Morning Sickness Causes and Medications

Morning sickness refers to the nausea and/or vomiting affected 50 to 80 of pregnant women during first trimesters. It is caused by the sudden increase in hormones during pregnancy. Although morning sickness is more common in the morning, it can occur at anytime of the day or night. Some pregnant women may develop hyperemesis gravidarum that is more serious condition involving severe vomiting, dehydration, and weight loss. Hyperemesis gravidarum that If the pregnant women vomiting many times a day, are unable to eat and drink without vomiting, and if they are losing weight then they probably have hyperemesis. Unlike normal pregnancy sickness, hyperemesis can affect your health and that of your baby.

Nausea is unpleasant sensation associated with vague epigastria and abdominal symptoms and usually precedes vomiting. Vomiting means emptying your stomach by a strong gag and retch that leads to throwing up. The stomach’s contents are forcefully expelled through themouth.

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Causes & risk factors

Nausea and vomiting Causes

Morning sickness happens because the bodys goes through many changes while the woman is pregnant. Although no one knows for sure what causes nausea and vomiting during pregnancy, rising levels of hormones like estrogen levels may increase during pregnancy, low blood sugar. Emotional stress, travel and some foods can exacerbate nausea vomiting pregnancy.

The exact cause of nausea and vomiting in pregnancy (NVP) is unknown. However, a number of different causes have been suggested, including: increased oestrogen levels, increased human chorionic gonadotrophin (hCG) levels, nutritional deficiency, gastric problems, evolutionary adaptation, psychological influences

Oestrogen

Changes in levels of the female sex hormone oestrogen during the early stages of pregnancy may cause short-term nausea and vomiting.

HCG levels

After conception (when the sperm fertilises the egg), the body begins to produce a hormone called human chorionic gonadotrophin (hCG). It is thought that a rise in the level of hCG may cause nausea and vomiting during pregnancy.

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Nutritional deficiency

A lack of vitamin B6 in the diet is thought to be another possible cause of nausea and vomiting during pregnancy.

It is thought that a lack of vitamin B6 may cause hyperemesis gravidarum, an uncommon but severe form of nausea and vomiting that some women experience during pregnancy.

Gastric problems

During pregnancy, levels of progesterone are increased. Progesterone is a hormone that helps prepare the womb for pregnancy and protects the womb lining.

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As progesterone production increases, the movement in the small intestine, oesophagus (gullet) and stomach reduces, causing nausea and vomiting during pregnancy. The reduction in movement occurs as a result of the muscle walls relaxing.

Evolutionary adaptation

Evolutionary adaptation is a change that occurs in an organism in order to make it better adapted to its environment. Some scientists believe that nausea and vomiting during pregnancy may be the result of an evolutionary adaptation that has occurred to protect women and their baby from food poisoning.

Risk factors

A number of different factors are associated with an increased risk of developing nausea and vomiting during pregnancy. These include:

• previous pregnancy with nausea and vomiting
• female foetus
• family history of nausea and vomiting during pregnancy
• history of motion sickness
• history of nausea while using contraceptives that contain oestrogen
• young maternal age
• obesity
• stress
• multiple pregnancies, such as twins or triplets
• first pregnancy

An enlarged placenta is also a known risk factor for nausea and vomiting during pregnancy. The placenta is the organ that attaches the mother to her unborn baby and provides the baby with food and oxygen.

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The placenta can become enlarged in multiple pregnancies, such as twins or triplets, or during a molar pregnancy, where the fertilisation of the egg goes wrong and leads to an abnormal growth of cells inside the womb.

Signs & Symptoms

Vomiting and Nausea Symptoms

Each woman is different where morning sickness is concerned. The 50% to 80% who do experience morning sickness will have bouts of nausea and vomiting. The symptoms of nausea and vomiting in pregnancy (NVP) usually begin before the ninth week of pregnancy, around six weeks after their last period.The symptoms of nausea and vomiting in pregnancy should improve as your pregnancy progresses. In about 90% of cases, symptoms disappear by the third month of pregnancy.

It is a feeling of unease that frequently includes an upset stomach, dizziness, and anxiety. There is often an urge to vomit. You often feel as if this sensation comes from your stomach, but it is mostly controlled by the brain.Vomiting, however, frequently improves the sensation of nausea, at least temporarily. Vomiting occurs when the stomach forcefully sends its contents up to and out the mouth. If the nausea is severe, vomiting can continue after all the food and liquid has been sent out. This is called the dry heaves.When vomiting leads to dehydration from loss of fluids, you may have increased thirst and dry lips and dry mouth. You may not urinate often. In children, signs of dehydration include dry lips and mouth, sunken eyes, rapid breathing, and dry diapers, indicating the child is not producing urine.

Other signs:

The morning sickness is accompanied by other signs of pregnancy like backaches, constipation, darkening of areola (breast nipple), excessive salivation, exhaustion or feeling sleepy, food cravings, frequent urination, headaches, increased sense of smell, lower abdominal cramps, and/or tender or swollen breasts.

