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Natural Approaches to Addressing Nausea & Vomiting in Pregnancy: An Evidence-based Review

Nausea and vomiting of pregnancy (NVP) is reported in 70-80% of pregnant women (1) especially in the first trimester. It's a common, normal response to the increase in hormonal levels, but boy oh boy it can sure affect quality of life! Feeling fine one moment and then getting a blind-siding wave of nausea that comes out of nowhere is distracting, unpleasant, and can really interfere with daily life.

Thankfully, there are natural options for relief that are safe and effective.

Note: Nausea and vomiting can become more serious when it affects a woman's ability to eat and drink, which obviously negatively impacts nutrient/hydration status and possibly fetal health. Hyperemesis Gravidarum (HG) is a medical condition when vomiting becomes frequent and excessive during pregnancy. This article is primarily focussing on nausea and vomiting that doesn't meet HG diagnostic criteria.

1. GINGER - Zingiber officinale

Ginger was my godsend (not to be dramatic) but I actually never threw up during my first trimester which is partly luck of the draw, but I think, also in part due to my ginger use. I used it to offset nausea as well as to address dyspepsia after eating, ie. that heavy feeling that food was just sitting in upper abdomen. Finding something that worked to address nausea gave me a peace of mind. I'd throw some capsules in my pocket and could leave the house without fear of vomiting in a public place! Before I put capsules in my pockets, there were a few dog walks where I was seriously concerned about throwing up on someone's lawn!

Ginger contains many different phytochemicals (like 6‑gingerol, 8‑gingerol, 10‑gingerol, and 6‑shogaol) so although the specific role of each is unknown, ginger is thought to: influence serotonin receptors, act as a pro-kinetic (assist gastric emptying and facilitate forward motility in GI tract), and to act as a carminitive (relax smooth muscles along GI tract and bring blood flow to the area) (2.)

Regardless of mechanism, many RCT studies show that ginger significantly reduces the frequency and intensity of NVP compared to placebo (2-3.) In fact, a meta-analysis published in January of this year found that it significantly reduces symptoms and severity of nausea, but did not significantly reduce vomiting relative to placebo (4.)

Safety: Ginger is safe up to 1g or 1000mg per day.

Interactions: There is a Level B "possible" interaction, considered moderate, with anti-platelet medications. Clinical data in humans show mixed results of ginger affecting platelets and risk of bleeding.

Form: I recommend ginger extract in capsules because of the ease to just quickly take when nausea came out of nowhere. The thought of a warm tea was not appealing to me in my first trimester but it's always an option. Traditional Medicinal makes an organic ginger tea containing 500mg/ tea bag. If you're drinking several cups per day, ensure the label provides dosage so you can consume safely.

Quality: Use GMP-certified products to ensure potency, purity, and accurate identity of materials.

Dose: I used NFH Ginger SAP (because GMP-certified) and found that one tablet of 250mg usually did the trick. When I was really hurting, I bumped up to 2 tablets but never required the upper limit of 1g.

Cost: A bottle of 60 capsules costs just over $10. The best $10 I spent in my first trimester...

Other benefits: You get a lot of bang for your buck with ginger which is why I reached for it first to address my nausea. Ginger is also a general anti-inflammatory that selectively inhibits COX-2 receptors - just like some NSAIDs, so ginger can be used as an alternative to Tylenol or Advil for headache relief. (2) Ginger has also been found to inhibit the growth of H.Pylori which can be an underlying factor in Hyperemesis Gravidarum. (1)

2. VITAMIN B6 - Pyridoxal-5'-phosphate (active form)

I can't speak to personal use of Vitamin B6 because ginger worked so well for me. However, the prenatal vitamin I used (again, a NFH product) contained the active form of Vitamin B6, supplying 50mg per day. So technically I was supplementing with Vitamin B6, I just didn't take any additional to address nausea.

Studies: The recent meta-analysis I referenced above also studied the effect of Vitamin B6 for nausea and vomiting in pregnancy. Ginger was more effective than Vitamin B6, however the difference was not clinically significant. Previous randomized controlled trials have found Vitamin B6 to be superior to placebo in reducing nausea and vomiting in pregnancy (5.)

Form: The naturally occurring form of Vitamin B6 found in food sources is pyridoxine or pyridoxamine and requires our body to covert it to the metabolically active form, P'5'P. This takes place first in the intestinal tract and then the liver. Professional supplement companies tend to use the active form of B6 just to skip the need for the conversion, so you may notice a difference in cost amongst product based on the form used (6.)

Dose: 30mg -100mg daily.

Safety: Excessive intake of 1000mg-6000mg of Vitamin B6 daily for greater than 12 months has been reported to cause severe neuropathy (tingling) and ataxia (loss of control of body movements) so please don't take 10x the recommended amount (7.)

Food sources: Chickpeas, beef liver, and fish are the richest sources, however it can be found in starchy veggies, fruit and grain products (8.)

Diclectin is a pharmaceutical approved for nausea and vomiting in pregnancy and is a combo product containing an anti-histamine and Vitamin B6. Guidelines for management of NVP recommend starting with Vitamin B6 before moving on to Diclectin.

3. ACUPUNCTURE/ACUPRESSURE: PC 6

There is an acupuncture point, PC 6, along the inner aspect of the forearm that has been used for thousands of years in Traditional Chinese Medicine to help manage nausea and vomiting.

Studies have found that activation of PC 6 acupoint influences autonomic regulation of vestibular functions and neural activity in the stomach, which makes sense for its use in nausea and vomiting control (9.)

