Morning Sickness and Hyperemesis Gravidarum

December 14, 2007

The word teleological refers to something that has a purpose or specific design, as in nature.  Sickle Cell Anemia, for instance, makes bad red blood cells happen, which is a tragedy.  Unless you have malaria, which doesn't like the sickled cells too much.  The whole thing of a racial predisposition to Sicklea Cell Anemia for those of African descent, in Africa of course, a continent where malaria happens a lot--well, you get the idea of the teleological implications of Sickle Cell Anemia as a mutation that may have even helped preserve racial survival in certain areas of the world.

Darwin, of course, would just say with a shrug that the Africans lucked out, developing a mutation as a fortuitous coincidence, and that there were just as many extinctions from those who weren't lucky enough to come up with the very random mutation that would save them.  We can't have a perspective on all this, however, because the only ones we can observe are the ones still around.  We don't know about the others who couldn't "luck out."  (Have you ever played pinball and "matched"?)

It is a romantic notion to suppose that morning sickness (nausea and vomiting of pregnancy) is a teleological condition, along with cravings.  That is, there's something unique to a particular pregnancy that would make certain foods harmful to that specific fetus and other foods particularly beneficial.  Unfortunately, teleological theories will always be cloaked heavily in ignorance and even superstition, because you cannot study them scientifically.  It's enough to make you sick!

What Is Hyperemesis Gravidarum?

Hyperemesis gravidarum is an excessive amount of nausea and vomiting, interfering with nutrition and hydration.

But before describing how to "treat" hyperemesis, we have to recognize that there are those who even question the wisdom of eliminating a teleological defense.  Regardless, nausea and vomiting to the point of dehydration is never good for the baby.  When it gets to the point that a pregnant woman can't hold anything down, it's prudent to intervene.

What exactly is excessive nausea and vomiting?

Any nausea and accompanying vomiting that causes weight loss or in which a woman cannot hold down any of her meals without vomiting; any nausea severe enough to compromise nutrition.
When bad things happen to good medicines:  the history of Bendectin

Bendectin was a combination of Vitamin B6 (pyridoxine) and an antihistamine, doxylamine.  It is still marketed in Canada as the drug, Diclectin.  In 1983 it was voluntarily removed from the market by its manufacturer, weary of defending it.  Its bad rep was much more of a populist uprising, fueled by tabloid accusations of deforming babies; scientifically, it could never be proven that it caused any more developmental defects than were present in the general population.  But the witch hunt and mob frenzy prevailed, and Bendectin is no longer available in the USA, except by a little creative alchemy (see below).  Personally, I miss the stuff.  I used it before 1983, and it really helped a lot of my patients.  Other antihistamines have been used for nausea as well, calming the labyrinthine inner ear.

So what are we left with?

Emetrol--An over-the-counter mixture of sugar syrups and phosphoric acid ( phosphorylated carbohydrate solution), it acts by soothing the actual wall of the gastrointestinal tract.  But since hyperemesis more than likely originates in the head, not the stomach, it may help--but it may not.

Prescription medicine

Compazine (Prochlorperazine) and Phenergan (Promethazine)--these are phenothiazine-like drugs, meaning that they act centrally in the brain to relieve nausea.  Technically, they're sedative-antihistamines, like the doxylamine in the old Bendectin.

An allergic reaction to phenothiazines is not like in other drugs.  With other drugs, one may develop hives.  But with phenothiazine reactions, there can be abnormal eye movements, protruding tongue, a feeling of tongue thickness and with it difficulty speaking.  Called oculogyric symptoms, this presentation will worry a patient greatly (understandably so!) until a trip to the ER for a Benadryl shot--the same thing for hives--which will usually cure the problem.

Tigan (Trimethobenzamide) is an actual antiemetic (anti-nausea medication), probably related to anesthetics.

Zofran (Ondansetron) is a newer very powerful antiemetic, the exact mechanism of action unknown.  But it has no real toxic levels and doesn't seem to interact badly with other drugs.  It's used to great effect for nausea after surgery.  It is extremely expensive.  (You get what you pay for!)

Wait a minute!  I'm pregnant!  These are drugs!

Compazine and Phenergan have been around for generations.  Like all prescription medicines, there is always the legal disclaimer to weigh the risks versus the benefits (theoretical risks to the baby from medicine vs. risk to baby from the dehydration of nausea).  But these have been used with little concern for generations I might add.  Hyperemesis is risky to the mother as well as to the baby.  The retching that accompanies vomiting, when severe enough, can tear the esophagus (Mallory-Weiss syndrome) or even the trachea (Boerhaave's syndrome).  These are very, very rare, but I've had cases of each and they're not pretty.

Tigan, likewise, has been around for a long time and has likewise been used with a comfort level.  Also, Tigan is a good replacement for Compazine and Phenergan if there's a phenothiazine allergic reaction.

Zofran, although newer, seems to cause no harm.  In fact, home health agencies have even used it in a pump-delivery system to great effect.  It's also available in pills.

Before slapping down that drug card...

You need to know that hyperemesis, although common, is abnormal.  Your doctor needs to rule out other causes of extreme nausea and vomiting in pregnancy.  Other causes:

  • hyperthyroidism--either the real thing or a hyperthyroid-like condition because of too much hCG (pregnancy hormone), as in hydatidiform moles and multiple gestations.

