesis gravidarum, you may need various urine and blood tests. Your pregnancy care provider may also do an ultrasound to confirm the number of fetuses and detect any underlying conditions that may be contributing to the nausea.

Morning sickness remedies

Treatment isn’t necessary for most cases of morning sickness.

If you have morning sickness, your doctor or midwife will initially recommend that you try a number of changes to your diet and daily life to help reduce your symptoms.

These include:

• getting plenty of rest – tiredness can make nausea worse
• if you feel sick first thing in the morning, give yourself time to get up slowly – if possible, eat something like dry toast or a plain biscuit before you get up
• drinking plenty of fluids, such as water, and sipping them little and often rather than in large amounts, as this may help prevent vomiting
• eating small, frequent meals that are high in carbohydrate (such as bread, rice and pasta) and low in fat – most women can manage savory foods, such as toast, crackers and crispbread, better than sweet or spicy foods
• eating small amounts of food often rather than several large meals – but don’t stop eating
• eating cold meals rather than hot ones as they don’t give off the smell that hot meals often do, which may make you feel sick
• avoiding foods or smells that make you feel sick
• avoiding drinks that are cold, tart (sharp) or sweet
• asking the people close to you for extra support and help – it helps if someone else can cook, but if this isn’t possible, go for bland, non-greasy foods, such as baked potatoes or pasta, which are simple to prepare
• distracting yourself as much as you can – the nausea can get worse the more you think about it
• wearing comfortable clothes without tight waistbands
• Aromatherapy. Although there is also little research on the topic, certain scents, normally created using essential oils (aromatherapy), can help some women deal with morning sickness.
• Acupuncture. Acupuncture involves inserting hair-thin needles into your skin. Acupuncture isn’t a proven way to treat morning sickness, but some women seem to find it helpful.
• Hypnosis. Although there’s little research on the topic, some women have found relief from morning sickness through hypnosis.

Check with your pregnancy care provider before using any herbal remedies or alternative treatments to relieve morning sickness.

Many women find that eating vegetables and some fruits causes immediate vomiting in the peak stages, making it even more difficult to follow a healthy diet. For some reason, women with hyperemesis gravidarum often find sweet and salty foods i.e. sweet drinks like lemonade, and crisps, are more likely to stay down than healthy foods.

If you have severe morning sickness, your doctor or midwife might recommend medication. Your pregnancy care provider may prescribe vitamin B-6 (Pyridoxone) supplements, antihistamines and possibly anti-nausea medications.

Vitamin B-6 (Pyridoxone) supplements

Pyridoxone, otherwise known as Vitamin B6, is a vitamin which is required to maintain a healthy nervous system. It has been shown to be effective in helping nausea and vomiting in pregnancy in two randomized controlled trials against placebo (one trial at 30mgs / daily, the other at 75mgs / daily). A retrospective cohort study concluded that pyridoxine monotherapy had no increased risk for major malformations. There are no apparent side effects for doses under 50mg per day.

Current research supports a dose of 10mg 1 tablet 4 x per day.

Getting enough fluid

If you are finding it difficult to drink water and/or keep it down, then you are not alone, it’s very typical. You may have to become quite creative about how to take fluids.

Suggested drinks and methods of taking them are:

• Lucozade
• lemonade
• milkshakes (try to fortify as suggested above)
• IronBru
• Dr Pepper
• orange squash
• apple juice
• lime juice
• ice cubes made of flat coke or just tap water or bottled water
• ice lollies
• sips of tepid water
• continually sipping tiny amounts of liquid through a straw
• just holding water/drinks in your mouth
• if you can’t tolerate tap water try mineral water, freeze a half empty bottle and then top up with fridge cold water – this keeps it cold for hours.

When solids do become bearable suggestions to try are:

• jelly (make with fortified milk)
• tinned fruit
• ice lollies
• ice cream
• ice cold cherries
• frozen grapefruit segments
• crisps
• fish fingers
• potato cakes
• crumpets
• soda bread
• other potato based or salty foods

If you are able to eat food with a high water content such as melon, cucumber, apples and other fruits, it is a good way of taking some fluids on board without having to drink water. If you develop a craving for something then go with it, it may be your body’s way of getting a nutrient it needs.

