Morning sickness

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Morning sickness:
What is morning sickness?
Morning sickness, also called nausea gravidarum, nausea, vomiting of pregnancy (emesis gravidarum or NVP), or pregnancy sickness is a pregnancy discomfort that affects more than half of all pregnant women. For some pregnant women, the symptoms are worse in the morning and ease up over the course of the day, but they can strike at any time and, for most women, last all day long. The intensity of symptoms can vary from woman to woman, too. Of course, just because morning sickness is common—and likely to last "only" a few months—doesn't mean it's not a challenge. Even a mild case of nausea can wear you down, and bouts of round-the-clock
nausea and vomiting can leave you exhausted and miserable
What are other facts you need to know?
Overall, this condition affects about three quarters of pregnant women during the first trimester. About half of pregnant women suffer from both nausea and vomiting, one quarter have nausea alone, and one quarter luck out altogether. The nausea usually starts around 6 weeks of pregnancy, but it can begin as early as 4 weeks. It tends to get worse over the next month or so.
About half of the women who get nausea during pregnancy feel complete relief by about 12-14 weeks. For most of the rest, it takes another month or so for the queasiness to ease up, though it

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may return later and come and go throughout pregnancy. A small percentage of women have symptoms that persist continually (or nearly so) until delivery.
Morning sickness is not harmful to you or your baby, but if you experience excessive vomiting and cannot manage to keep your food down, you may have hyperemesis gravidarum. Hyperemesis gravidarum can be harmful to you and your baby if severe and left untreated, due to the possible lack of nutrients and electrolyte imbalances. The most important thing is to inform your doctor when these symptoms appear and discuss possible options for treatment.
Causes
No one knows for sure what causes nausea during pregnancy, but it's probably some combination of the many physical changes taking place in your body. Some possible causes include:
Proximate causes:
 An increase in salivation during the first trimester, that often bitter taste (Ptyalism), is then ingested during the mother's sleep. This can upset the stomach enough to cause the morning nausea.
 Human chorionic gonadotropin (hCG). This hormone rises rapidly during early pregnancy. No one knows how hCG contributes to nausea, but it's a prime suspect because the timing is right: Nausea tends to peak around the same time as levels of hCG. What's more, conditions in which women have higher levels of hCG, such as carrying multiples, are associated with higher rates of nausea and vomiting.
 Estrogen. This hormone, which also rises rapidly in early pregnancy, is another suspect. However, there is no consistent evidence of differences in estrogen levels and levels of bilirubin between women that experience sickness and those that do not.
 Progesterone. This hormone relaxes the muscles in the uterus, which prevents early childbirth, but may also relax the stomach and intestines, leading to excess stomach acids and gastroesophageal reflux disease.
 An enhanced sense of smell and sensitivity to odors. It's not uncommon for a newly pregnant woman to feel overwhelmed by the smell. Certain aromas instantly trigger the gag reflex. (Some researchers think this may be a result of higher levels of estrogen, but no one knows for sure.)
 A sensitive stomach. Some women's gastrointestinal tracts are simply more sensitive to the changes of early pregnancy. Also, some research suggests that women with a stomach bacterium called Helicobacter pylori are more likely to have nausea and vomiting. Not all studies confirm this link, though.
 Stress. Some researchers have proposed that certain women are psychologically predisposed to having nausea and vomiting during pregnancy as an abnormal response to stress. However, there's no conclusive evidence to support this theory. (Of course, if you're constantly nauseated or vomiting a lot, you certainly may begin to feel more stressed!)
 An increase in bilirubin levels due to increased liver enzymes.

