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LEARNING OBJECTIVES

  1. Discuss the pathophysiology of nausea and vomiting, gastroesophageal reflux disease (GERD), constipation, insomnia, and thromboembolism of pregnancy.

  2. Compare and contrast medications used for the treatment of nausea and vomiting, constipation, diarrhea, GERD, cough and cold, and venous thromboembolism (VTE) during pregnancy.

  3. List antibiotics that can be safely used to treat infectious diarrhea during pregnancy.

  4. Formulate a comprehensive clinical plan, including non-pharmacologic and pharmacologic therapy for a pregnant woman with nausea and vomiting, GERD, constipation, and VTE.

INTRODUCTION

During pregnancy there are many common conditions which have unique management strategies as a result of the limited information on drug safety during pregnancy. These conditions include nausea and vomiting, gastrointestinal reflux, changes in bowel function, insomnia, infections, and thromboembolism. The principles of drug safety in pregnancy are discussed in depth in Chapter 17: Principles of Drug Therapy in Pregnancy and Lactation. In this chapter, the focus will be to review the management of symptoms associated with these conditions and discuss any potential impact on the mother or developing fetus. Unfortunately, there is often limited clinical data in the setting of treatments in pregnancy. Management recommendations are primarily conservative non-pharmacologic interventions, which proceed to pharmacologic interventions until there is resolution of symptoms.

Patient Case (Part 1)

A.M. is a 31-year-old woman who presents to the pharmacy. She states, “I need something to help me stop this nauseous feeling.”

HPI: A.M. describes the nauseated feeling being strongest in the morning then reappearing periodically throughout the day. She denies fever, weight loss, dehydration, abdominal discomfort, and vomiting. She is currently 7 weeks pregnant.

PMH: She has no active medical conditions. She has a history of one miscarriage.

Family History: Noncontributory.

Social History: Denies alcohol use. Quit smoking 2 years ago. She works as a middle school librarian and has missed 1 day of work this week because of her nausea.

Medications: A.M. takes a prenatal vitamin daily and has not tried any interventions to control her nausea.

Allergies: NKDA.

Laboratory values: Within normal limits.

Physical Examination: Weight 68 kg; Height: 166 cm; Temp 37oC; BP106/72 mm Hg (seated); P 84 (seated); BP 110/70 mm Hg (standing); P 88 (standing).

Assessment: Nausea—likely etiology is pregnancy-related nausea.

NAUSEA AND VOMITING DURING PREGNANCY /HYPEREMESIS GRAVIDARUM

Nausea and vomiting is a common occurrence in pregnancy. The duration and severity of these symptoms vary from one individual to another. It occurs along a continuum and can progress to a condition called hyperemesis gravidarum. In hyperemesis gravidarum, persistent vomiting can result in weight loss, ketonuria, gastrointestinal bleeding due to Mallory Weiss esophageal tears, electrolyte disturbances, fluid loss, and intrauterine growth restriction.1 Treatment in the early stages may prevent progression to more serious complications and hospitalization. One example of a tool is The Wellmom—Managing nausea and vomiting of pregnancy (NVP) application, which can assist the patient or patient’s primary obstetrical provider. The ...

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