Treatment of nausea and vomiting during pregnancy: presentation
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7434.276 (Published 29 January 2004) Cite this as: BMJ 2004;328:276All rapid responses
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The first priority, in my view, is to exclude any serious underlying
disease. We personally have seen gastric carcinoma, astrocytoma and
thyroid dysfunction masquerade as hyperemis gravidarum.
Besides this concern, the spectre of Thalidomide must cast a shadow over
all practising obstetricians. Therefore, pharmacological therapy ought to
be kept as a last resort. Furthermore, this should be restricted to those
patiens requiring rehydration and must be administered parenterally. The
habit of prescribing oral treatment to a patient who is vomiting
repeatedly can only be wasteful.
In our practice in SE Asia, we have witnessed some success with
stimulation of accupuncture point 6 in the wrist using a metal bangle
(accupressure). However, the ability to test the value of such a procedure
in a randomised controlled trial remains problematic.
Competing interests:
None declared
Competing interests: No competing interests
Hyperemesis can be a distressing condition and requires an open-
minded patient, doctor and midwife. From my own personal experience
pressure bands, ginger and prochlorperazine all failed.
As a last resort (with a BP of 80/50 and ketonuria), a hospital
midwife qualified in acupuncture, suggested I have some treatment. At 20
weeks gestation no decrease insymptoms, three half hour sessions were
carried out. The nausea and vomiting disappeared after the second session
with no recurrence.
From a patient perspective, there were no guidelines on how much
nausea and vomiting is acceptable during pregnancy nor at what stage
weight loss becomes significant. A better informed patient with a series
of treatment options available may help unearth the best treatment for
individuals.
Competing interests:
None declared
Competing interests: No competing interests
I have been asked by a GP to attach references for the benefits of
monitored nutritional repletion and low allergy high protein diet in
pregnancy sickness. Like me, she suffered from sickness and migraine in
pregnancy and has not found medications helpful or desirable.
In the 1970s I found that migraine headaches reduced ten fold when
patients stopped ergot medications, or contraceptive and menopausal
progestogens and oestrogens, or smoking.1 Patients who still had headaches
carried out Dr John Mansfield’s exclusion diet of lamb, pears and spring
water for a five day withdrawal period. Symptoms and pulse changes were
monitored when individual foods were reintroduced. The commonest foods
causing reactions, after this unmasking procedure, were wheat, oranges,
eggs, tea, coffee, chocolate, cow’s milk, beef, corn, cane sugar and
yeast. All patients improved and 85% of patients complying had no more
headaches and those with hypertension became normotensive. 2 Similar
results have been listed for a range of other conditions such as eczema,
hyperactivity, irritable bowel syndrome, and arthritis.3
The importance of preconception care and the results of nutritional
analysis and repletion, with zinc and magnesium being the commonest
deficiencies, were given at conferences held by the British Society for
Allergy, Environmental and Nutritional Medicine (BSAENM) and also by
Foresight; the Society for the Promotion of Preconceptional Care.4-7 The
BSEANM has useful textbooks and runs training courses for doctors. The
most accurate tests for zinc and magnesium deficiencies are assessments of
concentrations in white blood or red blood cells respectively, which are
available at Biolab Medical Unit in London. A functional blood superoxide
dismutase test is useful for diagnosing copper deficiency. Foresight has
recommended nutritional repletion and avoidance of toxins before
conception for couples since 1978. Assessing minerals in hair samples does
not always reliably diagnose zinc and magnesium deficiencies. Excellent
results appear to be achievable with nutritional supplementation in
preventing unexplained infertility, recurrent miscarriages, and illness in
pregnancy, and congenital abnormalities. A normally functioning immune
system needs to have an adequate essential nutrient status.8
1. Grant ECG. Food allergies and migraine. Lancet 1978;2:581.
2. Grant ECG .Food allergy and migraine. Lancet 1979;2:966- 968.
3. Anthony H, Birtwhistle S, Eaton K, Maberly J. Environmental Medicine in
Clinical Practice. BSAENM Publications 1997.
4. Barnes B, Grant ECG et al. Nutrition and preconception care. Lancet
1985;2:1297.
5. Grant ECG. The declining health of the pill generations. J Nutr Med
1994;4:283-86.
