Related guidance:

Nausea and Vomiting: treatment during pregnancy (SPS January 2022, updated April 2022)

The palliative care handbook, A Good Practice Guide (Wessex Palliative Physicians 2019)

Nausea/vomiting in pregnancy (NICE CKS updated February 2024)

If a woman (age 13 years to 60 years) has nausea and vomiting in pregnancy:

  • Offer advice on sources of information and support, such as:
  • Reassure that mild-to-moderate symptoms are common in pregnancy and usually resolve by 16–20 weeks of gestation.
  • Advise on the following self-care measures for mild-to-moderate symptoms:
    • Rest as needed, and try to avoid sensory stimuli that may trigger symptoms, such as odours, heat, and noise.
    • Try eating plain biscuits or crackers in the morning.
    • Try eating bland, small, frequent protein-rich meals which are low in carbohydrate and fat.
    • Cold meals may be more easily tolerated if nausea is smell-related.
    • Drinking little and often, rather than large amounts.
    • Ginger (can be taken in fresh, tea, capsule, or syrup form).
    • Acupressure (such as over the P6 point on the ventral aspect of the wrist using a wrist band or finger pressure).
  • Advise avoiding medications that may contribute to symptoms, such as iron-containing preparations, depending on clinical judgement.
  • Advise on the management of associated gastro-oesophageal reflux disease, oesophagitis, or gastritis symptoms.
  • Advise on the need for urgent medical review if the woman develops clinical features suggesting a complication or alternative cause for symptoms.
  • Advise that for any subsequent pregnancy, early use of lifestyle measures and antiemetic drug treatment before or immediately at the start of symptoms may be helpful.
  • If nausea and vomiting symptoms persist despite self-care information and advice, discuss the option of drug treatment(s), taking into account the woman’s preferences, severity of symptoms, response to treatments in previous pregnancies (if appropriate), and advantages and disadvantages of different treatments.
  • Prescribe oral cyclizine or promethazine (antihistamines), prochlorperazine or chlorpromazine (phenothiazines), first-line, and reassess the woman after 24 hours.
  • If symptoms respond to treatment, continue and review the woman once a week thereafter, depending on clinical judgement.
  • If first-line treatment is ineffective, switch to a second-line antiemetic from a different drug class, such as oral metoclopramide or domperidone (dopamine receptor antagonists), or ondansetron (a 5-HT3 receptor antagonist), and reassess the woman after 24 hours.
    • Oral metoclopramide should not be prescribed for longer than 5 days due to the risk of neurological extrapyramidal adverse effects.
    • Oral domperidone should not be prescribed for longer than 7 days due to the risk of cardiac adverse effects.
    • Oral ondansetron should not be prescribed for longer than 5 days.
      • Advise that exposure to ondansetron during the first trimester of pregnancy is associated with a small increased risk of the baby having a cleft lip and/or palate.If symptoms respond to second-line treatment, continue and review the woman once a week thereafter, depending on clinical judgement.
  • If second-line treatment is ineffective, seek specialist advice.
  • Review the need for ongoing treatment, and advise on gradually reducing and stopping medication when symptoms improve, depending on clinical judgement.
    • It may be possible to stop antiemetic medication at around 12–16 weeks of pregnancy when symptoms have usually improved.
    • Gradually tapering the dose may reduce the risk of symptoms recurring.
  • Consider arranging hospital admission if the woman has persistent moderate-to-severe nausea and vomiting and:
    • Suspected hyperemesis gravidarum despite oral antiemetic treatment.
    • A suspected severe or serious complication.
    • Symptoms are not controlled with management in primary care.
    • Is unable to tolerate oral antiemetics or oral fluids.
    • Is unable to tolerate other necessary oral drug treatment, such as antibiotics for a urinary tract infection or usual medication for comorbid conditions.
    • Note: have a lower threshold for admitting to hospital or seeking specialist advice if the woman has a co-morbidity such as diabetes mellitus, which may be adversely affected by symptoms.
  • Offer referral for psychological and social support if needed.
  • For adults 18 years of age and older, prescribe oral ondansetron: 4–8 mg 6–8 hourly, for a maximum of 5 days.
  • Do not prescribe ondansetron to people with: Congenital long QT syndrome, Hereditary problems of galactose intolerance, Lapp lactase-deficiency or glucose-galactose malabsorption.
  • Prescribe ondansetron with caution to people with: QT interval prolongation — for example electrolyte disturbances and use of drugs that prolong the QT interval, Moderate-to-severe hepatic impairment — decreased clearance. Do not exceed a daily dose of 8 mg, Subacute intestinal obstruction — ondansetron increases large bowel transit time and Adenotonsillar surgery.
Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Antiemetics and Antinauseants
AntihistaminesCyclizine50mg tablet: £3.14 (100)For nausea and vomiting.

Adult: 50 mg up to 3 times a day.

For palliative care as per Wessex palliative care handbook.
50mg/1ml solution for injection ampoule: £5.16 (5)
Promethazine10mg tablet: £13.29 (56)For nausea and vomiting.

