regnancy is often accompanied by many so- P matic complaints, most tolerable as short-lived nuisances. Some women (the actual percent is un- documented in the available literature) have pro- longed symptoms associated with pregnancy, such as

M A U R E E N C. V A N D I N T E R , R N , M S , F N P , c P N P persistent nausea, vomiting, or excessive salivation. Ptyalism is of unknown origin and is characterized pri- marily by its abrupt onset and its presentation of ex- cessive, unalterable salivation (in excess of 1,900 ml/ day) .l The author’s exposure to several patients with this affliction and the lack of documentation concern-

P R I N C I P L E S & P R A C T I C E

Rydism in Pregrtant Womm

Ptyalism affects few pregnant women. Those who suffer from it, however,

Jind it to be a little-known, but major irritant. This article presents several possible etiologies and discusses some vexatious cases of ptyalism. Nursing interventions are also offered. More nursing research must be conducted so that nurses can better understand this problem.

Accepted: August 1990

ing the condition led her to investigate the phenome- non more carefully.

Ptyalism (also known as sialorrhea) is usually de- fined as “an excessive secretion of saliva, common in women with nausea who might have difficulty in swal- lowing their saliva.’12 It usually begins at two to three weeks of gestation and ceases after delivery. In many instances, the increased salivation does not abate at the end of the first trimester but continues, or even increases in amount, until the day of delivery.

Although a slight increase in salivation commonly occurs with the onset of pregnancy, it is of question- able value as a diagnostic clue. With ptyalism, drool- ing is not normally evident, although patients com- plain of oral secretions that are thin and watery and leave an unpleasant, bitter taste in the mouth.3 Ptya- lism may diminish during sleep; however, many women complain of the excessive secretions as being one cause of nocturnal wakening.

Often, women with this condition typically pre- sent facies with distended cheek They also suffer from excessive expectoration and must wipe their mouths frequently when they are talking. Many women complain of speech difficulties because of swollen salivary glands and a tongue that is typically enlarged, red, and coated. Careful medical evaluation has been unable to diagnose either an infectious agent or an anatomic blockage as the cause. One researcher has suggested that the stimulation of the salivary glands by starch (possibly pica) may be an initiating factor, but this has not been p r ~ v e d . ~

In some women, familial incidences of ptyalism have been documented, with similar symptoms occur- ring in all women of a given lineage.’ Many of these women will have identical symptoms during succeed- ing pregnancies, with the salivary flow increasing in volume each time, although returning to apparently normal levels postpartum.

Salivation is a normal human process that occurs without conscious thought. The rate of saliva produc- tion has been noted to fluctuate over time but is not known to be a consistent indicator of physiologic changes. Because of variations in the rate of salivary

206 J O C N N Vohme 20 Number 3

Ptyalism in Pregnant Women

Ptyallsm is a little-known and poorly documented pregnancy problem with few successful therapeutic strategies.

secretion, clinicians have difficulty estimating the “average” flow rate and determining excessive or di- minished flow. Becks and Wainwright estimated that the average salivary flow for nonpregnant individuals between 15 and 45 years of age is 22 k 2.2 ml/hour.6 In most normal pregnant women, the actual amount of saliva produced during pregnancy does not change.6 Some researchers believe that ptyalism occurs be- cause of the inability of nauseated gravid women to swallow normal amounts of saliva rather than from a true increase in the production of ~ a l i v a . ~

In one study, the researchers documented that sal- ivary electrolytes decreased in sodium and increased in potassium concentration during pregnancy and rap- idly returned to normal during the first postpartum week.’ N o significant alterations in the blood chemis- try were observed during that same time period. The reliability of these data is hampered somewhat be- cause the women studied were in varying stages of pregnancy. The potential common denominators of food type, activity, gestational age, chronologic age, race, and eating behaviors (which may have correlated with uncustomary salivary changes) were missing. Therefore, insufficient longitudinal data exist to clearly document consistent salivary changes through- out pregnancy, both in terms of water content and sol- ute load.

Literature about ptyalism is sparse, outdated, and often conflicting, and current documented research has been limited.2,3,5 Bernstine and Friedman noted that women experienced an increase in salivation dur- ing the latter stages of pregnancy and a concomitant increase in salivary sedimentation.* Kullander and Sonesson refuted that observation by noting that a de- crease in salivary secretion occurred in women during the latter stages of pregnancy.’ They also found that a greater frequency of dental caries occurred with ad- vancing pregnancy, but they were unable to correlate this finding with their results on salivary secretion. Their subjects also had increased gingival disease, al- though this was not correlated with the salivary changes either.

Because researchers do not know the true etiol- ogy of ptyalism and because limited physical or bio- chemical changes are associated with the condition, women with the disorder are often incorrectly diag- nosed as psychoneurotic.2 Generally, this diagnosis has been based on the apparent anxiety and distress

that women with ptyalism exhibit when they are un- able to tolerate the continued excessive salivation. Limited evidence exists regarding significant changes in salivary flow when social supports are increased or when attempts have been made to modify psychoso- cia1 stressors.

