I had the privilege of caring for pregnant mothers for over 20 years (delivering over 1500 babies). During that tenure, I would tell moms, “I do NOT want you to experience ANY morning sickness during your pregnancy.” And, following the advice below, the vast majority did not! (Last Updated June 27, 2023)
Only about one-third of “morning sickness” occurs in the morning. About 1/3 occurs in the afternoon or evening. And, about 1/3 of women have it all day! No matter when nausea and vomiting during pregnancy occurs, using my recommendations, I found I seldom had to use any prescription remedies. So what did I recommend?
Before I tell you, let me recount for you the very sad story of a medication called “Bendectin.”
Bendectin (known as Debendox in the United Kingdom and Diclectin in Canada) was a mixture of pyridoxine (Vitamin B6) and doxylamine (an antihistamine) that was prescribed to treat nausea and vomiting associated with morning sickness. It was nearly 100% effective. So why is it no longer available?
The manufacturer, Merrell Dow Pharmaceuticals, spent more than $100 million defending the subsequent personal injury lawsuits, winning courtroom victories in virtually all of their cases. Nevertheless, to reduce litigation expenses, the company voluntarily removed the drug from the U.S. market in 1983.
Not only did an FDA panel conclude there was no association between Bendectin and birth defects, but over 30 epidemiologic studies have concluded that Bendectin was safe for use in pregnancy. Also, the World Health Organization and the March of Dimes have exonerated the drug. The Centers for Disease Control and Prevention hasn’t found any reduction in birth defects nationally since Bendectin was pulled from the market.
The most famous case involving the drug is Daubert v. Merrell Dow Pharmaceuticals (1993). These suits were led by flamboyant plaintiff attorney Melvin Belli. The star witness for the case against Bendectin, William McBride, was later found to have falsified research on the teratogenic effects of the drug and was disbarred in Australia.
The drug continues to be used around the world (not only in Canada and the UK but also across Europe) and no subsequent epidemiological studies have found any teratogenic effect.
Bendectin consisted of 10 mg of pyridoxine (vitamin B6) and 10 mg of the antihistamine, doxylamine, combined in a single tablet. It could be taken up to four times per day.
To create a “do-it-yourself” Bendectin, you can purchase pyridoxine in 10 mg tablets, or purchase scored 25 mg tablets and pop them in half.
Since a 10mg dose of doxylamine is not (to my knowledge) available in the United States, the closest American patients can get to Bendectin is to take one-half of a 25-mg tablet of doxylamine in the form of Unisom Sleep Tabs. But, be careful, as one form of Unisom (Unisom Sleep Gels) contains NOT doxylamine, but another antihistamine, diphenhydramine (Benadryl).
Since doxylamine is sleep-inducing, I had my patients do this:
Once you find your effective dose, continue it for a week or two and then “walk back down the dosing ladder” to find the lowest effective dose of medication to keep your nausea away. After a few weeks, you may be able to discontinue the treatment altogether.
I do not recommend more than 25 mg of pyridoxine three times a day. Why? A total daily dose of pyridoxine of more than 75 mg a day in pregnancy may cause problems with the nerves (neurotoxicity).
But, what if my recipe does not work?
I used to recommend oral ginger capsules. But, now new reports are questioning the use of ginger during pregnancy. The newest report, from the Finnish government, is warning pregnant women not to consume ginger supplements, drinks, or teas.
Why? Ginger contains chemicals that are cytotoxic in vitro. The concern is that these chemicals MIGHT be harmful to the unborn baby if consumed in large quantities.
So far, no obvious problems have been seen in pregnant women taking ginger supplements in doses of about one gram daily. But, I think it’s better to be safe than sorry.
So what is your doctor left with if the OTC meds do not work for you? A number of prescription medicines. Fortunately, I have rarely had to use any of these:
If you give my recipe a try, leave a note for me and our other readers about what dose worked for you.
JUNE 2023 UPDATE: A study just published the in Annals of Internal Medicine, titled, “Acupuncture and Doxylamine–Pyridoxine for Nausea and Vomiting in Pregnancy, A Randomized, Controlled, 2 × 2 Factorial Trial, concluded, “Acupuncture and doxylamine-pyridoxine alone and the combination of the two were effective in reducing morning sickness symptoms during pregnancy.” The authors warned, “Compared with placebo, a higher risk for births with children who were small for gestational age was observed with doxylamine–pyridoxine;” nevertheless, they concluded, “Both acupuncture and doxylamine–pyridoxine alone are efficacious for moderate and severe NVP (nausea and vomiting in pregnancy). However, the clinical importance of this effect is uncertain because of its modest magnitude. The combination of acupuncture and doxylamine–pyridoxine may yield a potentially larger benefit than each treatment alone.”
See more details in Primary Care Notebook here. The authors note:
SEPTEMBER 2015 UPDATE: In updating 11-year-old guidelines on treating morning sickness, the American College of Obstetricians and Gynecologists (ACOG) now suggests women pair vitamin B6 and the antihistamine doxylamine to treat persistent, disruptive nausea and vomiting. The medications are sold separately over the counter or combined in prescription form. Meanwhile, further review of a commonly used morning sickness drug, ondansetron (Zofran), has prompted ACOG to pull back on supporting its use since more recent data suggest the drug may be linked to birth defects.
JANUARY 2014 UPDATE: This, just out from the experts at the Prescriber’s Letter (2014(Jan); 21(1): 5:
Questions will come up about using ondansetron for morning sickness. It was thought to be relatively safe … but now there are concerns. Ondansetron use in the first trimester is linked to a two-fold increase in the risk of congenital heart defects and cleft palate. Plus ondansetron prolongs the QT interval … and electrolyte disturbances due to vomiting can increase the risk of torsades.
When drug therapy is needed for morning sickness, recommend OTC pyridoxine AND doxylamine 12.5 to 25 mg up to TID … or use the Rx combo product, Diclegis. But point out that Diclegis can cost over $500/month. If pyridoxine and doxylamine are not enough, try metoclopramide or a phenothiazine (prochlorperazine, etc). Save ondansetron for when other options aren’t enough. Monitor ECG and electrolytes for women with significant vomiting.
OCTOBER 2013 UPDATE: I am happy to let my readers know that (1) this is by far the most popular (and, I hope, helpful) blog I’ve written, and (2) the U.S. Food and Drug Administration just approved Diclegis® (doxylamine succinate 10mg, pyridoxine hydrochloride 10mg) delayed-release tablets, the first prescription treatment for nausea and vomiting of pregnancy (NVP) when conservative management fails in more than 30 years. However, it’s not cheap. In our area (Colorado Springs), the least expensive price for 30 tablets is about $155.00. For some women, it can cost over $500/month. But, for those with insurance, it may well be worth considering.