Apparently there are more than 40 randomized controlled trials that have good evidence that acupuncture attenuates or prevents nausea in vomiting (9.) PC 6 is well studied given it's use in managing chemotherapy-induced nausea in cancer patients. Quality studies in pregnant women however, are lacking.

Acupressure of PC 6 (literally activating the point by sustained pressure that you do yourself or get your partner to do) is safe, free, and easy to do. One study that used a Sea-band (which allowed for constant stimulation of PC 6) for 4 days found that it significantly reduced the frequency and severity of nausea and vomiting in women in their first trimester (10.) These bands can be purchased online, although I can't comment on quality and efficacy of different brands.

Acupuncture can be a supportive treatment in pregnancy because points can be chosen to address nausea/vomiting, as well as additional symptoms like anxiety. Unfortunately, I couldn't go for acupuncture because my first trimester was during the covid-19 pandemic.

OTHER CONSIDERATIONS:

1. Prenatal Vitamin Quality- Avoiding products that use binders and fillers is especially important when you're experiencing nausea or GI upset. The form of vitamins and minerals on the ingredient list matter too. For instance, iron should be in a gentle 'bisglycinate' form, definitely not iron 'fumarate' - that is known to upset the stomach. Calcium citrate may be more tolerable than calcium 'carbonate.'

Many conventional practitioners recommend switching to an iron-free prenatal vitamin during the first trimester to offset nausea since iron requirements by baby haven't increased yet. Try this if nothing else is working...but I think it's valuable to increase iron status before your baby is going to be drawing from your stores. Not to mention you will lose a significant amount of blood during childbirth. Also, a lot of young women do not have optimal iron status prior to conceiving, so I don't jump to this option right away.

2. Be mindful of blood sugar control.

Hunger and dips in blood sugar can be common triggers for nausea. Avoid refined carbohydrates that can quickly spike blood sugar, since it can be followed by a crash. These would be things like: candy, juice, baked goods and white flour products.

Eat as regularly as possible (I know, hard when you feel queasy and the enjoyment of eating is gone) but try not to go longer than 3hr without food. I found homemade energy balls really helpful because I tolerated them, and they provided fat, protein, and complex carbs to stabilize blood sugar.

3. Food Triggers

Avoid things that are off-putting, regardless of how 'healthy' they are. Many women put a lot of pressure on themselves to eat as healthy as possible during pregnancy but if something is causing an aversion and will make you gag, stay clear.

I sadly gave up my one cup of coffee in the morning and switched to tea and that made a big difference with my nausea. My biggest food aversion was homemade butternut squash soup - a previous favourite. I even had to make my husband sit across the room when he ate his! Hopefully your list of food aversions is short.

4. Sour Foods

Many women crave things like lemons during the first trimester. I was one of them and added whole lemon slices to my smoothies for that tart taste, in addition to frozen cranberries. I also tolerated green apples really well as a snack with a nut butter. It's worth a try!

Hopefully for most of you, this dreadful phase will be short and won't extend into your second or third trimesters.

Please let me know if you have any questions or would like to work together on your perinatal health.

drjackson@kawarthatherapeutic.com

References:

1. Bustos M, Venkataramanan R, Caritis S. Nausea and vomiting of pregnancy-What's new?. Autonomic Neuroscience. 2017 Jan 1;202:62-72.

2. Giacoasa, A., et al. “Can nausea and vomiting be treated with ginger extract?” European Review for Medical and Pharmacological Sciences Vol. 19, No. 7 (2015): 1291–1296.

3. Ding, M., M. Leach, and H. Bradley. “The effectiveness and safety of ginger for pregnancy-induced nausea and vomiting: A systematic review.” Women and Birth Vol. 26, No. 1 (2013): e26–e30.

4. Hu Y, Amoah AN, Zhang H, Fu R, Qiu Y, Cao Y, Sun Y, Chen H, Liu Y, Lyu Q. Effect of ginger in the treatment of nausea and vomiting compared with vitamin B6 and placebo during pregnancy: a meta-analysis. The Journal of Maternal-Fetal & Neonatal Medicine. 2020 Jan 14:1-0.

5. Vutyavanich, T., S. Wongtra-ngan, and R. Ruangsri. “Pyridoxine for nausea and vomiting of pregnancy: a randomized, double-blind, placebo-controlled trial.” American Journal of Obstetrics and Gynecology Vol. 173, No. 3, Pt 1 (1995): 881–884

6. Mackey A, Davis S, Gregory J. Vitamin B6. In: Shils M, Shike M, Ross A, Caballero B, Cousins R, eds. Modern Nutrition in Health and Disease. 10th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2005.

7. Simpson JL, Bailey LB, Pietrzik K, Shane B, Holzgreve W. Micronutrients and women of reproductive potential: required dietary intake and consequences of dietary deficiency or excess. Part I–Folate, Vitamin B12, Vitamin B6. J Matern Fetal Neonatal Med 2010;23:1323-43. [PubMed abstract]

8. U.S. Department of Agriculture, Agricultural Research Service. FoodData Central, 2019.

9. Streitberger K, Ezzo J, Schneider A. Acupuncture for nausea and vomiting: an update of clinical and experimental studies. Autonomic Neuroscience. 2006 Oct 30;129(1-2):107-17.

10. Steele NM, French J, Gatherer‐Boyles J, Newman S, Leclaire S. Effect of Acupressure by Sea‐Bands on Nausea and Vomiting of Pregnancy. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2001 Jan;30(1):61-70.