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 Low blood sugar (hypoglycemia) due to the placenta's draining energy from the mother, though studies have not confirmed this except for in Type I diabetic expectant mothers
Note that; gastroesophageal reflux disease can also be caused by pregnancy, and may result in nausea and vomiting.
Morning sickness as a defense mechanism:
Morning sickness is understood as an evolved trait that protects the fetus against toxins ingested by the mother. Many plants contain chemical toxins that serve as a deterrent to being eaten. Adult humans, like other animals, have defenses against plant toxins, including extensive arrays of detoxification enzymes manufactured by the liver and the surface tissues of various other organs. In the fetus, these defenses are not yet fully developed, and even small doses of plant toxins that have negligible effects on the adult can be harmful or lethal to the embryo. Pregnancy sickness causes women to experience nausea when exposed to the smell or taste of foods that are likely to contain toxins injurious to the fetus, even though they may be harmless to her.
There is considerable evidence in support of this theory, including:
 Morning sickness is very common among pregnant women, which argues in favor of its being a functional adaptation and against the idea that it is pathology.
 Fetal vulnerability to toxins peaks at around 3 months, which is also the time of peak susceptibility to morning sickness.
 There is a good correlation between toxin concentrations in foods, and the tastes and odors that cause revulsion.
Women who have no morning sickness are more likely to miscarry. This may be because such women are more likely to ingest substances that are harmful to the fetus. In addition to protecting the fetus, morning sickness may also protect the mother. A pregnant woman's immune system is suppressed during pregnancy, presumably to reduce the chances of rejecting tissues of her own offspring. Because of this, animal products containing parasites and harmful bacteria can be especially dangerous to pregnant women. There is evidence that morning sickness is often triggered by animal products including meat and fish.
If morning sickness is a defense mechanism against the ingestion of toxins, the prescribing of anti-nausea medication to pregnant women may have the undesired side effect of causing birth defects or miscarriages by encouraging harmful dietary choices. On the other hand, many domestic vegetables have been purposely bred to have lower levels of toxins than in the distant past, and so the level of threat to the embryo may not be as high as it was when the defense mechanism first evolved.

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Are some pregnant women more likely than others to feel nauseated?
You're more likely to have nausea or vomiting during your pregnancy if any of the following apply:
 You're pregnant with twins or higher multiples. This may be from the higher levels of hCG, estrogen, progesterone or other hormones in your system. You're also more likely to have a more severe case than average. On the other hand, it's not a definite thing— some women carrying twins have little or no nausea.
 You had nausea and vomiting in a previous pregnancy.
 You have a history of nausea or vomiting as a side effect of taking birth control pills. This is probably related to your body's response to estrogen.
 You have a history of motion sickness.
 You have a genetic predisposition to nausea during pregnancy. If your mother or sisters had severe morning sickness, there's a higher chance you will, too.
 You have a history of migraine headaches.
 You're carrying a girl. One study found that women with severe nausea and vomiting in the first trimester were 50 percent more likely to be carrying a girl.
Will my nausea affect my baby?
The mild to moderate nausea and occasional vomiting commonly associated with morning sickness won't threaten your baby's well-being. If you don't gain any weight in the first trimester, it's generally not a problem as long as you're able to stay hydrated and can keep some food down. In most cases, your appetite will return soon enough and you'll start gaining weight.
If nausea keeps you from eating a balanced diet, make sure you're getting the nutrients you need by taking a prenatal vitamin.
Severe and prolonged vomiting, however, has been linked to a greater risk of preterm birth, low birth weight, and newborns who are small for their gestational age. However, a large study of women who were hospitalized with severe vomiting found that those who were able to gain at least 15.4 pounds (7kg) during their pregnancy had no worse outcomes than other women.
When to see a doctor Contact your pregnancy care provider if:
 The nausea or vomiting is severe
 You pass only a small amount of urine or it's dark in color
 You can't keep down liquids
 You feel dizzy or faint when you stand up
 Your heart races
 You vomit blood

