By: Andria M. Keating - PowerPoint Presentation

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By: Andria M. KeatingResearch ProjectFACS 461

Severe Hyperemesis Gravidarum: Total Parenteral Nutrition Predisposing Factors for Infant Nutritional Deficiencies Slide2

In the United States there are 80,000 reported annual cases of Hyperemesis Gravidarum (HG)

Severe Hyperemesis Gravidarum occurs in 1% of pregnanciesHyperemesis gravidarum is extreme, persistent nausea and vomiting during pregnancy that may lead to dehydration and the inability to adequately meet caloric intakeHyperemesis Gravidarum can occur usually within the first trimester of

pregnancy

Believed to affect one in fifty women during pregnancyThe is no known cause/cure for HG

Introduction:Slide3

Anemia

Body odor (from rapid fat loss & ketosis)ConfusionDecreased urinationDehydration

Dry, furry tongue

Excessive salivationExtreme fatigue

Fainting or dizzinessFood aversions

Gall bladder dysfunction

HeadacheHypersensitive gag reflexIncreased sense of smell

Signs and Symptoms

Intolerance to motion/noise/lightJaundiceKetosisLiver enzyme elevationLoss of skin elasticityLow blood pressureOveractive thyroid or parathyroidPale, waxy, dry skinRapid heart rateRapid weight loss of 5% or more (from pre-pregnancy weight)Secondary anxiety/depressionVitamin/electrolyte deficiencyVomiting of mucus, bile or bloodSlide4

Normal Nausea/Vomiting VS. Hyperemesis GravidarumDiagnosis CriteriaSlide5

http://www.youtube.com/embed/MGOqqbBCWg8Hyperemesis GravidarumSlide6

Intravenous fluids (IV) – to restore hydration, electrolytes, vitamins, and nutrients

Tube feeding: Nasogastric – restores nutrients through a tube passing through the nose and to the stomachPercutaneous endoscopic gastrostomy – restores nutrients through a tube passing through the abdomen and to the stomach; requires a surgical procedure

Medications

– metoclopramide, antihistamines, and anti-reflux medicationsBed Rest

Acupressure Herbs

– ginger or peppermint

Homeopathic remedies are a non-toxic system of medicines. HypnosisTreatments:Slide7

TPN is a way of supplying all the nutritional needs of the body by bypassing the digestive system and dripping nutrient solution directly into a

vein. Your TPN may include a combination of sugar and carbohydrates (for energy), proteins (for muscle strength), lipids (fat), electrolytes, and trace elementsTPN will drip through a needle or catheter placed in your vein for 10 to 12 hours, once a day or five times a week.Electrolytes

include:

sodium, potassium, chloride, phosphate, calcium, and magnesium. Trace elements include: zinc, copper, manganese, and chromium.

Electrolytes are important for maintaining almost every organ in your body. They help your heart, muscles, and nerves to work properly and keep you from becoming dehydrated.

Total Parenteral NutritionSlide8

Jeff Johnson, PharmDTpn: Pharmacist Slide9

Fat Soluble Vitamins: Vitamin A,D,E,K-Toxcities

re-feeding and underfeeding syndrome- severely malnourished patients may result in "refeeding syndrome" in which there are acute decreases in circulating levels of potassium, magnesium, and phosphate

Aluminum found in TPN solutions

Precipitates that may form in solution: If the bag is not filtered into the PICC line than the potential for fatal complications existInfection :

Catheter-related sepsis occurs in about ≥ 50% of patients. Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in > 90% of patients.

Mechanical

complications-placement of a central venous catheter. Improper placement may cause pneumothorax, vascular injury with hemothorax, brachial plexus injury or cardiac arrhythmia. Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in some patients given TPN for > 3 mo.

