| The New York Times | April 27, 2004 | PERSONAL HEALTH |
Reasons, and Remedies, for Morning Sickness
By JANE E. BRODY
Most women experience morning sickness early in their pregnancies. But it does not necessarily strike only in the morning, nor does it always end after the first trimester.
I, for one, felt sick at various times of the day, especially when I smelled something off-putting, like garbage or meat being cooked, and every day on the subway on my way home, until I realized that it helped to eat something before I left the office.
A close friend was sick through the full nine months of two pregnancies and looked more like a ghost than a woman about to give birth. Fortunately, fetuses are like parasites, and her sons were born big and healthy. But she did stop at two.
In cases like my friend's, the problem can be so severe that the women have to be hospitalized to prevent dehydration and other complications. In fact, severe nausea accompanied by vomiting is the second most common reason, after premature labor, for hospitalization in pregnancy.
Some women suffer such serious psychological and social disturbances as a result of persistent vomiting that they choose to terminate their pregnancies, according to a new report from the American College of Obstetricians and Gynecologists. Severe nausea and vomiting, called hyperemesis gravidarum, occurs in up to 2 percent of pregnancies, the association reported in issuing new guidelines for diagnosing and treating the problem.
Why This Happens
Nausea and vomiting affect 70 to 85 percent of pregnant women, various studies show. Half experience both, and a quarter have nausea only. It is often said that these symptoms are signs of a healthy pregnancy — possibly indicating that the right hormones are circulating.
As the association guidelines point out, "numerous studies have documented a lower rate of miscarriage among women with nausea and vomiting of pregnancy and hyperemesis gravidarum when compared to controls." No adverse fetal effects have been noted when symptoms are mild to moderate, although women with severe, prolonged symptoms have a higher incidence of low-birth-weight babies. Yet, about one woman in four in Western countries manages to give birth to a healthy baby without these distressing symptoms.
The delay in understanding the cause or causes of nausea and vomiting of pregnancy has been attributed to longstanding beliefs that it reflected psychological conflicts or a woman's inability to respond to excessive stress. These notions are now discarded.
More plausible theories relate it to an evolved adaptation to protect the woman and her fetus from potentially dangerous foods. For example ,an evolutionary theory advanced several years ago by two Cornell scientists — Dr. Paul W. Sherman, an evolutionary biologist, and Samuel M. Flaxman, then a graduate student — suggests that the nausea and vomiting of pregnancy evolved to prevent exposure to potentially harmful infectious and toxic organisms in foods, especially during the time that fetal organ systems are developing. They suggested renaming the condition "wellness insurance."
The scientists noted that meats led the list of troubling foods, and meats (both undercooked and cooked but inadequately refrigerated) can harbor organisms that cause fetal malformations. Raw fish, popular in Japan where 84 percent of pregnant women experience nausea and vomiting is another source of parasites. But in societies where morning sickness rarely occurs, the dietary staples are grains, not meat or fish, the Cornell scientists reported.
The chance that a pregnant woman will experience nausea and vomiting, and particularly hyperemesis gravidarum, is in part determined by heredity. If the woman's mother or sister had the problem, she probably will too. Other factors that increase the risk include carrying multiple fetuses, carrying a female fetus, experiencing the problem in an earlier pregnancy and having a history of motion sickness or migraines.
The guidelines of the College of Obstetricians and Gynecologists emphasize the importance of making sure a woman's symptoms of nausea and vomiting are related only to her pregnancy and not to some serious undiscovered disorder like pancreatitis, ulcer, appendicitis, kidney stones, diabetes, overactive thyroid, brain tumor or preeclampsia (toxic high blood pressure of pregnancy).
Such unrelated causes should be suspected when nausea and vomiting occurfor the first time after nine weeks of gestation, the college says.
Prevention and Treatment
At least half of pregnant women with nausea and vomiting fail to seek help from their doctors or midwives. Some believe that little or nothing can be done, that they have to live with it until it passes. Others fear that any treatment may jeopardize the unborn child.
But as the obstetricians' group points out, there are many safe ways to relieve and possibly eliminate the problem. It advises early treatment of nausea and vomiting to prevent progression to hyperemesis gravidarum.
Prevention starts with taking a multivitamin every day from the time of conception. A woman trying to become pregnant would be wise to start taking a multivitamin even before she conceives. Failing that, over-the-counter pregnancy tests can reveal pregnancies within two weeks of conception.
Other simple and widely recommended remedies, most never tested for effectiveness, include eating frequent small meals, avoiding spicy or fatty foods, eliminating pills with iron, eating bland or dry foods or high-protein snacks, and eating dry crackers in the morning before rising.
Three effective treatments are capsules of powdered ginger (they can also curb motion sickness), electrical stimulation of an acupressure point on the inside of the wrists, and round-the-clock use of vitaminB6, particularly when taken with the over-the-counter drug doxylamine, an antihistamine often used as a sleep aid.
Once sold as the drug Bendectin until a fear of birth defects (since unsubstantiated) forced it off the market in 1983, this combination had been used by a quarter or more of pregnant women. It can reduce the incidence of nausea and vomiting in pregnancy by 70 percent, solid studies have shown.
According to the obstetrical association, "Several studies involving more than 170,000 exposures have found the combination to be safe with regard to fetal effects."
Now, the new guidelines point out, "individual compounding pharmacies in many communities will make up the combination of 10 milligrams of pyridoxine and 10 milligrams of doxylamine on request." Pyridoxine is vitamin B6.
A 12.5-milligram dose of doxylamine can also be obtained by cutting a 25-milligram tablet in half. The obstetrical group recommends its use with 10- to 25-milligram doses of B6 three or four times a day, if B6 alone is not effective enough.
Other medications listed as safe and effective are two kinds of prescription antiemetics, phenothiazines and benzamides.
If a woman suffers from severe and prolonged vomiting, she may need to be hospitalized for intravenous fluids to correct dehydration and electrolyte imbalance, a buildup of ketones in the blood and deficiency of vitamins, in particular the B vitamin thiamine. If a pregnant woman is so severely affected that she cannot maintain her weight, tube feeding may be required, the obstetrical group's guidelines say.
©Copyright 2004 The New York Times Company
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