The BirthGuide Podcast
The BirthGuide Podcast
Managing morning sickness and hyperemesis
Most women experience some degree of digestive upset during pregnancy, and an unfortunate few suffer from the serious condition, hyperemesis gravidarum. Our guests today -- two certified nurse midwives and two acupuncturists with expertise in Chinese medicine -- offer advice on how to manage morning sickness, and strategies for recognizing, managing and treating hyperemesis.
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DISCLAIMER: This podcast is for educational purposes only and is not a substitute for medical advice. You can see the full disclaimer here.
Anne Nicholson Weber: 00:01:00 Our topic today is morning sickness and the less common, more extreme condition called hyperemesis gravidarum. My guests are four experts who bring quite different perspectives to this topic. Ashlie Martin is a licensed acupuncturist and national board certified herbalist, practicing traditional East Asian medicine. Her practice is called Moon Hill Acupuncture. She has a strong focus on women's health, including gynecological issues, fertility, pregnancy concerns, and postpartum recovery. Anjalee Patel has a doctorate of acupuncture and Chinese medicine from Pacific College of Health and Science, and a BA in psychology from the University of Illinois at Chicago. In addition to her acupuncture and Chinese medicine practice, she's a licensed physical therapist assistant. She practices with A Touch of Ginger. Sarah Stetina is a board certified nurse midwife with over a decade of experience. She specializes in integrative holistic trauma-informed care for women across all life stages. Last Nora Calhoun is a practicing RN and also a certified nurse midwife. She's the mother of four and has suffered through hyperemesis with each pregnancy. So she brings the lived experience to our conversation . . . and she also just happens to be my daughter. So thank you all for joining me. Um, and let's start maybe by, uh, explaining the difference between morning sickness and hyperemesis. Sarah, could you just kick us off with a little explanation?
Sarah Stetina: 00:02:30 Yeah. Morning sickness is kind of misnomer. Um, it doesn't just occur in the morning. It can happen all day long in the middle of the night. And that's typically the experience that a majority of pregnancies have, where you may be having some intermittent vomiting, a baseline nausea that kind of permeates your day or affects your ability to eat or drink sometimes. But vomiting is typically infrequent, maybe once or twice a day, um, maybe a couple times a week if that. You can also have morning sickness that doesn't include any vomiting. And most traditional like remedies and simple measures like lifestyle changes will typically ease some of those symptoms. When we talk about hyperemesis, the more severe version, we talk about a condition that can last the entirety of the pregnancy, whereas morning sickness typically shows up in the first trimester only and then resolves with time. Hyperemesis can last the entire duration of the pregnancy. It's extremely severe. Multiple episodes of vomiting, uh, very little tolerating of food, water. You may be losing weight significantly. It can lead to severe dehydration, malnourishment. So it just takes it to a whole nother level. And most of those simple remedies and lifestyle changes don't touch it, and don't fix it. So, uh, it can often require a lot more medical intervention and it can have a lot of implications, which we'll talk about today.
Anne Nicholson Weber: 00:04:09 Nora, as someone who's been through it, do you want to add anything to that description of hyperemesis?
Nora Weber Calhoun: 00:04:14 I guess I would say only that there isn't one specific, like agreed upon set of diagnostic criteria 'cause it's kind of a set of symptoms along a spectrum. But in general, um, I've been told that if you're losing more than 5% of your body weight plus having symptoms of dehydration, we're probably headed into that territory. And then it also just has to do with how intractable it is, meaning if we do stuff, does it get better or does it not respond?
Anne Nicholson Weber: 00:04:47 Yeah. And are the causes, uh, the same? Is hyperemesis a more severe version of the same syndrome, or is it caused, does it have a different, uh, etiology?
Sarah Stetina: 00:04:59 Yeah, I, I did a little research on that question because it's still, I think, under research, but they do think -- there's an organization called the HER foundation. They study hyperemesis and they found a gene, a hormone growth factor, essentially, that is produced by the placenta and it rises really rapidly in early pregnancy. And they think that people that have hyperemesis have a variation in the gene that codes for that growth factor, which essentially means they have abnormally high levels of that hormone, um, or an abnormal sensitivity.
Nora Weber Calhoun: 00:05:34 Yeah, as you can imagine, I've been very interested in this topic because that study came out between my first and second pregnancy. So, I mean, it's unfortunate, but if you can point to a genetic basis for an illness, it becomes more legitimized in the medical community. Mm-hmm <affirmative>. Um, and they, they were able to pinpoint two genes that I think to memory, it's about 25% of the population has, but of people with hyperemesis, 85% of them have it. So there's clearly a strong correlation there. And then there's other things that are risk factors, but none of them would be causative. So it's having either mother or sister with the condition, prior history of severe, -- llike you're much more likely to get motion sick, like in the car or mm-hmm <affirmative>. So there's a few other things like that. But yeah, the genetic component seems to be the number one thing.
Sarah Stetina: 00:06:32 Hyperthyroidism as well, uh, seems to be strongly correlated with hyperemesis.
Ashlie Martin: 00:06:38 I have heard too that there might be a histamine reaction, like perhaps that's part of what the, they've found in the genome where certain people are more histamine reactive to the HCG hormones, so there might be something to do with that.
Anne Nicholson Weber: 00:06:53 Mm-hmm <affirmative>. Great. So we've kind of mapped out, um, what the two conditions are. Let's now go to morning sickness and focus on that for a little bit because it is so much more common. You've referenced lifestyle changes and some simple treatments, and I wonder maybe Ashlie and then Anjalee, if you could talk about the things that you have to offer for this condition. Sure.
Ashlie Martin: 00:07:14 Um, I mean, first trimester is really tough for many reasons. Morning sickness is one of them, but most people are quite fatigued as well. Um, and I think there's a, there's sort of a mental disconnect for a lot of women where they don't feel like they're really pregnant yet, and why would they be so tired? And, and I do think from a Chinese medical perspective, fatigue can increase the potential for nausea and just having like, lack of energy in the digestive system. So I think there is an element of like, you do actually need to rest <laugh>, um, even though you don't look pregnant and you just found out or whatever it happens to be, but your body is growing a new human, it's just beginning the process. The cells are dividing very rapidly and it takes a lot of energy. And so sometimes I think lifestyle wise, um, just getting my patients to stop the hecticness of their schedule, um, build in more rest, maybe reschedule some of their events that they didn't intend to stop just right away, like right away, first trimester <laugh> just slow down. So I do think that's one of the things I, I'm repeating often with my patients.
