Management of Ptyalism in Pregnancy
Ptyalism gravidarum should be managed primarily with supportive measures and reassurance, as it poses no specific risk to maternal or fetal health, though alternative therapies including hypnosis and acupuncture may provide symptom relief when conservative measures fail. 1
Initial Assessment and Reassurance
- Confirm the diagnosis by documenting excessive salivation (up to 2 liters per day) with associated symptoms including swollen salivary glands, sleep deprivation, and emotional distress 1
- Screen for hyperemesis gravidarum, as 40% of women with ptyalism also have concurrent hyperemesis requiring additional management 1
- Provide strong reassurance that ptyalism does not increase the rate of fetal or maternal complications or adverse perinatal outcomes 1
- Obtain family history, as 37% of affected women have a positive family history for this condition 1
Conservative Management Approach
- Recommend frequent spitting into a container or tissue rather than swallowing excessive saliva 2, 3
- Suggest dietary modifications including small, frequent meals and avoiding starchy foods that may worsen symptoms 3
- Encourage good oral hygiene with frequent mouth rinsing using astringent mouthwashes 2, 3
- Advise chewing sugar-free gum or sucking on hard candies to help manage saliva 3
Pharmacological Considerations
Anticholinergic medications like glycopyrrolate are theoretically effective for reducing salivation but lack safety data in pregnancy. While glycopyrrolate oral solution showed no increased incidence of gross external or visceral defects in animal studies at exposures up to 113 times the maximum recommended human dose 4, there are no available data in pregnant women to inform drug-associated risks 4. Given the benign nature of ptyalism and lack of maternal-fetal risk, pharmacological intervention is not recommended 1, 2.
Alternative and Complementary Therapies
Hypnosis with or without acupuncture represents the most promising intervention for refractory cases:
- Two women reported immediate resolution of symptoms following hypnosis with acupuncture treatment 1
- A documented case showed complete resolution of ptyalism by week 36 of pregnancy following hypnosis sessions starting at week 16 5
- Hypnosis can address concurrent hyperemesis when both conditions are present 5
- Psychotherapy should be considered as historical literature supports psychological interventions 6
Management Algorithm
First-line (all patients): Reassurance about benign prognosis + conservative measures (frequent spitting, dietary modifications, oral hygiene) 1, 2, 3
Second-line (persistent symptoms causing significant distress): Referral for hypnosis therapy, with or without acupuncture 1, 5
Third-line (severe cases with hyperemesis): Manage hyperemesis gravidarum according to standard protocols with vitamin B6, doxylamine, ondansetron, metoclopramide, or promethazine as needed 7
Avoid: Anticholinergic medications due to lack of pregnancy safety data despite theoretical efficacy 4, 2
Common Pitfalls to Avoid
- Do not dismiss the condition as trivial—it causes significant emotional distress, sleep deprivation, and social difficulties despite being medically benign 1, 2
- Do not prescribe anticholinergics empirically—the lack of human pregnancy data and the benign natural history make risk-benefit ratio unfavorable 4, 2
- Do not overlook concurrent hyperemesis gravidarum—40% of cases have both conditions requiring additional management 1
- Do not assume fetal gender plays a role—studies show no association between fetal gender and ptyalism risk 1
Expected Course and Follow-up
- Symptoms typically begin early in gestation and may persist throughout pregnancy 1, 2
- Resolution usually occurs by late third trimester or immediately postpartum 5, 2
- The incidence is rare at approximately 1 in 963 pregnancies (0.09%) 1
- Provide ongoing emotional support given the significant psychological impact of this socially distressing condition 1, 2