Individualised Homeopathic Treatment of Nausea and Vomiting in the First Trimester and of COVID-19 in the Third Trimester of Pregnancy—A Case Report

Abstract

Introduction/Background  Nausea and vomiting in pregnancy are common physiological disturbances, causing physical, social and psychological symptoms in the affected women. Though it is difficult to draw absolute conclusions on whether or not pregnant women are at high risk of acquiring severe consequences from corona-virus disease 2019 (COVID-19), clinical experience has shown them to be potentially vulnerable to other coronaviruses. Lack of specific conventional therapy for these conditions called for a complementary and individualised homeopathy approach in the presented case.

Methods  The homeopathic medical management of early symptoms of nausea and vomiting in pregnancy (NVP) and the beginning of COVID-19 symptoms shortly before a scheduled Caesarean section is described. No ongoing specific treatments were discontinued. The connection between intervention with individualised homeopathy and clinical improvement was assessed by two independent reviewers using the MOdified NARanjo Criteria for Homeopathy (MONARCH) inventory.

Results  There was improvement of NVP symptoms in early pregnancy and in later-onset COVID-19 symptoms following an individually prescribed unipotent homeopathic medicine, Sepia officinalis , after tele-consultation during lockdown. The agreed MONARCH score was +8 points, suggesting that homeopathy contributed to clinical improvement.

Conclusion  Individualised homeopathy may be a helpful complementary medical approach for managing symptoms associated with NVP and COVID-19 during pregnancy.

Introduction

Nausea and vomiting are among the most common disorders experienced during pregnancy. ¹ Clinicians are urged to treat the nausea and vomiting of pregnancy (NVP) as early as possible to prevent their progression to hyperemesis gravidarum. ² The global population has faced multi-dimensional medical emergencies due to the coronavirus disease 2019 (COVID-19) pandemic. Clinical experience with pregnancies has shown complications after infection by other corona-viruses: e.g., severe acute respiratory syndrome and Middle Eastern respiratory syndrome. The recent study by Wastnedge et al also describes the physiological adaptations to pregnancy, such as alterations of immunological response, respiratory response, coagulation response and endothelial cell function, and their implications for COVID-19. ³ As pregnant women pose a greater vulnerability to complications, the International Federation of Gynaecology and Obstetrics (FIGO) ⁴ has recommended replacing routine antenatal care with tele-consultation whenever possible during the pandemic. The lack of availability of population-specific observational studies of conventional medicinal intervention and scarcity of evidence on possible outcomes of maternal and foetal health add to the burden of treatment of pregnant women infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Besides the direct impacts of the disease, many indirect consequences of the pandemic adversely affect maternal health, such as increased mental health strain and socioeconomic deprivation, ³ among others. In the treatment of diseases, especially where other treatment options are limited, individualised homeopathy could play a major complementary medicine role. ^{5 6 7 8}

Described below is a case of a woman in her mid-thirties treated with individualised homeopathy for NVP in her first trimester, and for COVID-19 symptoms in her third trimester three and a half weeks prior to her scheduled delivery via Caesarean section. She gave her informed consent for anonymised data of her case to be used for academic purposes including publication.

The Patient

A businesswoman in her mid-thirties presented herself with exhausting nausea and vomiting without apparent underlying pathologies, as confirmed by her gynaecologist and general practitioner (GP). She was told that a period of time such as this was normal and transient in pregnancy. The patient had flushes of heat, lack of vital energy, painful breasts, tiredness, and a feeling of being worn out that affected her performance at work. She thought it was ‘sado-masochistic and unfair’ to cope with her symptoms while working, and that the world looks down on pregnant women as if it ‘serves them right’ to suffer. She could not eat well, and snacks helped only a little. Her body was in spasms and vomiting ameliorated these complaints for just a short period. She had profuse perspiration at night and had to get up three times to change clothes, leading to insufficient sleep. She had stupefying headaches, an exaggerated sense of smell and was devoid of energy. She tried all the non-specific therapeutic measures that were advised for her discomforts: resting, and taking vitamins, iron tablets and ginger, and her GP administered an intravenous infusion of saline. This did not keep her comfortable, and therefore she decided to try homeopathic treatment for the NVP and associated symptoms.