6. Ward N. Preconceptional care and pregnancy outcome. J Nutr Med
1995;5:205-6.
7. Grant ECG. The pill, hormone replacement therapy, vascular and mood
over-reactivity, and mineral imbalance. J Nutr Environ Med 1998;8:105-116.
8. Sherman AR. Immune dysfunction in iron, copper, and zinc deficiencies.
In: Bodgen JD, Klevay LM, eds. Clinical Nutrition of the Essential
Trace Elements and Minerals: The Guide for Health Professionals. Totawa,
NJ: Humana Press Inc., 2000: 309-331.
Competing interests:
None declared
Competing interests: No competing interests
It is important to remember to give thiamine to patients with NVP.
Dr. Nelson-Piercy has pointed to 3 maternal deaths in U.K. in the 90s from
Wernicke's encephalopathy.
I have also found it useful to keep the husband out of the way and this
was recommended by Ian Donald.
Competing interests:
None declared
Competing interests: No competing interests
We have been educated to believe that it was relatively safe for the
fetus for mothers to take medications after the first trimester when
organogenesis is complete. If DNA mismatch repair and the ability to
dispose of toxins is acquired in utero with the development of cellular
differentiation and specialised functions this may indeed be appropriate
but only relatively so.
The evidence-base upon which current practice is based has been
drived from studies of clearly defined congenital anatomic abnormalities,
such as those encounted following rubella infections and taking
thalidomide. These might well be the tip of a very large iceberg which
includes cognitive impairment, mood and behavioural disorders, learning
disabilities, mutant DNA, and the increased risk of chronic diseases such
as those encountered in survivors of the Leningrad siege (1). In other
words the evidence-base upon which current recommendations are being made
might be very specific but very poorly sensitive.
The risk of drug-induced damage to the gamete, fetus, infant, child
and adult might be better thought of as a continuum that extends for
generations. In which case no drug should ever be prescribed for an
extended period to any woman or indeed man unless there is no prospect of
them ever being a new parent or there is unequivocal evidence of life-
saving benefit in the short term. The same might well apply to those
chemicals and techniques being used in vitro fertilisation. The future of
humanity may depend upon us taking decisive global action on this issue
and related issues in the very near future, the risk to future generations
including all environmental exposures to pollutants in air, water and
food. Viewed in this context the proliferation of GM products is indeed
alarming.
The corollary is that the evidence-base for pharmacological
interventions can never be complete in people who might conceive a new
child in the future.
1. Pär Sparén, Denny Vågerö, Dmitri B Shestov, Svetlana Plavinskaja,
Nina Parfenova, Valeri Hoptiar, Dominique Paturot, and Maria Rosaria
Galanti
Long term mortality after severe starvation during the siege of Leningrad:
prospective cohort study
BMJ 2004; 328: 11-0
Competing interests:
None declared
Competing interests: No competing interests
Conventional treatment for this lady should start with the
reassurance that, because this is the first pregnancy in which she has
encountered nausea and vomiting of pregnancy (NVP), it does not mean that
there is anything wrong with her baby, or that the baby will be suffering
in any way. Indeed,we can say to her that there is good evidence that you
are less likely to miscarry if you have NVP with the pregnancy. NVP,
though unpleasant, is a symptom that is associated with the prospect of a
successful outcome to the pregnancy. In fact, at least a third of women
have varying symptoms of NVP in their pregnancies. NVP is a very common
condition, about 70% of women suffer from some degree of this condition
and it affects women of all psychological types, ethnic backgrounds and
types of employment. There is nothing you are doing or have done which
has brought on these symptoms, apart from being pregnant. Only about 10%
of NVP becomes worse after week 10 of a pregnancy and for 90% of women,
NVP will improve by weeks 12-14 of pregnancy, although a few women will
have symptoms for longer than 20 weeks of pregnancy.
Conventional treatment will include advice about lifestyle, which of
course, is perfectly safe. Your lifestyle is obviously affected, as you
say, you have some difficulty in managing your five year old daughter.
Women who have suffered from NVP recommend first that you avoid unpleasant
odours which make your NVP worse, particularly cooking odours. Ask your
partner, family member or friends if they will do more of the cooking for
you. (Is your partner supportive and understanding of your problems with
NVP?
