Most pregnant women experience some morning sickness, but around 3% develop hyperemesis gravidarum, marked by severe vomiting, nausea, and an inability to eat. The fetus dies in 40% of these cases, making the problem a high-stakes condition.

Although hyperemesis gravidarum can be managed effectively with fluids, anti-nausea drugs, and vitamin infusions, where to get these treatments is far more complicated. Most gynecologists do not offer the treatments, which is why many women experiencing the condition wind up in the emergency room (ER).

In recent years, intravenous (IV) hydration clinics have sprung up, offering concoctions for hangovers, jet lag –– and hyperemesis gravidarum. Some experts say the so-called ‘hangover’ clinics are necessary in a landscape in which conventional routes of care are unavailable, and that IV hydration companies could keep pregnant women out of the ER.

But a recent study showed these IV med spas lack regulation to ensure efficacy and safety of treatment. The FDA, as well as state medical boards, have documented cases of spas giving patients IV bags that resulted in hospitalizations and other adverse outcomes.

“There isn’t any real way of knowing which of these clinics follow better or worse procedures, if you go to them, you’re taking a chance,” said Peter Lurie, MD, president and executive director of the Center for Science in the Public Interest in Washington, DC, and an author of the study.

Other experts disagree.

“The risk is probably lower than the benefit of getting a bag of fluid,” said Kimber MacGibbon, RN, a former emergency department nurse and co-founder and executive director at the Hyperemesis Education & Research (HER) Foundation in Portland, Oregon, a non-profit advocacy and research organization.

MacGibbon said she supports sending women with hyperemesis gravidarum to so-called hangover clinics in a pinch.

When the condition goes untreated, the consequences can be serious. Compared with women who do not have the condition, those with hyperemesis gravidarum are more than twice as likely to develop deep vein thrombosis and pulmonary embolism, and about 1.5 times more likely to develop anemia or eclampsia during pregnancy. Recent research found a link between severe nausea and vomiting during pregnancy and an increased risk that a child will be diagnosed with autism spectrum disorder, developmental deficits, or brain atrophy.

Few Places to Turn

Because hyperemesis gravidarum is relatively rare, a single OB/GYN clinic would likely not have enough patients with the condition to make offering the service financially or operationally feasible, said Andrew Housholder, an emergency physician and co-founder of The Morning Sickness & HG Clinic in Birmingham, Alabama.

“If OBs had a way to fix it, they would, but it’s very difficult to offer it and they don’t have the patient numbers to offer infusions in-clinic,” Housholder said.

Providing IV bags to pregnant patients in a traditional OB/GYN clinic is “a lot of work and hassle, it requires an RN, and in some instances it can affect the cost of malpractice premiums,” said Wendy Warner, DO, a functional medicine gynecologist in Philadelphia.

In addition, many pregnant patients do not schedule their first prenatal visit until later in the first trimester.

“But the peak time these women visit the ER for HG [hyperemesis gravidarum]is around 8 weeks,” said Marlena Fejzo, PhD, a research scientist for the HER Foundation, an advocacy and research group for the condition.

Ideally, a health system with a busy obstetrics department would have a process in place to expedite treatment for pregnant patients, which could be administered by emergency department nurses, Warner said. But doing so would require education on the part of clinicians about the treatment of hyperemesis gravidarum. MacGibbon said clinicians in emergency departments often will not provide IV fluids, and vitamins in particular, unless pregnant women are acutely dehydrated or have severe deficiencies.

“Unfortunately, there are thousands of moms a year that don’t get that treatment and the ramifications can last decades,” MacGibbon said.

IV Clinics

While some experts warn that these ‘hangover’ clinics may not be run by appropriate medical professionals and provide a band-aid to a much larger problem, Andrea Emmerling, BSN-RN, senior manager of Mobile IV Nurses, said she views the work her company provides as filling a gap for patients.

Mobile IV Nurses markets IV bags for post-workouts, hair and nail growth, and hyperemesis gravidarum, among other uses, to consumers in their homes. The bags can include vitamins B6, B1, and C, zinc, and anti-nausea medications like Zofran. Nurses or emergency medical technicians administer the IVs. The company operates in ten states, including Florida, Delaware, and Nevada.

