Pod Insights Unexplainable Sick of “morning” sickness About this episode If pregnant people need to eat for two, why do so many of us puke morning, noon, and night?
Guests: Marlena Fejzo, Ph. D., geneticist, and Research Director at the HER Foundation.
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Transcript Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.
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1:13 Speaker 02 I'm Julia Longoria. This is Unexplainable. And this one's gonna get a little personal.
1:22 Speaker 02 That is the sound of me about to hurl. I really don't like making things about me, but that's not the reason I'm about to barf right now. If you've watched TV sitcoms or rom-coms in the last few decades, there's only one real reason a woman like me would be unexpectedly puking for a studio audience.
1:45 Speaker 03 She's been barfing for an hour.
1:52 Speaker 03 Do you have like the flu? I don't know. And I hope you're not pregnant. That sounds like morning sickness. Miranda?
2:01 Speaker 03 I don't know why they call it morning sickness when it's all [bleep] day long.
2:06 Speaker 02 Yep, it's morning sickness. And I can assure you, it's not just in the morning. I haven't been able to track down whoever coined that term, but I hope they have the afterlife's equivalent of diarrhea. Misery loves company.
2:23 Speaker 02 An early pregnancy, I was vomiting every day or every other day, mostly in the evenings. At week 15, I gave my pregnancy tracker apps the middle finger as they congratulated me on the end of my nausea. For lots of people, it stops in the second trimester, but not for me. I just puked everything I'd eaten that day.
2:46 Speaker 02 Some people have helpfully told me to eat more protein, just as others told me to eat less protein. Friends have gleefully announced that it must be a girl, while other family members maintained, "Well, that means it's a boy." My doctors have been just as unhelpful. Some pills prescribed to me seem to be helping some days, but other days, I still retch multiple times. The question I'm left with, shouted dramatically at the heavens, "Why?"
3:17 Speaker 02 Today on Unexplainable, you're gonna have to bear with me as I, Julia Longoria, turn my pain into art, or at least into journalism. And I'll ask, why? Why do pregnant people, who are presumably eating for two, why do so many of us barf so much?
3:51 Speaker 02 Pregnancy nausea has been in the human record since about the year 2000 B.C. But the story of how we finally got some kind of scientific answer to why starts with a woman in the 90s. If you could think back to the Marlena before you, you know, before you ever got pregnant, when you were maybe trying not to get pregnant, what is, what is your earliest memory of the term morning sickness?
4:21 Speaker 04 Just what I saw in television shows and movies, people saying, ha, ha, ha, she's pregnant.
4:31 Speaker 04 Like it's an aha moment.
4:33 Speaker 02 Marlena Fejzehzo is a geneticist. And like so many of us, she didn't think much about pregnancy nausea until she found out she herself was pregnant.
4:42 Speaker 04 When I woke up, I ran to the bathroom and I sort of laughed after thinking, this is morning sickness, ha, ha. But within a week, I realized that it was not very funny. I had nonstop nausea and vomiting, so I couldn't get out of bed until around noon without vomiting. When I called the nurse, she said, this is normal in the first trimester.
5:14 Speaker 02 From the sounds of it, Marlena's nausea was significantly worse than what I've been experiencing.
5:19 Speaker 04 I ended up going to the emergency room twice for intravenous fluids. In that pregnancy, I was able to keep something down every day. It did go away in the second trimester, and the rest of my pregnancy was really not so bad.
5:35 Speaker 02 By the time Marlena had seen a doctor, she was in her second trimester and she was already feeling better. She never brought it up and her doctor didn't ask about her nausea. Marlena gave birth to a healthy baby boy, and she never thought about pregnancy nausea again until two and a half years later.
