Nutrition is important for managing nausea and vomiting during pregnancy. Nausea affects 50-90% of pregnancies and is known as NVP. More severe cases are called hyperemesis gravidarum which is associated with weight loss. Treatment focuses on dietary changes like eating small, frequent meals and staying hydrated. For moderate NVP, medications like Vitamin B6, ginger, and antihistamines are recommended. Severe cases may require IV fluids and nutrition. While NVP usually improves by 18 weeks, it can negatively impact the mother and fetus if inadequately treated. Nutrition and medical intervention are essential for supporting the health of the mother and baby.

1. Nutrition for Nausea
and Vomiting during
Pregnancy
SOFIE RIFAYANI KRISNADI

2. 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 day—80% persist throughout the day ,
usually worst in the morning ( morning sickness)
 Mild or moderate, self limited, not disturb the patient’s health or fetus’s

3. 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

4. Risk Factors
 Primigravida , Young women, Houseworks
 Obesity, Multiple/molar pregnancy, History of motion sickness,
Eating disorder
 History of NVP/HEG, Sensitive to OC’s
 Psychiatric issues (stress, emotional tension, fear to be a parent,
excessive bond to mother
Female fetus (Mylonas et al, 2007)

5. Pathophysiology
o Not fully understood, multifactorial
o Correlated with increasing hormone hCG /others (thyroid,
progesterone, estrogen, adrenal hormones)
o Dysmotility GIT
o Nutrition deficiencies
o Psychologic, Genetic
o Helicobacter pylori infection

6. Algorithm for diagnosis of hyperemesis
gravidarum, according to Mylonas-2007
GOT, Glutamatoxalacetate transaminase;
GPT, Glutamatpyruvate transaminase

8. Differential Diagnosis NVP

9. 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

10. Table
Nutrient Requirements During Pregnancy
Nutrient RDA/DRI Key Considerations
Protein 0.8–1.0 gm/kg protein/d + 10 gm
protein/d per fetus using pre-
pregnancy 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

11. 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)

12. Management Considerations with
NVP
Mild NVP
(not interfering with work or
lifestyle)
Supportive measures
(eg, dietary, lifestyle,
reassurance)
Moderate NVP (interfering
with work or lifestyle)
Consider pharmacologic
treatment options
Severe NVP
(significant weight loss and
dehydration)
Hospitalization
(eg, fluid replacement,
nutritional supplementation, IV
medications)

13. • 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

14. 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

15. Outpatient Treatment
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.

16. 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

18. 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 25 mg po Q 4-6 hrs.
◦Dimenhydrinate (Dramamine) 50-100 mg po Q 4-6 hrs.
Metoclopramide 5-10 mg po TID. Category: B

19. 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.

20. 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

21. Inpatient procedure in hyperemesis
gravidarum, adapted from Mylonas-
2007

22. OTHER THERAPY (Non
Pharmacological)
Nutritional Therapy
Complementary and Alternative Medicine
Sensory Deprivation Therapy (SDT)
Behavioural therapy
 Bedrest
Psychotherapy
Therapeutic Abortion
.

23. NUTRITIONAL THERAPY-
 is the most important issues.
 Pregnant women require a variety of nutrients for
- their own healing and normal development of the fetus
- to form the plasenta, amniotic fluid,
- increase the size of the uterus and breast tissue
- support mother's blood ( increases by 25–50%) which need more fluids, iron,
Vit. B12, folic acid, zinc and copper, calcium, magnesium, and protein
 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.

24. 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  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

25. Nasojejunal feeding in hyperemesis gravidarum--a preliminary
study.
Vaisman N, et al.
Journal Clin Nutr. 2004 Feb;23(1):53-7.
• 11 pregnant women with hyperemesis gravidarum
• Consented to have a nasojejunal feeding tube inserted endoscopically.
• A clear reduction of vomiting apparent within 48 h after tube insertion,
• Vomiting ceased completely after a mean of 5+/-4 days (range 1-13 days).
• Weight gain was recorded in six patients (tube feeding for more than 4 days)
• Patients encouraged to start drinking and eating along tube feeding after 3-4 days.
• Ceasing vomiting and a sufficient oral intake of at least 1000 kcal/day resulted in the decision to
remove the tube after 4-21 days.
• In three cases, the tube was expelled by recurrent vomiting after 1-4 days, or was blocked as in
one case.

26. 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),
- no significant nutrition is obtained by other
routes.
Peripheral parenteral nutrition (PPN) when
administered through vein access in a limb,
rather than through a central vein (Central PN)
 High cost and Increased risk of infection.

27. PROGNOSIS
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)
 Morbidities (mother)
- including Wernicke's encephalopathy,
- Oesophageal rupture, Splenic avulsion
- Pneumothorax,
- Postpartum depression/ Posttraumatic stress disorder

28. POTENTIAL FETAL
COMPLICATION
THEY CAN RESULT FROM SEVERE HEG, INADEQUATELY TREATED, OR THERE IS A DELAY IN
MEDICAL INTERVENTIONS
Early delivery,
Congenital heart disease
Integumentary (skin) abnormalities
Low birth weight
Shorter length
Undescended testicles
Perinatal death
Hip dysplasia
Neurodevelopmental sequelae
Neural tube defects
Central nervous system
malformations
Skeletal malformations
Testicular cancer
Behavioral/emotional problems

29. "fetal programming"
Prolonged stress, malnutrition and dehydration in the mother can potentially put an unborn
child at risk for chronic disease
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)

30. 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 B),
promethazine (category C) and ondansetron (category B1).3
When NVP 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.

31. 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): 13–16
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.

32. 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