Relief for Moms-to-Be
When Loretta Killeen became nauseated during the second month of her pregnancy she convinced herself “it was just morning sickness.”
But after she endured days of relentless vomiting, her husband began to question whether Killeen’s experience represented typical morning sickness.
“My husband wanted me to go to the doctor. But I kept telling him, ‘There is nothing they can do for this.’ He had to drag me to the doctor,” says Killeen, 32.
It’s not surprising that Killeen believed there is no relief for a woman with hyperemesis gravidarum, the scientific name for pernicious nausea and vomiting during pregnancy. The cause of the disorder is a mystery and, until recently, no remedy had been proven safe and effective.
About 80% of pregnant women experience some nausea during the first trimester of pregnancy. About three to five among every 1,000 women develop such severe nausea and vomiting that weight loss and dehydration can jeopardize the health of the mother and baby. Each year, about 20,000 U.S. women are hospitalized for the condition.
Killeen was surprised and fortunate to learn there is a treatment that may represent the biggest stride yet in alleviating the misery of hyperemesis.
She was referred to the Women’s Center at Long Beach Memorial Medical Center where years of research has produced a successful tactic to treat hyperemesis.
Killeen felt better within hours of receiving the therapy. She stopped vomiting after one day and was back home the second--still sick, but not dangerously so.
“If more people are educated about this, maybe they would know that this is not the norm and that there is treatment,” says the Cypress woman, now halfway through her first pregnancy.
The treatment, designed by Dr. Michael Nageotte and pharmacist Gerald Briggs, consists of infusions of the drugs droperidol and diphenhydramine. Droperidol is an anti-emetic while diphenhydramine--also known as Benadryl--also works as an anti-emetic and helps reduce anxiety that can be a side effect of the droperidol.
According to recently published data from the Long Beach team, the droperidol is significantly better than any one of a number of regimens that have been tried in the past.
“Various approaches to treatment cover a wide spectrum and reflect a physician’s experience and not science,” says Nageotte, medical director of the Memorial Women’s Hospital Perinatal Center.
“What we did was compare a group of women [receiving the droperidol regimen] with the previous two years’ cohort of women with the same diagnosis but who had been treated any variety of ways. We were able to show the number of days in the hospital and the number of admissions was significantly less in the droperidol group.”
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Typically, women with hyperemesis are shuttled in and out of the hospital to receive intravenous solutions for dehydration while only the passage of time puts an end to the nausea and vomiting. But Briggs’ and Nageotte’s study showed that among 81 women receiving droperidol, only 15% required readmission to the hospital compared to 31.5% of a similar group of women receiving other treatments.
“My interest in this started in the ‘80s watching these patients come in with this severe disease, seeing them treated, sent home and then come back again 24 hours later. I could see it was a very frustrating disease for the patient and the physician,” says Briggs, who developed the protocol.
Killeen admits she was not happy initially about receiving medications during her pregnancy.
“I had all these things go through my head. You want to feel better. But what is going to happen to your baby?” she says. “I was so sick that I thought if the doctors don’t do something for me soon, I don’t know if I can go on.”
She credits pharmacist Briggs with taking the time to explain the medication regimen to her in a way that alleviated her anxiety. And while no medications are tested for safety in pregnant women, the Long Beach team feels confidant of their protocol.
“Like so many other drugs in pregnancy--antibiotics, for example--we commonly use drugs in pregnancy that we sense are safe based on animal data and some human data, as well,” Nageotte says. “But we do feel we have to follow these patients prospectively. We have to be cautious.”
So far, the team has found no higher incidence of birth defects in the babies born to women who took the droperidol regimen.
“Any one of these agents, theoretically, could have some risk,” Nageotte adds. “But we feel they are in a category of safety. And the treatment is so much more safe than the disease process itself.”
Hyperemesis gravidarum is thought to lead some women to terminate their pregnancies, although the numbers of abortions linked to the condition is not known.
Hyperemesis gravidarum is usually most severe in the first trimester, although some women remain sick throughout their pregnancies. Because the droperidol treatment is given intravenously, the Long Beach team has also devised a treatment that women can take after being discharged. It consists of the anti-emetic drugs metoclopramide (Reglan is one of the brand names for this drug) and hydroxyzine (also known as Atarax).
Women who undergo the droperidol treatment in the hospital usually still battle nausea after being sent home. Teresa Pollard, a Long Beach Memorial nurse, received the droperidol treatment for three days but remained sick for another eight weeks.
“Before I went into the hospital, nothing was working,” says Pollard, 37, and pregnant with her first child.
“After I was discharged, the nausea wasn’t gone but it was better than it was. Without [the oral medications] I think I would have been back in the hospital.”
Before leaving the hospital, the patients receiving droperidol undergo extensive nutritional counseling to help them avoid foods that might trigger nausea. They also receive social and psychological support.
“Teamwork is critical for the management of this condition,” Nageotte says. “You can’t cookbook it and say just give this drug and it will work.”
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The droperidol protocol is still reserved only for women with hyperemesis gravidarum who are severely sick; having, for example, lost 5% of their pre-pregnancy weight. “The patient who is a candidate for this is a patient who is resistant to some of the outpatient oral medical therapies or suppository therapies,” Nageotte says. “We are talking about the women who have such a degree of nausea and vomiting that they are incapacitated, lose weight and have an electrolyte imbalance.”
There is no way, for now, of predicting which women will become so severely sick. Nageotte says he believes the sickness is caused by estrogen levels that trigger a nausea response that is very sensitive in certain women.
But it’s important that women with hyperemesis gravidarum realize that treatment is possible despite the fears that both doctors and patients may harbor about using medications, Nageotte says.
“We did have patients who terminated their pregnancies because they were so sick. Those kinds of choices have not been needed in the patients choosing droperidol,” says Nageotte, who has seen other local hospitals begin to administer the treatment.