5:54 Speaker 04 I walked by a gelato store, and I didn't feel like going in. I thought, I must be pregnant, because normally that smell would be delicious, and I would have to go in. But I just did not feel like going in. And I was like, this is not normal. I must be pregnant. And I took a pregnancy test. And sure enough, I was pregnant. It got bad really fast. Pretty soon, I could not eat, drink, or move without violently vomiting. It was like that feeling that you have a few seconds before you vomit that I had all the time, where I'm just constantly about to vomit. And I had to spend every waking second trying not to vomit. Because once I started, I couldn't stop.
6:39 Speaker 04 And it would last hours and just be very violent, because there was nothing in there to vomit. So my body would reach further and further down my intestines to try to find something to vomit up. So it was very violent. And I had to do everything I could to try to stop that cycle from happening, because it was very hard to stop.
7:01 Speaker 04 It was torture.
7:03 Speaker 04 I didn't keep any food down for over a month.
7:08 Speaker 02 This time, Marlena told her doctor about it.
7:11 Speaker 04 The OB, he gave me the diagnosis. He said I had hyperemesis.
7:17 Speaker 02 Hyperemesis gravidarum. What was going through your mind when you heard the word hyperemesis? Did you know what that was?
7:25 Speaker 04 I don't think I knew what it was at the time. Must have been the first time that I'd heard it.
7:32 Speaker 02 Hyperemesis gravidarum, or HG, is an extreme form of pregnancy nausea that affects about 2% of pregnancies worldwide.
7:42 Speaker 02 What I personally have gone through in my pregnancy is nothing compared to this condition. And when Marlena got sick in 1999, just like now, there weren't any proven treatments for it.
7:55 Speaker 04 My doctor, he offered that I could have home health care, tried seven different medications at once. Actually had a Zofran pump in my leg because I couldn't swallow the medication without vomiting and I lost the fat in my thigh so quickly that they had to move that pump to IV. Eventually, my doctor gave me a feeding tube.
8:23 Speaker 02 A feeding tube?
8:24 Speaker 04 It goes through your vein. It's pretty dangerous because it gets inserted above your heart and if it gets infected, you can have serious consequences. So they try not to do it if they can, which is why I think my doctor waited so long, but I really was starving to death.
8:42 Speaker 02 This was extremely scary. A small percentage of people die from HG.
8:47 Speaker 04 I was in bed, lying flat at home. I couldn't even sit up. I couldn't go to the bathroom. I couldn't brush my teeth. I also had something called hypersalivation, so just buckets and buckets of saliva coming out of my mouth. So I had like, and it was really acidic. So I had kind of burn marks all over my face. And my doctor prescribed that suction machine that they have at the dentist office. I had to have pretty much 24-hour care. I mean, my husband took care of it at night. He had to wake up in the night to change my tubing and everything. We hired someone who took care of my, my son because I couldn't, I couldn't even see my two and a half-year-old.
9:30 Speaker 04 My, my husband would just bring him in at night to say goodnight to me.
9:34 Speaker 02 At one point in this fog, Marlena has a faint memory of getting a call from her doctor.
9:42 Speaker 04 I suppose I did at one point talk to my doctor on the phone because I know that he did tell me that. People who have this are trying to get attention.
9:54 Speaker 02 Wait, I'm sorry. What? He said this on the phone to you?
9:58 Speaker 04 Yeah, yeah. He said I was exaggerating my symptoms to get attention.
10:03 Speaker 02 He said this directly to you?
10:05 Speaker 04 Yeah.
10:05 Speaker 02 Are you like factually like in your hospital bed at home, talking to the doctor with a feeding tube in your? Like, where?
10:13 Speaker 04 Yes. Because I was only in one place the whole time. I couldn't even turn to my side. So I was lying flat on my back in my bed, talking to my doctor and he,
10:25 Speaker 04 you know, said that to me and starts telling me about, you know, he's actually even done this study. He's trying to be like scientific with me. Like, I've done a study on this. I never saw that study.
10:35 Speaker 02 Did you look for it?