Gallbladder complications include cholelithiasis, gallbladder sludge, and cholecystitis

.Volume Overload/ Abnormalities in electrolytes/mineralBlood clot starts in IV site and breaks off and goes to lungsConcerns for TPN use in Pregnant Women:Slide10

TPN Complications:Slide11

Identified Possible Causes/Influences for HGHormonal Imbalances-human gonadotropin

Vitamin B DeficiencyHyperthyroidismGERDHelicobacter Pylori

Infections

Psychological factorsDisturbances in Carbohydrate MetabolismNerve found in pelvic diaphragm

Twin

and molar pregnancies

Literature reviews:Slide12

Maternal Complications: Short-TermPre-term delivery <37 weeks gestational age

Reduced Pregnancy weight gain (<5.5 lbs.)Pregnancy induced HypertensionRenal Failure

Deep venous

thrombosisHypoglycemiaJaundice

Postpartum disorder/ Post traumatic stressVasospasms of cerebral arteries

Splenic avulsion

Wernicke’s encephalopathyMaternal Death

Literature Reviews:Slide13

Fetal Complications: Short-term Lower birth weights < 5lbs.

Organs not fully matureLow Apgar Scores- tests taken within 5 minutes after birth to assess baby’s conditionFetal death

Small for gestational age <10

th percentileCongenital Heart DiseaseIntegumentary abnormalities

Shorter length

Undescended Testicles- higher risk of testicular cancer later in life

Hip dysplasia Large for gestational ageNeural tube defects

Central Nervous System

Malformation/ skeletal malformationLiterature Reviews:Slide14

Definition of fetal programming that relates adjustments made during fetal life in response to adverse changes in the biological environment with permanent consequences that may have been advantageous in fetal life but confer disease after

birth. One study suggests a possible change in the fetus metabolic structure.http://abcnews.go.com/Health/video/fetal-programming-14021547

Fetal Programming:Slide15

Women that used TPN throughout pregnancy have delivered premature or under birth weight babies

. The researchers studied ten women who were on parenteral nutrition therapy, of which nine women delivered at the 36 week mark or beyond with positive outcomes. All women who had received total parenteral nutrition showed a reversal of the catabolic state; respiratory quotient values greater than 1.0 indicated lipogenesis and an anabolic state; along with shifting from fat to carbohydrate and protein substrate utilization.

Thiamine (B1) deficiency has been found in as many as 60% of HG patients. A woman who has HG is more likely to develop thiamine deficiency due to an increased demand for glucose metabolism, added to the inability to tolerate sufficient food and vitamin/mineral supplements. The cerebral progression of thiamine deficiency resulting in Wernicke’s encephalopathy has been discovered in 33 cases within the last 20 years.

Literature Reviews:Slide16

The study on TPN and HG sufferers discovered an increased chance of seeking an early termination of pregnancy (TOP) among participants of the study (Aubry et al., 2005). A helpline for HVP conducted a survey of 3,201 callers of which 413 had considered TOP and then 108 of the women went through with TOP.

Conversely, there is no evidence to support the use of TPN and it should only be used as a fallback when all other treatments have failed. The associations of severe complications such as thrombosis, metabolic disturbances and infection are reasons the study find it important to use total parenteral nutrition as a last resort. The study expresses the interest of further studies needed to further investigate complications that may arise due to total parenteral nutrition support.

Literature reviews:Slide17

Small population studiesNo studies completed after first year of life for the infant

No studies look at nutritional stores of the infant at birthResearchers believed there are positive associations with participants on TPN solutions and the increase of TPN complications. The researchers stated the benefits need to be weighed against potential for complications. At this time no studies have been performed on hyperemetic mothers treated with TPN.

