Research that forms the foundation of our approach

Not exactly light reading, but definitely worthwhile if you want to dig a little deeper

The positivity of Helicobacter pylori stool antigen in patients with Hyperemesis gravidarum
The pregnant women with Hyperemesis gravidarum have a significantly higher prevalence of Helicobacter pylori compared with control subjects.

Hyperemesis gravidarm and helicobacter pylori infection: a systematic review:
Fourteen case-control studies met established criteria, involving 1,732 participants and controls tested for H pylori infection. Studies were evaluated according to patient demographics and study methodology (case definition, exclusion criteria, H pylori testing). An estimate of the odds ratios with 95% confidence intervals was calculated by using a random effects model for dichotomous variables with review article software. Ten studies showed a significant association between hyperemesis gravidarum and H pylori infection.

Role of Helicobacter pylori in the pathogenesis of hyperemesis gravidarumSeventy-one cases among the 80 HG cases and twenty-four out of the 80 controls were H. pylori positive. Eight HG cases developed severe intractable vomiting. Three of them developed attacks of hematemesis. Gastroscopy done for the eight cases revealed antral gastritis and duodenitis. Gastric and duodenal erosions were found in two cases. The eight patients received a non teratogenic regimen for treatment. Attacks of vomiting decreased and pregnancy continued till delivery of healthy newborns. Screening for H. pylori should be added to the investigations of hyperemesis gravidarum cases. Non teratogenic treatment can be considered in intractable cases.

Helicobacter pylori seropositivity in patients with hyperemesis gravidarum: The authors investigated the association between H pylori infection and hyperemesis gravidarum. Conclusion: there is a powerful correlation between H pylori and hyperemesis gravidarum.

Managing hyperemesis gravidarum: a multimodal challenge
Chronic infection with helicobacter pylori may also cause HG.
The histological examination of the gastric mucosa in a total of 30 women (20 HG patients and 10 pregnant volunteers) showed that the bacterium was present in almost 95% of patients with hyperemesis but in only 50% of controls. Therefore, although a helicobacter pylori infection might not be the only cause of HG, it should be taken into consideration as a contributing factor in intractable cases of this condition.

Helicobacter pylori infection and hyperemesis gravidarum: a systematic review and meta-analysis of case-control studies
Exposure to H. pylori appears to be associated with an increased risk of hyperemesis gravidarum. The residual heterogeneity might have different reasons. Given the high prevalence of H. pylori, the public health consequence of H. pylori with regard to hyperemesis gravidarum may be important.

Evidence-Based Approaches to Managing Nausea and Vomiting in Early Pregnancy
Quality of life (QOL) and work efficiency are adversely affected by NVP for women who have  these symptoms. Fifty percent of women say NVP affects their ability to work, as many as 35% require time off from jobs (mean, 62 hours), 50% say it affects their relationships with family and partners, and 55% report being depressed. When QOL measures are used in research studies, the scores for women with NVP are worse than the scores of women who report chronic depression. 
An infectious origin is suggested by 14 published case-control studies that found a significant association between the presence of H pylori and HG. However, there are no directed studies addressing the efficacy of antibiotic treatments for H pylori in resolving the symptoms of HG. The most likely relationship is that women with H pylori and gastritis experience a more severe end of the NVP spectrum.

Update on Helicobacter pylori treatment
In a meta-analysis of 52 studies, adverse effects were noted in 39 trials comparing H. pylori eradication therapy plus an antisecretory agent versus antisecretory therapy alone (in 22 percent and 8 percent of patients, respectively [number needed to harm = 7 for H. pylori eradication]). The most commonly reported adverse events were nausea, vomiting, and diarrhea.

Management of Helicobacter pylori infection
Helicobacter pylori (H. pylori) remains a prevalent, worldwide, chronic infection. Though the prevalence of this infection appears to be decreasing in many parts of the world, H. pylori remains an important factor linked to the development of peptic ulcer disease, gastric malignancy and dyspeptic symptoms.

In vitro screening of lactobacilli with antagonistic activity against Helicobacter pylori from traditionally fermented foods:
Helicobacter pylori may cause stomach diseases such as chronic gastritis, peptic ulcer, and gastric cancer, and several studies reported that lactobacilli have inhibitory effects on H. pylori.