“These patients are sick, they don’t want to leave the house, but they can stay in bed if they want to and we can treat them,” Emmerling said.

Going to an IV clinic is often a cheaper option than an emergency department visit. Mobile IV Nurses offer an infusion recommended for nausea during pregnancy or flu, which includes fluids. It costs between $195 and $325.

Pregnant people do not qualify for treatment with Mobile IV Nurses after their first trimester if they have a history of preeclampsia. Screening entails an initial virtual visit with a nurse or paramedic to go over medical history and vitals. Patients are ineligible for treatment if their blood pressure is ≥ 140/90 mm HG. An in-house physician developed the treatment protocol for hyperemesis gravidarum at Mobile IV Nurses, based on guidelines from the American College of Gynecologists and Obstetricians (ACOG), Emmerling said.

“If there is even a slight risk of something, we err on the safe side because we don’t work at a hospital where there’s a doctor right down the hall,” Emmerling said.

Although every state does require some sort of medical professional, such as a medical assistant, to administer an IV, not all are compliant.

An investigation by the Alabama State Board of Medical Examiners in 2022 found several wellness clinics were offering IV fluids without a patient evaluation or diagnosis, and treatment plans were formulated without a physician’s input. Instead, they found registered nurses or chiropractors were delivering these services, which was illegal in the state.

Lurie recommends that women who choose to get IV fluids from settings other than a hospital or their OB/GYN’s office ask a few questions first, including “who owns this place, are they a physician, is there a physician prescription associated with my therapy?” he said.

Risks also come with compounding drugs and ingredients into IV bags, according to the FDA. In 2021, the agency issued an alert that IV hydration clinics and mobile IV infusion companies were adding vitamins to infusion bags and, “it is unknown if drug products are prepared, packed, or held under insanitary conditions by these entities.”

The FDA also cited several examples of a variety of medical spas giving patients IV bags that resulted in hospitalizations and other adverse outcomes.

“Whether a licensed practitioner is on-site to evaluate patients and write prescriptions for the drug products,” was also unclear, the FDA stated at the time.

The JAMA study found that although 32 states have issued some form of regulation for IV hydration spas, only seven states have policies that require specific compounding practices. Just five had requirements for both compounding and dispensing.

ACOG told Medscape Medical News in a written statement that while IV fluids or vitamins can provide nutrients and treatment, “the lack of evidence regarding their safety in pregnancy when not regulated by FDA or administered with medical oversight necessitates caution.”

Emmerling said Mobile IV Nurses follow the guidelines designed by the United States Pharmacopeia Convention, a non-profit organization that in part issues standards and procedures for compounding sterile drug preparations.

A Solution

Housholder remembers one evening in particular when he was working as an ER physician — a pregnant woman came in shaking and retching into a bag. He gave her fluids and anti-nausea drugs for hyperemesis gravidarum.

“Hyperemesis gravidarum is a chronic issue that just gets treated when it is at its absolute worst in the emergency room,” Housholder said.

Housholder’s experiences in the ER and his knowledge that women could not turn to their traditional OB/GYN was part of the impetus for his opening The Morning Sickness and HG Clinic in Birmingham in 2022.

At the clinic, Housholder treats patients with IV fluids and vitamins when needed. He can test his patients for vitamin deficiencies and closely manage their medications, tweaking dosages if necessary. If someone is severely deficient in a particular nutrient, patients can be admitted to a nearby hospital, he said.

Housholder said he hopes more clinics will offer wraparound care in the future. The infusion spas offer only what he likened to a band-aid, when patients need more management from clinicians. For example, if patients go to hydration clinics, their OB/GYNs may not know they should have their anti-nausea medications adjusted.

“There needs to be wraparound care clinics for HG, but that is just the start of it,” Housholder said. “There needs to be research, there needs to be drug development because there is a target that can be treated, and we need the investment to do that.” 

Kaitlin Sullivan is a freelance journalist living in Colorado.