A Treatment Guide for Clinicians
Chuck Gebhardt, M. D.
The following is the introduction to my monograph that discusses hyperemesis gravidarum along with a short discussion of the importance of properly managing this condition. The remainder of the text is now available as an eBook from Amazon.com (http://www.amazon.com/dp/B00DMJU0GK). For patients or clinicians who have questions about the recommendations in the book, just place your question on this site in the comment area and I will respond to it as soon as I am able.
This book is an updated version of an article I had written for obstetricians that was first published in 1994. At that time, I had summarized about ten years of my experience treating some of the most severe cases of hyperemesis gravidarum with total parenteral nutrition (TPN). In the interim, I have developed some new and very useful strategies that often make the use of invasive feeding, such as TPN, unnecessary. This revised version includes the content of the earlier version with the new strategies included.
First, you may want to know a little of my background. I began my formal training in nutrition with a BS in Nutritional Science from Drexel University in Philadelphia. Throughout my medical training at the University of Pennsylvania, my residency training in internal medicine, and my medical practice here in Albany, Georgia, I have focused on medical nutrition as a subspecialty to my internal medicine specialty. When I first arrived in Albany, our local obstetricians began to refer their hyperemesis patients to me because of my expertise in medical nutrition. Not a lot has changed in the fifteen years since I wrote my original article, but I have learned to be much more proficient in treating this problem in its earliest stages, making the need for TPN much less frequent.
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When nausea and vomiting develop early in pregnancy, most of the time it will be the typical “morning sickness” of pregnancy. This condition will usually resolve itself by the end of the first trimester and may even confer an improved prognosis compared to pregnancy without this problem.[i] However, for a small percentage of these women, nausea and vomiting will continue to worsen and will result in dehydration, electrolyte abnormalities and possibly significant malnutrition if not recognized and appropriately treated. Unfortunately, we do not have a test at present which will allow us to predict which of the women who appear to have typical “morning sickness” are actually in the early stages of hyperemesis gravidarum
Standard care for “morning sickness” is the appropriate initial management for all pregnant women who develop nausea and vomiting. For many women, no intervention is needed. For the more symptomatic women, separating the timing of the consumption of dry foods from liquids and/or minimizing the amount of the fat in the diet can be helpful. Restriction of activity can also be helpful.[ii] I now recommend starting vitamin B6 (pyridoxine hcl) 50 mg., three times a day, as soon as nausea and vomiting start. This vitamin is quite safe at this dosage and highly effective.[iii] If dietary adjustments, reduced activity, and vitamin B6 supplementation are not effective, oral Zofran, Phenergan and/or Reglan can be safely used and can be quite helpful. I add medications to control stomach acid if acid reflux symptoms develop due to vomiting.
When complications develop despite these conservative efforts, hyperemesis gravidarum is present and more intensive management is indicated. Before, I go into the specific management steps I recommend in this stage of the disease, let me very briefly review why we need to be concerned about malnutrition during pregnancy.
RISKS THAT RESULT FROM MALNUTRITION DURING PREGNANCY
A very high risk of poor outcomes has been extensively documented when a pregnant woman’s food intake is inadequate or of poor quality.[iv] Malnutrition, as indicated by inadequate weight gain, has been shown to dramatically increase perinatal mortality. The perinatal death rate for women with weight gain less than 25 percent of expected was 200 percent higher than women with appropriate weight gains in the Collaborative Perinatal Project. While maternal malnutrition results in only a small increase in pregnancy complications, once a serious disorder is established, large increases in fetal mortality are noted for women who are seriously malnourished. For example, in cases of abruptio placentae, fetal mortality rates in malnutrition are over 400 percent greater than in woman with optimal weight gain, and placenta previa confers a 700 percent increase in fetal mortality rates.
Maternal malnutrition has also been shown to result in fetal malformation. A high rate of severe malformations results from pregnancies complicated by acrodermatitis enteropathica, A form of zinc deficiency, have been clearly documented.[v] Neural tube .defects have also been shown to be linked to inadequate folic acid intake.[vi] Animal studies strongly suggest that deficiencies of numerous other nutrients play a role in fetal abnormalities.
Brain development has also been shown to be compromised in cases of maternal malnutrition. Autopsy studies of Chilean children of malnourished mothers who died in the perinatal period show a dramatic decrease in brain cellularity compared to children of well-nourished mothers. Animal studies and indirect evidence in humans suggest that catch-up brain development is incomplete after a period of malnutrition during pregnancy.[vii] This would imply that permanent cognitive defects can result from periods of maternal malnutrition.[viii]
Clearly, the available evidence suggests that malnutrition during pregnancy and the resulting increased mortality, fetal malformations, and impaired brain development should be avoided whenever possible. Studies of nutritional intervention in populations with high rates of malnutrition have shown improvements in both morbidity and mortality, confirming that malnutrition is the direct cause of these poor outcomes.[ix]
Link to book: Medical Treatment of Hyperemesis Gravidarum: A Clinicians Guide to the Treatment of ‘Morning Sickness’ [Kindle Edition]
What causes ptyalism gravidarum . Is it Hormones or some vitamin deficiency? What can be done to make this symptom better?
At this point in time, I have treated many hundereds of women with severe hyperemesis gravidarum. I have never done any exact studies, but my impression is that about 20% of women with HG have ptyalism as a complicating factor. (For those who are reading this and unfamiliar with ptyalism, it is the excessive production of saliva, but in the form of ptyalism in HG, it is also asociated with an inability to swallow saliva that causes the need to continually remove it from the oral cavity by spitting). I have treated quite a few people with other causes of malnutrition as well as nausea and vomiting, but I almost never see this kind of ptyalism as a complication of other nutrition-related diseases.
I have found that ptyalism seems to be more common in more severe HG, and when I effectively treat the nausea and vomiting, the ptyalism tends to resolve also. In all my readings about nausea and vomiting in pregnancy, I do not recall any discussion that claimed to understand the process. But, I have never specifically researched the literature on this issue.
I do not know if there is some sort of abnormality in the saliva that makes it repugnant to swallow, or if it is the act of swallowing that is the problem, due to HG. This monograph has been read by people from all over the world and is one of my more popular articles. I do not know, but I suspect many who read it are physicians who treat this condition. Perhaps someone reading these comments may have some helpful input.
