Nonpharmacologic Treatment Of Nausea And Vomiting Of Pregnancy And Hyperemesis Gravidarum

Mazotta et al. conducted an extensive review of MEDLINE, the Cochrane Database of Systematic Reviews, and bibliographies and texts for the effectiveness of maternal therapies for nausea and vomiting of pregnancy (including randomized controlled trials of drug treatment versus placebo or no therapy, or another drug therapy). The researchers focused on observational, controlled studies for adverse fetal effects, specifically, the incidence of major malformations, because treatment of nausea and vomiting of pregnancy usually involves administration of medication during the first trimester. Physical outcome measures were evaluated. The findings indicated that some women prefer more “natural,” nonpharmacologic therapies for nausea and vomiting of pregnancy, such as dietary and lifestyle changes, pyridoxine, ginger, and / or stimulation of the P6 Neiguan point (e.g., Seabands). Theoretically, these therapies are not considered harmful to the fetus. The goals of nonpharmacologic treatment for both nausea and vomiting of pregnancy and hyperemesis gravidarum include reducing the symptoms and enabling the mother to obtain nutrition from foods and fluids. Malnutrition and dehydration are both significant concerns when there is a near complete inability to eat or drink, or when there is persistent vomiting.

Nutrition: Food and Fluids

Trigger Avoidance

Women with hyperolfaction are especially prone to nausea and vomiting of pregnancy and hyperemesis. Avoiding triggers of nausea and / or vomiting, for example, offending smells or tastes can be helpful. This can be difficult to effectively achieve as preferences and aversions are continually changing for the pregnant woman, and are highly individual. It is for this reason that simple comfort measures, such as dry crackers, ginger ale, and so forth, may only yield fleeting results. Many women with nausea and vomiting of pregnancy find that most measures only work for a limited time, often for a few consecutive days, and that the very substance that led to some improvement may often then join the ranks of the offending agents. For some women, teeth brushing is a major trigger, stimulating gagging or vomiting. Avoiding brushing when nauseated can help, and using a toothpaste that is low-foaming and with a mild minty flavor can help minimize an adverse response. Some women find foregoing the toothpaste altogether for a time can be helpful. Using a child’s sized toothbrush, and avoiding getting the brush, toothpaste, or “spit” in the back of the mouth can be helpful. Many women find the sight of certain foods distasteful enough to trigger nausea or vomiting; for example, the meat or fish department of the market. Avoiding these departments or having someone else do the grocery shopping until intolerable nausea has passed, can reduce trigger exposure. Iron-containing supplements cause gastric irritation, and thus should be avoided until nausea and vomiting of pregnancy or hyperemesis is overcome. Women with very severe nausea and vomiting of pregnancy or hyperemesis may be triggered by even the thought or the mention of food. In such cases, avoiding exposure to all food images may be necessary. Additional triggers include stuffy rooms, odors (e.g., perfume, chemicals, smoke), heat, humidity, noise, and visual or physical motion (e.g., flickering lights, driving), and inadequate rest.

Protein and Carbohydrates

Avoid hypoglycemia by eating small, regular meals or snacks, including immediately upon waking in the morning, and prior to bed and even during the night, if necessary. Women with mild to moderate nausea, with or without minimal vomiting, often respond to intake of dry, slightly salty foods, for example, crackers, toast, and pretzels, as well as high-protein foods. Many women find that eating simple, carbohydrate-based meals, for example, a baked potato or plain pasta with a small amount of butter and salt, can be easily digested and allay nausea. A small amount of slightly sweetened yogurt is often a tolerable snack, and can easily be eaten at any time of day (or night).

Fluids

Fluids that pregnant women commonly find tolerable include cold water with a squeeze of lemon or lime; sparkling; water with lemon, lime, or orange flavor; ginger ale, and small amounts of grapefruit juice, lemonade, or purple grape juice. Clear broth, bouillon, or miso broth may also be tolerated by some women. Although it is critical that women with hyperemesis adequately replace lost fluids, drinking large amounts of fluids is, in itself, often a trigger for nausea and vomiting. Therefore, drinking very small amounts at a time, as little as several tablespoons of liquid every 15 minutes or so, is frequently more effective than trying to drink larger amounts of fluids. Women should also be encouraged to drink a couple of tablespoons of fluid after each episode or vomiting.

Nutritive Enemas

In severe cases, an enema containing Pedialyte can dramatically and quickly improve the mother’s status, and preempt the need to hospitalize her for intravenous (IV) nutrition. This can be repeated up to several times daily for a few days as a supplement to the woman’s nutritional intake. Quite often this is enough to raise her energy and fluid level so that appetite is restored and she is able to eat and drink on her own. Many women find this an option they prefer to try before a more invasive trip to the hospital becomes necessary.

Intravenous Fluid and Nutrient Replacement

Should oral fluid or food intake be impossible to achieve, and a nutritive enema either ineffective or an undesirable treatment to the mother, IV nutrition will be necessary. Infusion of intravenous Lactated Ringer’s solution supplemented with electrolytes and vitamins can relieve symptoms of dehydration in 1 to 2 days. Minerals including magnesium, phosphorus, and potassium need to be supplemented, and 100 mg IV thiamine for 2 to 3 days is recommended for women who have vomited for greater than 3 weeks. Plasma sodium should be corrected at a careful rate to avoid osmotic demyelination syndrome, which can occur with too quick a replacement.

