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Sommaire
nausea and vomiting in pregnancy:
Nausées-vomissements gravidiques : évaluation de l'acupuncture
| Articles connexes : - Nausées et vomissements post-chimiothérapie - Nausées et vomissements post-opératoires - |
1. Systematic Reviews and Meta-Analysis
| ☆☆☆ | Evidence for effectiveness and a specific effect of acupuncture |
| ☆☆ | Evidence for effectiveness of acupuncture |
| ☆ | Limited evidence for effectiveness of acupuncture |
| Ø | No evidence or insufficient evidence |
1.1. Generic Acupuncture
1.1.1. Nassif 2022 ☆
Nassif MS, Costa ICP, Ribeiro PM, Moura CC, Oliveira PE. Integrative and complementary practices to control nausea and vomiting in pregnant women: a systematic review. Rev Esc Enferm USP. 2022 Oct 21;56:e20210515. English, Portuguese. https://doi.org/10.1590/1980-220X-REEUSP-2021-0515en.
| Objective | to synthesize the evidence available in the literature on the effects of integrative and complementary practices in nausea and vomiting treatment in pregnant women. |
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| Method | a systematic review, reported according to PRISMA and registered in PROSPERO. The search for studies was carried out in 11 databases. To assess risk of bias in randomized clinical trials, the Cochrane Collaboration Risk of Bias Tool (RoB 2) was used. |
| Results | the final sample consisted of 31 articles, divided into three categories: aromatherapy, phytotherapy and acupuncture. It was observed that aromatherapy with lemon essential oil, ginger capsules, pericardial 6 point acupressure were the interventions that proved to be effective. Less than half of studies reported adverse effects, with mild and transient symptoms predominating. Most articles were classified as “some concern” in risk of bias assessment. |
| Conclusion | the three most effective interventions to control gestational nausea and vomiting were aromatherapy, herbal medicine and acupuncture, with significant results in the assessment of individual studies. |
1.1.2. Lu 2021 ★★
Lu H, Zheng C, Zhong Y, Cheng L, Zhou Y. Effectiveness of Acupuncture in the Treatment of Hyperemesis Gravidarum: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2021. [220826]. https://doi.org/10.1155/2021/2731446
| Background | Hyperemesis gravidarum (HG) is a common gastrointestinal disease afflicting gravidas. It usually results in hospital admission in early pregnancy. |
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| Objective | Through a meta-analysis, this study intended to explore acupuncture's clinical efficacy in treating HG. |
| Materials and methods | A comprehensive search of PubMed, the Cochrane Library, EMBASE, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biological Medical (CBM), Wanfang Database, and China Science and Technology Journal (VIP) for published clinical randomized controlled trials (RCTs) of acupuncture for treating HG was conducted from the date of database creation to 20th January 2021. We also searched grey literature in four databases: Chinese Cochrane Center, Chinese Clinical Trial Registry, GreyNet International, and Open Grey from their inception to 20th January 2021. Two authors independently screened the literature, extracted data, and evaluated the quality of the literature with Cochrane Handbook 5.1.0 and Review Manager 5.2 software. Review Manager 5.2 and STATA 12.0 software were applied to analyze data. Heterogeneity analysis was performed by the Cochran Chi-square test and I 2 statistic. Egger's tests together with funnel plots were used to identify publication bias. |
| Results | A total of 16 trials covering 1043 gravidas were included. Compared with the conventional treatment, acupuncture had a significantly higher effective rate (OR: 8.11, 95% CI: 5.29∼12.43; P < 0.00001), a higher conversion rate of urine ketone (RR: 1.36, 95% CI: 1.15∼1.60; P=0.0003), an improvement rate of nausea and vomiting (OR: 26.44, 95% CI: 3.54∼197.31; P=0.001), and a relatively higher improvement rate of food intake (RR: 1.17, 95% CI: 1.01∼1.36; P=0.04). Acupuncture also shortened hospitalization time and manifested with a lower pregnancy termination rate and fewer adverse events. Nevertheless, no statistical variation in the improvement of nausea intensity, vomiting episodes, and lassitude symptom, recurrence rate, and serum potassium was observed. |
| Conclusion | Our study suggested that acupuncture was effective in treating HG. However, as the potential inferior quality and underlying publication bias were found in the included studies, there is a need for more superior-quality RCTs to examine their effectiveness and safety. |
1.1.3. Sridharan 2020 ☆
Sridharan K, Sivaramakrishnan G. Interventions for treating hyperemesis gravidarum: a network meta-analysis of randomized clinical trials. J Matern Fetal Neonatal Med. 2020;33(8):1405-1411. [216323]. doi
| Background | Several interventions were explored in clinical trials for treating hyperemesis gravidarum (HG). The present study is a network meta-analysis of such interventions. |
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| Methods | Electronic databases were searched for appropriate randomized clinical trials comparing interventions for treatment of patients with HG. Control of HG symptoms was the primary outcome and emetic episodes, hospital stay, nausea scores, patients requiring rescue antiemetics, hospital readmission, adverse events, and adverse pregnancy outcomes were the secondary outcome measures. Random-effects model was used and odds ratio (OR) [95% confidence interval (CI)] was the effect estimate for categorical outcomes and weighted mean difference (WMD) [95% confidence interval] for numerical outcomes. |
| Results | Twenty studies were included in the systematic review and 18 in the meta-analysis. Acupuncture (OR: 18.9; 95% CI: 2.1, 168), acupressure (OR: 26.7; 95% CI: 2.5, 283.1) and methylprednisolone (OR: 6.7; 95% CI: 1.1, 38.8) were associated with better control of HG symptoms than standard of care. Acupressure decreases the requirement of rescue antiemetics (OR: 0.06; 95% CI: 0.01, 0.44); ondansetron with reduced hospital stay (WMD: -0.2; 95% CI: -0.31, -0.01) and diazepam with reduced risk of hospital admission (OR: 0.11; 95% CI: 0.01, 0.95). The quality of evidence is very low. |
| Conclusion | Acupuncture, acupressure, and methylprednisolone were observed with better therapeutic benefits than other interventions for treating HG. However, the pooled estimates may change with the advent of results from future head-to-head clinical trials. |
1.1.4. Sridharan 2018 ☆
Sridharan K, Sivaramakrishnan G. Interventions for treating nausea and vomiting in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials. Expert Rev Clin Pharmacol. 2018;11(11):1143-1150. [189851].
