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LifestyleandComplementaryMedicineforCommon
GastrointestinalDisordersinPregnancy
NicoleD.White,PharmD
AmJLifestyleMed.20148(2):9799.

AbstractandIntroduction
Abstract

Gastrointestinaldisordersincludingnausea,vomiting,heartburn,andconstipationarecommoninpregnancy.While
safeandeffectivepharmacotherapyexiststoamelioratethesymptomsoftheseconditions,manywomenprefera
morenaturalapproachthroughlifestylemodificationsorcomplementarymedicine.Evidenceconcerningsomeofthe
mostcommonlyusedlifestyleorcomplementarymedicineinterventionsisdiscussed,aswellastheirassociated
adverseeffectsandsafetyinpregnancy.
Introduction

Gastrointestinal(GI)disordersincludingnausea,vomiting,heartburn,andconstipationarecommoninpregnancy.
Manyoftheseconditionsarethoughttoarisefrommotilitydisturbancescausedbyincreasedlevelsofcirculating
progesterone.Whilesafeandeffectivepharmacotherapyexiststoamelioratethesymptomsoftheseconditions,
manywomenpreferamorenaturalapproachthroughlifestylemodificationsorcomplementarymedicine.
Upto78%ofwomenusecomplementaryoralternativemedicineduringpregnancy.[1]Themostcommonmodalities
reportedincludevitaminandmineralsupplements,herbalmedicine,massage,relaxation,andaromatherapy.[2]
Insteadofconsultingtheirhealthcareprofessional,manyexpectantmothersrelyonfamilyandfriendsfor
informationregardingtheselifestyleandnaturaltherapies.[2]Althoughwellintentioned,friendsandfamilymaynotbe
wellinformedonthesafeandeffectiveuseoflifestyleandcomplementarymedicineinpregnancy,soitisimportant
thathealthcareprovidersaskpatientsabouttheiruseandmakesoundrecommendationsbasedonevidence.
Thepurposeofthisarticleistoprovideasummaryoftheevidenceconcerningsomeofthemostcommonlyused
lifestyleandcomplementarymedicineinterventionstotreatnausea,vomiting,heartburn,andconstipationin
pregnancy.

