Determinants of Early Medical Management of Nausea and Vomiting of Pregnancy

Abstract

ABSTRACT: Background: Early medical management of nausea and vomiting during pregnancy is desirable but less than optimal. The aims of this study were to describe the management of nausea and vomiting during the first prenatal visit and to identify the determinants of 1) addressing the subject of nausea and vomiting during pregnancy with the health practitioner and 2) receiving an antiemetic prescription.Methods: A prospective study was conducted of 283 women who reported nausea and vomiting during the first trimester of pregnancy. Women were eligible if they were at least 18 years of age and ≤ 16 weeks’ gestation at the time of their first prenatal visit. Participants completed a questionnaire to determine their maternal characteristics, the presence of nausea and vomiting during pregnancy, and its management.Results: Of the 283 study participants, 79 percent reported that the condition was addressed during their first prenatal visit, 52 percent reported being asked about the intensity and severity of their symptoms, and 22 percent reported being questioned about the extent to which it disrupted their daily tasks. Health practitioners prescribed an antiemetic for 27 percent of women and recommended a nonpharmacological method for 14 percent. Multivariate models showed that the severity of the nausea and vomiting, previous use of an antiemetic, and smoking before pregnancy were significantly associated with an increased likelihood of addressing the subject of nausea and vomiting during pregnancy. Variables associated with an increased likelihood of women receiving an antiemetic prescription included nausea and vomiting severity, excessive salivation, previous antiemetic use, and work status.Conclusions: Health practitioners can improve their management of nausea and vomiting during pregnancy based on the available guidelines for treatment and they should address important factors such as symptom severity and work status at the first prenatal visit to assess women’s need for antiemetic treatment. (BIRTH 36:1 March 2009)

Nausea and vomiting affect 50 to 90 percent of pregnant women during their first trimester (1). The literature has shown that the condition has a significant impact on the health-related quality of life of pregnant women (2–4). Since in some cases, it can lead to a state of depression and the elective termination of the pregnancy (5,6), early management is warranted.

Health Canada recommends that health practitioners should always ask pregnant women if they are suffering from nausea and vomiting during pregnancy, take immediate action to manage the condition, and complete follow-up treatment even in mild cases of the condition (7). However, given that nausea and vomiting during pregnancy are common and generally not life threatening, both practitioners and pregnant women often tend to minimize their impact (3,8). As a consequence, we hypothesized that the management of this condition is less than optimal.

Although many studies have focused on nausea and vomiting during pregnancy, few have evaluated early medical management, and only one described its management in prenatal care from a woman’s perspective (9). However, since this study included mostly severe cases, giving an overestimated prevalence of antiemetic use, a study to address the possible determinants affecting the management of nausea and vomiting during pregnancy in the general pregnant population is warranted.

The aims of this study were to describe the management of nausea and vomiting during the first prenatal visit and to identify the determinants of 1) addressing the subject of nausea and vomiting during pregnancy with the health practitioner and 2) receiving an antiemetic prescription.

Methods

We conducted a prospective study of pregnant women who received prenatal care at the obstetrics and gynecology clinic of the Centre Hospitalier Universitaire Sainte-Justine (CHU Sainte-Justine) or the René-Laennec clinic, both affiliated with the University of Montreal, Quebec, Canada, from October 2004 to March 2006. Women were eligible if they met the following criteria: 1) were at least 18 years of age, 2) were at their first prenatal visit, 3) were pregnant within 16 weeks of the first day of their last menses, 4) were able to read and understand French or English, and 5) had given their written informed consent. Women whose prenatal care was provided by one of the research collaborators were excluded from analyses. Ethics approval was obtained from CHU Sainte-Justine’s ethics committee.

