Acupuncture for nausea in early pregnancy: a discussion and case.(Medical condition overview)
The Journal of Chinese Medicine
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Nausea and vomiting is very common in pregnancy. A patient presented with nausea at the 10th week of gestation and was treated with acupuncture, reporting a total elimination of her symptoms within five minutes. This article investigates the aetiology, physiology and pathology of morning sickness and is illustrated via a case study from the author’s own practice.
Keywords: Nausea, vomiting, pregnancy, acupuncture, case study, morning sickness.
Nausea and vomiting in pregnancy (commonly known as morning sickness) is estimated to be experienced by 75-80% of pregnant women (Jewell et al, 2003; Gadsby, 1993). It varies significantly in intensity, usually occurring between the fourth and sixteenth week of gestation and peaking around eight to twelve weeks. The aetiology of morning sickness is complex with many influencing factors, both intrinsic and extrinsic. Women suffering from morning sickness may experience nausea and vomiting at any time of the day, and symptoms may continue throughout their entire pregnancy. Excess vomiting (hyperemesis gravidarum) occurs in 1-2% of all pregnancies and can lead to severe dehydration requiring hospitalisation (Carlsson et al, 2000).
Physiology of emesis
The mechanics and physiology of nausea and vomiting are complex as they can be caused by a range of possible stimuli from different parts of the body. The part of the brain that controls vomiting is known as the vomiting centre, a collection of neurones located in the medulla oblongata. The vomiting centre receives afferent signals from the gastrointestinal tract (via the vagus nerve), vestibular system (as in Meniere’s disease), higher cortical centres within the brain (from unpleasant smells/ sights /memories/ feelings), intracranial pressure receptors (as in meningitis), spinoreticular system (with physical injury) and the chemoreceptor zone (from hormones, toxins, infections and drugs).
There is a wide variety of neurotransmitters and receptors involved in these afferent nerve pathways, and it is these neurotransmitters and receptors that are targeted by many anti-emetic drugs (Tate et al, 1996). A significant amount of research has focused on the neuropharmacology of different emetic receptors in post-operative or chemotherapy-induced emesis, although many fewer studies have looked at the treatment of nausea and vomiting associated with pregnancy (due to the obvious ethical issues (1)). This research has led to a number of evidence-based pharmacological options to manage post-operative or chemotherapy-induced emesis (anticholingerics, phenothiazines, antihistamines, benzamines and serotonin receptor antagonists), but it is not known how effectively or safely these anti-emetic drugs might be applied to the pregnant population (Kovac, 2000; Habib et al, 2004; Vayrat-Follet et a1,1997).
Aetiology and pathophysiology
The exact cause of nausea and vomiting in pregnancy is unknown, but is thought to be intrinsically and extrinsically multi-factorial. The wide spectrum of symptoms experienced suggest that a combination of various factors probably affects individual women differently.
The following factors have been found to be associated with an increased risk of nausea and vomiting in pregnancy (2):
* Non-white ethnic status
* Housewife status
* Low socio-economic status
* Low maternal age
* An increased number of prior pregnancies (full-term or otherwise)
* Multiple pregnancies
* Increased fatigue and stress levels
* Depression and anxiety
* High maternal body weight
Diet is thought to play a contributing role in morning sickness. A review of 56 studies of the average diet of women in 21 different countries showed nausea and vomiting to be associated with diets high in sugars, alcohol, stimulants, meat, milk and eggs. Diets that were low in cereals and pulses were also associated with nausea and vomiting (Pepper et al, 2006). Helicobacter pylori infection in the gut has also been associated with both nausea and vomiting in pregnancy and hyperemesis gravidarum (Frigo et al, 1998).
