Epidemiology of Vomiting in Early Pregnancy
MARK A. KLEBANOFF/ MD/ MPH/ PATRICIA A. KOSLOW£/ PhD/
RICHARD KASLOW/ MD/ MPH/ AND GEORGE G. RHOADS/ MD/ MPH
Factors associated with early pregnancy vomiting were in·
vestigated in 9098 first-trimester registrants in the Collabo•
rative Perinatal Project. Vomiting in the absence of hypere•
mesis or gastroenteritis was noted in 56% of all women, and
was more common among primigravidas (P = .002), youn•
ger women (P < .001), women with less than 12 years of
education (P < .001), nonsmokers (P < .001), and
women weighing 77.1 kg (170 lb) or more (P = .003).
Adjustment for
confounders did not change these associations. Women
reporting vomiting were less likely to experience miscar•
riage or stillbirth (P = .002) and delivery before 37 weeks'
gestation (P = .004), but there was no difference in infant
birth weight between mothers with and without vomiting
(P = .48). Women who vomit in one pregnancy are more
likely to vomit in subsequent pregnancies than are cornpara•
ble women who did not vomit. (Obstet Gynecol 66:612, 1985)
Nausea and vomiting have been described in conjunc•
tion with pregnancy since 2000 BC, but there have been
few epidemiologic studies of vomiting during preg•
nancy and most of these have focused on hyperemesis
gravidarum. To the best of the authors' knowledge
there have been only three studies published since
1957 that specifically address the epidemiology of
routine vomiting. These studies were based on small
numbers, 1 retrospective ascertainment of vomiting,"
and univariate analysis. 1 - 3 In addition, most studies
have considered both nausea and vomiting. Nausea is
a subjective symptom subject to individual reporting
differences, but vomiting is more objective and less
likely to be forgotten. This study investigates the
epidemiology of vomiting during pregnancy, using
data from a large multicenter perinatal study.
Materials and Methods
The Collaborative Perinatal Project is a prospective
multicenter study of approximately 56,0�pregnancies
From the Epidemiology and Biomeinj Research Program, National
Institute of Child Health and Human Development, and the Epidemiol•
ogy and Biometry Section, National Institute of Allergy and Infectious
Diseases, National Institutes of Health, Bethesda, Man;land.
612 0029·7844/85/$3.30
enrolled between 1959 and 1966.4 At each visit trained
interviewers asked each woman about the occurrence
of events relating to the pregnancy, including the
presence of vomiting. To categorize women with re·
gard to early pregnancy vomiting, the present study
was limited to women who registered in the Collabora•
tive Perinatal Project within the first 14 weeks
of gestation, which restricted the analysis to 7551
white and 3502 black women having their first
pregnancy in the Project. Those who had no
follow-up obstetric visits (N = 988) were eliminated,
as were women for whom there was uncertainty
about the duration of
gestation at either registration or delivery (N = 836)
and women who miscarried before 14 weeks (N =
131). The final study population consisted of 9098
women.
At her first obstetric visit each woman was asked,
"Since your last period have you had any of the
following: ... " The list of symptoms and events
included vomiting, diarrhea, and fever. At each subse•
quent visit she was asked if she experienced any of the
same symptoms or events since her last visit. The 829
women who reported vomiting only in conjunction
with fever or diarrhea were considered to have gastro•
enteritis and were analyzed separately from women
with presumed early pregnancy vomiting. If a woman
reported vomiting at one visit and gastroenteritis at
another visit, she was classified as having early preg•
nancy vomiting. In addition, because the purpose of
this study was to investigate routine vomiting, the 188
women diagnosed as having hyperemesis gravidarum
were analyzed separately. Fairweather's5 16-week limit
was used to define early pregnancy vomiting. There
were 4517 women who reported vomiting (vomiting
group) and 3502 women who had not vomited by 16
weeks (nonvomiting group). Vomiting status was un•
known for 62 women.
