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.