Hormonal changes during pregnancy are thought to influence nausea and vomiting. Levels of human chorionicgonadotropin hormone (hCG) rise in the first weeks of pregnancy, reaching peak levels between eight and eleven weeks gestation (the time when most women experience morning sickness), and then begin to plateau or diminish for the remainder of the pregnancy (Furneaux et al, 2001). Despite this coincidental timing, hCG levels vary hugely between women, and it has been difficult to draw a definite conclusion as to their role in morning sickness. Some studies have found higher levels of hCG to be associated with nausea and vomiting (Kauppila et al, 1984; Masson et al, 1985) while others have found no association (Soules et a1,1980). Increased levels of oestradiol have also been found to be associated with nausea in pregnancy and hyperemesis gravidarum, whilst estriol and progesterone have not (Depue et al, 1987; Lagiou et al, 2003). Progesterone can affect gastrointestinal function by decreasing smooth muscle contractility, resulting in gastric arrhythmias and delaying gastric emptying (Kosh et al, 1990). Non-pregnant women given first trimester levels of oestrogen and progesterone experienced similar gastric smooth muscle disruptions as those experienced by pregnant women with morning sickness. The presence of the pregnancy hormones may alter the digestive muscle function, giving rise to the sensation of nausea (Walsh et a1,1996).
It is worth pointing out here a positive association with morning sickness. A meta-analytical review of 11 studies found that nausea or vomiting in pregnancy is associated with a decreased risk of miscarriage or perinatal mortality (Weigel et al, 1989), although a later prospective cohort study found that this association was not significant (Weigel et al, 2006).
Acupuncture and pregnancy hormones
There has been limited research on acupuncture and hormone levels in pregnant women. Ying et al (1985) found no change in hCG levels with acupuncture for first trimester abortion. Dong et al (2001) found no change with acupuncture in follicle-stimulating hormone, luteinising hormone, oestradiol, progesterone, or prolactin in 11 menopausal women with climacteric symptoms. It is not known if these results can be extrapolated to pregnancy.
Basic TCM theory
The main structures, substances, vessels and organs involved in pregnancy and morning sickness are as follows (3):
* The uterus
* Nourishes the foetus and governs the birthing process; closely related to the Kidneys and the Penetrating (Chong) and Conception (Ren) vessels..
* The Extraordinary Vessels
* The Penetrating and Conception vessels are particularly important in menstruation and pregnancy. Both originate between the Kidneys and flow through the uterus.
* The Penetrating vessel (the “sea of blood”) governs the supply and circulation of blood in the uterus; the main pathway by which the Stomach and uterus are linked in morning sickness.
* The Conception vessel (the “sea of yin”) regulates the uterus and menstruation and governs yin and fluids.
* Kidney qi
* The foetus is nourished by the mother’s Kidney qi, which must be sufficient to sustain both mother and foetus.
* If a woman is deficient in Kidney qi prior to conception this is likely to be accentuated once pregnant, possibly compromising the development of the foetus and causing symptoms of fatigue and weakness in the mother.
* Formed at conception and stored in the Kidneys; governs birth, growth, development and reproduction.
* The mother’s essence is used to nourish the developing foetus; if essence is weak, it may adversely affect foetal development and miscarriage may result.
* Kidney yin
* The source of fluids throughout the body; nourishes the organs and tissues of both mother and foetus.
* Yin deficiency leads to depletion of moisture and nourishment and results in the body being unable to regulate the increase in yang that occurs naturally during pregnancy (see below).
* Nourishes the foetus via the uterus.
* Liver qi
* The Liver stores blood for menstruation and is responsible for the smooth flow of qi throughout the body; Liver qi is responsible for assisting proper digestion and helps the Stomach qi to descend; the Liver is particularly affected by stress and emotional problems.
* If Liver qi becomes stagnant, it will disrupt the descending of Stomach qi as well as generating pathological heat.
* Stomach qi:
* With the Spleen, the Stomach is the root of post-heaven qi and blood production.
* Stomach qi should descend; disruption to this downwards movement results in Stomach qi rebelling upwards, causing nausea and vomiting; if food stagnates in the Stomach this will create heat which further disrupts the descending of Stomach qi.
* Spleen qi:
* With the Stomach, the Spleen is the root of post-heaven qi and blood production; both Spleen and Stomach are adversely affected by worry and overthinking.