Thanks for your question.
There is a woman on the HG Sufferers Facebook Page who has failed 5 PICC lines due to skin infections from them. She has been on TPN, but this was discontinued when her PICC line was taken out. She is now vomiting blood. Her doctor told her that he does not have a plan for her, and neither does the radiologist or nutritionist. Is there a specific hospital or facility where she could go that could help her? Who are the doctors who specialize in HG? Is there a list of specialists who may be able to help her? Could you consult with her doctor? She is very desperate for help.
I would be happy to help advise if this lady’s physicians would like to talk to me. I will send you an email with my contact information. (My email address is listed in the page: New visitors please read this first. This page is accessed within the blog header.)
For the benefit of clinicians reading this, I will give a few general comments that apply to cases of very severe hyperemesis gravidarum requiring IV therapy. When conservative measures fail, reliable IV access is absolutely essential. I use PICC lines sometimes, but a tunneled central line in the subclavian artery is most reliable. If this hasn’t been tried in the situation Suzie mentions, this is what should be done. Any general surgeon should be able to handle this. Once IV access is available, IV therapy to suppress nausea should be maximized (as outlined in my monograph).
When hemetemesis develops during the course of hyperemesis gravidarum, it is almost always due to the frequent vomiting eroding the lower esophagus. Whenever there is any “heartburn,” and especially when bleeding occurs, intravenous proton pump inhibitor medications to suppress stomach acid should be started. Early use of these kinds of medications will improve the patient’s quality of life and usually prevent these erosions from developing.
I am always available to help advise physicians with problem cases. The most reliable way is to send me an email, but I monitor comments also.
Chuck Gebhardt, MD
I would love to know if you know if Epanutin can help to stop vomiting. My daughter battles badly with HG and they prescibe Epanutin today. She don’t get epileptic fits. & months pregnant. 27 times in hospital, lost more than 22kg, 118 drips…. Please help me. Marie
You probably know that Epanutin is a trade name for phenytoin, a medicine that has been used to manage sizure disorders for decades. I have no experience using it to treat hyperemisis gravidarum (HG) and I have no idea how well it works. I am sure the physicians recommending this treatment have this experience or they would not rcommend it. To my knowledge, the use of phenytoin during pregnancy has not been formally studied. In the US, the FDA gives phenytoin a risk classification of D. This means that there is evidence that it increases the risk of birth defects, but it is still reasonable to use if the benefits outweigh the risks. In this situation, it means that one must balance the risk of birth defects (probably very low, but not completely known) with the risks of poorly controlled HG (which can be very significant).
This situation with Epanutin sounds like a very similar situation I was faced with with deciding to use Zofran years ago for nausea and vomiting in HG. We had no formal studies, but several local obstetricians had been using it without any problems. We also knew it was quite effective in many cases. I started using it in difficult situations where nothing else was working. Eventually, after using it for several years, I became quite conmfortable with it in treating nausea due to HG, and now I rely on it heavily, particularly the intravenous forms of it.
A pregnant woman taking phenytoin shoud be receiving folic acid supplemnts as a precaution, though, since phenytoin is known to interfere with folic acid metabolism.
I hope this helps, sorry I do not have more information. Your daughter’s situation does sound very severe, but she is well past the first trimester in her pregnancy — the point where birth defects due to medications are most significant.
My daughter has severe HG with her 4th pg, retching, burning vomiting with strong food aversion resulting in a 10 pound wt loss during her first trimester. We are going to suggest IV therapy to her FP physician. How do you assess (after 2 liters) if you continue? If she still continues to vomit, do you give IV fluids every day? Every other day? Etc. she is 61 inches and 45.5 kg. for the esophageal burning she does take Prevacid. In addition, would you recommend Reglan? And if so, what dose and frequency?
Based on what you say here, your daughter does have severe hyperemesis gravidarum and her ten pound weight loss suggests that she probably has both dehydration and malnutrition complicating this condition. The first question is how bad is her dehydration at the present? It is usually the dehydration that brings pregnant woman into the emergency center or is the initial cause for hospitalization.
It is fairly easy to assess this. If a woman is not able to keep any fluids in her stomach for prolonged periods of time and is not on IV fluids to replace losses, she is virtually guaranteed to be dehydrated. A decreased urine output, with usually dark, concentrated urine helps to confirm this. Once her blood pressure gets low and her pulse gets high, her dehydration is severe and she definitely needs IV fluids. Patients with severe dehydration are often weak and dizzy when they try to stand up, also. When it gets to this point, a woman will generally need to be on continuous IV fluid infusion with the rate adjusted to prevent dehydration. In severe cases I have had women on continuous IVs for over seven months. (Fortunately, this is pretty rare.)
When dehydration gets severe, it almost always means a reliable long term IV catheter will need to be placed. Often this is a PICC line (peripherally inserted central catheter). Once a central line of some sort is in place, I generally begin 24 hour infusion and have experienced home care nurses help me assess the adequacy of the fluid infusions when my patients are at home. I recommend blood work about twice a week to be sure the electrolytes are stable on the IV fluids.
I add intravenous medications to these IV fluids to try to suppress nausea and to decrease stomach acidity when my patient is still vomiting a lot. (I address these medications in my article.) Unfortunately, IV fluids and medications do not always control the vomiting and allow adequate nutritional intake. With the kind of weight loss your daughter is experiencing, TPN will be needed if IV fluids and meds do not allow her to keep enough food in her stomach so she can begin to steadily gain at least some weight.
TPN should not be started by someone who is not trained to properly formulate it and monitor it. It is often life-saving, but it can be very dangerous if not properly handled. In the US, most hospitals have physicians on staff who are experienced in this therapy. The skills needed are not much different when providing for the needs of a pregnant woman compared to the skills needed to treat other patients who are malnourished and incapable of oral food intake.
In your daughter’s case, I will be happy to discuss your concerns with her physicians by phone of email if they are open to this and interested. This can be arranged through emailing me with necessary logistics to make this possible. firstname.lastname@example.org.
I hope this helps and I hope your daughter’s condition improves quickly.