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What causes morning sickness isn't clear, but the hormonal changes of pregnancy are thought to play a role. Rarely, severe or persistent nausea or vomiting may be caused by a medical condition unrelated to pregnancy — such as thyroid or liver disease
What to expect from your doctor Some potential questions your doctor or pregnancy care provider might ask include:
 How long have you been experiencing symptoms?
 How often do you experience bouts of nausea or vomiting?
 How severe are your symptoms?
 Do you notice certain triggers for your nausea or vomiting?
 Do you experience your symptoms at certain times during the day or all the time?
 Are you taking a prenatal vitamin? Do you regularly take any other medications?
 What, if anything, makes you feel better?
 What, if anything, makes you feel worse?
Morning sickness is typically diagnosed based on your signs and symptoms. If your pregnancy care provider suspects hyperemesis gravidarum, you may need various urine and blood tests. Your pregnancy care provider may also do an ultrasound to confirm the number of fetuses and detect any underlying conditions that may be contributing to the nausea.
Treatment isn't necessary for most cases of morning sickness. Unless If your morning sickness symptoms persist you may need treatment.
What can you do to get relief?
If you have a mild case of nausea and vomiting, some relatively simple measures may be enough to help. (If not, there are safe and effective medications you can take.) Many of the following suggestions are not supported by hard evidence, but obstetricians and midwives commonly recommend them, and many women swear by them.
 Eat small, frequent meals and snacks throughout the day so your stomach is never empty. Some women find that carbohydrates are most appealing when they feel nauseated, but one small study found that high-protein foods were more likely to ease symptoms. Whatever you eat, eat it slowly.
 Avoid lying down after eating (especially on your left side), as this can slow digestion.
 Keep simple snacks, such as crackers, by your bed. When you first wake up, nibble a few crackers and then rest for 20 to 30 minutes before getting up. Snacking on crackers may also help you feel better if you wake up nauseated in the middle of the night. By the way, getting up slowly in the morning—sitting on the bed for a few minutes rather than jumping right up—may also be helpful.
 Try to avoid foods and smells that trigger your nausea. If that seems like almost everything, it's okay to eat the few things that do appeal to you for this part of your pregnancy, even if they don't add up to a perfectly balanced diet.

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 Try to eat food cold or at room temperature, because food tends to have a stronger aroma when it's hot.
 Avoid fatty foods, which take longer to digest. Also steer clear of spicy, acidic, and fried foods, which can irritate your digestive system. It might help to stick to bland foods.
 Brush your teeth and rinse out your mouth after eating.
 Try drinking fluids mostly between meals. You might find cold, carbonated beverages easiest to keep down. (Some women also find sour drinks, such as lemonade, easier to handle.)
 Don't drink so much at one time that your stomach feels full, as that will make you less hungry for food. A good strategy is to sip fluids throughout the day. Try using a straw if sipping isn't going well.
 Aim to drink about a quart and a half each day. If you've been vomiting a lot, try a sports drink that contains glucose, salt, and potassium to replace lost electrolytes.
 Watch for non-food triggers, too. A warm or stuffy room, the smell of heavy perfume, a car ride, or even certain visual stimuli, like flickering lights, might trigger your nausea. So might changing positions too quickly. Avoidance of triggers can become an important part of your treatment.
 Get fresh air. A walk or an open window might ease your nausea.
 Nausea can become worse if you're tired, so give yourself time to relax and take naps when you can. Watching a movie (preferably not one about food!) or visiting with a friend can help relieve stress and take your mind off your discomfort.
 Try hypnosis—while there's no definitive evidence that it helps with morning sickness, it has been shown to be effective in combating nausea during chemotherapy.
 Try taking your prenatal vitamins with food or just before bed. You might also want to ask your healthcare provider whether you can switch to a prenatal vitamin with a low dose of iron or no iron for the first trimester, since this mineral can be hard on your digestive system. If the prenatal vitamin still makes you nauseated, ask if you can stop taking it until your nausea gets better.
 Ask someone else to cook for you and open the windows or turn on fans if the odor bothers you.
 Drink lemonade or eat watermelon to relieve nausea
 Eat salty potato chips ( they have been found to settle stomachs enough to eat a meal)
 Try ginger, an alternative remedy thought to settle the stomach and help quell queasiness. See if you can find ginger ale made with real ginger. (Most supermarket ginger ales aren't.) Grate some fresh ginger into hot water to make ginger tea, or see if ginger candies or crystallized ginger helps. Research shows that taking powdered ginger root in capsules may provide some relief. Unfortunately, there's no way to be sure how much of the active ingredient you're getting in these ginger supplements, so talk to your provider before taking them. (As with many other things that are helpful in small amounts, the effects of megadoses are unknown.)Also safety concerns have been raised regarding its anticoagulant properties