As yet, not everyone is! If not, encourage him to read the leaflet I
shall give you).
As you are vomiting 4 times per day, I am sure you will be having
nausea before and after mid-day. 85% of women have at least 2 episodes of
nausea each day. The condition should never be called morning sickness,
but pregnancy sickness or NVP. Between episodes of nausea there will be
nausea free periods which occur at about the same time each day, when
symptoms are at there worse. Keep this daily diary sheet which I give you
now and you will be able to anticipate the nausea free times of the day
when you can eat comfortably. Apart from the foods you have been advised
to avoid during pregnancy, such as pate, soft cheeses, liver, under cooked
eggs which may contain infection and peanuts, eat as soon as your nausea
improves and eat what you fancy. Do you have cravings for certain foods,
despite the NVP? 60% of women with NVP have at least one craving!
Drink plenty of alcohol free fluid, not more than 3 cups of coffee or
tea per day and avoid soft drinks with a high caffeine content. Water
alone is excellent, though you may prefer fruit drinks or lemonade. If
nausea is very persistent, eat and drink small quantities of each
alternately, still using your limited nausea free times effectively.
Rest, with your feet up, is described by women who have had NVP, as
the second most important factor to relieve their symptoms. Ask help from
your partner, family or friends for the daily jobs you cannot manage,
particularly after your child comes home from school. Explain you need
their help, as rest is essential to reduce your symptoms. Do you go to
work? If so, is your boss sympathetic and understanding of the symptoms
you are suffering? It may be necessary to tell him or her that
approximately 30% of pregnant women in paid employment need time off work
due to NVP. He may then agree to let you have more rest during the day
when you need it.
The safest prescribed medicine to take is tabs Diclectin (which
contain Doxylamine 10mg, an antihistamine, and pyridixine 10mg vitamin
B6). The same compounds were found in the tablets called Bendectin until
1983. It has been taken by 33 million women with NVP and is approved by
the Society of Obstetricians and Gynaecologist of Canada for the treatment
of NVP. It will improve your NVP, although not necessarily relieve it
completely. Its only side-effect may be drowsiness due to the
antihistamine, so the recommended dose is 1 tablet early in the morning, 1
at about 2 pm and 2 at night when you go to bed. The sooner you start
taking these tablets, the more likely it is that they will relieve your
NVP. I recommend we start these as soon as possible, if you agree.
As an alternative therapy, you can use acupressure in the form of
seabands, a band to be put 3 finger widths above your wrists, with a small
button to press on the P6 point - an acupunctue significant point. The
bands may decrease NVP in about 50% of sufferers, there are no theoretical
concerns about the safety of this type of acupressure at present.
Have you tried any treatments for NVP that you have purchased from a
health food shop or chemist? You may have felt you must try something!
The most commonly used herbal treatment is ginger, but there are concerns
about the safety of 1000mg of ginger per day. It would be very
interesting to survey a large group of women who have suffered from NVP,
asking if they used any therapy not recommended by a doctor and if they
have found anything helpful to reduce NVP. Would you be prepared to be
part of such an investigation?
Please don't worry about the pregnancy, all is well. However, NVP
can be most unpleasant for you. Try these simple lifestyle adjustments we
have suggested in this leaflet, which has been produced by the trustees of
the recently formed Pregnancy Sickness Support Charity. At present the
good news is that there is every chance your NVP will improve in the near
future. Please come to see me in 2 weeks time when I hope you will have
started the Diclectin tablets.
Competing interests:
I am a trustee of the pregnancy sickness support charity, which has received an unrestricted education grant from Duchesnay Inc, Canada.
Competing interests: No competing interests
Comments
Dr Tomasso gives an admirable description of an N of 1 trial for the
evaluation of treatments for nausea and vomiting in pregnancy. These
trials are good for trying to decide what treatment actually benefits an
individual patient and are a more scientific method of decision making
than the usual GP method of asking the patient to return if the first
treatment doesn’t work and trying a second one(1). However it is worth
mentioning a few problems associated with them. Firstly, they are usually
used in chronic illness, such as arthritis, to evaluate the best long term
treatment for a patient. Nausea in pregnancy is obviously a limited
illness. Few treatment periods will be available, and so for example even
with 3 pairs of treatment periods there would not be much power to detect
a big effect unless it was dramatic. They are also vulnerable to carry-
over effects, if the effect of treatment extens to the next treatment
period.
