“Nausea and Vomiting in Pregnancy and Hyperemesis” – with Dr. Jessica Spiegelman

Dr. Jessica Spiegelman meets with Dr. Nathan Fox to discuss nausea and vomiting in pregnancy and hyperemesis gravidarum, a more severe medical condition, as well as possible treatments.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, Dr. Jessica Spiegelman. Spiegs, welcome back to the podcast. How goes it?

Dr. Spiegelman: It’s good. Thanks for having me.

Dr. Fox: Oh, I love having you on the podcast. We were sort of game time decision whether to meet in person or over the phone, but since there’s, like, patients lining out the door to see you, we had to just squeeze this in between two of your scheduled patients. So, thanks for taking the time to speak with me and to all of our listeners around the world so they can hear your genius and glory.

Dr. Spiegelman: Thanks for having me. I appreciate the opportunity.

Dr. Fox: Good times. Well, if all of my accolades made you nauseated, here we go, a nice segue, we’re gonna talk about nausea and vomiting in pregnancy, and hyperemesis. So, pretty common stuff, nausea, vomiting.

Dr. Spiegelman: Yes, very common. Happens in most people in early pregnancy.

Dr. Fox: Yeah. I mean, what’s been your experience with patients? Like what’s typical, so to speak? For someone who hasn’t been pregnant before and they’re like, “What’s going on? What’s gonna happen when I get pregnant?” What is typical with the average, I guess, for nausea and vomiting?

Dr. Spiegelman: So, the majority of people have some nausea. Not everybody has vomiting. There’s a spectrum of kind of severity of symptoms. And some people will have nausea alone, other people will have nausea and vomiting, and some people will have a severe end of the spectrum which is hyperemesis gravidarum, which is a more serious medical condition. I think that people tend to minimize nausea and vomiting with pregnancy because it is so common. People, meaning patients themselves, physicians, society. But it really can impact life. Even if it’s not the most severe end of the spectrum, it can be a real serious issue in people’s daily lives, and it happens to most pregnant patients.

Dr. Fox: Yeah, I’ve never been pregnant, but I’ve been nauseous and it’s quite unpleasant. It is really one of the worst feelings to have. You know, it’s gross. I mean, you can’t eat, you wanna throw up, you wanna get in bed, you’re a little dizzy, and that’s like just the nauseous part. And then, you know, there’s the vomiting and, you know, like you said, it’s most people don’t have it severe. But when we talk about severe, we just mean like severe enough that it’s, like, dangerous to the mother, but there’s a lot of stuff less than that which is quite debilitating in terms of trying to go to work every day, trying to take care of your other kids. You’re just trying to, you know, get out of bed and function and have a happy day.

Dr. Spiegelman: Yeah, and it can be really, really tough, and especially people who work full-time and especially people who have more physical jobs, it can really interfere with your daily functioning, your daily life.

Dr. Fox: Yeah, and I think that it’s important to have sort of both sides of the balancing scale. I think that there’s obviously one side that’s gonna say, you know, “Okay, this is very common. It’s ‘normal in pregnancy.’ It’s not an unhealthy sign of pregnancy.” In fact, it’s, you know, common in normal healthy pregnancies to have nausea and vomiting. You know, it’s not dangerous to the mother, it’s not dangerous to the baby in the circumstances. And that’s sort of like the positive side of it. But there’s also the negative side of it that this is again, very annoying, very frustrating, can be debilitating, can really affect people’s daily lives. And so, on the one hand, you wanna be reassuring to people that this isn’t, like, “a problem for the pregnancy that’s gonna affect the health of the mother and baby,” but you also don’t wanna blow off the fact that it’s really significant in terms of, you know, someone’s life for several if not many weeks.

Dr. Spiegelman: Yeah, and what’s actually interesting is there’s a lot of theories as to why this happens. One of the theories is HCG, the, like, “pregnancy hormone” having maybe higher levels of HCG might cause more severe vomiting and nausea in pregnancy. And so in one sense it almost can correlate to robust pregnancy, and so it’s not really associated with poor pregnancy outcomes. And so it’s like a silver lining I like to give people when they are feeling miserable, but at the same time they feel miserable. And sometimes it’s all the time for weeks on end, and psychological implications of that are real.

Dr. Fox: Yeah, I mean as physicians, obviously, and obstetricians, we sort of deal with this all the time. I think for people out there listening who maybe have family and friends who are pregnant, a lot of times you’re not gonna know that they’re pregnant at this point. They may not have told you that they’re pregnant and so they’re sort of like “hiding it from you.” Again, that’s a whole separate discussion of why people do that, but whatever. But if you know someone is pregnant and they’re really nauseated, or vomiting or whatever, it’s like on the one hand, it’s nice to be sort of positive that, “Okay, it’s a sign of good pregnancy.” But on the other hand really like listen to them when they’re saying… They’re not complaining. Like, they’re really miserable, and it’s legit. It is legit misery for people, for a lot of people. And some people are lucky and they’re not and they don’t have a lot of it, but most people have some amount of time or some level of misery regarding this part of pregnancy.

