Managing N&V in Pregnancy

A 29-year-old who is 8 weeks pregnant presents with a chief complaint of nausea and vomiting. She states, “I’ve been like this for three weeks. I don’t know why this is called morning sickness since I feel sick to my stomach almost all the time”, reporting that she vomits 2-3 times nearly every day, stating, “I was worse 2-3 weeks ago, when I was throwing up 4-5 times a day. I figured out what food really bothers my stomach and cut those out.” A 24-h dietary recall reveals frequent low-fat meals and consistent sipping of liquids. She denies thirst or infrequent urination, and reports, “I’m just tired of feeling this way. I’ve missed so much work and can hardly keep up with my 3-year-old.”  Physical exam reveals the following; Alert, appears fatigued, with moist mucous membranes,  a 1 lb. weight loss since last visit 4 weeks ago, and minimal epigastric tenderness without rebound.  

 The NP considers advising on the following:

A.  Initiate therapy with an oral  5HT-3 antagonist such as ondansetron (Zofran®).

B.  Referral to high-risk for advise on further management. 

C.  Advise on the use of daily dose of oral  vitamin B6  with doxylamine. 

D. Increase fluid and fiber intake.
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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 29-year-old who is 8 weeks pregnant presents with the chief complaint of nausea and vomiting. She states, “'ve been like this for 3 weeks. I don't know why this is called morning sickness, since I feel sick to my stomach almost all the time" reporting that she vomits 2 to 3 times a day, nearly every day. 

Also stating, "I was worse 2 to 3 weeks ago when I was throwing up 4 to 5 times a day. I figured out what food really bothers my stomach and cut those out.” A 24-hour dietary recall reveals frequent low-fat meals and consistent sipping of fluids. She denies thirst or infrequent urination and reports, "I'm just tired of feeling this way. 

I've missed so much work and I can hardly keep up with my 3-year-old." Physical exam reveals the following: she's alert, appears fatigued, with moist mucous membranes and a 1-pound weight loss since last visit 4 weeks ago. There is mild epigastric tenderness without rebound. The NP considers advising on the following: 

A: Initiate therapy with an oral 5-HT3 antagonist such as Zofran. 

B: Referral to high-risk OB for advice on further management. 

C: Advise on the use of a daily dose of oral vitamin B6 with doxylamine. 

D: Increase fluid and fiber intake. 

And the correct answer is C: Advise on the use of a daily dose of oral vitamin B6 with doxylamine. First, let's determine what kind of a question this is. Given that all of the responses involve a clinical action on behalf of the NP, this is a planned intervention question. 

Let's take a look at some background information. Nausea and vomiting in pregnancy, often abbreviated NVP, is reported in up to 80% of all individuals during pregnancy. While often called morning sickness, this condition can occur at any time of the day. In fact, that's what this patient is reported. NVP onset is usually at about week 5 to 6 of pregnancy and typically is much improved or resolved by about week 12. 

Its ideology is not fully understood, with a variety of pregnancy-related hormonal shifts implicated. One of the things is, is that morning sickness tends to follow hCG levels rising and then falling. But again, there are other hormones that are implicated in this. And severity ranges from mild nausea in response to certain sense or triggers. If patients report of something like this, ‘I need to change my route to get from the bus to where I work, since I can't walk by Starbucks anymore, like the smell of coffee just being a trigger.’ 

But that's about it. All the way to debilitating vomiting that precludes participating in daily activity. For the majority of patients with NVP, successful management is targeted towards relieving the nausea by increasing rest, decreasing stress, eating frequent small meals like 5 to 6 tiny meals a day, avoiding high fat foods, and avoiding trigger situations. In it's most extreme form known as hyperemesis gravidarum, the pregnant individual is sufficiently ill and unable to maintain hydration and nutrition. And the scenario we have here, this is a woman who has done the tried and true methods of managing NVP. Good for her. And she actually got better. She's avoided the trigger foods. She's drinking small rather than large amounts of liquid at a time, and at the same time, she's really discouraged about how she feels. 