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Some women find similar relief from sipping peppermint tea or from sucking peppermint candies, especially after eating.
 Try an acupressure band, a soft cotton wristband that's sold at drugstores. You strap it on so that the plastic button pushes against an acupressure point on the underside of your wrist. This simple and inexpensive device, designed to ward off seasickness, has helped some pregnant women through morning sickness—although research suggests that it may be largely a placebo effect.
 Consider seeing an acupuncturist who has experience treating nausea during pregnancy.
 Ask your provider about a device that stimulates the underside of your wrist with a mild electric current. This "acustimulation" device is safe, though it can cause local skin irritation. (Be sure to use the gel that comes with it to help prevent this from occurring.)
 Experiment with aromatherapy. Some women find scents such as lemon, mint, or orange useful. You can use a diffuser to dispense an essential oil, or you can carry a drop or two of an essential oil on a handkerchief to smell when you start to feel queasy. (Essential oils are very strong, so use only one or two drops.)
Medications
If you've been unable to find relief from your nausea, talk with your provider about medication. There's no need to continue to suffer, and waiting too long to take appropriate medication may make your condition more difficult to treat. A number of antiemetics are effective and safe in pregnancy including: pyridoxine/doxylamine, antihistamines (such as diphenhydramine), and phenothiazines (such as promethazine).With respect to effectiveness it is unknown if one is superior to another. In the United States and Canada, the doxylamine-pyridoxine combination (as Diclegis in US and Diclectin in Canada) is the only approved Pregnancy Category "A" prescription treatment for nausea and vomiting of pregnancy.
Ondansetron may be beneficial, but there are some concerns regarding an association with cleft palate, and there is little high quality data.Metoclopramide is also used and relatively well tolerated. Evidence for the use of corticosteroids is weak. Also your pregnancy care provider may prescribe vitamin B-6 supplements,
If you have hyperemesis gravidarum, you may need to be treated with intravenous (IV) fluids and anti-nausea medications in the hospital.
NOTE: There’s no proven way to prevent morning sickness. Before conception, however, it may help to take prenatal vitamins. Several older studies suggest that women who take multivitamins at the time of conception and during early pregnancy are less likely to experience severe morning sickness. The folic acid in prenatal vitamins also helps prevent neural tube defects, such as spina bifida.

