Nausea and vomiting in pregnancy: An ‘alternative’ approach to care

It is thought that as many as 85% of expectant mothers experience nausea, vomiting and associated symptoms such as heartburn (Cardwell, 2012; Pasha et al, 2012; Festin, 2014). The causative factors are thought to be primarily endocrinological, namely human chorionic gonadotrophin, oestrogen, progesterone and thyroid hormones (Asakura et al, 2000; Kopp 2001; Patil et al, 2012; Festin, 2014). Immunological disturbance is thought to play a part (Fessler, 2002), as are nutritional factors, including hypoglycaemia and deficiencies of vitamins B6, B12 and C, plus zinc and magnesium (Dror and Allen, 2012; Wibowo et al, 2012). Associated food aversions may be a feto-protective mechanism, essentially deterring women from consuming foods containing pathogenic microorganisms and toxins (Flaxman and Sherman, 2000; Cardwell, 2012). More controversial aetiological theories include disturbance of the vestibular apparatus in the ear (Black, 2002; Golembiewski and O'Brien 2002), gastrointestinal Helicobacter pylori (Erdem et al, 2002) and musculoskeletal misalignment (Tiran, 2004a). More recently, genetic incompatibility has been explored (Patil et al, 2012) and it is known that familial history of pregnancy sickness predisposes daughters and siblings to the condition (Fejzo et al, 2008). This paper aims to provide midwives with an holistic approach to gestational nausea and vomiting, including some of the commonly-used self-help methods employed by women.

Nausea and vomiting in pregnancy—a complex syndrome

Nausea and vomiting of pregnancy can be relatively minor and short-lived, commonly quoted as ceasing at around 12–14 weeks' gestation (Lacroix et al, 2000). However, for many women the physiological manifestations are prolonged, continuous, and debilitating, affecting daily family life, yet without the pathological complications which define hyperemesis gravidarum. Furthermore, there is a plethora of research and review papers on hyperemesis gravidarum, but relative paucity of literature on mild–moderate nausea and vomiting of pregnancy. For women with moderate nausea and vomiting of pregnancy, while not requiring medical intervention, the condition is not a ‘minor disorder’ of pregnancy, as it is so often dismissively labelled, even though it may remain non-pathological.

Nausea and vomiting of pregnancy is not merely the sensation of nausea, interspersed with episodes of vomiting. It is a complex biopsychosocial syndrome of features, which affect individuals differently (Table 1) (Tiran, 2004a). It is essential to obtain a comprehensive history and to build up a picture of the physical symptoms, accompanying emotions and factors which make the condition better or worse. The history should include conventional personal and family medical history, but also needs to investigate the current condition in detail. It is important to obtain information about the times of day when symptoms are at their worst and to determine if any symptoms are related, for example, if food consumption is coincidental or related to the vomiting.

The midwife should investigate precisely what, if anything is vomited, and whether vomiting improves the nausea or not. Vomiting may be sporadic or absent, and may occur when the woman is hypoglycaemic, or immediately after eating. Vomitus may be undigested food, liquids, bile or excessive saliva and may relieve the nausea, have no effect or even exacerbate it. The duration and timing of nausea should be noted, with some women experiencing traditional ‘morning sickness’ and others feeling worse in the evenings or even during the night. It is also useful to note the mother's appetite and thirst and any cravings or aversions. Many women report an unpleasant taste in the mouth, which may be metallic, bitter or sour (possibly due to mineral imbalance) (Bedwal et al, 1993; Kuga et al, 2002). Motion, odours and even loud noises can also adversely affect the intensity of nausea.

Emotionally, women respond in many different ways to nausea and vomiting of pregnancy. Personal experience of the author in counselling over 5000 women with the condition indicates that they may be depressed, tearful and miserable or, conversely, overly cheerful. Some women may feel resentful or angry, either with themselves or their partner or, occasionally, with the baby. Many women are anxious about the baby's wellbeing, the risk of miscarriage, their ability to be a ‘good’ mother or about their relationship. In a few cases, usually when the condition has progressed to hyperemesis gravidarum, the woman may be so severely affected that termination seems the only solution.

A full account of all other accompanying symptoms is essential, both to determine any differential diagnosis and for the selection of appropriate self-help strategies or medical management, if necessary. Accompanying symptoms may include constipation or diarrhoea, flatulence, abdominal distension and discomfort, hyper-salivation, and neck and backache (Tiran, 2004b).

It is also useful to determine the mother's subjective view of the degree of severity of her condition, using a visual analogue scale. While there are specific validated scales for assessing nausea and vomiting, these tend to take a medical focus, considering primarily the frequency and duration of measurable signs and symptoms and do not, in the opinion of this author, give sufficient validity to the psychoemotional and social effects of nausea and vomiting on the mother and her family. The midwife should ask the mother to assess her biopsychosocial wellbeing, using a simple scale of 1–10; as symptoms improve and the mother's grading out of ten declines, she will recognise that she is feeling better, irrespective of how she chooses to measure her condition. The mother's perception may be influenced by the number of vomiting episodes, the duration and intensity of nausea, the combination of accompanying symptoms, or the difficulties of continuing to work or look after her family. It is irrelevant how she arrives at her score, but can be important after treatment commences to help her to understand that she feels better in some way.

