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 · hello@maternahealthcare.com