Eureka Herba Indonesia Vol 3 Issue 1 2022

Eureka Herba Indonesia

Journal Homepage: https://eurekabiomedical.com/index.php/EHI

Effectiveness of Ginger in Treating Nausea and Vomiting of Pregnancy

Ahmad Ramadhanu1*
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Sriwijaya/ Dr. Mohammad Hoesin General
Hospital, Palembang, Indonesia

ARTICLE INFO ABSTRACT

Keywords: Nausea and vomiting in pregnancy (NVP) is one of the common main
Nausea complaints in pregnancy. NVP can be a significant burden to the
patient, make a decrease in quality of life, pregnancy threatening or
Hyperemesis even worse can lead to nutritional loss and death. NVP diagnosed
Ginger when in first trimester of pregnancy and the other possible cause of
Literature review NVP is excluded. Management of NVP is included maintaining
hydration, nutrition, and lifestyle modification. Also avoiding the
smells, food, or activity that can cause nause are necessary. There are
*Corresponding author: some methods to treat NVP including pharmacological or non-
Ahmad Ramadhanu pharmacological. The non-pharmalogical approach is to change
nutritional habits, lifestyle and medications. Several pharmalogical
agents that can be used to relief the symptoms of NVP are pyridoxine,
E-mail address: anti-histamines, metoclopramide, pyridoxine/doxylamine,
promethazine and metoclopramide. Some patients also want to try
ramadhanu.og@gmail.com more “natural” medications for NVP like ginger. The pharmacological
activity is thought to stand in the pungent principles (gingerols and
The author has reviewed and approved the shogaols) and volatile oils (sesquiterpenes and monoterpenes). The
final version of the manuscript. true mechanism of action of ginger is probable to be a gastric effect,
to increase tone and peristaltic due to anticholinergic and anti
serotonin act. Ginger acts straight to the digestive tract and avoids
https://doi.org/10.37275/ehi.v3i1.46 the CNS side effects common to centrally acting antiemetics. Ginger
is available in capsule or syrup form or in candy, cookies, beer,
tinctures, teas, sodas, and jam. Nowadays, true dosing is available
only if one uses standardized extracts; however, women may choose
to use another form of ginger.

1. Introduction
Nausea and vomiting or NVP (often referred to as women between the fourth and the seventh gestational
morning sickness) are common symptoms in pregnant week and usually resolves by the 20th week.3
women approx. 70 – 85% and 40 –50% of pregnant Management of hyperemesis gravidarum includes
women, respectively.1 Nausea and vomiting can be a maintaining appropriate hydration, electrolytes, and
significant obstacle to the patient, resulting in dietary and lifestyle modifications.4 Women are
decreased quality of life, furthermore make wide commonly offered advice about the (usually) self-
medical complications, malnutrition, and in some limiting nature of the condition and advised to avoid
conditions, may result in management disruption and foods, smells, activities, or situations that they find
stoppage.2 Nausea and vomiting in pregnant women nauseating and to eat small frequent meals of dry,
are diagnosed when the first onset of symptoms is in bland foodstuffs. Many remedies are suggested for
the first trimester of pregnancy and the other nausea and vomiting in early pregnancy, including
possibilities of causes of NVP have been excluded. pharmaceutical and non-pharmaceutical
There are also risks of recurrence in a future interventions.5
pregnancy (15%–81%). It typically affects pregnant The non-pharmacological therapy for Nausea and