Dr Mann is an enthusiast of RCTs over observational studies. I think
he is rather pessimistic about the ability of RCTs to cope with patient
heterogeneity. In a large randomised trial one would expect on average
patients would be balanced. If there is a major confounder, such as
severity, then this can be allowed for by stratified randomisation. Lack
of balance after the trial can be adjusted for by an analysis of
covariance (although one must beware fitting large numbers of covariates
just to see what effect they have). We also need to consider whether this
is a pragmatic or an explanatory trial. Clearly lack of compliance and a
low dropout out are necessary for the validity of an explanatory trial,
However in a pragmatic trial which asks what is the effect of
_prescribing_ this medication rather than what is the effect of a patient
_taking_ the medication, these factors reflect what happens in real life.
The main problem is they tend to reduce the effect size, and so require a
larger sized trial for a given power.
1.Guyatt GH, Sackett DL, Adachi JD et al. A clinician’s guide for
conducting randomised trials in individual patients. Can Med J 1988; 139:
497-503.
Competing interests:
None declared
Competing interests: No competing interests
Looking at the early responses to this paper I am struck by the range
of anecdotal, experience-based, and evidence-based contributions. This is
real life - no different from raising an interesting question over coffee
with colleagues,except perhaps that BMJ enables us to reach a wider range
of colleagues than taht in the normal medical workplace.
I am struck by one comment, "There is really NO (sic) excuse for not
knowing about..."( a book published in the early eighties.
I beg to differ. In modern medical practice we don't need excuses for
being unfamiliar with even quite seminal texts on aspects of medicine and
science. Effective learning, I suggest, depends on the skills to derive
and update scientific proinciples, to refine approaches to problems and
critical thinking, and on nurturing a spirit of enquiry which leads us to
tap into the views and experience of others, and into the database of
scientific literature on an as-required basis.
That is how we learn from cases.
Competing interests:
I act in an editorial advisory role for the BMJ and receive honoraria for work in respect of Interactive Case Learning
Competing interests: No competing interests
I would suggest that first it must be ensured that the patient does
not have a major medical condition as a source of the vomiting, as it has
been suggested, some form of obstruction or a metabolic problem.
As it is used to treat nausea/vomiting in patients who are exposed to
chemotherapy, hypnosis ( and later on self-hypnosis) as well as guided
imagery can be used with success to treat the nausea and vomiting. These
are obviously purely psychological interventions that may have an
influence on the mechanisms triggering the nausea. They can be used also
in cases of hyperemesis gravidarum. The patient is trained, by a mental
health professional with training on the procedure, to imagine (perceive
in the mind) pleasant odors, objects with a sensory effect that is
refreshing or pleasurable to the patient (each patient selects their own
preferences) and can be helped to evoke these sensations at the most
difficult times, e.g. in the morning. After a few sessions when the
patient is able to feel these experiences, a tape can be made and taken
home with which the patient can practice the procedure; alterantively she
may just be sensitive enough to do it wihtout the aid of a tape. I know of
several patients with whom this approach has been quite helpful and at
least ameliorated the symptoms.
Competing interests:
none
Competing interests: No competing interests
Homeopathy in pregnancy
Patients often have symptoms in pregnancy where conventional
treatment is either inadequate or contraindicated. Homeopathy is safe and,
I believe, effective, particularly if a prescription is based on details
which are individual to the patient. I do not routinely ask about my
patients about the use of complementary or alternative treatments and I
think I should do this more. Evidence for effectiveness is important and
as a practicing homeopath I know that my colleagues and I could make
significant progress if all homeopathic prescriptions and the outcomes of
this treatment were recorded. The Faculty of Homeopathy is committed to
high quality research. "Soft" data recording is helpful in targetting
research projects where useful results are likely to be achieved. Other
Complementary and Alternative Medical practitioners should embrace this
committement. The resulting evidence base could be hugely helpful for
conventional GPs, so that advice can be safe and effective.
Competing interests:
None declared
Competing interests: No competing interests