Adult: 20–25 mg, to be taken at bedtime on night before travel, repeat following morning if necessary.
25mg tablet: £24.34 (56)
Doxylamine with pyridoxine

as Xonvea®
10mg and 10mg gastro-resistant tablet: £28.50 (20)Nausea and vomiting in pregnancy where other options not appropriate due to adverse effects.

Adult: 20/20 mg once daily for 2 days, to be taken at bedtime; increased if necessary to 10/10 mg, to be taken in the morning and 20/20 mg, to be taken at bedtime; increased if necessary to 10/10 mg, to be taken in the morning, 10/10 mg, to be taken mid-afternoon and 20/20 mg, to be taken at bedtime; maximum 40/40 mg per day.
Dopamine receptor antagonistsDomperidoneIndication restricted to nausea and vomiting, new contraindications, and reduced dose and duration of use. See MHRA (December 2014) for Domperidone: risks of cardiac side effects.

A European review confirmed a small increased risk of serious cardiac side effects. A higher risk was observed particularly in people older than 60 years, people taking daily oral domperidone doses of more than 30 mg, and those taking QT-prolonging medicines or CYP3A4 inhibitors at the same time as domperidone.

The overall safety profile of domperidone, and in particular its cardiac risk and potential interactions with other medications, should be taken into account if there is a clinical need to use it at doses or durations greater than those authorised (eg, to control side effects of Parkinson’s disease treatment in some patients).
Domperidone is no longer licensed for use in children younger than 12 years or those weighing less than 35 kg. Results from a placebo-controlled study in children younger than 12 years with acute gastroenteritis did not show any difference in efficacy at relieving nausea and vomiting compared with placebo. See MHRA (December 2019) for Domperidone for nausea and vomiting: lack of efficacy in children; reminder of contraindications in adults and adolescents.
10mg tablet: £0.66 (30)Nausea and vomiting and acute migraine for adults and adolescents over 12 years of age and weighing 35 kg or more, the recommended maximum dose in 24 hours is 30 mg (10 mg up to three times a day)

The maximum treatment duration should not usually exceed one week.
1mg/ml oral suspension sugar free: £24.85 (200 ml)
Metoclopramide Restricted dose and duration of use. See MHRA (December 2014) for Metoclopramide: risk of neurological adverse effects.

The EU review has recommended changes that include a restriction to the dose and duration of use to help minimise the risk of potentially serious neurological adverse effects. The risk of acute neurological effects is higher in children than in adults.

In adults, metoclopramide remains indicated for: prevention of postoperative nausea and vomiting radiotherapy-induced nausea and vomiting delayed (but not acute) chemotherapy-induced nausea and vomiting symptomatic treatment of nausea and vomiting, including that associated with acute migraine (where it may also be used to improve absorption of oral analgesics).

In children, age 1–18 years, metoclopramide should only be used as a second-line option for prevention of delayed chemotherapy-induced nausea and vomiting, and for treatment of established postoperative nausea and vomiting.

Use of metoclopramide is contraindicated in children younger than 1 year.
10mg tablet: £0.98 Nausea and vomiting and acute migraine for adults, the usual dose is 10 mg up to three times a day, the maximum dose in 24 hours is 30mg.

For children age 1 year or older, the recommended dose is 0.1–0.15 mg per kg bodyweight, repeated up to 3 times a day - the maximum dose in 24 hours is 0.5 mg per kg bodyweight.

Metoclopramide should only be prescribed for short-term use (up to 5 days).
5mg/5ml oral solution sugar free: £19.79 (150 ml)
Serotonin (5HT3) receptor antagonistOndansetronRecent epidemiological studies suggest exposure to ondansetron during the first trimester of pregnancy is associated with a small increased risk of the baby having a cleft lip and/or cleft palate. See MHRA (January 2020) for Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy.
4mg tablet: £1.50 (10)NHS Somerset classify as an Amber drug for nausea and vomiting in pregnancy or other non-chemotherapy related nausea and vomiting unresponsive to other antiemetics, only when initiated by a specialist (off-label).

Manufacturer advises avoid in first trimester—small increased risk of congenital abnormalities such as orofacial clefts and avoid in breast feeding.

Caution and maximum 8 mg daily in moderate to severe hepatic impairment.
8mg tablet: £3.94 (10)
Ondansetron is classified by NHS Somerset as a Red drug (specialist prescribing only) for emetogenic chemotherapy as per Traffic light guidance.
Antipsychotic- first generation Prochlorperazine5mg tablet: £1.34Adults:

Nausea and vomiting acute attack, initially 20mg, then 10mg after 2 hours.

Acute migraine, 10mg for 1 dose, to be taken as soon as migraine symptoms develop. Prevention 5-10mg 2-3 times a day.
Prochlorperazine 3mg buccal tablets are non-formulary as not cost effective
Levomepromazine25mg tablet: £20.86 (84)For palliative care as per Wessex palliative care handbook.
25mg/1ml solution for injection ampoule: £20.13 (10)