Anne Nicholson Weber: 00:08:30 Yeah. And Anjalee, what would you add?
Anjalee Patel: 00:08:33 Something that I usually tell my patients is to try to stick to smaller meals throughout the day. Instead of like breakfast, lunch, and dinner. Sometimes the appetite's not there. They can't have a full meal, so just having smaller meals throughout the day can be very beneficial. I also try to have them even sip on some, like chicken bone broth or beef bone broth, if that's appetizing to them because it's filled with nutrients. It does have a little bit of protein and it has gut healing properties as well. So I'll try to start off by having them make those little changes. Um, especially if they're working. I know a lot of moms, including myself, when I was having morning sickness all the time, it was hard for me to like, you know, rest throughout the day just 'cause of my schedule at work. Like, I couldn't take off any time.
Anjalee Patel: 00:09:34 But I feel like eating the smaller meals and resting in between patients, like even lying down in the treatment rooms if there were empty, you know, just taking any kind of breaks, just like Ashlie mentioned, can be very beneficial. And then prioritizing sleep, because your body needs all the resources to grow a little human being and sleep is going to be beneficial. So making sure that you're, you know, getting off, um, any kind of screens an hour before your bedtime and like doing a bedtime routine, making sure your body's like rested enough to fall asleep easily and stay asleep. Um, which of course, acupuncture can help with any kind of sleep issues, which tend to happen in first trimester pregnancy anyways. So that's like kind of the lifestyle changes that I'll advise to my early pregnant women.
Anne Nicholson Weber: 00:10:24 I think both of you have made the point that in the first trimester, you're kind of feel barely pregnant. And I don't think our culture, I mean, we, we tend not to talk about our pregnancies until the second trimester, so nobody's cutting us any slack. And I think maybe that also means that we tend not to cut ourselves any slack, not to recognize that actually our bodies are doing a huge amount of work, um, and need extra care, even though this is now kind of a private process that's happening. So in addition to lifestyle changes, let's talk about morning sickness that maybe is a little more severe and really causing anxiety and distress. What other, uh, kinds of interventions are available to try to help with that? Sarah?
Sarah Stetina: 00:11:07 Um, I did want to mention a couple other lifestyle tricks, uh, that I have seen work very well for folks. Um, a big one is cold. So cold fluids. Um, and cold food is sometimes better tolerated because it is not as odorous, it's a little bit more refreshing. Now, there's some cultures that would totally disagree with me, um, and would recommend warming foods only, so I totally respect that too. I just think that, um, finding what works for you is going to vary. So I think being open to trying different things and at different points in your first trimester to get relief is going to be really essential. Um, eating really slowly and as Anjalee mentioned, is like getting protein. So any food or meal that you can tolerate, prioritizing protein, um, will help even out those blood sugars, which I think have a big impact on morning sickness.
Sarah Stetina: 00:11:59 So having those small meals, having them with some kind of protein that you can tolerate, um, is a good way to kind of keep the nausea at bay. And drinking water, you know, in between meals. Plain water is also a big trigger for a lot of people. So I recommend either herbal teas and, uh, flavoring your water, putting lemon in it or, or something like that. Uh, electrolytes sometimes sit way better. Um, when I worked at the birth center, we had fruit-infused water in the fridge and people loved it because they were all first trimester and nauseous and we had something that they could really tolerate. But as far as next level, there's some really good first-line evidence on vitamin B6 and the use of that for nausea and vomiting in pregnancy that does not, um, include hyperemesis. So that's usually the first line.
Sarah Stetina: 00:12:56 It can be taken in a 25 milligram tablet in the morning, in the afternoon, and 50 milligrams right before bed. So essentially you're getting about a hundred milligrams a day. Um, and then it's not one of those kind of interventions that you do just when you're nauseous, you do it, uh, consistently, and over the course of several days there's usually an improvement. Um, and you can pair it with, uh, Unisom sleep tabs in the evening, uh, which combined together our, um, evidence shows even more effective. And it's about 12.5 milligrams or a half a tab at bedtime. It will make you very tired. But as we were talking, prioritizing rest is really essential in the first trimester.
Anne Nicholson Weber: 00:13:45 And so then Ashlie, um, sort of the Chinese medicine perspective on this, we were laughing, you were laughing when Sarah was saying no, not you, you're, she's saying cold and you're nodding and saying no hot. Well,
Anne Nicholson Weber: 00:13:57 So tell us a little bit about that perspective.
Ashlie Martin: 00:13:59 Yes, I mean, there, Chinese medicine prioritizes warm foods for the health of the energy in the body in general. So it, warm foods help us, um, build our energy, build our qi on a regular basis. So if you're tired and fatigued and pregnant and building a human, then you need a little bit more energy. So I would say prioritizing cooked foods rather than raw foods is better. It doesn't necessarily mean that they have to be hot, they just need to be cooked and easier to digest. Um, often I will tell my patients, uh, I, I agree with you Sarah. I have a lot of people say like, I am, there's no way I am drinking tea or bone broth. Like, it's too, it smells. And for those people I recommend cold waters with fruit in them, like Spindrift. A lot of people feel like the bubbles really help them with, or like sparkling waters not to put a product placement on there, but <laugh>, um, sparkling waters with some fruit flavoring are really helpful.
Ashlie Martin: 00:14:58 And that helps sometimes with the burping or belching that they might have along with the morning sickness. Um, so that helps some people. Other people I've recommended doing like a ginger tea that they make themselves so that they can adjust how strong the ginger taste is for them. So you just slice a, a little bit of ginger, put it in a pot, boil it for a while, and then you can taste it like, do you want a little honey? Do you want a little lemon? And then you can keep that in the fridge to have cold. But the ginger itself, no matter how hot or cold your actual fluid is, the ginger itself will warm the digestive system. So give you more energy generally. So those are my, those are just my responses to <laugh>, you know, responding to this the cold thing. It's true. Some people need cold fluids and that's fine.
Anne Nicholson Weber: 00:15:53 And Sarah mentioned some kind of western medicine approaches. I would, you know, with the, uh, B6 -- B12? -- B6 um, and the Unisom. Ashlie, are there things kind of the equivalent of those types of interventions that you use?
