Dr Jinwen He1, Dr Adam Morton1
1Mater Hospital, South Brisbane, Australia
Biography:
Jinwen is an obstetric medicine fellow at the Mater Hospital, Brisbane. She completed her MBBS at the University of Queensland, and her Masters of Medicine at the University of Sydney, and her FRACP in endocrinology. Her interests include diabetes management, metabolic disorders and obstetric medicine.
Abstract:
Ptyalism gravidarum (PG) is a highly distressing syndrome of hypersalivation often accompanied by difficulty swallowing saliva, which may result in social isolation, anxiety/depression, weight loss and disturbances to speech and sleep. There is marked geographical variation in prevalence, with the high rates being reported in Turkey (35% in first trimester), Haiti and Africa, with much lower rates of 0.07-0.3% in Western countries. (1)
A 24-year-old G1P0, Maori heritage, presented at 22 weeks gestation with presyncope in the setting of previous sleeve gastrectomy. She had severe hypersalivation, onset at 5-6 weeks gestation, as well as gastroesophageal reflux and vomiting. She denied herbal/complementary therapy or geophagia. Examination revealed a young woman continuously spittinginto a towel on her shoulder.
Investigations confirmed iron deficiency but other trace elements and vitamins normal. Cortisol was normal, ANA negative. Amitriptyline was trialed but not tolerated due to postural dizziness with 30mm Hg postural drop. She was subsequently commenced on proton pump inhibitor and clonidine 50mcg nocte po. Symptoms ptyalism resolved 3 days after commencement clonidine.
Ptyalism typically onsets at 5-6 weeks gestation, with 92% of cases presenting by 8 weeks gestation. It resolves in 2nd trimester in most women but may persist until delivery. (1) It is associated with hyperemesis – 40% of women with PG have hyperemesis. Theories of aetiology include hormonal (hCG, oestrogen, progesterone), psychological and neuronal. (1) Clonidine has been successfully used to treat PG in pregnancy (2) in one case report and a case series of 10 patients.
In non-pregnant patients, aetiologies of ptyalism include neurological disorders, cholinergic drugs, secretory phase menstrual cycle, heavy metal exposure (selenium, mercury), Wilson disease, oesophageal obstruction and Angelman syndrome. The best evidence for treatment in the non-pregnant population is salivary gland botox injection, but there’s also evidence for clonidine, sublingual/oral atropine drops, ipratropium spray, transdermal scopolamine (3).
Keywords
Ptyalism gravidarum, clonidine
References
1. Thaxter Nesbeth KA, Samuels LA, Nicholson Daley C, Gossell-Williams M, Nesbeth DA. Ptyalism in pregnancy – a review of epidemiology and practices. Eur J Obstet Gynecol Reprod Biol. 2016;198:47-9.
2. De Braga V, Dahdouh EM, Balayla J. Successful treatment of ptyalism gravidarum with clonidine hydrochloride: A case report. Case Rep Womens Health. 2022;34:e00409.
3. Jost WH, Baumer T, Bevot A, Birkmann U, Buhmann C, Grosheva M, et al. Botulinum neurotoxin type A in the interdisciplinary treatment of sialorrhea in adults and children-update and practice recommendations. Front Neurol. 2023;14:1275807.