Désirée A. Lie, MD, MSEd
January 14, 2014
What Would You Do?
Case 1: Morning Sickness
Vicky is a 25-year-old primiparous woman in her 11th week of a normal pregnancy. She is experiencing excessive nausea and vomiting that is unrelieved by taking small frequent meals and eating crackers upon waking. Ultrasonography confirms a singleton pregnancy, and her hemoglobin level, metabolic panel, and urine tests are normal. She would like to avoid medications and asks whether she should try acupuncture, acupressure, or ginger for her symptoms.
Case 2: Motion Sickness
Mike is a 40-year-old man with a history of severe motion sickness induced by long car rides and boat trips. He is preparing to take a 2-week cruise. He would like a nonsedating alternative to antihistamines and anticholinergics to control motion sickness during his vacation. What might you suggest?
Nausea and Vomiting of Pregnancy: Does Anything Help?
Nausea and vomiting are common symptoms during the first trimester of pregnancy, occurring in almost one half of all women, and often persist until the fourth or fifth month (weeks 10-16) of pregnancy. Although typically self-resolving, these symptoms can lead to dehydration requiring hospitalization in a small minority of women. Hyperemesis gravidarum, a condition characterized by persistent vomiting, weight loss, ketonuria, electrolyte abnormalities, and dehydration, can affect as many as 2 in 100 pregnant women.
Acupuncture and acupressure. Several reviews have examined the use of acupuncture or acupressure for symptom control.[1-3] Acupuncture uses acupoint 6 (P6) proximal to the distal wrist crease for control of nausea, whereas acupressure can be applied manually or with wrist bands. Although studies have found acupressure to be more effective than sham acupressure,[2] larger studies have not demonstrated efficacy of either acupressure or acupuncture over sham acupuncture or no treatment.[2,3]
Ginger. Ginger (the rhizome Zingiber officinale) is a food condiment widely used in Asian cooking and as a traditional remedy for many conditions, such as dyspepsia, nausea and vomiting, constipation, bloating, and gingivitis, and for nongastroenterologic conditions such as fever and hypertension.[4-6]
Both animal and human studies have supported the antiemetic properties of ginger. Ginger extract,[7] ginger syrup,[8] and ginger capsules[9,10] have been reported in clinical trials to be superior to placebo for control of nausea and vomiting in pregnancy. A comparison[11]of ginger capsules (1 g daily in 4 divided doses) with vitamin B6 (pyridoxine) in early pregnancy found ginger to be more effective in reducing the severity of nausea but not in reducing the number of episodes of vomiting for women in early pregnancy, confirming findings from an earlier, smaller study.[12]
An evidence-based review in 2011[13] summarized the available evidence on the use of ginger. It concluded, on the basis of small heterogenous trials comparing ginger with placebo and other comparators, that the effectiveness of ginger was similar to that of dimenhydrinate and pyridoxine, and ginger was probably as safe as placebo. Its safety has been shown in some trials,[8] but other researchers have expressed concern about the potential risk for anticoagulant effects[14,15] and advise caution in terms of the dosage used during pregnancy, suggesting that further studies are needed. Ginger should certainly be avoided by persons on anticoagulation therapy, those with duodenal ulcers, or those at risk for intestinal obstruction.[1]
The American College of Obstetricians and Gynecologists (ACOG)[16] and the National Institute for Health and Clinical Excellence[17] both include ginger on their lists of acceptable therapies for the treatment of nausea and vomiting during pregnancy.
Hypnosis. Hypnosis has been recommended for nausea and vomiting during pregnancy as well as for symptoms associated with chemotherapy. However, a systematic review[18] identified only 6 clinical studies on hypnosis, with the evidence for efficacy being weak. Better-designed studies should be conducted in the future to assess the efficacy of hypnosis for hyperemesis gravidarum.[18]
A case report[19] from 2011 provides some insight into the use of brief hypnosis for persistent nausea and vomiting throughout pregnancy. More data are needed before hypnosis can be recommended to patients.
Motion Sickness
Motion sickness is a normal response to real, perceived,[20] or anticipated movement and can be triggered by the movement of a car, train, or airplane. It is experienced as seasickness by those on boats and is a concern of many persons who are contemplating a cruise.
The symptoms of motion sickness tend to be limited to the duration of the motion experienced. The symptoms, which include nausea and vomiting, dizziness, vertigo, cold sweat, disorientation, and fatigue, can be debilitating and particularly interfere with functioning at work for those whose jobs entail motion. Motion sickness can be visually induced (when there is no real motion) in virtual environments, such as simulators, cinemas, and video games. It is postulated that symptoms occur as a result of a mismatch among the visual, vestibular, and propioceptive systems.
Pharmacologic approaches. Pharmacologic measures for vestibular or visually induced motion sickness include transdermal scopolamine, an anticholinergic agent worn as a patch behind the ear that is applied up to 8 hours before travel; its effects last up to 3 days. Oral promethazine can be taken 2 hours before travel, with effects lasting 6-8 hours. Over-the-counter treatments include antihistamines, such as dimenhydrinate, meclizine, and cyclizine, but these can be sedating, impair cognition, and interfere with daily function. The type of medication taken should be customized to the duration and purpose of travel.
Nonpharmacologic approaches. Nutritional tips to reduce motion sickness include avoiding fatty or spicy meals; staying well hydrated; drinking ginger ale; and eating small, frequent meals. Among alternative therapies, acupressure,[21] wristbands,[22] and ginger[6,23,24] have been proposed as safe treatments. Other potential remedies include biofeedback training and relaxation,[25] deep breathing techniques, and cognitive-behavioral therapy,[26-29] modalities that have been tested on airplane pilots and were found to be helpful.
More recently, the use of relaxing and pleasant music has been proposed as a noninvasive and inexpensive countermeasure to visually induced motion sickness.[30,31] During a visually induced motion sickness experience, persons who listened to music that they self-reported as pleasant showed a significant reduction in motion sickness symptoms, with concomitant improved mood and emotion, compared with those who did not listen to pleasant music. The researchers postulated that the effect could be mediated by physiologic autonomic changes that promote relaxation and suggested more studies to examine the mechanism of this effect.
Case Resolution
After exclusion of more serious conditions, such as hyperemesis, multiple gestation, or diabetes, Vicky appears to have typical nausea and vomiting of early pregnancy. ACOG states that “treatment of nausea and vomiting of pregnancy with ginger has shown beneficial effects and can be considered as a nonpharmacologic option.”[16] Clinical trials have not confirmed the efficacy of acupuncture or acupressure for symptom control.
If Vicky does not have a bleeding diathesis and is not on anticoagulant medication, a trial of ginger capsules at 250 mg 4 times daily is warranted. She can also be reassured that these symptoms should subside as pregnancy progresses.
Mike has troublesome motion sickness that may prevent his enjoyment of his vacation, and he is eager to avoid anticholinergics and antihistamines. There are several nonsedating complementary and alternative medicine options with minimal side effects that he can try. The use of pleasant music, which he can enjoy on any digital device, could act as a countermeasure before and during travel. Wristbands that provide acupressure at the P6 point can be worn during the cruise. In addition, ginger capsules at a dose of 250 mg given 3 times daily may alleviate the symptoms of seasickness.