Ashlie Martin: 00:16:08 Well, I often recommend B6 too. Um, and then again, like I don't do a lot of herbs with early, early pregnancy. Um, unless it's needed for other reasons, mostly just because I feel like sometimes these people are having trouble keeping things down already. So it's like complicating the situation if they also have to digest like an herbal pill. But I don't do, maybe Anjalee is a little bit different. I don't do the, um, the liquid herbal formulas. So I do pills in general, so that might be the difference in whether you use herbs or not. But I do recommend like the ginger, I call it ginger aid, it's like making your own ginger aid lemonade sort of thing. But for the more severe things, like I, I like to send my patients home with a press needle on a specific point that helps with nausea.
Ashlie Martin: 00:17:00 That's a great acupuncture point on kidney 27. It's right underneath the clavicle, near the sternum. And that has made the biggest amount of mpact on my patients. Um, where they'll come in with a, you know, we do a scale of one to 10, how horrible is your nausea today? They'll come in with like a six or a seven and leave with like a two. And I leave the kidney 27 on there as a press needle, that, that it'll stay, it's a sticker. It stays for several days for most people. And I'll send them home with replacements so that they can just put on another one if it falls off and they feel like they still need it. That has made a major difference in a lot of my patients' lives.
Anne Nicholson Weber: 00:17:44 Great. Um, Anjalee, what would you add?
Anjalee Patel: 00:17:46 Yeah, so I usually do herbal medicine in early pregnancy. If it's to a point where the morning sickness is terrible or especially for, um, hyperemesis, I will do -- we do granules here. Mm-hmm <affirmative>. So it ends up being kind of like a tea, uh, 'cause you put like hot water on it, it melts and you kind of sip on that throughout the day. You don't have to take it right away. 'cause like Ashlie said, some people are already nauseous, you don't want to gulp all this tea down. But I have seen it help a lot with patients that are experiencing the hyperemesis or morning sickness, um, to just keep it down so that they can like rest so that they can actually have a meal, um, that they can tolerate water, things like that. And then, yeah, uh, like point wise, sometimes I'll leave patients with like ear seeds or yeah, we call them like intradermal needles, which are just like the stickers.
Anjalee Patel: 00:18:43 Like she, uh, Ashlie was talking about on like PC six, which is on the wrist, which is good for like motion sickness or just nausea in general. Paired with, um, stomach 36, which is on the lower legs. That can help with nausea as well. And I'll have them just like massage it throughout the day or whenever they feel like they're experiencing a little bit of that creeping up again, I'll have them do that. And it's been beneficial. Also, I'll tell them to come regularly for their acupuncture at least once a week. Um, especially in the first trimester, that's super important. And usually not just for morning sickness, like there's other stuff going on, like trouble sleeping, they're feeling hot, they're feeling like crampy or bloated, they're feeling vexed, like whatever it is. Or really stressed out and anxious. 'cause pregnancy is, you know, a whole mental health journey. So trying to do all the things. And acupuncture is so unique where you can treat all those things at the same time. So yeah, I'll just, like I said, just have them come regularly. I'll send them home with some stuff, do some dietary recommendations, and then usually they go home with herbs.
Anne Nicholson Weber: 00:19:51 So, two follow up questions on that. One is, I believe there is pretty good evidence for the efficacy of acupuncture for morning sickness. Is that something that you all can talk about or is it more anecdotal in your case?
Ashlie Martin: 00:20:05 I mean, I think that there have been some studies that indicate PC six, the one that, the point that Anjalee just mentioned is good for nausea in general. Um, and so then it also helps with nausea and pregnancy. But just from clinical experience, I've noticed major differences in acupuncture, being able to reduce the frequency of nausea or reduce the frequency of vomiting, especially in hyperemesis where the, the person is able to have a more calmer quality of life, like throughout their pregnancy. Yes, they might still be nauseous, but it might be reduced to a point where they can manage life a little bit easier, get a little bit more rest, calm their anxiety. They're not worried about throwing up on the L or or you know, at work or whatever. 'cause they can manage it a little bit better if they're using acupuncture on a regular basis. And I want to second Anjalee’s point about acupuncture needs to be a very weekly thing for this sort of situation. 'cause you're pregnant, it's not going away. Your body is responding this way to the pregnancy. And so we need to continually remind your nervous system in your brain and your body that you can calm this nausea down internally. Um, and so getting that reintroduction of that message on a weekly basis is really helpful.
Anne Nicholson Weber: 00:21:28 And the other thing I wanted to follow up on is, um, I think in general when you're in your first trimester, you're very, uh, anxious about anything you ingest and you want to know that, you know, these herbs are safe. So how, um, can you just talk about the safety of some of the herbs you use?
Anjalee Patel: 00:21:46 Sure. So, um, the herbs that we use specifically in this clinic, um, it's from one source. We trust this company, um, for so many reasons. They do a lot of batch testing. Um, they make sure that their herbs have no lead, have no mold, pesticides, et cetera. Um, and so we, we really trust this company. We actually know the owner as well.
Ashlie Martin: 00:22:10 I, I want to mention too that these herbal formulas have been around for quite some time. So we're talking like several hundred if not a thousand years <laugh>. Um, and so there's clinical evidence and some research out of, um, the more Asian cultures have been doing more research on herbs. But the classic herbal formulas that we would be using for an early pregnancy situation where you need to improve your digestive energy, um, just lift the Qi in general, like help your body transform food better, like those sorts of things, those all would be very safe.
Sarah Stetina: 00:22:45 I did just want to add to working with an herbalist <laugh>, it makes it safer, right? You're working with someone who has the expertise to know which herbs to use and which not. So, um, working specifically with an herbalist is probably the safest way to go about it. Um, as a midwife there are certain herbs that, um, and like remedies that I know that are evidence-based and safe. And then anything beyond that, I really default to the herbalists team. Um, but we know like lavender and ginger and lemon, these are safe that you can prepare and, and you know, at home. But really beyond that, if, if it's not clear, you should be really connecting with an herbalist to get something tailored to you. Um, also magnesium, um, is something that I recommend a lot in the first trimester, um, because I find that it also helps, um, in addition to everything else that we've talked about. I don't know if that's something that you both also recommend, but
Ashlie Martin: 00:23:44 Yes, often I'm often telling people to take magnesium. Yes,
Anjalee Patel: 00:23:48 Yes.