Ginger eases morning sickness

There is some evidence that ginger supplements may help reduce nausea and vomiting. To date, there have not been any reports of adverse effects being caused by taking ginger during pregnancy.

However, ginger products are unlicensed in the US, so buy them from a reputable source, such as a pharmacy or supermarket. Check with your pharmacist before you use ginger supplements.

Some women find that ginger biscuits or ginger ale can help reduce nausea. You can try different things to see what works for you.

Acupressure might help morning sickness

Acupressure on the wrist may also be effective in reducing symptoms of nausea in pregnancy. Acupressure involves wearing a special band or bracelet on your forearm. Some researchers have suggested that putting pressure on certain parts of the body may cause the brain to release certain chemicals that help reduce nausea and vomiting.

There have been no reports of any serious adverse effects caused by using acupressure during pregnancy, although some women have experienced numbness, pain and swelling in their hands.

Vitamins, supplements and nutrition in pregnancy

Eating a healthy, varied diet in pregnancy will help you to get most of the vitamins and minerals you need.

But when you are pregnant you will need to take a folic acid supplement. It’s recommended that you take:

• 400 micrograms (mcg) of folic acid each day – you should take this from before you are pregnant until you are 12 weeks pregnant

Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida. If you didn’t take folic acid before you conceived, you should start as soon as you find out that you are pregnant.

You should also eat foods that contain folate (the natural form of folic acid), such as green leafy vegetables. Some breakfast cereals and some fat spreads such as margarine may have folic acid added to them.

It’s difficult to get the amount of folate recommended for pregnancy from food alone, which is why it is important to take a folic acid supplement.

Higher dose folic acid

Some women have an increased risk of having a pregnancy affected by a neural tube defect, and are advised to take a higher dose of 5 milligrams (5 mg) of folic acid each day until they are 12 weeks pregnant. Women have an increased risk if:

• they or their partner have a neural tube defect
• they have had a previous pregnancy affected by a neural tube defect
• they or their partner have a family history of neural tube defects
• they have diabetes

In addition, women who are taking anti-epileptic medication should consult their doctor for advice, as they may also need to take a higher dose of folic acid.

If any of the above applies to you, talk to your doctor as they can prescribe a higher dose of folic acid. Your doctor or midwife may also recommend additional screening tests during your pregnancy.

Vitamin D in pregnancy

All adults, including pregnant and breastfeeding women, need 10 micrograms (10 mcg) of vitamin D a day, and should consider taking a supplement containing this amount.

Vitamin D regulates the amount of calcium and phosphate in the body, which are needed to keep bones, teeth and muscles healthy.

Your bodies make vitamin D when your skin is exposed to sunlight. It’s not known exactly how much time is needed in the sun to make enough vitamin D to meet your body’s needs, but if you are out in the sun take care to cover up or protect your skin with sunscreen before you start to turn red or burn.

Vitamin D is also in some foods, including:

• oily fish (such as salmon, mackerel, herring and sardines)
• eggs
• red meat

Vitamin D is added to all infant formula milk, as well as some breakfast cereals, fat spreads and non-dairy milk alternatives. The amounts added to these products can vary and might only be small.

As vitamin D is found only in a small number of foods, whether naturally or added, it might be difficult to get enough from foods alone. So everyone over the age of five years, including pregnant and breastfeeding women, should consider taking a daily supplement containing 10mcg of vitamin D.

Most people aged five years and over in the US will probably get enough vitamin D from sunlight in the summer, so you might choose not to take a vitamin D supplement during these months.

However, if you have dark skin (for example, if you are of African, African Caribbean or south Asian origin) or always cover your skin when outside, you may be at particular risk of not having enough vitamin D (vitamin D insufficiency). You may need to consider taking a daily supplement. Talk to your midwife or doctor if this applies to you.

• Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby. Always check the label.

Iron in pregnancy

If you are short of iron, you’ll probably get very tired and may suffer from anemia. Lean meat, green leafy vegetables, dried fruit, and nuts contain iron. If you’d like to eat peanuts or foods that contain peanuts (such as peanut butter) during pregnancy, you can do so as part of a healthy balanced diet unless you’re allergic to them, or your health professional advises you not to.

Many breakfast cereals have iron added. If the iron level in your blood becomes low, your doctor or midwife will advise you to take iron supplements.

Vitamin C in pregnancy

Vitamin C protects cells and helps to keep them healthy.

