Hyperemesis Gravidarum, or super vomiting  of pregnancy. 

Right now our beloved Princess Kate is hospitalized with Hyperemesis Gravidarum. 

The royal spokesperson has said that she is less than 12 weeks pregnant, but has not given us her due date yet. We can assume that she is past 8 weeks or so, or the HG would not be at this stage. So she is between 8 and 12 weeks. That means she is due near July 1st 2013. 

HG happens when the pregnant women is so nauseous that she vomits nearly continuously. 

Nausea and Vomiting are completely normal parts of the first trimester of pregnancy. Most women will experience some of this. In fact, most women will lose some weight the first trimester of pregnancy, just because they cannot eat a lot of food. 

But, when a women suddenly gets so sick that she cannot tolerate fluids, and what fluid she does have vomits back up, two bad things will happen. First, she will get severely dehydrated. And that will make her very very weak. Her blood pressure will be low, and she may not have the stamina to even get out of bed. The second bad thing that happens is that she will lose electrolytes, such as sodium, potassium, and chloride. Losing the electrolytes is worse than plain dehydration because it can make the heart beat irregular, or worse. 

We can detect this severe dehydration by weighing the patient. If she loses 10 pounds over a few days, then she has certainly lost enough fluids to go to the hospital. There, we can replace the fluids and check the electrolytes. 

Obstetricians don't really know what causes such a severe intestinal problem. We know that progesterone, which is a hormone that the ovary and placenta makes in abundance, can make people sick. Some women get really bad PMS from the natural progesterone of a normal menstrual cycle. The progesterone peaks about day 23 or so of a normal 28 day cycle. A lot of women feel awful from that peak of progesterone. It makes their breasts sore. It retains fluid. It makes them crabby. It makes them gain a few pounds of fluid. It makes their intestines fill with gas, and they get really bloated. They really hate it. The peak progesterone level of a normal cycle is about 12 or so, according to my lab.  In pregnancy it may go up to several hundred, as the placenta makes a ton of it. The natural purpose of the progesterone seems to be to keep the uterus from having a menstrual period, and thereby pushing the baby out. The uterine muscle responds to the progesterone by getting very soft and dilated. Unfortunately, that same kind of muscle is in human intestines.  Under the influence of that much progesterone the intestinal muscles seem to dilate and get soft. This prevents peristalsis and makes the women nauseous as the food backs up into the stomach and esophagus. 

There is also a strong belief among some people that the nausea has an evolutionary purpose. 

What I mean is that the vomiting may be a defense mechanism to protect the fetus from noxious foods and exposures. This is because the first trimester has an importance unlike any other time in human events. It is the phase of organogenesis. 

The first trimester of pregnancy lasts from about 2 weeks of pregnancy (that is before the pregnancy is even known about) until about 13 weeks. The first trimester has an unbelievably important function for the fetus. It is the phase of "organogenesis". This means that the baby is actually forming it's own anatomy. The heart is being built into chambers, the kidneys are being made, all the tissue layers are folding into final position, the basic brain structure is starting up, and all of the events that create a human being are happening. After 14 weeks, all of this complicated tissue construction is done. The only thing left is to grow and fine tune the functions of the organs. 

What is the last organ to be completed? I like to tell my patients it is the brain. That is done, in some people, around the 40th year of life or so. There is a bit of humor and a bit of truth in that statement. It is my belief that the human brain never stops developing. Since we can all learn new things, and do new activities, it seems to me that the brain never stops growing. For this reason I believe in lifelong "effortful" learning. Effortful is the opposite of Effortless. For this reason, I like to say that people should push to learn and do and experience new things all the time. For me, my recent activities include learning to play the guitar, learning languages, and learning new computer processes. Such as learning how to write a blog on Google, learning the Java programming language, expanding my knowledge of Pascal, keeping up with the latest Basic compiler from Microsoft, and things like that. 

And to grow the brain we have to nourish it. That is why I recommend everyone including myself to take DHA omega three supplements. This is an essential fatty acid component of human brains, that no one gets enough of, that cannot be created inside of a human. I take and recommend 300 mg a day of DHA. 

Probably the second to last organ to be finished is the lungs. I don't know why, but the human lung has a lot of trouble oxygenating a human being until about 36 weeks of pregnancy or so. There are multiple issues with the function of an immature human lung, but one of the last factors to be created is Surfactant. The NICU now uses artificial surfactant and that helps the premees quite a bit. It helps them breath. 