Helicobacter pylori and probiotics
Helicobacter pylori infection, a highly prevalent pathogen, is a major cause of chronic gastritis and peptic ulcer and a risk factor for gastric malignancies. Antibiotics-based H. pylori eradication treatment is 90% effective. However, it is expensive and causes side effects and antibiotic resistance. Probiotics could present a low-cost, large-scale alternative solution to prevent or decrease H. pylori colonization.

Exploring alternative treatments for helicobacter pylori infection
Among probiotics, Bifidobacterium is one of the favourite genera used for the prevention of gastrointestinal infection, and it is commonly incorporated in fermented dairy products or food supplements. Bifidobacterium exerts an in vitro anti-H. pylori effect and inhibits adhesion to the mucosa by competition. Several studies have demonstrated a direct relationship between the addition of potential probiotic strains and the in vitro inhibition of H. pylori growth. Lactobacillus acidophilus, Lactobacillus casei strain Shirota, Bacillus subtilis, and Weissella confusa, among others, have an antagonistic effect on H. pylori.

Minimum inhibitory concentrations of herbal essential oils and monolaurin for gram-positive and gram-negative bacteria:
We examined in vitro the cidal and/or static effects of oil of origanum, several other essential oils, and monolaurin on Staphylococcus aureus, Bacillus anthracis Sterne, Escherichia coli, Klebsiella pneumoniae, Helicobacter pylori, and Mycobacterium terrae. Monolaurin was cidal to S. aureus and M. terrae but not to E. coli and K. pneumoniae. Unlike the other two gram-negative organisms, H. pylori were extremely sensitive to monolaurin. Similar to origanum, monolaurin was static to B. anthracis Sterne. Because of their longstanding safety record, origanum and/or monolaurin, alone or combined with antibiotics, might prove useful in the prevention and treatment of severe bacterial infections, especially those that are difficult to treat and/or are antibiotic resistant.

Susceptibility of Helicobacter pylori to bactericidal properties of medium-chain monoglycerides and free fatty acids:
In contrast, lauric acid (C12:0) was the only medium-chain saturated FFA with bactericidal activity against H. pylori. Collectively, our data demonstrate that H. pylori is rapidly inactivated by medium-chain MGs and lauric acid and exhibits a relatively low frequency of spontaneous development of resistance to the bactericidal activity of MGs.

Susceptibility of Helicobacter pylori to the antibacterial activity of manuka honey:
“Assessment of the minimum inhibitory concentration by inclusion of manuka honey in the agar showed that all seven isolates tested had visible growth over the incubation period of 72 h prevented completely by the presence of 5% (v/v) honey.” Manuka honey is effective against H. pylori but is best used in tandem with conventional treatments for total eradication. 

Bacteria Linked to Severe Morning Sickness and How to Really Treat Ulcers:
The first step is to drink 12 glasses of pure filtered, not distilled, water per day. This also means stopping soda, juice, milk, tea and coffee. Good bacteria (acidophilus and bifidus) cultures also help to create an environment that does not support their growth.

Helicobacter pylori infection and gastrointestinal symptoms on Chilean pregnant women:
73.4% of the pregnant women that showed gastric discomfort during the first three months had Helicobacter pyloriinfection. 53.7% of them continued with gastric discomfort after the first three months; of those, 95.8% were infected. Helicobacter pylori infection was present only in 1.5% of pregnant women without gastric discomfort. Both, gastric discomfort of pregnant women and the continuity of severe symptoms of dyspepsia and hyperemesis after the first three months of gestation are significantly correlated with Helicobacter pylori infection.

Gastrointestinal symptoms and Helicobacter pylori infection in early pregnancy. A seroepidemiologic study:
Sickness and vomiting during the whole day were more frequently noted with H. pylori infection (OR 2.5, 95% CI 1.2-4.9, p = 0.01). Of the evaluated gastrointestinal symptoms, H. pylori infection is significantly associated with sickness and vomiting during the whole day.

