Source: University of Texas at Austin, School of Nursing, Family
     Nurse Practitioner Program. Evaluation and management of nausea
     and vomiting in early pregnancy (less than or equal to 20 weeks
     gestation). Austin (TX): University of Texas at Austin, School of
     Nursing; 2002 May.

      RECOMMENDATIONS FOR THE EVALUATION AND MANAGEMENT OF NAUSEA AND
                        VOMITING IN EARLY PREGNANCY

     Contents

        * INTRODUCTION
        * EPIDEMIOLOGY
        * PATHOPHYSIOLOGY
        * SUBJECTIVE ASSESSMENT
        * OBJECTIVE ASSESSMENT
        * DIAGNOSIS
        * NONPHARMACOLOGIC THERAPY
        * NUTRITIONAL SUPPLEMENTS
        * PHARMACOLOGIC THERAPY
        * FOLLOW UP
        * REFERRAL
        * References
        * Rhodes Index of Nausea and Vomiting

     INTRODUCTION:

     DEFINITIONS
     Nausea: An unpleasant feeling in the throat or epigastric region
     alerting one that vomiting is imminent [1]
     Vomiting: The forceful expulsion of gastric contents through the
     mouth [1]
     Hyperemesis Gravidarum: severe nausea and vomiting with onset
     prior to the 20th week of pregnancy that may lead to weight loss,
     dehydration, electrolyte disturbances or death [2]
     Nausea and Vomiting of Pregnancy: nausea and vomiting during
     gestation not attributable to any other physiologic cause

     EPIDEMIOLOGY:

        * At least 66-80% of women experience nausea and 50% emesis in
          the first trimester [3-4].
        * Four million pregnant women in the US are affected annually
          [5].
        * Nausea and vomiting typically lasts 35 days [4].
        * Eighty percent of women have nausea that lasts all day [4].
        * Nausea and vomiting typically begins during the 4th to 8th
          week of gestation and lasts through the 14th-16th weeks [3].
        * Fifty percent of women have relief by the 14th week of
          gestation and 90% have relief by week 22 [4].
        * Incidence of nausea and vomiting tends to be inversely
          associated with the womans age [2].

     PATHOPHYSIOLOGY:

        * Expected changes with pregnancy
             * The peristaltic activity of the gastrointestinal (GI)
               system is reduced resulting in hypoactive bowel sounds
               [3]
             * Smooth muscles relax in the GI tract (atony) and may
               contribute to nausea and vomiting [3].
        * Pathogenesis of unspecified nausea and vomiting.
             * Afferent impulses from the pharynx, gastrointestinal
               tract, chemoreceptor trigger zone, and the limbic
               system stimulate the vomiting center (VC) located in
               the medulla [1-2].
             * Stimulation of the VC center results in transmission of
               impulses to the salivation center, respiratory center
               and musculature. Vomiting results from contraction of
               the pharyngeal, GI and abdominal musculature [1].
        * The precise etiology of NVP remains unclear. There are three
          prevalent theories
             * Endocrine theory: It has been postulated that elevated
               levels of progesterone, estrogen and human chorionic
               gonadotropin (HCG) precipitate nausea and vomiting.
               Rises in progesterone relax smooth muscle in the
               gastrointestinal (GI) system thereby contributing to
               decreased gastric motility and slowed gastric emptying.
               HCG has a thyroid stimulating affect that may
               precipitate nausea and vomiting [2-3].
             * Metabolic theory: Vitamin B-6 (pyridoxine) deficiency
               has been hypothesized as a trigger of nausea and
               vomiting in pregnancy [2].
             * Psychosomatic theory: Studies suggest that the
               prolonged duration of nausea and vomiting of pregnancy
               is associated with social difficulties, especially lack
               of social support. Increased nausea and vomiting is
               also associated with higher levels of depression,
               although the cause-effect relationship is unclear [2].

