Research Article / Originalarbeit

Complement Med Res Received: July 14, 2019

Accepted: December 24, 2019
DOI: 10.1159/000505637 Published online: February 4, 2020

The Effect of Acupressure on the Severity of

Nausea, Vomiting, and Retching in Pregnant
Women: A Randomized Controlled Trial
Fatemeh Tara a Hamidreza Bahrami-Taghanaki b
   

Masoud Amini Ghalandarabad c Ziba Zand-Kargar d Hamideh Azizi d

     

Habibollah Esmaily e Hoda Azizi b
   

a Department
of Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran;
b Department
of Chinese and Complementary Medicine, School of Persian and Complementary Medicine, Mashhad
University of Medical Sciences, Mashhad, Iran; c Medical student, Faculty of Medicine, Mashhad University of Medical
 

Sciences, Mashhad, Iran; d Gynecologist, Mashhad, Iran; e Department of Biostatistics, School of Health, Mashhad
   

University of Medical Sciences, Mashhad, Iran

Keywords
Acupressure · Pregnancy-induced nausea and vomiting ·
Hyperemesis gravidarum · Nausea · Vomiting
Abstract
Introduction: Nausea and vomiting are common problems
during pregnancy. Previous studies have shown that stimu-
lation at Neiguan (PC6) acupoint can be effective in control-
ling pregnancy-induced nausea and vomiting. However,
more evidence is required for approving this method on
controlling pregnancy-induced nausea and vomiting. The
aim of this study was to determine the efficacy of PC6 acu-
point pressure stimulation on the severity of nausea, vomit-
ing, and retching in pregnant women. Method: This ran-
domized, multi-center clinical trial was conducted on preg-
nant women referring to Health Centers and Ommolbanin
Hospital in Mashhad, Iran, during December 2016 to Sep-
tember 2017. Women with first singleton pregnancy and be-
low 12 weeks were included. Patients were randomly allo-
cated into three groups of (1) PC6 pressure (4 times a day, for
10 min), (2) sham acupressure, and (3) medication with vita-
min B6 and metoclopramide. Assessment of severity of nau-
sea, vomiting, and retching was done based on the Rhodes
Index on the first and fifth day (before and after the interven-
tion). Pearson chi-square test, one-way ANOVA, Kruskal-Wal-
lis, and Wilcoxon tests were used for statistical analysis using
SPSS version 18. This clinical trial was registered at the
Iranian Registry of Clinical Trials (IRCT) with the code
IRCT201512187265N6. Results: Ninety patients with a mean
age of 26.40 ± 4.73 years were studied in 3 groups of 30.
There was no significant difference between the 3 groups in
terms of the severity outcomes before the intervention,
while, after the intervention, the three groups were signifi-
cantly different on the fifth day in terms of vomiting frequen-
cy, distress from retching, distress from vomiting, duration
of nausea, distress from nausea, amount of vomiting, fre-
quency of nausea, and frequency of retching (p < 0.001 for
each outcome). According to the linear regression analysis,
the correlation between occupation with vomiting frequen-
cy (beta coefficient = 0.252) and nausea severity (beta coef-
ficient = –0.213) was statistically significant. Conclusion: It
seems that PC6 acupoint pressure can reduce the severity of
nausea, vomiting, and retching in pregnant women.
© 2020 S. Karger AG, Basel
130.241.16.16 - 2/6/2020 7:10:10 AM

karger@karger.com © 2020 S. Karger AG, Basel Hoda Azizi

www.karger.com/cmr School of Persian and Complementary Medicine
Göteborgs Universitet

Mashhad University of Medical Sciences

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Azadi Square, Pardis University Campus, Mashhad 9135913556 (Iran)