| Introduction | Several drugs were explored for their utility in treating nausea and vomiting in pregnancy (NVP). The present study is a network meta-analysis of such drugs. |
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| Methods | Electronic databases were searched for randomized clinical trials that have compared active interventions (with placebo or other active interventions) for treating NVP. Nausea scores were the primary outcome and changes in nausea scores, emetic episodes, adverse events, and vomiting control were the key secondary outcomes. Weighted mean difference was the effect estimate for continuous variable and odds ratio for the numerical variable. Random-effects model was used and the strength of the evidence was graded. |
| Results | Fifty studies were included in the systematic review and 42 in the meta-analysis. Acupuncture, chamomile, dimenhydrinate, doxylamine/vitamin B6, ginger, quince, metoclopramide, and vitamin B6 were associated with reduced nausea scores compared to placebo. Of these interventions, ginger and vitamin B6 were also associated with better vomiting control and less incidence of adverse events. Adequate evidence supporting the use exists only for ginger and the quality of evidence for this comparison is moderate. Strength of evidence for all other comparisons is very low. |
| Conclusion | Present evidence is conclusive on the therapeutic benefits of ginger in treating NVP. Although favorable results were obtained for several other interventions, the strength of evidence is very low. The results of this network meta-analysis should be interpreted with extreme caution as it might change with the advent of data from future head-to-head clinical trials. |
1.1.5. O'Donnel 2016
O'Donnell A, McParlin C2, Robson SC3, Beyer F, Moloney E4, Bryant A, Bradley J, Muirhead C, Nelson-Piercy C, Newbury-Birch D, Norman J, Simpson E, Swallow B, Yates L, Vale L. Treatments for hyperemesis gravidarum and nausea and vomiting in pregnancy: a systematic review and economic assessment. Health Technol Assess. 2016;20(74):1-268. [100354].
| Background | Nausea and vomiting in pregnancy (NVP) affects up to 85% of all women during pregnancy, but for the majority self-management suffices. For the remainder, symptoms are more severe and the most severe form of NVP - hyperemesis gravidarum (HG) - affects 0.3-1.0% of pregnant women. There is no widely accepted point at which NVP becomes HG. |
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| Objectives | This study aimed to determine the relative clinical effectiveness and cost-effectiveness of treatments for NVP and HG. |
| Methods | DATA SOURCES: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, PsycINFO, Commonwealth Agricultural Bureaux (CAB) Abstracts, Latin American and Caribbean Health Sciences Literature, Allied and Complementary Medicine Database, British Nursing Index, Science Citation Index, Social Sciences Citation Index, Scopus, Conference Proceedings Index, NHS Economic Evaluation Database, Health Economic Evaluations Database, China National Knowledge Infrastructure, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects were searched from inception to September 2014. References from studies and literature reviews identified were also examined. Obstetric Medicine was hand-searched, as were websites of relevant organisations. Costs came from NHS sources. REVIEW METHODS: A systematic review of randomised and non-randomised controlled trials (RCTs) for effectiveness, and population-based case series for adverse events and fetal outcomes. Treatments: vitamins B6 and B12, ginger, acupressure/acupuncture, hypnotherapy, antiemetics, dopamine antagonists, 5-hydroxytryptamine receptor antagonists, intravenous (i.v.) fluids, corticosteroids, enteral and parenteral feeding or other novel treatment. Two reviewers extracted data and quality assessed studies. Results were narratively synthesised; planned meta-analysis was not possible due to heterogeneity and incomplete reporting. A simple economic evaluation considered the implied values of treatments. |
| Results | Seventy-three studies (75 reports) met the inclusion criteria. For RCTs, 33 and 11 studies had a low and high risk of bias respectively. For the remainder (n = 20) it was unclear. The non-randomised studies (n = 9) were low quality. There were 33 separate comparators. The most common were acupressure versus placebo (n = 12); steroid versus usual treatment (n = 7); ginger versus placebo ( n = 6); ginger versus vitamin B6 (n = 6); and vitamin B6 versus placebo (n = 4). There was evidence that ginger, antihistamines, metoclopramide (mild disease) and vitamin B6 (mild to severe disease) are better than placebo. Diclectin® [Duchesnay Inc.; doxylamine succinate (10 mg) plus pyridoxine hydrochloride (10 mg) slow release tablet] is more effective than placebo and ondansetron is more effective at reducing nausea than pyridoxine plus doxylamine. Diclectin before symptoms of NVP begin for women at high risk of severe NVP recurrence reduces risk of moderate/severe NVP compared with taking Diclectin once symptoms begin. Promethazine is as, and ondansetron is more, effective than metoclopramide for severe NVP/HG. I.v. fluids help correct dehydration and improve symptoms. Dextrose saline may be more effective at reducing nausea than normal saline. Transdermal clonidine patches may be effective for severe HG. Enteral feeding is effective but extreme method treatment for very severe symptoms. Day case management for moderate/severe symptoms is feasible, acceptable and as effective as inpatient care. For all other interventions and comparisons, evidence is unclear. The economic analysis was limited by lack of effectiveness data, but comparison of costs between treatments highlights the implications of different choices. LIMITATIONS: The main limitations were the quantity and quality of the data available. |
| Conclusion | There was evidence of some improvement in symptoms for some treatments, but these data may not be transferable across disease severities. Methodologically sound and larger trials of the main therapies considered within the UK NHS are needed. |
1.1.6. McParlin 2016 ∼
McParlin C, O'Donnell A, Robson SC, Beyer F, Moloney E, Bryant A, Bradley J, Muirhead CR, Nelson-Piercy C, Newbury-Birch D, Norman J, Shaw C, Simpson E, Swallow B, Yates L, Vale L. Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy: A Systematic Review. JAMA. 2016;316(13):1392-140. [190439].