Towards the end of her pregnancy, shortly before her scheduled (and preferred) Caesarean section, she developed nose obstruction and discharge, anosmia, headaches, and felt weak. The Rapid Antigen Test was positive for SARS-CoV-2. That fact made her anxious that she could transmit the virus to her parents. The non-specific over-the-counter drugs she obtained in the pharmacy were not helpful enough and she finally again opted for individualised homeopathy. In her previous medical history, she had epistaxis and occasional systolic hypertension (up to 180 mm Hg) during her student days, for which she did not seek medication. She had random pain in her ears and right-sided neck pain before pregnancy, and had multiple birthmarks on her skin. She could not recall the last time she had high fever. An enquiry into family medical history revealed that her grandmother had multiple sclerosis and her sibling suffered from depression. The patient lived with her partner who travelled frequently, but that did not bother her: she liked giving time to herself.

Clinical Findings

The first homeopathic consultation for NVP was conducted via tele-consultation during lockdown, due to the pandemic protocols exerted by FIGO, by a certified private-practice homeopathic medical practitioner who at the same time was working part-time as a licensed general physician in a public health centre's COVID-19 dispensary in Slovenia. The patient had severe nausea, vomiting, and weakness. She was manifestly sleep-deprived from the lack of quality sleep in the last month. A physical examination—without any abnormal findings—was conducted independently in the local health centre by the patient's GP, who also suggested homeopathy, and by her gynaecologist in a private health institute in Slovenia. Her blood tests did not show anaemia at the beginning of pregnancy. Other differential diagnoses, such as hyperemesis gravidarum, infections and thyroid disorders, were excluded. The totality of symptoms was taken as the homeopathic prescription strategy. The repertorisation chart, using the VithoulkasCompass repertorisation program version 6.0, which provided the first prescription for the early pregnancy symptoms, is shown in Table 1 . Depending on how intensely it was expressed by the patient, each relevant finding for homeopathy was graded from the first to the fourth degree. For example, a symptom in the first degree, such as vomiting, was mild and rare, corresponding to 1 to 3 out of 10 points by the visual analogue scale (VAS). A symptom that was inserted in the repertorisation program in the fourth degree, e.g., nausea, was very strong and very frequent, corresponding to 8 to 10 out of 10 points by the VAS.

Table 1. The VithoulkasCompass repertorisation chart with symptoms of NVP and the list of the highest-ranking homeopathic medicines.

	Symptom	Degree	Homeopathic medicine
			Sep.	Nux-v.	Puls.	Phos.	Lach.	Ars.	Sil.
1.	STOMACH – VOMITING – pregnancy, during	1	3	3	2	2	2	2	2
2.	STOMACH – NAUSEA – pregnancy, during	4	3	3	2	2	2	2	2
3.	STOMACH – NAUSEA – eating – after – amel.	2	3	1		1
4.	GENERALITIES – VOMITING – amel.	2		1	1			1
5.	GENERALITIES – HEAT – flushes of – perspiration – with	3	3				2
6.	GENERALITIES – WEAKNESS	3	3	2	2	3	3	3	3
7.	EXTREMITIES – STIFFNESS	2	3	2	2	2	2	3	3
8.	VERTIGO – LOOKING – upwards	1	1	2	3	3	2		2
9.	GENERALITIES – MORNING	2	3	3	3	3	3	2	2
10.	SLEEP – UNREFRESHING	3	2	2	2	3	3	2	2
11.	PERSPIRATION – SLEEP – waking, after – amel.	2	2	3	3	3		2	1
12.	NOSE – SMELL – acute	3	3	3	1	3	1	2	1
13.	MIND – REPROACHES – others	1	1	2			3	3
14.	HEAD – PAIN (headache) – Stunning, stupefying	2	1	3	2	2	2	2	3
15.	HEAD – PAIN (headache) – Temples	3	2	2	3	1	2	1	1
16.	HEAD – PAIN (headache) – Occiput – extending – head, to	1			2				2
Total points / Sum of rubrics			33 / 14	32 / 14	28 / 13	28 / 12	27 / 12	25 / 12	24 / 12