10:37 Speaker 04 Later I did. I never found it, not at that time. But he said he had done a study that showed that women with hyperemesis were infantile and just wanted attention from their mothers. And
10:50 Speaker 02 Wow.
10:51 Speaker 04 It's really the reverse, where a lot of women with hyperemesis will end up moving in with their mothers because the mothers are the ones that will take care of them and take care of their children when they're going through this. But it's, it's not because they want attention from their mothers. It's because they don't have a choice. Right? You can't cook when you're extremely nauseous. So you need someone who's willing to do that for you.
11:17 Speaker 02 Like, what are you talking about?
11:19 Speaker 04 Exactly. Yeah. So,
11:23 Speaker 04 but it's actually pretty common for doctors to say that to their patients, unfortunately, even to this day. And I didn't have any energy to argue with him. I mean, I couldn't even barely stand up for more than a second.
11:40 Speaker 02 How did you feel in that moment?
11:42 Speaker 04 I, I was definitely angry because obviously it's imprinted in my brain and I remember it so well. But I was also really too sick to really, I mean, I was really struggling every second.
11:56 Speaker 02 Yeah.
11:56 Speaker 04 So, yeah.
12:00 Speaker 02 During this pregnancy, she never saw the inside of her doctor's office again after her very first visit when she got diagnosed. She had gotten an ultrasound at that first visit.
12:11 Speaker 04 That was the last picture of my baby that I ever got because I lost it in the second trimester.
12:23 Speaker 02 When you lost the pregnancy, how soon was it before you stopped feeling nauseous?
12:30 Speaker 04 It was immediate. It was crazy. Literally that day, I could eat again. And it was so strange because I was like, it's so easy to eat. And yet, it had been so hard to even just be near food.
12:43 Speaker 02 That must be so heartbreaking and so...
12:47 Speaker 04 It was very weird because it was like, I felt so good to be able to eat again physically, but I felt so bad having just suffered so much for no reason.
13:04 Speaker 04 It took me about a month to recover. But when I did recover, I started looking into what was known about it.
13:13 Speaker 02 Marlena is a geneticist. Up until this point, she'd been so sick and weak. She hadn't taken a scientific curiosity about why she was getting sick and what she could do about it. Now, out of a haze of hyperemesis, she put her scientist hat back on.
13:31 Speaker 04 And then I just searched PubMed for medical articles related to nauseum pregnancy and hyperemesis. But there was very little out there at the time.
13:44 Speaker 04 I just was like, OK, I have to work on this because there's nothing out there and I need the answers.
13:52 Speaker 02 So you were like, I'm going to go find the answers.
13:54 Speaker 04 Yeah, exactly.
13:58 Speaker 02 Answers after the break.
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17:43 Speaker 02 To be clear, I have not been diagnosed with hyperemesis gravidarum. My symptoms come nowhere near to what Marlena went through. But it has become bad enough that I've found myself researching the long history of pregnancy puking to try to understand why we seem to know so little.
18:06 Speaker 02 Apparently, the Greeks wrote about pregnancy nausea on papyrus circa 2000 B.C. Roman doctors, at one point, recommended a hot wine bath to combat the illness. Don't knock it till you try it, I guess. Fast forward, though, to the 1950s and 60s, and something happened that had a bit of a chilling effect on pregnancy nausea research.
18:32 Speaker 04 The thalidomide disaster. So, the drug thalidomide was given in the 50s and 60s for nauseating, vomiting, hyperemesis in pregnancy. And unfortunately, that drug led to babies being born with severe limb deformities.
18:48 Speaker 02 For decades after that, as far as I can tell, we didn't do much else to figure out why pregnancy nausea happens. But it's pretty clear, even from what little was out there when Marlena did her search, that pregnancy nausea is not in your head, contrary to what her doctor claimed.
19:06 Speaker 04 People said to me while I was sick that it must be psychological because only humans have it, but that is just not true. So, there's evidence from veterinary journals that dogs, cats, and monkeys all have a early period of appetite loss, just like humans. The most extreme example is the octopus. They actually lay their eggs and then starve to death and die.