NauseaandVomiting
Oneofthemostcommonandunpleasantconditionsofpregnancyisnauseaandvomiting,colloquiallyreferredtoas
"morningsickness."Itisoftenthefirstsymptomofpregnancyandaffectsasmanyas80%ofwomen.[3]Nauseais
mostcommonduringthefirsttrimesterofpregnancyandoftenabatesafter3to4monthsbutmaycontinuebeyond
thistimeinupto20%ofwomen.[4]Severalfactorscontributetothesesymptoms,includingpregnancyassociated
disturbancesingastricmotility(secondarytoincreasedprogesteronesecretion)elevationsofhumanchorionic
gonadotropinalterationsintaste,smell,andthevestibularsystemandotherpsychologicalaspects.
Severaldietarymeasureshavebeenproposedtoreducethefrequencyandseverityofpregnancyassociatednausea
andvomiting.Theseincludeeatingfrequent,smallmeals(every23hours)andavoidingsmellsandfoodtextures
thatcausenausea.Solidfoodshouldbeblandtastingandcomprisedofmostlycarbohydratesandlittlefat.These
interventionshavebeenrecommendedforyearsbutarebasedonclinicalexperienceandphysiologicalconjecture
ratherthanevidencebasedmedicine.[5]
Acupressureisanoninvasiveformofacupunctureandhasbeenproposedtotreatsymptomsofnauseaand
vomiting.TheP6orNeiguanpointisthemostcommonacupressurepointusedfornausea,located3fingerbreadths
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abovethewristonthevolarsurface.[6]Constantpressurecanbeappliedatthispointbythefingerorthroughvarious
commerciallyavailablewristbands(ie,SeaBand).Althoughtheliteratureisconflictingregardingtheefficacyofthis
modality,a2010Cochranereviewfoundnostatisticallysignificanteffectfromacupressurecomparedwithplaceboin
the4randomizedcontrolledtrialsavailable.[7]OnestudythatcomparedP6acupressuretovitaminB6
supplementationfoundnostatisticallysignificantdifferencebetweengroupsforimprovementofnausea.[7]Side
effectsofacupressureweremildandincludedirritationaroundthewristbandsite.
VitaminB6,orpyridoxine,hadfavorableresultswhenusedasasupplementforpregnancyrelatednauseaand
vomitingin2placebocontrolledstudies.[7]Onerandomizedcontrolledtrialdemonstratedthatpyridoxine,atadoseof
25mgevery8hours,wasmoreeffectivethanplaceboforcontrollingnauseaandvomitinginpregnantwomen.[8]In
pharmacologicaldoses,vitaminB6hasnotbeenfoundtobeteratogenicandisratedFDApregnancycategoryA.[9]
Theuseofgingerinthemanagementofpregnancyrelatednauseaandvomitingisawellknowntherapyinpopular
cultureandcommonlyrecommendeddespiteconflictingevidence.Arecentreviewfound4randomizedcontrolled
trialscomparinggingerwithplaceboorvitaminB6forpregnancyrelatednauseaandvomiting.[3]Dailydosesofginger
rangedfrom500to1050mg.GingerwasfoundtobeaseffectiveasvitaminB6inreducingnauseaandvomitingand
superiortoplaceboinreducingnausea,decreasingtheintensityofnausea,anddecreasingthefrequencyof
vomiting.[3,7]Themostcommonsideeffectsofgingertherapyincludedburningsensationandbelching.[3]Todate,
therehavebeennopublishedreportsoffetalanomaliesassociatedwithgingersupplementationatdoseslessthan4
gdaily.[3]

Constipation
ConstipationisalsoafrequentlyexperiencedGIsymptomofpregnancy,affectingupto40%ofwomen.[10]Many
womenwhoexperienceconstipationpriortopregnancyhaveworseningsymptomsduringpregnancy.Patientscan
alsodevelopconstipationforthefirsttimeduringpregnancy.Thecauseofconstipationinpregnancyismultifactorial
andmayincludedietchanges,ironsupplementation,anddecreasedphysicalactivity.Otherpotentialcausesinclude
smallandlargebowelhypomotilitysecondarytoincreasedprogesteronesecretion,excessivelydrystoolfrom
increasedcolonicwaterabsorption,andmechanicalimpedancesecondarytomovementsintheuterusandintestinal
tractduringlatepregnancy.
Firstlinetherapyforconstipationinpregnancyincludesincreasingfluids,dietaryfiber,andphysicalactivity.Although
thisinformationiswidelydisseminatedamongpatients,theevidencesubstantiatingthesetreatmentsislacking.One
randomizedcontrolledtrialcomparedincreaseddietaryfiberversusnoadditionalfiberfor2weeksinpregnant
patients.[11]Thefiberwasprovidedintheformofcornbasedbiscuitsorwheatbran(approximately10goffiber
addeddaily).Comparedwiththewomenwhoreceivednoadditionalfiber,thewomenwithincreaseddietaryfiberhad
asignificantlyincreasedfrequencyofbowelmovements.Thisstudy,althoughsmallinsamplesize(40womeninthe
thirdtrimesterofpregnancy),supportstherecommendationforincreasedfiberintakeinpregnancy,especiallyin
womenwhomayhavedeficientfiberintake.Therearenorandomizedcontrolledtrialsassessingtheefficacyof
increasedfluidintakeorincreasedphysicalactivitytotreatconstipationinthepregnantpopulation.[11]Inthegeneral
population,theserecommendationsarelargelyunsubstantiatedaswell.[12]Theliteraturesupportingthese
interventionsinvolvespopulationslackingordeficientinfiber,fluid,orphysicalactivity.Despitelackofclear
evidence,increasingfluidintake,dietaryfiber,andphysicalactivityshouldstillberecommendedformanagementof
constipationinpregnancy.Theinterventionsarelowincost,arereadilyavailable,andconferseveralotherbeneficial
effectsduringpregnancy.
Bulkingagentslikepsyllium(commerciallyavailableasMetamucil,Citrucel,etc)arenotsystemicallyabsorbedor
associatedwithincreasedriskofmalformationsduringpregnancy.[13]Norandomizedcontrolledtrialsexistcomparing
psylliumwithplacebointreatingconstipationinpregnancy,butitsuseissupportedbyatleast3randomized
controlledtrialsdemonstratingbenefitoverplaceboinimprovingstoolconsistencyanddecreasingcolonictransit
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timeinthegeneralpopulation.[12,14]Theseagentstakeseveraldaystobeginworkingbutcanbeusedforlong
periodsoftimetomanageuncomplicatedconstipation.Sideeffectsincludegas,bloating,andcramping,whichcan
bereducedwithadequatefluidintake.

