For most women, the first trimester is undeniably rough. After briefly reveling in being newly pregnant (two lines!), you start to feel sick as a dog, all day long.
About 70-80% of pregnant women experience nausea during their first trimester, and about 50% also experience vomiting.
Not that it will make you feel any better, morning sickness comes with one one big silver lining: Nausea often signals a healthy pregnancy. As you probably know, women with nausea have a much lower risk of miscarrying and–as is less widely known–a lower chance of preterm labor.
For miscarriage, the risk is not just a tiny bit lower, but a huge whopping amount lower. Women with nausea have roughly a third of the risk of women without symptoms. Women over 35 with nausea, who because of their age have a higher risk of miscarriage, have only about a fifth of the odds of a miscarriage as those without nausea.
These are sizeable effects. Still, a lack of morning sickness does not necessarily signal an impending miscarriage. A lucky 20-30% of pregnant women never experience any morning sickness but give birth to perfectly healthy babies.
Luck is not the only factor. The more babies you have had, the worse your nausea tends to be in subsequent pregnancies, and the more likely it is to last well into your second trimester. Your race and ethnic background also matter: White women are more prone to nausea than Black and Asian women, and Black women are more likely to have nausea that starts after the first trimester.
And finally, timing matters: Before 7 weeks, a lack of nausea does not predict miscarriage risk.
A Quick Note on Terminology
Although commonly called “morning sickness”, most medical professionals prefer the term nausea and vomiting of the pregnancy (NVP), because symptoms typically occur all day long, not just in the morning, as many first-time mums-to-be discover to their dismay. In fact, in one study, less than 2% of women with “morning sickness” had nausea and vomiting only in the morning. Others put the percentage of morning-only suffers at 14%.
The Onset of NVP and Miscarriage Risk
On average, women start to experience NVP 39-40 days after their last menstrual period, around the middle of the 5th week of pregnancy (counting from a woman’s last menstrual period), Symptoms typically begin to ease by around 12 weeks and usually disappear completely by 20 weeks.
That said, 39 days is only the average day of symptom onset. For an unlucky 10% of women, NVP begins much earlier, before they even miss their period. For the 90% women who will experience any morning sickness, though, that all day queasy, on-a-winding-road-with-a-bad-hangover feeling starts by your 9th week of pregnancy, or 7 weeks after conception.
It’s only then, in the 8th week of pregnancy, that a lack of morning sickness predicts higher chances of a miscarriage, according to a prospective study that tracked symptoms of 2407 pregnant women from early in their first trimester.
Whether symptoms start early or late did not seem to matter, provided nausea began by the 8th week. And once the first trimester was over, nausea no longer had bearing on the chances of a loss.
What Exactly Is Morning Sickness and Why Does It Predict Miscarriage?
NVP is one of pregnancy’s great mysteries. No one knows why it occurs. No one knows what, at a biological levels, causes NVP. No one knows whether NVP serves a purpose, as some evolutionary theorists have proposed, or whether it is just an unpleasant side effect of hormonal shifts during early pregnancy.
In terms of its biological underpinnings, rapid rises in hormones like estrogen, progesterone, and human chorionic gonadotropin (HCG)–a hormone produced by the embryo upon implantation and used to detect pregnancy–are often fingered as potential culprits, but the evidence for their role is only circumstantial.
HCG, the hormone with the most evidence for a role in NVP, rises exponentially during the early weeks of pregnancy and reached peak concentration between 8-10 weeks of pregnancy. This rise, perhaps not coincidentally, coincides with when NVP symptoms are usually at their worst. Conditions which cause high HCG levels like Down’s Syndrome, molar pregnancies, and twin pregnancies often cause particularly severe NVP. Still, HCG levels do not reliably distinguish women with and without NVP, and no one understands why, at a biological level, HCG would induce nausea.
Pregnancy often comes with a bloodhound-like ability to detect odors. This heightened sense of smell likely also contributes to NVP. In a small study of 9 women who had congenital anosmia–they were born with without the ability to smell–only 1 of the 9 suffered from NVP during pregnancy, a rate substantially lower than the usual 70-80%.
Despite our poor understanding what causes nausea biologically, few researchers believe that a lack of symptoms causes miscarriage.
Why not? For one, treating NVP does not lead to worse pregnancy outcomes. If anything, the opposite is true: Women who take anti-nausea medications have better outcomes, on average, than women who do not take anti-nausea medications–not because treatment itself improves outcomes, but because severe NVP severe usually indicates a healthy placenta.
So nausea and vomiting are good. But they are also bad. I mean, they really suck.
Let’s be clear: nausea and vomiting are more than a simple inconvenience. Just for starters, women with NVP, even those with so-called “mild” NVP accompanied by little or no vomiting, commonly report decreased productivity at work, taking sick time, strained relationships with their partners, and heightened anxiety and depression.
And for around 1 in 100 pregnant women, NVP is life-threatening. Women with especially severe NVP, a condition known as hyperemesis gravidarum, suffer from such severe nausea that they cannot keep food or water down, and require hospitalization. In the U.S. each year, around 50,000 women are hospitalized for severe NVP. If you are vomiting several times a day, seek help. Early treatment may help prevent NVP from becoming dangerously severe.
What Can You Do?
Women with NVP are advised to eat small, frequent meals of bland low fat foods like dry toast, bananas, and rice, to eat before getting out of bed in the morning, and to avoid strong odors (as if that were possible during early pregnancy!).
If these efforts fail to bring relief, an FDA-approved treatment is now available, for the first time in 30 years. (Many women take Zofran off label, but the FDA has never approved Zofran for use during pregnancy.)
In 2013, the FDA approved Diclegis (a delayed release combination of vitamin B6 and doxylamine, the active ingredient in Unisom) as pregnancy category A, meaning it is safe for use during pregnancy, including in the first trimester.
Diclegis is not a new drug, but an old one, pulled from the U.S. market in 1983 because its manufacturer could not afford to defend itself against what we now know to be groundless lawsuits alleging the drug caused birth defects. At its height, around 25% of pregnant women took it for NVP.
If you prefer natural therapies, some limited evidence suggests that ginger and vitamin B6 help alleviate nausea. Acupuncture, although popular, does not appear to be effective.