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Ptyalism in Pregnancy–A review of epidemiology and practices

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DOI: 10.1016/j.ejogrb.2015.12.022

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 European Journal of Obstetrics & Gynecology and Reproductive Biology 198 (2016) 47–49

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review

Ptyalism in pregnancy – a review of epidemiology and practices

Karen A. Thaxter Nesbeth a,*, Leslie A. Samuels b, Carla Nicholson Daley b,
Maxine Gossell-Williams c, Damian A. Nesbeth d
a
University of the West Indies School of Nursing, Mona, Kingston, Jamaica
b
Department of Obstetrics and Gynaecology, University of the West Indies, Mona, Kingston, Jamaica
c
Department of Pharmacology, University of the West Indies, Mona, Kingston, Jamaica
d
School of Natural and Applied Sciences, University of Technology, Jamaica

A R T I C L E I N F O A B S T R A C T

Article history: Ptyalism gravidarum is an oral pathological condition specific to gravidity. We present a review of the
Received 3 November 2015 literature regarding epidemiology internationally, and then highlight therapies reported by patients and
Accepted 21 December 2015 caregivers. This often distressing repeated filling of the mouth with watery saliva in a pregnant patient
was previously exclusively associated with hyperemesis gravidarum, and the consequent maternal-fetal
Keywords: risk. Our dissertation includes reference to a rare case of isolated sialorrhoea of pregnancy, without
Ptyalism gravidarum nausea or emesis. Both pharmacological and homoeopathic therapies are discussed, and inherent risks to
Pregnancy
mother and infant are highlighted. It is strongly recommended that this condition be given attention in
Salivation
Sialorrhoea
antenatal care settings, to optimize short, middle and long term pregnancy outcomes.
ß 2016 Elsevier Ireland Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
The case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Pharmacology, homoeopathy, opportunities and caveats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Competing interests. . . . . . . . . . . . . . . . . . . . . . . . . ........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . ........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Introduction
Although the gravid state is physiological, there are multiple
associated pathologies. Ptyalism gravidarum (also referred to as
sialorrhoea of pregnancy), or excessive salivation in pregnancy, is
regarded as an oral pathological condition specific to gravidity.
Women who experience this phenomenon complain of the
abrupt onset, usually in the 2nd or 3rd week following conception,
of excessive, unalterable salivation [1]. The volumes range from 1.5
to 2 L per day [2]. All studies to date agree that it ceases at delivery.
* Corresponding author. Tel.: +1 876 970 3304.
E-mail addresses: karen.thaxter@uwimona.edu.jm (K.A. Thaxter Nesbeth),
obgynja@gmail.com (L.A. Samuels), carlanik@yahoo.com (C. Nicholson Daley),
Maxine.gossell@uwimona.edu.jm (M. Gossell-Williams), dnesbeth@gmail.com
(D.A. Nesbeth).
This aligns with the proposal that b-hCG and oestrogen may be the
hormones implicated in the pathogenesis of ptyalism [3].
There is a spectrum of symptoms associated with sialorrhoea of
pregnancy. Distended cheek pouches, speech difficulties because
of unabating salivary flow, swollen salivary glands and a red,
enlarged, coated tongue are among the more marked symptoms
reported. The excessive oral secretions may be a cause of
diminished sleep. Fatigue, decreased appetite and reduced food
intake are also commonly reported by women suffering from
ptyalism. They appear depressed, and tired, and are seen carrying
around boxes of tissues, cups, or bags to facilitate expectoration
[1].
Whereas the majority of patients report that ptyalism resolved
during the second trimester, there is a report of 22 women carrying
singleton pregnancies whose ptyalism continued until delivery
[4]. Those authors found, via regression analysis, that ptyalism is

