Acupressure and Other Therapies for Nausea and Vomiting in Pregnancy
March 1998; Volume 1: 30-32
By Ronald A. Chez, MD
Nausea and vomiting in the first trimester of pregnancy are so common as to be cliche. Clinicians have few options when it comes to treating these sometimes debilitating maladies that only add to the fatigue and other symptoms women suffer early in their pregnancies. Benedectin, a prescription drug that had shown usefulness for this problem in some women was removed from the U.S. but not the Canadian market in the early 1980s. Given that so many medications are contraindicated in the first trimester of pregnancy, a nonpharamaceutical intervention would be very useful.How does the clinician provide treatment to women suffering from nausea and vomiting in pregnancy? Alternative therapies without supporting data abound, but one that shows some particular promise is acupressure, which also has the advantage of being easily self-administered and quick acting.
Introduction
The more frequent symptoms of pregnancy that occur in the first trimester are breast tenderness, fatigue, and nausea with or without vomiting. Both breast tenderness and fatigue are believed to be secondary to increasing levels of circulating progesterone. Nausea and vomiting, although synonymous with morning sickness, can occur at any time of the day or night. It is uncertain if the patient’s gastrointestinal symptoms are secondary to increasing circulating levels of estrogen or human chorionic gonadotropin.Nausea and vomiting occur in the majority of pregnancies and have been found to be associated with a favorable pregnancy outcome. In most patients, the problem disappears when they enter the second trimester, although for some it will remain until the middle of the second trimester.
Nonpharmacologic remedies include munching salted dry crackers upon awakening and before getting out of bed; avoidance of water, caffeinated drinks, milk, and fruit juices on an empty stomach; and frequent small feedings of bland foods. However, in spite of these measures, nausea and vomiting have a markedly negative impact on the quality of life of a number of women.
Acupressure/Acupuncture Methodology/ Studies
The use of acupressure and acupuncture are the best studied interventions in the complementary and alternative medicine literature that are recommended for the relief of the nausea and vomiting of pregnancy. Andrew J. Vickers recently published a systematic review of acupuncture antiemesis in the Journal of the Royal Society of Medicine.1 He analyzed 33 controlled trials in which acupuncture was used for the treatment of nausea and vomiting associated with pregnancy, chemotherapy, or surgery.The P6 (Neiguan) acupuncture point on the pericardium meridian was used in all of the studies in the review. P6 is approximately three finger-breadths proximal to the last crease of the wrist and is located between the two central tendons of the forearm. In these studies, stimulation of this point was achieved by needling, manual pressure, acupressure with the use of elasticized wrist bands sold as Sea Bands (trademark), transcutaneous electric nerve stimulation or acupoint injection.
There was no consistency in the frequency and duration of the stimulation applied in these studies. However, one more frequent regimen was the constant wearing of an acupressure band on both forearms with purposeful stimulation for five minutes every four hours while awake.
Seven of the studies were conducted in pregnant women. The total number of patients was 667. All except one study, with 42 patients, were prospective, randomized and double-blinded with dummy controls. A statistically significant decrease in the symptoms of nausea and the sign of emesis was found in all but this last study.1 No study was methodologically perfect.
In contrast, and since the analysis by Vickers, O’Brien, Relyea and Taerum reported the data from 161 patients who were randomly assigned to P6 acupressure with elastic bands, dummy bands, or control without bands.2 The patients in all three groups had a significant decrease in nausea, retching, and vomiting; there was no differential effect. One possible explanation for the absence of effect is the degree of the intensity of the acupressure applied. However, this study did have a control group that received no specific placebo or dummy treatment and most of the other studies did not.
The interested reader is encouraged to read the entire review by Vickers. This will provide not only the details of each experiment, but more importantly, analysis of both the research methodology and future directions of experimental design.
Adverse Effects
Of importance in considering acupressure as a therapy, no study described any adverse effects from this intervention.Administration/Procedure
When I see a pregnant patient in the first trimester who wants some information and advice about her nausea and vomiting, I first discuss the diet modifications described above. I also note that some women have found acupuncture helpful. I then show her on her wrist where to apply pressure and suggest that she try applying firm pressure for at least five minutes every several hours while awake.It is difficult to know when a patient will find relief from the use of acupressure. However, if there is no evidence of relief after two days of trying, it seems unlikely to be effective or helpful with further attempts. No data were found to show that acupuncture is helpful when acupressure fails.
Mechanism
The November 1997 National Institutes of Health Consensus Development Statement on Acupuncture included generic comments on the mechanism of action of this intervention.3. No data were found that describe how this intervention actually works with respect to postoperative nausea, nausea secondary to chemotherapy. or nausea in early pregnancy.Availability
Commercially available elastic bands with P6 pressure points (e.g., Sea Bands) are available at most drug stores. These elastic bands come with specific instructions as to where the P6 point is and how to apply the bands. The bands were invented to minimize sea sickness and they appear to be a convenient way to apply pressure.Alternative Pharmacological Options
Benedectin was a prescription drug available for treatment of the nausea and vomiting of pregnancy until the early 1980’s. Composed of doxylamine succinate and pyridoxine, twice a day dosing resulted in the relief of nausea and emesis in literally millions of women. Published epidemiologic reports concluded its use was not associated with congenital anomalies. However, on several occasions the company was sued when an anomaly occurred in a pregnancy in which the mother had used the medicine.In 1982, the manufacturer took the drug off of the market for this use rather than engage in the continued expense of litigation. Notably, the FDA did not withdraw its approval for its use. No FDA-approved agent is presently available that can serve as a suitable substitute for the relief of these symptoms. However, the individual components of Benedectin can be purchased as pyridoxine and the over-the-counter pill Unisom.
Other Alternative Therapies
Among herbal remedies, ginger is recommended for gastrointestinal distress including nausea. Fischer-Rasmussen, et al performed a double-blind, randomized, crossover trial using powdered root of ginger or placebo in 30 pregnant women with hyperemesis gravidarum.4 A daily dose of 250 mg of ginger four times a day for each of four days was significantly better than placebo in relieving symptoms.The homeopathic literature contains recommendations for the treatment of nausea and vomiting of pregnancy. This includes nux vomica for nausea with irritability, pulsatilla for nausea with tearfulness, and ipecac for constant nausea and vomiting. I was unable to find clinical research data supporting these recommendations.
Conclusion
Acupressure offers the hope for relief of severe nausea and vomiting in pregnancy with little indication of adverse effects. Physicians can safely recommend this therapy, easily learn it, and train women in its use. At this time, clinical data are lacking for the effectiveness of any other alternative therapies for this malady, though ginger evidences some promise.References
1. Vickers, AJ. Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. J R Soc Med 1996;89(6):303-311.2. O’Brien B, Relyea MJ, et al. Efficacy of P6 acupressure in the treatment of nausea and vomiting during pregnancy. Am J Obstet Gynecol 1996;174(2):708-715.
3. National Institutes of Health. NIH Consensus Statement. Online at http://odp.od.nih.gov/consensus/statements/cdc/107/107_stmt.html. November 1997;15:3-5. in press
4. Fischer-Rasmussen W, et al. Ginger treatment of hyperemesis gravidarum. Eur J Obstet Gynecol Reprod Biol 1991;38(1):19-24.
Dr. Chez is Professor of Obstetrics and Gynecology and Professor of Community and Family Health, University of South Florida, Tampa.
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