Dr. Spiegelman: Yes.

Dr. Fox: And just in terms of some definitions or whatever it is, it’s typical in the first trimester. Usually starts like a week or two or three after you miss your period and get a positive pregnancy test. Some people have earlier, but sort of on average it takes a few weeks. And then it usually peaks in the first trimester and starts to get better sometime around 10, 11, 12 weeks. That’s for most people, but again, there’s so much variation in this. I mean, we’ve seen people with everything.

Dr. Spiegelman: Yeah, so some people have this kind of classic, what you just said, it starts about a week after your missed period, peaks at around 10 weeks. So, when I see someone who is about 10 weeks and they’re feeling really miserable, I usually tell them, you know, “The good news is for most people you’re at the peak of this, so keep us posted, you know, if it’s not getting better, but it should hopefully.” For the majority of people it will, but there are people who have some level of nausea and vomiting for their entire pregnancy. So, there is no way to know for sure who’s gonna fit into which category. And so it’s something that we really recommend people tell us because there is a tendency to minimize symptoms because they’re so common and they’re so “normal.” And so it’s really important for people who are experiencing them to speak up because there are treatments, there’s things we can do to help.

Dr. Fox: Yeah, and I think it’s also what you mentioned is true throughout the pregnancy that this is something to definitely, you know, we’re supposed to ask about it, but if we don’t or we forgot to or whatever it is, it’s something you can obviously bring up on your own. But another important point is a lot of people don’t see their obstetrician or midwife in the first trimester until 10 plus weeks, right? And so, you may be at home really miserable and saying, you know, “What am I supposed to do? I don’t even have my appointment for three weeks.” This is something where you can call the office and say, “Hey, I know I’m not supposed to come in for three weeks, but I’m really feeling pretty sick. Can you either see me earlier or is there something you can do over the phone, or prescribe something, or give me some advice so that I can feel better over the next three to four weeks before my first visit?” And I think a lot of people are hesitant to do that, but this is something, like, we’d wanna know.

Dr. Spiegelman: Yeah, and people also are I think sometimes hesitant to bring it up because they think they’re not supposed to take medications in pregnancy unless it’s dire. And that’s not really true. We actually know about the safety of a lot of the therapies for nausea and vomiting in pregnancy and we can talk to people about that. So, it’s not just like, “Oh, well, I’m pregnant so I can’t take anything, so there’s no point in mentioning it.” There really are therapies out there and some of them are known to be safe.

Dr. Fox: When something is really common in pregnancy, one of the plus sides from a research perspective is you have a lot of data, right? You have a lot of people who have different treatments have been tried and studied and tested and compared to one another and all these things. And so you can do that if it’s something that’s very common. Something that’s uncommon, it’s harder to study. Another misnomer I would say is the term morning sickness.

Dr. Spiegelman: Oh, yeah.

Dr. Fox: Like, “Why am I nauseous at night?”

Dr. Spiegelman: Morning, afternoon, night. Like, it’s not, you know. I think part of where morning sickness came from is nausea and vomiting in pregnancy can sometimes be precipitated by hunger. So, if you haven’t eaten for a whole night, you may be more likely to have this feeling in the morning, but it is not temporally related in any other way and it can happen all the time anytime. A total misnomer.

Dr. Fox: Yeah. Now, we mentioned before that the nausea, vomiting, we call that nausea, vomiting in pregnancy or NVP. Again, this is what we’re discussing, sort of common, not dangerous to the mother or baby. Based on how bad it is or how long it it lasts it could be quite distressful or not. And, you know, we have treatments and whatnot. But then we were talking about hyperemesis gravidarum or HG, which is when you say something in Latin, it means it’s gonna be severe, right? Whenever we give you something in Latin, typically that’s bad. So, what is that and how do we distinguish sort of typical, so to speak, nausea, vomiting in pregnancy from hyperemesis or how would someone out there know that they have one versus the other?

Dr. Spiegelman: So, there’s not one established definition of hyperemesis gravidarum. There’s kind of clues to whether or not somebody might have this. Anybody who’s been an OB-GYN resident knows the call from the emergency room, somebody with hyperemesis gravidarum, and you’re just like, “Do they really have it?” But there are ways to kind of figure out if somebody does have the true condition. One criteria that’s used is weight loss. Someone who’s lost, you know, one of the parameters is potentially 5% of their body weight. There is an idea and kind of this more intractable nausea and vomiting, like multiple, multiple episodes of vomiting a day, not being able to tolerate any food or any oral intake. And then also potentially signs of starvation, something called ketones in your urine which can be a sign of starvation and dehydration.