* Deficiency of Spleen gi will typically cause symptoms of tiredness, poor appetite and loose stools alongside the nausea and vomiting in morning sickness.
* Heart qi
* Like Stomach qi, the qi of the Heart should descend. Heart qi is easily affected by emotional stress causing palpitations, anxiety and insomnia.
TCM pathology of morning sickness
Morning sickness is, by definition, caused by Stomach qi rebelling upwards, causing the characteristic sensation of nausea and the urge to vomit. This disharmony of Stomach qi is itself usually caused by other organ pathologies, which should be clearly differentiated in clinic in order to treat the condition successfully.
During the first months of pregnancy, the qi and blood of the mother begins to flourish and increases significantly in volume in order to nourish the developing foetus (4). It is the function of the Penetrating vessel to distribute this blood downwards to the uterus. One proposed explanation of morning sickness is that either because the foetus is “blocking” the uterus (now menstruation has stopped), or else because the foetus is unable to make use of the increased qi and blood, the excess is “backwashed” upwards along the Penetrating vessel towards the Stomach, causing its qi to rebel upwards. The qi of the Penetrating vessel will also rebel upwards if the essence and qi of the lower jiao is deficient and unable to “anchor” it, causing it to escape upwards.
One of the common patterns seen in morning sickness is a deficiency of Stomach and Spleen qi. If Stomach qi is deficient, it is easily affected by small changes in the Penetrating vessel and its qi counterflows upwards. In addition, if food stagnates in the Stomach it easily develops heat, the upward movement of which will further disrupt the natural descending of its qi.
Another typical cause of morning sickness is stagnation of Liver qi, which disrupts digestion and can invade the Stomach and Spleen, especially if their qi is deficient. Prolonged Liver qi stagnation will create heat, the ascending nature of which will further prevent Stomach qi from descending.
Heart qi may also play a role in morning sickness. Heart qi, like Stomach qi, should have a descending action. A deficiency in the flow of Heart qi can adversely affect the descending flow of Stomach qi.
Mrs B was a fit and healthy 42 year old in full-time work when she first attended the clinic. She had undergone two terminations in her early twenties for unplanned pregnancies with previous partners. Mr and Mrs B had been trying for a family for more than eight years and had been through two unsuccessful rounds of IVF in the past two years. Mr B was also fit and healthy, although tests had shown decreased sperm motility and morphology, thought to be due to a previous hepatitis A infection. Mrs B received weekly acupuncture at my clinic for six weeks prior to the IVF procedure, and both pre- and post-embryo transfer using the Paulus protocol (Paulus et al, 2002).
The IVF treatment was successful, and a happy Mrs B contacted me at 10 weeks gestation, reporting a progressive onset of nausea over the previous three weeks which was making it difficult to function at work. Her nausea occurred at various times throughout the day, ranging from zero to eight out of ten in intensity on a visual analogue scale (VAS). She reported rushing to the bathroom several times in anticipation of vomiting, but was not actually sick. Clearly this was disruptive to her day, and had prompted her to seek treatment.
At the time of her first treatment Mrs B rated her nausea at six out of ten in intensity. She reported having no appetite, although she did report some relief for a short time after eating. She had tried eliminating all dairy and wheat from her diet, without any noticeable effect. She disliked the smell of perfumes, tea, coffee and fruit, all of which caused her nausea to increase. Her stools were regular, if slightly loose, but she reported no tiredness or lethargy. Although her face was slightly flushed, she reported that her sleep was good, and she appeared calm and in good spirits. Her tongue was slightly pale without tooth-marks, and her pulse was weak.
My diagnosis was Stomach qi deficiency because of her weak pulse, lack of appetite and relief of symptoms after eating. During treatment Mrs B lay supine on a couch with needles (0.3 x 25mm) in place for 20 minutes. Deqi was obtained after insertion, and the needles manipulated using reinforcing technique. The needles were stimulated once or twice more during the 20 minutes, depending on how quickly her nausea decreased. The points (5) used with the aim of strengthening and harmonising Stomach qi are shown in order of placement in Table 1.