Vitamin C is found in a wide variety of fruit and vegetables, and a balanced diet can provide all the vitamin C you need. Good sources include:

• oranges and orange juice
• red and green peppers
• strawberries
• blackcurrants
• broccoli
• brussels sprouts
• potatoes

Calcium in pregnancy

Calcium is vital for making your baby’s bones and teeth. Sources of calcium include:

• milk, cheese and yogurt
• green leafy vegetables such as rocket, watercress or curly kale
• tofu
• soya drinks with added calcium
• bread and anything made with fortified flour
• fish where you eat the bones – such as sardines and pilchards

Vegetarian, vegan and special diets in pregnancy

A varied and balanced vegetarian diet should give enough nutrients for you and your baby during pregnancy. However, you might find it more difficult to get enough iron and vitamin B12. Talk to your midwife or doctor about how to make sure you are getting enough of these important nutrients.

If you are vegan, or you follow a restricted diet because of food intolerance (for example, a gluten-free diet for celiac disease) or for religious reasons, talk to your midwife or doctor.

Ask to be referred to a dietitian for advice on how to make sure you are getting all the nutrients you need for you and your baby.

Morning sickness medicine

If your nausea and vomiting is severe and doesn’t improve after you make changes to your diet and lifestyle, your doctor may recommend a short-term course of an anti-sickness medicine that is safe to use in pregnancy.

This type of medicine is called an antiemetic. The commonly prescribed antiemetics can have side effects. These are rare, but can include muscle twitching.

The combination of doxylamine and pyridoxine (vitamin B6) (Diclegis) has been approved by the Food and Drug Administration for treating nausea in pregnancy. Drowsiness can occur with this medicine, so it’s important to avoid activities that require mental alertness, such as driving, when taking it.

Doxylamine is an antihistamine that has been shown to be effective in treating nausea and vomiting in pregnancy. In combination with pyridoxine (Vitamin B6) it was called Diclegis which has been shown to be effective in at least 3 randomized controlled trials. Although Diclegis had been used by 33 million pregnant ladies it was withdrawn by its manufacturer in the early 1980’s because of exhaustive defence costs against liability suits for foetal defects. Eventually all these legal cases against Diclegis, which went to court, were unsuccessful as it was found that Diclegis caused no increased risk for birth defects and was safe to use in pregnancy. Doxylamine and pyridoxine (vitamin B6) are now among the very few therapies that are classed as having no risk to the fetus. As no credible evidence of human or animal teratogenesis or other undesirable effects existed, a Canadian company began to make a generic form of doxylamine with pyridoxine in delayed release form (Diclectin) in 1984. This has been prescribed for the treatment of nausea and vomiting of pregnancy in Canada since then. The evidence based guidelines (approved by the Society of Obstetricians and Gynaecologists of Canada) state that Diclectin should be the initial treatment of choice since it has the greatest evidence to support its efficacy and safety ¹⁾.

Some antihistamines (medicines often used to treat allergies such as hay fever) also work as antiemetics. Your doctor might prescribe an antihistamine that is safe to take in pregnancy. See your doctor if you would like to consider this form of treatment.

Other drugs which are considered safe to take in pregnancy:

• Promethazine (an antihistamine) and Cyclizine (an antihistamine):A wide body of evidence suggests that H1 receptor antagonist antihistamines have no human teratogenic potential (teratogenic means harmful defects in the fetus). Pooled data from 7 randomised controlled trials indicate that these antihistamines are effective in the treatment of nausea and vomiting in pregnancy. These antihistamines can cause drowsiness and should not be taken without medical advice, although they are available over the counter. It can take a couple of weeks to become accustomed to the drowsy effect.By using either cyclizine or promethazine in combination with pyridoxone (B6) it is very similar to the Canadian drug Diclectin which can be very effective if used as a prophylactic for women who have previously had hyperemesis gravidarum.
• Prochlorperazine (Stemetil):Prochlorperazine or ‘Stemetil’ is one of a number of drugs called phenothiazine. Prospective and retrospective cohort studies, case-control, and record linkage studies of patients with exposure to various and multiple phenothiazines have failed to demonstrate an increased risk of major malformations. It was found to be effective for nausea and vomiting in pregnancy in 3 randomised controlled trials in severe nausea and vomiting in pregnancy (Hyperemesis Gravidarum). Side effects include drowsiness, restlessness and occasional extra pyramidal effects (Such as tremor, slurred speech, anxiety, distress and others). These are prescription only medications.
• Metoclopramide (Reglan)The Food and Drug Administration (FDA) has recently recommended that it can be used for up to 12 weeks, but after this side effects can become more severe. Side effects include drowsiness, restlessness and occasionally extra pyramidal effects (such as tremor, slurred speech, anxiety, distress and others). This is a prescription only medication.