Dr. Fox: Yeah, I mean, this is something that’s much less common. It’s probably around, you know, 2%. So, maybe like 1 in 50 plus or minus pregnancies will have this. And like you said, there are definitions, but ultimately, the definitions don’t matter because it’s just a really severe form of nausea, vomiting, because it’s not like we use the criteria and say, “Oh, if you have the diagnosis, I can give you treatment, A. And if you don’t have the diagnosis, I won’t.”

Dr. Spiegelman: I won’t give you the treatment. Yeah.

Dr. Fox: But it doesn’t work like that. It’s basically for people to think like, “How do I know if I have this?” I just tell ’em, if your nausea and vomiting is so severe that you’re not only not gaining weight but you’re losing weight, and you basically can’t eat and drink normally, like you could barely get anything in, you have it. It’s severe and you need to be treated because then not only is it extremely annoying, distressful, debilitating, you know, yeah, wherever you go on that spectrum, it’s just, it’s awful. On top of that, it’s actually unsafe for the mother. Interestingly the baby doesn’t seem to care how much the mother throws up. I mean, people are really just like, at the time this is happening, the baby’s maybe the size of like you’re pinky or smaller. And so, like a, you know.

Dr. Spiegelman: Not very much.

Dr. Fox: They don’t need a lot of calories, they don’t need a lot of fluid, and they take whatever they need from the mother, but for her it could be really… And it can be dangerous and it could be really dangerous for her health. And when people don’t recognize that, not only is it, like, unfortunate that they’re miserable and no one’s helping them, or they’re not getting helped, it could also be dangerous. And so, this is something that we really are very, very aggressive about in diagnosing and treating.

Dr. Spiegelman: Yes. And then also just in the health of the mother category, sometimes this can be associated with certain pregnancy issues such as having twins or having like a molar pregnancy, anything that raises those HCG levels.

Dr. Fox: Yeah. So let’s actually talk about that. So, we mentioned in terms of like causes, we don’t really understand a lot of this. We don’t understand why people in general have nausea and vomiting in pregnancy. Like, again, the HCG correlates but not perfectly and not in all people. And so, that’s sort of, you know, it’s one factor, but we don’t really understand that there’s probably some other hormonal factors. And then we don’t understand why some people get it more severely than others. Some of the reasons seem to be tied to higher hormone levels, like you said, if you have twins, you know, sort of double the pregnancy, double the nausea. And also the thing with the molar pregnancy, which is a very high HCG. But it’s not perfect that way. It seems to be that the biggest risk factor is that if you had it before, you’re more likely to have it again. Again, not definitively. It does not always come back exactly the same way, but that seems to be the strongest risk factor. And it does seem to run in families to some degree as well. So, there’s probably some like inherent or genetic or whatever it is component to it that we haven’t quite mapped out yet.

Dr. Spiegelman: Yeah, it’s not exactly… You can’t like draw a straight line between any one thing in developing hyperemesis or even severe nausea and vomiting in pregnancy.

Dr. Fox: Yeah. And the other thing that’s interesting is that if, you know when you look at the studies about recurrence, so to speak, of hyperemesis, it ranges from like 15% to 90%, which is essentially useless. That’s like saying that that’s totally unhelpful. But I think that part of the issue is, number one, everyone defines it differently exactly how severe it is. And number two, let’s say someone had it the first pregnancy and part of the reason it was so bad the first pregnancies, they didn’t recognize it so quickly, it wasn’t treated as aggressively, and sort of it lingered for a longer time and they’re pretty miserable. And then the next pregnancy they’re like, “Dude, I don’t want that to happen again.” So, they were on medication right away and things were done more aggressively, and then they felt a lot better. So, did it recur or did it not recur?

And you have to sort of tease out, these studies are not done in a tight way where no one gets treated in either pregnancy and someone’s just following them around with a clipboard. Like, this is done in real life where they’re getting treated or not treated, and there’s a lot of circumstances that affect those numbers. But basically, if you had it before, you have a much higher chance of having it again.

Okay. So, let’s go through what we do for folks who have this. And I guess we’re gonna start with the simplest approaches and then work our way up the chain or down the chain. I don’t know which way we’re going here. But essentially, and that’s sort of what we do clinically, and it’s also how it works for like the less severe your symptoms are, the less you’ll probably need. And the more severe your symptoms are, you know, leading to hyperemesis, the more stuff you’re gonna need. So, let’s start. So, what are sort of the simplest recommendations that we give or people might wanna know in terms of helping, you know, nausea and vomiting sort of at the easiest level so to speak?

Dr. Spiegelman: So, really like the first goal is symptomatic improvement, and this is sort of before someone is at the level of weight loss, electrolyte balances in this kind of more severe hyperemesis category just for feeling nauseous all the time, not vomit all the time, and to stay hydrated and to not be malnourished basically would be the kind goals. And so with everything, we wanna work from the kind of most conservative to the most aggressive form of treatment as appropriate for someone’s symptoms. So, someone who presents with really severe symptoms, you’re not gonna be like, “Well, let’s try two weeks of drinking more.” That’s not gonna work. So, but tailoring it to the individual, just kind of making sure that they have their symptoms improved, stay hydrated, and get kind of the bare minimum of nutrition that they need for themselves because like we said, the fetus will take what it needs, but sort of staying appropriately nourished.

Dr. Fox: Yeah, there’s a lot of advice out there that people say and you read online about small meals and saltines and, you know, a little of this and little of that, and, you know, I don’t know.

Dr. Spiegelman: Yeah, and maybe [crosstalk 00:15:53.904].

Dr. Fox: I’m not so impressed with it.

Dr. Spiegelman: I like small meals. I think that trying to snack all day as opposed to eating a lot of food at once actually can work because hunger often really precipitates the feeling of nausea, because if you don’t let yourself really get hungry, you may mitigate your symptoms. And then also, I always joke, this is like the one time a doctor will tell you not to eat a salad, like just to avoid foods that precipitate nausea, foods with high acidity. There’s theories that protein is better than carbs, which is better than fat, but also figuring out kind of what your own triggers are and avoiding those foods.

Dr. Fox: Yeah. And again, it’s one of these things where you’re gonna read online the importance of nutrition in pregnancy and then you’re like, “Well, how am I gonna follow any of this? Like, I’m miserable. Like, I can’t eat that.” People all the time are like, “Dude, all I can eat are pretzels and ice cream.” I don’t know, like, whatever it is. I’m fine with whatever. Like what are you gonna do? Like you gotta eat and so just do whatever you can. And I think that, like you said, it’s individualized. Different people have different triggers and if you can find a diet that works for you to get through the first trimester, making you less nauseous and not vomiting, great, like go for it. That’s fantastic. But don’t be either upset or surprised if that’s not enough, right? Because frequently it’s not and that’s not gonna work enough. So, what are the things we might recommend people take, let’s say, or do that are, you know, sort of like recommended by us?

Dr. Spiegelman: So, if we’re working up or down, whatever we decided, the chain of aggression above treatment, one of the sort of nonpharmacologic treatments that’s very famous is ginger. Ginger helps with nausea and not vomiting, generally. And so they sell these little ginger candies or ginger flavored seltzer water, ginger ale, that can really help and actually have been shown to help with nausea symptoms.

Dr. Fox: Cool. I love it. I’m a fan of ginger. That’s good stuff.

Dr. Spiegelman: So, that’s a good one. Yeah. And then working our way up, vitamin B6 would probably be the next thing. We don’t know why this works, but B6 does tend to help with nausea and vomiting. It’s safe in pregnancy and sometimes that’s enough. A little bit of dietary modification, ginger maybe, and then taking a vitamin B6. Another thing also on a more conservative note is swapping out the prenatal vitamin for folic acid alone. The most important part of the prenatal vitamin in early pregnancy, aside from, you know, vitamins are important, but it’s really the folic acid. And sometimes prenatal vitamins themselves, they can come in really large pills, they can be hard to tolerate. So, swapping that out for just a plain folic acid, which is a smaller pill and easier to swallow, can also sometimes be helpful in not precipitating nausea and vomiting.

Dr. Fox: Yeah, I think that’s actually important for two reasons. Number one, like you said, sometimes the pills, I mean, you look at them and it’s like you need a fork and a knife…

Dr. Spiegelman: They’re huge.

Dr. Fox: …you know, to take them. And that can itself cause nausea, vomiting. Okay. But number two, sometimes because people are nauseated and vomiting, they can’t take their prenatals. Like, “I throw up every time I take it.” And then not only like are they nauseous and vomiting because of it…

Dr. Spiegelman: They’re not gonna [crosstalk 00:19:00.899].

Dr. Fox: … they’re not getting their folic acid. So, I think that that’s actually important. If the prenatals make you nauseous, you can stop the prenatal. Or if you are not able to take the prenatal, get a pickup folic acid. It’s a tiny, tiny pill. It’s remarkable how little the folic acid is. And that’s something you can sometimes get. And there’s even ways to get it. Certain like beverages have extra folic acid in it. And so you can somehow get your requirement that way. And the vitamin B6, the amount you’re gonna need to help nausea is not in a typical prenatal. There are some prenatals that are sort of tailored for people with nausea and will have more B6 in it and whatever. That’s fine. But you could also just pick up B6. It’s over the counter at the drugstore. Yeah.

Dr. Spiegelman: Although it also is sold in different amounts and I actually made this mistake in my own pregnancy is I bought the wrong dose and I would like quadruple the vitamin B6. So, it’s, you know, 25 to maybe 50, but usually 25, but not the 100-milligram capsules that it comes in.