Mrs B reported complete elimination of nausea within five minutes of needle placement. This lasted for several days, and she presented for treatment twice more with a similar elimination of symptoms within five minutes.
At 14 weeks gestation Mrs B reported a slight change in her nausea. She now experienced nausea after eating, accompanied by a bloated sensation. Her tongue was redder and her pulse remained weak but was more rapid. She was still not experiencing any vomiting. I repeated the same points as used in the previous three treatments and she reported a reduction, but not a complete elimination of her nausea. I therefore decided to add Neiting ST 44 to eliminate heat from the Stomach and promote the flow of Stomach qi, which resulted in a complete disappearance of her nausea.
Mrs B periodically called into the clinic over the next few months to say hello and keep me updated on her progress. She did not experience any further nausea and gave birth to a healthy boy by normal delivery.
Incidentally, Mrs B told me that she had a fifth acupuncture treatment for nausea with another acupuncturist ten days after her fourth treatment at our clinic (I was away on holiday). This acupuncturist chose to needle Youmen KID-21 and Shufu KID-27 bilaterally (6). This treatment did not cause any reduction in her symptoms. By the time I had returned from holiday she was no longer experiencing any nausea.
There have been mixed results in studies investigating the use of acupuncture in the treatment of nausea and vomiting in pregnancy. Systematic reviews assessing the effectiveness of stimulation of acupoint Neiguan P-6 show more favourable results for post-operative and chemotherapy-induced nausea than for nausea during pregnancy (7). Six trials investigating nausea and vomiting in pregnancy across 1150 patients showed mixed results, with some favourable and some showing no difference (Ezzo et al, 2006).
A single-blind randomised controlled trial studied 593 women at less than 14 weeks gestation divided into four treatment groups: TCM acupuncture (maximum of six needles), acupuncture using Neiguan P-6 only, sham acupuncture (maximum of six needles) and a control non-acupuncture group. The women received two treatments in the first week, and then weekly treatments over for three weeks, with symptoms assessed once a week. The TCM group, Neiguan P-6 group and sham acupuncture group all experienced a reduction in symptoms, with the TCM group more quickly than the Neiguan P-6 or sham groups (Smith et al, 2002).
Another trial compared acupuncture at Neiguan P-6 with superficial acupuncture elsewhere on the arm for 33 women hospitalised with hyperemesis gravidarum. This single-blind cross-over study showed a more favourable effect for the Neiguan P-6 group. The two groups had differing levels of baseline nausea (on VAS) however, which makes definite conclusions harder to draw (Carlsson et al, 2000).
Evidence for the efficacy of acupuncture in reducing nausea and vomiting in pregnancy is inconclusive. The role of acupuncture in the case of Mrs B can also be questioned for various reasons. Psychological components may, of course, have played a significant role in the improvement of her symptoms. Mrs B already held me as a therapist in high regard prior to commencing acupuncture treatment, due to my previous successful treatment of her husband’s shoulder problem. My enthusiastic presentation of acupuncture would also have positively influenced Mrs B’s perception of treatment. This might provide a powerful placebo effect–she was expecting the treatment to help her and it did. Mrs B was also of older maternal age, white, financially stable, working full-time, and was without a history of depression or anxiety. The pregnancy had been planned and very much wanted, and Mrs B had a positive attitude towards her situation. All of these factors are linked with lower incidence of morning sickness.
It is therefore impossible to say how much Mrs B’s positive and rapid response to treatment was indicative of a placebo effect, or whether it was due to successful harmonising her Penetrating vessel and strengthening her Stomach qi.