     SUBJECTIVE ASSESSMENT:

     HISTORY

        * History of progression of this pregnancy
             * Presence of multiple fetuses
             * Prenatal health care
             * Complications
        * Diet history, with special attention to current fluid intake
        * Current medications
        * Past surgical history, particularly abdominal surgeries
        * Past Medical History
             * Past gynecological and obstetric history
             * Cholecysititis or GI disorders
             * Thyroid disorders
             * Depression
        * Social History
             * Exposure to communicable diseases
             * Environmental exposures
             * Access to prenatal health care
             * Roles, responsibilities, employment
             * Absenteeism
        * History of present illness
             * Onset
             * Duration
             * Emesis
                  * Color
                  * Volume
                  * Frequency
                  * Quality
             * Precipitating and alleviating factors
             * Any home treatment attempts
        * Associated symptoms
             * Belching or flatus
             * Diarrhea or constipation
             * Abdominal pain
                  * Location
                  * Severity
                  * Quality
                  * Radiation
                  * Precipitating and alleviating factors
        * Other evaluation tools: Rhodes Index of Nausea and Vomiting
             * This eight-question tool assesses the severity and
               frequency, as well as the distress from nausea and
               vomiting [6].
             * This tool has been demonstrated to be both valid and
               reliable in this population [6-7].

     FOCUSED REVIEW OF SYSTEMS

        * General, constitutional
             * Fatigue
             * Comfort level
             * Chills
        * Gastrointestinal
             * Abdominal pain
             * Appetite
             * Associated GI symptoms
        * Psychological
             * Interference with daily activities
             * Perceived stress levels
             * Depression
             * Coping skills
        * Genitourinary
             * CVA pain
             * Dysuria

     OBJECTIVE ASSESSMENT:

     FOCUSED PHYSICAL ASSESSMENT

        * Vital signs: fever, tachycardia, or postural hypotension
        * General appearance
             * Emotionally distressed
             * Toxic appearance
        * Weight gain or loss
        * Hydration status
             * Skin turgor
             * Dry versus moist mucous membranes
             * Oliguria
        * Cardiovascular status
             * Quality of pulse: strong versus thready
             * Tachycardia
             * Postural hypotension
        * Abdominal
             * Bowel sounds (hypoactive can be normal in pregnancy)
             * Tenderness, rigidity, guarding, rebound, distention
             * Hepatosplenomegaly
             * Epigastric, Murphys or McBurney's point tenderness
        * Genitourinary
             * CVA tenderness
             * Suprapubic tenderness
        * Fetal well being, as appropriate for gestational age
             * Heart tones
             * Fundal height

     DIAGNOSTIC PROCEDURES

        * Urinalysis to rule out infection and/or dehydration
        * Electrolytes if dehydration is suspected or excessive
          vomiting
        * TSH to rule out thyroid disease
        * CBC, amylase, lipase, liver profile if infectious or
          inflammatory cause is suspected
        * Imaging if indicated for acute abdominal process
        * Quantitative beta hCG if multiple gestation or molar
          pregnancy suspected

     DIAGNOSIS:

        * The diagnosis of NVP is one of exclusion
        * Differential diagnoses
             * Acute gastroenteritis both viral and bacterial
             * Medication side effects
             * Cholecystitis
             * Appendicitis
             * Obstruction
             * Hepatitis
             * Pancreatitis
             * Thyroid disease
             * Multiple gestation
             * Molar pregnancy
             * Urinary tract infection

     NONPHARMACOLOGIC THERAPY:

     ALTERATION OF NORMAL ACTIVITIES AND REDUCTION OF ENVIRONMENTAL
     STIMULATION

     A qualitative analysis of 124 diaries provided by pregnant women
     found that frequent naps or rest periods, especially after meals,
     reduced the frequency, severity, and duration of nausea and
     vomiting in pregnancy. The diaries also revealed that a reduction
     in sensory stimulation such as walking, talking on the phone,
     loud noises, and tight clothing reduced NVP [8].

     The authors state that results of this study cannot be
     generalized to the entire population of symptomatic pregnant
     women, since the sample was not randomly selected and could not
     be quantified. However, the interventions pose no danger to the
     mother or fetus and therefore should be offered. (strength of
     recommendation B; quality of evidence III)

     ACUPRESSURE AND ACUPUNCTURE

     Acupressure and acupuncture stimulate the bodys integrative
     regulatory systems and activate a variety of endocrine and
     neurologic mechanisms, which in turn stimulate a variety of
     physiologic functions toward homeostasis. For nausea and
     vomiting, manual or wristband acupressure is applied at the P6
     Neiguan pressure point, on the volar surface of the forearm,
     about three fingerbreadths from the distal wrist crease and
     between the two tendons.