azizih @ mums.ac.ir; azizi.h.md @ gmail.com
 Wirkung der Akupressur auf den Schweregrad
von Übelkeit, Erbrechen und Würgereiz bei
Schwangeren: eine randomisierte kontrollierte
Studie
Schlüsselwörter
Akupressur · schwangerschaftsinduzierte Übelkeit
und Erbrechen · Hyperemesis gravidarum · Übelkeit ·
Erbrechen
Zusammenfassung
Einleitung: Übelkeit und Erbrechen treten in der
Schwangerschaft häufig auf. Frühere Studien haben
gezeigt, dass die Stimulation des Akupunkturpunkts Nei-
guan (PC6) Übelkeit und Erbrechen in der Schwanger-
schaft wirksam kontrollieren kann. Für die Zulassung die-
ser Methode zur Behandlung von Übelkeit und Erbrechen
in der Schwangerschaft sind jedoch weitere Belege er-
forderlich. Mit der vorliegenden Studie sollte die Wirksam-
keit der Druckstimulation am Akupunkturpunkt PC6 auf
den Schweregrad von Übelkeit, Erbrechen und Würgereiz
bei Schwangeren ermittelt werden. Methode: Die vorlie­
gende randomisierte multizentrische klinische Studie
wurde an schwangeren Frauen durchgeführt, die sich
zwischen Dezember 2016 und September 2017 in Ge-
sundheitszentren und im Ommolbanin Krankenhaus in
Mashhad, Iran, vorgestellt hatten. In die Studie wurden
Erstgebärende mit einer Einlingsschwangerschaft bis zur
12. Schwangerschaftswoche aufgenommen. Die Patien-
tinnen wurden nach dem Zufallsprinzip einer von drei
Gruppen zugewiesen: (1) PC6-Druckstimulation (viermal
täglich für 10 Minuten), (2) Scheinakupressur und (3) me-
dikamentöse Behandlung mit Vitamin B6 und Metoclo­
pramid. Die Bewertung des Schweregrads von Übelkeit,
Erbrechen und Würgereiz erfolgte an Tag 1 und Tag 5 (vor
und nach der Intervention) mithilfe des Rhodes-Index. Bei
der statistischen Analyse kam SPSS Version 18 zur An-
wendung und es wurden der Pearson-Chi-Quadrat-Test,
eine einfaktorielle ANOVA sowie Kruskal-Wallis- und Wil-
coxon-Tests durchgeführt. Die klinische Studie war beim
iranischen Register für klinische Studien (Iranian Registry
of Clinical Trials, IRCT) unter der Kennung
IRCT201512187265N6 registriert. Ergebnisse: Neunzig
(90) Patientinnen mit einem Durchschnittsalter von 26,40
± 4,73 Jahren wurden in drei Gruppen mit je 30 Teilneh­
merinnen untersucht. Vor der Intervention bestand kein
signifikanter Unterschied zwischen den drei Gruppen in
Bezug auf den Schweregrad der Zielkriterien. Nach der In-
tervention zeigte sich jedoch am 5. Tag ein signifikanter
Unterschied zwischen den drei Gruppen hinsichtlich Häu-
figkeit des Erbrechens, Belastung durch das Würgen, Be-
lastung durch das Erbrechen, Dauer der Übelkeit, Belas-
2 Complement Med Res
DOI: 10.1159/000505637
tung durch die Übelkeit, Menge des Erbrochenen, Häufig-
keit der Übelkeit und Häufigkeit des Würgereizes (p <
0,001 für jedes Zielkriterium). Gemäß linearer Regres­
sionsanalyse fiel die Korrelation zwischen Beschäftigung
und der Häufigkeit des Erbrechens (Betakoeffizient =
0,252) sowie der Schwere der Übelkeit (Betakoeffizient =
–0,213) statistisch signifikant aus. Schlussfolgerung: Es
scheint, dass die Druckstimulation am Akupunkturpunkt
PC6 die Schwere von Übelkeit, Erbrechen und Würgereiz
bei Schwangeren verringern kann. © 2020 S. Karger AG, Basel
Introduction
Pregnancy is often associated with many problems, the
most common of which is nausea and vomiting, which is
reported by 50–80% of women between 6 and 12 weeks
of pregnancy [1–3], although it is reported that morning
nausea and vomiting can continue until the 20th week of
pregnancy in 20% of cases [1, 2]. Hyperemesis gravi-
darum, which is commonly reported as a frequent and
severe nausea and vomiting in pregnant women, is less
common, accounting for 0.3 to 3% of pregnancies [3, 4].
Various therapeutic interventions are recommended for
pregnancy-induced nausea and vomiting, which are di-
vided into two groups of pharmaceutical and non-phar-
maceutical treatments [5, 6]. Pharmaceutical treatments
include antihistamines and vitamins B6 and B12 as well as
dopamine antagonists and H3, or a combination of them
[2, 7]; however, the results of the studies show that these
therapeutic interventions are rarely successful to lead to
a complete recovery in affected mothers [1, 2, 8]. In addi-
tion, pregnant women’s concern of possible side effects of
drugs and their teratogenic effects on the fetus sometimes
