Parenteral (Intravenous) Nutrition
In women with hyperemesis gravidarum (HG) who become very
malnourished or have a history of moderate to severe HG,
Total Parenteral
Nutrition (TPN) may be initiated
to ensure she receives adequate nutrition. Once a woman loses
over 5% of her body weight (pre-conception), nutritional
therapies are highly recommended,
especially
if she is continuing to have significant nausea and vomiting.
Once she loses 8-10% of her body weight or has been vomiting
for more than a month, it is imperative that she receive
some sort of intervention to replace the many nutrients she
has lost and to maintain her hydration. This also decreases
the risk of adverse fetal
effects. Dehydration perpetuates
the vomiting cycle, as do nutritional deficiencies.
At a minimum, IV home therapy with added vitamins should
be administered before she becomes too depleted. Ideally,
this would be initiated after only a few weeks of frequent
vomiting.
Total Peripheral Parenteral Nutrition (TPPN) or TPN
is the next choice for ongoing replacement. Numerous vitamins
and
nutrients are depleted in only a few weeks, exacerbating
her symptoms and making them more resistant to medical interventions.
It is important to note that TPPN/TPN is not a complete
formula and it should be evaluated to ensure sufficient
calorie content
for a pregnant woman, as well as appropriate levels of
vitamins and minerals based on her gestational age. Added multivitamins are
very important to avoid complications such as Wernicke's
Encephalopathy which
is related to thiamine deficiency. Multiple vials may be
needed initially to replenish her deficits.
"According to the American Medical Association (AMA),
the physician should not await the development of
clinical signs of vitamin deficiency before initiating
vitamin
therapy. The use of a multivitamin product obviates the
need to
speculate on the status of individual vitamin nutriture.
Patients with multiple vitamin deficiencies or with markedly
increased requirements may be given multiples of the daily
dosage for two or more days as indicated by the clinical
status. M.V.I.-12® does not contain vitamin K, which
may have to be administered separately. " aaiPharma®
Medications v. Parenteral Nutrition
While nutritional support is important, some physicians
initiate home TPN without having first attempted an adequate
trial of antiemetic medications and fail to realize the serious
risks involved. Life-threatening complications of catheter
insertion such as pericardial tamponade, pneumothorax
and subclavian artery laceration may occur. Also, metabolic and
infectious complications are not uncommon, such as hyperglycemia
and gram-negative septic shock with severe cellulitis requiring
surgery. The liver may enlarge if too many calories, particularly
from fats, are consumed. The excess fat in the veins may
also cause backaches, fever, chills, nausea, and a low platelet
count. Pancreatitis is also a frequent problem. However,
these problems are estimated to occur in only a small percentage
of those receiving total parenteral nutrition for HG. TPN
should be offered to hyperemetic women when aggressive medical
management has failed and the patient is at risk for malnutrition.
While
some physicians are reluctant to utilize newer medications,
which have yet to show adverse maternal or fetal effects,
they are more willing to offer TPN which has a known history
of complications which can be life-threatening. A growing
number of women report that drugs from the serotonin antagonist
class (e.g. Zofran, Kytril, Anzemet) have been used in
higher doses in their subsequent pregnancies, eliminating
the need
for TPN and even IV's in some cases. These women report
beginning these medications at the onset of symptoms and
increasing
the dose as needed, then gradually weaning off of them
in later pregnancy. Not only are her symptoms better controlled,
she is also less miserable and will likely recover faster.
This results in a net savings as the cost for additional
physician visits, treatment of complications, TPN, and
repeated
hospital visits are much greater than the cost of these
drugs. Perhaps a change in perception of risk would decrease
the
need for TPN and repeated IV hydration in women with HG.
| Hyperglycemia |
Most common metabolic complication
of parenteral nutrition. Related to rate of dextrose
infusion, concentration, level of stress, etc.
May cause hypertriglyceridemia which may cause
pancreatitis. Close monitoring is important during
pregnancy, esp. if using glucocorticoid therapy. |
| Hypoglycemia |
Most commonly related to abrupt
discontinuation of TPN without tapering, especially
with high dextrose concentrations. |
| Essential fatty acid deficiency |
May result from parenteral nutrition
regimen devoid intravenous fat administration.
May occur in as little as 2 weeks, particularly
in malnourished patients. Replacement is very important
during pregnancy. |
| Electrolyte imbalance |
Inadequate or excess administration
of electrolytes in parenteral nutrition solutions.
Losses due to vomiting should be accounted for. |
| Fluid volume disturbances |
Volume deficit or volume overload
(particularly important in patients with renal
impairment and during pregnancy to maintain uterine
flow). |
| Acid/base imbalance |
Solution design must take
into account acid/base status of patient, i.e.
chloride, acetate etc. |
| Hepatic complications |
Such as steatosis, possibly
due to excessive carbohydrate administration. |
| Refeeding syndrome |
The metabolic
cascade of events that takes place when a malnourished
patient is refed. Hypophosphatemia, hypokalemia,
hypomagnesemia, body-fluid disturbances, vitamin
deficiencies such as thiamine, cardiac arrhythmias,
and congestive heart failure may result. |
| Catheter related |
Pneumothorax, vessel damage,
thrombosis, occlusion, catheter breakage, infection,
etc. |
| Infection |
Fever, pain, redness at site. |
| Site related |
Pain, inflammation, or redness,
drainage. |
| Air embolism |
A result of air being introduced
into catheter. |
| Delivery device related |
Most commonly device failure. |
| Septic complications |
Patients with indwelling access
devices and a compromised immune system are at
high risk for catheter related sepsis. |
|
| |
| Adapted from www.nyschp.org,
www.medscape.com and
other sources. |
Care of the Mother Receiving Parenteral Nutrition
- Use strict aseptic technique and utmost caution when
caring for a central line.
