Last month, the Society of Obstetricians and Gynaecologists of Canada (SOGC) released new guidelines for managing morning sickness during pregnancy—their first update since 2002.
“The good news is that some things are actually safer and more effective than we initially thought,” says Kim Campbell, a principal author and a registered midwife in BC.
The revised guidelines, published in the December 2016 issue of the Journal of Obstetrics and Gynaecology Canada, don’t mean the old recommendations are harmful, says Campbell. The goal is to help Canadian healthcare providers recommend the most recent, evidence-based treatments for pregnant women suffering from nausea and vomiting, stomach-churning symptoms that 50 to 80 percent of us will experience, especially during the first 12 to 14 weeks.
(Disclaimer: if you’ve ever been the pregnant lady barfing in the office bathroom at 3 pm or feeling queasy during a 6 pm commute home, you know—all too well—that “morning sickness” isn’t exactly accurate. But it’s the most commonly used term, whether you simply feel permanently hungover and miserable, or you’re dealing with bouts of vomiting all day, every day.)
Here’s what you need to know:
1. If your prenatal vitamins are making you puke, you have options
Many women find that prenatal vitamins, which are usually high in iron, may further irritate their stomach, while other women find their over-active gag reflex in early pregnancy makes it impossible to swallow the giant pills in the first place. The new guidelines say that it’s safe for women in their first trimester to replace prenatal vitamins with just folic acid, or with an adult or children’s vitamin that contains folic acid but is low in iron. (Unless you have a diagnosed iron deficiency, the fetus doesn’t need that extra iron in the first trimester.) But the fetus definitely does need the folic acid contained in prenatal vitamins, so be sure to consult your healthcare provider before switching to a different kind of vitamin.
2. Eat what you want
Despite what your mother-in-law, cousin, neighbour and everyone else might have told you, the latest guidelines have found that there is still no clear scientific evidence to support the common advice to eat small, frequent meals, or to eat more protein, carbs or any other food group to manage nausea. It’s basically impossible to do a randomized controlled trial of dietary changes, especially with a population of women who can’t stomach certain foods at all. In the absence of clear evidence, Campbell says it makes sense to adopt a grazing approach: “If you feel like you’re going to throw up, of course you aren’t going to want a huge meal.” The bottom-line, says Campbell, is that pregnant women should maintain as much of a balanced, healthy diet as they can manage, but otherwise her advice is to eat “whatever you like, and when you like.”
The one food that has been proven to reduce symptoms in some women is ginger, and the SOGC’s official recommendation is 250 mg of ginger four times a day.
While ginger might be helpful for women experiencing milder cases of nausea and vomiting, this may not work for women who are gagging and vomiting repeatedly, and who can’t keep meals down at all.
When I mentioned the evidence for ginger to a friend suffering through her first trimester, I could practically hear her eyes rolling over the phone. Her sweet husband had looked up ginger tea recipes and bought her candied ginger when she started to feel nauseated about a month ago. “But I can’t even stand the smell of it, let alone imagine drinking that tea,” she told me. For women who are struggling to keep any food down, often the only relief comes from medication.
3. Vitamin B6 and Diclectin are both safe medications for morning sickness, but you might try B6 alone first
In the 2002 guidelines, the SOGC called doxylamine/pyridoxine—a combination of an antihistamine and Vitamin B6, marketed as Diclectin in Canada and Diclegis in the US—the “standard of care” and recommended it as the safest and most effective drug to treat morning sickness. It’s a popular coping method for moms-to-be: According to 2010 data from seven Canadian provinces, there is approximately one Diclectin prescription written for every two births in Canada.
In these updated guidelines, Diclectin is still a “first line” treatment, but this time around, just pyridoxine alone (Vitamin B6) is given equal billing as one of the first treatments to try before moving on to other options. Campbell says there is now some evidence that Vitamin B6 alone is an effective treatment, which prompted the committee to upgrade it from being a potential add-on treatment to a primary therapy option. “Vitamin B6 is low-risk, very affordable and doesn’t require a prescription, which makes it easily and immediately accessible,” says Campbell.