causes improper and insufficient consumption of such
medication in this group of people. Therefore, finding a
safe, immediate, and strong intervention with high access
at any location, even at the patient’s home, has seemingly
remained a research priority [2, 4, 8].
Pressure stimulation at Neiguan (PC6) acupoint is a
very ancient method in Chinese acupuncture, which has
been used effectively to control nausea [9]. The PC6 acu-
point is located three fingerbreadths below the wrist on
the inner forearm in between the two tendons [9]. It has
been stated that the PC6 acupoint pressure may control
nausea and vomiting by controlling the functioning of the
intestine [10]. In addition, other researchers believe that
acupressure acts through inhibition of cerebrospinal flu-
id function by neurostimulation, which reduces the de-
gree of nausea and vomiting [10, 11]. So far, pressure
stimulation at the PC6 acupoint has been used to control
chemotherapy-induced vomiting, and some studies have
also shown that this intervention can also be effective in
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Tara et al.
Göteborgs Universitet
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pregnancy-induced nausea and vomiting [3, 4, 12, 13]. A
review study conducted by Cluver et al. [2] indicated a
need for further interventional studies, although there is
evidence regarding the effect of pressure stimulation at
the PC6 acupoint on controlling pregnancy-induced nau-
sea and vomiting. Therefore, this study was conducted
with the aim to determine the efficacy of PC6 acupoint
pressure stimulation intervention compared with the
sham group and also, to examine the impact of drug in-
tervention in the severity of nausea, vomiting, and retch-
ing in pregnant women.
Materials and Methods
Study Design and Setting
This randomized, single-blind, multi-center clinical trial was
conducted on pregnant women referring to health centers in
Mashhad, Iran, during December 2016 to September 2017. In this
study, the Daneshamooz and Villashahr Health Centers as well as
the Ommolbanin Hospital, Mashhad, Iran were selected as the
study locations. The study was conducted according to the extend-
ing Consolidated Standards of Reporting Trials (CONSORT)
statement of Revised Standards for Reporting Interventions in
Clinical Trials of Acupuncture (STRICTA).
Participants
The inclusion criteria were: (1) first pregnancy, (2) pregnancy
below 12 weeks, and (3) singleton pregnancy. The exclusion crite-
ria included: (1) proof of fetal death, (2) history of underlying or
associated disease, (3) history of mental disorders (based on being
hospitalized in a psychiatric hospital), (4) pregnancy after infertil-
ity treatment, (5) smoking, (6) acupressure history for any disease,
(7) any gastrointestinal problems like gastritis, GERD, heartburn,
IBS, etc. and urinary tract infection, (8) dehydration, (9) hyper-
emesis gravidarum, and (10) history of infertility.
Sampling Methods, Blinding, and Allocation
Patients were allocated into one of the three groups of (1) acu-
pressure at PC6 4 times a day, for 10 min, (2) sham acupressure,
and (3) vitamin B6 plus metoclopramide treatment, using the ran-
domized block method. This is a small-sample pilot study with a
sample size of 30 individuals for each group. The patients in both
the acupressure and sham acupressure groups were unaware of
their group. The interviewer and the statistical analyst were blind,
but there was no possibility for blinding the intervener.
Interventions
The acupressure group was treated with Neiguan (PC6) acu-
point pressure. The sham acupressure group was treated by pres-
sure at Waiguan (TE5), and the medication group by vitamin B6
(tab 40 mg, oral, Darou Pakhsh Co., Iran) ½ tab every 8 h and
metoclopramide (tab 5 mg, oral, Hakim Co., Iran) 5 mg every 8 h
before meals. All study assistants were trained for the acupressure
by one acupuncturist who was a medical doctor, PhD in acupunc-
ture, and university assistant professor with 10 years of clinical
acupuncture experience. The study assistants consisted of mid-
wives of Daneshamooz and Villashahr Health Centers and Om-
molbanin Hospital. The education included how to locate PC6 and
TE5, the duration of acupressure 4 times a day (in the morning