Lit. Review ProblemsSlide18

Existing research studies have associated infants of women who experienced HG having

complications of lower birth weights, small for gestational age, and born prematurely. Studies have proven women that have had subsequent hospitalizations for HG have the highest rates of low birth weights compared to those experiencing HG for the first time. There are no studies establishing the long-term effects that HG and the use of total parenteral nutrition may have exposed the off spring to nutritional deficiencies. The problem exists that no long-term follow-up studies have been done to date on children born to hyperemetic women. There is unknown knowledge of TPN solutions providing adequate nutrition for the mother and the fetus. The lack of long-term effects of total parenteral nutrition during serve

HG could

potentially put the fetus at risk for chronic diseases later in life (Fetal Programming).

Problem StatementSlide19

•To determine the maternal and fetal outcome and nutritional stores of participants experiencing severe HG with treatment of total parenteral nutrition.•To

determine association between infants of hyperemetic mothers and the exposure to nutritional deficiencies due to total parenteral nutrition treatment.•To determine the long-term health complications of infants from hyperemetic mothers. Specific Aims:Slide20

This study will be necessary to research because of the lack of knowledge concerning the long-term complications that result from infants born from hyperemetic women. The role of Total Parenteral nutrition in providing enough nutritional support for maternal and fetal needs to be further explored. TPN use needs to be evaluated to determine if the infant is placed at greater risks for chronic diseases. Research is beginning to suggest that the prolonged malnutrition and dehydration in the mother puts the unborn child at risk for chronic diseases such as diabetes and heart disease later in life. At this time it is important to determine the correlation between the condition and the potential for fetal programming as there are 80,000 women who experience HG each year.

Significance:Slide21

Longitudinal observational prospective cohort study-observational study is based upon clinical and field observations due to ethical concerns

. The observational study will observe for long-term complications for infants of hyperemetic women treated with total parenteral nutrition during pregnancy. Research Team: Pediatrician, Pharmacists, Registered Dietitian, and a

Statistician

The study will be approved by the Institutional Review Board of Health Sciences at University of VirginiaThe participants will sign a consent form to

participate in the study that will allow release of all medical records (Mother/Child).

Methodology

:Slide22

. Participants will be selected from a database on the Hyperemesis Education Research Foundation website: http://www.helpher.org/mothers/

The website has a database of women that have experienced Hyperemesis during pregnancy due to referral from their physician. Advertisement for the study will be placed on website’s homepage. Interested participants will complete a survey that requires them to answer questions.

A sample size of 100 participants will be chosen and sent an informational email to the registered email account listed on database.

The maternal nutritional records throughout pregnancy will be evaluated and fetal nutritional stores at birth will be analyzed.

The infants of both the intervention and control group will be monitored yearly until reaching adulthood (18 years of age). The mothers will be the primary participants since they will be completing the surveys.

Methodology:Slide23

Follow-up studies will be completed by annual physicals at the infant’s check-ups with physicians.

Complications that may arise will be closely monitored for relevance relating to being born from a hyperemetic mother on Total Parenteral Nutritional Support. The mothers will complete a survey yearly and send it by email or postal service. The survey will ask the following criteria: any diagnosed chronic diseases documented for your child, does the child have any nutritional related deficiencies, has the child had problems with weight gain/loss, and has the child had problems with growth.

The

results will be configured annually each year by a statistician.

Methodology:Slide24

Methodology:Slide25

The participants of the study were of the female gender and in the age ranges

of 18 to 35 years of age for the study.The age range was chosen based upon possible risk factors that may result from maternal age <18 y/o and >35 y/o

The participants in the intervention group all were hospitalized with the diagnoses of severe hyperemesis

gravidarum. These participants were treated with Total Parenteral Nutrition Intravenously throughout pregnancy. There will be a control group that was not treated with Total Parenteral Nutrition for their diagnoses of severe hyperemesis

gravidarumThere will be secondary participants, infants of both the intervention and control group.