In the first analysis, the vomiting and nonvomiting
groups were compared on baseline characteristics,
such as age, race, gravidity, smoking at registration,
education, twinning, and 20 other characteristics that
Obstetrics & Gynecology
 are either known risk factors for pregnancy outcome or riage (at 14 to 19 weeks' gestation) or stillbirth (at 20 or
have been described as being associated with vomit• more weeks). Fourteen weeks was chosen as the lower
ing. 1 3 5 10
• • -Age was considered as less than 20, 20 to 34, limit because all study participants had registered by
and greater than or equal to 35 years; gravidity was that time. The relationship between vomiting and fetal
entered as primigravida or other; smoking was dichot• loss was adjusted for race, age, gravidity, education,
omized as any or none; and education was dichoto• and smoking by the Mantel-Haenszel procedure. 11
mized as less than 12 years versus 12 or more years. The associations between vomiting and birth weight
Heavy women were defined as women who weighed and vomiting and duration of gestation were examined
77.1 kg or more. Statistical significance was assessed for live-born singleton infants of at least 20 weeks'
by the x2 test, and continuous variables were evaluated gestation (N = 7933). The mean values of birth weight
with the Student t test. As many of the above factors and gestational age for the vomiting and nonvomiting
are interrelated (eg, age and gravidity), the relation• groups were compared using the Student t test and
ship between all variables approaching significance at · were adjusted for race, age, education, gravidity,
the P = .002 level (overall P = .05, corrected for 26 smoking, and prepregnant weight using multiple lin•
comparisons) and vomiting was investigated using ear regression. The percentage of low birth weight
multiple logistic regression. Twinning was included (less than 2500 g) and pre term (less than 37 weeks)
because of its described association with vomiting. 2·3 ·5 births were compared using the x2 test and adjusted by
Logistic regression gives the odds of suffering from multiple logistic regression for the noted confounders.
vomiting when a risk factor is present as compared The last analysis concerned vomiting in subsequent
with when it is absent, all other risk factors being pregnancies. Because vomiting is associated with preg•
equal. The statistic generated, called the odds ratio, is nancy outcome':" and women experiencing one fetal
used to estimate the relative risk. loss are at increased risk of fetal loss during subsequent
The relationship between vomiting and fetal loss pregnancies, 12 this analysis was limited to women
was next explored. Fetal loss was defined as miscar- having live births in two consecutive study pregnan•
cies (N = 1852). Results are presented separately for
Table 1. Characteristics Associated With Vomiting women who were primigravidas or gravida 2 or more
in their first study pregnancy.
Multivariate
analysis
Vomiting Results
N• (%)
The fraction of women experiencing vomiting was
Primigravida 2929 62 1.46 1.41 .002 fairly constant over the first 16 weeks: 37% of those
Gravida 2+ 5078 53 1.00 1.00 having a prenatal visit during weeks 1 through 4, 44%
Age
<20 1246 65 1.00 I.Ob
during weeks 5 through 8, 39% in weeks 9 through 12,
20-34 604;5 56 .68 .92 .31 and 29% in weeks 13 through 16. The fraction of
35+ 728 44 .42 .56 <.001 women experiencing vomiting decreased to 20% dur•
Education ing the 17- to 20-week interval, and only 9% of the
<12 yr 3096 60 1.00 1.00 women complained of vomiting unassociated with
:2:12 yr 4773 54 .78 .74 <.001
Nonsmoker 4572 60 1.00 1.00
fever or diarrhea after 20 weeks. Cumulatively, 52% of
Smoker 3413 51 .69 .69 <.001 all women had vomiting without fever or diarrhea on
White 5394 54 1.00 1.00 at least one occasion by 16 weeks. If the 829 women
Black 2625 61 1.33 1.19 <.001§ with presumed gastroenteritis are eliminated from the
Prepregnant weight denominator, then 56% of the women vomited.