after getting up, at noon, in the evening, and at night before bed-
time) for 10 min, and the strength at the maximum possible endur-
Acupressure for Nausea in Pregnancy
ance of the patient (with constant pressure and not with massag-
ing). The PC6 point location was described as 2 cun (three finger-
breadths) below the wrist on the inner forearm in between the two
tendons of the palmaris longus and flexor carpi radialis muscles.
The TE5 point location was described as 2 cun (three finger-
breadths) above the transverse crease of the dorsum of the wrist,
between the radius and ulna. Then the study team taught patients
to do the acupressure themselves. In all the 3 groups, the first day
was dedicated to the control phase, and the intervention was initi-
ated on the second day, which continued until the end of the fifth
day. In the acupressure group, this pressure was applied to the
Neiguan (PC6) acupoint 4 times a day (in the morning after getting
up, at noon, in the evening, and at night before bedtime) for 10 min
at the maximum possible endurance of the patient (with constant
pressure and not with massaging). If the patients had severe nausea
during the pressure intervals, they could just once undergo the ex-
periment earlier than the four specified times during a day. In the
sham acupressure group, pressure was applied to Waiguan (TE5),
the counterpart of Neiguan, located on the dorsal aspect of the
forearm. During the study period, all the patients received the
same training on diet (using low-fat foods, solid foods, frequent
meals, low volumes per meal, etc.).
Data Collection
For each patient, a checklist including demographic informa-
tion such as age, sex, education, occupation, body mass index
(BMI), gestational age by week, type of pregnancy, as well as infor-
mation related to the assessment of severity of nausea, vomiting,
and retching based on the Rhodes Index was completed. The reli-
ability and validity of the Rhodes Index of nausea, vomiting, and
retching have been confirmed in previous studies in different
countries [14, 15]. In Iran, the validity and reliability of this ques-
tionnaire has been confirmed by Modares and colleagues [16].
This index has also been used frequently in other studies in Iran
[17, 18]. The questionnaire consisted of eight questions that in-
cluded the times of vomiting episodes per day, the volume of the
vomiting, the degree and length of nausea and retching, as well as
the distress associated with the conditions. The questionnaire was
completed at the end of each day by the patient, and its findings on
the initial day (before intervention) and fifth day (after the inter-
vention) were used for comparison. In addition, the frequency of
patients who felt recovery from nausea, vomiting, and retching at
each day of study in the study groups was recorded daily. The
training of the patients, prescribing medications to them, and ar-
rangements for their follow-up in this project were performed by
the study team trained by one faculty member acupuncturist.
Outcomes
The primary outcome of this study was the severity of nausea,
vomiting, and retching based on the Rhodes Index including vom-
iting frequency, distress from retching, distress from vomiting, du-
ration of nausea, distress from nausea, amount of vomiting, fre-
quency of nausea, and frequency of retching. The secondary out-
come was the frequency of patients who felt recovery from nausea,
vomiting, and retching at each day of study.
Ethics
Written informed consent was received from all the patients.
The patients had the right to withdraw from the study and a phone
number was given to them as a 24-h support service in case of any
urgent inquiries. According to the provisions of the Helsinki Dec-
laration, the project executives were required to preserve the con-
fidentiality of the patients and conduct the research without men-
tioning their names. The questionnaires were kept confidential
and the names and characteristics of the patients were disclosed.
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Complement Med Res 3
DOI: 10.1159/000505637
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 Table 1. Baseline characteristics of patients in three groups of PC6 acupressure, medication, and placebo

