EA for NVP 2023

Stimulated by Wu et al 2023.[1]

EA – electroacupuncture
NVP – nausea and vomiting of pregnancy
PCOS – polycystic ovarian syndrome
Lisa SV – Professor Elisabet Stener-Victorin, Karolinska Institutet
PUQE – pregnancy unique quantification of emesis
IF – impact factor
GWAS – genome wide association study
hCG – human chorionic gonadotrophin
GDF15 – growth/differentiation factor 15

key to acronyms

This is the largest sham controlled trial of acupuncture in NVP to date. It was based in Harbin, which is in the northeast of China, but involved 13 centres across mainland China.

The first author is the same as in the huge (n=1000) PCOS trial that Lisa SV helped co-ordinate,[2] and the design is rather similar. I often refer to such trials as double dummy, since they involve two different placebo controls, but the more correct term is 2×2 factorial design.

In this case the trial tested both EA and a drug combination including an antihistamine (doxylamine) and a vitamin (pyridoxine). The trial was not as big as the PCOS trial, but still a considerable undertaking with 352 women randomly assigned to the 4 groups.

The primary outcome was the appropriately named PUQE score,[3] which ranges from 3 to 15. Moderate NVP is 6 to 12 and severe NVP is from 13 to 15. It is a three-item scale measuring daily duration of nausea, frequency of vomiting, and frequency of dry retching.

In this trial, 71% of women had moderate NVP at baseline and 29% had severe NVP.

The women received either doxylamine 10mg plus pyridoxine 10mg or an identical placebo tablet. The dose was increased after 2 days if there was no benefit, up to a maximum of 4 tablets a day. The women also received either EA or a non-penetrating sham. The main points were PC6, ST36 and CV12, and ST40 or LR3 were added based on one of 3 Chinese medicine syndromes. PC6 was stimulated manually, and the EA was applied from ST36 to either ipsilateral ST40, ipsilateral LR3, or to CV12. The women received up to 14 sessions over a 2-week period. The EA was applied for 30 minutes at a frequency of 2Hz with a pulse width of 0.5ms and an intensity between 0.8 and 1.0mA.

The results indicate that both treatments work to some degree, and they are independent of each other. The combination appears to be slightly better numerically. The reduction in PUQE score was about 4 with the double dummy over 2 weeks and 6 with the active combination. Each of the active interventions managed a reduction of about 5 on the PUQE score.

The drug combination looked slightly better, especially in the early days when the dose was increased, but there also seemed to be a reduced birth weight associated with this intervention.

So, these are modest but statistically significant results from a very well conducted and reported trial.

Before wrapping up the topic, I spotted a reference to a recent review of NVP in Nature Reviews Disease Primers (IF 65+). Well, can you believe that GWAS data has helped to unseat hCG as the likely culprit for NVP in favour of something called GDF15, and a few others? It looks as though there is no escaping from the genomics these days.

References

1          Wu X-K, Gao J-S, Ma H-L, et al. Acupuncture and Doxylamine-Pyridoxine for Nausea and Vomiting in Pregnancy: A Randomized, Controlled, 2 × 2 Factorial Trial. Ann Intern Med Published Online First: 20 June 2023. doi:10.7326/M22-2974

2          Wu X-K, Stener-Victorin E, Kuang H-Y, et al. Effect of Acupuncture and Clomiphene in Chinese Women With Polycystic Ovary Syndrome: A Randomized Clinical Trial. JAMA 2017;317:2502–14. doi:10.1001/jama.2017.7217

3          Koren G, Boskovic R, Hard M, et al. Motherisk-PUQE (pregnancy-unique quantification of emesis and nausea) scoring system for nausea and vomiting of pregnancy. Am J Obstet Gynecol 2002;186:S228-231. doi:10.1067/mob.2002.123054

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Declaration of interests MC