<77.1 kg 7417 56 1.00 1.00
:2:77.1 kg 490 61 1.23 1.35 .003
The characteristics of women experiencing vomiting
Singleton 7933 56 1.00 1.00 are outlined in Table 1. Vomiting was more common
Twin 86 65 1.47 1.51 .08 among primigravidas, younger women, women with
• Due to missing values, some numbers may total to slightly less less education, nonsmokers, blacks, and heavy wom•
than 8019 .. en. All of these associations were highly significant.
+ As vomiting during pregnancy is a common event, the odds ratio
will overstate slightly the magnitude of the relative risk, but the Vomitingwas more commonin twin pregnancies, but
significance levels of the odds ratio and relative risk are comparable. this association did not reach statistical significance,
:i Adjusted by logistic regression for all of the factors in the
table;
possibly due to small numbers. The possibility that
odds ratio of 1.00 = reference group. vomiting caused women to give up smoking was
§ After adjustment for study center, odds ratio = 1.05 (P = .56). considered, but this was not the case. Among current
None of the other P values or odds ratios were influenced by this
adjustment. nonsmokers, 34% of the vomiting group and 33% of

VOL. 66, NO. 5, NOVEMBER 1985 Klebanoff et al Early Pregnancy Vomiting 613
 the nonvomiting group had smoked in the
past (P = .49). Among women who never smoked,
58% vomited, whereas 46% of current smokers
vomited.
Several of the factors investigated were not associat•
ed with vomiting. Most noteworthy of these was
weight gain. The mean weight gain of the non vomiting
group was 10.07 kg, which was not significantly differ•
ent from the 10.09 kg gained by the vomiting group
(P = .87). If the results are limited to women deliver•
ing live-born infants of at least 20 weeks' gestation, the
mean weight gains for the vomiting and nonvomiting
groups were 10.2 and 10.3 kg, respectively (P = .46).
Vomiting was not more common among women expe•
riencing prior fetal losses, among women with hyper•
tension, among women with proteinuria of 2 + or
greater, among diabetics, among diethylstilbestrol us•
ers, nor among women whose partners were not
cohabiting, once race was controlled. Women who
became pregnant unintentionally vomited at the same
rate as women who had planned pregnancies, and
vomiting was unassociated with hyper- or hypothy•
roidism. No association was found between vomiting
and gall bladder or liver disease (present either before
or during pregnancy); however, less than 50
women were affected by these conditions. There was a
tenden• cy for women who vomited to be
hospitalized more frequently than women who did
not vomit (12 versus
14%, P = .075), but this difference was not statistically
significant.
Many of the factors associated with vomiting were
related to each other. For example, whites were more
likely than blacks to smoke and to have 12 or more
years of schooling, and young women were more
likely to be primigravidas. Multiple logistic regression
enables the effect of one factor to be studied while all
other factors are controlled. The results of this proce•
factors
dure aresignificantly
shown for associated
all women with vomiting
in Table 1. All in
of the
univariate analysis remained significant when the oth•
er factors were controlled. Whites and blacks differed
significantly with respect to two risk factors for vomit•
<2500g"
ing. Increasing age was strongly protective against
vomiting for whites (vomiting present in 69, 54, and
38% of women age less than 20, 20 to 34, and 35 +,
respectively; P < .001), whereas age had little effect on
vomiting among blacks (60, 62, and 55% for age less
than
White20, 20 to 34, and
primigravidas were35 +, respectively;
considerably = .15).to
moreP likely
vomit than were white multigravidas (62 versus 49%,
P < .001), but gravidity exerted significantly less effect
among blacks (62% of primigravidas versus 60% of
multigravidas, P = .25). The difference among whites
did not appear to reflect a general increase in com•
plaints among women pregnant for the first time, as
614 Klebanoff et al Enrly Preg11n11cy Vo111iti11g
other symptoms such as fever were reported with
equal frequency by both primigravidas and multigravi•
das.