Variables Acupressure Medication Sham acupressure p value

(n = 30) (n = 30) (n = 30)

Age, years 26.0±4.7 26.5±4.3 26.6±5.2 0.853

Weight, kg 64.9±9.4 58.7±7.8 68.6±9.0 0.024*
Body mass index 24.1±2.9 22.8±3.4 24.4±3.6 0.153
Pregnancy duration, weeks 9.6±1.7 9.3±1.3 8.7±2.2 0.081
Education level
Elementary school 3 (10.0) 1 (3.3) 3 (10.0) 0.208
Middle school 3 (10.0) 1 (3.3) 5 (16.7)
High school 15 (50.0) 14 (46.7) 11 (36.7)
Higher education 9 (30.0) 14 (46.7) 11 (36.7)
Job
Housewife 25 (83.3) 29 (96.7) 26 (86.7) 0.001*
Practitioner 5 (16.7) 1 (3.3) 4 (13.3)

Data are presented as mean ± SD or n (%). * Significant.

This research was approved by the Ethics Committee of Mashhad
University of Medical Sciences under the code IR.MUMS.
REC.1388.100. Also, this clinical trial was registered at the Iranian
Registry of Clinical Trials (IRCT) with the code
IRCT201512187265N6.
Sample Size
For a pilot study with 95% confidence and 80% power to reach
a standardized effect size (f = 0.75), at least 30 samples were re-
quired in each group [19].
Statistical Analysis
Pearson chi-square test was used to analyze the nominal data.
In cases where more than 20% of the expected frequencies in the
tables were less than 5, Fisher’s exact test was used. Moreover, one-
way ANOVA, Kruskal-Wallis, and Wilcoxon tests were used for
statistical analysis using SPSS version 18.0 (released 2009; PASW
Statistics for Windows, Chicago: SPSS Inc.). The significance level
in all the tests was less than 5%.
vomiting (p < 0.001), duration of nausea (p < 0.001), dis-
tress from nausea (p = 0.001), amount of vomiting (p =
0.007), frequency of nausea (p = 0.002), and frequency of
retching (p = 0.007) were decreased post-intervention
compared to baseline.
In the sham acupressure group, all the mentioned se-
verity outcomes were increased post-intervention com-
pared to baseline (p = 0.013, 0.005, 0.006, 0.042, 0.002,
0.009, 0.024 for vomiting frequency, distress from retch-
ing, distress from vomiting, distress from nausea, amount
of vomiting, frequency of nausea, and frequency of retch-
ing, respectively) except for the duration of nausea (p =
0.470).
In the medication group, no significant changes were
observed in any of the severity outcomes post-interven-
tion compared to baseline (p > 0.05).

Comparison of the Severity of Nausea, Vomiting, and

Results
Baseline Characteristics
This study was performed on 90 patients with a mean
age of 26.40 ± 4.73 years. The patients were studied in 3
groups of 30. The distribution of the variables of age,
BMI, gestational age, and education level were homoge-
neous in the three groups of acupressure, drug therapy,
and placebo; however, there were significant differences
between the three groups in terms of weight and occupa-
tion (Table 1).
Within-Group Comparison of the Severity of
Retching, Nausea, and Vomiting before and after the
Intervention
In the acupressure group, vomiting frequency (p =