At the end of their first prenatal visit, eligible women who agreed to participate were asked to complete a self-administered questionnaire at home. Data were collected related to women’s demographic variables, lifestyle, nausea and vomiting during pregnancy, the health practitioner met at the first prenatal visit, and the management of nausea and vomiting during pregnancy. Our study included only the subgroup of pregnant women who reported having experienced nausea and vomiting during their pregnancy in the self-administered questionnaire. The women were asked to return the questionnaire within 1 week of their prenatal visit to minimize recall bias.

The severity of nausea and vomiting during pregnancy was measured by the modified Pregnancy-Unique Quantification of Emesis and Nausea (modified-PUQE) (10). This index, which measures the severity during the pregnancy’s first trimester, is based on three physical symptoms: the duration of nausea in hours and the number of retching and vomiting episodes on an average day since the beginning of pregnancy. The total scores could range between 3 and 15, with 3 to 6 representing mild symptoms, 7 to 12 moderate symptoms, and 13 to 15 severe symptoms. In a validation study, the modified-PUQE was significantly associated with an outcome of direct importance for women who experience nausea and vomiting during pregnancy, such as quality of life (SF-12 physical component scale: p < 0.0001 and SF-12 mental component scale: p= 0.0008). Moreover, a substantial concordance was found between the modified-PUQE and the frequently used Motherisk PUQE (intraclass correlation coefficient = 0.71) (10).

Women were also asked about the methods used to relieve their symptoms before the first prenatal visit, including antiemetic drug use, lifestyle and dietary changes, natural or homeopathic product use, and acupuncture or acupressure. With respect to the management of nausea and vomiting during pregnancy at the first prenatal visit, women were asked whether the subject was addressed during the visit (yes or no), if their practitioner asked about the intensity and severity of this condition (yes or no), inquired about the extent to which it disrupted their daily tasks (yes or no), prescribed antiemetic drugs (medications not available over the counter; yes or no), or offered nonpharmacological methods (yes or no; many examples were specified in the questionnaire to enhance validity).

Given the differences between the two recruitment sites (CHU Sainte-Justine and René-Laennec clinics), the prenatal visit location was considered in the analyses. In fact, even if the same group of obstetricians provides prenatal care in both clinics, CHU Sainte-Justine is a university health care center where team work with medical residents occurs. Moreover, women receiving prenatal care at CHU Sainte-Justine usually meet a nurse before seeing their physician.

Statistical analyses

Descriptive statistics were used to estimate the distribution of maternal characteristics, nausea and vomiting during pregnancy in the first trimester, and the management of this condition at the first prenatal visit. Since data from pregnant women receiving prenatal care from the same practitioner cannot be treated as if they were independent, generalized estimation equations (GEE) with exchangeable correlation structures were used to identify and quantify determinants in the early management of nausea and vomiting during pregnancy. More precisely, the GEE statistical procedure extends the logistic model to handle outcome variables that have dichotomous correlated responses (PROC GENMOD) (11).

Univariate and multivariate regression models were carried out to identify separately the determinants of addressing the subject of nausea and vomiting during pregnancy and receiving an antiemetic prescription during the first prenatal visit. Covariables included in the multivariate regression models were selected on the basis of their association with the outcome (management of nausea and vomiting during pregnancy) in univariate regression models (determinants with p≤ 0.15 were included in the multivariate models). Because of the small number of women experiencing severe nausea and vomiting during pregnancy, those with moderate (n= 126) and severe (n= 7) symptoms were grouped together in the regression models. All statistical analyses were performed using SAS version 9.1 (11).

Results

Maternal characteristics of the study sample of 283 women who reported nausea and vomiting during pregnancy in the first trimester are shown in Table 1. In the first trimester of pregnancy, 51.3 percent of women reported mild symptoms, 46.2 percent moderate symptoms, and 2.6 percent severe symptoms.