Three and a half weeks before the planned Caesarean section, the patient fell ill with new acute symptoms. They were mild in the beginning and no physical examination was conducted. After testing positive for SARS-CoV-2 with the Rapid Antigen Test for COVID-19 (ICD: U07.2), the patient refused to have the Polymerase Chain Reaction test that soon became the gold standard for confirming the diagnosis. The acute disease was immediately attended homeopathically via tele-consultation and the symptom totality repertorised as presented in Table 2 . She had headache, nose obstruction with discharge, and complaints of diminished smell and interrupted sleep. No ongoing specific treatment strategies were discontinued for either NVP or COVID-19.

Table 2. The repertorisation chart of the Radar Repertory 10.5.003 for the COVID-19 symptoms.

Symptom	Degree	Homeopathic medicine
		Sep.	Merc.	Nux-v.	Nat-m.	Lyc.	Nit-ac.	Sil.
Head—pain—forehead	1	2	3	3	3	2	2	3
Head—pain—pressing—outwards	2	2	2	2	3	1	0	2
Nose—obstruction—left	3	1	0	0	0	0	1	0
Nose—sneezing	1	2	3	3	2	2	2	2
Nose—smell—diminished	3	3	2	2	3	2	1	3
Stomach—nausea—eating ameliorates	2	1	0	0	0	0	0	0
Stomach—appetite—diminished	1	1	1	1	1	2	0	1
Stomach—heartburn—eating—after—agg.	3	1	1	2	2	1	2	1
Sleep—waking—4 am after	1	1	1	2	1	2	1	1
Stomach—nausea—night	1	2	2	3	1	1	1	1
Extremities—heat—hands	3	3	1	2	1	3	3	1
Mind—anxiety—health—about relatives	1	0	1	0	0	0	0	0

Therapeutic Interventions

The simillimum Sepia officinalis ⁹ in LM potencies was prescribed for the symptom totality in the case of NVP in the first trimester. The homeopathic medicines were produced by the pharmacies Remedia (Eisenstadt, Austria) and Homeocur (Retz, Austria) according to the Homeopathic Pharmacopoeia (Instruction 17) and the European Pharmacopoeia (Instruction 5.2). For Sepia officinalis in an LM potency, a specific sequence of trituration, dilution and succussion is needed to obtain a solution in a ratio of 1:50000. That is the first potency level of this scale, i.e., LM1. For the preparation of LM2, one globule of the LM1 is diluted in a drop of water. Then the solution is mixed with 100 drops of 86% alcohol and vigorously shaken 100 times. Next, globules are medicated with the solution in a ratio of 1:500 and dried. ¹⁰ The process was first explained in Paragraph 270 of the 6 ^th edition of Hahnemann's Organon of Medicine. The patient was advised to dissolve the homeopathic medicine in the LM potency in 14 teaspoons of 30% alcohol; the solution was shaken ten times every day. One spoonful was additionally diluted daily in a glass of water, stirred, and a sip taken just before bedtime.

Follow-up and Outcomes

An outline of main reports, comments and the sequence of prescriptions for the individualised homeopathic treatment of NVP, COVID-19 symptoms, and the symptoms after delivery, are included in the Timeline in Table 3 . The patient soon felt better after taking the homeopathic medicine for the NVP and associated symptoms. After reducing its intake, the symptoms reappeared so she continued taking it. Later in her pregnancy, after developing new symptoms and testing positive for the SARS-CoV-2 virus, she continued with the individualised homeopathic treatment and again experienced rapid improvement of symptoms.

Table 3. Timeline.