| Objectives | Nausea and vomiting affects approximately 85% of pregnant women. The most severe form, hyperemesis gravidarum, affects up to 3% of women and can have significant adverse physical and psychological sequelae. Objective- To summarize current evidence on effective treatments for nausea and vomiting in pregnancy and hyperemesis gravidarum- |
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| Methods | Databases were searched to June 8, 2016. Relevant websites and bibliographies were also searched. Titles and abstracts were assessed independently by 2 reviewers. |
| Results | Results were narratively synthesized; planned meta-analysis was not possible because of heterogeneity and incomplete reporting of findings. Findings: Seventy-eight studies (n = 8930 participants) were included: 67 randomized clinical trials (RCTs) and 11 nonrandomized studies. Evidence from 35 RCTs at low risk of bias indicated that ginger, vitamin B6, antihistamines, metoclopramide (for mild symptoms), pyridoxine-doxylamine, and ondansetron (for moderate symptoms) were associated with improved symptoms compared with placebo. One RCT (n = 86) reported greater improvements in moderate symptoms following psychotherapy (change in Rhodes score [range, 0 {no symptoms} to 40 {worst possible symptoms}], 18.76 [SD, 5.48] to 7.06 [SD, 5.79] for intervention vs 19.18 [SD, 5.63] to 12.81 [SD, 6.88] for comparator [P < .001]). For moderate-severe symptoms, 1 RCT (n = 60) suggested that pyridoxine-doxylamine combination taken preemptively reduced risk of recurrence of moderate-severe symptoms compared with treatment once symptoms begin (15.4% vs 39.1% [P < .04]). One RCT (n = 83) found that ondansetron was associated with lower nausea scores on day 4 than metoclopramide (mean visual analog scale [VAS] score, 4.1 [SD, 2.9] for ondansetron vs 5.7 [SD, 2.3] for metoclopramide [P = .023]) but not episodes of emesis (5.0 [SD, 3.1] vs 3.3 [SD, 3], respectively [P = .013]). Although there was no difference in trend in nausea scores over the 14-day study period, trend in vomiting scores was better in the ondansetron group (P = .042). One RCT (n = 159) found no difference between metoclopramide and promethazine after 24 hours (episodes of vomiting, 1 [IQR, 0-5] for metoclopramide vs 2 [IQR, 0-3] for promethazine [P = .81], VAS [0-10 scale] for nausea, 2 [IQR, 1-5] vs 2 [IQR, 1-4], respectively [P = .99]). Three RCTs compared corticosteroids with placebo or promethazine or metoclopramide in women with severe symptoms. Improvements were seen in all corticosteroid groups, but only a significant difference between corticosteroids vs metoclopramide was reported (emesis reduction, 40.9% vs 16.5% at day 2; 71.6% vs 51.2% at day 3; 95.8% vs 76.6% at day 7 [n = 40, P < .001]). For other interventions, evidence was limited. |
| Conclusions | For mild symptoms of nausea and emesis of pregnancy, ginger, pyridoxine, antihistamines, and metoclopramide were associated with greater benefit than placebo. For moderate symptoms, pyridoxine-doxylamine, promethazine, and metoclopramide were associated with greater benefit than placebo. Ondansetron was associated with improvement for a range of symptom severity. Corticosteroids may be associated with benefit in severe cases. Overall the quality of evidence was low. |
| acupuncture | In summary for acupressure (three RCTs compared acupressure with placebo in women with mild symptoms) : treatment with acupressure was associated with symptom improvement for mild cases (level A, class IIa). For nerve stimulation:evidence indicates treatmentmay be considered, but the benefit was unclear (level B, class IIb). For acupuncture (three RCTs compared acupuncture with other treatments) : the benefit was unclear (level A, class IIb). |
1.1.7. Van den Heuvel 2016 ∼
Van den Heuvel E, Goossens M, Vanderhaegen H, Sun HX, Buntinx F. Effect of acustimulation on nausea and vomiting and on hyperemesis in pregnancy: a systematic review of Western and Chinese literature.. BMC Complement Altern Med. 2016. [187820].