Table 1. Characteristics of the Study Cohort (n= 283)

Characteristic	Measure No. (%)^a
^a For these variables, the number of missing values was < 5%. ^b Including asthma, anemia, depression, hypothyroidism, diabetes, epilepsy, hypertension, and various problems such as infections, eczema, and migraines. RAMQ = Régie de l’assurance maladie du Québec (i.e., name of government drug insurance program); NVP = nausea and vomiting during pregnancy; BMI = body mass index.
Maternal age (yr) (mean ± SD)	31.61 ± 4.64
Gestational age (wk) (mean ± SD)	11.00 ± 1.75
Country of birth
Canada	186 (65.72)
Other	97 (34.28)
Race/ethnicity
Caucasian	232 (81.98)
Asian	9 (3.18)
Black	26 (9.19)
Hispanic	16 (5.65)
Rx insurance plan
Provincial plan (RAMQ^b)	81 (28.83)
Other insurance	200 (71.17)
Work status
Student or not working	71 (25.18)
Working	211 (74.82)
Living arrangement
With spouse or with someone (family or cotenant)	276 (97.87)
Living alone	6 (2.13)
Education level
University completed	180 (63.83)
University not completed	102 (36.17)
Household income (CDN$/yr)
< 40,000	88 (32.00)
Between 40,000 and 79,999	69 (25.09)
≥ 80,000	118 (42.91)
Exercise during first trimester	107 (38.21)
Smoking before pregnancy	37 (13.07)
Smoking during first trimester	9 (3.18)
Caffeine intake before pregnancy	229 (80.92)
Caffeine intake during first trimester	161 (57.09)
Use of alcohol before pregnancy	185 (65.37)
Use of alcohol during first trimester	19 (6.74)
Severity of NVP
Mild	140 (51.28)
Moderate	126 (46.15)
Severe	7 (2.56)
Excessive salivation	73 (26.45)
Antiemetic use during first trimester before first prenatal visit	54 (19.64)
Nonpharmacological methods use to relieve NVP during first trimester before first prenatal visit	49 (17.82)
Comorbidities before pregnancy^b
0	203 (71.73)
1	69 (24.38)
2 or 3	11 (3.89)
Gravidity
Multigravida	235 (83.04)
Primigravida	48 (16.96)
Prepregnancy BMI
Underweight or normal (BMI < 25 kg/m^2)	188 (68.12)
Overweight (25 ≤ BMI < 30 kg/m^2)	65 (23.55)
Obese (BMI ≥ 30 kg/m^2)	23 (8.33)

A detailed description of the management of nausea and vomiting during pregnancy at the first prenatal visit is shown in Table 2. Within the study population, 79 percent reported that the subject of nausea and vomiting during pregnancy was addressed at the first prenatal visit, 52 percent reported being asked about the intensity and severity of their symptoms, and 22 percent reported being questioned about the extent to which the condition disrupted their daily tasks (Table 2). The proportion of women who reported having been questioned about the latter two items (intensity and severity and disturbance of daily tasks) was not different between the nausea and vomiting severity groups (Fisher’s exact tests p= 0.40 and p= 0.78, respectively). When women were asked whether they had been offered methods to relieve the condition at their first prenatal visit, 14 percent reported being offered nonpharmacological methods and 27 percent reported having received an antiemetic prescription (Table 2).

Table 2. Description of the Management of Nausea and Vomiting During Pregnancy at Women’s First Prenatal Visit (n= 283)

Management	No. (%)^a
^a For these variables, the number of missing values was < 4%. NVP = nausea and vomiting during pregnancy.
Location of the first prenatal visit
CHU Sainte-Justine clinic	105 (37.1)
René-Laennec clinic	178 (62.9)
Health practitioner met at the first visit
Nurse and obstetrician/gynecologist	68 (24.7)
Obstetrician/gynecologist	207 (75.3)
Questioned about intensity or severity of NVP	144 (51.8)
Questioned about extent to which their NVP disturbed their everyday tasks	61 (22.0)
Received an antiemetic prescription	76 (27.3)
Doxylamine/pyridoxine combination	(95.7)
Metoclopramide	(1.4)
Nonspecified prescribed antiemetic	(2.9)
Were offered nonpharmacological methods to alleviate NVP	39 (14.0)
Dietary changes	(67.7)
Ginseng	(5.9)
Stop prenatal vitamins	(5.9)
Lifestyle changes	(2.9)
Reassurance and psychological support	(2.9)
Combination of these methods	(14.7)