     A 1994 randomized, blinded study found that acupressure was
     effective in reducing symptoms of nausea, but not frequency of
     vomiting, in pregnant women [9]. However, a 1996 study failed to
     find a medical benefit from the use of P6 acupressure [10]. On
     the other hand, studies examining the use of wristbands to
     administer acupressure have shown these to be an effective method
     to decrease NVP [11-12].

     Though the evidence for the therapeutic benefit of manual P6
     acupressure is conflicting, the evidence regarding its use
     through wristbands is consistent. Acupressure is low in cost and
     is a harmless modality worth offering (strength of recommendation
     A; quality of evidence I).

     Acupuncture uses needles instead of pressure to stimulate points,
     and is thought to be more effective than acupressure because it
     provides a stronger stimulus. However, research has failed to
     substantiate its use [13].

     While relatively harmless, acupuncture is more costly than
     acupressure in that a trained practitioner must be consulted. Due
     to the lack of research for this modality, acupuncture for the
     control of nausea and vomiting in early pregnancy cannot be
     recommended at this time (strength of recommendation E; quality
     of evidence I).

     DIET

     In women with first trimester pregnancy, protein meals
     selectively reduce nausea and gastric slow wave dysrhythmias [14]
     (strength of recommendation A; quality of evidence II-1).

     Other modifications such as frequent small meals and avoiding
     strong odors may also be helpful [8]. The notion that nausea and
     vomiting of early pregnancy protects women from "harmful" meats
     and vegetables has not been substantiated by scientific inquiry
     [15].

     NUTRITIONAL SUPPLEMENTS:

     PYRIDOXINE (VITAMIN B6)

     Pyridoxine has proven to be effective in reducing NVP. Two
     randomized clinical trials have been published to date [16-17].
     Pyridoxine in doses of 10-25 mg orally every eight hours on an
     intermittent basis of 2-3 days at a time are recommended as a
     first-line therapy for NVP (strength of recommendation A; quality
     of evidence I).

     The use of pyridoxine in the treatment of nausea and vomiting of
     pregnancy has been studied since the early 1940s [18-20].
     Pyridoxine carries pregnancy classification A [21]. The available
     evidence does not suggest a teratogenic risk.

     GINGER

     Ginger has been studied in many forms: dried ginger root, ginger
     tea from fresh ginger root, and Zingiber officinale extract. The
     actual form studied determines what active ingredients are
     present. The primary active ingredients in ginger are thought to
     be a class of compounds called the gingerols. 6-Gingerol and
     6-shogaol are implicated in gingers antinauseant properties as
     they are found to suppress gastric contraction and increase both
     gastrointestinal motility and spontaneous peristaltic activity
     [22].

     Two randomized clinical trials of ginger in the treatment of
     nausea and vomiting in pregnancy have demonstrated that ginger is
     effective over placebo. One trial was a randomized, double blind,
     crossover study of twenty-seven pregnant women with hyperemesis
     gravidarum. Subjects were given 250 mg of dried ginger root
     contained in a capsule four times a day. Ginger was shown to
     significantly decrease both nausea and vomiting of hyperemesis
     gravidarum [22]. A recent randomized, double-blind,
     placebo-controlled clinical trial of seventy pregnant women
     showed this same preparation and regimen of ginger effectively
     reduced both nausea and vomiting in pregnant women not
     categorized as hyperemesis gravidarum. No adverse effects of
     ginger on pregnancy outcome were detected [24].

     Two randomized, controlled, experimental rat studies have been
     conducted to evaluate the effect of ginger on fetal development
     [25-26]. Ginger produced neither maternal nor developmental
     toxicity at daily doses up to 1000 mg/kg of body weight. With
     doses of 2200 mg/kg and 5500 mg/kg in the Wilkinson study, there
     was increased embryonic loss without a concentration-related
     effect and treated fetuses were significantly heavier than
     controls, perhaps secondary to the increased calories present in
     the ginger tea. Considering the evidence from these two studies
     of fetal development in rats, ginger appears to be safe in
     concentrations less than 1000 mg/kg. The recommended human dose
     is 500 to 1000 mg/day [23-24] far less than that used in the
     above rat studies.