The outpatient management and special considerations of nausea and vomiting in pregnancy:
With 50-90% of pregnant women experiencing nausea and vomiting of pregnancy (NVP), the burden of illness can become quite significant if symptoms are under-treated and/or under-diagnosed, thus allowing for progression of the disease. The majority of these women will necessitate at least one visit with a provider to specifically address NVP, and up to 10% or greater will require pharmacotherapy after failure of conservative measures to adequately control symptoms. Of note, co-existing gastroesophageal reflux disease (GERD), Helicobacter pylori infection, and psychosocial factors may have a negative impact on the management of NVP. 


Ginger use to treat pregnancy nausea, morning sickness, and hyperemesis gravidarum:

Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting
Ginger has been shown to be an effective treatment for nausea and vomiting in pregnancy. 

Safety of ginger use in pregnancy: results from a large population-based cohort study
Use of ginger during pregnancy does not seem to increase the risk of congenital malformations, stillbirth/perinatal death, preterm birth, low birth weight, or low Apgar score. This finding is clinically important for health care professionals giving advice to pregnant women with NPV.

Ginger for nausea and vomiting in pregnancy: randomized, double-masked, placebo-controlled trial:
Another study demonstrating age-old knowledge: Ginger is effective for relieving the severity of nausea and vomiting of pregnancy.

Effects of ginger for nausea and vomiting in early pregnancy: a meta-analysis:
Our meta-analysis suggests that ginger is an effective nonpharmacological treatment for nausea and vomiting in early pregnancy (NVEP).

Ginger treatment of hyperemesis gravidarum
Thirty women participated in a double-blind randomized cross-over trial of the efficacy of a natural product, the powdered root of ginger (Zingiber officinale), and placebo in hyperemesis gravidarum. Subjectively assessed, 19 women (70.4%) stated preference to the period in which ginger, as was later disclosed, had been given (P = 0.003). More objectively assessed by relief scores a significantly greater relief of the symptoms was found after ginger treatment compared to placebo (P = 0.035). No side effects were observed. Powdered root of ginger in daily doses of 1 g during 4 days was better than placebo in diminishing or eliminating the symptoms of hyperemesis gravidarum.

Treatment of Hyperemesis Gravidarum:
In a double-blind, randomized, crossover trial, 1 g of ginger was administered daily for 4 days. The preference among the patients to receive ginger versus placebo was significant. Concurrently, the relief of nausea and vomiting found with the use of ginger compared with placebo was significantly greater. In a study by Vutyavanich and associates, 1 g of ginger was given to women with hyperemesis for 4 days, and two measuring scales were implemented to quantify patients’ nausea. The improvement in the nausea scores of patients receiving ginger was significantly greater than that of the placebo group. Also, after 4 days of treatment, there was a significant decrease in vomiting in the ginger-treated group versus the placebo-treated group. 

Effect of ginger on relieving nausea and vomiting in pregnancy: a randomized, placebo-controlled trial:
Nausea and vomiting are common and unpleasant complications in pregnancyThis seven-day clinical trial was performed on 120 eligible pregnant women with symptoms of mild to moderate nausea and vomiting before 16 weeks gestation. They were divided into; ginger, placebo and control groups, by block randomization. Women were asked to record their nausea and vomiting for three days, and then participants received either ginger capsules, or a placebo for four days. Ginger was effective for the relief of mild to moderate nausea and vomiting in pregnant women at less than 16 weeks gestation.

Key statistics for nausea and vomiting during pregnancy (NVP):

A prospective study of nausea and vomiting during pregnancy:
Great overview of NVP. Key takeaway: The median total number of hours of nausea per pregnancy in those 292 women experiencing symptoms was 56, with peak symptoms occurring in the ninth week.

Nausea and vomiting during pregnancy: A prospective study of its frequency, intensity, and patterns of change
Seventy-four percent of women reported nausea lasting a mean of 34.6 days. “Morning sickness” occurred in only 1.8% of women, whereas 80% reported nausea lasting all day. Only 50% of women were relieved by 14 weeks’ gestation; 90% had relief by week 22.