Date	Main report/symptoms	Comments	Prescription
First consultation. May 2020	Nausea for 1 month, vomiting, weakness, prostration, headache in temples, occipital pain radiating to head, profuse perspiration during sleep, unrefreshing sleep, vertigo when looking up; cold hands during the night unless wearing long sleeves. Water seems too sweet. Desire for squid. Generally worse in the mornings. Yearns for recreation, but cannot even walk; motion aggravates her. Sensitive to odours. Planning a Caesarean section for delivery ‘to avoid suffering’.	Strategy for repertorisation and prescribing: totality of symptoms repertorised with VithoulkasCompass Repertory 6.0. The patient's level of health (Vithoulkas): 2–3, group A. 15	Sepia officinalis , 14 doses of LM2 and later LM3. The patient described herself, by text message, as feeling “a million times better after taking the medicine for 10 days”. Therefore reducing the frequency of intake was advised, but symptoms returned, so she continued taking the medicine.
Follow-ups (FUs) FU1: at 5 weeks FU2: at 7.5 weeks FU3: at 11.5 weeks	Improvement of symptoms: slept longer hours; cessation of flushes of perspiration; nausea only on empty stomach—reported during FU1 over the phone. Old complaints of neck pain have returned; appearance of sleepiness. Physically active. Slight swelling in ankles, better by morning. Loss of hair; bleeding gums, appearance of metallic taste. Eruption on face (Hering's law). Walking, cycling and attending fitness regularly again. Blood pressure: 126/66 (the first measurement during the treatment was 98/54); no vertigo. Desire for soda water.	No initial aggravation—as usual with LM potencies. New minor transient symptoms: loss of hair; bleeding gums, appearance of metallic taste. An old symptom has reappeared: old complaints of neck pain. Reaction to the medicine—Observation No. 4 (Vithoulkas) after centesimal potencies: 15 there is local and general amelioration, but new symptoms belonging to the given remedy have appeared in the patient; no evident initial aggravation.	The single homeopathic medicine Sepia officinalis in LM5 potency was prescribed for 21 days. After gradual general improvement, a placebo of one globule per day was prescribed, and Sepia officinalis in LM6 potency was taken from time to time in between.
FU4 for acute state. November 2020	The rapid antigen test is positive for COVID-19. Headache pressing outward above eyebrows; left-sided nose obstruction and clear discharge, loss of smell; nausea if a meal is delayed; anxiety after testing positive for COVID-19; fears parents could die; longs for physical activity even in this acute state; desire for chocolate; heat in hands. No more swelling in ankles.	Repertorisation of new acute symptoms with Radar Repertory has led to the same unipotent homeopathic medicine. Differential diagnoses: sinusitis (ICD: J01.1) and COVID-19 (ICD: UO7.2).	Sepia officinalis LM6 continued every day.
FU5: at 1 week; FU 6: at 2.5 weeks	Nose obstruction is better. Generally much better 5 days later; smell returned 90%; improvement of all symptoms. Appearance of sciatica, ameliorated by pressure. Looking forward to not having a natural delivery. Complains that fitness centres for exercise in pregnancy are closed down due to lockdown.	No initial aggravation—as usual with LM potencies. The new leg pain might have arisen due to late anatomical changes in pregnancy or the evolution of events due to Hering's law. The approximate reaction to the medicine—Observation No. 3 (Vithoulkas) after centesimal potencies: the patient is much better in almost every aspect, but still has some problems, 15 though without the appearance of an evident initial aggravation.	Sepia officinalis LM6 was continued. Due to sciatica, one sip was taken from the third glass (90% of the spoonful of medicine diluted in the first glass of water was poured away, refilled and the process repeated once more) every 20 minutes, three times, in order to relieve the pain on the first day, followed by placebo.
FU7: at 4.5 weeks	No immediate amelioration of the sciatica. She feels that physiotherapy helped to relieve 90% of the pain. Successful planned delivery of a healthy baby by Caesarean section at 3.5 weeks. Started breastfeeding; post-partum problems with profuse perspiration and hot flushes during the night; started adding infant milk formula.	No sciatica after delivery.	Sepia officinalis LM8—14 doses.
FU8: at 6.5 weeks	11 days after the prescription, no waking from flushes of perspiration any more; scanty leucorrhoea; happy with her weight. Says she will not be able to stay off work for long. Tearful three times for no reason. Has stopped breastfeeding.	Improvement of the burdensome symptoms after delivery. Appearance of a proving symptom 15 —weeping without knowing why.	Continued with Sepia officinalis LM9 and later LM10 daily; asked to decrease the frequency as symptoms have faded.