Canadian Family Physician, a peer-reviewed medical journal read by family doctors across Canada, recently published an article explaining why the College of Family Physicians of Canada is withdrawing their previous recommendation of prescribing Diclectin as the primary treatment for morning sickness. The journal article doesn’t say Diclectin is unsafe, just that it may not be as effective as doctors once thought.
Toronto mom Amy Swenson took over-the-counter Vitamin B6 lozenges and drank homemade ginger broth when she was pregnant with her daughter in 2013 and experiencing mild but persistent nausea (without vomiting). “The B6 lozenges were the only thing that really helped my all-day nausea,” says Swenson.
My six-weeks-pregnant friend—who was vomiting several times a day and was so ill she was unable to get out of bed—noticed an improvement one day after starting Diclectin. Her quality of life still isn’t great, but on Diclectin she has been able to go back to work. “I still feel pretty miserable and nauseated all day, and I throw up in the evenings,” she says. “But at least I can get out of bed and function.”
If you continue to have sporadic flare-ups of nausea after going on Diclectin or B6 vitamins, the guidelines list Gravol and Benadryl as proven safe and effective for acute nausea. A drug called ondansetron (also known as Zofran) should only be considered when other drugs have failed, due to a potential risk of birth defects and other side effects. The SOGC also recommends against prescribing corticosteroids (like prednisone) in the first 10 weeks of pregnancy because there is not enough good evidence they are effective for reducing nausea, and there is a possible risk of birth defects.
4. Mindfulness may also work
Along with acupressure and ginger supplements (which were both mentioned in the 2002 guidelines), the alternative therapies section of the update now includes a recommendation in support of psychotherapy. A randomized controlled trial found that women who did three weeks of mindfulness-based cognitive therapy, in addition to taking Vitamin B6, reported a reduction in nausea and vomiting symptoms compared to the group that only took B6 (and received no therapy). The women who were in therapy also reported reduced anxiety and depression scores. Campbell stresses that this recommendation is not meant to suggest that women’s nausea symptoms are “all in their head,” or that managing morning sickness is more mind over matter. “But how we deal with the information we’re getting from our bodies, and how well our mind is in synch with our bodies, can help reduce symptoms,” she says.
5. Seek treatment early on
Don’t just resolve to tough it out, ladies. The guidelines recommend that any woman with a high risk of nausea and vomiting should consider starting Diclectin early in pregnancy before she starts feeling really sick in order to reduce the severity and the duration of symptoms. Campbell says women who’ve had severe nausea and vomiting in a previous pregnancy, women pregnant with multiples, or women whose mother also experienced nausea and vomiting are all more likely to suffer from morning sickness in their first trimester.
Even if you’re managing to get through your day, it’s best to seek out help before the nausea gets any worse, says Campbell. “We find that if we can help people sooner, we can get on top of it before they get really sick.” Consult with your doctor or midwife as soon as possible.
If you’re not sure whether your nausea and vomiting is considered mild, moderate or severe, or how your morning sickness measures up to other women’s symptoms, try doing a self-assessment of the last 24 hours using the aptly named “PUQE score” chart. (It’s the same rubric that health care providers use.)
Less than two percent of women will be diagnosed with Hyperemesis Gravidarum (HG), on the extreme end of the pregnancy symptom spectrum. HG (the same condition Kate Middleton suffered from during both her pregnancies) is defined as persistent and excessive vomiting and can lead to dehydration and weight loss, among other serious complications. It is the leading cause of hospitalization in the first 20 weeks of pregnancy.
In her experience as a midwife, Campbell has seen at least one client whose nausea continued through labour right up until she delivered her baby (!), but that is rare. Know that most women start feeling better, and regain their appetite, around 12 to 14 weeks.