Dietary and clinical impacts of nausea and vomiting during pregnancy
The proportional intakes of carbohydrates were higher in NVP subjects [50.1E% (IQR 46.7-53.6)] than in non-NVP [46.8E% (IQR 43.6-51.9), P = 0.008]. Dietary and total intakes of vitamin B(12), total intake of magnesium and dietary intake of zinc were lower in women with NVP. Changes in diet remained throughout pregnancy. Women with NVP had shorter pregnancies [39.9 (95% CI 39.6-40.1)] compared with those without [40.4 (95% CI 40.1-40.8) weeks. 
Nausea and vomiting in pregnancy modified dietary intake and has potential clinical impacts as suggested by the altered pregnancy duration. In view of the programming effect of early nutrition, these alterations may carry long-term health consequences.

Recurrence of hyperemesis gravidarum across generations: population based cohort study
Daughters who were born after a pregnancy complicated by hyperemesis had a 3% risk of having hyperemesis in their own pregnancy, while women who were born after an unaffected pregnancy had a risk of 1.1% (unadjusted odds ratio 2.9, 95% confidence interval 2.4 to 3.6). Female partners of sons who were born after pregnancies complicated by hyperemesis had a risk of 1.2% (1.0, 0.7 to 1.6). Daughters born after a pregnancy not complicated by hyperemesis had an increased risk of the condition if the mother had hyperemesis in a previous or subsequent pregnancy (3.2 (1.6 to 6.4) if hyperemesis had occurred in one of the mother’s previous pregnancies and 3.7 (1.5 to 9.1) if it had occurred in a later pregnancy). Adjustment for maternal age at childbirth, period of birth, and parity did not change the estimates. Restrictions to firstborns did not influence the results.

Hyperemesis gravidarum is more strongly influenced by the maternal genotype than the fetal genotype, though environmental influences along the maternal line cannot be excluded as contributing factors.

The nutritional status and treatment of patients with hyperemesis gravidarum
More than 60% of the patients had suboptimal biochemical status of thiamine, riboflavin, vitamin B6, vitamin A, and retinol-binding protein. Vitamin C, calcium, albumin, hematocrit, and hemoglobin values were significantly higher in those patients where the duration of vomiting had been longer, suggesting the presence of dehydration. The hyperemetic pregnant patient is at nutritional risk; prompt initiation of corrective therapy is recommended.

Diet before pregnancy and the risk of hyperemesis gravidarum:
The intake of seafood, allium vegetables and water was significantly lower among women who developed hyperemesis than among women in the non-hyperemesis group. The findings suggest that a moderate intake of water and adherence to a healthy diet that includes vegetables and fish are associated with a lower risk of developing hyperemesis.

Broccoli Eliminates H. Pylori, Protects Against Ulcers, Stomach Cancer:
Broccoli and broccoli sprouts contain a chemical called sulforaphane that kills helicobacter pylori, the bacteria responsible for peptic ulcers and most gastric cancers, according to researchers at the Johns Hopkins University School of Medicine. As such, broccoli is strongly recommended for pregnant women and women looking to conceive. 

Pregnancy and neonatal outcomes following hyperemesis gravidarum:
Undernutrition during pregnancy is associated with detrimental pregnancy and neonatal outcomes, which can have long-term implications for the infant. Hyperemesis gravidarum may severely limit nutritional intake. Infants born to women with hyperemesis gravidarum had smaller head circumferences. Given the reported associations between smaller head circumference at birth and lower cognitive ability and higher risk of cardiovascular disease in later life, further study is necessary to confirm these results and to determine whether there are any long-term implications for the offspring.

Nausea and vomiting of pregnancy
An increased incidence of infection with Helicobacter pylori (H. pylori) has been observed in women with HG and is now considered to play a role in its pathogenesis. Frigo et al. found that 90.5% of women with HG were H. plyori IgG positive, compared to 46.5% of controls. Bagis et al. used the gold standard of testing, histologic exam of the mucosal biopsy, and found that 95% of HG patients tested positive for H. pylori compared with 50% in the control group. They also found higher H. pylori densities in the gastric antrum and corpus in HG patients, suggesting a possible relationship between H. pylori density and the severity of symptoms. Case reports and cases series suggest that treatment and eradication of H. pylori can decrease nausea and vomiting in pregnancy and should be considered in patients with intractable symptoms.