Nutrient Supplements

Pyridoxine (vitamin B6), 10 to 25 mg by mouth, three to four times daily, has been demonstrated to improve mild to moderate nausea in women with nausea and vomiting of pregnancy, although it does not seem to be effective in the treatment of vomiting.

Acupuncture / Acupressure

A number of studies have been published demonstrating the effectiveness of acupuncture and acupressure for the suppression and relief of nausea and vomiting, including nausea and vomiting of pregnancy. Treatment has focused on what is referred to in traditional Chinese medicine as the Neiguan point, pericardium 6 (P6), an acupuncture point on the underside of the wrist. Acupuncture has been systemically tested in a limited number of trials. A single-blind, randomized, controlled trial in which 593 women less than 14 weeks with nausea and vomiting were treated weekly for 4 weeks found no difference in vomiting but less nausea and dry retching in treatment women versus controls. Although acupuncture clearly seems to be effective, it requires administration by a trained acupuncturist, regular access to which is a limitation for many women, and shows no apparently greater benefit than acupressure, which women can self-administer. Further, acupuncture treatment requires ongoing visits, which incur a much greater cost than the one-time purchase of acupressure bands, which can be used repeatedly.

In one study, researchers randomly assigned 33 women with hyperemesis gravidarum to acupuncture treatments on P6 or to mock treatments at a different location. After 2 days, all treatments were stopped for an additional 2 days to allow any effects to dissipate. The groups were then reversed for two additional days of treatment. Before treatment, all women were vomiting. On day 3, only 7 out of 17 women (41%) receiving active acupuncture were still vomiting compared with 12 out of 16 (75%) receiving mock treatment. After the active and mock treatment groups were switched, more of the women in the active treatment group ceased vomiting. The women in the active treatment group also reported decreased nausea. In another study, reported in the Journal of Reproductive Medicine, 41 patients were treated with acustimulation of P6 with an acustimulation device at the Department of Maternal-Fetal Medicine at Eastern Virginia Medical School. Prior to treatment, patients averaged a score of 4.2 on a nausea severity scale, with 5 being completely debilitating nausea. Posttreatment device effectiveness averaged 4.2, with significant or complete relief rated 5. All neonates were evaluated for congenital abnormalities and all neonates were found to be normal. The researchers concluded that because current pharmacologic treatments for nausea in early pregnancy are not consistent, efficacious, or without unwanted side effects or increased teratogenic risks, acustimulation of pericardium 6 in pregnancy may prove to be a significant therapeutic alternative. Stimulation of the pericardium 6 Neiguan point, three fingers above the wrist on the palmar aspect of the forearm, has been shown to alleviate nausea and vomiting of pregnancy by at least 50%. (pericardium 6 stimulation for 5 minutes four times daily, or as continuously as possible, may be administered by acupuncture, acupressure, manual pressure, Seabands, or possibly by a small TENS unit, Relief Band.) However, the small sample sizes and the failure of most trials to blind outcome assessment complicate interpretation of results. The acupuncture principles and practices for the treatment of nausea and vomiting using pericardium 6 and for the alleviation of pain also have been effectively and successfully extended to the treatment of postsurgical nausea and postsurgical pain relief. Because acupressure stimulation is safe and inexpensive as well as simple for women to achieve on their own at home with the use of wrist bands (e.g., Seabands), it is a reasonable part of a protocol for the treatment of nausea and vomiting of pregnancy and hyperemesis. For nausea and vomiting, pressure is applied to the pericardium 6 point on the inside of the wrist, about 2 to 3 fingerbreadths proximal to the wrist crease, between the tendons, about 1 cm deep. Manually, the woman or someone else applies pressure for 5 minutes every 4 hours. Alternately, pressure can be applied by wearing an elasticized band with a 1-cm round plastic protruding button that is centered over the acupuncture point. The FDA has recently approved a wristband type, miniaturized, battery-operated transcutaneous electrical nerve stimulator designed to stimulate the P6 acupuncture site. Called the ReliefBand, it has been found to be helpful for mild to moderate nausea and vomiting but not for severe symptoms. It is available over the Internet for less than $100, and clients with nausea and vomiting of pregnancy may want to pursue this option.

When Is Hospitalization for nausea and vomiting of pregnancy Recommended?

According to the American College of Obstetricians and Gynecologists, 2004 “When a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment is recommended. After the patient has been hospitalized on one occasion and a workup for other causes of severe vomiting has been undertaken, intravenous hydration, nutritional support, and modification of antiemetic therapy often can be accomplished at home. Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in affect or who continue to lose weight.

Hypnosis and Psychotherapy

A limited number of studies have demonstrated the efficacy of hypnosis in reducing nausea and vomiting of pregnancy in some patients. Psychotherapy is more likely to be beneficial if anxiety is playing a role in the etiology of the condition. Because it is a safe intervention, and because many women become anxious, depressed, or isolated when dealing with protracted vomiting, some form of counseling is a reasonable part of a treatment plan if it can be afforded.