Researchers have not documented the occurrence of dehydration with excessive salivation. Also, re- searchers have not found a higher incidence than usual of hyperemesis gravidarum in patients with ptyalism, although the condition is correlated with the onset of n a u ~ e a . ~

There are no identified physiologic bases for ptyalism.

The development of pharmacologic agents for re- lief of symptoms has met with little success. Gan- glion-blocking drugs such as hexamethonium, anti- cholinergic drugs such as atropine or belladonna, and oxyphenonium bromide have all been considered.6 Three decades ago, reports suggested the use of phe- nobarbital (7.5 mg every six hours) to control the ner- vousness that accompanies the excessive salivation.’

Ptyalism during pregnancy has been associated with one case of hydatidiform mole*; however, re- searchers have not confirmed a causal relationship. This case is the only purported anomaly related to ptyalism.

Most women with the affliction complain of fa- tigue due to the copious amounts of fluid produced and the decline in appetite and food intake. Often the women appear depressed and tired and are usually seen carrying boxes of tissues. Many have tried throat lozenges, lemon drops, frequent drinks of water or other unflavored fluids, and cool solids in an attempt to dispel the bitter taste in the mouth and the exces- sive fluid production. Their attempts usually do not meet with success. Interestingly, most women do not experience an increase in urine production, despite their increased fluid intake.

Reports of ptyalism in males are limited. Of those reviewed, one report cited hypnotherapy as successful in providing some, but not complete, relief? N o docu- mentation exists regarding similar therapeutic at- tempts with gestational women.

Despite anecdotal reports of ptyalism in pregnant

Many women with ptyalism appear anxious and fatigued.

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P R I N C I P L E S A N D P R A C T I C E

women, health-care providers have rarely docu- mented information concerning the causes of or treat- ments for this condition. The following case studies present women who typify the problem of ptyalism during pregnancy.

Case studies

Case I Z.C., a single, unemployed, 23-year-old woman, lived with her three-year-old daughter. Z.C. began to have severe nausea and excessive salivation at two weeks postconception. These symptoms continued unabated during her entire pregnancy and only ceased after she delivered a healthy 8-pound, 7-ounce male at 40 weeks’ gestation. Z.C. complained of frequent spitting and vomiting of such intensity that it interfered with her sleep. She had eaten many small high-carbohy- drate meals without getting significant relief. Her coated tongue felt uncomfortable, and she was unable to moisten it sufficiently to relieve the “spitting cot- ton” taste in her mouth. She reported that both her mother and her sister had similar symptoms during their pregnancies. Z.C. was ambivalent about her pregnancy, primarily because it interrupted her return to school and her opportunity to escape the welfare system. She did not have an ongoing relationship with the infant’s father; in fact, he left town when informed of the pregnancy. Z.C. was hospitalized twice and was rehydrated numerous times in the clinic for hypere- mesis gravidarum.

Case 2 T.C., a married, 28-year-old financial counselor, suf- fered from excessive salivation during her first preg- nancy. She continued to smoke one pack of cigarettes per day in an attempt to control the excessive saliva- tion. She also sucked constantly on sugar candies, thinking that they would help her swallow the saliva easier. However, this did not prove successful, and she continued to use numerous boxes of tissues daily. She continued to work full time and became extremely fatigued during the latter stages of pregnancy because the excessive salivation interfered with her sleep. The ptyalism ceased after she delivered a healthy 7-pound, 10-ounce female at 40 weeks’ gestation.

Case 3 C.D., a single, 27-year-old secretary, was pregnant with her first child. The fetus’s father severed all ties with her after she informed him of the pregnancy. She was mortified by her excessive salivation because it limited her ability to communicate effectively with clients on the telephone and in person. She tried

chewing gum constantly in an attempt to control the excessive salivation but did not find it useful. She did not report similar problems in her female relatives. Her ptyalism continued until she delivered a healthy 6-pound, 10-ounce female at 39 weeks’ gestation.

Discussion

Each of the women in the case studies made impres- sive attempts to control her ptyalism through dietary control-increased carbohydrates, decreased fluids, limited fats-without success. Efforts were made to use a variety of oral agents to enhance swallowing of saliva, bur the use of gum, lozenges, or fruit did not help to decrease the amount of saliva produced. Z.C. used EmetroP in an effort to decrease her nausea and vomiting, also hoping that it would control her ptya- lism. However, the Emetrol did not provide relief.

The medical literature has recommended the use of ganglion-blocking agents, anticholinergics, or oxy- phenonium bromide for relief of ptyalism. However, local pharmacologic and obstetric consultants were uncomfortable approving the use of any medications during pregnancy, so these were not used.

Nursing Implications

The obstetric nurse must always be sympathetic to the pregnant patient’s common physical complaints, and increased empathy must be provided to women with ptyalism. Oral discomfort is common in these women because of the increased salivation, dry tongue, swol- len salivary glands, irritated perioral skin, and speech difficulties. Although complete symptom relief is not possible, symptomatic care modalities must be at- tempted. Some women have limited success in de- creasing salivation with small, balanced, frequent meals, gum chewing, or the use of oral lozenges. The health-care practitioner should suggest to the patient that she use nonirritating facial tissues to wipe her mouth. This will help decrease the chafing of the perioral skin.