Olfaction (sense of smell) strongly linked to NVP episodes:

Linking olfaction with nausea and vomiting of pregnancy, recurrent abortion, hyperemesis gravidarum, and migraine headache
The frequency of nausea and vomiting, caused most often by nonpregnancy-related triggers, is high among women. In a small sample of women with congenital anosmia (lack of smell), nausea and vomiting of pregnancy occurred in only 1 pregnancy, suggesting that olfaction is a highly selected trigger for nausea and vomiting of pregnancy.

Marked changes in olfactory perception during early pregnancy: a prospective case-control study
Early pregnancy might be related to significant changes in olfactory performance. The distortion of odor identification in the first trimester might be a causative factor for the development of pregnancy-specific conditions, such as morning sickness and hyperemesis gravidarum, which are both common complaints during the early phase of parturition.

Care options for hyperemesis gravidarum patients:

Peripherally Inserted Central Catheter (PICC) Complications During Pregnancy:
PICC lines provide a short term solution with potential long-term consequences. Complications are common. 

Long term consequences for offspring born to mothers with hyperemesis gravidarum:

Severe hyperemesis gravidarum is associated with reduced insulin sensitivity in the offspring in childhood:
Children born to mothers who experienced SHG (severe hyperemesis gravidarum) have lower insulin sensitivity, which may increase their long-term risk of developing diabetes mellitus. Follow-up of SHG offspring is essential to determine later risk of metabolic disease.

Weight loss in pregnancy and cardiometabolic profile in childhood: findings from a longitudinal birth cohort: 7818 pregnant women were included, of which 3165 consented to having their children examined at 5-6 years of age. Severe weight loss (SWL) occurred in 6.8% of cases. Women with SWL had similar preterm birth rates compared with women without these complaints (adjusted OR 1.1, 95%CI 0.7, 1.7). Birthweight (adjusted difference – 31 g, 95%CI -76, 15) and BMI at 5-6 years of age (adjusted difference 0.2 kg/m2, 95%CI 0.0, 0.5) were similar in children born to mothers with SWL and without SWL, but blood pressure was increased. Early pregnancy weight loss, usually occurring as a manifestation of hyperemesis gravidarum, could have long-term consequences for offspring health.

Monolaurin (primary ingredient of Cocolaurin) during pregnancy 

Monolaurin: The Secret Disease Fighter: 
Monolaurin is a component of mother’s milk; milk that must provide powerful disease-fighting factors to sustain the infant as its own immune system develops. While there have been no studies of monolaurin in pregnant and lactating women, it is a component of mother’s milk, and it has been used by pregnant and lactating women for years without reported problems.

Chris Kresser:
So I would consider other possibilities that might be less harmful to the mom and the baby’s microbial environment, and one possible option is monolaurin, which we’ve talked about before.  We talked about it in the episode where I discussed treating viral infections.  When lauric acid, which is in mother’s milk and coconut oil, is attached to glycerin, it forms a monoglyceride known as monolaurin, and that is effective not only against viruses, which we discussed, and yeast and fungi, but also parasites and bacteria.  I haven’t seen any studies of the safety of monolaurin in pregnant or lactating women, but it is a component of mother’s milk and it’s been used by pregnant and lactating women for years without reported problems.  

Info on prescription medicine to treat hyperemesis gravidarum and morning sickness

Should doxylamine-pyridoxine (Diclegis) be used for nausea and vomiting of pregnancy?
…some conflicting evidence links doxylamine-pyridoxine use to pyloric stenosis and childhood malignancies. The role of doxylamine-pyridoxine as the first-line pharmacological treatment for NVP in Canada should be reconsidered

Intestinal obstruction in pregnancy by ondansetron:
This study illustrates a case of intestinal obstruction from a woman who was treated with ondansetron, or Zofran. Zofran reduces gut motility and intestinal obstruction is a potentially life threatening condition. The authors encourage further reporting on this potential issue. 

Use of ondansetron during pregnancy and congenital malformations in the infant:
This study examines links between ondansetron (Zofran) and the risks for a cardiovascular defect and notably a cardiac septum defect were increased and statistically significant   

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