Trip Answers

Question answered:27/09/08

According to the NLH's speciliast library for Women's Health:

More than 80% of pregnant women experience nausea and 50% vomiting in the first trimester. The symptoms do not adversely affect the mother or fetus, but can have an impact on quality of life. Pregnant women should be advised that nausea and vomiting are usually normal and harmless symptoms, which resolve spontaneously by 16 to 20 weeks gestation. Hyperemesis gravidarum is excessive vomiting leading to a state of fluid and electrolyte imbalance; it has an incidence of 3.5/1000 deliveries. Symptomatic relief is available. Effective interventions are P6 acupressure, ginger and antihistamines. There is good evidence that antihistamines are safe in this context. Although one cohort study showed that vitamin B6 appeared safe, doubts about its safety still exist so it is not recommended (NICE guidance, 2008).

Lacasse et al (2008) validated the “Health-Related Quality of Life for Nausea and Vomiting during Pregnancy" (NVPQOL).  Their data suggested that the NVPQOL is a reliable and valid index to measure nausea and vomiting specific quality of life in the first trimester.

Ginger and Vitamin B6
A systematic review looked at six studies (total n=675) and confirmed that ginger improves both nausea and vomiting (Borelli et al., 2005). The review lacked large enough data sets to be able to confirm the safety of ginger. Another systematic review in 2005
described doses of ginger up to 6g/day as safe, but recommended that it should only be administered in a clinical trial due to lack of good safety data (Betz et al., 2005).

Two RCTs (n=291, n=138) compared vitamin B6 to ginger. Both RCTs concluded on the basis of weakly significant results that both ginger and vitamin B6 were equally effective in reducing nausea and vomiting. Safety data for neither ginger nor vitamin B6 were reported (Smith et al., 2004; Sripramote and Lekhyananda, 2003).

There is no new evidence on the safety of vitamin B6 in pharmacological doses, although a drug containing it, Benedictin (Debendox), was withdrawn in 1983 due to an apparent increase in limb abnormalities. Reviews of the studies reporting its teratogenicity do not support this fear.

Acupuncture and Acupressure
A review was undertaken of acupuncture for nausea and vomiting of any cause, including chemotherapy, motion sickness and pregnancy: results were mixed for pregnancy, but the review highlights the growing evidence for the general efficacy of acupuncture point
stimulation (Streitberger et al., 2006).

A RCT (n=230) compared acupuncture point nerve stimulation to placebo for mild to severe first trimester nausea and vomiting. This is in contrast to most other studies which involved in-patients with hyperemesis gravidarum. The study showed significant reduction of symptoms measured by the Rhodes index (P=0.02) thereby promoting weight gain (P=0.003) (Rosen et al., 2003).
 
A single-blind RCT (n=80) showed no reduction in anti-emetics required when acupressure was used (Heazell et al., 2006). Another single-blind study (n=66) showed no benefit of acupressure when compared to vitamin B6 (Jamigorn and Phupong, 2007).  A trial (n=88) compared a combined acupuncture and acupressure regime with antihistamine plus vitamin B12. The trial was not blinded or placebo controlled. The trial measured somatic and functional improvement, showing similar benefit for both (Neri et al., 2005).

A more recent small (n=75) Turkish RCT (Can Gürkan and Arslan, 2008) compared acupressure to placebo in women with nausea with and without vomiting who were unable to receive conventional treatments.  Over a 9 day period 26 women received P6 acupressure on days 4-6 while the placebo group (n =  24) received sham acupressure, and 25 women acted as a control group.  The P6 acupressure group reported improvements in frequency of nausea (P<0.001), severity of nausea (P<0.05) and intensity of discomfort felt from nausea (P<0.001) during the treatment days when compared to the pre-treatment days 1-3.  However, the placebo group also reported an improvement in all areas (P<0.05).

Steroids
Two small RCTs (n=40, n=80) agreed that corticosteroids improved symptoms (Bondok et al., 2006; Ziaei et al., 2004). A slightly larger RCT (n=126) did not use symptomatic improvement as an end point, but showed hospital readmission was not reduced by adding a corticosteroid to an antihistamine regime (Yost et al., 2003).

Helicobacter Pylori 
A recent systematic review (Golberg et al 2007) looked at the relationship between Helicobacter Pylori (H.Pylori) and hyperemesis gravidarum.  Fourteen case control studies were identified, involving 1732 participants and controls.  Ten studies showed a significant association and odds ratios varied from 0.55 to 109.33, three results were less than 1.  While an association between H.Pylori and hyperemesis gravidarum was suggested by this review, considerable heterogeneity in the studies involved highlights study limitations.

Source: http://www.library.nhs.uk/womenshealth/ViewResource.aspx?resID=294902&tabID=290&catID=6193

 

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