http://dx.doi.org/10.1016/j.ejogrb.2015.12.022
0301-2115/ß 2016 Elsevier Ireland Ltd. All rights reserved.
48 K.A. Thaxter Nesbeth et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 198 (2016) 47–49
strongly associated not only with hyperemesis gravidarum, but
also with neonatal male sex, and delivery of small for gestational
age (SGA) infants. They proposed that it was the concomitant
hyperemesis gravidarum that created the risk of SGA fetuses, and
not the ptyalism itself. No difference was found between
populations with, or without ptyalism in maternal age, height,
pre-pregnancy weight, gestational weight gain or gestational age
at delivery.
There have been varied reports of incidence of ptyalism
gravidarum, depending on location. An incidence of 0.08% was
reported from a clinic in the USA. Interestingly, 100% of patients
who reported this disorder were Haitian females [2]. A Japanese
study reported a prevalence of 0.3% of pregnant patients with
ptyalism among 7743 women seeking antenatal care [4]. As many
as 35% of women presenting for antenatal care in a clinic in Turkey
complained of excessive salivation in the first trimester [5]. Among
the subset of women presenting with nausea and vomiting to a
hospital clinic in Quebec, Canada, 26% complained of sialorrhea at
their first prenatal encounter [6]. It has previously only been
reported by women who also complain of nausea and vomiting in
pregnancy. There may be a possible familial association, and a
trend of ptyalism in successive pregnancies [1].
The case
We present a 28-year-old G1 P0 patient from Kingston, Jamaica,
from whom informed consent was obtained prior to publication.
Her gynaecological history included a previous diagnosis of
symptomatic uterine fibroids and irregular menses. She had
undergone a myomectomy a year prior to the index pregnancy. She
initially presented to her gynaecologist complaining of easy
fatigability, and at that encounter she was found to have a positive
urine b-hCG test. An ultrasound done at that time revealed a single,
live intrauterine pregnancy corresponding to a gestational age of 5
weeks and 3 days.
The patient presented to the University Hospital of the West
Indies for antenatal care, starting at 13 weeks gestation. Her initial
investigations showed that her HIV and VDRL serology was
negative and unreactive, respectively; that her haemoglobin
electrophoresis was A + A2, and that her blood group was A,
Rhesus positive. Her only complaints throughout her entire
antenatal course were excessive salivation from early pregnancy,
and then symptoms of gastroesophageal reflux disease (GERD)
later on in the gestation.
At her initial visit, she complained of persistent, markedly
increased amounts of thin, watery saliva that filled her mouth
throughout the entire day, and which was associated with drooling
onto her pillow at night. She did not note bitterness or any
unpleasant odour associated with the saliva, and did not suffer
excoriations of the lips or skin. She expectorated into a cloth, tissue
or the trash can at work. She was mildly bothered by the constant
re-filling of her mouth during the day – her biggest concern being a
negative social impact of the constant expectorating, and saliva
interrupting speech. She sometimes opted to swallow, but
preferred spitting as the latter ‘felt better’ but she reported no
nausea with swallowing. Her sialorrhoea lasted from about 10
weeks to about 20 weeks gestation, at which time it resolved
spontaneously. She did not try any specific manoeuvre to resolve
the excessive salivation, but noted a remarkable thirst throughout.
In response she drank copious quantities of water. No nausea or
vomiting was reported before, during or after the onset and
abatement of ptyalism.
She continued to receive regular antenatal care, and had normal
blood pressures and weight gain throughout, with her only
medication being a prenatal multivitamin supplement. After the
resolution of ptyalism, however, symptoms of epigastric burning
and pain began, associated with frequent belching and abdominal
bloatedness; this continued until after she was delivered.
She gave birth to a healthy male infant at term, with a birth
weight of 3.96 kg, and APGAR scores of 9 and 9, at one and five
minutes, respectively. Delivery was via caesarian section, conse-
quent to her history of a prior myomectomy. The infant remained
well, and had normal growth and developmental parameters
throughout the follow-up period.
Discussion
Ptyalism gravidarum was previously regarded as a condition
exclusively found in patients complaining of nausea and vomiting
in pregnancy. Our patient, however, unequivocally denied nausea
or vomiting prior to, during, or after resolution of ptyalism during
her term pregnancy.
Ptyalism gravidarum was addressed in a dissertation on
pregnancy-related eating disorders [7]. The author reported
associations of ptyalism with impaired swallowing function,
altered sense of taste, and disturbances of sleep and speech. He
presented the rare, anecdotal association of increased ptyalism
after dairy consumption. We support his recommendation that
screening for pathology related to eating disorders, including
ptyalism gravidarum, be a part of routine antenatal care. The
screen may include questions about nausea, food intake, and
coping strategies to identify risk – e.g. pica, and/or the use of herbal
preparations. He further proposed that any patient identified with
any component of an eating disorder in pregnancy should have
close attention to hydration state and electrolyte balance during
each antenatal encounter.
The most clinically significant condition associated with
sialorrhoea of pregnancy is hyperemesis gravidarum. Such patients
have the risk of weight loss from vomiting, worsened by
swallowing the bitter, copious saliva. In addition, excoriation of
the buccal mucosa and maceration of the skin of the neck and chin
have been cited as adverse effects of ptyalism in medical patients
with neurological disease. Few authors have reported this extreme
effect in gravid patients, the latter being more at risk when the