Participants:Slide26

Maternal weight gain/loss, changes in skin condition(Jaundice), changes in heart rate, blood pressure, electrolyte levels, nutritionally relevant lab values (Iron, Vitamin K, Vitamin A, B Vitamins), Serum Bicarbonate, Urinalysis(Ketones), Liver function tests, White Blood Cells, Thyroid Function test, Hematocrit, Albumin, and

Pre-Albumin. Indirect calorimetry for nutritional assessment of nutrient needs during pregnancy.Annual physical exam results will be monitored by the research team. Infants will have annual medical examination (check-up) with their pediatrician. The pediatrician will monitor for the following values: vitals, presenting complaints, medication changes, functional status, review of lifestyle behaviors and activities, vaccinations and immunizations, growth percentile charts, and nutritionally relevant lab values (Iron, Albumin, PreAlbumin, B vitamins).

Lab Measurements:Slide27

Abell T., Riely

C., Hyperemesis Gravidarum, Journal of Gastroenterology Clinics of North America, 1992, 21(4):835-849Allen V., Butler B., Dodds L., Fell D., Outcomes of Pregnancies Complicated by Hyperemesis Gravidarum, Journal of American College of Obstetricians and Gynecologists, 2006, 107(2):285-291

Allen

V., Butler B., Dodds L., Fell D., Risk Factors for Hyperemesis Gravidarum Requiring Hospital Admission During Pregnancy, Journal of American College of Obstetricians and Gynecologists, 2006, 107(2):277-284Bazer

F., Cudd T., Meininger C., Spencer T., Wu G., Maternal Nutrition and Fetal Development, The Journal of Nutrition, 2004, 134(9):2169-2172

Deitel

M., Hew L., Total Parenteral Nutrition in Gynecology and Obstetrics, Journal of Obstetrics and Gynecology, 1980, 55(4):464-468Banchik

L., Trujilo K., Hyperemesis Gravidarum: Feed the Mother, Feed the Child, Journal of Parenteral and Enteral Nutrition, 2005, 29(2):134-135

References:Slide28

Buck G., Haughey B.,

Marecki M., Snell L., Metabolic Crisis: Hyperemesis Gravidarum, Journal of Perinatal and Neonatal Nursing, 1998, 12(2): 204-210Sheehan P., Hyperemesis Gravidarum: Assessment and Management, Journal of Australian Family Physician, 2007, 36(9):698-701Benotti

P.,

Bistrian B., Blackburn G., Martin R., Trubow M., Hyperalimentation during Pregnancy: A case report, Journal of Parenteral and Enteral Nutrition, 1985, 9(2): 212-215

Jimbo M., Hoshi S., Iwasaki M., Okai

T.,

Sugito Y., Cell-Free Fetal DNA is Increased in Plasma of Women with Hyperemesis Gravidarum, Journal of Clinical Chemistry, 2001, 47(12): 2164-2165Barkai G., Farfel Z., Hassin

D., Movallem M., Rotman P.,

Wernickes Encephalopathy in Hyperemesis Gravidarum: Association with Abnormal Liver Function, Israel Journal of Medical Sciences, 1994, 30(3): 225-228Ching C., Fejzo M., Goodwin M., MacGibbon K., Mullin P., Risk Factors, Treatments and Outcomes Associated with Prolonged Hyperemesis Gravidarum, Journal of Maternal-Fetal and Neonatal Medicine, 2011, 1(5): 251-254Sonkusare S., The Clinical Management of Hyperemesis Gravidarum, Journal of Obstetrics and Gynecology, 2011, 283: 1183-1192 References:Slide29

Aubry R., Brown H., Folk J., Nosouition J., Silverman R., Hyperemesis Gravidarum: Outcomes and Complications with and without Total Parenteral Nutrition, Journal of Nutritional Clinical Practice, 2005, 20(3): 364-365

Jueckstock J., Kaestner R., Mylonas I., Managing Hyperemesis Gravidarum: A Multimodal Challenge, Journal of BMC Medicine, 2010, 8: 46-48Novak

D., Nutrition in early life. How important is it?, Journal of Clinics in Perinatology, 2002, 29(2): 203-223

References: