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Complementary approaches to pregnancy induced nausea and vomiting.

Nausea and vomiting continue to be uncomfortable symptoms associated with pregnancy. The precise etiology of nausea is unknown, but the most commonly referenced possible cause is the fluctuation of hormones during pregnancy (Cisek & Bucholc, 2015; Goodwin, 2002; Lagiou et al., 2003; Sherman & Flaxman, 2002). Nausea arises around week four of pregnancy and could last through the duration, but normally minimizes after week 12 (Lacroix, Eason, & Melzack, 2000). Nausea can be mild, moderate, or severe, and can lead to a severe form of the condition known as hyperemesis gravidarum (Almond, Edlund, Joffe, & Palme, 2016; Miller, 2002). This paper does not address hyperemesis because this is considered a medical condition, not a normal discomfort of pregnancy.

It is estimated that eighty percent of pregnant women will be burdened with nausea and vomiting and its untow ard effects (Cisek & Bucholc, 2015). Women are not only physically compromised; it also affects psychological and social well-being (Tiran, 2012). Though the protective effects of the nausea and vomiting have been linked to better fetal outcomes, it can be difficult to manage (Koren, Madjunkova, & Maltepe, 2014; Sherman & Flaxman, 2002).

Management is critical for a multitude of reasons: 1) to maximize comfort level of the expected mother; 2) to decrease risk to the fetus associated with fluid and nutrition deficiencies; and 3) to diminish troublesome physical, psychological, and social effects. The purpose of this paper is to review current management for normal pregnancy-induced nausea and vomiting, including complementary approaches that have been recognized in the literature.

Management

Current management of nausea and vomiting is comprised of dietary and behavioral interventions, limited pharmaceutical management, and various types of complementary therapies (Fantasia, 2014). Many pregnant women are open to the use of complementary therapies, with an estimated 35% disclosing use of at least herbs while being pregnant (Frawley et al., 2015; Holden, Gardiner, Birdee, Davis, & Yeh, 2015). Maternal safety and teratogenic risks are primary concerns for any of these recommended changes, management, or therapies.

Dietary and Behavior Changes

Dietary and behavioral changes are very common and are usually the first recommendation for early onset of symptoms. The changes are variable and tailored to personal needs. Recommendations include to limit intake to small frequent meals, and be mindful of the effects of food. East dry carbohydrates between meals and before getting out of bed in the morning. Increase protein particularly before bed. Decrease fatty foods and anything that seems to increase symptoms. Decreasing or eliminating smoking is important for all pregnant woman and may help reduce nausea. (Fantasia, 2014; King & Murphy, 2009; Maltepe & Koren, 2013). Attention to nutritional habits, lifestyle changes, and psychosocial influences is crucial to supporting and treating these women and managing their symptoms (Tiran, 2012). If these changes and modifications are not effective and the symptoms begin to interfere with quality of life, further measures may be considered, such as pharmaceuticals.

Pharmaceutical Management

Pharmaceuticals are commonly prescribed for treating pregnancy-induced nausea and vomiting. Types of medications that have been used to treat nausea and vomiting are vitamins, antihistamines, anticholinergics, dopamine antagonists, phenothiazines, butyrophenones, serotonin antagonists, and corticosteroids (King & Murphy, 2009; Meltzer, 2000; Niebyl, 2010). However, only 2.1% of these medications are Federal Drug Administration (FDA) approved (Koren, 2014). Extensive caution arose with the use of thalidomide in the 1960's and the associated birth defects (Ding, Leach, & Bradley, 2013). Again in the 1980's, Bendectin (doxylamine plus pyridoxine) was removed from distribution in the US by the pharmaceutical company because of concern associated with birth defects and associated litigations (Koren, Pastuszak, & Ito, 1998). It has since then been reintroduced into the market in 2013, as no scientific evidence has substantiated those claims. The only medication that has evidence-based recognition for maternal and fetal safety with FDA approval is pyridoxine (Vit. B)-doxylamine combination (Koren, 2014; Koren et al., 2010; Matok et al., 2014). The high percentage of off label pharmaceutical use during pregnancy is alarming and women need to be aware of the other options available.