ptyalism is accompanied by vomiting [2].
Pharmacology, homoeopathy, opportunities and caveats
In Turkey, excessive salivation was among the top 5 pregnancy-
associated discomforts recorded in one study [5]. Some of those
women chewed gum, and ate hard candy in response to symptoms.
Similar attempts by patients to dispel the bitter taste associated
with the phenomenon using throat lozenges and lemon drops have
been recorded elsewhere [1]. The consumption of numerous
sweets during the first 2 trimesters as an attempt to dispel
sialorrhoea is not, however, without risk. A 2011 study reported
that neonatal/childhood obesity risk increased based on prenatal
exposure to sweets [8]. The authors found that the strongest
predictor of higher weight-for-age Z score during infancy was
consumption of a greater percentage of calories from sweets early
in pregnancy. The latter was found to be significantly related to a
10–20% increase in odds of macrosomia and weight-for-age >90th
percentile, which may put both mother and child at risk. Higher
birth weight is a recognized risk factor for obesity [9], and the
relationship between high sweet intake, excessive maternal
weight gain and adverse obstetric outcomes is clearly established
[8,10].
On the other hand, frequent drinks of water or other
unflavoured fluids were reported as common anti-sialorrhoea
strategies [1,5]. Adequate hydration is universally associated with
improved pregnancy outcomes in otherwise healthy women.
There is also recent evidence that increased water consumption
 K.A. Thaxter Nesbeth et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 198 (2016) 47–49
among health young females improved overall mood, which is
another contributor to favourable maternal-fetal outcomes [11].
In Quebec, Canada, women who complained of ptyalism
accompanying nausea and vomiting were more likely to have
prescription antiemetic medication as part of their management
[6]. Such medication included a combination of doxylamine and
pyridoxine (Vitamin B6), and metoclopramide. These authors also
noted that non-pharmacological methods were also offered by
practitioners giving antenatal care, in keeping with the recom-
mendation by the Society of Obstetricians and Gynaecologists of
Canada for management of nausea and vomiting in pregnancy and
associated symptoms. Only 14% of participants in that study were
offered non-pharmacological interventions, however, as practi-
tioners agreed that the efficacy of most is not well established.
A belladonna alkaloid with antimuscarinic properties was
employed in a case series aimed at relieving ptyalism linked with
hyperemesis gravidarum [2]. They created a regimen of intrarectal
promethazine hydrochloride for days 1–5 (antiemetic), followed
by belladonna alkaloid for a further 5 days, for a total of 10 days of
treatment. They successfully eliminated hyperemesis and ptyalism
gravidarum in the 2 cases presented, and both pregnancies yielded
healthy infants. We propose that medical practitioners providing
antenatal care be open to treating ptyalism pharmacologically,
with safe, approved treatments, even in the absence of nausea and
vomiting.
Ptyalism gravidarum has been included among the unique ear,
nose and throat disorders associated with pregnancy [12]. Those
authors refer to the use of barbiturates (especially for anxiety
associated with the social stigma of sialorrhoea), anticholinergics,
or phosphorated carbohydrate as abatement or coping strategies.
Geophagia (pica) was reported as a popular strategy for dealing
with excess salivation associated with nausea and vomiting in
pregnancy [3]. Those authors studied geochemical properties of
soils ingested by pregnant women in Cameroon for relief of
ptyalism and nausea in pregnancy. They correlated the usefulness
of soil to reduce excess salivation to its ability to absorb moisture
during mastication. Interestingly, preferred soils went from solid,
through semi-plastic, to plastic in the mouths of patients, by
absorbing excess saliva in the oral cavity. This left the mouth dry,
and alleviated sialorrhoea and nausea in the individual. A sour
taste, imparted by an acidic pH, also reportedly increased the
usefulness of the soil for this purpose. Women pointed out that the
discomfort and perceived psycho-social stigmatization associated
with excessive salivation in public places encouraged geophagia,
and that this provided welcome relief for those women.
Unfortunately, this practice is associated with numerous health
risks, including chemical toxicity, iron deficiency anaemia,
hypokalemia, excessive tooth wear, enamel damage and erosion
of the mucosal surface of the stomach, perforation of the colon,
parasitic infections such as Ascaris lumbricoides and highly
toxigenic bacteria such as Clostridium tetani, and so should be
actively discouraged by medical practitioners.
Ptyalism gravidarum has not traditionally been given signifi-
cant attention in antenatal care as it has been considered benign. In
View publication stats
49
this discourse we have highlighted that there may be short,
medium and long term risks associated with the disorder itself, and
especially with the choices made by the woman enduring its
effects. We encourage obstetric care providers to screen for, and
address management of ptyalism gravidarum with each antenatal
opportunity.
Funding
This work did not receive specific funding for any aspect of
compilation or publication.
Competing interests
There are no competing interests or associations of any author
of this work. All authors have completed the Unified Competing
Interest form at www.icmje.org/coi_disclosure.pdf (available on
request from the corresponding author) and declare: no support
from any organization for the submitted work; no financial
relationships with any organizations that might have an interest in
the submitted work in the previous three years, no other
relationships or activities that could appear to have influenced
the submitted work.
Acknowledgments
The authors thank the University of the West Indies for
fostering a rich research environment.
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