It is possible that the racial difference in the frequen•
cy of vomiting is accounted for by geographic or
socioeconomic differences that were not considered. In
the Collaborative Perinatal Project the northernmost
centers (Boston, Buffalo, and Minneapolis) were large•
ly white and relatively middle class, whereas the
southernmost centers (New Orleans, Memphis, and
Richmond) were mainly black and lower class. Addi•
tionally, the frequency of vomiting varied substantially
between centers, with no obvious geographic pattern.
When the odds ratio for vomiting was further adjusted
for study center the excess risk to blacks was no longer
present (odds ratio = 1.05, P = .56), although the
other risk factors did not change. Presumably, geo•
graphic, socioeconomic, or local factors (such as inter•
viewer technique) account for the racial difference.
The relationship between vomiting and pregnancy
outcome is presented in Table 2. Among pregnancies
carried to at least 14 weeks there were 153 miscarriages
and stillbirths (3.4%) among the vomiting group and
184 (5.3%) among the non vomiting group. The crude
relative risk of 0.64 increased to 0.70 (P = .002) after
adjusting for race, age, education, gravidity, smoking,
and weight. The analyses of birth weight and
gesta• tional age were limited to singleton live-born
infants of at least 20 weeks' gestation. The mean birth
weight of infants born to women both with and
without vomit• ing was 3203 g. When race, age,
education, smoking, maternal weight, and gravidity
were controlled, in-
Table 2. Pregnancy Outcome by Vomiting
Multivariate analysis
Vomiting
Fetal loss
Birth weight
Gestation
<37 wk"
Mean values Adjusted difference'
Birth weight" (g) 3203 3203 10 .48
• For singleton live births of at least 20 weeks' gestation.
' Adjusted for age, race, smoking, education, gravidity, and
weight. Fetal loss adjusted by Mantel-Haenszel procedure, low birth
weight and preterm delivery adjusted by logistic regression.
Odds ratios less than 1 indicate reduced risk among women
experiencing vomiting.
I
Adjusted by linear regression for age, race, smoking, education,
gravidity. and weight. Positive numbers indicate higher values in
women who vomit.
0/,sfl'lrics & Gy11ecolog11
 fants born to the vomiting group were 10 g heavier
than infants of the nonvomiting group (P = .48). The
fraction of low birth weight infants followed a similar
pattern. Infants of vomiting mothers were not more
likely to be of low birth weight than were infants of
nonvomiting mothers in either the crude or adjusted
analyses. Vomiting was associated with a modest but
statistically significant prolongation of gestation.
Women who vomited carried their pregnancies ap•
proximately 1.5 days longer on average both before
and after adjustment (P < .001), and the vomiting
group was significantly less likely to deliver a
preterm infant in both the crude and adjusted
analyses.
Patients suffering from hyperemesis and gastroenteri•
tis were excluded from the previous analyses. In general,
women with gastroenteritis had baseline characteristics
intermediate between the vomiting and nonvomiting
groups, but appeared closer to the nonvomiting group.
The outcomes for women with gastroenteritis were also
more like those of the nonvomiting group than those of
the vomiting group. The fetal loss rate for women with
gastroenteritis was 4. 9%, the low birth weight fraction
was 10.5%, and the preterm fraction was 10.4%.
Hyperemesis gravidarum was not well defined in
the Collaborative Perinatal Project. Thirty-five percent
of women with this diagnosis required intravenous
fluids, and an additional 6% had ketonuria but did not
require parenteral therapy. In terms of risk factors,
women who had hyperemesis appeared more like
women experiencing routine vomiting than like wom•
en not experiencing any vomiting. In fact, their differ•
ences from women with routine vomiting with respect
to age, smoking, and prepregnant weight placed them
at the extreme end of the spectrum from the non vomit•
ing group. Only in education were women with hyper•
emesis more like the nonvomiting group than like
the vomiting group. Hyperemesis was significantly
more common in twin gestations. This remained
significant (P < .001) after adjustment for
confounding variables. The fetal loss rate for women
with hyperemesis was
3.3%, and the low birth weight and preterm rates
(for singleton live-born infants of at least 20 weeks'
gesta-
Table 3. Vomiting in Subsequent Pregnancies
Vomiting in next Relative
N pregnancy ('le)
First pregnancy-primigravida
First pregnancy vomiting 505 80
First pregnancy no vomiting 314 54
First pregnancy-gravida 2 +
First pregnancy vomiting 479 83
VOL. 66, NO. 5, NOVEMBER 1985
tion) were 10.3 and 16.5%, respectively. None of
these rates was significantly different from those
of the routine vomiting group after adjusting for
confound• ers.