But, until all of this complicated organogenesis is done, there is a very delicate fetus. If there is some unfortunate exposure to a toxin of any sort, it may have a disastrous effect on the organogenesis. The heart may not form right. The cover over the spine may fail to fuse, causing anything from a spina bifida to anencephaly. There may be entire limbs missing. There may be a tiny imperfection, like a cleft lip. There may be a huge central failure, like syrinomelia, where the legs are fused. This is why most physicians are loath to prescribe any medicines in the first trimester. We will, if possible, defer any medical treatments to the second trimester. Sometimes, we will defer treatments of minor infections. We will push hard to defer X-rays, if possible. We will certainly advise against smoking, drinking, and illegal drugs. We do not advise refraining from exercise or sex, unless there is a specific reason to do so. 

So, some people believe that Hyperemesis is Mother Natures way of protecting the fetus from noxious exposures. Most pregnant women will run away from any noxious fumes, because it makes them extremely nauseous. This serves a very important purpose of keeping those toxic fumes away from the baby. 

As an obstetrician, my job is to keep the baby safe. Keeping the baby safe means keeping the mother comfortable.  

If a pregnant women has more vomiting than is safe for the baby, then we need to take action. The first thing to do is to see if dietary modifications will help. I will ask the women to start taking a tiny sip of Gatorade every 20 minutes. This will replace the electrolytes and the fluid slowly, and prevent there from being too much fluid in the stomach as to make her vomit it back up. I will ask her to stop all spicy and greasy foods. I might ask her to have one salty cracker (called a saltine her in the USA) every  twenty minutes. Sometimes the saltines and Gatorade diet does the trick. 

Sometimes we try the BRAT diet. This is bananas, rice, apples, and toast. This diet is explained on Wikipedia page here: http://en.wikipedia.org/wiki/BRAT_diet. 

If the women needs medications to stay hydrated, then we usually start with phenergan and or odansetron (Zofran). If pills get vomited, then go to suppositories. Women don't like that of course. If that doesn't work, then go to IV or Subcutaneus pumps of these meds. Plenty of women are maintained on these meds, sometimes they need them for most of the pregnancy, if the situation is really bad. 

If nothing else works, then the women needs both IV fluids and IV nutrition. These IV's can save both the mother and the fetus, and I have managed this many times. Most of the time I will ask for the help of a specialist in IV nutrition. Our hospital has several of these specialists available. I call them into the case, and their help is very much appreciated.  

Sometimes, in bad cases, such as if the gallbladder goes bad at the same time as Hyperemesis, these women will need IV nutrition for the whole pregnancy. It is certainly possible. These women are really suffering, though. 

If the vomiting is not managed well enough, then the stomach acids can inflame the esophagus  This can get really painful, and needs to be managed as well. These stomach acids are really bad for the teeth, too. Just like in a bulimic patient. 

Let's hope that Princess Kate doesn't need this kind of service, but if she does need it, I am sure that it can be provided. 

Thanks once again for reading. 

Dr John W Marcus MD FACOG 

89 North Maple Ave 

Ridgewood NJ 07450 

phone 201-447-0077 

fax 201-447-3560 

blog at doctorjohnmarcus.blogspot.com 

comments below are very much appreciated. 

Stem Cells


Everybody asks, "Should I have my umbilical cord blood stem cells frozen and stored?" Usually, by the time patient is asking me this question, she has been bombarded with advertisements from the stem cells storage companies. But, even if the patient doesn't ask me, I will ask the patient at about 20 weeks. In my practice, it  is a prenatal care checklist item for 20 weeks, along with the 20 week genetic and anatomy sonogram. So, I will make sure that the patient has the information that she needs to make a good decision.

First of all, everybody should be aware that umbilical cord stem cell storage has not been endorsed by any professional group other than the stem cell companies themselves. My ACOG states that this procedure is unnecessary. Anything that is unnecessary is not going to be a covered benefit under the health insurance. So, anyone who does it is going to have to find a way to pay for it.

It costs anywhere from $1350 to $9000 or so to get the process started. The price varies from company to company. There is also variance on what exact services you have contracted for. There are some companies that will take the whole placenta and use it to get more of the stem cells. Other companies will take a short segment of the umbilical cord itself. All of these things are added cost.

Once the stem cells are frozen and kept under liquid nitrogen, the companies that do this work will charge you once a year to keep the cells frozen. The yearly charge is something on the order of 150 to 250 dollars a  year. I suppose that if you don't pay, they would throw out the stem cells. Or maybe donate them to science, or a public stem cell bank.

What is the benefit of doing this?