Pyridoxine (vitamin B6)

Pyridoxine is one of the most commonly used vitamins to effectively treat nausea and vomiting during pregnancy (Matok et al., 2014; Smith, Crowther, Willson, Hotham, & McMillian, 2004; Sripramote & Lekhyananda, 2003). Note that vitamins are studied as both pharmaceutical and complimentary (Matthews, Haas, O'Mathuna, & Dowswell, 2015). It has been used since the early 1940's and has been proven to be effective to prevent and suppress nausea (Willis, Winn, Morris, & al, 1942).

Complementary Therapies

With the increasing concern for maternal and fetal safety, women are open to the use of complementary type recommendations that include herbal treatment as well as a variety of therapies during pregnancy (Frawley et al., 2015; Holden et al., 2015). Herbal supplements have medicinal qualities, and they are not regulated by the FDA. Pregnant women should always use caution with any supplements or therapies. The US National Center for Complementary and Integrative Health (NCCIH) categorizes complementary approaches as natural products or mind and body practices (NCCIH, 2016). To assure complementary type therapies are safe and effective, we will only discuss those treatments that have been researched and/or validated in the literature. After the 2015 Cochrone review of the literature, it was recognized that acupressure, acustimulation, acupuncture, ginger, chamomile, vitamin B6, lemon oil, and mint oil had variable results with limitations (Matthews et al., 2015). The research on these types of therapies is growing, but the intrinsic nature of treating individuals as a whole is problematic in research. Adjusting dosage, timing and delivery of these therapies/treatments becomes a barrier to the current standards of research accepted in the scientific community. Even with such barriers, research validation is surfacing and more studies are yielding respectable results. The review is limited to acupressure, acustimulation, acupuncture, and ginger.

Acupressure and Acupuncture

Acupressure, a traditional Chinese healing practice, is noninvasive form of touch therapy. Unlike acupuncture that utilizes needles to stimulate areas, acupressure gently stimulates through touch. These forms of Chinese healing practices are grounded in principles that embrace the life force of Chi or the specific flow of energy along a mapping of physical areas in our bodies (meridians) (Kafaei-Atrian et al., 2016). The area of the body that is associated with treating nausea and vomiting is called Nei Guan point (P6) (Jamigorn & Phupong, 2007). This area can be manually stimulated through acupressure/acupuncture or it can be stimulated by wearing a wrist band that holds pressure on the P6 point inside the wrist (Jamigorn & Phupong, 2007). Stimulation of this pressure point either by acupressure or wrist bands has been proven to be safe and effective (Gurkan & Arslan, 2008; Roscoe & Matteson, 2002). Another randomized control trial on P6 stimulation through acustimulation (low level electrical impulses) yielded favorable results for reducing nausea and vomiting (Rosen et al., 2003).

Ginger (zingiber officinale)

Ginger is a root that can be ingested in many different forms: freshly grated, extracts, syrups, teas, soda, or even pill form. Ginger has been proven to be safe and effective (Firouzbakht, Nikpour, Jamali, & Omidvar, 2014; Saberi, Sadat, Abedzadeh-Kalahroudi, & Taebi, 2013; Smith et al., 2004; Sripramote & Lekhyananda, 2003). Ding's 2013 systematic review identified four more randomized control trials that validated its safety and efficacy; dosage and timing was variable and warrants further investigation (Ding et al., 2013).

Other

Chamomile, lemon oil, mint oil, peppermint, and raspberry tea have been identified as potential useful remedies, but minimal studies have provided any evidence of their safety or effectiveness.

Conclusion

Treating nausea and vomiting during pregnancy continues to be challenging for the expectant mother and the health care provider. Although frequently mild or manageable, nausea can progress into conditions that threaten the safety of the mother and fetus. The continued awareness to provide maternal and fetal safety is imperative when considering treatment options. There are a wide range of dietary and behavioral changes that can be effective according to individual needs and preferences. Pharmaceutical approaches are limited but those that are researched and have proven to be safe and effective. The use of complementary approaches, such as acupressure and ginger, are the most recognized therapies that are proven to be safe and effective through research. They offer promise for providing an improved quality of life during the vulnerable time of pregnancy.

References

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Dr. Christine Argenbright is an Assistant Professor of Nursing at James Madison University School of Nursing in Harrisonburg, Virginia. She received her PhD in Nursing from University of Arizona. She currently teaches in the undergraduate and graduate nursing program specializing in adult health and complementary approaches to health and wellness.
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Author:Argenbright, Christine A.
Publication:International Journal of Childbirth Education
Geographic Code:1USA
Date:Jan 1, 2017
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