Anne Nicholson Weber: 00:23:49 And I've just learned about, uh, transdermal magnesium. Um, there are, uh, preparations that you can rub with, uh, beeswax with magnesium that you put on the bottom of your feet. So that doesn't have to be another thing that you're putting on your poor unhappy stomach. Right. Um, Sarah, before we leave morning sickness, obviously Anjalee and Ashlie have a particular, um, skillset and set of tools. Is there anyone outside of acupuncture in Chinese medicine in the holistic world or other kinds of approaches -- you know, I don't know, exercise or something that you have found helpful?
Sarah Stetina: 00:24:24 Yeah, I'm glad that you brought up exercise. Um, we mentioned fatigue and the importance of resting, but I do really encourage clients to get outside and to move their bodies even in small five, 10 minute increments because I do think that one, it helps boost your mood and your energy, um, which are both typically very low in the first trimester. And I just think in the healing properties of being outside and moving your body seems to help a lot. It helped me personally. So that's something that I recommend. But outside of that, like referral sources, uh, it's usually going to be acupuncture that I'm referring to or herbalism if folks are wanting to avoid, you know, more like western medicines. The tricky part about nausea in pregnancy is that it's most common in the first trimester, which is when we're really trying to minimize any medications. Um, and even some of the nausea medications that are normal go-tos in western medicine are not really recommended in the first trimester. So, um, this is where that integrative approach really shines.
Anne Nicholson Weber: 00:25:32 And just one more thing, talking about morning sickness in the first trimester before we turned to hyperemesis: I remember feeling kind of anxious about the fact that I didn't feel like eating because I was, had this notion that it was really important to nourish myself. Um, so what, what is your answer to that concern?
Sarah Stetina: 00:25:51 Yeah, that is, something comes up a lot and I try to provide a lot of reassurance and something I say often is, the first trimester is all about surviving <laugh> and not necessarily thriving yet. Um, uh, when people get pregnant, they picture themselves being the healthiest version of themselves. Maybe they've already been doing really healthy things leading up to that first trimester. And so it can feel really discouraging when they're gravitating towards carby foods or things that they don't normally eat and they are not exercising 'cause they just can't get off the couch and they can feel really down on, oh my gosh, I'm already, you know, failing all this pressure we put on ourselves and they can feel anxious or depressed, um, on top of all the hormone shifts. So I really reassure people that what you're feeling is normal. Your body is telling you that you need this rest for a reason. It's mean, it's meant to slow you down. And you will hopefully start to feel better. We'll talk about hyperemesis next <laugh>, um, but that, you know, this is this, you're not doing harm essentially to your baby.
Anne Nicholson Weber: 00:26:59 And this is maybe the very beginning of trusting your body: that this is kind of how it is for everybody and there's -- or most people -- and there's probably a reason why that's just fine.
Sarah Stetina: 00:27:09 Right. And I find it really like from an evolutionary standpoint, really interesting that a lot of food aversions are towards foods that could historically have been the most likely to carry illness or disease or cause um, you know, complications in a first trimester pregnancy. So I think there's a lot of wisdom in our bodies, even if they're not as applicable to modern times.
Anne Nicholson Weber: 00:27:33 Go ahead, Nora.
Nora Weber Calhoun: 00:27:35 I was just going to say, I, I think there can also be a couple of opportunities, uh, presented by nausea and vomiting in early pregnancy and feeling low and feeling tired. And one of those is, this is the first of many, many, many times in motherhood that your picture of how things should be and how things actually are don't match. And getting a little practice with that before there's an actual baby in your arms and then a toddler and child, um, is actually a really important part of the parenthood process. And then the other thing is that this also means that this is an opportunity to start leaning on your people and your community earlier in pregnancy. Then we usually imagine, um, I think a lot of, especially first time pregnancies don't realize how impossible it is to do it alone, even though alone is, you know, autonomy is kind of our favorite thing in this culture.
Nora Weber Calhoun: 00:28:34 So it's, it, it doesn't make it nice or fun, but there are these, these opportunities to um, start to find out who's there for you and how they can help and start to get practice with saying yes to help and getting practice with saying no to doing things that are too much because you need to rest. Um, and that can really then help in the postpartum period. 'cause those are two things that you really have to be good at <laugh> or learn to be good at, um, when you have a small baby. You know, accepting help and letting what you imagined and what's real be different.
Anne Nicholson Weber: 00:29:11 Yeah, that's an interesting point. Anjalee, or Ashlie, anything to add to this, um, topic before we move on to hyperemesis?
Ashlie Martin: 00:29:19 I just want to say I love what Nora just said. <laugh>.
Anjalee Patel: 00:29:21 Yes.
Ashlie Martin: 00:29:22 I, um, I am regularly having that conversation with my patients and it is hard, it's hard to just recognize the change is there so soon. And I think having somebody with you like making a team and going in to see people on a regular basis that can help keep you normalized. Like whether it's acupuncture or a friend group that understands or whatever, or a therapist, whatever it needs to be, um, to just help you remember that I, it's okay that I'm slowing down,that I can't eat vegetables right now, that I'm craving more mac and cheese than I have in 10 years. And, um, it's all going to be okay. The baby's fine. The baby will be fine, you know, hopefully, and like getting that reassurance is I think part of what calms the mind, which will help calm the body in the first trimester there.
Anjalee Patel: 00:30:23 Mm-hmm <affirmative>. Yeah, I always just reiterate to anybody. It doesn't have to be a patient, it could just be a friend who's struggling, um, to just be kind to yourself. You're doing this amazing thing, um, growing this entire human being and so like, be kind to yourself, be patient, which is really hard to do.
Anne Nicholson Weber: 00:30:44 And obviously this is all much harder in a world where so many women are working, uh, in jobs and, and haven't, you know, yet gone public with their pregnancies. But, um, . . . and the other thing that's just come up is the mind-body connection and how central that is in pregnancy and how anxiety's going to make symptoms worse and symptoms make anxiety worse. And finding ways to break that cycle. Okay. Hyperemesis! Nora, would you like to describe what that was like?
Nora Weber Calhoun: 00:31:15 Well, um, it's important to understand that this is a condition that is along a spectrum. So as I mentioned earlier, there's not one definitive cutoff point that, um, makes hyperemesis diagnosis a hundred percent,” yes, this is it, no, this isn't it.”However, um, on the one hand we've got what we were just talking about, mild nausea and vomiting. It responds to lifestyle changes. It's typical, it's a sign of a healthy pregnancy, all the way up to, um, extreme untreated hyperemesis can be fatal. Actually one of the Bronte sisters, that was her cause of death. Now obviously this was in a time before we had the interventions that we have now, but I just want to kind of set the understanding that there's a really wide level of extremes here, <laugh> in what people can experience. So, um, my experience, while pretty awful, was on the less extreme end of what is already the more severe version, because it was hyperemesis.
