Using Forbidden Points in Pregnancy: Adverse Outcomes and Quality of Evidence in Randomized Controlled Trials—A Systematic Narrative Review

Abstract

Objective: Pregnancy is a complex physical and hormonal condition. Many women experience back and pelvic pain, reflux, and headaches during pregnancy. There has been a significant rise in the popularity of acupuncture for pain conditions in pregnancy, wherein nonpharmacologic options are important. Concerns have been raised by both traditional and medical acupuncturists about using ''forbidden points'' during pregnancy and the risk of preterm contractions (PTC), as this could limit women's and practitioners' willingness to continue treatment during pregnancy. There is also a risk of bias introduced into clinical trials when participants are highly selected or they drop out of studies due to adverse outcomes. This review examined randomized controlled trials (RCTs) of acupuncture using forbidden points prior to 37 weeks of pregnancy to treat pain conditions, with the primary outcome of PTC. Methods: A database search identified RCTs, including trials of penetrating acupuncture that used forbidden points in their protocols to treat pregnancy-related pain conditions. STRICTA [Standards for Reporting Interventions in Clinical Trials of Acupuncture] and GRADE [Grades of Recommendation, Assessment, Development, and Evaluation] criteria were used to assess the quality of evidence. This review includes 8 RCTs reporting on 713 women. Results: Only 2 studies reported on the primary outcome of PTC, and there were insufficient data to perform a primary analysis. In these 2 studies, 6 participants withdrew due to PTC. No study was at a low risk of bias for all GRADE domains, and 3 studies were at high or unclear risk of bias in all domains. Conclusions: PTC is an important clinical outcome and should be reported routinely. The strength of evidence to date is insufficient to recommend using forbidden points prior to 37 weeks of pregnancy. Highly selected patient populations, risk of bias in study design, and participant withdrawal rates, suggest that high-quality trials are required.

Acupuncture for low back and/or pelvic pain during pregnancy: a systematic review and meta-analysis of randomised controlled trials

“…It also suggested that studies collect and report on safety outcomes for trials involving pregnancy women. 22 One previous review 23 reported the effectiveness of acupuncture in treating LBPP for pregnant and postpartum women. However, the number of studies associated with LBPP during the pregnancy included were small.…”

“…It was recommending that due to the concern of high dropout rates from studies that use forbidden points, alternative points should be considered in the treatment of LBPP, which have demonstrated effectiveness. It also suggested that studies collect and report on safety outcomes for trials involving pregnancy women 22. One previous review23 reported the effectiveness of acupuncture in treating LBPP for pregnant and postpartum women.…”

Review article: Functional dyspepsia and pregnancy—Effects and management in a special population

“…Nevertheless, while it improved heartburn, it also reported no adverse effects other than one patient having ecchymosis at insertion points 192 . There have been concerns from acupuncturists regarding the risk of preterm contractions with acupuncture during pregnancy 193 . Nevertheless, when used correctly, acupuncture has been successfully and safely used for migraine during pregnancy and labour and back pain in pregnancy 194–196 .…”

Acupressure and Acupuncture Use in the Peripartum Period

“…89 Generally, there are several acupoints that are "forbidden" before 37 weeks of gestation due to concerns about preterm contractions and there is a recent systematic review that confirms this view. 90 Several studies have investigated the safety of moxa use. They found that cardiotocograms were normal and there were no fetal side effects including, no fetal heart rate abnormalities, preterm uterine contractions, fetal distress, changes in short-term or long-term variability, or maternal cardiovascular changes.…”