0.004), distress from retching (p < 0.001), distress from
Retching among Study Groups
Based on the statistical analysis performed in this
study, the results of Kruskal-Wallis test showed no sig-
nificant difference between the three groups based on
the frequency distribution of vomiting frequency (p =
0.165), distress from retching (p = 0.548), distress from
vomiting (p = 0.27), duration of nausea (p = 0.923), dis-
tress from nausea (p = 0.489), amount of vomiting (p =
0.075), frequency of nausea (p = 0.663), and frequency
of retching (p = 0.224) before the intervention, while,
after the intervention, the three groups were significant-
ly different on the fifth day in terms of the severity out-
comes (Table 2).
Furthermore, 90% of the subjects in the sham acupres-
sure group stated that pressure at the Waiguan not only
did not reduce nausea, retching, and vomiting, but also
increased the severity of them. Also, the data showed that
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4 Complement Med Res Tara et al.

DOI: 10.1159/000505637
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 Table 2. Severity of nausea, vomiting, and retching 5 days after intervention based on Rhodes Index

Variables Acupressure Medication Sham acupressure p value

(n = 30) (n = 30) (n = 30)

Vomiting frequency
7 and more 1 (3.3) 11 (36.7) 2 (6.7) <0.001
5–6 0 4 (13.3) 6 (20.0)
3–4 0 2 (6.7) 10 (33.3)
1–2 7 (23.3) 9 (30.0) 9 (30.0)
None 22 (73.3) 4 (13.3) 3 (10.0)
Distress from retching
None 16 (53.3) 2 (6.7) 1 (3.3) <0.001
Mild 10 (33.3) 7 (23.3) 1 (3.3)
Moderate 0 4 (13.3) 11 (36.7)
Great 2 (6.7) 5 (16.7) 13 (43.3)
Severe 2 (6.7) 12 (40.0) 4 (13.3)
Distress from vomiting
None 17 (56.7) 3 (10.0) 4 (13.3) <0.001
Mild 9 (30.0) 3 (10.0) 1 (3.3)
Moderate 3 (10.0) 4 (13.3) 8 (26.7)
Great 0 7 (23.3) 12 (40.0)
Severe 1 (3.3) 13 (43.3) 5 (16.7)
Distress from nausea
None 12 (40.0) 1 (3.3) 2 (6.7) <0.001
Mild 12 (40.0) 7 (23.3) 1 (3.3)
Moderate 2 (6.7) 3 (10.0) 7 (23.3)
Great 3 (10.0) 5 (16.7) 12 (40.0)
Severe 1 (3.3) 14 (46.7) 8 (26.7)
Duration of nausea or abdominal discomfort
Not at all 17 (56.7) 3 (10.0) 4 (13.3) <0.001
1 h or less 9 (30.0) 3 (10.0) 1 (3.3)
2–3 h 3 (10.0) 4 (13.3) 8 (26.7)
4–6 h 0 7 (23.3) 12 (40.0)
More than 6 h
Amount of vomiting
None 22 (73.3) 4 (13.3) 3 (10.0) <0.001
Small (up to ½ cup) 3 (10.0) 4 (13.3) 2 (6.7)
Moderate (½–2 cups) 2 (6.7) 5 (16.7) 9 (30.0)
Large (2–3 cups) 2 (6.7) 5 (16.7) 11 (36.7)
Very large (3 cups or more) 1 (3.3) 12 (40.0) 5 (16.7)
Frequency of nausea
7 times and more 2 (6.7) 10 (33.3) 4 (13.3) <0.001
5–6 times 2 (6.7) 6 (20.0) 11 (36.7)
3–4 times 3 (10.0) 5 (16.7) 10 (33.3)
1–2 times 6 (20.0) 6 (20.0) 3 (10.0)
None 17 (56.6) 3 (10.0) 2 (6.7)
Frequency of retching
7 and more 2 (6.7) 10 (33.3) 4 (13.3) <0.001
5–6 2 (6.7) 6 (20.0) 5 (16.7)
3–4 3 (10.0) 3 (10.0) 11 (36.7)
1–2 9 (30.0) 9 (30.0) 7 (23.3)
None 14 (46.7) 2 (6.7) 3 (10.0)

