Grounded Pregnancy: Evidence-based Advice for Morning Sickness and Hyperemesis Gravidarum

Welcome to my new series, Grounded Pregnancy, where I will explore topics related to pregnancy and childbirth, without the woo or natural childbirth bullshit found all over the Internet. As an added bonus, you get to join me for the next eight months, as I grow a tiny human in my uterus. TMI note: As amazing as it is to grow a human in your body, pregnancy is not pretty. Feel free to message me with your pregnancy and childbirth-related questions and concerns, and I will find you woo-free answers.

Yes, it’s true. I’m pregnant. Yay. A couple of months ago, my husband and I decided to pull my Nexplanon goalie and try to conceive. We had no idea how long it would take, but we wanted to make sure I had the chance to run my first full marathon first (I did). Also, we had been planning a late honeymoon in Hawaii, and I wanted to drink a few Mai Tais (I did). As it turns out, we were able to conceive right away (which makes me reflect on all of the times over the years I didn’t want to get pregnant, for which I am eternally grateful for access to effective birth control).

This is my third pregnancy. My first was fairly uneventful and even pleasant at times. I had some morning sickness, but it passed after about 12 weeks of ginger ale and lemon drops. I was able to stay active and had an adorable baby bump and share cute anecdotes about running a 24 minute 5K, eating 5 lbs of clementines in one sitting, and dreaming about faeries bringing me a changeling. My second, however, was a doozy marked by months of Hyperemesis gravidarum (HG) a severe form of nausea and vomiting in pregnancy.

It took months for me to find the right combination of medications – exhausting months caring for a busy toddler by myself, who quickly learned words like nausea, vomit, and dehydration, trips to the ER for fluids and IV medications, uncontrollable vomiting (many times so intense I would pee myself or break blood vessels in my eyes), while people helpfully suggested that I try saltines and ginger ale, and then finally finding some relief through the miracle of Zofran (ondansetron), which unfortunately was not covered by my insurance, and which had been demonized on social media causing me tremendous guilt and worry.

HG impacts many pregnant people, including at least one of my GP colleagues, and many suffer in silence and don’t get help until well into their pregnancies for a variety of reasons. Namely – non-supportive work and home environments, inadequate medical leave, bullshit cultural ideas about women’s illnesses being made up or exaggerated, and the media’s tendency to portray morning sickness as a bad hang over.

As you can imagine, I was nervous about getting pregnant this time around. I remember having a conversation early on with my husband about what I would do if I had HG again – don’t wait, call my health care provider, get help. Breathe. And at about six weeks, the first waves of nausea hit long before my first prenatal appointment. And the hits kept on coming – uncontrollable nausea, intolerance to heat, smells, textures and movement, frequent vomiting, dehydration, repeat.

Luckily, I got help early (IV fluids and medication), and have a wonderful, supportive partner, a great health care provider, and a flexible work situation. I took a leave of absence from one job and am finding a new rhythm to my pregnant life punctuated by ding of my thrice daily reminders to take my medication (currently Diclegis and Zofran + Colace for the resulting unreal constipation – as if HG wasn’t bad enough). I still get carsick (no Skepchick Con for me this year), and am trying to cope emotionally with a daily routine that no longer includes running and cycling, but for the most part, I will survive.

What’s different this time?

HG treatment has come a long way in the United States in the past four years. Diclegis (a time-release tablet containing doxylamine succinate – an antihistamine found in over the counter sleep aides and pyridoxine hydrochloride – vitamin B6) was approved by the FDA to treat nausea and vomiting in pregnancy. While pregnant people have been taking a combination of Unisom and vitamin B6 to treat morning sickness for years, this time-released formulation works better than taking OTC doses and/or cutting pills in half (which I tried unsuccessfully during both my last and current pregnancies). When my OB prescribed it, I honestly didn’t believe it would work. I was shocked after day three when I finally felt some relief. The key is taking the drug nightly and adding daytime doses on a schedule  to keep a certain level in your blood stream at all times, hence my alarms.

The other good news for people with HG is that a recent UCLA study shows that despite what you might read on social media or in magazine solicitations from class action law firms, exposure to Zofran is not linked with birth defects. In fact, the birth defects once thought to be connected with the drug, may actually be linked with HG that is NOT managed well, possibly related to nutritional deficiencies during pregnancy. Women in the study group who took Zofran reported fewer miscarriages and terminations and experienced higher live birth rates. Yay for Zofran.

For more evidence-based advice, I sat down with my favorite grounded midwife, Anette Ferrell, MSN, ARNP, CNM, to talk about the best woo-free ways to survive HG.

What’s the difference between morning sickness and HG?

Morning Sickness (which can actually happen any time of day) is believed to be caused by elevations in HCG and estrogen affecting the nausea center of the brain. Morning sickness is characterized by nausea, occasional dry heaving or rare vomiting, food aversions, and decreased appetite and generally resolves by the beginning of the second trimester (around 14 weeks). It tends to be worse in the morning because of the stomach is empty. This is believed to be an evolutionary response: the first trimester is when teratogens will affect fetal development and organogenesis, so if you don’t eat anything noxious, you are less likely to cause a defect in your baby.

Hyperemesis Gravidarum is a severe condition in pregnancy with intractible nausea and vomiting, associated with weightloss, dehydration, acute starvation, malnourishment, and electrolyte imbalances. HG is a very severe form of nausea and vomiting of pregnancy affecting up to 3% of pregnancies and requires immediate medical intervention. A pregnant woman should call her OB or midwife if she is unable to keep down fluids and food down for more than 8 hours. Signs of dehydration to look for include decreased urination, abdominal pain, dizziness and weakness.

Is HG dangerous? What are the long-term effects of not getting it under control?

Risks to the fetus from HG are associated with malnourishment, in severe cases, can cause low birth weight or small for gestational age babies, but for the most part, the fetus takes what it needs from the mom, further depleting her stores. Miscarriage is less likely with morning sickness and HG. Very rare cases of fetal demise have been reported in the literature, but essentially this condition affects the mother.

What advice do you give people with morning sickness?

For people with just nausea and occasional vomiting, or uncomplicated morning sickness we encourage Diclegis small, frequent high-protein meals, sour candies, and ginger. If these measures don’t help stop vomiting, a patient should call their provider right away.

What is your recommended protocol for treating HG?

In our practice, if a client calls with vomiting unresponsive to conservative measures, we send them to the ER for immediate assessment, IV hydration and prescription anti-emetics, such as Zofran or Phenergan. Once the initial episode is treated, follow-up in the office to develop a management plan, which includes Diclegis, Zofran on schedule, small frequent high protein meals, chewable vitamins, and possible outpatient IV fluids 3-5 times per week. Preventing dehydration is very important, because it makes the nausea and vomiting worse. We encourage our patients to not drink plain water, but mix 50/50 with a sports drink or other flavoring they can tolerate. And eat literally anything that appeals to them. When even these measures do not work, we have had patients who required PICC lines with daily IV fluids and hyperalimentation (very rare) with home care nursing visits.

Until I went through it I honestly had no idea how bad it could be. And as an HG survivor, I tell my story so that others know they aren’t alone and can get some real help, and maybe (please) people will stop pushing crackers and folk remedies on people with a serious health condition. More evidence-based information and support for HG can be found at the Hyperemesis Education and Research Foundation.

I am hopeful that the worst is in the past for me this pregnancy. If you need me, I will be here in the dark, drinking Limonata, and marking another good day on the calendar.