Multivariate analyses showed that more severe nausea and vomiting symptoms, antiemetic use before the first prenatal visit, and smoking before pregnancy were significantly associated (p < 0.05) with an increased likelihood of a practitioner addressing the subject of nausea and vomiting during pregnancy at the first prenatal visit (Table 3). A higher gestational age, receiving prenatal care at the René-Laennec clinic, and a higher weight gain during the first trimester were significantly associated with a decreased likelihood of a practitioner addressing the subject of nausea and vomiting during pregnancy (Table 3). More severe nausea and vomiting symptoms, the presence of excessive salivation during the first trimester, antiemetic use before the first prenatal visit, and working were significantly associated with an increased likelihood of receiving an antiemetic prescription at the first prenatal visit (Table 4).

Table 3. Determinants of a Practitioner Addressing the Subject of Nausea and Vomiting During Pregnancy at the First Prenatal Visit

Characteristic	No (n = 59)	Yes (n = 222)	Crude OR (95% CI)	Adjusted OR^a (95% CI)
	No. (%)	No. (%)
^a Adjusted for all variables of this column for which an adjusted odds ratio is presented. ^b Because of the small number of women experiencing severe NVP, those with moderate (n = 126) and severe (n = 7) symptoms were grouped. ^c Including gastroenteritis, motion sickness, and food poisoning. ^d Including asthma, anemia, depression, hypothyroidism, diabetes, epilepsy, hypertension, and various problems such as infections, eczema, and migraines. NVP = nausea and vomiting during pregnancy.
NVP status
Severity of NVP
Mild	39 (69.64)	101 (46.54)	1	1
Moderate/severe^b	17 (30.36)	116 (53.46)	2.77 (1.23–6.23)	3.55 (1.77–7.12)
Antiemetic use in first trimester before the first prenatal visit	4 (7.14)	50 (22.83)	3.66 (1.39–9.63)	2.68 (1.03–6.95)
Sociodemographic characteristics
Maternal age (yr) (mean ± SD)	32.34 ± 4.74	31.48 ± 4.59	0.97 (0.93–1.01)	0.95 (0.89–1.02)
Gestational age (wk) (mean ± SD)	11.54 ± 1.83	10.86 ± 1.71	0.80 (0.71–0.91)	0.69 (0.56–0.86)
Race/ethnicity
Caucasian	48 (81.36)	183 (82.43)	1	1
Asian	2 (3.39)	7 (3.15)	0.79 (0.20–3.11)	0.58 (0.07–4.77)
Black	4 (6.78)	22 (9.91)	0.98 (0.29–3.30)	4.32 (0.67–28.11)
Hispanic	5 (8.47)	10 (4.50)	0.50 (0.26–0.95)	0.67 (0.20–2.22)
Work status
Student or not working	18 (30.51)	51 (23.08)	1	1
Working	41 (69.49)	170 (76.92)	1.74 (1.02–2.95)	1.58 (0.72–3.45)
Lifestyle habits
Smoking before pregnancy	4 (6.78)	32 (14.41)	2.21 (0.95–5.16)	5.10 (1.45–18.00)
Caffeine intake before pregnancy	44 (74.58)	183 (82.43)	1.52 (0.88–2.61)	1.50 (0.50–4.48)
Use of alcohol before pregnancy	36 (61.02)	148 (66.67)	1.45 (0.98–2.16)	1.10 (0.55–2.20)
Prenatal care characteristics
First prenatal visit location
CHU Sainte-Justine	14 (23.73)	89 (40.09)	1	1
René-Laennec clinic	45 (76.27)	133 (59.91)	0.71 (0.54–0.95)	0.53 (0.31–0.88)
Practitioner met at first visit
Nurse and obstetrician/gynecologist	9 (15.25)	57 (26.64)	1	1
Obstetrician/gynecologist	50 (84.75)	157 (73.36)	0.50 (0.33–0.74)	0.72 (0.21–2.55)
Health status and medication
Infections or another situation causing nausea and/or vomiting during first trimester^c	5 (8.62)	40 (18.18)	2.07 (1.07–4.01)	1.74 (0.78–3.88)
Comorbidities before pregnancy^d
0	39 (66.10)	163 (73.42)	1	1
1	18 (30.51)	50 (22.52)	0.66 (0.41–1.07)	0.61 (0.31–1.17)
2 or 3	2 (3.39)	9 (4.05)	1.13 (0.29–4.35)	0.73 (0.14–3.73)
Anthropometric measures
First trimester weight gain (kg) (mean ± SD)	2.25 ± 2.13	1.61 ± 2.81	0.90 (0.84–0.97)	0.87 (0.79–0.95)