Complementary therapy strategies

Most women acknowledge that mild nausea and vomiting is considered normal in pregnancy, but it is the unremitting nature of nausea and vomiting of pregnancy, which affects women so strongly, yet they are often left to cope alone. Consultation with the general practitioner is often unsatisfactory, with women either being told that ‘it's normal’ or given anti-emetic medication, which many women report reduces vomiting episodes but does not always suppress the nausea. The need to continue with day-to-day life, and a concern about the possible harmful effects of medication, therefore often lead women to explore a range of self-help strategies including complementary therapies and natural remedies.

Midwives need to be sufficiently well-informed to advise women accurately and comprehensively on the use of complementary therapies and natural remedies, referring to contemporary evidence to support their information. The Nursing and Midwifery Council (NMC, 2010: 36) permits midwives to administer or advise on complementary therapies and natural remedies if they are adequately and appropriately trained, but many are ill-equipped to do so, often leading to inaccurate or incomplete information being given to women (Tiran, 2004b; Tiran, 2007; Hall et al, 2012; Hall et al, 2013). Conversely, where midwives have little or no interest in alternative medicine, their attitude may be to dismiss them as ineffective or to direct women to seek alternative sources of information. This can be equally damaging, as the information available in the public domain, particularly via the internet, is not always appropriate and is sometimes dangerously inaccurate (Ernst and Schmidt, 2002).

Ginger

There is a common misconception that ginger biscuits ease nausea and vomiting of pregnancy, but this is not the case. There is insufficient ginger in a biscuit to have any real therapeutic effect, and although the sugar surge may temporarily alleviate the symptoms this is quickly followed by hypoglycaemia, with a consequent return of the nausea.

There is, however, considerable evidence to support the use of raw root ginger as an antiemetic (Ding et al, 2013). Unfortunately, there are wide variations in research methodology, making it difficult to draw comparisons. Different studies use fresh or dried root ginger, in capsule, syrup or tea form. Recommended dosages vary from 1 g per day in the UK, 2 g in the USA, up to 3 g in China, whereas Danish authorities completely discourage therapeutic use of ginger in pregnancy (Jacobsgaard, 2008). Viljoen et al (2014) concluded that ginger does not decrease the number of vomiting episodes but may reduce nausea, notably with a dose below 1500 mg, which avoids side-effects. Some studies have investigated ginger in combination with, or compared to, vitamin B6 (Chittumma et al, 2007; Ensiyeh and Sakineh, 2009; Smith, 2010; Haji Seid Javadi et al, 2013), but dosages and administration methods vary between studies. Ginger has also been compared with other strategies; it may be more effective than acupressure wristbands (Saberi et al, 2013) but less effective than prescribed anti-emetics (Pongrojpaw et al, 2007; Mohammadbeigi et al, 2011), throwing yet more variables into the mix.

The National Institute for Health and Care Excellence (NICE, 2012) takes the substantial evidence for the effectiveness of Ginger as an antiemetic at face value but ‘evidence for effectiveness is not the same as proof of safety’ (Tiran, 2012: 22). While Heitman et al (2013) found no evidence of increased risk of fetal loss, malformation or wellbeing when women use ginger for a relatively short period of time, it is not appropriate for all women. Side effects include heartburn or drowsiness, and in some women, nausea and vomiting of pregnancy symptoms are exacerbated rather than relieved (Tiran and Budd, 2005).

Tiran (2012) and Ding et al (2013) have questioned the optimum safe dose of Ginger and the risks of drug–herb interactions. Thomson et al (2014) erroneously state that ginger is non-pharmacological: all herbal remedies act pharmacologically. Ginger is known to have significant anticoagulant effects and should not be taken in conjunction with anticoagulant medication, nor with drugs with similar effects, such as aspirin (Shalansky et al, 2007; Spolarich and Andrews, 2007; Ulbricht et al, 2008). It should be avoided by women with any history or potential for bleeding, while taking large quantities continuously for more than 3 weeks requires assessment of clotting factors (Tiran, 2012). Ginger also has a hypoglycaemic effect and should be avoided by women with insulindependent diabetes mellitus (Heimes et al, 2009).

As with all herbal remedies, it is essential to identify contraindications and precautions before advising women to take Ginger root for nausea and vomiting of pregnancy (Tiran, 2012). A suitable alternative to Ginger is peppermint, taken as a tea. Peppermint is effective in relieving nausea and vomiting of pregnancy (Pasha et al, 2012) or postoperative sickness (Ferruggiari et al, 2012), but it should be avoided by those with cardiovascular conditions as it is a cardiac stimulant.