Dr. Fox: Yeah. Basically, like, it’s like 100 maybe a day or something. So you get to… Yeah, usually I tell people like, yeah, “25 like three times a day, or 50 twice a day, or something like that based on what you get.” And that is, again, totally safe, has pretty much no side effects even. And if it works, fantastic. And then often vitamin B6 is recommended at the same time as another medication, which the generic is doxylamine or sometimes the brand’s called Unisom, which is interesting because you’re gonna find that in, like, the sleep medicine section of your local drugstore.

Dr. Spiegelman: Yeah, so it’s an antihistamine and can be very effective in treating nausea and vomiting, especially in combination with B6. You can buy them separately or they also with a prescription can come together. And this is really the first line kind of pharmacologic treatment for nausea and vomiting of pregnancy. If you can’t get the combined pill, you combine them separately and sort of tailor it to whatever helps you. The kind of first way that you would take this is to take the doxylamine at night, Unisom, you know, it’s a sleep aid. So, ideally the kind of first step is to take it at night so that it doesn’t impact your alertness during the day but kind of escalating to taking it twice a day in different doses of escalating doses.

Dr. Fox: Yeah, this is one of the most fascinating discoveries and it’s been known for, you know, 50 years that combining vitamin B6 and doxylamine or Unisom together is very effective for nausea for pregnancy. It’s not particularly effective for nausea for any other reason, right? If you have like a gastroenteritis or unfortunately you’re getting chemotherapy or something and you’re nauseated from it, this is not gonna help you. It’s something unique to nausea, vomiting, in pregnancy, and we don’t really understand…

Dr. Spiegelman: We don’t know why.

Dr. Fox: Yeah, why these things work, but they do. That’s number one. Number two, there’s a tremendous amount of data how safe this is. It’s a remarkable story. In fact, like in the ’70s and ’80s there was a lot of lawsuits claiming that this combination caused birth defects, and it was just total nonsense and literally the court like threw it out, like summary judgment, like this is total bonkers because it’s been studied so much and it’s so obvious that they’re safe, that essentially this is the first line. And it’s also great because again, this is something you can get over the counter if you don’t have access maybe to your doctor or midwife to get a prescription of this. You know, you can buy the Unisom over the counter. You can get generic, it’s not expensive. You could sort of mix and match. You could take it like you said, just at night. You could take, you know, one pill which is 25 milligrams, or two pills which is 50 milligrams at night. If you’re having a hard time sleeping, this will help you with that as well. And during the day different people tolerate it differently. It’s like a Benadryl, some people it makes them very sleepy during the day and they can’t take it. Other people they can. You can break it in half, take a lower dose. And then you take it with the B6, which has no side effects and it really works. And if you can get the prescription which puts them together, what’s interesting is they sort of make it like an extended release, so it doesn’t tend to make people as sleepy.

Dr. Spiegelman: As sleepy. Yeah.

Dr. Fox: The one that puts ’em together. So, that’s aside from taking fewer pills, although it doesn’t actually end up being fewer pills because you have to take like two or three or four a day based on the, you know, sort of which one you use, but it does tend to not make people as sleepy when you get the combination. So, this is really good and this is like my first line, and this should not be withheld from anybody who wants it or needs it. You know, this is like definitely should be done.

Dr. Spiegelman: Yeah, absolutely. And people really do, a lot of people really do feel better with just this, and they can kind of stop the algorithm here and they don’t need anything more than that.

Dr. Fox: Yeah, I tell people it’s about 50/50. You take, you know, all comers with nausea, you know, and vomiting in pregnancy and you give them this. Half of them are gonna say, you know, “That’s enough. I’m either good or good enough.” And the one…

Dr. Spiegelman: That’s pretty good when you’re talking about almost everybody being affected.

Dr. Fox: Yeah. No, this is like, yeah, this is, it’s a great percentage. Now, what about things that are sort of first line and probably, you know, safe, but how well do they work? Things like acupressure, they have the wristbands and whatnot, or maybe like getting hypnosis, or sort of like DBT, stuff like that, are those helpful?

Dr. Spiegelman: So, my favorite thing about those studies on these types of therapy is like acupuncture and hypnosis is a lot of the studies are like, “We can’t tell if this is real or a placebo,” and I don’t really understand how that’s different in nausea and vomiting in pregnancy, because a placebo effect where you feel less nauseous is the goal. Like, I mean a placebo effect is not the goal, but the effect of feeling less nauseous is the goal. So, I always think that that’s kinda funny when the studies are framed like that. So, we don’t know for sure if it works, but it might, and it’s almost definitely safe because you can’t really envision what negative effect these things would have on a pregnancy.

Dr. Fox: Yeah, no, I agree. It is like someone’s like, “I’m less nauseous but it’s from a placebo, well, I don’t care.”

Dr. Spiegelman: What is that? Yeah.

