Cheryl Martin (Host): Morning sickness, occasional vomiting and nausea is extremely common during pregnancy. But there is a more severe and traumatic form of morning sickness we don't hear much about. It's called hyperemesis gravidarum or HG. Up next, we learn about the symptoms, causes and treatments with pharmacist, Dr. Danielle Plummer. She's an advocate for improving maternal healthcare.

This is Health Talk with the Valley Health System presented by The Valley. I'm Cheryl Martin. Danielle, so glad you're on to talk about this extreme form of morning sickness, hyperemesis gravidarum or HG. I understand you know about it firsthand. So, what is it and how is it different from morning sickness?

Dr Danielle Plummer: Cheryl, thank you so much for having me on the podcast today. This is just truly a passion of mine because not only did I experience it myself, but now I just see it all the time and have women reaching out to me for help from literally all around the world, but also local in Las Vegas.

So, hyperemesis gravidarum literally means too much vomiting during pregnancy. But it's much more than that, it's a spectrum that affects the patient's quality of life to where they can't do activities of daily living, like going to work or taking care of their family.

Host: How common is HG?

Dr Danielle Plummer: So, there's no accurate numbers, because most of the women who have hyperemesis gravidarum are not diagnosed correctly. If we look at insurance coding or some studies, you'll see that it affects 1-3% of pregnant women. But there's other studies that show up to 10%. When we look at the numbers, you're looking at the millions of women who are pregnant. Even if you're saying about 2% of that annually, you're looking at 75,000 to 100,000 pregnancies. So of those, a lot don't even make it to term. It is a very serious condition that can lead to maternal mortality.

Host: Wow. So when you talk about the symptoms, and you said some of them, they have to take leave from their jobs. Are we talking about just consistent vomiting throughout the day and for how long you're pregnant?

Dr Danielle Plummer: Yes and yes. So, a lot of times, it's dismissed. We're told it's a normal part of pregnancy, you'll get over it, have crackers or have ginger. And unfortunately, in the case of hyperemesis gravidarum, that does not work and that does not help. It's a true medical condition. So, I advise clinicians to look at not only objective results. How much weight are they losing? How many times are they vomiting in a day? Let's look at their electrolytes, their ketones and other levels that are really important, like sugar, iron, thyroid. But even more important are those subjective questions that need to be answered. As you said, how long has the vomiting been going on? How often is it? Are you able to get up and go to work? So many of these women can't even get out of bed to get to the bathroom. If you're missing work, what treatments have you tried? What has worked? What's failed?

And I like to use the example of pregnancy brain. It's a phrase that should not exist. What's happening is there's a vitamin deficiency. Is it lack of sleep? Is it stress? It is this serious. And if it's not treated early and appropriately and consistently, it can last those nine months. It doesn't go away at 12 weeks like old wives' tales tell us. Some women, it does subside in middle of the pregnancy, maybe 20, 24. Many women, it does go on the whole nine months.

Host: So, at what point should a woman get her doctor involved or go to the hospital? When does it click for her that this is more than morning sickness and I need to get to the doctor.

Dr Danielle Plummer: I like to use the perspective as soon as that mom realizes that if it continues, she will be unable to do those activities of daily living. If you're losing days of work, if you can't take care of loved ones, go out and socialize, can't get out of bed, it starts to affect your physical, your mental, your financial health. You've probably waited too long at that point. I remember being told, if you vomit for more than 24 hours, that's very black and white. I think the picture's bigger than that. And for our women who are going repeat visits to the ER, that's where you want to ask, what else can I do so I don't keep coming back to the emergency room?

Host: I'm glad we're having this conversation because if we're talking about HG, then the mother can actually say, "Hey, do I have this?"

Dr Danielle Plummer: Absolutely. You had asked me how common is it, how serious is it? It's actually one of the leading causes of maternal morbidity and mortality in early pregnancy. In the United States today, we have the highest maternal mortality rate of any developed country. For some reason, we're waiting later into the pregnancy to diagnose serious conditions where if we treated the mom medically appropriate earlier in the pregnancy, potentially it wouldn't lead to these escalating disease states. In fact, going back to the time of Charlotte Brontë, they know now she actually passed away from hyperemesis gravidarum from refeeding syndrome. That's one of the things we're going to look for when the mom goes to the emergency room.

I helped found a campaign for a woman named Maria called One Mom Is Too Many in her memory because no mom should be dying during pregnancy, let alone from hyperemesis gravidarum. And just this past winter, a woman in the UK did pass away from this. So, this is real. When we look at numbers, we're looking at half a million ED visits every year, billions of dollars annually, job losses. Why? Because we're ignoring syndromes and just saying, "Oh, it's a normal part of pregnancy." That's when that mom needs to reach out. If she's getting medication help, she needs to weigh that risk versus benefit. The actual cause of this was published about five years ago, did not get a lot of publicity, and now is being presented at industry events and it's called the GDF15 gene.