Chuck Gebhardt, MD
Dr. Gebhardt, we were able to get the FP to start IVs for dehydration. My daughter is getting LR (2liters) plus MVI 3xweekly in Infusion Ctr. She is going to try Kytril 1 mg every 8 hours for vomiting since nothing else works. She is now able to eat small amts of food (cheese and crackers) and must fight food smell aversion. You mentioned monitoring electrolytes which is we will suggest. Shouldn’t she at least get dextrose in her IV for some calories? Any other thoughts? She is approx at 12 weeks.
Thank you again!
I think the IV regimen you describe for your daughter in the infusion center is a big improvement over no IV therapy at all. I can tell you how I would manage her situation a little differently, but this is based on the availability of resources in my town that may or may not be available to you.
My guess is that your daughter gets a peripheral IV in her arm each time she comes in for her IV infusion. My preferred approach would be to have a PICC line inserted in her arm and give her infusions 24/7 at home. (This presumes home care services are available in your area to help with this). This would give her a lot more fluids and often helps decrease nausea and vomiting. I believe the Kytril could be added to her IV solutions so she would get a continuous infusion of this medication, if it is helping with her nausea (an IV pharmacist will know if Kytril is compatible with the other ingredients in her Lactated Ringers solution). I have no experience with Kytril, but I assume it works about as well as Zofran, which I use a lot in continuous infusion treating HG.
If vitamin B6 (pyridoxine) has not been tried with your daughter, I would strongly recommend this. I have found this vitamin to be the most effective treatment available for HG. In severe cases of HG, I use 300mg of IV vitamin B6 infused over 24 hours/ day. I mix it right in with the other IV additives in a 24 hour infusion bag. It takes about 3 days of continuous vitamin B6 infusion to know if this additive will be helpful. It is very common for this vitamin infusion (at this dose level) to completely control the nausea and vomiting and allow adequate oral intake to be reestablished.
Our local obstetricians often use Lactated Ringers as the IV fluid base for rehydration. It has the advantage of including some calcium and potassium. But I usually use D5 normal saline solution instead of LR, since it includes about 200 calories worth of glucose per liter. I have noticed that this low amount of glucose seems to be helpful in decreasing nausea in some women (I have no idea why), but this is not a very significant nutritional repletion, in and of itself, if a woman is losing weight.
If your daughter is only getting 2 liters of fluid 3 times a week, monitoring her electrolytes may not be needed to monitor her response to her IV fluid infusions, but if she is still vomiting a lot, it is a good idea anyway since prolonged vomiting can cause electrolyte abnormalities.
I hope this helps and I hope your daughter begins to improve soon.
Chuck Gebhardt, MD
Dear Dr. Chuck,
I have hyperemesis gravidum, am 22 weeks pregnant, with a PICC line and severe anemia, for which I am receiving iron infusions. I am now on 4 liters of Lactated Ringers and .0660 ml of IV Zofran per hour. I had a placental tear, have had cramping & bleeding, and frequent Braxton Hicks (a couple per hour). I also have a history of miscarriage, and am on Progesterone shots twice weekly for low progesterone and also due to the placental tear. I am also on my third hospitalization, the current one being for Bacteremia – a blood infection in my PICC line. I am currently in the short-stay, or observation unit in the hospital. I have a couple of questions: 1.) Have you known IV antibiotics (Ancef, 2 g/ 2 hrs) to affect unborn babies? 2.) Can I stay on the OB unit with this blood infection, or is it considered to be a risk to the other patients? 3.) My OB’s office manager has indicated that I need to call on a less frequent basis because I am overburdening their staff with the number of calls that I am making. She did state that they were all legitimate medical calls. I am concerned because she suggested that I wait until my office visits to address my concerns, and yet so many very serious things seem to come up on a frequent basis. I have not called the office to tell them that I am going to the ER, and did not tell them of my suspicion of a blood infection with the PICC. Today I called and discovered that they had no knowledge that I had been hospitalized and now have a blood infection. Instead, my hospital records had been sent to my family doctor, whom I have not seen for 2 years, and has no knowledge of obstetrics, let alone hyperemesis gravidum, and a PICC line blood infection! How do I explain that I feel that my care is being severely compromised by not being able to contact the OB office as things come up? Do you feel that this is “fair”, given the fact that I have had numerous complications? I now feel anxious about contacting the office, as the office manager happens to be married to the doctor. 3.) The same office manager also complained about the fact that have been lying on their couch with a blanket. She stated that other patients have complained about this and that it appears “unprofessional”. ( I also have had low blood pressure and dyhydration which causes me to be very cold and I did explain to her this fact and the constant nausea and vomiting that is part of my condition. When asked my OB about whether he was okay with me bringing a blanket and lying down, he brushed me off with a statement about “balancing all of the other patients’ needs”
This is an excellent OB, and he has been very aggressive in my treatment and taken very good care of me thus far. I would hate to have another OB who might provide me lesser care or who might not understand my condition as much. Do you have any words of wisdom as to how I can address these issues? I suppose I can wait in my car (not the most pleasant thing) until they are ready for me at the office. However, it bothers me that they are putting “professionalism” and appearances over the sake of a patient’s desire to obtain a small measure of comfort with such a debilitating condition.
Dear Concerned patient,
No medication is without risk during pregnancy, but Ancef’s risk is relatively low. I have used it a lot for central line infections during pregnancy without any problems. Your physicians must always balance the risk of the medication against the risk of not treating the problem effectively.
A central line infection is not a risk to anyone else if standard precautions are used by everyone in your care.
I don’t feel I can give any helpful input about how to interact with your doctor’s office. I can tell you that physicians are usually very careful to surround themselves with competent and concerned medical staff and assistants. Communication problems are unfortunately very common since medical care in the modern office and hospital settings is an exceedingly complex undertaking. Add to this that a woman who has hyperemesis gravidarum often feels miserable, you can see that conflicts may easily develop. Tempers can easily flare. Please try to put yourself in the place of those who are doing their best to help you. Sometimes you just have to overlook policies that are not in line with your wishes.
You say your OB is excellent. Be thankful for this and do your best to calmly and courteously let your preferences in your care be known. Then follow his or her advice to the best of your ability.
