I’m not in the habit of feeling sorry for members of the British royal family. But last month, when the press reported that a pregnant Kate Middleton had been hospitalized with hyperemesis gravidarum, my stomach lurched in sympathy. Pregnancy-related hyperemesis is usually described as “severe morning sickness,” but that doesn’t capture the suffering it involves. Unlike the intermittent, typically short-lived nausea of morning sickness, hyperemesis gravidarum is characterized by debilitatingly severe, nearly constant nausea, sometimes accompanied by vomiting, that can last for an entire pregnancy. Stephanie Nolen, a hyperemesis sufferer, described her experience in the Globe and Mail in December:
For the first months of my pregnancies, the world pitched and roiled and heaved. I could tolerate no food, or the smell of food. I don’t mean that I was a little pukey. I mean that I spent 50 days curled up motionless in the dark under a blanket, unable to bear rolling over at even a glacial pace. I lost five kilograms in a couple of weeks. I could not speak, I could not open my eyes, and when a sympathetic friend crept in to see me, the undulating pattern of her black-and-white striped pants triggered a round of heaving.
Only a few drugs are known to ease hyperemesis, and none of them work very well. Most sufferers are hospitalized periodically for dehydration and then sent home to curl up in bed, try not to worry about fetal weight gain and hope striped pants go out of style.
My own bouts of morning sickness paled in comparison, thankfully, but as someone who’s prone to carsickness, seasickness, airsickness, international travel and what might kindly be called adventurous eating, I have a long-running acquaintance with nausea, and I’ve been all too impressed by its effects.
Nausea is known to cause powerfully aversive reactions, often more aversive than those created by pain, and its negative associations can last a lifetime. I believe it: Given a choice between re-experiencing unmedicated childbirth and being forced to eat an entire bowl of raspberry Jell-O, with which I had an unfortunate experience in kindergarten, I’d choose … oh, I’d choose the Jell-O. But it says something about the staying power of nausea that I’d think pretty hard about the decision. And while I haven’t stopped boarding small boats or lurching trucks, I dread them, and I’m certain I remember every damn one of them.
It turns out that I remember not only nausea, but also articles about nausea, and Kate Middleton’s news led me to dig up a nearly 15-year-old New Yorker piece by Atul Gawande. In “A Queasy Feeling,” Gawande chronicles the horrific experiences of a hyperemesis sufferer named Amy Fitzpatrick, whose vomiting during pregnancy was so violent and resistant to treatment that her doctors proposed an abortion. (Fitzpatrick, an observant Catholic, did not consider it. She eventually gave birth to healthy twins.) While hyperemesis gravidarum is rare — it occurs in roughly 5 of every thousand pregnancies — milder nausea is, of course, common among people of all ages and conditions, and is second only to pain in numbers of related patient complaints.
Why can’t we treat nausea more effectively? Gawande suggests that multiple triggers are part of the trouble — no one drug can soothe the nausea induced by pregnancy, unfamiliar motion, and questionable food — but there’s a more profound problem, too. To most doctors, nausea is just a symptom, a normal response to, say, hormonal changes or chemotherapy. “The patient, we say, is ‘fine,’ but the suffering is no less,” Gawande writes.
Specialists in palliative medicine have made some progress, finding, for instance, that treating pregnancy-related hyperemesis when it’s relatively mild is much more effective than waiting until it reaches epic proportions. And they’ve found, unsurprisingly but importantly, that sympathy alone goes a long way. Gawande explains:
Perhaps the most striking observation palliative specialists have made is that there is a distinction between symptom and suffering … for some patients simply receiving a measure of understanding — of knowing what the source of the misery is, seeing its meaning in a different way, or just coming to accept that we cannot always tame nature — can be enough to control their suffering. A doctor can still help, even when medications have failed.
So spare a thought for the Duchess of Cambridge. She might enjoy a life of luxury, with endless supplies of cute hats and lavender shortbread, but hyperemesis gravidarum, no matter the circumstances, is hell on wheels. Stephanie Nolen, the Globe and Mail columnist, remembers hearing about a fellow hyperemesis sufferer who regularly “lay on the cold tile of her bathroom floor and yelled, ‘Please, God, let me die! Just let me die!'” In desperation, Nolen took up the practice, and found it “did more for me than anything else.”
Hang in there, Kate. And remember: England can get by with just one heir.
Toilet photo from iStockphoto.
It wasn’t until seeing the coverage of this case last year that I realized what I had experienced, undiagnosed, during my own pregnancy — I hadn’t even heard of the condition. All I knew was that I’d had gale-force morning sickness, food poisoning-style.
Once, during my pregnancy, a friendly nurse asked “so how many times a day are you throwing up?” My answer was, “I’m not sure how to count.” She looked confused, so I elaborated: If I vomit once, then vomit again thirty seconds later, is that once or twice? If I vomit steadily for thirty seconds is that ten times or just once? And if I spend thirty seconds retching uncontrollably over the toilet, but nothing comes up but bile, does that count or not? Also, if I pause at a sewer grate on the street and decide that I should let myself throw up here to avoid the indignity of losing it farther along the sidewalk, does that count, since I really let myself throw up?
We agreed to put “more than 10x daily” on her form. I didn’t really think that number did it justice, but it was close enough.
I did learn, though, that mint ice cream is the absolute best food to eat when you think you might throw up. If you time it right, it’s still cool and soothing on your throat when it comes back up, and the mint taste is much nicer than brushing your teeth.
I have always wondered what nausea really IS. It seems to me that its only indirectly correlated with vomiting. You can be horribly nauseated for hours or days without throwing up. You can throw up with only mild and brief nausea (I’ve met people like that who don’t understand what all the fuss is about).
And what is all this, It’s only a symptom nonsense? If a guy breaks his leg skiing, do the doctors tell him soothingly that the pain is only a symptom?
My understanding was that the Bendectin fiasco scared pharmaceutical companies away from pursuing drugs to treat morning sickness.
I would like to “like” Sarah’s comment.
And now, being very suggestible, my tummy is gently heaving and it’s time to move onto other subjects.