The symptoms of COVID-19 gradually diminished, but sciatic nerve inflammation appeared. The pain was evaluated with a severity of 8 out of 10 points according to the VAS. The symptoms were again repertorised and the same medicine seemed appropriate. Sepia officinalis LM6 had not yet been taken 14 times, so the next dose was prescribed to be taken from the third glass in a higher dilution, after being stirred, providing higher potentisation as described in Table 3 in the Timeline. The patient found that the intervention did not ameliorate sciatic pain and she opted instead for physiotherapy. Additionally, the patient developed profuse perspiration at night after the Caesarean section. The repertorised symptoms again pointed to Sepia officinalis , which was prescribed in a higher, LM8, potency and the patient was advised gradually to decrease the medicinal intake with the subsiding of symptoms, as described in the Timeline.

An evaluation of changes in health status followed each prescribed medicine. Monitoring these changes in the symptomatology after the prescribed medicine from follow-up to follow-up enabled assessing the past and necessary further management of the case. The patient did not report experiencing any adverse effects during the course of treatment and follow-ups.

The modified CARE guidelines for homeopathic medical intervention (HOM-CASE) suggest including a scientific rationale with a numerical evaluation to assess the causality of improvement in case reports treated with homeopathy. ¹¹ Completion of the MOdified NARanjo Criteria for Homeopathy (MONARCH) inventory was performed by two independent reviewers, reflecting the homeopathic treatment of both complaints (namely NVP and COVID-19) during pregnancy, and gave an agreed score of +8 points on the scale of –6 to +13 ( Table 4 ). The specific treatment with individualised homeopathic medicine could thus have been the cause of positive changes in the case. The completed HOM-CASE checklist is shown in Supplementary Table 1 , available in the online version only.

Table 4. MOdified NARanjo Criteria for Homeopathy (MONARCH), with agreed total score.

	Domains	Reviewer 1	Reviewer 2	Agreed score
1.	Was there an improvement in the main symptoms or condition for which the homeopathic medicine was prescribed?	2	2	2
2.	Did the clinical improvement occur within a plausible timeframe relative to the medicine intake?	1	1	1
3.	Was there a homeopathic aggravation of symptoms?	0	0	0
4.	Did the effect encompass more than the main symptom or condition?	0	0
5.	Did overall well-being improve?	1	1	1
6.a	Direction of cure: Did some of the symptoms improve in the opposite order from the development of the disease?	0	0	0
6.b	Direction of cure: Did at least one of the following aspects apply to the order of improvement in symptoms: From organs of more importance to those of less importance? From deeper to more superficial aspects of the individual? From top downwards?	1	1	1
7.	Did ‘old symptoms’ reappear temporarily during the course of improvement?	1	1	1
8.	Are there alternative causes (i.e. other than the medicine) that—with a high probability—could have produced the improvement?	1	1	1
9.	Was the health improvement confirmed by any objective evidence?	0	2	0
10.	Did repeat dosing, if conducted, create similar clinical improvement?	1	1	1
	Total	+8	+10	+8

Discussion

Morning sickness is common in early pregnancy and it is often under-treated, though it affects the health of a pregnant woman and her foetus and can affect her quality of life. ¹² It seems rational to attend early pregnancy, as well as COVID-19 symptoms, with individualised homeopathy where there is no other specific treatment available, or where therapeutic possibilities are limited or have failed. After Sepia officinalis in different LM potencies was prescribed for NVP and COVID-19, symptoms seemed to improve rapidly. No initial aggravation appeared after the prescriptions. The homeopathic consultations during lockdown were undertaken via tele-consultation. Apart from that, necessary clinical and diagnostic examinations were performed by conventional medicine specialists and important differential diagnoses were excluded. Individualised homeopathy after tele-consultation may have helped to shorten the duration of illness. Generally, the lack of specific treatment of COVID-19 may cause additional stress ¹³ —both for the patients and for the physicians. According to Centers for Disease Control and Prevention surveillance, investigators concluded that among women of reproductive age with COVID-19, though mostly a mild infection during pregnancy, those who are pregnant are more likely to be hospitalised and to be admitted to the Intensive Care Unit and to receive mechanical ventilation, but that the risk of death is similar to non-pregnant women. ¹⁴

