Episode Description

In this episode of Smart Start, Kristin Williams sits down with Dr. Rick Pescatore, emergency physician, founder of BellyMD, former Chief Physician for the Delaware Division of Public Health, and editor-in-chief of Emergency Medicine News. Together they unpack one of the most overlooked conditions in women’s healthcare: hyperemesis gravidarum (HG).

Dr. Pescatore shares what he sees at the bedside, why so many HG patients arrive at the ER blaming themselves, and why thiamine (vitamin B1) deficiency has become what he calls one of the largest in-our-face public health crises of his career. The conversation moves from acute ER protocols to preconception planning, the limits of genetic studies, the gut-brain axis, and what truly specialized outpatient HG care should look like.

What You’ll Learn

• Why HG is a biological condition, not a failure of resilience, and how decades of treating women’s health as a “hardware problem” have left patients behind
• How often Dr. Pescatore actually sees HG in the ER (hint: it’s not once every five years)
• The ACOG stepwise treatment protocol and where it falls short
• Why thiamine deficiency is dramatically underrecognized, and why up to a third of pregnant patients presenting to the ER with nausea and vomiting meet criteria for Wernicke’s
• The difference between thiamine mononitrate and benfotiamine, and why Dr. Pescatore recommends the lipid-soluble form for preconception and pregnancy
• Everyday thiamine blockers most women don’t know about: coffee tannins, sushi, GLP-1 medications, and alcohol
• How to think about MTHFR, GDF-15, and the recent wave of HG genetic research with appropriate skepticism
• Why women who have had HG once are more likely to have it again, and what to do about it before the next pregnancy
• The case for specialized outpatient HG care over repeat ER visits, PICC lines, and Zofran pumps
• A preview of BellyMD’s upcoming phenome app for disorders of gut-brain interaction

Key Quotes

• “We’ve approached medicine for decades as a hardware problem. If we don’t see a problem, there must not be a problem. We’re finally starting to shift that narrative.”
• “About one third of women with nausea and vomiting who present to the emergency department in pregnancy have thiamine levels so low as to qualify for a Wernicke’s diagnosis.”
• “If you have suffered hyperemesis gravidarum, you have suffered an injury to your brain-gut axis. We’ve normalized this for so long, but it is not normal.”

Chapter Markers

• 00:00 — Welcome and introductions
• 01:07 — The Instagram post that started it all: Wernicke’s in the ER
• 02:03 — How HG patients actually present, and the emotional weight they carry
• 04:01 — Inside the ER treatment protocol for HG
• 05:28 — How Materna keeps patients out of the ER with proactive IV care
• 07:17 — What happens after discharge: outpatient supplementation and prevention
• 09:23 — Preconception planning and the case for benfotiamine
• 11:08 — Surprising thiamine blockers: coffee, sushi, GLP-1s, alcohol
• 12:46 — MTHFR, evidence-based medicine, and why population-level data fails individual patients
• 14:48 — GDF-15, the new HG genetic studies, and why to pump the brakes
• 17:19 — Preparing for a second pregnancy after HG
• 20:01 — Designing the ideal specialized HG outpatient center
• 21:25 — Why Dr. Pescatore became a “big B1 guy” and the science of proton tunneling
• 23:20 — Thiamine deficiency in children and a new randomized trial on pediatric bedwetting
• 24:43 — A first look at BellyMD’s upcoming phenome app

About the Guest

Dr. Rick Pescatore is an emergency physician, founder of BellyMD (focused on disorders of gut-brain interaction), former Chief Physician for the Delaware Division of Public Health, former White House task force advisor, and editor-in-chief of Emergency Medicine News. Follow him on Instagram for ongoing education on thiamine, HG, and gut-brain health.

About Materna Health

Materna Health is a boutique functional fertility and OB/GYN practice in the West Village, NYC, closing the gap in women’s healthcare with same-day access, IV hydration and vitamin replacement protocols for HG, and continuity of care that keeps patients out of the emergency room.

Visit maternahealthcare.com · 130 7th Ave South, New York, NY · 917.382.0336 · [email protected]