| Background | Nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG) have a significant impact on quality of life. Medication to relieve symptoms of NVP and HG are available but pregnant women and their caregivers have been concerned about the teratogenic effect, side effects and poor efficacy. The aim of this review was to investigate if there is any clinical evidence for the efficacy of acustimulation in the treatment of NVP or HG. |
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| Methods | A systematic review of randomized controlled trials (RCTs), including both English and Chinese databases was conducted to assess the efficacy of various techniques of acustimulation for NVP and HG. The methodological quality of the studies was assessed using the Cochrane's risks of bias tool. Revised STRICTA (2010) criteria were used to appraise acustimulation procedures. Pooled relative risks (RRp) and standard mean deviations (SMD) with 95% confidence intervals (CI) were calculated from the data provided by the investigators of the original trials. |
| Results | Twenty-nine trials including 3519 patients met the inclusion criteria. Twenty trials could be included in statistical pooling. The overall effect of different acustimulation techniques shows a significant reduction for the combined outcome for NVP or HG in pregnancy as a dichotomous variable (RRp 1.73, 95% CI 1.43 to 2.08). Studies with continuous outcome measures for nausea, vomiting and the combined outcome did not show any evidence for relieving symptoms of NVP and HG (SMD -0.12, 95% CI -0.35 to 0.12). |
| Conclusions | Although there is some evidence for an effect of acustimulation on nausea and vomiting or hyperemesis in pregnancy, results are not conclusive. Future clinical trials with a rigorous design and large sample sizes should be conducted to evaluate the efficacy and safety of these interventions for NVP and HG. |
1.1.8. Boelig 2016 Ø
Boelig RC, Barton SJ, Saccone G, Kelly AJ, Edwards SJ, Berghella V. Interventions for Treating Hyperemesis Gravidarum. Cochrane Database Syst Rev. 2016. [186424]
| Background | Hyperemesis gravidarum is a severe form of nausea and vomiting in pregnancy affecting 0.3% to 1.0% of pregnancies, and is one of the most common indications for hospitalization during pregnancy. While a previous Cochrane review examined interventions for nausea and vomiting in pregnancy, there has not yet been a review examining the interventions for the more severe condition of hyperemesis gravidarum. |
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| Objectives | To assess the effectiveness and safety, of all interventions for hyperemesis gravidarum in pregnancy up to 20 weeks' gestation. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register and the Cochrane Complementary Medicine Field's Trials Register (20 December 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomized controlled trials of any intervention for hyperemesis gravidarum. Quasi-randomized trials and trials using a cross-over design were not eligible for inclusion.We excluded trials on nausea and vomiting of pregnancy that were not specifically studying the more severe condition of hyperemesis gravidarum. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed the eligibility of trials, extracted data and evaluated the risk of bias. Data were checked for accuracy. |
| Main Results | Twenty-five trials (involving 2052 women) met the inclusion criteria but the majority of 18 different comparisons described in the review include data from single studies with small numbers of participants. The comparisons covered a range of interventions including acupressure/acupuncture, outpatient care, intravenous fluids, and various pharmaceutical interventions. The methodological quality of included studies was mixed. For selected important comparisons and outcomes, we graded the quality of the evidence and created 'Summary of findings' tables. For most outcomes the evidence was graded as low or very low quality mainly due to the imprecision of effect estimates. Comparisons included in the 'Summary of findings' tables are described below, the remaining comparisons are described in detail in the main text. No primary outcome data were available when acupuncture was compared with placebo. There was no clear evidence of differences between groups for anxiodepressive symptoms (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.73 to 1.40; one study, 36 women, very low-quality evidence), spontaneous abortion (RR 0.48, 95% CI 0.05 to 5.03; one study, 57 women, low-quality evidence), preterm birth (RR 0.12, 95% CI 0.01 to 2.26; one study, 36 women, low-quality evidence), or perinatal death (RR 0.57, 95% CI 0.04 to 8.30; one study, 36 women, low-quality evidence).There was insufficient evidence to identify clear differences between acupuncture and metoclopramide in a study with 81 participants regarding reduction/cessation in nausea or vomiting (RR 1.40, 95% CI 0.79 to 2.49 and RR 1.51, 95% CI 0.92 to 2.48, respectively; very low-quality evidence).In a study with 92 participants, women taking vitamin B6 had a slightly longer hospital stay compared with placebo (mean difference (MD) 0.80 days, 95% CI 0.08 to 1.52, moderate-quality evidence). There was insufficient evidence to demonstrate a difference in other outcomes including mean number of episodes of emesis (MD 0.50, 95% CI -0.40 to 1.40, low-quality evidence) or side effects.A comparison between metoclopramide and ondansetron identified no clear difference in the severity of nausea or vomiting (MD 1.70, 95% CI -0.15 to 3.55, and MD -0.10, 95% CI -1.63 to 1.43; one study, 83 women, respectively, very low-quality evidence). However, more women taking metoclopramide complained of drowsiness and dry mouth (RR 2.40, 95% CI 1.23 to 4.69, and RR 2.38, 95% CI 1.10 to 5.11, respectively; moderate-quality evidence). There were no clear differences between groups for other side effects.In a single study with 146 participants comparing metoclopramide with promethazine, more women taking promethazine reported drowsiness, dizziness, and dystonia (RR 0.70, 95% CI 0.56 to 0.87, RR 0.48, 95% CI 0.34 to 0.69, and RR 0.31, 95% CI 0.11 to 0.90, respectively, moderate-quality evidence). There were no clear differences between groups for other important outcomes including quality of life and other side effects.In a single trial with 30 women, those receiving ondansetron had no difference in duration of hospital admission compared to those receiving promethazine (MD 0.00, 95% CI -1.39 to 1.39, very low-quality evidence), although there was increased sedation with promethazine (RR 0.06, 95% CI 0.00 to 0.94, low-quality evidence) .Regarding corticosteroids, in a study with 110 participants there was no difference in days of hospital admission compared to placebo (MD -0.30, 95% CI -0.70 to 0.10; very low-quality evidence), but there was a decreased readmission rate (RR 0.69, 95% CI 0.50 to 0.94; four studies, 269 women). For other important outcomes including pregnancy complications, spontaneous abortion, stillbirth and congenital abnormalities, there was insufficient evidence to identify differences between groups (very low-quality evidence for all outcomes). In other single studies there were no clear differences between groups for preterm birth or side effects (very low-quality evidence).For hydrocortisone compared with metoclopramide, no data were available for primary outcomes and there was no difference in the readmission rate (RR 0.08, 95% CI 0.00 to 1.28;one study, 40 women).In a study with 80 women, compared to promethazine, those receiving prednisolone had increased nausea at 48 hours (RR 2.00, 95% CI 1.08 to 3.72; low-quality evidence), but not at 17 days (RR 0.81, 95% CI 0.58 to 1.15, very low-quality evidence). There was no clear difference in the number of episodes of emesis or subjective improvement in nausea/vomiting. There was insufficient evidence to identify differences between groups for stillbirth and neonatal death and preterm birth. |