Table 4. Determinants of Women Who Received an Antiemetic Prescription During the First Prenatal Visit

Characteristic	No (n = 202)	Yes (n = 76)	Crude OR (95% CI)	Adjusted OR^a (95% CI)
	No. (%)	No. (%)
^a Adjusted for all variables of this column for which an adjusted odds ratio is presented. ^b Because of the small number of women experiencing severe NVP, those with moderate (n = 126) and severe (n = 7) symptoms were grouped. NVP = nausea and vomiting during pregnancy; BMI = body mass index.
NVP status
Severity of NVP
Mild	121 (62.05)	18 (24.00)	1	1
Moderate/severe^b	74 (37.95)	57 (76.00)	5.51 (2.66–11.42)	4.40 (1.90–10.17)
Excessive salivation	39 (19.80)	33 (43.42)	2.95 (1.72–5.05)	2.21 (1.11–4.38)
Antiemetic use in first trimester before the first prenatal visit	19 (9.69)	33 (43.42)	7.53 (4.57–12.38)	7.22 (3.39–15.38)
Sociodemographic characteristics
Country of birth
Canada	59 (29.21)	35 (46.05)	1.84 (1.21–2.79)	2.15 (0.82–5.64)
Other	143 (70.79)	41 (53.95)	1	1
Race/ethnicity
Caucasian	172 (85.15)	57 (75.00)	1	1
Asian	8 (3.96)	1 (1.32)	0.40 (0.03–4.93)	0.24 (0.01–4.24)
Black	12 (5.94)	13 (17.11)	2.96 (1.41–6.22)	2.23 (0.41–12.16)
Hispanic	10 (4.95)	5 (6.58)	1.47 (0.58–3.73)	1.13 (0.16–7.83)
Work status
Student or not working	51 (25.37)	17 (22.37)	1	1
Working outside the home	150 (74.63)	59 (77.63)	1.43 (1.05–1.94)	3.76 (2.36–6.00)
Education level
University completed	136 (67.66)	42 (55.26)	1	1
University not completed	65 (32.34)	34 (44.74)	1.63 (1.14–2.32)	1.91 (0.65–5.62)
Household income (CDN$/yr)
< 40,000	56 (28.43)	28 (38.36)	1	1
Between 40,000 and 79,999	53 (26.90)	16 (21.92)	0.65 (0.37–1.13)	0.73 (0.36–1.49)
≥ 80,000	88 (44.67)	29 (39.73)	0.71 (0.32–1.55)	1.27 (0.25–6.53)
Lifestyle habits
Exercise during first trimester	88 (44.22)	17 (22.37)	0.36 (0.21–0.61)	0.47 (0.17–1.28)
Caffeine intake during first trimester	124 (61.39)	37 (48.68)	0.58 (0.37–0.89)	0.58 (0.34–1.02)
Use of alcohol during first trimester	17 (8.46)	2 (2.63)	0.30 (0.07–1.35)	0.19 (0.01–2.39)
Prenatal care characteristics
First prenatal visit location
CHU Sainte-Justine	74 (36.63)	28 (36.84)	1	1
René-Laennec clinic	128 (63.37)	48 (63.16)	1.17 (1.03–1.33)	1.30 (0.67–2.55)
Practitioner met at first visit
Nurse and obstetrician/gynecologist	51 (25.76)	14 (19.44)	1	1
Obstetrician/gynecologist	147 (74.24)	58 (80.56)	1.42 (1.13–1.80)	1.09 (0.48–2.51)
Anthropometric measures
Prepregnancy BMI
Underweight or normal (BMI < 25 kg/m^2)	138 (69.35)	46 (63.89)	1	1
Overweight (25 ≤ BMI < 30 kg/m^2)	45 (22.61)	20 (27.78)	1.44 (0.90–2.30)	2.08 (0.83–5.16)
Obese (BMI ≥ 30 kg/m^2)	16 (8.04)	6 (8.33)	1.19 (0.61–2.34)	2.42 (1.00–5.85)

