Acupressure for hyperemesis gravidarum

Letters

Volume 176, Number 6 AmJObstetG~ecol

III or IV pelvic organ prolapse treated successfully with their modification of the Gittes' needle suspension and laparoscopic r o u n d ligament uterine ventrosuspension. None of us has had any experience with the two procedures recommended by the authors as the only surgical treatment for advanced stages of prolapse. However, our experience is that in such cases multiple defects in support (including almost universal defects in the posterior cul-de-sac) must be addressed for successful and durable repair. We have b e e n disappointed in the objectively documented long-term cure rates, for both genuine stress incontinence and anterior segment prolapse, when needle procedures are used. As noted in the Comment section in our original paper, we are not alone with respect to our concerns regarding the long-term durability of these procedures. We know of nothing in the surgical literature that supports the effectiveness of a ventral suspension of the uterus with the r o u n d ligaments as the sole treatment for stage III or IV uterine prolapse. The inherent weakness of the r o u n d ligaments, which are primarily smooth muscle, does not make us optimistic regarding the long-term outcome of such a suspension. In general, we discourage ventral suspensions of the pelvic organs because they predispose both to the development of new enteroceles and the accentuation of existing enteroceles. We encourage the authors to submit their series, when it is of sufficient size and includes 2 to 3 years of objective follow-up, for publication and peer review, This report should thoroughly characterize the patients they treat with this c o m b i n a t i o n of procedures and use standard measures to objectively d o c u m e n t their cure rates for i n c o n t i n e n c e and stage III or IV pelvic organ prolapse. Richard C. Bump, MD, and W. Allen Addison, MD Department of Obstetrics and Gynecology, Duke University Medical Center, Boa 3609, Baker House, Room 203, Durham, NC 27710 W. Glenn Hurt, MD Medical College of Virginia, Department of Obstetrics and Gynecology, 40I N. 12th St., Room 8-206, Richmond, VA 23298 6/8/81761

Acupressure for hyperemesis gravidarum To theEd~tors: Vickers 1 recently analyzed the results of 33 controlled trials on the efficacy of P6 acupressure for antiemesis. Twelve of the trials are high-quality, randomized placebo-controlled studies. He concluded that "except when administered u n d e r anesthesia, P6 acupuncture point stimulation seems to be an effective antiemetic technique." It is therefore surprising to read in the recent article of O'Brien et al. in this Journal (O'Brien B, Relyea MJ, Taerum T. Efficacy of P6 acupressure in the treatment of nausea and vomiting during pregnancy. AmJ Obstet Gynecol 1996;174:708-15) that there was no apparent medical benefit from the use of P6 acupressure. On closer look it is apparent that O'Brien et al. have

1395

cun

1

a

1 cun

b Fig. 1. a and b, Definition of 1 "cun."

applied the acupressure on a poorly defined point, which may explain their ineffective result. O'Brien et al. define the P6 acupuncture point (point No. 6 of the pericard meridian) as being at "three fingerwidths up from the wrist crease between the flexor tendons on the medial aspect of both arms." Because tile width of three fingers (presumably the index, middle, and ring fingers) varies according to the site of measurement, three fingerwidths may measure <2 "cun" (pronounced "dju:n") at the tip of the index and ring fingers, or >2.5 "cun" at the base of the fingers. Thus the patients may not apply acupressure on the same point. As described in the most authoritative textbooks of acupuncture, 2-4 the P6 point is located 2 "cun" proximal from the wrist crease and P5 3 "cun" from the wTist crease between the tendons of m. palmaris longus and m. flexor radialis. Although stimulation of P6 and, to a lesser degree, P5 may" exert antiemetic effect, stimulation of a point in between would not yield the expected result. "Cun" is a relative or an individualized measurement used in traditional Chinese medicine to locate the acupuncture points. The exact,length of one "cun" is different for each individual. One " c u n ' for a particular patient is defined as the width of the interphalangeal j o i n t of the patient's thumb (Fig. 1, a) or aS the distance between the two radial ends of the flexor creases of a flexed middle finger of the patient (Fig. 1, b). Four fingers (index, middle, ring, and little fingers) at the level of the dorsal skin crease of the proximal interphalangeal j o i n t of the middle finger measure 3 "cun." A "cunometer," which has the function of calipers and the mechanism of scissors (Fig. 2), allows the precise measurement of 0.25 to 4 "cun." In a patient with arachnodactyly, brachydactyly, or other congenital finger anomalies, other criteria of "cun" measurement needs to be

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Letters

June 1997 Am J Obstet G y n e c o l

O. 5 cun

2 cun l

l

i l.5

cun

~......4 tun

Fig' 2. Sketch of cunometer, which was originally developed in Ceylon (Sri Lanka).