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Could my prenatal vitamin be making me nauseated?
From The BabyCenter Editorial Team
It could be. Some pregnant women do have trouble tolerating certain prenatal supplements, especially those with a lot of iron.
The American College of Obstetricians and Gynecologists (ACOG) recommends that all pregnant women get 27 milligrams (mg) of iron per day, and the Centers for Disease Control and Prevention (CDC) recommends that all pregnant women take a daily supplement containing 30 mg of iron. Some prenatal vitamins contain more than that, so check the label.
If your vitamin contains excessive iron, switch to one with less (as long as you're not anemic). Ask your doctor or midwife to recommend a vitamin with the right amount of iron for you.
You can also try taking your prenatal vitamin with food or just before you go to bed. Or break the tablet in half and take it in divided doses. If these suggestions don't help, ask your provider whether you can switch to a prenatal vitamin without iron during your first trimester and get iron from food sources instead.
Also, make sure that your prenatal vitamin contains vitamin B6. Research indicates that vitamin B6 may help relieve nausea in some women during pregnancy.
If you just can't stomach prenatal vitamins, try to make sure you get enough folic acid. The CDC reports that taking folic acid (a synthetic form of folate) in the months before pregnancy and during the first trimester reduces the risk of neural tube birth defects by up to 70 percent.
Experts recommend consuming 400 micrograms (mcg) of folic acid daily while trying to conceive and when pregnant. (This is in addition to the folate you get from food, which your body doesn't absorb as well as the synthetic kind.) Your prenatal supplement should contain at least that much.
Does vitamin B6 help relieve morning sickness?
From The BabyCenter Editorial Team
Research studies have shown that taking extra vitamin B6 (also known as pyridoxine) helps relieve queasiness for some pregnant women, though no one knows exactly how it does this.
Pregnant women need only 1.9 milligrams (mg) of this vitamin a day to help make antibodies, red blood cells, and neurotransmitters and to meet the needs of their developing baby.
Vitamin B6 is found in a wide variety of foods, so you may satisfy this requirement by eating a varied and nutritious diet. Foods such as bananas, nuts, green beans, carrots, cauliflower,

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potatoes, lean meats, and fish are good sources of vitamin B6. (Prenatal vitamins contain B6 as well.)
To ease nausea and vomiting, your practitioner may suggest that you start by taking 25 mg, three times a day. (Up to 200 mg of vitamin B6 a day can be used to treat morning sickness.)
Check with your healthcare provider. She can tell you how much to take and whether or not the amount in your prenatal vitamin should count as one of the doses. (The amount of vitamin B6 in prenatal supplements varies.)
Don't take more B6 than your caregiver recommends. Too much can cause numbness and nerve damage for you and may not be safe for your developing baby.
REFERENCE:
1. Lagiou, P; Tamimi, R; Mucci, LA; Trichopoulos, D; Adami, HO; Hsieh, CC (April 2003). "Nausea and vomiting in pregnancy in relation to prolactin, estrogens, and progesterone: a prospective study". Obstetrics and gynecology 101 (4): 639–44. doi:10.1016/s0029-7844(02)02730-8. PMID 12681864. Retrieved 27 February 2014.
2. Erick, Miriam (2004). Managing Morning Sickness: A Survival Guide for Pregnant Women. Bull Publishing Company. ISBN 0-923521-82-8. Retrieved 2008-07-06.
3. Profet, Margie (1992). "Pregnancy Sickness as Adaptation: A Deterrent to Maternal Ingestion of Teratogens". In Barkow, John; Cosmides, Jerome; Tooby, Leda. The Adapted Mind: Evolutionary Psychology and the Generation of Culture. Oxford University Press
4. Sherman, Paul W.; Flaxman, Samuel M. (2002). "Nausea and vomiting of pregnancy in an evolutionary perspective". Am J Obstet Gynecol 186 (5): S190–S197. doi:10.1067/mob.2002.122593. PMID 12011885.
5. Tiran, Denise (Feb 2012). "Ginger to reduce nausea and vomiting during pregnancy: Evidence of effectiveness is not the same as proof of safety". Complementary Therapies in Clinical Practice 18 (1): 22. doi:10.1016/j.ctcp.2011.08.007. ISSN 1744-3881.
6. Koren, G (October 2012). "Motherisk update. Is ondansetron safe for use during pregnancy?". Canadian family physician Medecin de famille canadien 58 (10): 1092–3. PMC 3470505. PMID 23064917
7. Jarvis, S; Nelson-Piercy, C (Jun 17, 2011). "Management of nausea and vomiting in pregnancy.". BMJ (Clinical research ed.) 342: d3606. doi:10.1136/bmj.d3606. PMID 21685438.
8. http://www.babycenter.com/404_does-vitamin-b6-help-relieve-morning-sickness_2519.bc
9. http://www.babycenter.com/404_could-my-prenatal-vitamin-be-making-me- nauseated_2076.bc

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