19:35 Speaker 02 For humans, I read, pregnancy nausea in general is associated with positive pregnancy outcomes, leading some scientists to believe that it's evolution. We puke to protect our babies. Like, if we eat less, then we won't need to go out and hunt and gather and risk getting eaten by predators, I guess?
19:55 Speaker 04 Clearly, we don't need that anymore as humans. You know, maybe animals still need it, but for us, it's just click Uber Eats. Our food is very safe and easy to get without risking our lives. So, it's a mechanism that I think we should try to evolve away from.
20:16 Speaker 02 Leave in the past.
20:18 Speaker 04 Yeah.
20:19 Speaker 02 I could not agree more. But Marlena's doctors seemed to still be stuck in, maybe it's all in your head. She was determined to dump that hypothesis. But if you want to get rid of a bad theory, you got to come up with a better one. And that's not easy. At this point, Marlena was very early in her career, a postdoc at UCLA, who was not focused on pregnancy nausea. She didn't have any funding to go into this. She just had a hole in her heart from her last pregnancy and a burning curiosity. And what did you do next?
20:55 Speaker 04 I wrote a survey with all the questions I could think of related to hyperemesis.
21:02 Speaker 02 She wrote a survey intended for people who'd been diagnosed with hyperemesis gravidarum, asking a lot of questions.
21:08 Speaker 04 It was very long. It was like 30 pages.
21:11 Speaker 02 But the main things she was curious about.
21:13 Speaker 04 What is the recurrence risk?
21:15 Speaker 02 If you have this once, what's your chance you'll have it again?
21:18 Speaker 04 I asked about medications and which ones were effective and what the side effects were.
21:24 Speaker 02 And most importantly, for her potential research.
21:27 Speaker 04 Did it run in families? I wanted to do a genetic study and so I needed evidence to show that it was genetic.
21:33 Speaker 02 If she got anecdotal evidence that hyperemesis gravidarum ran in families, then she could go out and get some funding to try and prove it.
21:42 Speaker 04 My little brother was a statistician and he put the survey up on his website. And we started getting faxes back at that time.
21:52 Speaker 02 This was around the year 2000, before things like Survey Monkey and Google Forms were common. So Marlena and her little brother had gotten creative.
22:01 Speaker 04 I had a lot of trouble publishing my survey results because people didn't believe the internet and who are these people that are like filling out these things? And how do you know they really have what they have? But like, why would someone sit down and fill out a 30-page survey if they didn't have it?
22:18 Speaker 02 And over the course of two years, they got over 800 responses back.
22:26 Speaker 02 And what did you, what did you find?
22:29 Speaker 04 So we found that there was a 17-fold increased risk of having it. If your sister had it, women that had it once had it again in 80% of their pregnancies, which also suggests a genetic component.
22:44 Speaker 02 Next, Marlena set out to find biological proof that this was genetic. That meant collecting surveys wasn't enough. She had to collect DNA samples.
22:54 Speaker 04 And so people were sending in saliva samples from all over the country.
22:59 Speaker 02 This was still a sort of pet project of hers. So she got permission to store these samples in the fridge at work in one of UCLA's labs. And when she got enough samples, she applied for official funding to try and sequence them.
23:13 Speaker 04 I applied for funding from the NIH. I applied twice and was rejected twice, unfortunately. So I had all these saliva samples sitting there.
23:22 Speaker 02 And once again, 10 years into this pet project, Marlena got creative.
23:27 Speaker 04 My brother gave me a 23andMe kit for my birthday in 2010.
23:32 Speaker 02 23andMe, the direct-to-consumer genetic testing business. It had been named the invention of the year a few years earlier, and it had started a bit of a craze. Over 15 million people have sent the company their saliva. Marlena approached 23andMe with a small request.