Data are presented as n (%).

medication therapy had no significant effect on nausea, Regression Analysis

and almost 50% of the patients reported complete ineffi-
cacy of this method, while for acupressure intervention,
86.7% of patients were cured during a 7-day follow-up
(Table 3).
Based on the results of the regression test, the correla-
tion between occupation with vomiting frequency (beta
coefficient = 0.252) and nausea severity (beta coefficient
= –0.213) was statistically significant (Table 4). No im-
portant adverse event was observed in the study groups.
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Acupressure for Nausea in Pregnancy Complement Med Res 5

DOI: 10.1159/000505637
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Table 3. Frequency of patients who felt recovery from nausea, apy intervention, which is consistent with the findings of
vomiting, and retching at each day of study in the study groups the majority of other studies. A study published recently
in 2017 states that PC6 acupressure intervention for 12 h
Variables Acupressure Medication Sham
(n = 30) (n = 30) acupressure for 3 days can significantly reduce pregnancy-induced
(n = 30) nausea and vomiting [11]. In a study conducted in Tur-
key, it was shown that in subjects undergoing PC6 acu-
Nausea pressure between days 4–6, there was less severity of nau-
Initial day 2 (6.7) 6 (20.0) 1 (3.3)
1st day 11 (36.7) 4 (13.3) 0 (0)
sea, frequency of vomiting, and feeling of discomfort after
2nd day 11 (36.7) 2 (6.7) 1 (3.3) nausea [20]. Another study showed that the frequency of
3rd day 1 (3.3) 3 (10.0) 1 (3.3) vomiting, nausea, and retching, as well as the discomfort
4th day 1 (3.3) 0 (0) 0 (0) caused by nausea and vomiting were significantly lower
7th day 0 (0) 0 (0) 0 (0) in the PC6 acupoint pressure treatment group than in the
Sum of recovery 26 (86.6) 15 (50.0) 3 (10.0)
control group under drug therapy [21]. The average age
Vomiting
Initial day 2 (6.7) 7 (23.3) 1 (3.3) of the patients, onset of the treatment, frequency of acu-
1st day 9 (30.0) 3 (10.0) 0 (0) pressure exercises, and findings in their study are fully
2nd day 11 (36.7) 2 (6.7) 1 (3.3) consistent with those in our study. Yet in another study,
3rd day 3 (10.0) 2 (6.7) 1 (3.3) the result of the intervention on 138 patients at the PC6
4th day 1 (3.3) 1 (3.3) 0 (0)
acupoint by 30 bands and one acupressure button showed
7th day 0 (0) 0 (0) 0 (0)
Sum of recovery 26 (86.6) 15 (50.0) 3 (10.0) that pregnancy-related nausea and vomiting were signif-
Retching icantly reduced in the acupressure group compared with
Initial day 2 (6.7) 6 (20.0) 2 (6.7) the placebo group [22]. At a higher level of the value pyr-
1st day 8 (26.7) 4 (13.3) 0 (0) amid for studies, Festin’s review study [8] also showed
2nd day 11 (36.7) 2 (6.7) 0 (0)
that pressure at the PC6 acupoint, compared with the pla-
3rd day 4 (13.3) 3 (10.0) 1 (3.3)
4th day 0 (0) 0 (0) 0 (0) cebo acupoint, reduces nausea and vomiting. In another
7th day 1 (3.3) 0 (0) 0 (0) meta-analysis by Helmreich et al. [23], 14 randomized
Sum of recovery 26 (86.6) 15 (50.0) 3 (10.0) clinical trials including 8 randomized controlled trials
and 6 crossover studies (n = 1,655) were performed to
Data are presented as n (%).
determine the effect of PC6 acupoint pressure stimula-
tion on the prevention of nausea and vomiting in preg-
nant women. The results of their study showed that this
type of intervention can reduce the incidence of nausea
Discussion and vomiting by up to 50% [23]. Also, a meta-analysis
performed on six pregnancy-related nausea and vomiting
This study was conducted with the aim to compare the treatments including 292 acupressure cases and 288 con-
interventions including Neiguan (PC6) acupoint pres- trols showed that acupressure significantly reduced post-
sure (4 times a day), placebo (Waiguan, TE5) acupoint operative nausea and frequency of vomiting by almost
pressure, and medication therapy with vitamin B6 and 15% [12].
metoclopramide. The results showed that the frequency However, there were also other studies showing, con-
distribution of vomiting in pregnant women was signifi- trary to our study, no higher efficacy of PC6 acupoint
cantly different at the post-intervention phase between pressure stimulation in the prevention of pregnancy-re-
the three groups. In our study, the results showed a de- lated nausea and vomiting as compared to drug therapy
crease in the variables including retching complaints, or placebo. In the group of studies opposed to our study,
vomiting, and nausea and vomiting severity and frequen- Jamigorn et al. [24], in a comparative study between PC6
cy as well as nausea and retching frequency in pregnant acupressure and vitamin B6, showed that the severity of
women at the post-intervention phase compared with the nausea and vomiting, based on moderate changes in the
pre-PC6 pressure intervention. This is while all the above Rhodes Index, was not significant between the two groups.
variables increased in the placebo group. However, there In another study, it was found that there was no signifi-
was no significant difference in the drug therapy group cant difference between the duration of admission,
between the pre- and post-intervention. The duration of amount of drug received, and amount of fluid therapy
nausea also decreased significantly in the acupressure required between the two groups of PC6 acupoint pres-
group after the intervention, but this difference was not sure and placebo [25]. Norheim et al. [26] also reported a
significant in the other two groups. Therefore, the overall reduction in both the PC6 and placebo groups in terms of
results of our study indicate that PC6 pressure interven- nausea severity (71 and 63%, respectively) and nausea du-
tion could be significantly more effective than drug ther- ration (71 and 59%, respectively).
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6 Complement Med Res Tara et al.

DOI: 10.1159/000505637
Göteborgs Universitet
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Table 4. Regression analysis of the relationship between job, weight, age, and body mass index with nausea, vomiting, and retching of
pregnant patients

Variables Job Weight Age Body mass index

Beta p value Beta p value Beta p value Beta p value

Retching severity –0.076 0.490 –0.252 0.247 0.041 0.718 0.151 0.481
Vomiting severity –0.118 0.278 –0.252 0.342 –0.030 0.787 0.041 0.849
Nausea severity –0.213 0.034* –0.012 0.954 0.130 0.249 0.006 0.978
Vomiting times –0.252 0.019* 0.412 0.173 0.011 0.309 –0.020 0.925
Retching times –0.036 0.744 –0.242 0.265 0.006 0.959 0.320 0.138
Nausea times 0.203 0.062 –0.170 0.427 –0.107 0.337 0.023 0.912
Nausea duration –1.750 0.084 0.212 0.321 0.118 0.291 –0.296 0.163
Vomiting volume 0.151 0.169 –0.056 0.794 –0.005 0.965 0.140 0.512

* Significant.