The stem cells that are retrieved from the umbilical cord, fetal blood, and placenta, are processed and examined by the cord blood storage companies. Then they are deep frozen under liquid nitrogen. This does not kill the cells. It preserves them for future use. If, in the future, this baby has some kind of medical problem that can be cured with an infusion of stem cells, then the stem cells are there for the baby to use. These problems are usually some kind of leukemia or cancer. In that case, the future oncologist has the option of removing this victims bone marrow cells, curing the cancer, then thawing out the stem cells, and then restoring the immune system with those stem cells. This is all only theoretical, because the successful cases done like this are rare.

The stem cell companies claim that about one out of 200 stored units are eventually put to use. I have not seen an independent validation of this claim. If this is so, then I think that everybody should do the stem cell storage. I think it is more likely that there is a small number of stem cell units that are used. The rest will stay frozen indefinitely.

There is a ton of ongoing research right now to see if stem cells can be used to treat a bunch of other conditions. There is some some studies being done for heart disease, and some even on autism. So the applications for stem cells seem to be widening. It may be that the future for stem cells is very wide indeed.

On the other hand, biotechnology marches on. It seems now, that many times, the biologists can get stem cells retrieved even from grown ups. If this is so, then there is no reason to store the fetal cells, as everyone has stem cells. We can use the adult stem cells to do the job of the fetal stem cells. If that is true, then no one needs to freeze the fetal stem cells, we have our adult cells and that will be good enough.

So, in the final decision making, a family needs to decide the odds of using these stem cells, versus the odds of not using them or not needing them because the body makes it's own. I also tell my patients that if they need the stem cells years later, and they didn't store them, they may be very sorry.

And then the decision is affected by how much you value the 2000 dollars or so you invest in it.

I tell a family, "if you have a lot of money, then you can spend a lot on the stem cell fees". On the other hand, "If you don't have a lot of money, and 2000 dollars will break the bank, then don't do it. Either way, I will help you both figure out the right thing to do is, and I will help you do it. You need to make your decision some time before the placenta comes out."  I will then note in the chart that we had the discussion, and I will note whatever they seem to be deciding at the moment. We will revisit this discussion throughout the rest of the pregnancy and I will offer to help decision making.

The majority of the people in Bergen County will decide that they do not want to pay for it.

If they do, there are a couple of good choices available.

Viacord is the biggest company. They are based in Ohio. They will not let you visit your unit of blood. They generally will not negotiate with you. They will provide my office with 500 dollar coupons that people can use to lower the price from 2300 to 1700 dollars.

Neostem is the best local company. They are based in the next town, Allendale New Jersey. I personally have met some of the people, and I like them. They will let you visit your unit of blood. They have good prices. They will talk to you on the phone. They also have a coupon available in my office.

CBR is another big company.

There are a hundred others.

The local blood bank still does it as well. I don't know why more people don't use them. Maybe they are being out marketed by the commercial providers? I don't think the blood bank markets the service at all. They used to have an open donation program that was free to donors. I sent a lot of donors their way. The donor program is now closed due to lack of money. As you can imagine, the donor program was quite expensive to administer. If it ever opens again, I will send a lot of patients to the blood bank for stem cell donations. It was a very very popular program with my patients when it was still open.

Ultimately, the decision to store the stem cells is difficult for most people. It is an assessment of risks, potential benefits, and costs.

Sometimes, the grandparents have a very strong opinion, and take action. It's great watching them when they do this. It becomes a parent taking care of a child, but the parent is the new grandparent, and the child is the pregnant women and her husband. The grandparents say, "where doing this, that's all their is to say about it". They will allow no dissent. And then the stem cells are stored.

I don't know how the stem cell companies find the pregnant women to market to, but they seem to use some kind of internet magic. There was a story of a 17 year old girl who got pregnant, and did some looking around the internet on Google. Pretty soon, there were items in her mail box to help her with the pregnancy, and try to sell her things. This, despite nobody but her knowing about the pregnancy. Her Father read the mail, and found out she was pregnant. I don't know the outcome of that story. There is a strong lesson there, though. The lesson is, almost nothing one does is the modern world is completely private. I think, for the sake of safety, always assume there is a camera watching you, and there is someone who knows what you do on the internet. There are technical ways to block that snooping, but I am pretty sure they are not completely successful at blocking your trail.

I think the next post will be about Hyperemesis Gravidarum, as that is what our beloved princess Kate is hospitalized with right now.

Thank you sincerely,

John W Marcus MD FACOG
89 North Maple Ave
Ridgewood NJ 07450

phone 201-447-0077
fax 201-447-3560
blog at doctorjohnmarcus.blogspot.com