- Perform routine blood studies
similar to the following (based on your policy)
- Perform
serum glucose measurements daily for 4 days, then on
Monday, Wednesday, and Friday.
- Measure serum electrolytes
and blood urea nitrogen levels on Monday, Wednesday,
and Friday.
- Perform complete
blood count with differential, prothrombin time, partial
thromboplastin time, platelet count,
liver function
tests, and phosphorus, calcium, albumin, total protein,
magnesium and creatinine levels at the start of TPN
and weekly thereafter.
- If the patient is receiving lipids,
determine triglyceride levels daily for 2 days, then weekly.
- Determine urine
urea nitrogen levels weekly (collect 24-hour urine
Sunday for Monday).
- Ensure family has adequate support
and training to effectively and safely care for the
mother.
Adapted from Van Way III, Allen JA. Intravenous nutrition. In: Van Way III, ed. Handbook of Surgical Nutrition. Philadelphia: JB Lippincott , 1992: 73–77 and other sources
Other Resources:
- Hankins, J et al., editors. Infusion Nurse
Society: Infusion Nursing in Clinical Practice, WB Saunders.
2001
- Phillips, Lynn. Manual of IV Therapeutics. 3rd ed. FA
Davis. 2001
- Weinstein, S. editor. Plumer's Principle & Practice
of IV Therapy, 7th ed. Lippincott Williams, Wilkins. 2000
| Offsite
Research:
Pregnancy outcome and total parenteral nutrition in malnourished pregnant women.
Caruso A, De Carolis S, Ferrazzani S, Trivellini C, Mastromarino
C, Pittiruti M.
Department of Obstetrics and Gynecology,
Catholic University, Rome, Italy.
Fetal Diagnosis & Therapy 1998 May-Jun;13(3):136-40.
We evaluated pregnancy outcome and fetal growth in women
requiring total parenteral nutrition (TPN). The duration
of TPN ranged from 14 to 220 days. Maternal nutritional state
was well preserved and no complications were related to treatment.
A gestational age of 35+/-3 weeks at delivery (mean +/- SD),
birth weight of 2,251+/-670 g (mean +/- SD) and birth percentile
of 29+/-16 (mean +/- SD) were observed. One intrauterine
death occurred. The comparison between the sonographic findings,
before and 2 weeks after starting TPN, showed a fetal percentile
gain with a statistically significant increase in the abdominal
circumference percentile (p < 0.05) from a median percentile
of 2 (range 2-32) to 33 (range 2-78). CONCLUSIONS: TPN proved
to be helpful and lifesaving in malnourished pregnant women
and promoted fetal growth, as shown by the longitudinal ultrasonographic
evaluations.
Use of the peripherally inserted central catheter for parenteral
nutrition during pregnancy.
Greenspoon JS, Rosen DJ, Ault M.
Department of Obstetrics-Gynecology,
Cedars-Sinai Medical Center, Los Angeles, California.
Obstetrics & Gynecology 1993 May;81(5 ( Pt 2)):831-4.
The peripherally inserted central catheter was successfully
placed, and central venous administration of hyperosmolar
solutions was accomplished without complication for periods
of 28-137 days. Maternal weight gain and fetal growth were
adequate. The peripherally inserted central catheter avoids
some of the risks related to obtaining central venous access
and permits long-term administration of parenteral nutrition
into the central venous circulation.
Total peripheral parenteral nutrition in pregnancy.
Watson LA, Bommarito AA, Marshall JF.
Department of Obstetrics
and Gynecology, Saginaw Cooperative Hospitals, Inc., Michigan.
JPEN Journal of Parenteral & Enteral Nutrition 1990 Sep-Oct;14(5):485-9.
Twenty pregnant patients needing nutritional support for
various indications received hypercaloric, hyperosmotic, "3
in 1," peripheral parenteral nutrition as a bridge to
enteral therapy. This system, named total peripheral parenteral
nutrition, was evaluated as to tolerance and efficacy in
pregnant patients. Patients were in various stages of pregnancy
and had an average weight loss of 10.4 pounds prior to admission.
Patients were maintained on total peripheral parenteral nutrition
for an average of 5 days and gained an average of 4.1 pounds.
Good tolerance with minimal side effects of the treatment
was noted. Intravenous sites were changed an average of 1.1
times per patient during the course of therapy and only one
serious complication was noted in 20 patients. Patients were
followed through delivery and this information is presented.
Total peripheral parenteral nutrition appears to be an acceptable
alternative to conventional total parenteral nutrition to
pregnant patients needing nutritional support. These hypertonic
solutions can supply total caloric/metabolic needs without
unacceptable side effects.
More PubMed Research on Parenteral Nutrition in Pregnancy »
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Updated on:
Aug. 09, 2006 |