However, the difference between the findings of our
study and those of other studies could be attributed to the
difference in the studied age groups, duration of interven-
tion, tools used to measure the volume and severity of
nausea and vomiting, as well as type of drug therapy. Ac-
cording to Werntoft and Dykes [27], the duration of in-
tervention required to exert pressure could be an impor-
tant factor. They report that if the band is used each day
for 24 h compared to the short-term effects of placebo, the
improvement will be enhanced. Moreover, Heazell et al.
[25] found that the use of acupressure bands for 8 h per
day results in a significant improvement in the amount of
intravenous fluid used or hospitalization length. Al-
though we agree on this issue that the use of the band is
less invasive, the need to use the band for a long time
causes the patients to reduce compliance and decline the
precision of applying pressure, especially at night. Thus,
it is assumed that the use of acupressure band for only 12
h a day can lead to desired results and also, assures prop-
er application, noncompliance reduction, and better sat-
isfaction rates [11].
Another point to be noted is that the therapeutic inter-
ventions in complementary medicine, apart from the
therapeutic efficacy issues, require to be culturally accept-
ed in order to be effective; therefore, the findings of this
study, as the first study of its type in Iran, might be of ut-
most importance. Our findings could be considered as
valuable since they are adding to the number of studies
agreeing with the effectiveness of acupressure treatment
in controlling pregnancy-related nausea and vomiting.
However, it should be noted that we cannot claim the ef-
ficacy of PC6 acupoint pressure in the treatment of hy-
peremesis gravidarum, although it can be a complemen-
tary therapy with standard supportive therapy. In a simi-
lar vein, the majority of health system personnel are
skeptical about the benefits of PC6 acupoint pressure, al-
though it received the US Food and Drug Administration
license as a complementary treatment [11]. In addition to
the existing confirmations, the findings of the performed
clinical trials, along with our findings, confirm the lack of
serious complications in this treatment [11, 21].
Limitations
The lack of cooperation of some of the patients in re-
turning the questionnaire to the research team was one of
the limitations of this study. Moreover, the amount of
pressure might differ from patient to patient, as it was
done by the patients themselves. It was another limitation
of the study, which was due to the unavailability of the
standard wrist band. In addition, the duration of the
study might have been very short. We only studied single-
ton pregnancies with low risk and thus, the results may
not be applicable to high-risk or multifetal pregnancies.
A future study that examines multifetal pregnancies with
high risk can be beneficial. Also, more accurate studies
could be conducted if pressure is applied using standard
wristbands or by a doctor.
Conclusions
Based on the study findings, it seems that PC6 acu-
point pressure can reduce the severity of nausea, vomit-
ing, and retching. Therefore, due to few adverse events,
low costs, and easy application compared to other thera-
pies, it could be used as an appropriate therapeutic option
in relieving the symptoms of pregnant women.
Acknowledgments and Funding
This article is derived from the findings of the thesis for MD
degree (code 6385) at the Faculty of Medicine, Mashhad Univer-
sity of Medical Sciences (MUMS). This study was funded by the
Research Deputy of MUMS under a research proposal approved
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Acupressure for Nausea in Pregnancy Complement Med Res 7

DOI: 10.1159/000505637
Göteborgs Universitet
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with the grant number 86722 and authorized by the Ethics Com-
mittee of MUMS (Ethics Code: IR.MUMS.REC.1388.100). The
protocol was registered in the Iranian Registry of Clinical Trials
with the code No. IRCT201512187265N6.
We would like to thank the personnel and midwives of Dane-
shamooz and Villashahr Health Centers as well as the Ommol-
banin Hospital, especially Mrs. Farzaneh Hashemi Bakharzi and
Mrs. Nadereh Keshmiri, and also all the patients who participated
in this trial for their sincere cooperation.
University of Medical Sciences under the code IR.MUMS.
REC.1388.100. Also, this clinical trial was registered at the Iranian
Registry of Clinical Trials (IRCT) with the code
IRCT201512187265N6.
Disclosure Statement
The authors declare that they have no conflict of interest.

Statement of Ethics
Written informed consent was received from all the patients.
The patients had the right to withdraw from the study and a phone
number was given to them as a 24-h support service in case of any
urgent inquiries. According to the provisions of the Helsinki Dec-
laration, the project executives were required to preserve the con-
fidentiality of the patients and conduct the research without men-
tioning their names. The questionnaires were kept confidential
and the names and characteristics of the patients were disclosed.
This research was approved by the Ethics Committee of Mashhad
Author Contributions
Fatemeh Tara, Hoda Azizi, Ziba Zand-Kargar, and Hamidreza
Bahrami-Taghanaki contributed substantially to the conception
and design of the study. Masoud Amini Ghalandarabad and Hami-
deh Azizi contributed to the acquisition of data. Habibollah Es-
maily and Masoud Amini Ghalandarabad contributed to the anal-
ysis and interpretation. Hoda Azizi drafted the article. Fatemeh
Tara provided critical revision of the article. Hoda Azizi provided
final approval of the version to publish.

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