Nora Weber Calhoun: 00:32:29 I did, you know, meet those criteria and, and it was miserable. So the main thing I think that for me . . . well, I'll say each pregnancy is different and that's another important thing to understand. So while I did meet those criteria with all four, what that looked like was very different. So in my first pregnancy, I went into it very holistic and natural minded. Um, I was already a doula. I knew I wanted to become a midwife someday. All my babies have been community births, out of hospital. My first was a home birth, so I was under the care of a home birth midwife, um, from the start. And I was living in New York. I was pretty young. This was my first baby. I knew less than I thought I did <laugh>. And so in that case, I had essentially untreated hyperemesis because one of the issues is that early pregnancy is when we have the fewest visits, that frequency of visits is really spread out.
Nora Weber Calhoun: 00:33:29 And I was really scared of any type of medical intervention and I didn't really understand what was happening to me. So I just white knuckled it. Um, I lost a lot of weight. I was severely dehydrated. I basically just drank Gatorade. But I was able to keep down some food and I didn't ask for help and I was not offered help. So in retrospect, it definitely met the criteria for hyperemesis, but that was not how I understood what was happening to me. I thought it was just, just quote unquote bad morning sickness, except for that it was 24 7 and I couldn't get off the couch and I couldn't eat and I couldn't drink, and I was having headaches and migraines triggered by dehydration, all that stuff. However, it spontaneously resolved a little bit before 20 weeks. And my life situation at that time allowed me to put up with that.
Nora Weber Calhoun: 00:34:25 And I wasn't like, you know, I didn't have a family dependent on my income at that point. I was in school, um, things like that. So, -- and I don't think that my midwife really understood what was happening to me. She was not very focused on weights, which in general there's a lot of good around that. You know, we have a lot of anxiety and there's a lot of negative history around, uh, hyper focus on weight gain in pregnancy and not too much or not too little. But, um, anyway, so just that was what happened there. And then my second pregnancy, uh, that was by far my most traumatic, so it was even more severe than the first one. Again, at the first half of the pregnancy, I was planning a home birth under the care of a home birth midwife. Um, and I, it hit so hard and so fast that I -- if you've ever had, um, food poisoning, you know, that experience of being so ill that all you can do is like interiorly, hunker down and wait for it to pass.
Nora Weber Calhoun: 00:35:37 Um, you can barely talk. You know, you're just, it's, it's like the, the wild animal that goes to be alone behind a bush until the illness or injury resolves. That that's part of the human brain. And that happens. And that's, and that's the space I was in. So, um, it's really hard to advocate for yourself, one, if you don't really understand what's happening.; two, if you don't know what you need; and three, if you're scared of the options that are offered. Because I, I was, I was very nervous about taking anything. And I think we don't have good narratives in how we talk about pregnancy and nausea, vomiting, complications of pregnancy, that non-intervention in some cases is as harmful or more harmful <laugh> than an intervention that carries a risk. Non-intervention carries risks too, if you're as sick as I was. So I did eventually start taking Diclegis, which is the, um, like brand name formulation of B6 and Unisom that, um, Sarah was talking about earlier.
Nora Weber Calhoun: 00:36:46 And so I slept all the time. And I think one of the difficulties in helping your care provider to understand how bad things are bad is, um, again, like when, you know, we were talking about, well, what defines it? If you're only vomiting once or twice a day, that doesn't sound so bad. But in my case, I was only vomiting once or twice a day 'cause I didn't eat at all. I'd stopped eating and I wasn't drinking. I had nothing but basically frozen Gatorade. So if that information isn't included with the number of nausea and vomiting episodes, because I couldn't, I just couldn't bring myself to eat. I knew it would come right back up again. There was no point. And also our insurance coverage was a really cheap, doesn't-cover-anything marketplace plan. Um, so going to the ER felt impossible and irresponsible.
Nora Weber Calhoun: 00:37:33 So I, of the four pregnancies, that's the only one where I, that I would describe it as truly traumatic. So I did eventually start taking Diclegis. Um, I even tried Zofran and it didn't help me at all. That was as much as I was offered. So I just took the absolute highest limit of Diclegis as I could and stayed in bed. And I lost a lot of weight. I lost like 12 to 15% of my body weight in that pregnancy. And I was, I was undertreated. My provider should have asked more questions to get to the bottom of it. But with that medication, with the Diclegis, I was at least able to stop losing weight. So, you know, my total weight gain in that pregnancy was about 17 pounds and nine pounds of that was baby <laugh>. So, um, not, not great, but uh, we got through and I had a happy healthy delivery at the PCC birth center.
Nora Weber Calhoun: 00:38:27 So then for my third pregnancy, I went in and I did a lot of work before I got pregnant. I knew how bad it could be and I knew I didn't want that again. And I had to make a lot of promises to myself about how I'm not going to go longer than five to seven days if things don't get better without stepping onto the next rung of interventions. You know, 'cause non-action was so much of the problem. And how similar hyperemesis feels to crippling depression. I mean, the, uh, the mental state that you're in is like acute depression. You can't move, you can't think straight, you can't advocate for yourself. You just let the suffering wash over you <laugh> until it's, until it's over. But the problem is it's not over. It goes on month after month. So I went, um, and saw my midwife before I even got pregnant and said, listen, this is the situation.
Nora Weber Calhoun: 00:39:17 This is what I want. I was given a prescription for Diclegis before I even got pregnant so that I could start taking it with first positive pregnancy test. I did end up in the ER with that pregnancy one time, and I got so lucky. And it's not fair that it should rely on luck, but it was. And as it happens, the ER doc that treated me, his wife had had hyper hyperemesis. So he understood what we were talking about. He was not gaslighting, he was not saying, well, have you tried ginger? No offense to ginger. I love ginger. But we were way past that <laugh>, um, and he was willing to try, uh, some of the less first line drugs. And I ended up on Reglan, which is actually a, an older medication that had kind of fallen out of favor in other uses, but for me was very effective.