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  • gall bladder disease--The gall bladder, like the intestines, is sluggish in its own job of eliminating bile, leading to distention, inflammation (cholecystitis) and even stones (cholelithiasis).  Nausea is a common feature of gall bladder problems.

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  • HELLP syndrome--an end-stage condition of Pregnancy-induced Hypertension (PIH), there is liver toxicity from the pregnancy.  But this is a condition well out of the first trimester, which is when hyperemesis is most likely seen.  Any nausea and vomiting after 16 weeks or so is probably no ordinary morning sickness gone awry.

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  • appendicitis--almost always associated with nausea, the actual point of the pain may not be in the classical right lower quadrant, because the increasing size of the uterus will push the position of the appendix up during the pregnancy. 

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  • other gastrointestinal problems, like Irritable Bowel Disease (Crohn's Disease or Ulcerative Colitis), ulcers, hepatitis, pancreatitis, obstruction of the intestinal tract from adhesions, etc.

   Also, before jumping to prescriptions, there are other ways to address hyperemesis:
 

  • Change of diet--low fat, low sugar diet, with a lot of vegetables and fruits.  Many homeopathic clinicians feel the liver is getting the brunt of the pregnancy, causing the nausea, so a diet that doesn't stress the liver is seen as an answer to decreasing the nausea.
  • Avoid caffeine and of course nicotine.
  • Raise Bendectin from the dead!  Even though Bendectin is no longer commercially available, may obstetricians and gastroenterologists consulted by them are making their own.  It is simply a combination of pyridoxine (Vitamin B-6) + Unisom.
  • Acupressure--Pressure on the NeiGuan Pressure Point (P6).  Apply direct pressure either with fingers are with the use or wrist bands.  The P6 Point is about 2 inches below the wrist crease dividing the wrist from the hand, on the underside of the wrist, between the two tendons.  Studies have disagreed as whether it helps with hyperemesis or not.  Like most therapies, it probably works for many women.  One commercial product is a wrist band, powered by a battery, which gives continuous electrical stimulation to P6.
  • Other cited pressure points are the "liver"  (Liver Meridian 3, or Li3 Taichong) and "spleen" (Spleen 6, or Sp3 Sanyinjiao) points.
  • Hypnotherapy--the problems with this is that it's a long therapy during which time the nausea of pregnancy may abate on its own.  There are no studies to support or refute it.  Certainly, though, if nausea is perceived in the brain, relaxation training and behavior modification may provide help to some.
  • Herbal--Ginger has been used for centuries for nausea.  But high doses may affect the testosterone-receptor binding and sex steroid differentiation in the fetal brain.  But this theoretical possibility seems to be dose-related, and since it's never been observed or proven, these warnings are vague at best.  A cup of ginger tea (~250 mg. of ginger) is much less than the 3 - 12 g (3,000-12,000 mg) that would worry those knowledgeable about traditional Chinese medicine and who worry about effects on the fetal brain.  Ginger tea bags would result in the smaller dosage.  3 - 8 capsules of standardized ginger root upon rising, then 3 - 5 more capsules throughout the rest of the day has been recommended by Shari Lieberman, PhD, a biochemist and clinical nutritionist, as cited in the April 1999 issue of OBG Management, a practice management and patient care magazine with a wide traditional physician audience.

Management of hyperemesis gravidarum, in chronological order:

1.    Thyroid function tests to rule out hyperthyroidism; hCG determination to rule out hydatidiform mole-like conditions.
2.    Avoid foods known to worsen the situation, like dairy products or fatty foods.
3.    Emetrol, home-made Bendectin (pyridoxine + Unisom), herbal ginger tea.
4.    Prescribed Compazine, Phenergan, or Tigan.
5.    Prescribed Zofran.
6.    Parenteral hydration.  The dehydration of nausea and vomiting can make the nausea worse--a vicious cycle. An IV with fluids can break this chain.  Usually one overnight stay in the hospital with a liter or two of merely physiologic solution through an IV can cure a severe hyperemesis episode.
7.    Zofran pump--a continuously delivered dose of Zofran, managed by a home health company, like Matria.
8.    Psychiatric evaluation--yes, some patients just may have a psychosis or neurosis.
9.    Parenteral nutrition--IV infused nutrition.  If this is necessary, then something's been missed, because there's something else besides pregnancy going on.

Conclusion

Although it may be the sign of a healthy pregnancy, still hyperemesis gravidarum is not pleasant.

It's not "cute," even though it's the running joke of identification with the otherwise joyous condition of pregnancy.  Throwing up is a massive physical upheaval that can trap us in a body that we're powerless to help.  I know.  I've been to college--I've called Ralph on the big porcelain phone myself.  But whether it's teleological or merely the unfortunate chemical struggle between two persons occupying the same body, it can have serious consequences if unremitting for any period of time.  All of our treatments are band-aids at best.  But what I've presented is what we have.

So far. Sometimes the best treatment will be what is called the Tincture of Time, because when the hCG levels plateau at around 12 weeks, hyperemesis usually resolves as mysteriously as it developed.And with the second trimester, teleological gives way to existential.

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