Your medical situation is quite complex and I am sure you are both very worried and often feel quite sick. I wish you the best. I wish we had better treatment options for these difficult situations.
i was pregnant three times with hyperemesis gravidarum its no joke got admitted to hospital to much the doctor:’S was treat me with pills and iv i be okay for fews days i get back sick again back in hospital for seven days one day am get on internet find a doctor stop hyperemesis gravidarum thru my pregnancies to this really sad some womans have to go thru this problems plus me >>>>
It is common for women suffering with hyperemesis to be admitted several times for short periods during a single pregnancy. Being admitted to the hospital and receiving IV fluids and IV medications will often bring the nausea under control, but just temporarily. If these therapies are stopped when the woman with HG is discharged, it is common for the symptoms to come back within a few days.
I have treated a large number of women with this problem. Through this experience, I have learned to be fairly quick to place a long lasting central line to be able to continue to infuse IV fluids and medications at home. I have also helped train home care nurses to monitor my patient’s needs once she is discharged to home. Home IV therapy often prevents the need for readmission to the hospital. These days I rarely have to use intravenous feeding, and I attribute this to very aggressive IV hydration and the use of IV meds at home.
My heart goes out to anyone suffering from this condition. It is amazing what mothers will tolerate and withstand to bring babies into the world. I have nothing but admiration and respect them.
Really liked what you had to say in your post, Hyperemesis Gravidarum | Dr. Chuck's Chat, thanks for the good read!
Dr. Gebhardt: My daughter is at 13 weeks and has been receiving IV solutions and vitamins 2-3 times a week which has really helped control her emesis. She is also taking Vit B6 with doxylamine and that has helped too. She is eating and drinking some. The problem we are now facing is a significant clinical depression. She can’t get out of bed this week to go anywhere and is quite sad about facing nausea for at least her 5 th month (when nausea typically has stopped). My question for you is what you have prescribed for pregnancy during depression? She has never needed or taken anything for depression. Any thoughts on possible options is greatly appreciated.
I am glad your daughter is somewhat better. This is good news! One of the things I have learned over the years treating hyperemesis gravidarum is that once it begins to improve, it almost always steadily improves until it is completely gone. It would be a significant mistake for your daughter to expect to be sick for a certain period of time because this is what happened in the past with other pregnancies. Every pregnancy is different. I have seen women have several pregnancies complicated by HG, and then have a nausea free pregnancy. All kinds of possibilities can happen.
I have used a number of anti-depressant medications during pregnancy without any problems. Your daughter’s doctors will balance the risk of drug treatment with the risk of not treating her. Almost all of the available drugs are listed as Category C by the US FDA. This means there are no large controlled studies available to verify safety and effectiveness during pregnancy, but also no reports indicating serious problems like birth defects clearly associated with the drug in question. I have most often used Zoloft, Lexapro and Wellbutrin, all with good effect and no problems. You must rely on your daughter’s obstetricians’ judgment here.
I have used acupressure for HG a lot, sometimes with remarkable benefit (sometimes with no benefit at all, and most often just some value but still worth doing). I have placed an article on my blog that describes how I developed my acupressure technique and how to use it. In my experience, it has been risk free, and anyone can learn to use it without any prior training. It can also be used for many other problems once it is learned. Here is the link should you want to try it:
A Simple, Highly Effective Healing Technique (https://chuckgebhardtmd.com/2011/07/01/a-simple-highly-effective-healing-technique/)
I am optimistic that your daughter will continue to improve throughout the rest of her pregnancy; I wish her the best.
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Muy bueno. Me gusta mucho el modo en que se expone. Un abrazo!
Dear Dr. Gebhardt,
I was wondering if it’s possible to have HG without any vomiting. My friend is 32 weeks pregnant and has lost a significant amount of weight (about 25%) over the last couple of months and says she can barely eat or drink anything, but she has not vomited once during her pregnancy. She mentioned she has HG, but I wasn’t sure if this was possible, as most of what I’ve read talks about severe nausea and vomiting. She has also mentioned that she is repulsed by the thought of vomiting and that it’s “disgusting”, so I sometimes get the impression that she may not be eating so she won’t risk vomiting. Or is it that the nausea can be so severe that she physically can’t eat? I’m concerned for her and the baby’s health, especially if she continues to lose weight. I know she’s on nausea medication and sees her high-risk OB frequently, but do you have any additional thoughts on this? Also any thoughts on things that can be done to help with the nausea? I’d very much appreciate your thoughts and feedback. I want to be supportive and really understand this particular condition.
It is so nice that your friend has someone concerned about her and looking to help.
The problems that show themselves as Hyperemesis Gravidarum (H.G.) are not limited to nausea and vomiting. There is a more basic problem that just has its most dramatic and common appearance as severe nausea and vomiting. There is indeed a form of H.G.where the only thing you see is a lack of appetite and inability to eat. Your friend sounds like she definitely has H. G. without any vomiting. I treat this variant just like any other H. G. Often, the same treatments used to control vomiting also help with improving both appetite and nausea. I would add that vitamin B6 seems to treat this form of H. G. better than nausea medications, and should be tried first.
Even if there is no nausea or vomiting, I still treat this variant with intravenous therapy up to and including intravenous feeding, if needed. It is the malnutrition that is the greatest threat to the baby. Your friend’s malnutrition does sound to be severe.
If it hasn’t been tried for her, I would consider using anti-nausea medications like Phenergan, Zofran and Reglan, either oral or IV if needed. I would definitely try oral vitamin B6 100 mg three times a day, and if she can’t keep this down try it IV for at least 3 days — sometimes it takes that long to start seeing some benefit. It would be also worth your time to look up my article on acupressure and try this for her (https://chuckgebhardtmd.com/2011/07/01/a-simple-highly-effective-healing-technique/ ). Even if it does not help your friend it is a great technique to learn that can be useful for all kinds of problems. And it is both free and virtually risk-free.
I wish you and your friend the best.