Nurses must be alert to signs of increased oral discomfort and symptoms of ptyalism in pregnant patients.

The health-care practitioner should closely moni- tor the hydration status of the gravid woman with ptya- lism. A statistical correlation does not exist between ptyalism and hyperemesis; however, the combination is a possibility because of the fluid changes and persis-

208 0 6 N N Volume 20 Number 3

Ptya1h-m in Pregnant Women

Nurses can identijy symptoms of ptyalism and offer suitable management strategies.

tent nausea experienced by women with ptyalism. The health-care practitioner should monitor the pa- tient’s hydration and nutrient status regularly, as well as attend to the patient’s psychosocial needs.

Patients with ptyalism have reported that the con- dition is embarrassing and interferes with normal daily activities. Health-care practitioners who work with these patients must use a wide range of problem- solving strategies to find acceptable and workable management methods. When recommending behav- ior-modification techniques to the patient, the health- care practitioner must be careful not to infer that ptya- lism has a psychosomatic etiology.

More research must be conducted to explore fur- ther the etiology of ptyalism and develop more accept- able solutions. Because of the inherent dangers of us- ing pharmacologic intervention in early pregnancy and the likelihood that many teratogens remain un- identified, many health-care providers hesitate to use medications that may decrease salivation. Ptyalism has not been defined as an ethnically or racially related problem; however, more research could help to de- fine trends and problems. Even more crucial is the need for health-care practitioners to recognize the condition as it exists and to provide assistance and psychosocial support to women who suffer from the disorder.

Because limited information is available about ptyalism, increased observation and assessment must be conducted. Scientific research is necessary to in- vestigate the physiologic bases for the condition. In- creased discussion in published literature may indi- cate a higher prevalence of this problem than initially e~ t ima ted .~ .~ .~ Nurses who provide care to pregnant women should evaluate and document cases of ptya- lism and share their knowledge with fellow health- care professionals.

Summary

Ptyalism is a serious condition for women who must contend with its symptoms. The problems associated with ptyalism have made the most desired of pregnan- cies difficult, and for those women ambivalent about

their pregnancies, ptyalism often provides seemingly insurmountable barriers. Nurses who work with preg- nant women suffering from ptyalism must be sensitive to the women’s physiologic discomforts and attend to relief of symptoms immediately. Although complete relief is not possible, by helping the women find re- lief, nurses can increase the women’s comfort levels substantially. In caring for gravid women, nurses strive to assist the women in accepting their pregnancies, in becoming comfortable with the physiologic changes expected, and in developing bonds with their fetuses. By ameliorating the discomforts of ptyalism, nurses work toward meeting these goals.

References

1. Kullander, S., and B. Sonesson. 1965. Studies on saliva in menstruating, pregnant and post-menopausal women. Acta Endocrinol (Copenh). 48(2):329-36.

2. Gleicher, N. 1985. Principles of Medical Therapy in Pregnancy. New York: Plenum.

3. Pritchard, J., and P. MacDonald. 1985. William’s Obstet- rics. 16th ed. East Norwalk, Connecticut: Appleton- Century-Crofts, 263.

4. Bernstine, R.L., and M.H.F. Friedman. 1957. Salivation in pregnant and nonpregnant women. Obstet Gynecol.

5. Cruikshank, D., and P.M. Hayes. 1986. Maternal physiol- ogy in pregnancy. In Obstetrics: Normal and Problem Pregnancies. S . Gabbe, J.R. Niebyl, and J.L. Simpson, eds. New York: Churchill Livingstone.

6. Becks, H., and W.W. Wainwright. 1943. Human saliva: Rate of flow of resting saliva of healthy individuals. J Dent Res. 22(2):391-96.

7. Ptyalism during pregnancy. Letter to the editor. 1955. JAMA. 157(August): 1457.

8. Hartfield, V.J. 1983. Ptyalism and partial hydatidiform mole associated with a normal term male fetus. AustNZ J Obstet CynaecoZ. 23(1):53-56.

9. Schenck, J.M. 1977. Hypnotherapy for ptyalism. Znt J CZia Exp Hypn. 25(1):1-6.

10 (1) : 184-89.

Address for correspondence: Maureen C . Van Dinter, RN, MS, FNP, CPNP, University of Wisconsin, Department of Family Medicine and Practice, 777 S. Mills St., Madison, WI 53715.

Maureen C. Van Dlnter is a senior clinfcal nwse specialist in tbe Department of Family Medicine andPracttce at the Uniuerstty of Wtsconsin, Madtson, Wisconsin. Ms. Van Dinter is a member of tbe National Association of Pediatric Nurse Associates and Practtttoners and tbe Soclety of Teacbers of Farntly Medictne.

Mav/uune 1991 J O G N N 209