Heartburn
Heartburnaffects40%to80%ofwomenatsometimeduringpregnancyandisassociatedwithdecreasedqualityof
life.[15]Thecauseforheartburninpregnancy,likenauseaandconstipation,ismultifactorial.Increasedprogesterone
relaxessmoothmuscle,whichdecreasesgastrictoneandmotilityanddecreasesloweresophagealsphincter
pressure.[11]Additionally,mechanicalchangesincludingpressurefromthegrowinguterusonstomachcontentsmay
playarole.
Lifestylemodificationstoreduceheartburninpregnancyincludeeatingfrequentsmallmeals,avoidingfoodsthat
inducereflux(spicyorgreasyfoodsacidicfoodsincludingtomatoes,citrusfruits,andcarbonateddrinks),avoiding
lyingdownwithin3hoursofeating,elevatingtheheadofthebedwhilesleeping,andavoidingcaffeineintake.While
consensusexiststhattheseinterventionsberecommendedasfirstlinetherapyforheartburninpregnancy,evidence
islacking.[16]
Therearenorandomizedcontrolledtrialsassessingtheefficacyofraisingtheheadofthebed,reducingcaffeine
intake,reducingtheintakeoffattyfoods,orreducingthesizeandfrequencyofmealsforheartburninpregnant
women.[11]Inthegeneralpopulation,thereisnorandomizedcontrolledtrialevidencetosupportdietarychangesand
caffeineavoidanceforheartburn,andthereisincompleteevidencetosupportavoidinglatenightmeals.[17]Thereis
someevidencetosupporttherecommendationofraisingtheheadofthebedorsleepingonawedgetoprevent
heartburninthegeneralpopulation.[17]Thisinterventionhasbeenshowntosignificantlyreduceandshortenreflux
episodesanddecreaseesophagealacidexposure(significantonlyinthosewhosleptonawedge)comparedwith
sleepingflat.[17]

