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Archive for November 8th, 2009

HG Research

The problem with hyperemesis gravidarum is that there isn’t a really good and consistent way to treat it.

Okay, I’m lying.  The problem with HG is that it sucks, plain and simple.

The other problem with HG is that there isn’t a really good and consistent way to treat it.   You start with oral medications like phenergan or compazine, then ondansetron.  Maybe try some vitamin B-6.  My doctor even suggested Unisom (which is an antihistamine – doxylamine succinate, I think).  The problem with each of these options is that they require you to be able to tolerate oral medications.  The ondansetron (Zofran) comes in oral disintegrating tablets, so you don’t actually have to swallow them, but there are two problems with them – you have to be able to tolerate the taste of them, and they’ve got aspartame in them – so if you’re like me and aspartame causes migraines… well, it’s not a great option.  Take the anti-emetic, get a migraine, throw up from the pain.  Good times.

Oral medications aren’t working?  Still losing weight?  Can’t keep fluid down?  Go to the ER for IV fluids and IV Zofran and/or phenergan.  That’ll hold you for a couple days.  Maybe it will even break the cycle.  You might also have the joy of having snarky ER doctors tell you that part of why you can’t put food in your stomach is because you haven’t put any food in your stomach.   Gosh, if you just eat, you’ll be able to eat!  Makes total sense.  Except, it doesn’t, because the lack of eating isn’t for lack of trying.

So multiple ER visits for rehydration don’t work, and the next step is inpatient hospitalization for IV hydration, IV antiemetics, etc.  Sometimes even just having the time to not be moving around helps.  And while I was in the hospital – it’s true, I felt reasonably okayish since I was very still, not eating, getting lots of fluid and antiemetics.  But I still wasn’t really able to tolerate food or much oral fluid.  Meanwhile, I was missing my first week of work.  Indefinite time inpatient is not an ideal answer for treating HG.

The biggest danger in patients with HG is dehydration.   Also nutritional deficiency, but let’s face it, I’ve got “reserves”, if you will, so malnutrition isn’t the biggest issue for me.  (I will note that I did, and possibly do, have nutritional deficiencies in my labwork – it just was the least of my problems at the time).    But dehydration is not so great for anyone, let alone someone who is pregnant.  Later in pregnancy, dehydration can actually trigger contractions – not a great thing for a chick with a history of early onset preterm labor (even for a triplet pregnancy, I started contracting extremely early last time – so although this is a singleton, I *am* at risk for having PTL again).

And so – while I was in the hospital, I had a PICC line put in.  A PICC line is a central catheter inserted through a vein in the arm threaded through to the vena cava.  A PICC line is useful because it gives long-term access (a regular IV has to be changed every 3-5 days), and can be used for TPN (total parenteral nutrition) if necessary (a regular IV line can be used for PPN but not TPN).    Having the PICC line enables me to get home IV fluids and I also run my Zofran pump through it.  This way, I can be treated as an outpatient, instead of staying inpatient indefinitely.  A good thing, right?  Of course right.  And at the rate I’m going… TPN may not be out of the question in a couple weeks anyway.

I am against TPN.  I lost so much weight in my last pregnancy, couldn’t eat much of anything, and no one batted an eyelash at the perinatology practice.  This pregnancy, with my regular OB and everyone’s hysterical about a 20 pound weight loss.  I don’t really see the medical difference here, except I have only ONE baby and a FAR less high risk pregnancy than before.   I don’t mind doing TPN if it’s truly necessary, but I’m clearly not malnourished, so I don’t see a true medical necessity.  Having TPN would also mean that my Zofran pump would have to be run subcutaneously, instead of through the PICC line (they can’t run both), which would mean I’d have to lower my dose of Zofran unless they changed my PICC line to a double-lumen line.  Therefore, I see a myriad of reasons to avoid TPN if at all possible.

Which brings me, in a long, roundabout way, to the title of my post.  I’ve been doing a little bit of research on HG and have found a few things.  First, I’ve found that the treatment protocol that my doctor has used up to this point has been completely appropriate, and absolutely textbook.  Second, I’ve found that I *can* get IV phenergan – so I’ll be calling my doctor about that this week.  I can’t keep down the oral phenergan consistently, but it *does* help at night, and helps me sleep in addition to helping the nausea abate, so I’d like to be able to get that in me more consistently.

But I also learned that there’s a pretty aggressive steroid protocol that can be used and seems to have some very promising results.  I hate what steroids do to me – but I also hate what HG is doing to me, and the steroids might have the added benefit of breaking the migraine cycle I’m in right now.  That would be lovely.  (Having been unable to consistently take oral medications to prevent the migraines lately – well, you can imagine that it hasn’t been pretty).

Also, I’m probably not getting enough thiamine – so that’s something we can add to my IV fluids (I already add a multivitamin and folic acid to my IV fluids once per day), but that’s easy to fix (I’m guessing it won’t help the nausea, but it’s still important).

So I have a lot of things to talk to my doctor about this week… and my next appointment isn’t until next week.  Hrm…

I’ve also pretty much given up hiding this pregnancy from anyone other than my employer.  I’m past the first trimester, and everyone I know locally pretty much figured it out when I spent a week in the hospital.  I hate that I have no control over it.  I’m still not telling anyone how far along I am or what my due date is.  I hate the countdown that people get into.  I’m even still getting it now.  “Oh for sure you’ll be better by 12 weeks!  What?  You aren’t?  13 then!  It’s worse?  14 for SURE!…”  Frankly, I can’t handle the pressure.  I’m trying to get through each day, not each week, and I just don’t need everyone around me continuing the countdown, so I’m doing my best to avoid telling anyone my due date under any circumstances.  Other than, of course, my medical team members.

Oh, and my husband.  Him too.  Though I’m not sure he can be trusted with that information.

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