It is so nice to hear about people doing well, and so sad to hear about those that have had problems. Sometimes I wonder If I should stop hanging around for a while, but occasionally I find myself with something to say.
Here we go, ramblings of a crazy woman . . .
I really think it is interesting that we have had several people with severe complications from steroid use here. Typically I tend to think that is because it is the people with the worst complications that tend to seek out a support group like ours, but many were here well before the complications occurred. Aside from the two people who have already posted the other I know about is someone (with hg, but on steroids for a different reason) who had a preterm delivery (from ruptured membranes - a known association with long term steroid use) and then a debilitating chronic parvovirus infection for a year after delivery. Seems like a lot considering so few are on steroids long term.
Short term use of steroids is not particularly controversial, but I think the goals of long term use need more evaluation. It would be nice of someone would do the studies, but I don't think that will happen. Avoiding TPN is probably a good reason to accept the risks, but is avoiding all IV use? Is the right goal to make you feel good enough to eat and gain weight, or is the goal to make you feel good? How much is too much? and how long is too long? I don't think that even the "experts" would agree, and I wouldn't consider just any perinatologist an expert on this.
Nobody has ever considered the psychological complications of hg when evaluating risk. Should you? How would you?
For me, it was a difficult decision. We decided after over a month of steroids that the benefit was not enough to justify staying on them and I have always wondered about that. I feel much more comfortable with it now. Steroids were the thing that made the most noticeable difference for a short while, but even on the higher doses (32-48mg) I was only eating about 300-500 calories in a day and so I still needed to stay on TPN. We figured that TPN and steroids made for a bad combination and so eventually after several unsuccessful attempts to get below these doses without spiraling out of control I went off of them and spent the rest of the pg in bed, on TPN, and miserable.
Everyone's situation will be different, but I think the obvious lesson is that you should continue to reassess the dose and the need to continue steroids.
As for what those "experts" do recommend. Most of what is written about steroids and hg recommends a dose of 10-12 mgs or less, for a maximum of 6-10 weeks.
This stuff is a bit technical, but I'm going to put it out here for those who are interested.
First, the recommendation from ACOG in the educational bulletin on hg for doctors that came out a couple of months ago:
-----------------------------------
Corticosteroids may be considered as a last resort in patients who will require enteral or parenteral nutrition because of weight loss. The most commonly described regimen is methylprednisolone, 48 mg daily for 3 days, given orally or intravenously. Patients who do not respond within 3 days are not likely to respond, and treatment should be stopped. For those who do respond, the dose may be tapered over a period of 2 weeks. For recurrent vomiting, the tapered dose may be stopped and the patient continued on the effective dose for up to 6 weeks. To limit serious maternal side effects, corticosteroids should not be continued beyond this period for the treatment of hyperemesis gravidarum
----------------------------------------------
This second piece is quoted from the article by Goodwin who is the person who has written the most about steroid use in hg, on this website
http://www.nvp-volumes.org/ which is a summary of reasearch presents at a conference on hg. He is also one of the authors of the first article I quoted and seems to suggest the possibility of using them longer here. This was written in 2000 and I don't know if there is any reason for the stricter restictions in the more recent one.
----------------------------------------------
After the first weeks of therapy we have limited the use of corticosteroids to low dosages (12 mg methylprednisolone per day or less) for no more than six weeks of total treatment. Others have used lower doses from the start with reported efficacy. Some have continued the corticosteroids for as long as 10 weeks. It is our view that usage of this duration begins to pose a significant risk of maternal complications and should be strictly limited. Since the vast majority of hyperemesis, even if refractory to antiemetic therapy, can be managed with supportive care, a reasonable risk-benefit ratio demands a high degree of confidence regarding the safety of the regimen.
Even chronic steroid use has not been shown to pose significant foetal risk. Although it is still debated whether corticosteroids could have any teratogenic effect in humans, therapy can usually be delayed until at least 10 weeks' gestation. Recently, an increased risk of preterm birth and preterm premature rupture of membranes has been attributed to corticosteroids; this effect has been described only with use throughout pregnancy, however.
Serious maternal morbidity has not been reported with exposure comparable to that which our patients received. Reported complications from steroid therapy for hyperemesis are clearly related to prolonged treatment at very high dosages. This emphasizes the need to taper the medication and limit the duration of usage. In our experience, corticosteroids for the treatment of hyperemesis are safe and effective and can significantly reduce the need for hospitalization.
-----------------------------------------