Dr. Fox: “Okay. Great.” So, yeah, no, I think and if it works for people, great. They don’t tend to be, at least the acupressure, they’re not particularly expensive. You can probably get ’em on Amazon. I mean, it’s really not, you know, a big deal. You can do formal acupuncture, which is probably more expensive potentially if it’s not covered, but it’s also safe to do in pregnancy. That’s not an issue. So, if it works, great. The one thing that’s now becoming much more common and might be effective but we really don’t know about safety would be marijuana. The smoking, the gummies, the whole thing. Let’s talk about that.

Dr. Spiegelman: So, I would say it very well may work. I think we have work to do to figure out if it’s safe. It may or may not be. I think smoking, probably not, just in terms of all of the effects that we know can happen because being around smoke in pregnancy. Edibles don’t have that same component, but I just don’t think that we can really say that it’s safe in pregnancy and we have other options. So, it would probably not be on my list of recommendations.

Dr. Fox: Yeah, this is tough because it is used for nausea in other situations and it is effective, so it’s definitely possible that someone who’s pregnant and nauseated will feel better because of this. That’s definitely a possibility. We really, the data on if and how this affects like fetal brain development, we’re still working out. There’s definitely some studies that are concerning about the possible effects of marijuana and brain development. Again, I’m not saying that to be an alarmist, like it may not be that bad, but there are early studies that indicate there may be some problems with this. And since we haven’t sorted it out, we don’t have enough data on people in the age of legalization where it’s not used at the same time as other illicit drugs. And, you know, it’s sort of like people are, like, sort of having a healthy life and using this in pregnancy. We’re still sorting that out.

Another interesting thing though is people who use it a lot when they’re not pregnant, sometimes their nausea and vomiting will be due to like the withdrawal, like not…

Dr. Spiegelman: Withdrawal. Yeah.

Dr. Fox: …using as much. And that’s something to sort of, we have to start asking about that now because since, you know, it’s legal and it’s so much more common like, “Hey, are you taking less than you did before?” And sort of try to, you know, figure that out, it could work in both directions, but right now it’s not recommended as a treatment.

All right. So, let’s say you’ve done these things, the ones that are basically safe, somewhat effective, not working, someone’s still pretty sick or they’re getting sicker. What’s the next line?

Dr. Spiegelman: So, then we move on to kind of these other categories of medications. So, common names, Reglan, Zofran, Pepcid, lots of different medications that can mitigate these symptoms. And the way in which we use them, there’s kind of a lot of options of like a mix and match, combining things and the order in which to introduce them. Reglan is one of the probably more popular ones, and that some people may have heard of. It’s probably safe in pregnancy. All of the data that we have suggests that it is and it tends to be effective. Zofran is another kind of famous medication which was very popular for a long time and still is. There was some data to show that potentially there may be some association with some birth defects, like especially in the heart and in the palate. Sort of loose association. Most of the data suggests that it’s safe and effective, but it’s one of those where, you know, before 10 weeks we would maybe not give it as readily as after 10 weeks just because of that possible association, but most of the time we would not expect there to be an issue from Zofran.

Dr. Fox: Right. And 10 weeks is just because at that point…

Dr. Spiegelman: That’s when all the [inaudible 00:28:15].

Dr. Fox: Exactly. And that’s an important thing like medications that even if let’s say there’s questions about the safety, meaning it’s not unsafe but it’s just not sure, that’s really only for early in pregnancy. Once you get into the second trimester, that sort of falls off, I mean except something like alcohol or potentially marijuana stuff with brain development, that’s like a different issue, not birth defects specifically.

Dr. Spiegelman: Birth defects. Yeah.

Dr. Fox: So, that’s an important distinction to make. Okay. And so how do you decide when and how to use these medications?

Dr. Spiegelman: So, if someone has kind of failed all of these first-line therapies that we’ve been talking about, and if they’re still experiencing significant symptoms that are affecting their life or if they’re getting more severe towards the hyperemesis gravidarum end of the spectrum, they need to be hospitalized. These are all reasons you would kind of escalate medications. What’s nice about some of them is they don’t all need to be given orally. So, like Zofran for example, I mean, this is oral but there’s a disintegrating like dissolvable tablet, so you can just kinda like stick it under your tongue, you don’t have to swallow it. Some of these medications come in suppository form, which is, I don’t wanna say nice, which is convenient if you are vomiting.

Dr. Fox: Right. Less unpleasant.

Dr. Spiegelman: Yeah, exactly. So, if you already gotten into this cycle of, “I’m nauseous and I’m vomiting everything that I consume,” then an oral swallowable medication is not necessarily gonna help you because you may just throw it back up or it might even precipitate more nausea. So, something that you don’t have to swallow can be really helpful.

Dr. Fox: Yeah. Like you said, there’s no specific line of treatment that everyone follows exactly the same way, but basically there’s a bunch of these medications out there. It’s not always predictable which one’s at which dose is gonna work on somebody. And so, you just try different things until something works. And like you said, if they’re really, really sick and can’t swallow pills, all right, I’m gonna start with something that’s either dissolvable or a suppository. And if they can swallow pills, maybe something else. And you sort of work your way around. But the key is it’s with all of these is there’s frequent feedback. Like these things should work pretty quickly.