Discussion

Our study shows that the subject of nausea and vomiting during pregnancy was addressed at the first prenatal visit in most cases. However, the intensity or severity of symptoms and the extent to which they disturbed daily tasks were not routinely measured or addressed. The likelihood of women receiving an antiemetic prescription during the first prenatal visit was 27 percent. Globally, after adjustment for potential confounders, more severe nausea and vomiting symptoms, excessive salivation, antiemetic use before the first prenatal visit, lower gestational age, smoking before pregnancy, working outside the home, lowerfirst trimester weight gain, and receiving prenatal care at CHU Sainte-Justine clinic were found to be associated with a better management of nausea and vomiting during pregnancy compared with women at the René-Laennec clinic.

A low proportion of women reported being questioned about the intensity and severity of the symptoms or the extent to which the condition disrupted their daily tasks. This finding indicates that the subject of nausea and vomiting during pregnancy is not thoroughly investigated, and thus, clinical practice improvements are possible.

The doxylamine/ pyridoxine combination, the only antiemetic specifically indicated and labeled for the management of nausea and vomiting during pregnancy in Canada (12), was found to be the most commonly prescribed antiemetic in our study population, as it was in other Canadian studies (9,13). However, in our study population, a minority received a prescription for an antiemetic (27%), although some antiemetics have been proved effective and safe (1). This finding may be partly explained by the fact that our study population predominantly included women suffering from mild symptoms. It is also possible that women in the course of discussions with their physician minimized their symptoms or declined a prescription. As stated earlier, only one study has evaluated the management of this condition during prenatal care from a woman’s perspective (9). In that study, 41 percent of Canadian and 10 percent of American women reported that their health practitioner had recommended that they should take an antiemetic drug, but since that study mainly included severe cases, the generalizability of the results may be affected.

Similarly to a previous study (9), we found that few women (14%) who experienced nausea and vomiting during pregnancy were advised to use nonpharmacological methods to relieve their symptoms, even though the Society of Obstetricians and Gynaecologists of Canada recommends that dietary and lifestyle changes should be liberally encouraged (1). However, we cannot exclude the possibility that some practitioners might have avoided suggesting nonpharmacological methods since the efficacy of most is not well established (14,15).

Determinants of addressing nausea and vomiting of pregnancy

As hypothesized, more severe symptoms and antiemetic use during the first trimester were associated with an increased likelihood of addressing the subject of nausea and vomiting during pregnancy at the first prenatal visit. We found an association between smoking before pregnancy and the likelihood of addressing the subject of nausea and vomiting during the first prenatal visit. Since smoking is discouraged during pregnancy and special medical attention is given to smoking women (16), being a smoker could increase the likelihood of discussing other health issues during prenatal visit, such as nausea and vomiting.