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Vomiting in Pregnancy (NVP) during pregnancy is true mechanism of action of ginger is thought to be a
underpinned by a change in nutritional habits, gastric effect, to increase tone and peristaltic due to
lifestyle, and medications, which have received scant anticholinergic and anti serotonin action. Ginger acts
attention in the literature. The drugs widely used to straight to the digestive tract and avoids the CNS side
treat the mild to moderate cases of NVP are pyridoxine, effects common to centrally acting antiemetics. Ginger
antihistamines, metoclopramide, pyridoxine is available in capsule or syrup form or in candy,
/doxylamine, promethazine, and metoclopramide. In cookies, beer, tinctures, teas, sodas, and jam.
the event of more severe symptoms, ondansetron and Currently, true dosing is available only if one uses
corticosteroids can be prescribed. However, there is standardized extracts; however, women may choose to
little on the efficacy of these drugs. Many mothers feel use another form of ginger.9
helpless in dealing with this condition, especially out The recommendation of the daily dose of ginger for
of concern for the side effects of these drugs on the the medication of PNV is 1000 mg. In addition to
unborn fetus.7 concerns about dosage, ginger also has the potential
Medication options for nausea and vomiting during to interact with other medications. It is recommended
pregnancy are limited because of concerns about that ginger not be combined with medications such as
safety. Initially, treatment consists of identifying and dimenhydrinate (Dramamine) since the possible
avoiding nausea triggers, avoidance of spicy and fatty interactions are currently unknown. Ginger should
foods, and cessation of iron supplements. If these also be avoided in patients prescribed oral
nonpharmacologic approaches do not alleviate hypoglycaemic agents or insulin, as some of the
symptoms, other options, including multivitamins, constituents of ginger could theoretically potentiate
vitamin B6, doxylamine, ginger, antihistamines, the hypoglycaemic effect of these medications.10
anticholinergics, and corticosteroids, may be tried.
Many patients prefer to avoid “drugs” during 2. Methods
pregnancy, choosing instead “natural” alternatives. The researcher searched for all studies published
One of these popular options is ginger. The efficacy between 01 January 2000 and 01 August 2021, using
and safety of this product are still in question, and it the following databases: PubMed. The following
is classified as pregnancy category C. Ginger root is keywords were used in the databases during the
commonly used as a flavoring agent in food and literature search: "((ginger) AND (morning sickness))
beverages and as a fragrance additive in cosmetic AND (pregnancy)". The research was limited to a
products. The antiemetic constituents of ginger exert human study published in the English language. More
their effects on the gastrointestinal tract, but the studies were identified through a manual search of the
specific mechanism is unknown. In vitro, it shows that bibliographic references of the relevant articles and
to have some ability to antagonize serotonin 5- HT3 existing reviews. The inclusion criteria were studies
receptors.8 that describe the pharmacology of ginger. The
Ginger rhizome (Zingiber officinale), used worldwide exclusion criteria were studies that include other
as a spice and an herbal remedy, has a long history as conditions (e.g. comorbid conditions (anxiety,
a digestive aid and antinausea remedy. It is the herb socioeconomic status, nutrition level, and the number
most commonly used to treat nausea and vomiting of previous pregnancies), endocrine problems,
during pregnancy, either recommended by providers neurovascular problems, immunopathological
or used as self-treatment by women. The problems, hematological problems, and oncology
pharmacological activity is thought to stand in the problems that could play an important role in nausea
pungent principles (gingerols and shogaols) and and vomiting in pregnancy. Moreover, because these
volatile oils (sesquiterpenes and monoterpenes). The confounding factors are difficult to account for in this