Dr. Spiegelman: Quickly.

Dr. Fox: I mean, the medications should work if not immediately, like within a day or two. I mean, you’re talking about very, very quickly, and if it’s not, all right, we gotta, you know, pivot. Either add something or try something different. And really do that. It’s not just something, “Hey, try this for three weeks and come back.” There has to be such a feedback.

Dr. Spiegelman: Another thing also when you’re at this level of treating is not waiting until you feel sick to take some medication because at that point it can be too late. It’s really hard to kind of get out of the cycle of nausea and vomiting once you’re in it. And so these medications are prescribed around the clock to prevent the symptoms from developing, so really take them that way.

Dr. Fox: Yeah, I 100% agree. I almost always tell people start by just taking it, whatever it is, twice a day, three times a day, however it’s prescribed. And then if you’re like, “This may be too much,” back off and see what happens if you go from three times a day to twice a day or extend the time between them. And you’ll know pretty quickly how that makes you feel, but don’t start… You don’t wanna ease in slowly. You wanna like be better and then you can back off them. And they don’t tend… You know, these medications don’t tend to have a ton of side effects. Some of them make you sleepy. Zofran can make you constipated but nothing crazy. There’re some people who have reactions to medications like Reglan that are rare but a little wonky that we ask about sort of like with movement and neurologic and stuff. So, we like to know that.

I think also, another important point is sometimes there’s a cycle where if you get dehydrated you feel more nauseous, and then you can’t drink. And so part of this also is during this trying to figure out a way to stay hydrated. And so, it’s much more so about your fluids and your hydration than it is about your calories.

Dr. Spiegelman: And food. Yeah.

Dr. Fox: And so if you can get liquids in, get some Gatorade in, get some, you know, soda and get some juice in, whatever it’s you could tolerate, that’s great. If there’s some sugar in there, great. If not, that’s okay. And the same thing, if you could tolerate very small amounts of food, maybe try something that has water in it, you know, like melons or popsicles or, you know, whatever. And that’s more to stay hydrated because not only is that the most important thing you need physiologically, it also is something that’s gonna help you feel better.

Dr. Spiegelman: Yeah. It’s really, really important to stay hydrated and that’s usually actually what I tell people who are kind of at this level of feeling unwell is the goal is not for you to be eating beef, the goal is for you to be able to drink and to have like really small amounts of food.

Dr. Fox: Yeah. Yeah. You can go without a lot of calories for quite some time interestingly. It’s as long as you stay hydrated.

Dr. Spiegelman: Yeah. It’s the hydration.

Dr. Fox: Yeah. All right. So, let’s say we’re trying these things and someone was just getting sicker. And I would say at this point they’re in the hyperemesis category. If you’re trying these medications and they’re getting sicker, they probably, they may have already crossed that line, but certainly by now they’ve crossed that line.

Dr. Spiegelman: So, this is where sometimes people actually need to be hospitalized so that we can hydrate them through an IV, because sometimes we’re at the point where we can’t really have… The person can’t take in anything orally and so we do need to give things IV, hydration, medications, whatever it is, nutrition. Before you are hospitalized or at the same time kind of the next step is potentially introducing steroids. This is also something we try to reserve for after 10 weeks if possible. There’s an association between steroids and cleft lip and palate before 10 weeks. You know, it’s still not common, and most people who take steroids in that early pregnancy period won’t have that happen. Like the vast, vast, vast majority won’t. But because of that association we try not to do it as a first line and we try to kind of wait until after 10 weeks if possible. But a short course of steroids can be very, very effective in sort of breaking the cycle of nausea and vomiting.

Dr. Fox: Yeah, and I think that when you get to this point, essentially what’s happening is we’re crossing the line from giving you treatments in pill form to you need something intravenously. And usually, it’s gonna start with fluids, right? That’s usually the first sign that someone’s just clearly not getting enough fluids, they’re dehydrated, they’re miserable. And we could tell that just based on their history, their physical, sometimes we can do a quick urine test and see that they’re dehydrated, but basically they need to get intravenous fluids and sometimes they’ll need intravenous medications. Though, again, some of the strong intravenous medications like Zofran is one of the strongest, like you said, there is a dissolvable pill. So, it’s not as much the medication as the fluids. And if they really, really can’t tolerate anything, any food by mouth, sometimes we have to make a decision how to get calories in them or vitamins in them if this is not happening by mouth.

