Sympathetic nerve entrapment point injection for intractable nausea and vomiting in pregnancy: a case report

Nausea and vomiting during pregnancy (NVP) occurs in up to 80% of pregnant women worldwide. Severe intractable NVP accompanied by acute starvation may threaten the health of the mother and fetus, and greatly reduce the quality of life during pregnancy. Symptoms that cannot be controlled with pharmacotherapy are difficult to relieve in severe NVP. Dysfunction of the autonomic and enteric nervous systems is an important component of NVP pathogenesis. It is thought to be controlled by the autonomic nervous system. In the present case, a 30-year-old married female came to the emergency department complaining of severe nausea and vomiting. Her symptoms had not improved with medication, such as Diclrectin® and intravenous metoclopramide. Tenderness was detected in the multifidus area on both sides of the T7 spinal cord level. Normal saline (3 cc) was injected into the multifidus areas at both tenderness points, and her symptoms improved 30 min after the injections because intervertebral pressure and constriction of the vasa nervorum were alleviated. This approach improved the compression of sympathetic preganglionic fibers and increased blood flow to the sympathetic nerves. Nausea and vomiting symptoms improved as the imbalance in the autonomic nervous system improved and vagal tone was normalized. Sympathetic nerve entrapment point injection should be considered an alternative treatment to control severe NVP not resolved by medication.

Morning sickness; Pregnancy; Autonomic nervous system; Sympathetic fibers

[1] Mares R, Morrow A, Shumway H, Zapata I, Forstein D, Brooks B. Assessment of management approaches for hyperemesis gravidarum and nausea and vomiting of pregnancy: a retrospective questionnaire analysis. BMC Pregnancy and Childbirth. 2022; 22: 609.

[2] Hughes JD, Nayak NG, Aslam N, Rashed H, Cardoso S, Familoni B, et al. Autonomic and enteric nervous system dysfunction may play a role in hyperemesis gravidarum. Gastroenterology Research. 2015; 8: 153–156.

[3] Herrell HE. Nausea and vomiting of pregnancy. American Family Physician. 2014; 89: 965–970.

[4] Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin No. 189: nausea and vomiting of pregnancy. Obstetrics and Gynecology. 2018; 131: e15–e30.

[5] Syn NL, Chan S, Chia EWY, Ong WX, Phua D, Cai S, et al. Severity of nausea and vomiting in pregnancy and early childhood neurobehavioural outcomes: the growing up in Singapore towards healthy outcomes study. Paediatric and Perinatal Epidemiology. 2021; 35: 98–108.

[6] Nana M, Tydeman F, Bevan G, Boulding H, Kavanagh K, Dean C, et al. Hyperemesis gravidarum is associated with increased rates of termination of pregnancy and suicidal ideation: results from a survey completed by >5000 participants. American Journal of Obstetrics and Gynecology. 2021; 224: 629–631.

[7] Liu C, Zhao G, Qiao D, Wang L, He Y, Zhao M, et al. Emerging progress in nausea and vomiting of pregnancy and hyperemesis gravidarum: challenges and opportunities. Frontiers in Medicine. 2022; 10: 809270.

[8] Liu W, Jin Y, Wilde PJ, Hou Y, Wang Y, Han J. Mechanisms, physiology, and recent research progress of gastric emptying. Critical Reviews in Food Science and Nutrition. 2021; 61: 2742–2755.

[9] Browning KN, Travagli RA. Central nervous system control of gastrointestinal motility and secretion and modulation of gastrointestinal functions. Comprehensive Physiology. 2014; 4: 1339–1368.

[10] Masliukov PM, Emanuilov AI, Budnik AF. Sympathetic innervation of the development, maturity, and aging of the gastrointestinal tract. To be published in The Anatomical Record. 2022. [Preprint].

[11] Seong JW. Principle and insights into pain. 1st ed. Koonja Press: Seoul, South Korea. 2015.

[12] Kornum DS, Terkelsen AJ, Bertoli D, Klinge MW, Høyer KL, Kufaishi HHA, et al. Assessment of gastrointestinal autonomic dysfunction: present and future perspectives. Journal of Clinical Medicine. 2021; 10: 1392.

[13] Kovacic K, Li BUK. Cyclic vomiting syndrome: a narrative review and guide to management. Headache. 2021; 61: 231–243.

[14] Lee S, Oh CJ, Seong JW. Sympathetic nerve entrapment point injection as an antireflux procedure for refractory laryngopharyngeal reflux: a first case report of innovative autonomic regulation. Innovations in Clinical Neuroscience. 2016; 13: 32–36.

[15] Nah S, Kim K, Choi S, Woo S, Han S. Sympathetic nerve entrapment point injection as an adjuvant treatment for intractable cluster headache: a case report. To be published in The Journal of Emergency Medicine. 2023. [Preprint].