TPN and Pregnancy

Related to Hyperemesis Gravidarum

BY STEPHANIE ORMSBY, DI
Goals of this Presentation
OUTLINE OBJECTIVES

▪Hyperemesis Gravidarum ▪State the MNT for hyperemesis gravidarum

▪Pregnancy ▪Understand the complications and
considerations of nutrition support during
▪Nutrition Support pregnancy
▪TPN
▪ Evidence Analysis Library
▪ Monitoring

▪Case Study
HYPEREMESIS
GRAVIDARUM
Hyperemesis Gravidarum (HG)
▪Excessive vomiting, weight loss, and electrolyte imbalances,
▪While morning sickness affects 70%-80% (Jewell 2003) of all pregnant women, only 2%-5% have
it severe and prolonged enough to be HG ( Dumican 2000; Furneaux 2001; Erick 2000).
▪Complications may include:
▪ global subluxation
▪ chondrodysplasia punctate
▪ splenic avulsion
▪ ruptured esophagus
▪ gestational malnutrition

▪Hospitalization for nutrition support is generally indicated

Risk Factors
▪History of allergies
▪Anxiety disorder
▪Dental cavities
▪Depression
▪Immune disorder
▪Migraine headaches
▪Motion sickness
▪PMS
▪Temporomandibular joint disorder
Management of Hyperemesis (Mcparlin, 2016)
Small, frequent meals that are low-fat, high carbohydrates
Avoidance of trigger foods and strong odors
Supplemental B6, ginger, and acupressure
Antihistamines, dopamine/serotonin antagonists, and IV fluids
Corticosteroids, gabapentin, transdermal clonidine, EN, TPN
PREGNANCY
Physical Changes During Pregnancy
▪Blood volume expands by 50%
▪ Decrease in serum proteins and water-soluble vitamins
▪ Increase in fat-soluble vitamins and other lipids
▪Cardiovascular Function
▪ Increase cardiac output and size increases by 12%
▪ First 2 trimesters blood pressure decreases
▪ Oxygen requirements increase, feeling of dyspnea is common
▪Gastrointestinal Function
▪ Increased progesterone relaxes uterine muscles which leads to decreased GI motility
▪ Gallbladder volume doubles and had reduced ability to empty
▪ Heartburn, N/V, cravings/aversions
▪Hormonal Changes
▪ Preeclampsia or Hypertension
Effects of Nutritional Status
▪The effects of poor maternal nutrition follows both infant and mother for decades (Cox and
Phelan, 2008).
▪ Infant birth weight
▪ Birth defects and developmental delays

▪One theory hypothesizes that without adequate nutrients for growth, the fetus aborts early
increasing the risk for a premature infant.
Nutrition Assessment
▪Assessment of Pregravid Nutrition Status
▪ Unplanned pregnancies
▪ Prior medical needs or comorbidities

▪Assessment of Current Nutrition Status

▪ Malnutrition in pregnancy cannot by categorized by usual criteria
▪ Weight changes
▪ Micronutrient status
Weight Gain During Pregnancy
Inadequate
weight gain is
associated with
low body weight
and SGA infants
Nutrition Needs During Pregnancy
▪Energy Requirements: ▪28 g/day fiber
◦ 1St Trimester – No excess kcal/day
▪1,000 mg/day calcium
◦ 2nd Trimester – 340 extra kcal/day
◦ 3rd Trimester – 450 extra kcal/day ▪27 mg/dl iron

▪Protein Requirements: ▪600 mcg/day folate

▪ 0.8 g/kg/day for first half (Krause) ▪1.4 g/day omega-3 fatty acids
▪ 1.1g/kg/day for second half (IOM)
▪ Recent 1.2 for early and 1.52 for late ▪450 mg/day choline from foods
▪35-40 ml/kg/day water
▪ 3L total - 2.3 L from beverages and the
remaining amount from food
NUTRITION
SUPPORT
Nutrition Support
ENTERAL NUTRITION PARENTERAL NUTRITION

▪Functional GI tract ▪Nonfunctional GI tract

▪Hyperemesis ▪EN Contraindicated
▪ Variable effectiveness
▪Severe Hyperemesis
▪ Patient willingness
▪ Limits risk for aspiration
▪ Tube placement
▪ Delayed gastric emptying
▪ Loss in LES tone
ASPEN, 2017
TPN
Parenteral Nutrition in Pregnancy
▪Peripheral vs Central Access
▪ Often cannot obtain a sufficient rate of infusion through a peripheral line

▪Composition
▪ Based on macronutrient needs
▪ Lipid injectable emulsion – important to provide omega-3 and essential fatty acids
▪ MVI – additional supplementation is often needed