| Authors' Conclusions | On the basis of this review, there is little high-quality and consistent evidence supporting any one intervention, which should be taken into account when making management decisions. There was also very limited reporting on the economic impact of hyperemesis gravidarum and the impact that interventions may have. The limitations in interpreting the results of the included studies highlights the importance of consistency in the definition of hyperemesis gravidarum, the use of validated outcome measures, and the need for larger placebo-controlled trials. |
1.1.9. Matthews 2015 ☆
Matthews A, Haas DM, O'Mathúna DP, Dowswell T, Doyle M. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2015. [160202]
| Purpose | To assess the effectiveness and safety of all interventions for nausea, vomiting and retching in early pregnancy, up to 20 weeks’ gestation. |
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| Methods | We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register and the Cochrane ComplementaryMedicine Field’s Trials Register (27 April 2013). Selection criteria : all randomised controlled trials of any intervention for nausea, vomiting and retching in early pregnancy. We excluded trials of interventions for hyperemesis gravidarum, which are covered by another Cochrane review. We also excluded quasi-randomised trials and trials using a cross-over design. Data collection and analysis : four review authors, in pairs, reviewed the eligibility of trials and independently evaluated the risk of bias and extracted the data for included trials. |
| Results | Thirty-seven trials involving 5049 women, met the inclusion criteria. These trials covered many interventions, including acupressure, acustimulation and acupuncture (RCTs 11, 1859 patients), ginger, chamomile, lemon oil, mint oil, vitamin B6 and several antiemetic drugs. We identified no studies of dietary or other lifestyle interventions. Evidence regarding the effectiveness of P6 acupressure, auricular (ear) acupressure and acustimulation of the P6 point was limited. Acupuncture (P6 or traditional) showed no significant benefit to women in pregnancy. The use of ginger products may be helpful to women, but the evidence of effectiveness was limited and not consistent, though two recent studies support ginger over placebo. There was only limited evidence from trials to support the use of pharmacological agents including vitamin B6, and anti-emetic drugs to relieve mild or moderate nausea and vomiting. There was little information on maternal and fetal adverse outcomes and on psychological, social or economic outcomes. We were unable to pool findings from studies for most outcomes due to heterogeneity in study participants, interventions, comparison groups, and outcomes measured or reported. Themethodological quality of the included studies was mixed. |
| Conclusion | Given the high prevalence of nausea and vomiting in early pregnancy, women and health professionals need clear guidance about effective and safe interventions, based on systematically reviewed evidence. There is a lack of high-quality evidence to support any particular intervention. This is not the same as saying that the interventions studied are ineffective, but that there is insufficient strong evidence for any one intervention. The difficulties in interpreting and pooling the results of the studies included in this review highlight the need for specific, consistent and clearly justified outcomes and approaches to measurement in research studies. |
1.1.10. Festin 2014
Festin M. Nausea and vomiting in early pregnancy. BMJ Clin Evid. 2014. [151511].
| Introduction | More than half of pregnant women suffer from nausea and vomiting, which typically begins by the fourth week and disappears by the 16th week of pregnancy. The cause of nausea and vomiting in pregnancy is unknown, but may be due to the rise in human chorionic gonadotrophin concentration. In 1 in 200 women, the condition progresses to hyperemesis gravidarum, which is characterised by prolonged and severe nausea and vomiting, dehydration, and weight loss. |
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| Methods and outcomes | We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatment for nausea and vomiting in early pregnancy? What are the effects of treatments for hyperemesis gravidarum? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). |
| Results | We found 32 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. |
| Conclusions | In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupressure; acupuncture; corticosteroids; ginger; metoclopramide; ondansetron; prochlorperazine; promethazine; and pyridoxine (vitamin B6). |
1.1.11. Matthews 2010 ø
Matthews A, Dowswell T, Haas DM, Doyle M. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2010;9:CD007575. [183357].
| Objectifs | Nausea, retching and vomiting are very commonly experienced by women in early pregnancy. There are considerable physical and psychological effects on women who experience these symptoms. This is an update of a review of interventions for nausea and vomiting in early pregnancy previously published in 2003. To assess the effectiveness and safety of all interventions for nausea, vomiting and retching in early pregnancy, up to 20 weeks' gestation. |
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| Méthodes | SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 May 2010). SELECTION CRITERIA: All randomised controlled trials of any intervention for nausea, vomiting and retching in early pregnancy. We excluded trials of interventions for hyperemesis gravidarum which are covered by another review. We also excluded quasi-randomised trials and trials using a crossover design. DATA COLLECTION AND ANALYSIS: Four review authors, in pairs, reviewed the eligibility of trials and independently evaluated the risk of bias and extracted the data for included trials. |
| Résultats | Twenty-seven trials, with 4041 women, met the inclusion criteria. These trials covered many interventions, including acupressure, acustimulation, acupuncture, ginger, vitamin B6 and several antiemetic drugs. We identified no studies of dietary or other lifestyle interventions. Evidence regarding the effectiveness of P6 acupressure, auricular (ear) acupressure and acustimulation of the P6 point was limited. Acupuncture (P6 or traditional) showed no significant benefit to women in pregnancy. The use of ginger products may be helpful to women, but the evidence of effectiveness was limited and not consistent. There was only limited evidence from trials to support the use of pharmacological agents including vitamin B6, and anti-emetic drugs to relieve mild or moderate nausea and vomiting. There was little information on maternal and fetal adverse outcomes and on psychological, social or economic outcomes. We were unable to pool findings from studies for most outcomes due to heterogeneity in study participants, interventions, comparison groups, and outcomes measured or reported. The methodological quality of the included studies was mixed. |
| Conclusions | Given the high prevalence of nausea and vomiting in early pregnancy, health professionals need to provide clear guidance to women, based on systematically reviewed evidence. There is a lack of high-quality evidence to support that advice. The difficulties in interpreting the results of the studies included in this review highlight the need for specific, consistent and clearly justified outcomes and approaches to measurement in research studies. |
1.1.12. Jewell 2010 Ø
Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2010. [185641].