23:51 Speaker 04 I asked them to include hypermesis in their surveys, and they were very receptive to it.
23:59 Speaker 02 A few years passed, and Marlena got some data back.
24:02 Speaker 04 We found the first connection with the vomiting hormone, GDF-15.
24:09 Speaker 02 Having at this point raised $0 from the NIH to fund her research, Marlena had identified a gene that looked like it might play a role in HG, a gene, GDF-15, that made the vomiting hormone.
24:23 Speaker 04 A hormone that everybody has, whether you're male or female, and whether you're pregnant or not.
24:28 Speaker 02 For men and women, it's associated with stress.
24:32 Speaker 04 This hormone is why you often lose appetite when you're under some kind of physical or mental distress.
24:38 Speaker 02 It's probably why some people stop eating during finals week, for instance.
24:42 Speaker 04 When it gets high enough, we think that it's a signal that's telling your body either to expel a poisonous food and not eat that again, or in our hunting and gathering days, telling you, hey, stay in your cave until you feel better.
24:59 Speaker 02 23andMe customers who said, yes, I have HG, seemed to share a similar variant of the vomiting hormone gene.
25:07 Speaker 04 It was really an aha moment.
25:12 Speaker 02 It turned out, we already knew that placenta makes a lot of this vomiting hormone.
25:18 Speaker 04 So it already had a connection with pregnancy.
25:20 Speaker 02 She didn't yet know how exactly the vomiting hormone played a role, but it was something. So she published her findings.
25:28 Speaker 04 After my paper came out, I was contacted by a scientist from the company Regeneron. He said he was very interested in my paper and could they do anything for me? And so I said, well, actually, I have all these DNAs in my freezer that haven't been sequenced and I had actually applied to the NIH again and they denied me funding.
25:52 Speaker 02 She'd been denied funding yet again.
25:55 Speaker 04 Even though they funded a study very similar size on erectile dysfunction genetics. So I was not happy about that.
26:05 Speaker 02 But the biotech company Regeneron would help her. They sequenced those saliva samples that she'd been storing in the university fridge for years, and yet again?
26:15 Speaker 04 Same gene showing up.
26:16 Speaker 02 The vomiting hormone gene surfaced. Very strong evidence that the vomiting hormone and its corresponding gene were the stars of the morning sickness show.
26:31 Speaker 02 But how? What exactly was going on with the hormone? Why was it causing certain people to get really, really sick? To get to the bottom of this, Marlena did another study. Again, she was not funded by the NIH. But this one involved researchers from around the world.
26:50 Speaker 04 Our next paper was international collaboration of many researchers, where we figured out what was going on.
26:57 Speaker 02 And after years of Marlena just DIY-ing it, the team finally found an answer.
27:03 Speaker 04 People with hyperemesis have lower levels before pregnancy.
27:07 Speaker 02 For people who got really sick during pregnancy, like people with HG, they were making very little vomiting hormone before they got pregnant. So when they got pregnant, the levels shot up, and that change was an utter shock to the system. So like, they had a low... It had to do with like, the sort of change in the level of the hormone.
27:32 Speaker 04 Exactly.
27:33 Speaker 02 Rather than how much?
27:35 Speaker 04 Exactly.
27:37 Speaker 02 How convinced are you that you have found the cause of hyperemesis? And I guess like, is it also the cause of morning sickness, quote unquote, more generally?
27:50 Speaker 04 Yeah, so it is the cause of all nausea and vomiting in pregnancy, as well as other forms of nausea. I'm convinced of that.
28:03 Speaker 02 She says other factors might also contribute to it, but she's convinced this is the main cause.
28:12 Speaker 02 I was honestly kind of shocked to hear her say this. She figured this out almost single-handedly? Eventually, yeah, she had a team of researchers. But it's thanks to her curiosity about her own health that we know the cause of morning sickness. That she knows it, and I know it, and now you know it.
