Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 19-07: Vomiting of Pregnancy & Hyperemesis Gravidarum + Key Features Download Section PDF Listen +++ ++ "Morning sickness" Up to 75% of women complain of nausea and vomiting during early pregnancy Vast majority of symptomatic patients note nausea throughout the day Symptoms are particularly common with multiple pregnancy and hydatidiform mole Exerts no adverse effects on the pregnancy and does not presage complications + Clinical Findings Download Section PDF Listen +++ ++ Morning or evening nausea and vomiting usually begin soon after the first missed period and ceases after the fifth month Persistent, severe vomiting is hyperemesis gravidarum, a distinct entity (see Hyperemesis Gravidarum) + Diagnosis Download Section PDF Listen +++ ++ Clinical + Treatment Download Section PDF Listen +++ ++ Reassurance and dietary advice are adequate in most cases Vitamin B6, 50–100 mg orally once daily, is nontoxic and may help some patients Pyridoxine alone or in combination with doxylamine (10 mg doxylamine succinate and 10 mg pyridoxine hydrochloride, two tablets at bedtime) is first-line pharmacotherapy To limit the risk of teratogenicity, drug use in the first half of pregnancy should be limited to those of major importance to life and health (Tables 19–1 and 19–2) ++Table Graphic Jump LocationTable 19–1.Common drugs that are teratogenic or fetotoxic.1View Table||Download (.pdf)Table 19–1. Common drugs that are teratogenic or fetotoxic.1 ACE inhibitors Alcohol Androgens Angiotensin-II receptor blockers Antiepileptics (phenytoin, valproic acid, carbamazepine) Benzodiazepines Cyclophosphamide Diazoxide Diethylstilbestrol Disulfiram Ergotamine Estrogens Griseofulvin Isotretinoin Lithium Methotrexate Misoprostol NSAIDs (third trimester) Opioids (prolonged use) Radioiodine (antithyroid) Reserpine Ribavirin Sulfonamides (second and third trimesters) Tetracycline (third trimester) Thalidomide Tobacco smoking Warfarin and other coumarin anticoagulants 1Many other drugs are also contraindicated during pregnancy. Evaluate any drug for its need versus its potential adverse effects. Further information can be obtained from the manufacturer or from any of several teratogenic registries around the country.Go to https://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm134848.htm for more information.ACE, angiotensin-converting enzyme; NSAIDs, nonsteroidal anti-inflammatory drugs. ++Table Graphic Jump LocationTable 19–2.Drugs and substances that require a careful assessment of risk before they are prescribed for breastfeeding women.1View Table||Download (.pdf)Table 19–2. Drugs and substances that require a careful assessment of risk before they are prescribed for breastfeeding women.1 Drugs Concern Atenolol Has been associated with hypotension and bradycardia in the infant. Metoprolol and propranolol are preferred. Ciprofloxacin Association with adverse effects on fetal cartilage and bone. Must weigh risks versus benefits. Codeine, oxycodone Cause CNS depression. Unpredictable metabolism. Cyclophosphamide Neonatal neutropenia. No breastfeeding. Diphenhydramine Present in very small quantities in milk; sources are conflicting with regard to its safety. Fluoxetine Present in breast milk in higher levels than other SSRIs. Watch for adverse effects like an infant’s fussiness and crying. Lisinopril Unknown effects. Captopril or enalapril is preferred if an ACE inhibitor is needed. Lithium Circulating levels in the neonate are variable. Follow infant’s serum creatinine and blood urea nitrogen levels and thyroid function tests. Tetracyclines Concern for bone growth and dental staining. Valproic acid Long-term effects are unknown. Although levels in milk are low, it is teratogenic, so it should be avoided if possible. 1The above list is not all-inclusive. For additional information, see the below reference from which this information is adapted or the online drug and lactation database, Lactmed, at http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm.ACE, angiotensin-converting enzyme; CNS, central nervous system; SSRIs, selective serotonin reuptake inhibitors.Data from Rowe H et al. Maternal medication, drug use, and breastfeeding. Pediatr Clin North Am. 2013 Feb;60(1):275–94.