| Objectifs | Nausea and vomiting are the most common symptoms experienced in early pregnancy, with nausea affecting between 70 and 85% of women. About half of pregnant women experience vomiting. To assess the effects of different methods of treating nausea and vomiting in early pregnancy. |
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| Méthode | Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register (December 2002) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2002). Selection criteria: Randomised trials of any treatment for nausea and/or vomiting in early pregnancy. Data collection and analysis: Two reviewers assessed the trial quality and extracted the data independently. |
| Résultats | Twenty-eight trials met the inclusion criteria. For milder degrees of nausea and vomiting, 21 trials were included. These trials were of variable quality. Nausea treatments were: different antihistamine medications, vitamin B6 (pyridoxine), the combination tablet Debendox (Bendectin), P6 acupressure and ginger. For hyperemesis gravidarum, seven trials were identified testing treatments with oral ginger root extract, oral or injected corticosteroids or injected adrenocorticotropic hormone (ACTH), intravenous diazepam and acupuncture. Based on 12 trials, there was an overall reduction in nausea from anti-emetic medication (odds ratio 0.16, 95% confidence interval 0.08 to 0.33). |
| Conclusions | Anti-emetic medication appears to reduce the frequency of nausea in early pregnancy. There is some evidence of adverse effects, but there is very little information on effects on fetal outcomes from randomised controlled trials. Of newer treatments, pyridoxine (vitamin B6) appears to be more effective in reducing the severity of nausea. The results from trials of P6 acupressure are equivocal. No trials of treatments for hyperemesis gravidarum show any evidence of benefit. Evidence from observational studies suggests no evidence of teratogenicity from any of these treatments. |
1.1.13. Festin 2009
Festin M. Nausea and vomiting in early pregnancy. Clin Evid (Online). 2009. [157038].
| Introduction | More than half of pregnant women suffer from nausea and vomiting, which typically begins by the 4th week and disappears by the 16th week of pregnancy. The cause of nausea and vomiting in pregnancy is unknown, but may be due to the rise in human chorionic gonadotrophin concentration. In 1 in 200 women, the condition progresses to hyperemesis gravidarum, which is characterised by prolonged and severe nausea and vomiting, dehydration, and weight loss. |
|---|---|
| Methods and outcomes | We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatment for nausea and vomiting in early pregnancy? What are the effects of treatments for hyperemesis gravidarum? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review).We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). |
| Results | We found 30 systematic reviews, RCTs, or observational studies that met our inclusion criteria.We performed a GRADE evaluation of the quality of evidence for interventions. |
| Conclusions | In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupressure; acupuncture; antihistamines; corticosteroids; corticotrophins; diazepam; dietary interventions other than ginger; domperidone; ginger; metoclopramide; ondansetron; phenothiazines; and pyridoxine (vitamin B6). [Likely to be beneficial: Acupressure for treating nausea and vomiting in early pregnancy ; Acupressure for treating hyperemesis gravidarum. Unknown effectiveness: Acupuncture for treating nausea and vomiting in early pregnancy ; Acupuncture for treating hyperemesis gravidarum]. |
1.1.14. Helmreich 2006 ☆☆
Helmreich RJ, Schiao SY, Dune LS. Meta-analysis of acustimulation effects on nausea and vomiting in pregnant women. Explore (NY).2006;2(5):412-21.[141417].
| Purpose | We used meta-analysis ta examine the effects of acustimulation (AS) on the prevention of nausea and vomiting in pregnant women (NVP). |
|---|---|
| Methods | Meta-analysis of effects of acustimulations (ie, acupressure, acupuncture, and electrical stimulation [ETS]) on NVP was conducted. Fourteen trials, eight random controlled trials (RCTs), with one RCT having two treatrnent modalities with four groups, and six crossover controlled trials (N = 1655) published over the last 16 years were evaluated for quality according to the Quality of Reports of Meta-analysis of Randomized Controlled Trials (QUORUM) guidelines. Relative risks (RR) and 95% confidence intervals (CI) were calculated from the data provided by the investigators of the original trials. |
| Results | Before the treatment, 100% of the women (13 trials, n = 1615 women) were nauseated, but and 96.6% (1599/1655) reported vomiting. After the treatment, compared with the controls, AS (ail modalities combined) reduced the proportion of nausea (RR = 0.47, 95% CI: 0.35-0.62, P < .0001) and vomiting (RR = 0.59, 95% CI: 0.51-0.68, P < .0001). Acupressure methods applied by finger pressure or wristband reduced NVP. The ETS method was also effective in reducing NVP. However, the acupuncture method did not show effects on reducing NVP. There was a placebo effect when compared with controls in reducing nausea (three trials, RR = 0.63, 95% CI: 0.39-1.02, P =.0479) and vomiting (five trials, RR = 0.67, 95% CI: 0.50-0.91, P= .0084). |
| Conclusion | This meta-analysis demonstrates that acupressure and ETS had greater impact than the acupuncture methods in the treatrnent of NVP. However, the number of acupuncture trials. was limited for pregnant women, perhaps because it is impossible ta self-administer the acupuncture and thus inconvenient for women experiencing NVP as chronic symptoms. |
1.1.15. Jewell 2003 ☆
Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2003;(4):CD000145.[141049]..