And so, usually, if we start with fluids and sometimes that’s enough to just, if they get fluids twice a week, once a day, like whatever it is that they could sort of get by, but others can’t. And what’s tough about this is there’s really nothing about intravenous fluids that requires someone to be in a hospital, right? You don’t need to be hospitalized to get fluid. It could be done in a doctor’s office, infusion center, sometimes at home. It’s just so hard logistically sometimes to do this. Some people are fortunate enough that it could be arranged, they can get a nurse to come to their house and this. They can either they can pay for one or insurance covers it. And others it’s essentially impossible. So, a lot of the, are you seen in an emergency room, are you admitted to a hospital, or do you stay at home and go to your doctor’s office? Is purely logistics. It’s not so much the actual treatments.

Dr. Spiegelman: That’s true. I mean, I think there’s definitely a lot of hoops that we need to jump through to get somebody to IV anything at home. It’s not impossible, like we do it, but sometimes just it’s so much easier to do that in the hospital setting that that’s the default and that’s what ends up happening. I will say one sort of plug for being in the hospital is like if we’re still kind of working through which therapies are gonna work for someone, sometimes we can do that a lot faster in the inpatient setting because we try something, it works or it doesn’t work, and then we try something else even that same day. So, that’s one sort of benefit of being admitted. And these admissions do tend to be pretty short, like a day or two while we just figure out how to get you rehydrated and what therapy regimen is gonna be most effective for you.

Dr. Fox: Yeah, and also there’re certain things where you have to get blood work and give certain things based on the results of the blood work, and that’s just very hard to do unless you’re, you know, in a hospital getting seen, you know, by nurses and doctors all the time. And yeah, absolutely. I’m not, you know, anti-hospital.

Dr. Spiegelman: Got it.

Dr. Fox: You know, I’m in one. But it’s just, no, I hear you, it’s tough. And that’s sort of one tough decision is do we park someone in a hospital for, again, one day, two days, three days, whatever, versus not? And then another one is if and/when it gets to the point that it’s pretty clear that for the foreseeable future this poor person’s not gonna be able to eat anything by mouth, what do we do? And that’s a tough one.

Dr. Spiegelman: It’s hard because, so sometimes people do end up needing basically IV nutrition, and that’s usually the category of people who have really, really severe nausea and vomiting that lasts for many weeks, potentially the entire pregnancy. Because like we said, you can go without calories for a period of time as long as you can stay hydrated, but, you know, a whole pregnancy you can’t go without eating anything. And so some people do require nutrition through an IV, but that’s really hard to do. They require special types of IV lines and those lines do have some risk associated with them, especially in pregnancy they can get infected and they can, you know, cause a host of issues. And so we really reserve that for the sickest people.

Dr. Fox: Yeah, it’s tough because the alternative to that is sometimes putting a tube up their nose, down their throat, into their stomach or the small intestine, which is probably safer than doing the intravenous line, but certainly uncomfortable to say the least. And it’s a really tough situation to be in either way. But that’s sort of, again, reserved for the sickest of the sick who are gonna be probably without calories for prolonged periods of time and we just have to give them nutrition one way or another. That’s a tough situation, but it happens, and we can get people through pregnancy with this. And if they’re treated well then they will be okay, and the baby’s gonna grow, and they ultimately will deliver and feel better, but it requires a lot of care. And again, hopefully we don’t get to that point, but it does happen even with the best of care.

Now, there actually is a nice resource for people out there. There is a hyperemesis foundation, and they have, you know, some good stuff online and some good information. There’s a lot of evidence-based stuff there. It’s, you know, not everyone follows it exactly the way that the website puts it up. But in addition to this podcast and instead of just doing the Google, it’s a pretty easy website, it’s hyperemesis.org, which is fortunately easy to remember, but that’s a nice resource for people in addition to Dr. Spiegelman.

Dr. Spiegelman: Yeah. It is a good resource and it’s good that they nabbed that domain name.

Dr. Fox: Yeah, we can try and buy it. I think just as a review, again, like we said, just from the basics, it’s really, really common and it’s mostly sort of “fine” in terms of like the pregnancy and outcomes. So, that’s the positive side of the coin. But on another side we really can’t neglect or forget the fact that this is quite distressing and debilitating for a lot of people, and really deserves to be addressed and treated. People should be able to function as best as humanly possible and enjoy their pregnancy as much as humanly possible, especially if there are safe and effective ways to get them there. And so, that’s like a really important message. Like don’t blow it off yourself, don’t blow it off on others. Really pay attention to this because, again, we can treat it for almost everyone.

Dr. Spiegelman: Yeah, I think that’s the takeaway is speak up. Like ,if you are experiencing this, tell your doctor or tell someone, and there are treatments out there, there’s therapy and there’s ways to make you feel better so you don’t have to feel miserable just because you’re pregnant.

Dr. Fox: Wonderful. All right. Spiegs, thank you so much for coming on the podcast and talking about this really important topic. I appreciate it.

Dr. Spiegelman: Thanks for having me.

Dr. Fox: Thank you for listening to the “Healthful Woman” Podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s H-E-A-L-T-H-F-U-L-W-O-M-A-N.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

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