Conclusions
Moreresearchisnecessarytosupportdietarymodifications(eatingsmaller,morefrequentmeals,consumingbland,
carbohydratedominantsolids)toreducenauseaandvomitinginpregnancy.Theseinterventionsarebasedonclinical
experienceandphysiologicalconjecture.Becausethereislittleriskassociatedwiththeirimplementation,theyare
reasonablerecommendationsforpregnantwomen.Thedataregardingacupressuretherapyareconflictingand
incomplete,butitmaybeanotherviablealternative.EvidenceindicatesthatvitaminB6andgingeraresafeand
effectivetreatmentsforpregnancyassociatednauseaandvomitingatpharmacologicaldoses(ginger1000mgdaily,
vitaminB625mgevery8hours).
Firstlinetherapyforconstipationinpregnancyincludesincreasingfluids,dietaryfiber,andphysicalactivity,despite
lackofevidence.Inthegeneralpopulation,theserecommendationshavebeensupportedinpatientsdeficientinfluid,
fiber,orexercise.Theseinterventionscarrylittleriskandhaveotherbeneficialeffectsinpregnancy,andthusthey
arereasonablerecommendationsforconstipationinpregnancy.Iflifestylealonedoesnotmanagetheconstipation,
bulkformingagentssuchaspsylliummaybesafelyusedinpregnancy.
Althoughthereisphysiologicalevidencethatcertainfoodsmayadverselyaffectsymptomsofheartburn,thereis
littleevidencethatavoidanceoftheseagentsimprovesgastroesophagealreflux,eveninthegeneralpopulation.
Theseinterventionscarrylittleriskandarethereforereasonableoptionsforpregnantpatients.Raisingtheheadofthe
bedatnightorsleepingonawedgepillowhasfavorableevidenceintreatingheartburninthegeneralpopulationand
mayalsobeapplicableforpregnantwomenfurtherresearchisnecessarytosubstantiatethis.
References

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1. GaffneyL,SmithC.Theviewsofpregnantwomentowardstheuseofcomplementarytherapiesand
medicines.BirthIssues.200413:4350.
2. HallHG,GriffithsDL,McKennaLG.Theuseofcomplementaryandalternativemedicinebypregnantwomen:
aliteraturereview.Midwifery.201127:817824.
3. DingM,LeachM,BradleyH.Theeffectivenessandsafetyofgingerforpregnancyinducednauseaand
vomiting:asystematicreview.WomenBirth.201326:e2630.
4. JewellD.Nauseaandvomitinginearlypregnancy.AmFamPhysician.200368(1):143144.
5. NiebylJR.Nauseaandvomitinginpregnancy.NEnglJMed.2010363:15441550.
6. VickersAJ.Canacupuncturehavespecificeffectsonhealth?Asystematicreviewofacupunctureantiemesis
trials.JRSocMed.199689:303311.
7. MatthewsA,DowswellT,HaasDM,DoyleM,O'MathunaDP.Nauseaandvomitinginearlypregnancy
(review).CochraneDatabaseSystRev.2010(9):168.
8. SahakianV,RouseD,SipesS,RoseN,NiebylJ.VitaminB6iseffectivetherapyfornauseaandvomitingof
pregnancy:arandomized,doubleblindplacebocontrolledstudy.ObstetGynecol.199178:3336.
9. QuinlanJD,HillA.Nauseaandvomitingofpregnancy.AmFamPhysician.200368:121128.
10. CullenG,O'DonoghueD.Constipationandpregnancy.BestPractResClinGastroenterol.200721(5):807818.
11. VazquezJ.Constipation,haemorrhoids,andheartburninpregnancy.ClinEvid.20108:1411.
12. LeungL,RiuttaT,KotechaJ,RosserW.Chronicconstipation:anevidencebasedreview.JAmBoardFam
Med.201124(4):436451.
13. TrottierM,ErebaraA,BozzoP.Treatingconstipationduringpregnancy.CanFamPhysician.201258(8):836
838.
14. JewellDJ,YoungG.Interventionsfortreatingconstipationinpregnancy.CochraneDatabaseSystRev.2001
(2):CD001142.
15. KellerJ,FrederkingD,LayerP.Thespectrumandtreatmentofgastrointestinaldisordersduringpregnancy.
NatClinPractGastroenterolHepatol.20085(8):430443.
16. TytgatGN,HeadingRC,MullerLissnerS,etal.Contemporaryunderstandingandmanagementofrefluxand
constipationinthegeneralpopulationandpregnancy:aconsensusmeeting.AilmentPharmacolTher.
200318:291301.
17. KaltenbachT,CrockettS,GersonL.Arelifestylemeasureseffectiveinpatientswithgastroesophagealreflux
disease?ArchInternMed.2006166(9):965971.
AmJLifestyleMed.20148(2):9799.2014SagePublications,Inc.

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