| Purpose | To assess the effects of different methods of treating nausea and vomiting in early pregnancy. |
|---|---|
| Methods | We searched the Cochrane Pregnancy and Childbirth Group trials register (December 2002) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2002). Selection Criteria : randomised trials of any treatment for nausea and/or vomiting in early pregnancy. Data collection and analysis : two reviewers assessed the trial quality and extracted the data independently. |
| Results | Twenty-eight trials met the inclusion criteria. For milder degrees of nausea and vomiting, 21 trials were included. These trials were of variable quality. Nausea treatments were: different antihistamine medications, vitamin B6 (pyridoxine), the combination tablet Debendox (Bendectin), P6 acupressure (six trials, 1309 women) and ginger. For hyperemesis gravidarum, seven trials were identified testing treatments with oral ginger root extract, oral or injected corticosteroids or injected adrenocorticotropic hormone (ACTH), intravenous diazepam and acupuncture. Based on 12 trials, there was an overall reduction in nausea from anti-emetic medication (odds ratio 0.16, 95% confidence interval 0.08 to 0.33). |
| Conclusion | Anti-emetic medication appears to reduce the frequency of nausea in early pregnancy. There is some evidence of adverse effects, but there is very little information on effects on fetal outcomes from randomised controlled trials. Of newer treatments, pyridoxine (vitamin B6) appears to be more effective in reducing the severity of nausea. The results from trials of P6 acupressure are equivocal. It has not been shown to be clearly more effective than sham or dummy acupressure. |
1.1.16. Jewell 2001 Ø
Jewell D et al. Interventions for nausea and vomiting in early pregnancy (cochrane review). Cochrane Library Oxford. 2001. [101019].
| Background | Nausea and vomiting are the most common symptoms experienced in early pregnancy, with nausea affecting between 70 and 85% of women. About half of pregnant women experience vomiting. Objectives: The objective of this review was to assess the effects of different methods of treating nausea and vomiting in early pregnancy. |
|---|---|
| Methods | Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: October 2001. Selection criteria: Randomised trials of any treatment for nausea and/or vomiting in early pregnancy. Data collection and analysis: Trial quality was assessed and data were extracted independently by two reviewers. |
| Main results | Twenty-three trials were included. These trials were of variable quality. Nausea treatments were different anti-histamine medications, vitamin B6 (pyridoxine), the combination tablet Debendox (Bendectin) and P6 acupressure. For hyperemesis gravidarum five trials were identified testing treatments with oral ginger root extract, oral corticosteroids or injected adrenocorticotropic hormone (ACTH) and intravenous diazepam. Based on 13 trials, there was an overall reduction in nausea from anti-emetic medication (odds ratio 0.17, 95% confidence interval 0.13 to 0.21). |
| Reviewers' conclusions | Anti-emetic medication appears to reduce the frequency of nausea in early pregnancy. There is some evidence of adverse effects, but there is very little information on effects on fetal outcomes from randomised controlled trials. Of newer treatments, pyridoxine (vitamin B6) appears to be more effective in reducing the severity of nausea. The results from trials of P6 acupressure are equivocal. No trials of treatments for hyperemesis gravidarum show any evidence of benefit. Evidence from observational studies suggests no evidence of teratogenicity from any of these treatments. |
1.1.17. Aikins 1998 ☆
Aikins Murphy P. Alternative Therapies for Nausea and Vomiting of Pregnancy. Obstet Gynecol. 1998;91:149-55. (eng). [94779]
| Objectives | To review available evidence about the effectiveness of alternative therapies for nausea and vomiting of pregnancy. |
|---|---|
| Methods | Data Sources: MEDLINE and 13 additional US and international data bases were searched in 1996-1997 for papers that described use of alternative medicine in the treatment of pregnancy and pregnancy complications, specifically those addressing nausea, vomiting, and hyperemesis. Bibliographies of retrieved papers were reviewed to identify additional sources. Methods of Study Selection: All relevant English language clinical research papers were reviewed. Randomized clinical trials addressing specifically the use of nonpharmaceutical and nondietary interventions were chosen for detailed review. |
| Results | Ten randomized trials studying the effects of acupressure, ginger, and pyridoxine on nausea and vomiting of pregnancy were reviewed. Evidence of beneficial effects was found for these three interventions, although the data on acupressure are equivocal. Insufficient evidence was found for the benefits of hypnosis. Other interventions have not been studied. |
| Conclusions | There is a dearth of research to support or to refute the efficacy of a number of common remedies for nausea and vomiting of pregnancy. The best-studied alternative remedy is acupressure, which may afford relief to many women; ginger and vitamin B, also may be beneficial |
1.2. Special Acupuncture Techniques
1.2.1. Pharmaco-acupuncture
1.2.1.1. Lin 2019
Lin Xiaoyang, Shen Qiuxian , Zhuang Lixing. [Clinical Efficacy of Acupoint Injection in Treating Hyperemesis Gravidarum : A Meta - Analysis]. Journal of Clinical Acupuncture and Moxibustion. 2019;35(8):62. [203011].