28:35 Speaker 02 So why does the medical establishment act like we don't know the cause of morning sickness? When I asked my doctor about the cause of nausea, he said there could be lots of contributing factors, which I guess is true, but we have a pretty good idea for the main cause. And Marlena says she has some pretty good ideas for how we could treat the root cause of pregnancy nausea, thanks to an experiment that a colleague of hers at Cambridge did. He gave mice a high dose of vomiting hormone, and they predictably got sick. But when he gave them just a little bit of the hormone before giving them a high dose, the mice seemed to be desensitized.
29:15 Speaker 02 Marlena applied for NIH funding last year to try and test this treatment on actual patients, to try and desensitize patients with a history of HG. Shocker, the NIH denied her proposal. And another shocker? That's not stopping Marlena from trying to find an answer herself to her remaining unanswered questions.
29:37 Speaker 04 I am doing a study of women that are trying it on their own, because many people are trying it on their own anyway with their doctors and are contacting me, saying they're trying it.
29:47 Speaker 02 Based on your research, basically? They've decided to just give it a go?
29:52 Speaker 04 Yes.
29:53 Speaker 02 Is insurance covering it for them? Or they're just kind of going on their own?
29:58 Speaker 04 For some people, I think it is. Some people it isn't, but you know, people want to complete their families and they want to be able to carry their pregnancies healthfully and safely. I mean, I can totally understand why these women are doing it.
30:11 Speaker 02 Yeah. And I am curious, just hearing your story and hearing about your research, if your experience with your second pregnancy affected your decision to try to get pregnant again?
30:25 Speaker 04 Oh, yeah, definitely. In my second pregnancy, my body killed my baby. So I feel like I'm not going to take that risk again and risk my body killing another potentially healthy pregnancy. So I ended up doing surrogacy, gestational surrogacy, and I was very lucky to have twin daughters as well. So I was able to complete my family, which, you know, really allowed me to feel happy and be able to work on this and give back. So I'm very grateful.
31:00 Speaker 02 And I mean, you know, the experience that I guess I'm going through right now, just like even any pregnancy, and I'm sure it's on a heightened scale with with folks who have HG, but like, talk about unexplainable, right? Like, pregnancy is like so mysterious even to the person, especially to the person who's pregnant. Like, you have so little communication or feedback or information about the fetus or the baby. And to me, I guess, like, I've been reflecting on how like, this sickness almost feels like one form of feedback, and it's easy to feel like, oh, I'm, am I doing something wrong?
31:40 Speaker 02 Is there like, meaning in this? I don't know. What do you say to people who are looking for meaning in the vomit?
31:48 Speaker 04 Yeah, no, I definitely think we don't need that anymore. I think that it's just a mechanism that our evolution has not evolved out of fast enough.
32:02 Speaker 02 It's like your appendix or something.
32:04 Speaker 04 Yeah, I don't think we need it anymore, that heightened sense of smell and that extreme nausea and vomiting. You know, maybe animals still need it, but we do not.
32:23 Speaker 02 This episode was produced by me, Julia Longoria. We had editing from Jorge Just, mixing and sound design from Christian Ayala, music from Noam Hassenfeld, and fact checking from Esther Gim. Meredith Hadadon runs the show, and Bird Pinkerton backed away slowly from the platypuses as more and more kept coming out of the tall grass. "How could you?" she yelled. One platypus stood up and said quietly, "We had no choice."
32:54 Speaker 02 Thanks, as always, to Brian Resnick for co-creating our show. If you have thoughts about the show, send us an email. We're at [email protected] . You can also leave us a review or a rating wherever you listen. It really helps us find new listeners. You can also support this show and all of Vox's journalism by joining our membership program. You can go to vox.com/members to get ad-free podcasts and a whole bunch of other good stuff. Plus, you'll be helping keep this place running and make sure journalists like me get paid. Unexplainable is part of the Vox Media Podcast Network, and we will be back next week.
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