Host: I was going to ask you what causes it. So, it's been determined what causes it?

Dr Danielle Plummer: Yes, it's been determined. And I want the shout it all over the loudspeakers because it's not what everyone thinks. And unfortunately, a lot of major medical resources have false and misleading information about this disease state. It's a gene that's actually higher in these pregnant women than in patients going through chemotherapy. And the researcher who published this spoke to me directly on it with that statistic. Think about how we treat our chemotherapy patients. We have such phenomenal guidelines in place. And my hope is that we get the same for hyperemesis gravidarum patients.

Host: So, there is a gene that causes this. So, could a pregnant woman be tested to find out if she has this gene, even before she gets pregnant?

Dr Danielle Plummer: We do not yet have a diagnostic test. From my understanding, there are negotiations happening. Once we have that diagnostic test then, the dream then is to have that targeted therapy just like we do for other disease states. Right now, it's really trial and error between what medications we can use to decrease the emesis while we increase the nutrition in that mom.

Host: So at this point, you cannot prevent getting it, of course, if you have the gene.

Dr Danielle Plummer: Correct.

Host: So, how best can it be treated? Or does it depend on whether or not a woman has a mild case or a severe case?

Dr Danielle Plummer: Absolutely. And the idea is to get it while that mom is mild. What can we do to prevent it from escalating? And that's where that early aggressive treatment is really important. And it's a combination of using IV therapy. Now, not just fluids, but you need to replenish vitamins, electrolytes and other nutrients while giving that mom your anti-emetic therapy and other adjunctive medications, maybe like antacids or bowel support.

Host: Now, give me an example of a mild version versus a severe.

Dr Danielle Plummer: So mild, we're looking at it's not morning sickness, right? It's not literally just in the morning. The mom's probably feeling nauseous, but she can keep a little bit of food down, she can keep a little bit of water down. Where we want to look at, is she getting nutrients? Is she getting her vitamins that she needs to prevent birth defects, that she needs to prevent brain defects? And that's where we're going to go. Is she able to go to work every day and is it getting worse? Is it getting better? And it's not going to be on one straight plane. It's going to have these ups and downs. And moms will always tell me as soon as I have a good day, it's followed by some really horrible days and I end up back into the emergency room.

So a horrible day, I met a mom recently and literally she was living on little bites of watermelon and she was about nine weeks' pregnant. That cannot sustain you, the mom, and that growing baby through nine months of pregnancy. We need to intervene now and get that mom help right away.

Host: Whereas someone with a severe form, they're just vomiting, let's say, continually throughout the day?

Dr Danielle Plummer: Absolutely. I've also met moms, even though the name is hyperemesis, that emesis being vomiting, if you have constant nausea that's preventing you from eating and getting nutrients, that can cause severe outcomes as well. So, that's where we're not going to look at just one marker, one lab test.

I've had moms tell me they've lost work, they can't go to work and protections aren't there for these moms. We know FMLA. covers 13 weeks. Not all moms have that protection. And if they do, this disease, they can last up to nine months. So, I've also learned that disability insurance may or may not cover diseases of pregnancy. Some insurance companies are calling it a preexisting condition. So, we need to be real careful if this mom, maybe she's not vomiting everything or constantly, we know if they are that severe, they need to go in and get evaluated now. But if it's this ebb and flow, if her work is being affected, if her social life is being affected, if her mental health starts to deteriorate because she's isolated and she's not believed, well, that can be severe also.

Host: Are there certain triggers to be on the lookout for?

Dr Danielle Plummer: Absolutely. And the truth is really anything can be a trigger, any taste, any smell, any sight, any sound. I urge emergency room clinicians. And this is like, I'm talking even the ultrasound technicians, your nurses, your intake administrators, it doesn't necessarily have to be that licensed clinician that's treating the patient, pay attention to that mom so that you have low lights, low noise levels, and definitely away from odors. Smells in the hospitals can trigger escalating events of this.

Host: Now, if you get HG one time, does that mean you will have it in future pregnancies?

Dr Danielle Plummer: So, research shows that it recurs in 70-80% of women, but most of the women that find me that reach out for help have had one pregnancy, always wanted to have more children, but are absolutely terrified for good reason of going through this again. And when I have a plan in place for them and I follow them through their pregnancy and I see that they're communicating really well with their providers and their friends and their family and getting the support they need, even if they do have a second or consecutive pregnancy with hyperemesis gravidarum, because they have that support, the medication management, they know how to get their IV therapy, they know their medical team is supporting them, not just their obstetricians or midwife, but they might have a nutritionist on board, physical therapy in place, they know their work is rooting for them and have set them up in a way where they're not going to lose their job, the severity seems to decrease. In fact, stress can increase levels of the GDF15 gene. And so, we really want to keep those levels under control so that the mom, even with hyperemesis, knows this is nine months, but I'm going to do the best I can to keep my bones strong, my teeth strong, my gut healthy, my mental health supported so that I can get through it and I'm going to come out shining with a healthy baby on the other end.