| Objective | To evaluate the clinical efficacy of adupoint injection in treating hyperemesis gravidarum. |
|---|---|
| Methods | By computer retrieval, literatures of randomized controlled trials about adupoint injection in treating hyperemesis gravidarum were collected from Pubmed, Embase, China Biology Medicine disc (CBMdisc), China National Knowledge Infrastructure ( CNKI) , WangFang and VIP databases. After data extraction and quality evaluation by using Cochrane Review Handbook 5. 1 , the eligible clinical trials underwent meta - analysis by using RevMen5. 3 software. |
| Results | A total of 10 articles met the inclusion criteria, including 834 patients with 417 cases in the treatment group and 417 cases in the control group. The meta - analysis showed that the cure rate, the effective rate and the ameliorative situation of urine ketone of acupoint injection were better than those of intravenous infusion in the treatment of hyperemesis gravidarum. In terms of the cure rate, OR =4. 18,95% CI(3. 02, 5.78), P <0.00001. In terms of the effective rate, OR= 4.95 ,95% CI(2. 66, 9.23), P <0.000 01. Moreover, with the Egger's test, the publication bias were analyzed. The cure rate was chose to analyze the efficiency of the meta - analysis. |
| Conclusion | Compared to single intravenous infusion, acupoint injection and acupoint injection plus intravenous infusion can produce a better clinical efficacy with less adverse reactions. |
2. Clinical Practice Guidelines
| ⊕ positive recommendation (regardless of the level of evidence reported) Ø negative recommendation (or lack of evidence) |
2.1. Collège national des gynécologues et obstétriciens français (CNGOF, France) 2022 ⊕
Deruelle P, Sentilhes L, Ghesquière L, Desbrière R, Ducarme G, Attali L, Jarnoux A, Artzner F, Tranchant A, Schmitz T, Sénat MV. Consensus formalisé d’experts du Collège national des gynécologues et obstétriciens français : prise en charge des nausées et vomissements gravidiques et de l’hyperémèse gravidique [Expert consensus from the College of French Gynecologists and Obstetricians: Management of nausea and vomiting of pregnancy and hyperemesis gravidarum]. Gynecol Obstet Fertil Senol. 2022 Sep 21:S2468-7189(22)00261-6. https://doi.org/10.1016/j.gofs.2022.09.002
| Proposition 2.6 – Il est proposé de réserver l’acupression, l’acupuncture et l’électrostimulation aux femmes ayant un score PUQE ≤ 6, si elles devaient être utilisé en sachant que l’amélioration des symptômes après leur prescription n’est pas démontrée. |
2.2. National Institute for Health and Care Excellence (NICE) 2021 ⊕
NICE guideline NG201 : Antenatal care [R] Management of nausea and vomiting in pregnancy. National Institute for Health and Care Excellence (NICE). 2021. [211646]. Recommendations: doi. Argument: doi
| Recommendations. For pregnant women with moderate‑to‑severe nausea and vomiting: consider intravenous fluids, ideally on an outpatient basis, consider acupressure as an adjunct treatment. Argument: The committee recommended that acupressure should be considered as an adjunct treatment of moderate to severe nausea and vomiting in pregnant women because there was evidence that acupressure in addition to standard care is effective in aiding symptomatic relief during pregnancy, compared to placebo. |
2.3. World Health Organization (WHO) 2021 ⊕
WHO Guideline on Self-Care Interventions for Health and Well-Being. Geneva: World Health Organization. 2021.186P. [219406]. doi
| Recommendation 3. Interventions for nausea and vomiting Ginger, chamomile, vitamin B6 and/or acupuncture are recommended for the relief of nausea in early pregnancy, based on a woman’s preferences and available options. |
2.4. Aetna (insurance provider, USA) 2018 ⊕
Acupuncture. Aetna (insurance provider, USA). 2018. 73P. [188029].
| Aetna considers needle acupuncture (manual or electroacupuncture) medically necessary for any of the following indications:Nausea of pregnancy |
2.5. Emblemhealth (insurance provider, USA) 2017 ⊕
Acupuncture — Medicare Dual-Eligible Members Emblemhealth. 2017. [111547].
| Members with the Medicare Dual-Eligible benefit are eligible for acupuncture when performed by an individual licensed by New York State to perform acupuncture and when performed for the following diagnoses: 1. Adult postoperative nausea and vomiting 2. Chemotherapy related nausea and vomiting 3. Pregnancy related nausea and vomiting 4. Carpal tunnel syndrome 5. Epicondylitis (tennis elbow) 6. Headache 7. Low back pain 8. Menstrual pain 9. Myofascial pain 10. Osteoarthritis |
2.6. Royal College of Obstetricians and Gynaecologists 2016 (RCOG, UK) 2016 ⊕
Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum. RCOG Green-top Guideline No. 69. 2016;:27p. [100755].
| Acustimulations – acupressure and acupuncture. Women may be reassured that acustimulations are safe in pregnancy. Acupressure may improve NVP [B, evidence level 1+]. |
2.7. Société des Obstétriciens et Gynécologues du Canada (SOGC, Canada) 2016 ⊕
Campbell, K., H. Rowe, H. Azzam et C.A. Lane. Prise en charge des nausées et vomissements de la grossesse . Journal of Obstetrics and Gynaecology (Canada). 2016; 38(12): 1138-11. [190415].
| 4.L'acupression peut atténuer les NVG chez certaines femmes. (I-B) |
2.8. World Health Organization (WHO) 2016 ⊕
WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization. 2016:172P. [196767].
| Recommendation D.1: Ginger, chamomile, vitamin B6 and/or acupuncture are recommended for the relief of nausea in early pregnancy, based on a woman’s preferences and available options. (Recommended) |
2.9. South Australia Health 2016 (SAH, Australia) ⊕
SA Health. South Australian Perinatal Practice Guidelines Hyperemesis in Pregnancy Department of Health, Government of South Australia. 2011. [100841].
| Treatment option : acupuncture. |
2.10. Haute Autorité de Santé (HAS, France) 2005 ⊕
Comment mieux informer les femmes enceintes ? Recommandations pour les professionnels de santé (recommandation) Haute Autorité de Santé. 2005. Argumentaire ; Recommandation.
| Si une femme demande ou envisage un traitement, les mesures suivantes peuvent s’avérer efficaces et réduire les symptômes : méthodes naturelles : gingembre en gélule ; stimulation du point d’acupuncture P6 ou point de Neiguan (point situé à la face interne de l’avant-bras, trois doigts au-dessus du poignet) (grade A) |
2.11. Société des Obstétriciens et Gynécologues du Canada (SOGC, Canada) 2002 ⊕
ArsenaulT MY, Lane CA. Prise en charge des nausées et vomissements durant la grossesse. J Obstet Gynaecol Can. 2002;24(10):824-31. [141048].
| Certains traitements de médecine douce tels que les suppléments de gingembre, l’acupuncture et l’acupression peuvent avoir des effets favorables. (I-A) |
