Vomiting in pregnancy (including hyperemesis gravidarum) 

First line agents (mild symptoms )

1. Ginger
   • 250 mg orally, up to 4 times a day
   • Maximum dose 2g per day
   • May cause acid reflux
2. Pyridoxine (vitamin B6) 25 mg tablets
   • 10 mg to 25 mg orally, up
   • to 3 – 4 times a day,
   • maximum 200 mg/day
   • More effective when used in combination with doxylamine
   • Prolonged high doses are associated with peripheral neuropathy (associated with doses >500 mg/day)
3. Doxylamine – 25 mg tablets
   • 6.25mg mg to 25 mg orally up
   • to 3 times a day, maximum of 50 mg/day
   • May cause sedation
   • Use in combination with pyridoxine

Second line agents (moderate symptoms)

4. Cyclizine – 50 mg tablets
   • 12.5 mg to 50 mg orally
   • up to 3 times a day
   • maximum 150 mg/day
   • May cause sedation
5. Promethazine – 10 mg, 25 mg tablets or 50mg/2 mL injection
   • 10 mg to 25 mg orally, up to 3 to 4 times a day
   • 25mg IM 3 to 4 times a day
   • Maximum 100mg/day
   • High doses given close to delivery have caused prolonged neurological disturbances in the infant
6. Prochlorperazine – 5 mg tablets, 12.5 mg/mL injection
   • 5 mg to 10 mg orally, up to 3 to 4 times a day
   • maximum 30 mg/day
   • 12.5 mg IM 3 times a day
   • 5mg to 10 mg IV 3 to 4 times a day
   • High doses given close to delivery have caused prolonged neurological disturbances in th infant
7. Metoclopramide – 10 mg tablets, 10 mg/2 mL injection
   • 10 mg orally 3 times a day
   • 10 mg IM or IV 3 times a day
   • Maximum 30 mg/day
8. Domperidone – 10 mg tablets
   • 10 mg orally, up to 3 times a day, maximum 30 mg/day
9. Ondansetron – 4 mg, 8 mg tablets, 4 mg, 8 mg wafers, 4 mg/2 mL injection, 8 mg/2 mL injection
   • 4 to 8 mg orally, 2 to 3 times a day
   • 4 to 8 mg IV, 8 to 12 hourly (usual maximum 16 mg/day) 
   • Conflicting suggestions that first trimester use is associated with increased rates of cardiac defects
   • and oral clefts
   • Consider laxatives and patient education about constipation
   • Can also cause headaches and Dizziness

Third line agents (severe symptoms – PUQE-24 score ≥13)

10. Hydrocortisone – 100 mg/ 2 mL injection
    • 100 mg IV twice a day
    • Once clinical improvement occurs switch to oral prednisolone
11. Prednisolone – 1 mg, 5 mg, 25 mg tablets
    • 5 mg/mL oral liquid
    • 40 mg to 50 mg orally
    • once a day
    • Gradually taper dose until the lowest dose to reduce the symptoms is reached 
    • Limit to women with intractable nausea and vomiting