US Pharm. 2006;10:HS-20.
Morning sickness affects 50% to 90% of all pregnant women, leading to complaints of nausea andvomiting in early pregnancy.1 Hyperemesis gravidarum (HG) is the extreme form of morning sickness, occurring between the fourth and sixth week of pregnancy, causing intractable vomiting; dehydration; electrolyte disturbance; a 5% weight loss with ketosis; disturbed nutrition; acid aspiration; retinal, kidney, or hepatic damage; or neurological alterations in some individuals.1,2 Both conditions can significantly impact the quality of life of those who experience it.3
Regarding prescription medications used in the treatment of morning sickness, an FDA-assigned pregnancy category A indicates that adequate and well-controlled studies have not demonstrated a risk to the fetus in the first trimester of pregnancy and that there is no evidence of risk in later trimesters.1 Currently, there are no prescription medications for the treatment of morning sickness that are classified with a pregnancy category A. Due to the fact that many pharmacological agents usually prescribed for this condition may also induce symptoms of morning sickness and that research is not conducted on pregnant women due to the uncertainty of the teratogenic effects of medications, acupuncture is a viable alternative for treating pregnant patients seeking relief.
Acupuncture and Acupressure
According to the NIH's
According to several studies, acupuncture and acupressure are virtually void of unwanted side effects and compatible with herbs and pharmacological agents. When these techniques are performed by a trained licensed practitioner, they can be effective in the treatment of a variety of ailments including morning sickness and HG.5-7 Specifically, an acupuncture point called Neiguan or pericardium 6 (PC6), the sixth point located on the pericardium meridian, has been studied and researched with respect to its effectiveness in treating nausea and vomiting in general and during pregnancy. The classic location of this acupuncture point is 2 cun (which equals the width of the index and middle fingers measured at the knuckles) above the transverse crease of the wrist, between the tendons of m. palmaris longus and m. flexor radialis.8,9 Most pharmacists are familiar with this location, which is also used for the placement of motion sickness prevention wristbands.10,11 These devices are designed to apply acupressure to the acupuncture point PC6.12 One study found that acu stimulation of PC6 in pregnancy may prove to be a significant therapeutic alternative, since current pharmacologic treatments for nausea in early pregnancy are not consistent, efficacious, or without unwanted side effects or increased teratogenic risks.13 Clinical literature also supports the use of acupressure on PC6 as an effective adjunct maneuver for emesis control, as was shown in postoperative stomach cancer patients.14
A Typical Acupuncture Treatment
Traditionally, acupuncture consists of the insertion of fine, solid-filament sterile needles into one of the 365 traditional acupuncture points on the body. These points correspond to locations on one of the 14 main channels (meridians) that traverse the body and contain the qi (pronounced chee) energy responsible for maintaining a well-balanced and healthy body.15 In addition to the classical acupuncture points, there are a variety of other acupuncture points that are not located on any specific meridian and may be used in conjunction with or without the classical acupuncture points. With the inclusion of miscellaneous points as well as new points used in ear acupuncture (auriculotherapy) and other recent methods, there are at least 2,000 points for possible use.15,16 When there is a blockage of energy flow to a specific area of the body, pain or discomfort ensues. The goal of acupuncture is to restore the balanced flow of energy in the body.