Chuck Gebhardt, MD
I am 14 weeks and zofran 8 mg ODT doesnt seem to be helping all that much at this point. It has possibly only stopped excessive constant vomiting. but I am still losing weight. I was overweight before i got pregnant and am now at about 15 lbs of weight loss and zofran and the terrible diet ive had since i was 6 wks caused me to be constipated for an entire month with no bowel movement. I finally needed a hospital grade enema because milk of magnesia, colace, laxatives, and an at home fleet did nothing but cause me the most severe pain and vomiting ive ever experienced. Since i suffered from constipation since before my pregnancy my ob told me to stop zofran but i am worried if i do the little im already consuming in regards to liquids and food will reduce to nothing and i will be back to vomiting even my bile. Im already malnourished and i can consume very few things, sometimes i just vomit from walking to my bathroom if im not careful. My nausea is very strong on a daily basis and it doesnt alow me to consume much of anything. Im really in a catch 22 and i think my ob doesnt know what else to do for me so he referred me to maternal fetal medicine and mentioned a feeding tube and picc line. I really dont want it to come to this but i have no idea how sick I am because I have no idea what to compare it to. What do you think?
Constant nausea and vomiting are bad enough, but I am sure the severe constipation makes this even worse for you. Of the two problems, though, the malnutrition resulting from poor food intake is the most dangerous.
I will address the constipation first. You have three different factors making your constipation so bad right now. You have an underlying tendency toward constipation being aggravated by the hyperemesis. In addition, the inability to keep food and liquids in your stomach causes dehydration as well as decreasing the bulk and fiber that helps your colon to function more normally. Controlling the nausea should improve the constipation (as well as improving your nutritional status), by improving your hydration and improving your fiber intake.
If you were referred to me by one of our local OBs, here is what I would do. If you agreed, I would have a picc line placed in your arm. I would start you on about 2 liters of D5W solution with 24 mg. Zofran, IV vitamins and minerals, and 300 mg. of vitamin B6, and have this mixture to run over 24 hours per day. Often the dextrose in the IVs will help the nausea. Vitamin B6 (if it has not been already tried at this dosage) is often even more effective than Zofran. The benefits of all these are additive. IV Phenergan and/or Reglan can also be added to try to get even better control of the nausea, if needed.
Your electrolytes would be checked with a blood test weekly and the ingredients adjusted as needed. If this strategy worked like I expect it would, it will control the nausea, improve your hydration and allow enough food intake to improve the constipation also. In the unlikely case that all this did not normalize your nutritional status and stop your weight loss, intravenous feeding (through this same picc line) might be considered.
You will need the assistance of your physicians, of course, to try these recommendations. If your doctor would like to discuss them, just send me an email with his or her phone number: email@example.com.
I hope this helps,
Chuck Gebhardt, MD
Thank you very much I will discuss this picc line option with maternal fetal medicine tomorrow. It sounds like a risk im willing to take considering it may improve my quality of life drastically and may even prevent a feeding tube. Thank you for putting it into perspective. Hopefully i wont need it more than a month and by then the worst of it is over, but i know in some cases it may not be. My brother and father are both internists and concerned for me. My parents finally told me I was toughing it out too much. Thank you again for taking the time. Have you written a book? Obs are so little informed about this issue i feel so consistently concerned for women who suffer through this. And why do they say this is a Western society disease?
I am glad you changed your mind. A picc line is much lower risk than the dehydration and other problems you are already dealing with. Besides, If past experience is any guide, you will feel a whole lot better. Picc lines involve minimal discomfort.
Keep in mind that once you begin too feel even a little bit of improvement, this is a reliable sign that you are on your way to recovery. Almost always, whenever you start to improve with this disease, improvement continues until the problem is gone. For most women, the problem resolves itself within a month or two. Exceptions are very rare.
I have published a short eBook on this topic available on Amazon, targeted to physicians. It is targeted to physicians, but does not sell well. I have done little to promote it. That it doesn’t sell well surprised me since there are a lot of people who read this page on my blog. And it is even more popular to readers outside the US than within. (There is a link to this Kindle eBook at the very end of the article, above).
Best of luck to you. Let me know if I can be of any other assistance.
Dr Gebhardt, I suffered from HG during my first pregnancy. We live in a small town with (not to be rude) average doctors. We would like to have another child(our first one is 2yrs old) but we’re worried about encountering the same difficulties again. We had hoped maybe there’s something I can do prior to getting pregnant, and during the beginning of pregnancy to help control it better. Any help you could provide would be great! Thanks, April
It is natural for people to assume that when a woman suffers from hyperemesis gravidarum (HG) during one pregnancy, she will also have the same problems if she gets pregnant again. Fortunately, this is not necessarily true. I have seen all different patterns during multiple pregnancies. A woman could have very severe HG during one pregnancy and never have it again with several subsequent pregnancies. A mild case of HG could be followed by a severe case in a future pregnancy, or vice-versa. I have seen women with two severe cases in a row, followed by completely normal pregnancies. What it comes down to is that having one pregnancy with HG increases your risk if you get pregnant again, but it does not necessarily mean you will have to deal with the same problem if you decide to have more children.
Since I am not aware of any research where strategies to prevent HG were studied, I will give you the advice I would give my daughter if she was in your circumstances and wanted to have another child badly enough that she would be willing to run the risk of facing the same problem again. I would have her begin taking 50 milligrams of vitamin B6 three times a day as soon as she found out she was pregnant. I am not sure this would work, but the risk is very low and it might help. (It is logical and it seemed to work several times in the past when I recommended it, but this is not much evidence.) I would also suggest that she look up my article on how to use acupressure, and try out this technique before she gets pregnant (learning to use it for other problems so she will be proficient with it if she gets nauseated again). There is also no guarantee that this will help, but I almost always try it for my HG patients, and teach it to those who respond to it with improvement in their nausea. It has been helpful about half the times I have tried it with the severe nausea of HG. (You can find my article here)
If you get nauseated with a future pregnancy and these prevention strategies don’t work, your obstetrician could try prescription medications like Zofran and/or Reglan to add to the vitamin B6. Should these fail, the next step involves the start of IV supplementation, as I describe in my eBook for doctors. (The introduction is available above, and the book itself is available on Kindle). Any physician should be able to comfortably manage IV therapy using a PICC line, both to prevent dehydration and to serve as a vehicle to deliver IV medications by continuous infusion. If you get to the point where you need intravenous feeding due to malnutrition, though, I have no way to know who would be experienced with this therapy in your area. If any of your physicians would like to discuss these recommendations with me, just send a message with their name and email address.
