An Integrated Approach to Caring for Patients with Hyperemesis
Originally published September 19, 2011.
I would like to share a story about a patient of mine with hyperemesis. I share this story to point out that there are times when a practitioner must realize the limits to what can be done with TCM treatments and that, at those times, it is necessary and prudent to quickly ask for additional help. In some of the cases of hyperemesis I have dealt with, it was necessary for the pregnant woman to receive IV nutritional therapy, and for those whose symptoms were recalcitrant, a western medication (an anti- emetic) was also used. This case demonstrates how quickly one might need to act when presented with a severe case of hyperemesis, and elucidates the necessity of having colleagues in the western medical world that can be called upon at a moment’s notice to help our patients.
Hyperemesis gravidarum is fortunately a rare condition that presents in pregnancy, often seen initially as a violent and constant morning sickness. For most cases of morning sickness that begin at approximately six weeks into a pregnancy, acupuncture, vitamin and herbal therapy, and careful meal planning relieve the condition. With these aids, a woman with morning sickness is able to take in enough fluid and food that the symptoms are bothersome at best, last approximately six weeks, and happily fade away by the end of the first trimester. However, there are some women for whom these symptoms do not even begin to abate, and the symptoms of morning sickness linger until it is clear that what you are seeing and what the woman is dealing with is another condition entirely - hyperemesis gravidarum . This is sometimes easy to miss because the normal symptoms of morning sickness are generally expected and accepted, and for some women, the symptoms are worse than for others. Two of the telltale signs for differentiating between the morning sickness and hyperemesis follow. One, for women who suffer from hyperemesis, herbal and vitamin therapy does not readily help because the women are unable to swallow anything at all. Two, acupuncture, which works extraordinarily well for morning sickness, is limited to quieting the symptoms of hyperemesis for a day and more likely just a few hours. In hyperemesis, symptoms linger as unrelentingly as ever and a woman will go into the second trimester as if there is no end of her symptoms in sight, which unfortunately there may not be. For these women there is often weight loss (sometimes excessive), dehydration, constipation, depression, and an inability to lead any type of normal life. For some, this condition is life threatening, and the author Charlotte Bronte is believed to have died from it.
A colleague with a patient suffering from morning sickness called on a Sunday afternoon to ask if I would see this woman in her absence, as she was going on a two-week vacation. I replied that she should tell her patient to give me a call and that I would come in early Tuesday, my first day of practice for the week. Beside the patient’s first name, the fact that it was a strong morning sickness case, that it was a first pregnancy, and that the woman was responding to the herbs and needles, no other information was given.
Later that afternoon I received a call from a woman whose voice I could barely decipher on the telephone. At first I wondered if her perceptible and strong accent was getting in the way of my understanding her, but after spending a few minutes on the phone with her, it became clear that she simply had no vocal strength and was, as a result, audibly imperceptible to me. Finally, in some exasperation, I asked if her partner was home and if so, could she please pass the phone to him. Within seconds I heard a clear loud booming voice and within the next two minutes I gave him the directions to my office and a time for his partner to meet me that coming Tuesday.
On Tuesday at the appointed time, I saw that a van had pulled up and stopped right in front of my office door. A woman got out bent over, and hobbled right into my office. Instead of stopping at the desk, which was at the entry by the door, she went to a bench about five feet away from the door and collapsed onto it. In her hand she had a plastic bag and inside of it were some used tissues and a roll of toilet paper. The van had pulled away from the clinic’s entrance and gone to park. When I spoke to this woman, she answered me, and while I still could not clearly hear her, I recognized her as the patient my colleague had referred to me. This was Paulette.
I took her cold hands into mine for a few moments to make contact and then introduced myself. Then I gave her my two-sheet intake form. It was apparent that she was not going to be able to fill out these two sheets, so I asked her to just fill in her name, age, phone number, and sign the paper at the bottom of the second page, which stated that she was giving me permission to treat her. She took the clipboard from me and made a mark on the spot for her signature. After that she gestured that her husband, who had just entered the clinic, would fill out the rest. I introduced myself to him, handed him the clipboard and asked him to fill in these small few facts. I then said to them both that I was surprised at the level of discomfort and weakness that I saw before me, that I was going to take Paulette into a room and put her in a comfortable chair or on a treatment table, and that it was fine for him to accompany us, if that was okay with her. He immediately declined the invitation to join us, saying that he would prefer to return when the treatment was over. Within another few minutes I was in the treatment room with Paulette. Since her voice was barely audible, I pulled up my chair within inches of hers and asked a series of questions. She looked dry, green, and weak, so I got right to the point.
“How far along in your pregnancy are you?” She whispered, “ Eleven weeks. ”
“Are you vomiting daily?” “ Twenty five to thirty times a day. ”
“How long has this been going on?” “ Six weeks. ”
“Are you able to eat anything?” “ No. ”
“Can you drink any water?” “ Just sips. ”
“When was your last bowel movement?” “ One week ago today. ”
“Are you passing waters?” “ Only a little bit. ”
“How much is a little bit in one day?” “ A few teaspoons. ”
“What color is it?” She looked around the room and pointed to the bright orange of a Tibetan flag hanging in the treatment room.
“Can I see your tongue?” She stuck it out and it was deeply shriveled, dry, and nearly cadmium red in the center with some purple on the edges. I audibly gasped.
“How much weight have you lost?” “ Twenty-five pounds. ”
“Are you in the care of a physician/obstetrician?” “ Yes. ”
“Who is the doctor?” She gave me his name.