▪Complications
▪ Glucose control
▪ Infection
▪ Limited research with pregnant women
▪ Fetal development
Evidence Analysis Library
Evidence Analysis Library
Evidence Analysis Library
Nutrition Monitoring
A challenge because changes in blood volume and
composition occur during pregnancy
Markers of Nutrition
▪Creatine levels greater that 0.9 mg/dL – possible renal insufficiency
▪TAG levels compared to standard for trimester of pregnancy
▪Nitrogen balance study +4-6 g nitrogen/day to support fetal growth
▪Serum iron level less than 60-70 mcg/dL may indicate iron deficiency
▪ Serum hemoglobin and hematocrit levels less than 11 mcg/dL and 33% may indicate iron deficiency
CASE
STUDY
General Information
◦ 33 year old
◦ Ht: 5’5”
◦ Admit wt: 71.7 kg
◦ BMI: 26.29 kg/m2
◦ Admitted 1/25 @ 2:20
◦ Mom to 3 year old
◦ 8-9 weeks pregnant
◦ Two prior unsuccessful pregnancies
Previous Medial History
▪ Alcohol dependence
▪ Drug abuse
▪ Anxiety/Depression
▪ Type 1 DM diagnosed at age 15
▪ GERD
▪ Chlamydia, gonorrhea, and herpes
▪ MRSA
▪ Vit A and Vit D deficiency
▪ Tracheal stenosis and reconstruction
▪ Cholecystectomy
▪ Pregnancy
▪ 1998 miscarriage
▪ 2004 medical abortion due to complications
▪ 2016 gravida
Present Admission
▪ Admit Dx: Hyperemesis Gravidarum
▪ Hyperglycemia
▪ Abdominal pain

▪ Other Concerns
▪ Hypertension
▪ Left ovarian cyst with torsion
▪ Tachycardia
▪ Anemia
▪ Asthma
▪ Leukocytosis
Medical Treatment
▪IV Fluids:
▪ D5% and 0.45% NaCl at 100 ml/hr (provides 408 kcal)
▪ 15 mg Labetalol x 2 daily
▪ Banana bag
▪ Thiamine 100 mg
▪ Folic acid 1 mg
▪ B6 25 mg
▪ Multivitamin for infusion (MVI) 10ml
▪ Magnesium sulfate 3 g

▪Antiemetic
▪Management of DM
Medical Nutrition Therapy
Small, frequent meals that are low-fat, high carbohydrates – patient unable to tolerate anything
Avoidance of trigger foods and strong odors
B6, ginger, and acupressure- gave education advising ginger may help
Low blood sugars in evening, educated on importance of HS snack
Antihistamines, dopamine/serotonin antagonists, and IV fluids
Corticosteroids, gabapentin, transdermal clonidine, EN, TPN
Diet Orders
▪Admit Jan 25-Jan 26: Carbohydrate consistent diet – emesis 6-12 x per day
▪Jan 27- Jan29: NPO
▪Jan 30: Clear Liquid
▪Jan 31-Feb 1: Full Liquid
▪Feb 1-Feb 6: TPN
▪Feb 6-Feb 8: Carbohydrate consistent, PO intakes improved 75%, 75%, 100%
Nutrient Needs
▪Energy: 2017 kcal ▪Started TPN at 53% of caloric needs x 3 days
▪ 14.6 kcal/kg
▪Protein: 81 g protein
▪ 0.9 g/protein
▪Fluid: 3 L
▪Progressed to 62% of caloric needs (17 kcal/kg) x 2 days
▪ 17 kcal/kg
▪Patient was at risk for ▪ 1.2 g/protein
refeeding and potassium ▪TPN Discontinued
was low at 3.4
▪In addition to TPN, pt was
consuming 350-400 kcal/day
Nutrient Needs
▪Carbohydrate: ▪TPN Bag 1-3:
▪ 175 g dextrose
▪RDA in pregnancy is 175 g/day
▪ 70 g amino acids
▪ Fetal use of free fatty acids is limited
▪ 100 g fat
▪ Hyperglycemia is a major concern. Target blood ▪TPN Bag 4-5:
glucose levels for women with DM: ▪ 190 g dextrose
▪ <95 mg/dL fasting ▪ 90 g amino acids
▪ <140 mg/dL 1 hour postprandial ▪ 120 g fat
▪ <120 mg/dL 2 hour postprandial
Tolerance & Challenges
▪Pt tolerated TPN very well, no abnormal labs
▪Managing DM was greatest challenge
▪ Pt usual Carb ration is 1:9
▪ Per Dr. Trachenbarg provide 80% of insulin in TPN
▪ Apple Juice used to treat hypoglycemia
 Weight History
▪Pre-pregnancy weight: 74 kg (163 lbs)
▪Admit weight on Jan 25th : 71.7 kg (158 lbs)
▪Jan 30th: 69.3 kg (152.5 lbs)
▪Feb 1st: 68.2 kg (150 lbs)
▪Feb 4th: 70.6 kg (155 lbs)
▪Feb 5th: 70.7 kg (155.5 lbs)
▪Feb 6th: 71.5 kg (157 lbs)
▪Discharge weight Feb 8th: 71.3 kg (157 lbs)
Prognosis & Continued Care
▪Generally resolves after 1st trimester
▪ Occasionally hyperemesis will not resolve throughout pregnancy

▪Given handout on nutrition during pregnancy

▪ Patient can tolerate prenatal gummy

▪Management of DM
▪ Patient has been seen in the emergency department on 3 additional occasions since for hypoglycemia.
Reflection
▪What would you have done differently?

▪ Advocated for patient diet order to accommodate dry foods

▪ Explore EN options more extensively