Stimulation of the Neiguan acupuncture point (Pericardium 6 point)

Acupuncture and self-help acupressure wristbands are well-known to relieve nausea and vomiting of pregnancy, as well as sickness from other causes and numerous studies having been conducted since Dundee et al's research in 1988 (Markose et al, 2004; Ezzo et al, 2006; Shin et al, 2007; Can Gürkan and Arslan, 2008). Acupuncture is based on the principle of internal channels carrying energy (Qi) around the body, connecting one part to another, with focus points along the channels, which can be stimulated or sedated when the body, mind or spirit is diseased. One such point is the Neiguan point on the inner aspect of the wrist, located approximately three finger-breadths up from the wrist crease. Qualified acupuncturists may insert needles into this and other points, with good effect (Cheong et al, 2013), but the value of the wristbands is that women can purchase and use them easily and are not precluded from trying other methods of treatment.

Specific studies on the use of Neiguan point acupuncture (with needles) or acupressure (with thumb pressure or wristbands) have generally shown positive results for nausea and vomiting of pregnancy (Belluomini et al, 1994; Werntoft and Dykes, 2001; Can Gürkan and Arslan, 2008), or for post-caesarean section nausea (Noroozinia et al, 2013). Shin et al (2008) suggested that it can even be helpful for hyperemesis gravidarum. However, Puangsricharern and Mahasukhon (2008) did not find auricular acupressure (using magnetised pellets in the ear) particularly effective for hyperemesis gravidarum.

Stimulation of the vestibular apparatus in the ear

The neuroanatomical relationship between the vomiting centre in the brain and the balancing mechanism in the ear can be adversely affected by gravitational imbalances caused by postural changes. Inappropriate positioning of the head and neck in relation to the body can lead to over-stimulation of dendrites in the vestibular neurons, with impulses transmitted via the vestibule-cochlear nerve to the medulla. Exaggerated stimulation of the vestibular apparatus due to excessive movement may result in nausea and vomiting. It is also possible that previous neck or upper spinal injury or trauma, coupled with the relaxation effects of progesterone and relaxin, may lead to increased susceptibility to over-stimulation of the vestibular apparatus, perhaps through a mechanism as yet not fully understood. Nausea and vomiting of pregnancy exacerbated with motion is particularly troublesome for women who experience travel sickness (Stone, 2007).

Treatments involving stimulation of the vestibular apparatus seem to be particularly successful for women whose nausea and vomiting is exacerbated by movement (Mayo, 2001). Electrostimulation of the vestibular apparatus in 26 women with hyperemesis gravidarum was found to be 89% effective (Golaszewski et al, 1995). Auditory stimulation of the vestibular apparatus, using a range of specific frequencies, pulses and tones aims to intercept the impulses between the gut and the brain, and has demonstrated a 90% success rate for nausea and vomiting of pregnancy (Mayo, 2001). In cases where musculoskeletal misalignment exerts strain on the head and neck, potentially causing tension on the vestibular apparatus, osteopathy or chiropractic may be useful.

Hypnosis

Hypnosis, or hypnotherapy, as a means of birth preparation is very popular among pregnant women. However, appropriate clinical hypnosis can be useful during pregnancy for conditions with an underlying emotional component, including nausea and vomiting of pregnancy. Stress and anxiety can have a profound effect on the progress and outcome of pregnancy, and women with unplanned pregnancies, poor socioeconomic circumstances or inadequate social support are more likely to suffer severe and/or prolonged nausea and vomiting of pregnancy (Swallow et al, 2004; Chou et al, 2008). Similarly, Kramer et al's (2013) Canadian study found that depression, social support and employment status affected the severity of nausea and vomiting of pregnancy; and smoking appeared to be a protective mechanism. Although no large-scale randomised controlled trials specifically investigating hypnotherapy for nausea and vomiting of pregnancy have been conducted, there are promising results for individualised treatments (Buckwalter and Simpson, 2002; McCormack, 2010; Madrid et al, 2011) which address psychosocial determinants.

Box 1.Further sources of information

Conclusion

Nausea and vomiting of pregnancy is a common physiological disorder affecting large numbers of expectant mothers. It is important that health professionals do not dismiss it, but support the mother through validation of her symptoms and attention to her psychosocial needs and are able to give correct and comprehensive advice on how to deal with the condition. Pharmacological medication should be avoided unless the woman is vomiting frequently, or has progressed to pathological hyperemesis gravidarum. Women should be asked what, if any, self-help strategies they have used. Midwives are in an invaluable situation to advise women about suggested complementary therapies, as shown in Table 2, but they should diplomatically attempt to correct women if they are misusing natural remedies.

Key points

• Nausea and vomiting is a common but distressing biopsychosocial condition in pregnancy which should not be dismissed as a ‘minor’ disorder
• Midwives should take a comprehensive history to determine the precise nature of the signs and symptoms for each woman
• Midwives are permitted to use or advise on complementary therapies and natural remedies if they have been appropriately trained to do so, have the permission of their employing authority and have local guidelines in place
• Midwives should ensure that they can advise women accurately and appropriately on the possible use of self-help methods for nausea and vomiting, especially the most commonly-used therapies such as ginger and acupressure wristbands
• Midwives should discuss with women suffering moderate nausea and vomiting the possibility of consulting specific practitioners of complementary medicine, including acupuncturists, osteopaths or chiropractors