There are a variety of approaches to
diagnosis and treatment in American acupuncture that incorporate the medical
traditions of countries such as
A comprehensive acupuncture treatment consists of the documentation of the patient's history and complaints, an analysis of pulses (i.e., there are 28 basic pulses that can be felt on three levels and in three positions on each wrist), and an inspection of the tongue.15 After diagnosis, the acupuncturist begins the specific needle placement. A treatment session generally lasts from 15 minutes to more than an hour and involves five to 20 acupuncture points that are usually stimulated depending on the patient's specific situation. In fact, the more skillful the acupuncturist, the fewer needles he or she will use.18 Treatments may be carried out while the patient is lying face up, face down, or on his or her side on a massage table or seated in a chair, although pregnant patients would not be treated face down. The needles are inserted and left in place for about 25 minutes or longer depending on the treatment protocol, during which time they may be manipulated. Manipulation consists of twirling the needle back and forth or gently lifting it in and out. Acupuncture treatments are tailored to the individual, meeting each patient's needs and addressing his or her chief complaints. The duration of each treatment and number of treatments included in the treatment plan may vary based on the individual patient, practitioner style, and progress during the course of treatment. Clean needle technique is essential in the delivery of acupuncture and requires the practitioner to follow clean needle procedures based on an official manual for acupuncturists.19
The Basis of the Acupuncture
Patients who undergo acupuncture report a sense of relaxation soon after the needles have been inserted. Some describe euphoric effects and a feeling of wellbeing or floating. This sensation is attributed to a release of endogenous endorphins.20 A focus of attention, with regard to acupuncture, has been the role of endogenous opioids in acupuncture analgesia. Considerable evidence supports the claim that opioid peptides are released during acupuncture and that the analgesic effects of acupuncture are at least partially explained by the actions of these peptides.21 Enkephalins, endorphins, and dynorphins are three major polypeptides found in the brain that have opioid activity. Endorphin is a general term that includes many peptides in the brain that suppress pain.22 Subgroups of endorphins have been isolated and identified, including beta-endorphin, an analgesic substance that is much more potent than enkephalin.22 Dynorphin is an endorphin found in the pituitary gland, hypothalamus, and spinal cord. This is the most potent pain-relieving substance discovered; dynorphin is 50 times more potent than beta-endorphin and 200 times more potent than morphine.22 Endorphin release in the body is higher after acupuncture and trancutaneous electrical nerve stimulation, and it has been shown that both effects may be reversed by the use of naloxone, the potent opioid antagonist.21,22
Many studies in animals and humans have demonstrated that acupuncture can cause multiple biological responses.21 These responses can occur locally (i.e., at or close to the site of application) or at a distance, mediated mainly by sensory neurons to many structures within the central nervous system.21 This can lead to activation of pathways affecting various physiological systems in the brain as well as in the periphery.
According to the NIH, stimulation by acupuncture may also activate the hypothalamus and the pituitary gland, resulting in a broad spectrum of systemic effects. Alteration in the secretion of neurotransmitters and neurohormones and changes in the regulation of blood flow, both centrally and peripherally, have been documented.21
Because of acupuncture's value, pharmacists, who are intimately familiar with the pharmacology of analgesics, the variability and subjectivity of the perception of pain, and the understanding of neurotransmitters, should have a certain comfort level in referring patients to a reputable acupuncturist for the treatment of certain conditions.
According to principles of Chinese medicine, the nausea, vomiting, and loss of appetite during the first trimester of pregnancy (morning sickness) can be differentially diagnosed into a spleen and stomach disharmony or a liver and stomach disharmony.23 A disharmony is not the cause of disease but an expression of patterns in Chinese medicine reflecting specific signs and symptoms.24 Identifying the causes of disharmony is necessary to restore harmony or balance to the patient.24 Common acupuncture treatment points for both disharmonies would include PC6, stomach 36, and conception vessel 12 (CV12).25 After examining the tongue and pulses, the practitioner may use additional treatment points, including CV13 and spleen 4 for a spleen and stomach disharmony or CV17 and liver 3 for a liver and stomach disharmony.25
The NIH has funded a variety of acupuncture research projects, including clinical trials and studies of the mechanisms by which acupuncture may produce its effects.21 The World Health Organization lists a variety of medical conditions that may be improved with acupuncture or moxibustion.21 Such interventions include the prevention and treatment of nausea and vomiting; treatment of pain; addictions to alcohol, tobacco, and other drugs; treatment of pulmonary problems such as asthma and bronchitis; and rehabilitation for neurological damage such as that caused by stroke.21
In a recent clinical anesthesiology
As the most accessible health care professionals, pharmacists are in a position to refer patients to other health care practitioners. Pharmacists may be called upon to recommend alternative treatments for a patient who has had poor response to or prefers not to use pharmacological agents during pregnancy.
Based on neurobiological principles, clinical evidence, and support from national and international institutions, pharmacists may recommend acupuncture. Treating nausea in pregnancy with current pharmacological agents is not consistent, efficacious, or without unwanted side effects. The stimulation of acupuncture point PC6 has proved to be a significant therapeutic alternative in the treatment of nausea in pregnancy. When used clinically and performed by trained licensed practitioners, acupuncture for the treatment of morning sickness is safe and highly effective.
Pharmacists seeking licensed practitioners of acupuncture should contact the National Certification Commission for Acupuncture and Oriental Medicine (www.nccaom.org) and/or the American Association of Oriental Medicine (www.aaom.org).
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