Finally, women having repeat study pregnancies
were examined for the recurrence of vomiting. Table 3
shows that vomiting in one pregnancy is highly associ•
ated with vomiting in the subsequent pregnancy. This
was equally true wheth_£r the woman was a primigra•
vida or a multigravida during the first study pregnan•
cy. Both of these risks remained highly significant (P <
.001) after adjustment for age at each pregnancy
and
smoking during each
pregnancy.
Discussion
This study has shown that vomiting during pregnancy
is a common event: Over half of all women vomited on
at least one occasion during the first 16 weeks. Vomit•
ing began early, peaked in the second and third
months, and was uncommon after 20 weeks. These
figures fall within the range of 37 to 88% quoted in the
literature. 1 · - - In only two of these earlier reports":"
were the patients asked specifically about vomiting, as
opposed to nausea or vomiting; these studies quote
rates of 37 and 58%. In the present study if
women with gastroenteritis are eliminated, 56% of
women vomited. If women with gastroenteritis are
counted as vomiters, then 62% of gravidas vomited,
and if these women are counted as nonvomiters,
then 52% of women vomited.
Factors associated with vomiting during pregnancy
have been described. In particular, Little and Hook
13
noted that nausea and vomiting did not appear to
cause smokers to quit smoking. Vomiting has been
found to be more common among primigravidas, but
10
this has not been consistently confirmed. u.7 The au•
thors' description of the association between race,
gravidity, and vomiting agrees with that of Fairweather,
5
who also found that gravity exerted a stronger
influ• ence on vomiting among whites than among
blacks.
The present data are consistent with previous
re• ports indicating that the presence of nausea and
vom• iting is a favorable risk factor for pregnancy
1 3 14
out• come.
- • Brandes:' found that women who did
not
86.0 per 1000, whereas women complaining of nausea
risk or vomiting had a fetal loss rate of 49.1 per 1000. This
unadjusted relative risk of fetal loss for nausea/vomit•
F t pregnancy no vomiting 554 55
i
r * P < .001.
s
Klebanoff et al Early Preg111111cy Vo111iti11g 615
1.48* 57 agrees well with the authors' unadjusted figure of
in
g 0.64. Medalie1 found that none of 52 women who had
I.SI* of moderate-to-severe nausea and vomiting aborted,
0. versus 11 of 48 women with mild-to-no nau• sea and
vomiting. [arnfelt-Samsioe et a!2 noted that

VOL. 66, NO. 5, NOVEMBER 1985 Klebanoff et al Early Preg111111cy Vo111iti11g 615
 nausea or vomiting was present in 70% of pregnancies
ending in live birth versus 50% of pregnancies ending
in spontaneous abortion. Presumably, lower estrogen
and/or human chorionic gonadotropin (hCG) levels
associated with nonviable pregnancies+" account for
these findings.
Women who did not vomit were older and more
likely to smoke. However, the effect of vomiting on
fetal loss was not mediated by these factors, as vomit•
ing was associated with reduced risk of fetal loss after
adjustment for age and smoking. Future studies of the
effect of antiemetics on pregnancy outcome need to
take these factors into account. If infants with malfor•
mations of unknown etiology are compared with in•
fants with known malformation syndromes (ie, Down
syndrome), one might find antiemetic use to be more
frequent among women delivering infants in the first
group. This may indicate not that antiemetics cause
malformations, but rather that older mothers are less
likely to vomit and therefore less likely to require
antiemetics.