Simply put, morning sickness is exhausting and she's here asking for help. With this is background information, let's take a look at the question and answers. Given a 29-year-old who is 8 weeks pregnant presents with the chief complaint of nausea and vomiting. She states, “I've been like this for 3 weeks. I don't know why it's called morning sickness since I feel sick to my stomach almost, almost all the time,” reporting that she vomits 2 to 3 times a day, nearly every day.  

She also states, “I was worse about 2 to 3 weeks ago when I was throwing up 4 to 5 times a day, I figured out what food really bothers my stomach and cut those out close." A 24-hour dietary recall reveals frequent low-fat meals and consistent sipping of liquids. 

She denies thirst or infrequent urination and reports, “I'm just so tired of feeling this way. I've missed a good deal of work, and I can hardly keep up with my 3-year-old.” Physical exam reveals the following: alert, appears fatigued, with moist mucous membranes and a 1-pound weight loss documented from last visit. Minimal epigastric tenderness without rebound is present. 

The NP considers advising on the following: A: Initiate therapy with an oral 5-HT antagonist, such as Zofran. This is not the best answer here. Well, there is support for the use of this drug class in treating NVP. It's not considered first-line therapy. Part of this is due to conflicting evidence of the medications safety for use during pregnancy. 

Therefore, general rule you're going to try another intervention before you go to a product like a 5-HT antagonist. This is an answer you might reach for is you're likely quite comfortable with Zofran. You speak from your in practice it is used so commonly on the inpatient and even the outpatient setting. But of course now you have two patients. 

You're caring for the person carrying the pregnancy and also the unborn child. So therefore we're going to consider this a second-line therapy. If other oral therapy for the minimization of NVP is not helpful, B: Referral to high risk OB for advice on further management. This is incorrect for a pregnancy where the symptoms, while really bothersome are milder and there is no evidence to support the diagnosis of hyperemesis gravidarum or other concerning condition. 

And I just need to throw it in here is I've been privileged to see women during pregnancy for my entire NP career of more than 30 years now, and never be dismissive of how miserable somebody is with morning sickness because like I said, it's exhausting. So this woman is suffering. She's asking us for help. So, C: Advise for the use of a daily dose of oral vitamin B6 and doxylamine. 

This is the best answer. These two medications are found together in a combined prescription product with the brand name of Diclegis®. With evidence of efficacy coupled to its long-term safety.-in fact, it's FDA-approved this combination for the treatment in NVP. As an aside, this medication combo is actually better at preventing NVP than it is at treating acute vomiting. 

In other words, it should be taken every day to prevent symptoms. Another key intervention for the treatment of NVP is reassurance and empathy. Not dismissing the patient's complaint. It takes a few days for clutches to kind of kick in, if you will. So please make sure that the patient is aware of that. Option D: Increase fluid and fiber intake. 

As mentioned, fluid intake is certainly important in this scenario. Like it is with every patient. But in this scenario, the patient saying I'm not thirsty, I don't have infrequent urination and we have documentation that the person is, by the 24-hour dietary recall, taking in small amounts of fluids really frequently. So, this is not an answer that really addresses the question well. 

In addition, high fiber foods are often not tolerated well in early pregnancy in the presence of NVP. Like to give you an idea, if it was a bowl of cold cereal, chances are the person is going to do much better at keeping down. Like let's say, a bowl of a low fiber cereal like Rice Krispies or Corn Flakes with some low-fat milk. 

Then they’ll have less upset with that than they would if they tried, like, let's say, a bowl of Raisin Bran, that high fiber cereal with a high fiber fruit in it. Key takeaway: when prescribing during pregnancy, knowing which interventions are effective for the degree of patient presentation and have stood the test of time is important. 

A lot of times with prescribing during pregnancy and lactation, you see, we go back to meds that have been around for decades. And this is because we have long-term observational study of their safety for use during pregnancy and lactation. 

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