Nora Weber Calhoun: 00:40:07 So that was when I was finally able to find a cocktail of drugs that worked for me. I want to mention a little bit about Diclegis. So it's a very old,-- uh, well, in the world of western medicine -- decades old medication that was in use for a long time, both in, both in America and Canada. Um, and, uh, it was known to be safe and effective. It had been used for decades, no link to birth defects, but there was a big lawsuit here. The science to back it up wasn't there, but the, uh, result of the lawsuit was a very expensive loss to the company that manufactures it. Um, and so they just stopped making it. And so you couldn't get it, not because it wasn't safe and not because it wasn't, um, well studied, but because it wasn't financially viable for the manufacturer. But they did continue to use it and make it in Canada.
Nora Weber Calhoun: 00:41:03 And I will say anecdotally, I did not experience that over the counter Unisom and B6 was as effective as Diclegis. Yes, it's the same active ingredients, but for whatever reason, maybe it has to do with the release rate, I don't know. But Diclegis was way more effective. So I had like researched ahead of time Canadian pharmacies where I could get Diclegis <laugh> and I was ordering it that way. So I just, there was a lot of stuff in place. I intentionally lost some weight. Um, and I know weight stigma is a problem, but it is also true that adipose tissue releases estrogen and higher levels of estrogen can make nausea worse. So that was one of the things I did ahead of time. And I just had a written list of all the things that I promised myself I was going to do if it got worse.
Nora Weber Calhoun: 00:41:49 So then, um, that actually ended up being not too bad of a pregnancy. Once I got the right meds and I gained weight, um, and was able to work and I wasn't, I felt bad, but livable bad. I could take care of my other kids. I could, I could do what I needed to do. Um, so I felt how most women feel in the first trimester when they're nauseous and low energy, but can cope. If I had Reglan, Diclegis and would go and get IV fluids in the ER as needed, I could achieve that kind of first trimester level of nausea and fatigue. And that lasted throughout the entire pregnancy. Um, and then for my fourth pregnancy, again, I had a plan. I knew what worked. I started it right from the beginning. And there's really good evidence to show that starting meds before you experience the nausea, so with the first positive pregnancy test, is way more effective.
Nora Weber Calhoun: 00:42:49 Um, and so that's what I did and it worked really well. So, and then it was in the forums on the, um, HER foundation that Sarah mentioned. They really are the leading group for helping people with hyperemesis. They have a wonderful tool that's, um, you can give to your provider, because not all providers, in fact, most, are not well educated on this. And it's essentially a treatment ladder. It's a, it's a graphic written out, like, try this. If that doesn't work, then this, if that doesn't work, then this run, these labs, keep track of this, that, and the other. Like, it just lays it out like what the most evidence based treatment options and diagnostic criteria are. And it's, and it's a weird experience, you know, 'cause I, I was miserable, but I had it so much better than a lot of the women in that online group.
Nora Weber Calhoun: 00:43:39 You know, hyperemesis can look like round the clock IVs, it can look like PICC lines. Um, and there can be a lot of complications. And I want to emphasize this is, this is a very, very rare condition, you know, um, it's come into the kind of public consciousness because, um, who was it -- Kate, that's right, Kate Middleton. Thank you. Um, she had it. And that was like the first kind of legitimizing move I think in the public consciousness. People saw it as something different. And then, um, and then as I said, this study came out with the genetic link. Um, you know, it's important to understand that the history of hyperemesis is that it was initially treated as a psychological condition. It's obviously an extremely gendered condition because it's pregnancy related. And the initial kind of medical consensus on hyperemesis was that it originated in ambivalence, maternal ambivalence about the pregnancy. You know, that was, that was the history. That's how it was treated.
Sarah Stetina: 00:44:45 Nora, thank you for sharing that story. Just the challenge of that.
Anne Nicholson Weber: 00:44:51 I think it's actually, I, I know you're a little diffident about how long that was, but I think that for a listener, uh, it's the most direct emotional way to connect. Um, and to think about what this could be or if you're going through it, how you can approach it. So I want to return to one thing you said, Nora, and it echoes something that I think Ashlie said earlier on, which is that intervening early and kind of, um, uh, breaking the cycle that can happen where because it's bad, then it gets worse. <laugh>, um, can be a really helpful principle to take away. And whether it's at the very low intervention end of having normal morning sickness, but, um, taking good care to treat it as, um, effectively as you can. And if it's acupuncture going weekly, just taking, uh, just understanding that it can get worse because it gets worse, so to speak.
Anne Nicholson Weber: 00:45:48 Mm-hmm <affirmative>. Um, and that if you can fend it off early, that can have an impact. And so that seems to be true both for morning sickness, which we talked about earlier. And then for hyperemesis, which you just gave us such a heart wrenching, uh, narrative about <laugh>. Um, so yeah, I wonder if any of the three of you can -- obviously Nora's story is idiosyncratic in one way. She's just one person and, as she kept telling us, she didn't have it as bad as it can be. What would you add to the wisdom that she's given us both about what worked for her and kind of how to think about this, um, that she didn't bring up? Sarah, you look like you've got something to say.
Sarah Stetina: 00:46:28 I think the things that's, that popped out during Nora's recounting of her experiences kind of ties back to what she said about the historical understanding of hyperemesis and how it used to be treated and some of that stigma still underlying. And I think we see that in how underdiagnosed and undertreated this condition is. And like Nora said, she didn't have the capacity or energy to advocate for herself. And the only time that her symptoms really improved is when she was not pregnant and she created a plan to address this after having two really miserable pregnancies. And I think that just kind of points to some of the trauma informed piece of when our, when our clients are coming to us and telling us that they are having these symptoms, that we need to believe them and we need to work with clients to come up with a plan and having an, uh, an advocate early on.
Sarah Stetina: 00:47:25 So Nora, you mentioned that you were really like averse to intervention and that kind of prevented you from disclosing some of your symptoms in the first pregnancy. And I think as providers, we need to be asking the right questions and we need to be, um, advocating for our clients and giving them some of that wisdom of that, hey, this condition can actually cause more harm. Like, you don't need to suffer through this. Let me, let me work with you. And I think one helpful thing for anyone listening is to be an advocate for people in your life that you know are pregnant, who maybe don't have the capacity to ask for help. If you're a spouse or a friend or you yourself are pregnant early on and starting to have, um, symptoms to just know that the earlier you intervene sometimes the easier it is to manage and finding a provider who will listen to you.