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Differential diagnosis

• Travel sickness
• Hangover
• Food poisoning
• IBS
• Morning sickness

Treatment (OTC, POM, non-drug)

Non-pharmacologic treatment to prevent morning sickness:

Dietary Measures (dietary changes) :

• Affected pregnant women should be instructed
• to eat frequent, small meals.
• to avoid smells and food textures that cause nausea.
• Solid foods should be bland tasting, high in carbohydrates, and low in fat.
• Drink sour and tart liquids(e.g., lemonade)
• Sniff lemons or ginger, to relieve nausea.

Ginger

A popular alternative treatment for morning sickness, ginger has been used in teas, preserves, ginger ale, and capsule form. One European study demonstrated that ginger powder (1 g per day) was more effective than placebo in reducing the symptoms of hyperemesis gravidarum.

Relief Band Device:

Device that can be worn continuously for relief of mild to moderate nausea and vomiting associated with pregnancy

Pharmacologic treatment to prevent morning sickness:

Nonprescription drug:

Vitamin B6-doxylamine combination (Diclectin®)

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FDA Category : B

Mechanism of Action:

The action of Diclectin is due to 2 unrelated compounds. Doxylamine, an antihistamine, provides antiemetic activity; pyridoxine provides a supplement of vitamin B6 to prevent a possible pyridoxine deficiency during pregnancy. Also, studies have shown that pyridoxine itself could have an antinauseant activity. It recommended as first-line treatment for nausea and vomiting during pregnancy.The onset of the antiemetic activity of Diclectin is delayed by a special coating of the tablet; a dose taken at night will be effective in the morning, the time when it is most needed.

Dose: tablet Contain pyridoxine 10 mg and doxylamine 10 mg , extended release; 2 tablets at bedtime, 1 tablet in the morning (pnr) plus 1 tablet in the afternoon (pnr).

Commune side effects:confusion, dizziness, drowsiness or headache.

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Diphenhydramine (Benadryl ®):

One of antihistamine which has been used to control nausea and vomiting during pregnancy.

FDA Category: B

Mechanism of Action

Diphenhydramine blocks histamine H1-receptors on effector cells of the GI tract, blood vessels and respiratory tract. It also has some anticholinergic action.

Absorption: Absorbed well from the GI tract (oral); peak plasma concentrations after 1-4 hr.

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Distribution: Widely distributed, CNS; crosses the placenta and enters breast milk. Protein-binding:Highly bound.

Metabolism: Extensive first-pass metabolism.

Excretion: Via urine (as metabolites, small amounts as unchanged drug); 1-4 hr (elimination half-life).

Dose: 10-50 mg tablets every 4-6 h prn.

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Side effects: commonly cause sedation, tiredness, sleepiness, dizziness.

Prescription drug:

Promethazine (Avominec®):

One of Phenothiazines which given to reduce nausea and vomiting of pregnancy.

FDA Category: C

Mechanism of Action:

The predominant action of promethazine is antagonism of H1-receptors. Although promethazine is classified as a phenothiazine. Its ability to antagonize dopamine.

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Dose: 25 mg tablet at bedtime, increased if necessary to max.100 mg daily (Available as Tab, liquid, IM, IV, supp).

Half-life: 16-19 hours

Side effects: Drowsiness, dizziness, constipation or blurred vision.

Ondansetron(5HT3 antagonist anti-emetic)

FDA Category: B

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Mechanism of Action

Selective 5-HT3-receptor antagonist blocking serotonin both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone.

Dose:4-8 mg every 6 h

Half Life: 3-6 hours

Side-effects: constipation; headache; flushing; injection site-reactions.

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Counselling issues

• Eat little and often, every two or three hours – even if you’re not hungry.
• Drink a lot of liquid, preferably 10 to 12 glasses of water, fruit juice or herbal tea each day.
• Avoid food containing a lot of fat or spices.
• Avoid alcohol and caffeine.
• Rest several times a day. Lie down with a pillow under your head and legs.
• Move slowly and avoid sudden movements.
• After eating, sit down so that gravity helps to keep the food in your stomach.
• Avoid smells that make you feel sick or throw up.
• Don’t brush your teeth immediately after eating because this can cause vomiting.
• Get some fresh air and exercise by going for a little walk every day.
• Avoid smoking. Not only is it harmful for you and your child, it also diminishes your appetite.

At night

• Before going to bed, it may help to eat a snack such as yoghurt, bread, milk, cereal or a sandwich.
• If you wake up during the night, eating a small snack may stop you feeling sick in the morning.
• Sleep with the windows open to get some fresh air, if possible.

Referral Criteria

Affected pregnant women should be instructed to:

• Eat small meals frequently throughout the day.
• Drink small amounts of fluids during the day to avoid dehydration.
• Avoid foods and smells that increase nausea (strong smells ).
• Get plenty of rest and nap during the day.
• Avoid fatty foods and spicy foods.