     Ginger appears to be effective in the reduction of nausea and
     vomiting in pregnancy without adverse effects on pregnancy
     outcome (strength of recommendation B; quality of evidence I).
     The recommended dose is 250 mg four times a day.

     PHARMACOLOGIC THERAPY:

     If a trial of nonpharmacologic interventions is not successful,
     or if symptoms are severe, medications should be offered.

     Current randomized, double-blind, placebo-controlled trials of
     antinausea and antiemetic medications given in pregnancy are
     scarce due to the inherent ethical and medicolegal issues
     involved in such research. However, it is possible to draw some
     conclusions based on the evidence that is available.

     DOXYLAMINE:

     Several antihistamines have been used to treat NVP. The best
     studied of these is doxylamine, which carries a pregnancy
     classification of A (no evidence of risk). Doxylamine is commonly
     given concurrently with pyridoxine (vitamin B6), which also
     carries pregnancy classification A. This combination was found in
     Bendectin, which was voluntarily withdrawn from the market in
     1983 following allegations of possible teratogenic effects.
     Bendectin was originally formulated as a compound of doxylamine,
     pyridoxine and dicyclomine. In 1976 dicyclomine was removed from
     the formulation. A meta-analysis of sixteen cohort and eleven
     case control studies concluded that there is no evidence that the
     original Bendectin formulation contributes to birth defects [27]
     (quality of evidence II-2). Another meta-analysis reviewed 12
     cohort and three case-control studies of both the two- and
     three-drug formulation. Again, no increased risk for
     malformations was detected [28] (quality of evidence II-2).

     Studies demonstrate that this combination of medication is
     efficacious in treating NVP. A meta-analysis of four clinical
     trials found that a combination of doxylamine/pyridoxine (with
     and without dicyclomine) was effective [28] (quality of evidence
     II-2). A review by the Cochrane groups also found that the
     three-drug combination was effective in reducing nausea [29]. A
     correlational study described the increase in hospitalizations
     for excessive vomiting in pregnancy that occurred with the
     voluntary withdrawal of Bendectin from the Canadian market. The
     same study demonstrated the decline in hospitalizations when
     Diclectin (containing doxylamine 10mg and pyridoxine 10 mg) was
     released in Canada [30] (quality of evidence II-3). The authors
     of one meta-analysis describe a regimen for the prevention of
     recurrence of nausea and vomiting in which two Diclectin tablets
     are taken at bedtime. If symptoms persist one tablet may be added
     in the morning and another may be added in the afternoon [31].
     The safety of Diclectin in doses greater than four tables per day
     has also been documented [32] (quality of evidence III).
     Doxylamine is available over-the-counter in the United States
     under the brand name Unisom, a 25 mg scored tablet. It is
     reasonable to recommend that one half of a tablet, in combination
     with pyridoxine 10 mg be given up to three times a day. The
     provider should note that the doxylamine insert advises, Do not
     take this product if pregnant or nursing a baby, and counsel the
     patient accordingly. The patient should also be counseled as to
     the sedating effects of doxylamine. (strength of recommendation
     A)

     OTHER FIRST GENERATION ANTIHISTAMINES:

     Other first generation antihistamines (for example,
     diphenhydramine, pregnancy classification B; dimenhydrinate,
     pregnancy classification B; hydroxyzine, pregnancy classification
     C) have favorable safety profiles. One meta-analysis revealed no
     association between first trimester antihistamine use and major
     malformations [33] (quality of evidence II-1). Another
     meta-analysis demonstrated no teratogenic effect [34] (quality of
     evidence II-2). A third meta-analysis showed no increased risk
     for anomalies [28] (quality of evidence II-1). Pooled data
     indicate that antihistamines are effective in treating NVP,
     however, the data are not homogenous [28] (quality of evidence
     II-2). Furthermore the meta-analyses do not report dosages.
     Sedation is a common side effect of first generation
     antihistamines. (strength of recommendation B)

     PHENOTHIAZINES:

     A meta-analysis failed to show any teratogenic effect of
     phenothiazines [28] (quality of evidence II-1). However, one case
     of fatal shock was reported when a pregnant woman with
     undiagnosed pheochromocytoma was given promethazine [34] (quality
     of evidence III). Phenothiazine effectiveness was demonstrated in
     a meta-analysis of three randomized control trials [28] (quality
     of evidence I). Promethazine (pregnancy classification C) is
     available both as an oral preparation and as a rectal
     suppository. Sedation is a common side effect. (Strength of
     recommendation B)

     FOLLOW UP:

     The patient should be counseled on signs of dehydration including
     dry skin, dry mucosa, decreased voids and concentrated urine. The
     patient should return for follow up in 2-4 weeks, or sooner if
     she notes signs of dehydration, increased nausea or persistent
     vomiting. Follow up evaluation includes assessment of weight
     gain, quality of life, hydration status, Rhodes score and
     absenteeism from work.

     REFERRAL:

     If the condition progresses to hyperemesis gravidarum the patient
     will likely require inpatient management.

     The algorithm for "Recommendations for the Evaluation and
     Management of Nausea and Vomiting in Early Pregnancy" is
     available on request from the guideline developer.

                                 References

     General References:

     Aikins Murphy, P. (1998). Alternative therapies for nausea and
     vomiting of pregnancy, Obstetrics and Gynecology, 91(1), 149-155.

     Briggs, G., Freeman, R. & Yaffe, S. (2002). Drugs in pregnancy
     and lactation: A reference guide to fetal and neonatal risk (6th
     ed.). Philadelphia: Lippincott Williams & Wilkins.

     Jewell, D. & Young, G. (2001). Interventions for nausea and
     vomiting in early pregnancy. Cochrane Database of Systematic
     Reviews (3): CD000145.

     Jewell, D. (2001). Nausea and vomiting in early pregnancy. In
     S.W. Barton, (Ed.), Clinical Evidence, 1093-1099. London: BMJ
     Publishing Group.

     Specific References:

       1. Uphold, C. & Graham, M. (1998). Clinical Guidelines in
          Family Practice. Gainesville, Florida: Barmarrae Books, Inc.
       2. Snell, L., Haughey, B., Buck, G. & Marecki, M. (1998).
          Metabolic crisis: Hyperemesis gravidarum. Journal of
          Perinatal & Neonatal Nursing, 12(2), 26.
       3. Beckmann, C., Ling, F., Herbert, W., Laube, D., Smith, R. &
          Barzansky, B. (1998). Obstetrics and Gynecology, 3rd ed.
          Philadelphia: Lippincott Williams & Wilkins.
       4. Lacriox, R., Eason, E. & Melzack, R. (2000). Nausea and
          vomiting during pregnancy: A prospective study of its
          frequency, intensity, and patterns of change. American
          Journal of Obstetrics and Gynecology, 182(4), 931-937.
       5. Mazzotta, P., Maltepe, C., Navioz, Y., Magee, L. & Koren, G.
          (2000). Attitudes, management and consequences of nausea and
          vomiting of pregnancy in the United States and Canada.
          International Journal of Gynecology and Obstetrics, 70 (3),
          359-365.
       6. Koren, G., Magee, L., Attard, C., Kohli, M., Atanackovic,
          G., Bishai, R., Chandra, K., Navioz, Y. & Maltepe, C.
          (2001). A novel method for the evaluation of the severity of
          nausea and vomiting of pregnancy. European Journal of
          Obstetrics & Gynecology and Reproductive Biology, 94 (1),
          31-36.
       7. Zhou, Q., OBrian, B. & Soeken, K. (2001). Rhodes index of
          nausea and vomiting - form 2 in pregnant women: A
          confirmatory factor analysis. Nursing Research, 50(4),
          251-257.
       8. OBrien, B. & Relyea, J. (1997). Diary reports of nausea and
          vomiting during pregnancy. Clinical Nursing Research, 6(3),
          239-252.
       9. Belluomini, J., Litt, R. C., Lee, K. A., & Katz, M. (1994).
          Acupressure for nausea and vomiting of pregnancy: A
          randomized, blinded study. Obstetrics & Gynecology, 84(2),
          245-248.
      10. OBrien, B., Relyea, M. J., & Taerum, T. (1996). Efficacy of
          P6 acupressure in the treatment of nausea and vomiting
          during pregnancy. American Journal of Obstetrics and
          Gynecology, 177(2), 708-715.
      11. Norheim, A., Pedersen, E., Fonnebo, V. & Berge, L. (2001).
          Acupressure treatment of morning sickness in pregnancy: A
          randomized, double-blind, placebo-controlled study.
          Scandinavian Journal of Primary Care, 19(1), 43-47.
      12. Stainton, M. & Neff, E. (1994). The efficacy of SeaBands for
          the control of nausea and vomiting. Health Care for Women
          International, 15(6), 563-575.
      13. Knight, B., Mudge, C., Openshaw, S., White, A., & Hart, A.
          (2001). Effect of acupuncture on nausea of pregnancy: A
          randomized, controlled trial. Obstetrics & Gynecology,
          97(2), 184-188.
      14. Jednak, M., Shadigian, E., Kim, M., Woods, M., Hooper, F.
          G., Owyang, C., & Hasler, W. (1999). Protein meals reduce
          nausea and gastric slow wave dysrhythmic activity in first
          trimester pregnancy. American Journal of Physiology,
          277(40), G855-G861.
      15. Brown, J., Kahn, E., & Hartman, T. (1997). Profet, profits,
          and proof: do nausea and vomiting of early pregnancy protect
          women from "harmful" vegetables? American Journal of
          Obstetrics and Gynecology, 176(1), 179-181.
      16. Sahakian, V., Rouse, D., Sipes, S., Rose, N.B. & Niebyl, J.
          (1991). Vitamin B6 is effective therapy for nausea and
          vomiting of pregnancy: A randomized double-blind-controlled
          trial. Obstetrics and Gynecology, 78 (1),33-36.
      17. Vutyavanich, T., Wongtra-ngan, S. & Ruangsri, R-a. (1995).
          Pyridoxine for nausea and vomiting of pregnancy: A
          randomized, double-blind, placebo-controlled trial.
          Obstetrics and Gynecology, 173 (3 Pt 1), 881-884.
      18. Wills, R., Winn, W., Morris, A., Newsom, A. & Massey, W.
          (1942). Clinical observations in treatment of nausea and
          vomiting in pregnancy with vitamins B1 and B6. A preliminary
          report. American Journal of Obstetrics and Gynecology, 42,
          265-271.
      19. Weinstein, B., Mitchell, G. & Sustendal, G. (1943). Clinical
          experiences with pyridoxine hydrochloride in treatment of
          nausea and vomiting of pregnancy. American Journal of
          Obstetrics and Gynecology, 46, 283-285.
      20. Weinstein, B., Wohl, Z., Mitchell, G. & Sustendal, G.
          (1944). Oral administration of pyridoxine hydrochloride in
          the treatment of nausea and vomiting of pregnancy. American
          Journal of Obstetrics and Gynecology, 47, 389-394.
      21. Briggs, G., Freeman, R. & Yaffe, S. (2002). Drugs in
          pregnancy and lactation: A reference guide to fetal and
          neonatal risk (6th ed.). Philadelphia: Lippincott Williams &
          Wilkins.
      22. Suckawa, M., Ishige, A., Yuasa, K., Sudo, M., Aburada, E. &
          Hosoya, E. (1984). Pharmacologic studies on ginger.
          Pharmacological actions of pungent constituents,
          (6)-gingerol and (6)-shogaol. Journal Pharmacobiodyn, 7,
          836-848.
      23. Fischer-Rasmussen, W., Kjaer, S.K., Dahl, C, Asping, U
          (1990). Ginger treatment of hyperemesis gravidarum. European
          Journal of Obstetrics and Gynecology Reproductive Biology,
          38 (1990), 19-24.
      24. Vutyavanich, T., Kraisarin, T. & Ruangsri, R. (2001). Ginger
          for nausea and vomiting in pregnancy: Randomized,
          double-masked, placebo-controlled trial. Obstetrics &
          Gynecology, 97(4), 577-582.
      25. Wilkinson, J. (2000). Effect of ginger tea on the fetal
          development of Sprague-Dawley rats. Reproductive Toxicology,
          14 (6), 507-512.
      26. Weidner, M. & Sigwart, K. (2001). Investigation of the
          teratogenic potential of a Zingiber officinale extract in
          the rat. Reproductive Toxicology, 15 (1), 75-80.
      27. McKeigue, P., Lamm, S., Linn, S., & Kutcher, J. (1994).
          Bendectin and birth defects: I. A meta-analysis of the
          epidemiologic studies. Teratology, 50 (1), 27-37.
      28. Mazzotta, P. & Magee, L. (2000). A risk-benefit assessment
          of pharmacological and nonpharmacological treatments for
          nausea and vomiting of pregnancy. Drugs, 59 (4), 781-800.
      29. Jewell, D. & Young, G. (2001). Interventions for nausea and
          vomiting in early pregnancy. Cochrane Database of Systematic
          Reviews (3): CD000145.
      30. Neutel, C. (2000). Variation in rates of hospitalization for
          excessive vomiting in pregnancy by Bendectin/Dilectin use in
          Canada. In Koren, G. (ed.), Nausea and Vomiting of
          Pregnancy: State of the Art 2000. Retrieved February 17,
          2002, from the World Wide Web:
          http://www.nvp-volumes.org/p1_9.htm
      31. Bishai, R., Mazzotta, P., Atanackovic, G., Levichek, Z., &
          Pollle, M. (2000). Critical appraisal of drug therapy for
          nausea and vomiting of pregnancy: II. Efficacy and safety of
          Diclectin (doxylamine-B6). Canadian Journal of Clinical
          Pharmacology, 7 (3), 138-143.
      32. Atanackovic, G., Navioz, Y., Moretti, M., & Koren, G.
          (2001). The safety of higher than standard dose of
          doxylamine-pyridoxine for nausea and vomiting of pregnancy.
          Journal of clinical pharmacology, 41 (8), 842-845.
      33. Seto, A., Einarson, T. & Koren, G. (1997). Pregnancy outcome
          following first trimester exposure to antihistamines:
          Meta-analysis. American Journal of Perinatology, 14 (3),
          119-124.
      34. Schatz, M., & Petitti, D. (1997). Anti-histamines and
          pregnancy. Annals of Allergy, Asthma, and Immunology, 78
          (2), 157-159.
      35. Hall, P. (1987). Use of promethazine (Phenergan) in labour.
          Canadian Medical Association Journal, 136 (7), 690-691.