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study, the adjusted results were used and discussed however, the clinical relevance of some studies is less
in this article when available. In the first step, the certain. Common obstacles within the literature
researcher assesses the titles and abstracts of the include the lack of standardized extracts, not very
studies to exclude articles based on the criteria. In the good controlled or blinded studies, and limited sample
second step, the researcher read and evaluated the size. Respectively, recent evidence has provided
full-text studies that met the criteria. further support for 5-HT3 receptor antagonism as a
mechanism by which ginger may show its potentially
3. Results beneficial effect on nausea and vomiting.
The PubMed search results identified 62 potential Several differences were shown in the different
studies, with 50 potential studies remaining after guidelines for the management of NVP. Frequent
duplicates were removed. After a quick review of the snacks and avoidance of iron supplements in NVP are
titles and abstracts of all 50 studies, 20 studies were recommended for prevention. The intake of ginger,
identified for potential inclusion in the review. After a dopamine acustimulations, antihistamines,
deep examination of the full text of the 20 studies phenothiazines, and serotonin 5-hydroxytryptamine
against the inclusion criteria, a total of 10 trials were type 3 receptor antagonists is a routine
excluded Reasons for exclusion were: studies that recommendation for use in the community as
include other conditions (e.g. comorbid conditions treatment.
(anxiety, socioeconomic status, nutrition level, and a Twenty studies were included in the systematic
number of previous pregnancies), endocrine problems, review and eight teens in the meta-analysis.
neurovascular problems, immunopathological Acupuncture (OR: 18.9; 95% CI: 2.1, 168),
problems, hematological problems, oncology acupressure (OR: 26.7; 95% CI: 2.5, 283.1) and
problems. See Figure 1 for the study selection and methylprednisolone (OR: 6.7; 95% CI: 1.1, 38.8) was
inclusion process. associated with better control of HG symptoms than
the standard of care. Acupressure decreases the
4. Discussion requirement of rescue anti-emetics (OR: 0.06; 95% CI:
Six double-blind RCTs with a total of 675 0.01, 0.44); ondansetron with reduced hospital stay
participants and a prospective observational cohort (WMD: -0.2; 95% CI: -0.31, -0.01) and diazepam with
study (n = 187) met all inclusion criteria. The reduced risk of hospital admission (OR: 0.11; 95% CI:
methodology quality of 4 of 5 RCTs was high. Four of 0.01, 0.95). The quality of evidence is very low.
the 6 RCTs (n = 246) showed the superiority of ginger Thirty-seven trials involving 5049 women, met the
over placebo; the other 2 RCTs (n = 429) showed that inclusion criteria. These trials covered many
ginger was as effective as the reference drug (vitamin interventions, including acupressure, mint oil,
B6) in relieving the severity of NVP episodes. The acustimulation, acupuncture, ginger, chamomile,
observational study obtained and RCTs (including lemon oil, vitamin B6 and several antiemetic drugs. We
follow-up periods) show the absence of significant side identified no studies of dietary or other lifestyle
effects or adverse effects on pregnancy outcomes. interventions. Evidence-based on the effectiveness of
There are no spontaneous or case reports of adverse P6 acupressure, auricular (ear) acupressure, and
events during ginger treatment in pregnancy. acustimulation of the P6 point was limited.
This article identifies nine studies and seven Acupuncture (P6 or traditional) showed no significant
reviews that investigated ginger for morning sickness, plus for women during pregnancy. The use of ginger
postoperative NVP, chemotherapy-induced, and products may be helpful to women, but the evidence
antiretroviral-induced NVP. All studies reported that of effectiveness was low and not consistent, though
ginger provides a significant reduction in NVP; two recent studies support ginger over placebo. There