applied, such as d e t e r m i n i n g the 2 "cun" distance f r o m the generally a c c e p t e d division of the whole f o r e a r m into 12 "cun." W h e n inserting a needle, an acupuncturist would usually ask the patient about the feeling o f light pain, numbness, or tingling to ensure the correct p l a c e m e n t of the needle. Likewise, w h e n acupressure is p e r f o r m e d , it is r e c o m m e n d e d that the patient be asked a b o u t those sensations to ensure the accurate location of the acup o i n t where the pressure is b e i n g applied. Aside f r o m the P6 point, traditional chinese m e d i c i n e recognizes several o t h e r primary points for antiemesis, such as Ren12 (point No. 12 of the R e n / c o n c e p t i 0 n a l meridian) o n the u p p e r a b d o m e n , $36 (point No. 36 of the stomach meridian) on the knee, and Sp4 (point No. 4 of the spleen meridian) on the foot. Application o f multiple acupoints may be m o r e effective for the treatm e n t of nausea. At this early stage o f scientific validation o f an a n c i e n t t r e a t m e n t m e t h o d , it is r e c o m m e n d e d that e a c h i n s t i t u t i o n t h a t c o n t e m p l a t e s a p p l y i n g this techn i q u e s h o u l d u n d e r g o its own r a n d o m i z e d c o n t r o l l e d trial to b e c o m e absolutely c o n v i n c e d a b o u t its effectiveness. A c u p r e s s u r e for n a u s e a is a n o t h e r alternative o r c o m p l e m e n t a r y t r e a t m e n t m e t h o d , that c o u l d benefit o u r patients. Joe J. Hoo, MD Division of Genetics, Department of Pediatrics, State University of New York Health Science Center, 750E. Adams St., Syracuse, NY 13210

REFERENCES 1. Vickers AJ. Can acupuncture have specific effects on health? A systematic review of acupuncture antiernesis trials. J R Soc Med 1996;89:303-11. 2. Cheng X, editor. Chinese acupuncture and moxibustion. Beijing: Foreign Languages Press; 1993. 3. Stux G, Stiller N, Pomeranz B. Akupunktur--Lehrbuch und Atlas. 4th ed. Berlin: Springer-Verlag; 1993. 4. The location of acupoints--state standard of the People's Republic of China. Malaysia; Delta Publishing; 1995.

6/8/81846

Reply To the Editors: We do n o t agree that participants in our study applied wrist bands to a p o i n t that was poorly defined. We u n d e r s t a n d that the exact length of 1 cun will vary a m o n g individuals of different stature. As reco m m e n d e d by the manufacturers of Sea Band, we instructed participants to locate the acupressure p o i n t with their three middle fingers. In all in w h o m we m a d e the comparison, this a p p r o x i m a t e d the width of the interphalangeal joints of b o t h thumbs, so all participants applied acupressure to the same point. Measuring with three fingers was likely m o r e accurate, given the awkwardness of obtaining the exact m e a s u r e m e n t with use o f the interphalangeal j o i n t with each application of the intervention. We also provided a r e p e a t d e m o n s t r a t i o n and a diagram of the technique. We investigated a commercially available p r o d u c t that can be acquired without consultation. We c a n n o t comm e n t of the efficacy of b e i n g treated by a highly skilled acupuncturist. H o o suggests that our findings were inconsistent with 12 high-quality, r a n d o m i z e d , placebocontrolled studies. T h r e e of the 12 articles described by Vickers were c o n c e r n e d with " m o r n i n g sickness." O f these, D u n d e e et al.1 r e p o r t e d that o n e cun is approximately the width across the interphalangeal j o i n t of the thumb. Participants carried a diagram o f the pressure p o i n t and applied pressure for 5 minutes every 4 hours. G r o u p assignment was n o t r a n d o m in that "'to balance the series the allocation of patients to particular treatm e n t groups was adjusted accordingly" after periodic e x a m i n a t i o n of the series (p. 440). Belluomini et al. 2 describe the P6 p o i n t as 2 inches proximal to the wrist crease. Participants were taught how to locate and apply acupressure to the "assigned point." It is n o t clear w h e t h e r commercially available wrist bands were used or w h e t h e r the p o i n t was d e t e r m i n e d by m e a s u r i n g 2 inches f r o m the wrist crease. T h e authors r e p o r t that the severity of nausea was less in the t r e a t m e n t group, but there was no difference between groups in the a m o u n t o f vomiting or retching. Authors of the third study used a c o m m e r cially available p r o d u c t (Sea Bands) but did n o t r e p o r t instructions given to participants. 3 O u r primary c o n c e r n is to p r o m o t e comfort and