                    Rhodes Index of Nausea and Vomiting

     During the past 12 hours, have you vomited or thrown up

     [ ]7 or more times     [ ]5-6 times     [ ]3-4 times     [ ]1-2 times     [ ]0 times

     During the past 12 hours, how much distress have you felt from retching or dry heaves?

     [ ]no distress     [ ]mild distress     [ ]moderate distress     [ ]great distress     [ ]severe distress

     During the past 12 hours, how much distress have you felt from vomiting or throwing up?

     [ ]severe distress     [ ]great distress     [ ]moderate distress     [ ]mild distress     [ ]no distress

     During the past 12 hours, for how long have you felt nauseated or sick at your stomach?

     [ ]none     [ ]1 hr or less     [ ]2-3 hr     [ ]4-6 hr     [ ]more than 6 hr

     During the past 12 hours, how much distress have you felt from nausea or sickness at you stomach?

     [ ]no distress     [ ]mild distress     [ ]moderate distress     [ ]great distress     [ ]severe distress

     During the past 12 hours, how much did you vomit or throw up each time that you vomited or threw up?

     [ ]very large amount     [ ]large amount     [ ]moderate amount     [ ]small amount       [ ]none
        (3 or more cups)         (2-3 cups)          (half to 2 cups)       (up to half a cup)
        
     During the past 12 hours, how many separate or different times have you felt nauseous or sick to your stomach?

     [ ]7 or more times     [ ]5-6 times     [ ]3-4 times     [ ]1-2 times     [ ]0 times

     During the past 12 hours, how many times have you had retching or dry heaves without bringing anything up?

     [ ]no periods     [ ]1-2 periods     [ ]3-4 periods     [ ]5-6 periods     [ ]7 or more periods

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     School of Nursing, Family Nurse Practitioner Program.