Variables associated with a decreased likelihood of discussing the subject of nausea and vomiting during pregnancy with a practitioner included higher gestational age, higher first trimester weight gain, and receiving prenatal care at the René-Laennec clinic. Indeed, as a woman progresses in her pregnancy, symptoms tend to decrease. Furthermore, since earlier studies reported an association between small weight gain during pregnancy and nausea and vomiting during pregnancy (17), it is reasonable to think that women with smaller weight gain will experience more symptoms and thus have more chances to address the subject of nausea and vomiting compared with women with greater first trimester weight gain. In addition, since more attention was given to women who did not present with the expected first trimester weight gain (7), this factor could increase the chances of the condition being discussed.

Our results also suggest an association between the prenatal visit location and the management because CHU Sainte-Justine is a university health center. In this teaching unit, the learning process and the team work with medical residents could lead to a more complete history taking by medical students and residents than in a different clinic location.

Determinants of receiving an antiemetic prescription

As our results suggest, the severity of nausea and vomiting and excessive salivation (a condition related to nausea and vomiting during pregnancy) affects the likelihood of a woman receiving an antiemetic prescription during the first prenatal visit. Moreover, an association was found between the antiemetic use before the first prenatal visit and the likelihood of receiving an antiemetic prescription during this first visit. The reasons that could partly explain why antiemetics were used before the first prenatal visit are that 78 percent of women who received an antiemetic prescription during the first prenatal visit already had experienced one or more previous pregnancies and 52 percent of them had consulted other health professionals for their pregnancy before their first prenatal visit.

Our results also showed that working outside the home increased the likelihood of a woman obtaining an antiemetic prescription during the first prenatal visit. In fact, nausea and vomiting during pregnancy are associated with changes in an individual’s occupational tasks, and thus, patient time loss from work is worse for women employed outside their home than for unemployed women (3,8). Therefore, it is possible that employed women might be more likely to inquire about symptom relief to enable them to perform their work-related tasks.

Strengths and limitations

This study is the first to determine women’s likelihood of receiving an antiemetic prescription during the first prenatal visit and also the first to address the possible factors that can affect the management of nausea and vomiting during pregnancy. Because women experiencing this condition could be more likely than unaffected women to enroll in studies such as ours, the study was presented to eligible women as a general evaluation of their quality of life during pregnancy without specifically focusing on nausea and vomiting, thus avoiding selection bias. The questionnaire was distributed to pregnant women after their first prenatal visit, so that they would not be prompted to talk about nausea and vomiting during pregnancy more than they would have normally with their practitioner and, thus, increasing the validity of the study.

Having more than one recruitment site may increase the generalizability of the results, but women’s high education level and the high proportion having a household income greater than $80,000 per year from one of the sites may limit the external validity. Although our results reflect obstetrician practices and may not be representative of the prenatal care provided by family physicians or midwives, we believe that the management of nausea and vomiting during pregnancy can be improved and that our findings will help optimize the management irrespective of who provides prenatal care.

Conclusions

Our findings indicate that the management of nausea and vomiting during pregnancy can be improved. In fact, the subject of nausea and vomiting during pregnancy should be thoroughly investigated with respect to the severity of the symptoms and the extent to which this condition disrupts daily tasks. Nonpharmacological methods, such as dietary and lifestyle changes, should be routinely proposed. In view of our results, management of nausea and vomiting during pregnancy is suboptimal, based on the available guidelines for treatment. Moreover, this study showed that important factors such as symptom severity and work status should be considered to assess the need for providing antiemetic treatment. Continued medical education could address increasing knowledge about the management of nausea and vomiting during pregnancy. The findings of this study will hopefully help improve the management of this condition for women during prenatal care visits.

Acknowledgments

We thank the research nurses Marie Saint-Jacques, Valérie Tremblay, and Sophie Perreault for the recruitment of study participants in the different clinics.