Ptyalism in pregnancy – a review of epidemiology and practices

Abstract

Ptyalism gravidarum is an oral pathological condition specific to gravidity. We present a review of the literature regarding epidemiology internationally, and then highlight therapies reported by patients and 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 risk. Our dissertation includes reference to a rare case of isolated sialorrhoea of pregnancy, without nausea or emesis. Both pharmacological and homoeopathic therapies are discussed, and inherent risks to mother and infant are highlighted. It is strongly recommended that this condition be given attention in antenatal care settings, to optimize short, middle and long term pregnancy outcomes.

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. This aligns with the proposal that β-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 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].