Several limitations of the data should be noted. The
Collaborative Perinatal Project is now more than 20
years old, and it is possible that these findings might
not apply to women today. Nevertheless, there is little
reason to believe that the epidemiology of vomiting
has changed since the 1960s. The present study was
limited to women who registered by 14 weeks to study
fetal loss, as well as to minimize the elapsed time
between symptoms and recall. Approximately 20% of
the total population registered by 14 weeks, and the
early registrants were more likely than later registrants
to be white, high school graduates, nonsmokers, pri•
migravidas, and older than 20 years. Despite these
differences, the incidence of vomiting and the risk
factors associated with vomiting were similar for both
the early and late registrants. Finally, it should be
noted that statistical significance does not necessarily
imply clinical significance. Except for the relatively
strong age effect, particularly among whites, all of the
associations (including the protective effects of vomit•
ing) were of modest magnitude. The high frequency of
vomiting during early pregnancy is possibly as note•
worthy as the associations that were found.
In conclusion, vomiting during early pregnancy is a
common event, occurring in more than half of all
women. Vomiting occurs a little more often among
·primigravidas, younger women, women with less edu•
cation, nonsmokers, heavy women, and twin gesta•
·tions. It is doubtful whether or not there is a racial
616 Klebanoff et al Early Pregnancy Vo111iti11g
difference in the incidence of vomiting. Women who
vomit are at modestly decreased risk of fetal loss
and preterm delivery, but vomiting did not exert a
signifi• cant effect on birth weight.
References
l. Medalie JH: Relationship between nausea and/or vomiting in
early pregnancy and abortion. Lancet ii:117, 1957
2. jarnfeit-Samsioe A, Samsioe G, Velinder G-M: Nausea and vomit•
ing in pregnancy-A contribution to its epidemiology. Gynecol
Obstet Invest 16:221, 1983
3. Brandes JM: First trimester nausea and vomiting a_s related to
outcome of pregnancy. Obstet Gynecol 30:427, 1967
4. Niswander KR, Gordon M (eds): The Women and Their Pregnan•
cies. Philadelphia, PA, W. B. Saunders, 1972
5. Fairweather DVI: Nausea and vomiting in pregnancy. Am J
Obstet Gynecol 102:135, 1968
6. Semmens JP: Hyperemesis gravidarum: Diagnosis and treatment.
Obstet Gynecol 32:587, 1968
7. Fitzgerald JPB: Epidemiology of hyperemesis gravidarum. Lancet
i:660, 1956
8. Fairweather DVJ: Nausea and vomiting during pregnancy. Ob•
stet Gynecol Ann 7:91, 1968
9. Coppen AJ: Vomiting of early pregnancy: Psychological factors
and body build. Lancet i:172, 1959
10. Diggory PLC, Tomkinson JS: Nausea and vomiting in pregnancy:
A trial of meclozine dihydrochloride with and without pyridox•
ine. Lancet ii:370, 1962
11. Kleinbaum DG, Kupper LL, Morgenstern H: Epidemiologic
Re• search. Belmont, CA, Lifetime Learning Publications, Inc.,
1982, p 345
12. Warburton D, Fraser FC: Spontaneous abortion risks in man:
Data from reproductive histories collected in a medical genetics
unit. Hum Genet 16:1, 1964
13. Little RE, Hook EB: Maternal alcohol and tobacco consumption
and their association with nausea and vomiting during pregnan•
cy. Acta Obstet Gynecol Scand 58:15, 1979
14. Little RE: Maternal alcohol and tobacco use and nausea and
vomiting during pregnancy: Relation to infant birth weight. Acta
Obstet Gynecol Scand 59:495, 1980
Address reprint requests to:
Mark A. Klebanoff, MD, MPH
EBRP, NICHD, NIH
Landoto Building
Room 8A04
Bethesda, MD 20205
Submitted for publication Jan 11ary 7,
1985.
Revised April 5, 1985.
Accepted for publication April 10, 1985.
Copyright © 1985 by The American College of Obstetricians and
Gynecologists.
Obstetrics & Gynecology