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was only a little evidence from trials to support the use studies concluded that there was no increased risk of
of pharmacological agents including vitamin B6, and birth defects in women taking gin-ger, the inclusion of
anti-emetic drugs to relieve mild or moderate NVP. those >12 weeks’ gestation means that their data are,
There was little information on maternal and fetal in reality, inconclusive.
adverse outcomes and on psychological, economic, or In all 4 studies reviewed here, no rationale was
social outcomes. We were unable to pool findings from offered for the choice of dose and length of treatment.
studies for most results due to heterogeneity in study As with all herbal, prescription, and over-the-counter
participants, interventions, comparison groups, and medications, it is important to know the maximum
outcomes measured or reported. The methodologic safe dose and length of treatment with the fewest side
quality of the included study was mixed. effects, the consequences of overdose, and potential
In a study of 27 women, 250 mg powdered ginger drug/herb interactions. In no study was the safety of
root appeared to be superior to placebo in reducing ginger consumption during pregnancy explicitly
NVP. The placebo was an equivalent dose of lactose, addressed, nor was any study powered well enough to
which may not be an inert ingredient for some get statistically significant results concerning safety.
subjects. Ginger root, however, is reported to contain The studies were time-limited, yet nausea and
a thromboxane synthetase inhibitor, which may affect vomiting of pregnancy can last for weeks. Animal
testosterone receptor binding in the fetus. Whether studies have reported both mutagenic and
powdered ginger root in quantities of 250 mg might antimutagenic effects of isolated components of ginger,
adversely affect fetal development is not known. and human studies have conflicting results regarding
All studies showed that ginger had a positive effect the potential inhibition of platelet aggregation when
on nausea in pregnant women. Unlike other studies, ginger is consumed at high doses. One recent study
one study reported that ginger was not beneficial to examines pregnancy outcomes of 187 women known
the treatment of vomiting. Herbal medicines such as to have consumed ginger during the first trimester and
Matricaria chamomilla, Elettaria cardamomum, found no statistically significant difference in major
pomegranate and spearmint syrup, and lemon provide malformations, spontaneous abortion, and stillbirth
safe and effective medical alternatives for treating rates among the ginger and the comparison group.
pregnant women with mild to moderate NVP. The Four RCTs met the inclusion criteria. All trials found
results suggested that ginger was more effective than orally taken ginger to be significantly more effective
vitamin B, but at the dose of 35–500 mg ginger, than placebo in reducing the frequency of vomiting
vitamin B6 and ginger had an identical effect. and intensity of nausea. Side events were generally
However, over a longer treatment period (60 days), mild and infrequent.
vitamin B6 was proven to be more effective than
ginger. The same effect was shown in the comparison 5. Conclusion
of quince and vitamin B6 as well as ginger and Gingers may be an effective treatment for nausea
doxylamine plus pyridoxine. Mentha did not generate and vomiting in pregnancy. However, more
a positive effect on NVP. However, this finding should observational studies, with larger sample size, are
be considered in light of the above limitations. needed to confirm the encouraging preliminary data
There is evidence suggesting that ginger is effective on ginger safety. The results of a study in this article
in reducing nausea and vomiting experienced during suggest that ginger is a promising treatment for
pregnancy. The studies used divided doses ranging nausea and vomiting in a variety of clinical settings
between 500 and 1500 mg/day, with no higher and possesses a clinically relevant mechanism.
incidence of birth defects, miscarriages, or deformities However, further studies are required to address the
than in the general population. While most of the limitations in the current clinical literature before firm

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recommendations for its use can be made. 10. Ding, E et al. The effectiveness and safety of
ginger for pregnancy-induced nausea and
6. References vomiting: A systematic review. Women and
1. Borrelli et al. Effectiveness and Safety of Birth Elsevier. 2013.
Ginger in the Treatment of Pregnancy-
Induced Nausea and Vomiting. The American
College of Obstetricians and Gynecologists.
2005; 105(4)
2. Marx et al. Is ginger beneficial for nausea and
vomiting? An update of the literature. Wolters
Kluwer Health. 2015; 9(2).
3. Tsakiridis et al. The Management of Nausea
and Vomiting of Pregnancy: Synthesis of
national guidelines, obstetrical and
gynecological survey. 2019; 74(3).
4. Sridharan, K & Sivaramakrishnan, G.
Interventions for treating hyperemesis
gravidarum: A network meta-analysis of
randomized clinical trials, The Journal of
Maternal-Fetal & Neonatal Medicine. 2018.
5. Matthews et al. Interventions for nausea and
vomiting in early pregnancy (Review), The
Cochrane Library. 2014.
6. Erick, M. Vitamin B and Ginger. EITBII. 1995;
95(4).
7. Khorasani, F. et al. A systematic review of the
efficacy of alternative medicine in the
medication of nausea and vomiting of
pregnancy, Journal of Obstetric and
Ginecology. 2019.
8. Boone, S and Shields, K., Treating Pregnancy-
Related Nausea and Vomiting with Ginger.
The Annals of Pharmacotherapy. 2005; 39.
9. Bryer, E., A Literature Review of the
Effectiveness of Ginger in Alleviating Mild-to-
Moderate Nausea and Vomiting of Pregnancy.
Journal of Midwifery & Women’s Health.
2005; 50(1).

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