“When did he last see you?” “ Last Thursday at 4. ”
“What did he say about your condition?” “ To return in one month. ”
I sighed, and asked if her acupuncturist was bleeding the back of her neck and if it was helping. She replied that it was of tremendous help, but the relief lasted just hours, curbing the vomiting for only a portion of one day. I then asked for her permission to call another doctor and get her immediate treatment, as I believed she needed to be in hospital receiving nutritional therapy and hydration. Her eyes widened, a smile came over her lips, and she said that she would very much like that and that she would be happy to have another doctor, as she did not know the doctors in this area and felt no rapport with the obstetrician she was seeing. I then proceeded to treat her using a combination of gua-sha and bleeding. For cases such as these, the combination of acupuncture and gua-sha gives the best and most immediate relief and does not require the woman to swallow anything, as treatment with herbs or vitamins would require.
The first step when treating Hyperemesis is gua-sha. The area treated is on the back of the neck, beginning at the hairline and moving down the neck along the Du Mai and including the upper shu points. It is important to use unscented oil and my favorite tool for gua-sha is the porcelain soup spoon found in most Chinese restaurants. It is important to use a porcelain spoon and not a plastic one, as the plastic ones cause too much discomfort. The next step is to bleed the back of neck, 1 cun below Ya Men/Du 15, a Master Tung technique that I learned from my teacher Dr. Miriam Lee. Bleeding this area is very effective for nausea and vomiting, and usually gives immediate relief.
The treatment described above involves the art of touch. Certainly spooning the back of the neck and the upper shoulders with vigor is an aggressive form of touch. So as you do this, check in with the woman and see how she is doing. Since many women feel instantly better from this procedure, don’t be timid. If your vigor is too much, your patient will tell you, and then it is best to let her be your guide. After the bleeding most women feel the nausea is gone or at least greatly diminished. All of this touch is strong, yet most women love it, due to its immediate relief. If you get a woman who cannot handle the vigor of the gua-sha, then limit yourself to the bleeding only, as it is the bleeding which gives the greatest relief for this condition.
Once I had finished with the gua-sha and bleeding, Paulette sat up a bit straighter, and was then able to lie down on the treatment table. I decided to treat the Chong Mai using Gong Sun/Sp 6 and Nei Guan/PC6 and added Zhong Wan/CV 12, Xian Gu/St 43 and Nei Ting/St 44. At this point, Paulette’s nausea had passed and she was able to release her hold of the plastic bag and rest. At that time, I made a call to an obstetrician whom I rely upon when I see conditions that require immediate western medical care. Fortunately, the phone at the doctor’s office was answered and I gave a minute or two sketch of Paulette’s condition, saying that I felt she needed to be admitted to hospital right away. I was put on hold for just a few minutes and then told to “Send the patient over as soon as she was done with the treatment.”
A few hours later, I received a message from the obstetrician’s office that Paulette had been admitted to the hospital and was given her room number. I called Paulette the next morning. A strong, high-pitched voice with an accent answered the phone, and while I was completely surprised, I realized immediately that it was Paulette. It seemed beyond credibility. She sounded nothing like the person I had sent out less than 24 hours before. Paulette’s voice alone answered most of what I needed to know, and with a smile on my face, I asked her what had happened since her arrival at the hospital.
Paulette was given an IV of fluids and nutrition, and an anti-emetic suppository. In less than 24 hours she sounded like a different person and said happily that she felt like one, too. She remained in hospital for one full week, returning home on the 8th day, still having some mild nausea and vomiting, and still taking her anti-emetic. Hyperemesis gravidum can be life threatening and when it is, it needs to be treated the way the hospital treated it. Herbs and needles can be a very helpful adjunct therapy, but for cases this difficult they cannot and should not be the only therapy. Herbs, vitamins, or acupuncture alone are not strong enough to keep a condition this severe from overtaking a woman and rendering her practically voiceless and lifeless. Prior to IV therapy and medication, many unlucky women with this condition deteriorated into dire physical conditions that sometimes resulted in death.
After Paulette was discharged from hospital, I treated her with herbs and acupuncture until my colleague returned from her vacation. For the next six months Paulette received both TCM treatment as well as anti-emetic medications. The combination of western and eastern treatments worked well enough that she never had to return to hospital or have another IV. The nausea of pregnancy as well as some of the vomiting accompanied her till the last day of her pregnancy, but it remained under control and she was able to eat, drink, gain weight, and have a relatively normal pregnancy. She birthed a beautiful full term baby and recovered remarkably well in her post-partum. Paulette’s case provides a beautiful example of how vital it is to develop relationships with doctors who have hospital privileges. Knowing you have someone on board that you can turn to in situations where you need help and need it fast not only provides peace of mind, but also the best possible care for your patients.
Raven Lang was one of the first homebirth midwives in California. In 1970 she founded the Santa Cruz Birth Center, the first birth center in North America. Two years and fifty births later she wrote “Birth Book”. In 1972 Raven helped to found the first birth center in British Columbia. Six years later she returned to California and founded the Institute of Feminine Arts, the first non-medical school for midwifery in North America. In 1982 she began her training in TCM and incorporated TCM into her midwifery. For the next three years she studied with Dr. Miriam Lee, a nurse midwife from China and one of the first licensed acupuncturists in California. Now retired, Raven practiced TCM in Santa Cruz, California for more than 30 years.