I hope this helps with your difficult decision, and wish you the best. I really admire your willingness to even consider facing this problem again.
Chuck Gebhardt, MD
Dear Dr Chuck,
Its been a delight reading through the questions and answers you’ve been giving to women with this awful condition. I am a Nigerian and i have been diagonised with HP. Am just 8 weeks pregnant and have am into the 3rd week of this ailment. Doctor, its so bad that i cant even hold down my saliva without vomitting something. Sometimes even in empty stomachs, i vomit bile and brownish fluids. I’ve been placed on IV fluids (Dextrose Saline, 5%) twice daily, but it doesnt seem to help me at all. I’ve lost so much weight tht i even for the well being of my baby. Am also concerned about birth defects, since i’ve not bin able to take preg supplements like folic acid and othwrs. No one seems to understand my plight and all my family n friends keep telling me is that its normal with all pregnant women, but deep within me, i know its not normal and i just feel like i will die any second. Am so emaciated, always tired, dizzy and light-headed. Doctor pls help, before something worse happens.
Thank you for your kind comments. Hyperemesis gravidarum is an awful condition, indeed. Unfortunately, we still lack treatments that reliably control this illness. Often, the best we can do is to treat the symptoms and complications until the problem resolves itself.
Unfortunately, when the condition starts early in pregnancy, like it has for you, it is often the most severe form. Starting you on IV fluids, as your clinicians have done, is very appropriate. This illness is most definitely not normal, but it is fairly common. Either way, what you need is the most effective care possible to minimize or eliminate the risk to you and your developing baby.
I do not know what resources are available to you and your doctors where you live, but I will describe what my approach would be for you if you here in my home town. First, I would try to provide the IV fluids on a continuous basis to run over 24 hours per day, seven days per week. There are two reasons for this. First, sometimes IVs with dextrose alone seem to help decrease the nausea. Second, the continuous infusion will allow the most effective use of medications in the IV mixture designed to minimize your nausea and vomiting.
Next, I would try different common IV medications to see which may improve your symptoms. I almost always use intravenous vitamin B6 (pyridoxine hcl) at the maximum safe rate of 300 mg. per 24 hours. It may take 3 or 4 days to see if this is helping. Other intravenous medications I try in the IV fluid mixture might be Phenergan, Zofran, Reglan or any similar medications that help suppress nausea and are available where you live.
If this IV intervention is not effective and you continue to lose weight, intravenous feeding would greatly decrease the risk you child is facing. Of course, I do not know what is available in your country. You would need to find someone with the training and experience to help you with this, if this resource is available.
If these efforts are unsuccessful, or even if you want to try something else in addition the above, you might try using acupressure in an effort to decrease your nausea. This is safe, easy to learn, and sometimes very helpful. Here is the link to my article that teaches this technique called: A simple, highly effective healing technique. If you try this technique and need further help with it, email me at firstname.lastname@example.org.
I wish I could do more to help. I hope this problem resolves soon and you and your child do well with this pregnancy.
Chuck Gebhardt, MD
Dear Dr Chuck,
Firstly, thank you so much for your informative and useful blog, particularly in the light of the little amount of information available on nutritional deficiencies resulting from hyperemesis.
I live in Australia and am 16.5 weeks pregnant. I have been suffering from HG since week 6. The vomiting is controlled by ondasetron but it has not stopped the relentless and severe nausea. Since week 9 I have subsisted on a diet of small amounts of dry biscuits and plain bread, have lost 7kgs (approx 15.5 pounds), although in the last week I have gained half a kilo (approx 1.2 pounds), and have been unable to take a multi vitamin, but I have been able to tolerate folic acid. I have been hospitalised twice for IV hydration treatment and now force myself to drink approx 1.2 litres of fluid a day despite how nauseated this makes me but have not been able to cope with additional food.
I am very concerned about my inadequate diet and the effects this might have on the baby. At this stage is my baby at risk? My obstetrician and other health professionals have reassured me not to be concerned at this stage about my diet and weight loss, and have been more concerned about preventing dehydration again. From most things I’ve read and from people I’ve spoken to the message tends to be that the baby will get everything it needs from my reserves but surely my “reserves” will be depleting if I’m unable to adequately nourish my body. I’m going to start to taking half a multi vitamin a day to see if that is easier to tolerate as I figure that is better than nothing.
Your guidance would be much appreciated.
Thank you for your kind comment about my blog.
Unfortunately, you seem to have a quite severe case of hyperemesis gravidarum. I can completely empathize with you that your main concern is about your baby’s health. Generally, the mother’s health will not permanently suffer, since most women can handle the degree of malnutrition that develops even with severe cases of HG. This, though, is not the same situation as your developing baby.
I have explored the risks of malnutrition during pregnancy in depth, so I believe I can give you reliable guidance about them. First, the good news. There is very little evidence of any significant birth defects related to malnutrition in the first two trimesters of pregnancy. Now the bad news. The risk from malnutrition does start to develop and accumulate throughout the course of pregnancy, but the main risks are of a different nature. While the risks of complications associated with pregnancy do not increase much due to malnutrition, the likelihood of a poor outcome due to these complications, should they happen to develop, increases a lot. This is one reason HG should be treated aggressively early in pregnancy — to prevent severe malnutrition toward the end of pregnancy where the risks become much higher.
There is an additional risk related to severe malnutrition that continues into the last trimester. There is strong evidence that children that are born of mothers who are significantly malnourished toward the end of pregnancy are at increased risk of mental and emotional problems. Good nutrition for the baby after delivery will help minimize these problems, but not completely eliminate them. It is not quite so simple as saying the mother’s reserves will be used for her baby. This idea provides false reassurance and is only partially true.