Neiguan P-6, combined with other points according to TCM patterns, appears to be very effective at reducing pregnancy-induced nausea. Mrs B achieved rapid elimination of her symptoms without pharmacological intervention. Acupuncture at the points used for Mrs B has been found to be safe, with no evidence of spontaneous miscarriage or tetragenetic effects (Smith et al, 2002). Although there is limited research regarding the efficacy of acupuncture for morning sickness, there is plenty of evidence testifying to acupuncture’s effectiveness in reducing post-operative and chemotherapy-induced nausea and vomiting. If extrapolated to pregnancy, this supports the use of acupuncture as a safe, non-pharmacological treatment of significant benefit to pregnant women. In addition, acupuncture may reduce the risk of dehydration and hyperemesis gravidarum (Streitberger et al, 2006). Nausea and vomiting during pregnancy can have a profound effect on a woman’s personal and professional life, affecting her ability to work and subsequent financial status. Severe vomiting can lead to dehydration and hospitalisation, with a consequent drain on healthcare resources (Arsenault et al, 2002). If symptoms of nausea and vomiting in pregnancy can be reduced without pharmacological intervention, then this must surely be better for both mother and foetus.
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(1) For example, the devastating tetragenetic effects of thalidomide.
(2) Weigel et al, 1998; Depue et al, 1987; Kallen et al, 2003; Louik et al, 2006; Buckwalter et al, 2002; Betts, 2003.
(3) A comprehensive analysis of TCM obstetric theory is beyond the scope of this article; readers are referred to the excellent texts by Maciocia (1998) and West (2001) for a full description of the relevant TCM theory.
(4) An increase in blood, heat, dampness and Liver gi(along with a decrease in Kidney qi) can usually be observed as a normal part of early pregnancy; these changes can put significant pressure on the balanced functioning of the qi mechanism in a pregnant woman.
(5) Choice of points and functions are based on Stux and Pomeranz, 1995; Mao-liang 199; Personal notes, 2002.
(6) These points are recommended by Betts (2006) to treat morning sickness by harmonizing the Chong Mai.
(7) Invasive and non-invasive stimulation of P-6 for postoperative nausea and vomiting was found to be consistently effective in 26 trials with over 3000 patients, with minimal side effects (Lee et al, 2004). Electroacupuncture (but not manual acupuncture) was found to be effective for first day vomiting for chemotherapy-induced nausea and vomiting for 1200 patients over 11 trials.
Julie Gear is a physiotherapist working in private practice in the UK. Her initial training in acupuncture was a foundation course with the Acupuncture Association for Chartered Physiotherapists (AACP) in 2002. She completed further studies of TCM acupuncture in Beijing. Julie can be contacted at [email protected]
Table 1: Points used to strengthen and harmonise Stomach qi.
Point Special information Traditional uses
Neiguan P-6Luo-connecting point Regulates Heart qi and
Confluent point of blood, Yin Linking
Zusanli ST-36 He-sea pointTonifies Stomach qi,
qi, promotes nourishment
of internal organs
Fenglong ST-40 Luo-connecting point Clears dampness, clears
shen, eliminates heat
from the Stomach,
regulates Stomach qi,
Zhongwan REN-12 Front-mu point of Stomach Harmonises Spleen and
Hui-meeting point of the Stomach, resolves
4th Treatment (in addition to points
Neiting ST-44Ying-spring Point Eliminates heat and
flow of Stomach qi
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Gear, Julie. “Acupuncture for nausea in early pregnancy: a discussion and case.(Medical condition overview).” The Journal of Chinese Medicine. The Journal of Chinese Medicine. 2008. HighBeam Research. 18 Jun. 2009 <http://www.highbeam.com>.
Gear, Julie. “Acupuncture for nausea in early pregnancy: a discussion and case.(Medical condition overview).” The Journal of Chinese Medicine. 2008. HighBeam Research. (June 18, 2009). http://www.highbeam.com/doc/1G1-177719247.html
Gear, Julie. “Acupuncture for nausea in early pregnancy: a discussion and case.(Medical condition overview).” The Journal of Chinese Medicine. The Journal of Chinese Medicine. 2008. Retrieved June 18, 2009 from HighBeam Research: http://www.highbeam.com/doc/1G1-177719247.html