Host: Dr. Plummer, I want you to talk about your personal experience with HG. It's obvious that you are passionate about this topic, but also how, as a result of your personal experience, you've alluded to this. You've helped hundreds of HG patients overcome physical, mental and financial complications. Share some of what you've learned and then passed on.

Dr Danielle Plummer: Thank you for asking because I always tried not to make this about me, but about the women and their families who are experiencing this now. When I first became pregnant, I was the first in my family. For some reason, I missed the boat with all my friends just from where I was moving and living. And only really knew what I knew from pop culture and movies and thought it was okay to be sick and it would go away and then I'd glow. I didn't glow. I joke, I turned green and I got greener and greener and did not have the support necessary. And it was just extremely difficult and was left malnourished for those full nine months and not really believed and wasn't offered treatments.

Now, there are risks and benefits to every treatment. I say, you know, we need IV therapy. We know every time there is a line put into their body, there's also risk of infection. So, we want to be careful. All the medications that we can use, the one that I was offered first time around was Phenergan. Well, it comes in a form that doesn't have to be absorbed orally. It comes in other forms, but it also made me sleep for 12 hours. That's not living and that's not getting nutrients. So, I knew when I wanted to have, I waited many years between my pregnancies, thought I had a caring doctor, great insurance, medical support, and still suffered terribly to the point that one of the medications I was given in an ER, Reglan, I remember it's actually my third pregnancy. I knew what I was getting into. I thought all my ducks in a row and it gave me panic attacks, which I'd never had before and I've never had since. Well, now I know it was probably pushed too quickly and it was a dopaminergic adverse effect that I was experiencing. So, all of our medications have this risk versus benefit.

It was actually later after my three pregnancies, I was in pharmacy school and I remember sitting in a lecture learning about TPNs, total parenteral nutrition, and how we feed people who cannot eat and thought, ?How was I left to suffer for literally 27 months of my life?" Nobody spoke to me about nutrition. And actually, I started a blog, which just exploded. And I'm just so grateful to be in a position to help these other women. And now I think we're at a turning point, not just the United States, but around the world where focus is on maternal health. And now, like I said, we have things in motion now to get diagnostic tests going to get treatments personalized, working with pharmacogenetic testing so that we can do what's safest and most effective for the mom. When we say a medication is safe during pregnancy, it's colloquial speaking about not being a teratogen. It's not going to cause birth defect. But most often, we're not talking about how is it affecting that mom. Many medications can have adverse effects for the mom and it's really a risk versus benefit. And I encourage every mom now talk to your pharmacist and say, "Hey, would this work for me? Do I need to add a medication? Do I need to decrease a dose of one to increase another? Should I change? Should I stop one completely?" Because the adverse effects are outweighing the benefits, and these are discussions that everybody needs to have.

Host: Dr. Plummer, any closing tips you'd like to share?

Dr Danielle Plummer: So for friends and family, I just want to say, believe that mom. Support them the best you can, and please do not suggest ginger, crackers or a bland diet. These moms, anything that they can keep down, encourage them to take that, and really believe them. For our patients, please bring somebody, an advocate with you when you go to the emergency room, because you don't have the strength to speak for yourself. Ask the doctors, "What are the criteria for hospitalization opposed to discharge?" Talk to your insurance. You know what medications are covered. Talk to your work, so you know what insurance or disability insurance or FMLA might be covered. And if you're considering cannabis, know your state laws. Talk to your dentist if you're thinking about getting pregnant to get all that in check. For our clinicians, please tell them the name of their disease state, have it coded correctly. And take a look at what's the patient's goals. They want to be able to eat and drink. Calm their fears of taking medications and reassure them that baby is safe. They just want an improved quality of life. And just for everybody, get that treatment plan early so that the disease doesn't escalate. Know the safety of medications. Consider newer treatments like continuous glucose meters, so you don't have to drink that oral glucose test and try to just stay positive because it is not forever and there is a shining, beautiful outcome.

Host: Dr. Danielle Plummer, thanks so much for educating us about hyperemesis gravidarum and for sharing your story and just giving great tips

Dr Danielle Plummer: Cheryl, absolutely. Thank you so much for having me. It's just been a pleasure and I'm really grateful for this opportunity to educate everyone on what actually is hyperemesis gravidarum.

Host: For more information, visit valleyhealthsystemlv.com. That's valleyhealthsystemlv.com. If you found this podcast helpful, please share it on your social channels and check out the full podcast library for other topics of interest to you. This is Health Talk with the Valley Health System presented by the Valley. Thanks for listening.

Disclaimer: Physicians are independent practitioners who are not employees or agents of the Valley Health System. The system shall not be liable for actions or treatments provided by physicians.