I assume you have already tried oral vitamin B6 and this has not helped when added to the ondansetron you are taking. If not tried, I would recommend you discuss this with your OB. If this fails to control your nausea and allow reasonable food intake, you might try the acupressure technique I recommend in my blog article. If all these efforts fail, I would recommend the continuous (24 hours a day) IV infusion of fluids that include glucose, electrolytes, IV ondansetron and IV multivitamins and minerals by way of a PICC line or similar long term catheter. I usually also add IV vitamin B6. Often these continuous IV infusions will control your nausea enough to allow you to consume enough food to at least stop your weight loss. If this infusion fails, and your weight loss continues, I would recommend IV feeding through your central line, but this will require the assistance of a physician familiar with this kind of nutritional support.
I will be happy to discuss these recommendations with your physicians should they want to send me an email. (email@example.com)
Wishing you the best,
Chuck Gebhardt, MD
Thanks so much for the speedy reply. I haven’t tried B6 so will get onto that ASAP and will also try your acupressure technique.
Thank you again,
You are welcome, FT. I would recommend 100 mg vitamin B6 three times a day, but no higher. Let me know how it goes.
Hi again Dr Chuck,
Further to our earlier correspondence I am now 21 weeks pregnant and have been taking vitamin B6 and an increased dose of ondasetron (8mg twice a day) the last 4 weeks. My nausea has improved somewhat but I only experience relief when I’m lying in bed. A lot of movement, attempts at eating different foods (other than dry biscuits and plain bread) and food smells all trigger long bouts of nausea, some more severe than others. I’m surprised that I’m unable to tolerate any other food even when I’m in bed and feeling relief from the nausea (I’m pretty much bedridden as a lot of movement exacerbates the symptoms). My rate of weight loss has slowed but I have lost 8.5/9kgs (18.5 – 19.5 pounds).
My obstetrician has suggested we could possibly try steroids which I am open to exploring. However, given that I do have these periods of relief I am not sure if that is necessary, although I am conscious of the fact that despite feeling relief I am still unable to eat anything other than what I mentioned above. I wonder if the relief that I am feeling is a sign that I might be improving and it might be a matter of time before I can eat more.
I’d appreciate your thoughts on the use of steroids and how you might approach my particular situation.
Here are a number of generally helpful guides that usually work, in answer to your questions.
1. When nausea is severe, it is best to stay as still as possible. If you have kids, it is far better for
someone to care for them for you, and avoid traveling and housework as much as possible.
2. Meals are best tolerated in very small amounts consumed as frequently as possible.
3. Try to have foods you crave available to you as much as possible. Getting as many calories into
your stomach that you can keep down and absorb is better than eating smaller quantities of
what you might think are more healthy choices.
4. Generally it is best to separate eating solids and drinking liquids, to minimize the nausea.
I have never tried steroids for nausea. Steroids are great for stimulating appetite, but I am not aware of them helping to decrease nausea. It would be an experiment, and if it worked it would be useful. Let me know what happens if you try this, please.
In your situation, I would increase the ondansetron to 8 mg. three times a day, to see if you do better with the higher dose. (Of course, you should always get medication changes approved by your OB first.)
Continuous IV infusions containing some glucose often have some anti-nausea benefit and should be considered if you are not trying this already. This will also keep you better hydrated and more comfortable.
Also, it may be very helpful for you to know the pattern that this illness almost always takes over time. (I have seen quite a few patients through their entire pregnancies, so I have a lot of experience to base this information on.) Almost always, nausea starts slowly and steadily gets worse until it finally hits a plateau and stays the same for a few days to a few weeks. Then, from that point on, it usually slowly improves until it goes away completely. The duration of these stages can vary a lot, but this pattern is almost always evident. Typically, the problem resolves by the beginning of the third trimester. Very rarely, it can last until the end of pregnancy (but, unfortunately, it does happen).
My impression is (but I know of no studies to back this up), the earlier the nausea is effectively treated, the less likely it will be to progress to more severe stages. I have been pretty successful in encouraging our local obstetricians to treat these problems earlier and more aggressively. As a result, over the years, I have seen less and less severe cases of HG that require intravenous feeding, even though the number of deliveries in our local area has slowly increased. In my opinion, the most important factor behind this improvement is the early use of continuous IV infusions.
If you have further questions about these ideas, let me know.
Best of luck to you, my dear,
Chuck Gebhardt, MD
Thank you so much for your reply. It’s funny, after I wrote to you I wondered whether increasing the dose of odansetron might be a strategy worth trying first. I will definitely talk to my OB about your recommendations, particularly having another IV infusion as I haven’t had one since 14 weeks.
I am relieved to hear that the usual trajectory of HG involves a gradual decrease of symptoms and rarely continues into the third trimester, that gives me some hope!
Thank you again and I will let you know whether I do end up taking steroids.
Hi, Dr. Gebhardt,
My name is Jason. I’m an inpatient pharmacist in San Jose, CA. I received a phone call from an OB MD saying pt is on 1.66mg/hr of SQ zofran pump at home. Now she’s in the hospital. We don’t do SQ zofran pump in the hospital. She wants to do zofran continuous IV infusion at 2mg/hr, which is 0.57mg/kg/day. Is this safe?
Thank you very much
Jason Liu, PharmD BCPS
I can only share what has been the practice in using IV Zofran in my community. I know that oncologists use much higher infusion doses of Zofran to counteract the nausea associated with chemotherapy, but these are not involving pregnancy. In these settings, there do not seem to be any concerns about side effects even at doses that exceed the 48 mg. per day you mention..
I have fairly extensive experience using Zofran by continuous infusion at 24 mg. per day. I have never exceeded this rate, but it would not surprise me in the least that higher rates might be even more effective. This infusion rate has been effective and well tolerated.
If I had a patient who responded well to 48 mg. per day infusions, but not at lower infusion rates, I would not hesitate to use this dose after explaining to her that this is outside the usual dose range of Zofran and the risks are not known in pregnancy. If this higher dosage is all that has been found to work effectively for her, my opinion is that this risk would be low compared to the known risks of uncontrolled, severe nausea and vomiting during pregnancy.