  Recent European recommendations are that metoclopramide should only be given for 5 days. This is because it is felt that longer courses are more likely to produce side effects in the person taking this therapy. Specifically, there is concern that beyond 5 days there is more chance of oculogyric crisis and dystonia developing, which put into more understandable terms is facial and skeletal muscle spasms and dizziness.

• Domperidone (Motilium)Domperidone works by speeding up the passage of food through the stomach into the intestine, which then prevents nausea and vomiting. It also prevents food from flowing the wrong way through the stomach and so can prevent reflux. Domperidone blocks dopamine receptors found in an area of the brain known as the chemoreceptor trigger zone (CTZ). The chemoreceptor trigger zone is activated by nerve messages from the stomach when an irritant is present or when certain chemicals are in the blood stream, such as pregnancy hormones. Once activated, messages are sent to the vomiting centre which sends messages to the gut and triggers vomiting. By blocking the dopamine receptors in the chemoreceptor trigger zone, domperidone prevents nausea messages from being sent to the vomiting center and in turn reduces the nausea and vomiting.

  As with many of the treatments mentioned here, the safety of Domperidone has not been established in proper medical trials. It has, however, been used for a number of years in pregnancy and as yet no adverse effect on the fetus has been reported. As with all these treatments, their use should be restricted to cases where first line treatment has failed to suppress symptoms and the benefits of further treatment would outweigh the risks to the fetus.

  Domperidone can be given as a suppository (in your back passage) which some women may find easier then swallowing orally.

• OndansetronIf your nausea and vomiting is so severe that the first and second line treatments have not suppressed symptoms to an adequate level then your doctor may prescribe Ondansetron (known also as Zofran). It is a relatively new medication which was originally used to treat nausea and vomiting caused by chemotherapy for cancer patients but is increasingly used for Hyperemesis Gravidarum and you are likely to read about it on internet forums and websites ²⁾.

  Research regarding the saftey of this drug is increasing. A study in Canada by the Motherisk ³⁾ program looked at fetal outcomes for mothers who had taken Ondansetron as well as mothers who had taken other anti emetics and compared them to the baseline rate of birth defects. It was found that there was no increase in the rate of birth defects for mothers who had taken Ondansetron.

  A more recent study in Denmark by Pasternak et al ⁴⁾ looked at 1,233 women exposed to ondansetron between weeks 7-12 of pregnancy (from last menstrual period) and compared the birth defect rate with that of 4,932 women not exposed to ondansetron. They found that the birth defect rate was 2.9%, at birth, for both groups. The literature review found the baseline risk of 1-3% for a major congenital birth defect at birth for all pregnancies which is in line with this research. The reference and abstract for the article is on our references page. This is very encouraging research.

  It is a prescription only medication and side effects include constipation and headaches. it can be taken orally, as an injection, as a suppository (inside your rectum) or as an ‘oro-dispersal’ tablet (melted on the tongue).

• Prednisolone (this is a steroid)There is increasing evidence for the use of Steroids for the treatment of the more severe end of the Nausea and Vomiting spectrum, know as Hyperemesis Gravidarum. Steroids have been used for a number of years in pregnancy for conditions such as acute asthma and Crohns disease. There may be a small increased risk of oral clefting associated with the use of corticosteroids and many authorities say that they should not be used to treat nausea and vomiting in pregnancy in the first 12 weeks of pregnancy, however, recent more recent studies are questioning this. There is emerging data on the effectiveness of corticosteroids to treat severe and persistent nausea and vomiting in pregnancy and hyperemesis gravidarum. Corticosteroids need to be given under medical supervision and assessment. They are normally started in hospital Intravenously at a high dose and then tapered off over a number of weeks.

  If your hyperemesis is so severe that you are considering termination of the pregnancy then your doctor should be willing to try steroids first.