Sarah Stetina: 00:48:19 Um, the HER Foundation assessment tool is something that everyone can access for free. Uh, you can print it off and complete it and give it to your provider and tell them, this is what I, what is going on, this is why I need help. And it's a really tangible tool that prevents, you know, <laugh> disagreement or at least it's a good tool to advocate for yourself and, and then point them to that resource. Because, like Nora said, it really spells out for providers what to do. And it's excellent. It's a tool I've used many times without ever having received specific training on hyperemesis. You can really help someone, um, by utilizing it and, and then just validating like the experience and, and increasing the amount of visits that you have. So you're really addressing this in a timely way for people because yeah, it, it really robs the joy out of pregnancy, this condition. It's really, it's really intense. So anything providers can do to kind of lighten that trauma.
Anne Nicholson Weber: 00:49:25 And it, it's such a good example of the tension in pregnancy and, um, childbirth, which is, yes, it's a system that usually works really well, and by and large we in our culture overintervene, but knowing that can then become a block to intervening when it really is called for. This is a, a true pathology. And the other thing I just want to say as a grandmother is that those four babies who went through those very different pregnancies, including a very, um, fairly high level of intervention in the last two are all totally healthy. Wonderful. You don't have, -- I mean, of course there's this anxiety about what are you’re doing to your baby, but knowing that you really can take some of these medicines when it's called for and the result is going to be better and your, your baby's going to be as adorable and perfect as my four granddaughters.
Sarah Stetina: 00:50:15 And the alternative is really tragic. I mean, one in three people with hyperemesis will have a fetal loss if it's untreated, which is intense. And knowing that you can get . . there are treatments that can help keep you from becoming extremely malnourished or dehydrated that could impact the safety of you and your pregnancy.
Anne Nicholson Weber: 00:50:36 So Ashlie and Anjalee, we got into hyperemesis, which is this more extreme version. Um, you know, Nora said at one point, :”I was way past ginger,” but I suspect that there are things that you can offer to someone going through hyperemesis. Do you want to, do you want to talk about that?
Anjalee Patel: 00:50:53 Um, I would love to. I, um, again, just like kind of how we mentioned before is like really keeping up with coming in for your acupuncture appointments as soon as, as soon as you can. Um, I had a really intense hyperemesis case and they were getting some, um, like Western intervention as well. Um, but it was still kind of bad. And they actually came to me twice a week just to help with getting symptoms down enough so they could eat something or drink something, and then again, I would have them sip on some herbs. Um, and each case is so different. So like, you know, one person could be on this formula but doesn't mean it's going to work for the second person. So, you know, like just staying on top of, you know, your symptoms, like letting us know if things change, you know, just being your -- I feel like if you're an acupuncturist or a midwife or doula, like you are going to be a huge advocate for your patient and you're not going to gaslight them. So just, you know, assuring them that this is a safe space. I believe you, tell me what I can do to help. So having that piece in it too, um, as well as just like coming in as much as possible to just get those symptoms under control.
Anne Nicholson Weber: 00:52:21 Ashlie, is there's anything you wanted to add, uh, on the subject of your work with hyperemesis?
Ashlie Martin: 00:52:28 Well, I just want to double up on what Anjalee just said about how, you know, sometimes you do have to come in twice a week and I realize acupuncture is, it's a commitment to getting to the acupuncture clinic, um, and you know, taking the time out of your day to do that. But I have had a couple of cases where nausea is quite, maybe not quite as bad as Nora's, but pretty close, and twice a week acupuncture is very useful. The other thing is, like we've been saying, each person in each pregnancy is completely different. So, uh, from a clinical standpoint or Chinese medical standpoint, I would have to figure out, you know, what is it that this person needs? And there are varying types of nausea and vomiting. Um, some people vomit when they're too hungry and haven't eaten yet. Some people vomit right after eating before they can even swallow their food.
Ashlie Martin: 00:53:28 Some people have a lot of acidic elements to their nausea or their vomiting and some people don't. So all of those are informative from a Chinese medical perspective, that's a different pattern for each of those. And so we would treat those individuals differently in the clinical setting. And then again, like I do use Kidney 27, which I mentioned early on as a press needle, um, for people to go home with because I feel like no matter who it is, um, that usually helps to a certain degree. So this, this point on the sternum, next to the sternum is, um, we, it's part of the meridian that helps balance what we call the sea of blood, which is which houses the uterus. So when the uterus is blocked, um, by growing a human, it kind of reverses its flow, whereas normally it wouldn't do that.
Ashlie Martin: 00:54:24 So we have this, this point here at the top of that channel that just kind of was like, it's okay, you can, you can nourish the uterus <laugh>, we don't need to like have it all come up here. So from a Chinese perspective, there's a lot of pictorial ways of understanding that, like, that aren't necessarily like biomedical, but they, they give you a good understanding that, you know, this is something that the body does do, it's an imbalance. And acupuncture really does help balance out the imbalances. And like I said before, I've used different strategies with almost each one of my hyperemesis patients
Anne Nicholson Weber: 00:55:02 And that's the art of the healer, right? That not everybody is the same. And, um, having that kind of support, I have to imagine, even just emotionally having someone paying attention and doing everything they can to help is helpful. Nora, were you going to say something?
Nora Weber Calhoun: 00:55:17 I had just gotten curious, Ashlie, if you've worked with women who have been through hyperemesis or other types of difficult pregnancies afterwards and what your care for, um, postpartum or non-pregnant, uh, patients with that history, what does that look like?
Ashlie Martin: 00:55:37 So I do a lot of postpartum visits. Um, and I mean, thankfully the hyperemesis stuff kind of dissipates a little bit <laugh> after birth, but you do still lose so much energy giving birth and that does tax your digestive system. And so some people just don't have an appetite at all after birth. So I often will have to work with people, um, postpartum to make sure they're getting nutrients so that they can make breast milk and just have an appetite, um, build back their iron, et cetera. As far as like pre- pregnancy preparation, uh, if someone's coming into me with, with the intention of getting pregnant, um, we do work a lot on, again, keeping your energy levels up so that you can tolerate the dramatic change in energy when it, when you do become pregnant. So that immediate fatigue, the immediate, um, nausea for some people in like four or five weeks, uh, you can tolerate it a little bit better if you're coming into that place a little bit more nourished or like you said Nora, um, getting the movement in and making sure, uh, you don't have, you're at a healthy weight before pregnancy.