The limitation of the presented case is that it reports the treatment of complaints that commonly tend to improve spontaneously. Nevertheless, the attendance took place promptly, and the homeopathic management was performed according to the standardised medical education of the European Committee for Homeopathy as well as to the theory of Levels of Health. ¹⁵

The HOM-CASE Guidelines and the MONARCH Inventory

A clinical case report does not enable conclusions about efficacy of a medical intervention. Thus, the HOM-CASE guidelines recommend the evaluation of causality of improvement using the MONARCH inventory, which itself is subject to evolving change and improvement. ¹⁶ The original inventory was elaborated by experts through a modified Delphi technique—in which the topic of homeopathic aggravation was included. A therapeutic homeopathic aggravation is specific for many cases treated with individualised homeopathy, though not for all of them. Moreover, the therapeutic aggravation does not usually appear after prescriptions of LM potencies. And, according to the observations described by Vithoulkas, ¹⁵ it may not appear after correct prescriptions of homeopathic medicines in centesimal potencies in the treatment of some patients who are in the first to the third (‘group A—most healthy’) or in the tenth to the twelfth Levels of Health (‘group D—incurable’). Making transparent the possible causal attribution of changes in homeopathic clinical case reports is nevertheless a major step forward. ¹⁶

The Levels of Health

This theory is based on the observations of its author who, for the past 60 years, has been treating patients with long-term chronic diseases. ¹⁵ It reflects his experience and critique of the existing model of conventional medicine that treats acute cases by suppressive means, thereby creating chronic conditions. It classifies patients according to the depth and severity of their diseases, decided by the diagnosis itself and by the analysis of the disease history, past treatments, and the familial disease load. ¹⁷ The theory systematically explains the homeopathic healing process depending on observed reactions to a prescribed homeopathic medicine. It is gaining scientific support while being applied in case reports. ^{18 19 20 21} It is connected with ‘The Continuum of a Unified Theory of Diseases’. ²² The patient's level of health and the observation of the reaction to the prescriptions for NVP and COVID-19 in the presented case are described in the Timeline ( Table 3 ) according to this theory. The reason for the rapid positive reaction in this case could be the correctness of the prescription based on the patient's clear symptom pattern that is usually seen in the higher levels of health. ¹⁵ Since a condition is not considered ‘cured’ despite removal of the symptoms, ²³ it is anticipated that two to three different correctly prescribed homeopathic medicines, ¹⁷ at appropriate times in the future, will be required to reach the best level of health in this case. Certain burdensome, overlooked and under-treated health issues continue to be a challenge in conventional medicine and await further evidence for their potentially successful management by complementary medical options. Individualised homeopathy in the present case was not an alternative medical intervention but was a complementary treatment approach: no other ongoing specific treatment strategies were discontinued.

Conclusion

The case report presents the sequential, systematic homeopathic management of NVP and COVID-19 in pregnancy after tele-consultations during lockdown. One specific unipotent homeopathic medicine, Sepia officinalis , was prescribed throughout. Monitoring the changes enabled the evaluation of the observed reaction to each prescription and its follow-up. The observed improvements in symptoms suggest that individualised homeopathy is a helpful complementary medical approach for managing NVP and COVID-19 during pregnancy.

Highlights

• Early pregnancy and COVID-19 symptoms of a patient were alleviated by an individualised homeopathic medicine, Sepia officinalis , when prescribed after tele-consultation during lockdown by a homeopathic medical practitioner.

• The MONARCH inventory included in the HOM-CASE guidelines indicated a likeliness of association between clinical outcomes and the treatment with homeopathic medicine.

• Individualised homeopathic medicine may be considered as the first option of the attendance where other therapeutic possibilities are limited or have failed.