I hope this helps,
Dr. Chuck Gebhardt
Dear Dr Chuck
Thank you so much for your website. It’s so hard to find information on HG. I am 15 weeks today I have have severe nausea, vomiting, food aversion and acid reflux since about a week after conception. It’s been a very rough few months, I barely leave my home. I recently switched to a new doctor who had to go in for my first IV hydration and Reglan and Benadryl treatment. The Reglan, even with the Benadryl made me very anxious and my skin crawl. The following 2 days were fantastic, my symptoms were very manageable and I had energy to do normal things. Since this, I am on Compazine at home but my HG symptoms are returning. What are your thoughts? Is it the Reglan or the hydration that is asking me so much better? A your thought on Compazine? And is the side effect of Reglan just something I need to deal with?
Thank you so much for your response and everything you do for woman.
Sometimes I see IV hydration alone improving the nausea and vomiting, and sometimes Reglan can be very helpful, so it could be either or both that are helping. The anxious feeling sometimes happens with Reglan. When this happens with this drug, I try to reduce the dose and see if I can get a level with tolerable side effects and still providing useful effects.
I do not have as much experience with Compazine, but when I have used it, it has been well tolerated. It is best to try each of these medications by itself a few days and find out which works. It is pretty common for me to combine two or more drugs together, each providing some benefit. With any improvement, it is worth continuing whichever medication helps for as long as it is needed.
If you haven’t tried vitamin B6, I would definitely give it a try. It is available by mouth or IV. Since your HG has been so bad, I would start at what I feel is the maximum dose: 300 mg. per day. This is very safe, and often more effective than the medications we just discussed. It takes longer to know for sure it it will work though, it could take a week to begin to work.
I hope your nausea improves soon,
Chuck Gebhardt, MD
Dear Dr. Chuck,
How long should I take Vit B6? Or when do I change the dosage? I’m 13 weeks already. I started with 200mg a day but has stopped 2 weeks ago. My OB prescribed Vit B complex but it contains only 10mg Vit B6, aside from Vit B1 and Vit B12. She also prescribed antacids (combination of oxetacaine, magnesium hydroxide and aluminum hydroxide). Is that enough? My vomiting is now limited to night time, as compared to whole day since week 6. I am able to take in small amount of food during the day time. I have not lost any weight anymore but I’ve not gained any of the 15lbs I have lost yet. However, my ptyalism is still 24/7. I feel that if the ptyalism only stops, I’d be able to manage the nausea better.
Thank you for your article and experience regarding HG. I am about ten weeks pregnant with my second child. I believe I suffered through HG with my first, through the entire pregnancy with weight loss, severe vomiting and a handful of ER visits for dehydration. However nothing was ever said to me about why I was experiencing such severity. I did not know about HG at all. Now that I am experiencing it with my second pregnancy, more than four years later, it has finally been explained to me, by an ER Dr when I got to the point that I had to go get fluids. I am very concerned and want to talk to my OB very efficiently. I have commonly received brush offs from other women who claim “its normal” Recently a nurse practitioner connected to my OB’s office gave me similar dismissal when I tried to tell her the severity of it. I am on phenergan around the clock and was prescribed diclegis, however I cannot take that prescription because the cost is very high and not covered by insurance. Although the phenergan has helped some I’m still struggling to keep any food or liquid down. I am so embarrassed to admit this, but I have been so weak that I lay in bed at least 20 hours per 24 hours. I am scared, worried, depressed, and anxious. I have an appointment early next week to address my concerns with my OB (his nursing staff has mostly been handling my prescriptions and care to this point and I’m not sure he knows how sick I’ve been). I’m wondering if you have any advice for how I should speak with my OB, what kind of treatment step should I be looking for next?
I am sorry it took so long for me to respond to your questions. Thanks for your kind comments. I will do my best to help with useful information.
First, unfortunately, it is quite common that women afflicted with hyperemesis gravidarum do not understand what they are suffering with. The attitudes and misunderstanding of friends and relatives add additional burdens. If this were not bad enough, even the medical profession and their office staff often are poorly prepared to assist. This is no one’s fault, medical schools and medical residencies just do not teach much about even the little we do know about this condition.
To assist you with your discussions with your OB, you may want to give him (or her) a copy of these comments. I will write it both for you and your OB in mind. As a background about my knowledge in this area for your OB, I am an internal medicine specialist with a lot of experience with medical nutrition problems. Local obstetricians have been referring their most difficult cases of HG to me for my management for over twenty years. My experience involves hundreds of women with HG, some with multiple pregnancies involving this condition, others requiring long term intravenous feeding.
The first step is always to use oral medications, but this only works if oral medications can be kept down long enough to be absorbed (about 30 minutes is a good rule of thumb). If the nausea and vomiting are so severe that oral medications cannot be absorbed, intravenous therapy is needed.
It sounds like you are already dehydrated, so I expect that your OB will handle this. Once this is controlled, further oral medications may still work. Continuing the Phenergan seems like a good idea, since it is helping. Alternatively, Zofran or even Zofran ODT could be tried to see if either is more effective than Phenergan.
Fortunately, the two components of Diclegis (doxylamine and pyridoxine) are both available as generic drugs, so you can avoid the high cost of Diclegis quite easily. Pyridoxine is just vitamin B6. Doxylamine is available without prescription also, as Unisom. In my opinion, while Diclegis contains two highly effective components, neither is at the dosage that is optimal. You should clear this with your OB first, but I would recommend trying one 25 mg. Unisom at night along with 50 mg. vitamin B6 three times a day as a cheaper and more effective combination than Diclegis. If you try this, take these medications when your stomach feels as settled as possible, and use only as much water to swallow them as absolutely necessary ( to avoid exacerbating your nausea, so you can absorb them).
If these oral treatments do not work, intravenous therapy would be the next step I would institute. I would usually order the placement of a peripherally inserted central catheter (called a PICC line) to be placed in an arm vein. I would then begin infusing enough IV fluids to control the dehydration with added Phenergan, Zofran and/or pyridoxine (at 300 mg. per 24 hours) as needed to control the nausea and vomiting (so as to allow nutritional repletion with an oral diet). Usually continuous (24 hours per day) infusion is best. If this strategy fails, total nutritional therapy with IV foods will be indicated (if this expertise is available where you live).
If your OB would like my direct input, my email is firstname.lastname@example.org. I will email a response or call, whichever is preferable.
I wish you the best during this difficult time for you,
Chuck Gebhardt, MD