Ashlie Martin: 00:56:59 Sometimes that really is what needs to happen so that you, your body isn't holding on to the extra estrogens 'cause your body is going to flood with estrogen when you become pregnant. So the, the, the better you can mediate that for yourself prior to pregnancy it, it does make a difference.
Anne Nicholson Weber: 00:57:18 Sarah, I know you had said, um, before we started that you wanted to be sure we talked a little bit about follow-up care after hyperemesis. So Ashlie just talked about what she does. What do you do?
Sarah Stetina: 00:57:29 Um, so I think, again, very individualized, um, depending on the severity of it, but something that people forget is the impact that it has on all of your systems when you are chronically malnourished or chronically dehydrated. Um, dental care is a big one because of, uh, -- especially if you're someone that's vomiting on a regular basis, A lot of hyperemesis people will lose teeth or have a lot of, uh, tooth damage during or after pregnancy. So making sure that you're getting regular dental care during and after pregnancy. Even seeing a cardiologist or um, or checking in with a GI doc, can be helpful after pregnancy. Um, depending again on the severity that's not always necessary, but I think a big, um, emphasis on slowly restoring, uh, and that's the case for all pregnancies postpartum, but especially when you come out of this incredibly depleted situation, um, that could have long-term effects.
Sarah Stetina: 00:58:29 I think mental health is something that we did, we touched on a little, but throughout pregnancy, um, really making sure that people have connections to mental health resources. There's sadly like a very, uh, increased rate of suicide, um, and termination of pregnancies for people who are dealing with hyperemesis because of that, that severe depression that that Nora mentioned. Um, so making sure that those mental health resources are available during, but especially postpartum, um, as you're kind of navigating from coming out of that traumatic experience, um, and considering what that means for your, your family going forward. I know many people who've changed their entire family plan because they experienced hyperemesis and when they thought they wanted more children decide maybe not <laugh>. Um, so having people, um, like therapists to help process those feelings and and those plans, um, is a big one. Um, and then just slowly regaining any weight that was lost if needed and, and working with, um, you know, a, a team to help you do that safely and, um, and just kind of get back to a healthy baseline.
Ashlie Martin: 00:59:42 A lot of what Sarah just mentioned of the things that you have to mediate after, after birth, of like heart racing or heart conditions or um, teeth issues, a lot of that's, you know, electrolyte imbalances will create those heart issues and that is like a nutrition thing. So I just want to just reiterate like after birth renourishing your body is the number one thing you're supposed to do. So getting an appetite back is a big deal, so that what you eat creates the nutrients, so you absorb those nutrients that you need to replenish like your heart and your teeth, et cetera. Your body is going to give everything to that baby, which is why Nora had four beautiful, healthy babies, <laugh>. Um, but it's going to take from you, so it's going to take from your teeth, it's going to take from your bones, it's going to take from the internal organs. So you have to really prioritize deep nourishment in your food. So that's hard one in our culture. <laugh>?
Anne Nicholson Weber: 01:00:46 Yes. I was just going to say in our culture, um, I think kind of a, a dark side maybe of feminism, certainly the notion that women, you know, can be out in the world doing everything, be strong,and somehow has gone along with that the notion that we just work till the last minute, we drop our babies, we go back to work. And that the, the idea of a long time of both being nurtured before, during, and after has kind of disappeared. And if you go through something as extreme as hyperemesis, I think it's all the more important to realize that this is not, it's, it's normal and it's healthy, but it's also extremely, uh, exerting <laugh> and needs to be treated as a special different time. It's not just business as usual. I, I think this whole hole in our culture for creating, um, a circle of support -- both from people like Ashlie and Anjalee and from your providers like Sarah and also peers and all of the other, and then obviously family and friends -- just recognizing that you need a lot more help. That's sort of where Nora began. Well, I think unless anybody thinks we've missed anything, we've gone way over <laugh>. Is there anything that, uh, a gaping hole in our treatment of these subjects?
Sarah Stetina: 01:02:06 I just wanted to say one thing and I feel like it's less about feminism as it is capitalism that causes that problem of women feeling this need or pressure to kind of not focus on their own individual needs, but to go back and produce or work. And, um, and I feel like feminism is, is the emphasis that you are a priority and your needs are valid and whatever space you need to take up to do that is just as important as producing.
Nora Weber Calhoun: 01:02:37 Yeah, and I actually, that touches on something that I had wanted mentioned before, which is that it's really important for providers to understand that just because someone is working doesn't mean they're not horribly ill. Because I did work at times when I had no actual ability to do it, but I had to, there was no choice. I just had to work; financially that was what was required. So I think that part of my undertreatment in my second pregnancy was that when I said I was working, i was back to work, even though I was so sick that I could barely stand it, you know, I would just just go from bed to work to bed. It's, it, it is the economic necessity, not a clinical judgment. It doesn't tell you anything about someone's physical state or tells you very little I should say. Um, so that is another thing to look to look out for that. Some of the questions we ask about, are you able to do your daily activities? Well, I took care of my daughter 'cause what was the other option? Not take care of her? My husband did most of it. But if someone asks you, are you doing your daily activities and how often are you vomiting, you can sound pretty well when in fact you're very, very unwell. <laugh> because you know, people, uh, women, mothers, we do what we have to do.
Ashlie Martin: 01:04:00 Yeah. I think actually that's hard to admit. For some people it's, yes, Nora like you are experiencing that and you're like, I can't do this, but I'm doing this. I have some patients who are like, I'm just supposed to do this right? And it's like, no, no, actually, like this is not okay <laugh>, we need to adjust this for you. This is not okay.
Anne Nicholson Weber: 01:04:20 But the reality is, and this is true in all of these conversations I have with wonderful providers who are so able and expert in offering help, not everybody can afford and not everybody has the option. And that's a, a real tragic side of, um, of all of this. You know, we can draw a beautiful picture of what ideal care would look like. It's not actually available all the time. But also Nora's story and all the things we've heard give, um, give hope for what you can do just by self-advocacy, um, and making sure that you're seen and heard. Alright, thank you so much everybody. This was, uh, really enlightening and even for me, I knew Nora's story, but <laugh> in this context, it was really helpful to learn from all of you. So thank you. Thank
Ashlie Martin: 01:05:07 You. Thanks for having us.
Sarah Stetina: 01:05:08 Thank you Anne
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