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My Experience With Ptyalism Gravidarum During the COVID-19 Pandemic

An immigrant woman and nurse describes her experience of ptyalism gravidarum in the United States during the COVID-19 pandemic.


My Experience With Ptyalism Gravidarum During the COVID-19 Pandemic
Nellipher Lewis Mchenga I am sharing my experience with ptyalism gravidarum (PG) in the hopes that my story may be helpful for those providing care to women with PG. PG is defined as excessive salivation (sialorrhea) during pregnancy, which typically appears abruptly in the first trimester. It usually ceases within the first month following birth. PG was not a new phenomenon to me. During my first pregnancy, I experienced sialorrhea until childbirth, but during this, my second pregnancy, the experience was different. In my first pregnancy, I never experienced nausea and vomiting. This time, I could hardly keep anything down. Although I was never formally diagnosed with hyperemesis gravidarum, I was prescribed an antiemetic. Before beginning the antiemetic, I had been taking vitamin B6, but my condition worsened.
While I was still struggling with nausea and vomiting, I sensed an alteration in my swallowing ability. It was like pulling teeth to get the saliva swallowed. As I progressed into my third month following conception, my saliva became thicker, copious, and unpleasant. Every attempt to swallow saliva caused a retching reflex. I was left with no choice but to be spitting frequently. Although I had experienced PG before, changes in my living situation significantly affected my second experience with PG. During my first pregnancy, I was a stay-at-home mom in my home country in Africa, which meant that I could freely expectorate and that I was not obligated to speak when it was not comfortable. PG was very common in my community, and people were empathetic and accepting of my need to expectorate. During my second pregnancy, I was a clinical nursing instructor in a foreign country, the United States. At the university, I was embarrassed to have to explain to my students that I was pregnant and that they would see me spitting. At my teaching hospital, because I was working on a postnatal floor, I did not think there was a need to explain my condition to my colleagues. Surprisingly, I later learned that the majority of my colleagues had never heard of PG and felt vulnerable to potentially contracting what they believed was a communicable disease from me.
One of the greatest difficulties I faced was the impact of PG on communicating with others; in fact, speaking increased my sialorrhea. This difficulty was exacerbated by the COVID-19 outbreak. Mask mandates made expectorating nearly impossible in public settings. When I encountered care providers, few offered understanding and support for my condition or provided options that could make it possible to communicate effectively with regard to mask policies. In one instance, a care provider demanded that I should not spit while speaking to her, and the situation led to inaccurate information being formulated about the purpose for my hospital visit and, subsequently, inadequate care. In addition to concerns about COVID-19, being pregnant and living abroad increased my feelings of vulnerability during health care visits, making the lack of understanding particularly difficult at a time when I needed competent, compassionate care.
PG is not common in the United States, but there are greater rates in my home country in Africa, as well as in other countries, such as Turkey. As the world has become more globalized, many people from different countries and diverse backgrounds, including women with PG, have immigrated to the United States for study, work, or to be with family members, among other reasons. This highlights the need for pregnant women with PG-or other conditions that may be atypical to a particular location-to have access to knowledgeable, competent, culturally sensitive care, regardless of their background or whether they are in their home country or abroad. In the United States and other countries where PG is atypical, all health care providers who provide care to pregnant individuals should be educated about PG.
PG, which is not contagious, can adversely affect individuals' sleeping and eating patterns, emotional well-being, and relationships. Clinicians should be cognizant that women with PG may not get adequate nutrition or sleep; therefore, it is necessary to frequently assess these healthrelated behaviors. In addition, having PG is a very unpleasant experience that often is accompanied by feeling uncomfortable and stressed. Although there is little that can be done to cure PG, experiences with compassionate care providers who understand the challenges that women with PG face could enhance positive experiences during pregnancy.
PG often makes speaking difficult and may also increase sialorrhea. To communicate effectively, women with PG need to be able to expectorate. Where masks are mandated because of the pandemic, women with PG need special considerations, especially when they are seeing their care providers. Clinicians should be flexible and attempt to understand the unique needs of pregnant women with PG, including the challenge of having to consistently wear a mask. Care providers who feel unsafe taking care of a woman with PG should consider adding an extra layer of protection instead of demanding that the woman stop spitting or chewing gum.
In addition, constant expectorating can be embarrassing to women with PG; therefore, care providers need to be intentionally compassionate. During health visits, women with PG should be encouraged to feel comfortable to expectorate and to express their concerns about their condition. As a patient, I felt valued and respected by the care providers who asked me questions about my PG symptoms. These were sometimes simple questions, such as "Is your excessive salivation getting better or worse?", but they meant a lot to me. It was not the specific questions that mattered, but the feeling that someone cared.
I believe that women with PG can still have a positive experience during their pregnancy if they feel empathy from their loved ones, friends, colleagues, and care providers. This level of understanding is especially important during a health crisis like the COVID-19 pandemic. In addition, it is critical that women with PG be allowed to spit, chew gum, or suck on hard candy, especially during their antenatal visits, so that they can engage in effective communication with their health care providers.

Author Disclosures
The author reports no conflicts of interest or relevant financial relationships.