Take a Poll

If HG continued past mid-pregnancy, did you experience complications during delivery related to your poor health such as a strained ligaments/joints, pelvic floor damage, prolonged or weak pushing, fainting, low blood pressure, low pain tolerance, forceps/assisted delivery, broken bones, nerve damage, low amniotic fluid, fetal problems due to difficult delivery, etc.?

Yes
No
Probably
Unsure




View Results »
Offsite Patient Education & Support

Parenteral (Intravenous) Nutritional Therapy

After several weeks of vomiting, mothers with hyperemesis can become very malnourished, yet this may not be realized by health professionals who only see them periodically. This is especially true if they are above their ideal body weight prior to pregnancy. TPPN (Total Peripheral Parenteral Nutrition) or TPN (Total Parenteral Nutrition) may be ordered to ensure she receives adequate nutrition. TPPN supplies many more nutrients than basic IV fluids, and may be given in a regular (peripheral) IV in the arm. However, the IV will typically only last for a few days and will then need to be replaced at another location.

TPN supplies most of her daily nutritional requirements and is usually given through a catheter called a PICC line placed in the forearm, or a central venous line placed in the neck/shoulder area. Local anesthetic is given during the procedure. These catheters are much longer and the end point is in the heart. This allows very concentrated nutrients to be given without damage to the smaller blood vessels of the arms.

It is important to note that TPPN/TPN is not a complete formula. Added multivitamins are very important in women with HG to avoid nutritionally-related complications.

Management of HG with Parenteral Nutrition

Once she loses over 5% of her pre-pregnancy body weight, nutritional therapies should be discussed, especially if she is continuing to have significant nausea, vomiting, and weight loss. At a minimum, IV home therapy with added vitamins should be administered after a few weeks of frequent vomiting. Blood tests can determine deficiencies long before you will see them. Encourage her physician to give her replacement multivitamins.

"According to the American Medical Association (AMA), the physician should not await the development of clinical signs of vitamin deficiency before initiating vitamin therapy.

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." aaiPharma®


Once she loses 8-10% of her body weight or has been vomiting for more than a month, it is imperative that she receive support to replace the many nutrients she has lost and to maintain her hydration. TPPN or TPN is the next choice for ongoing replacement. Dehydration perpetuates the vomiting cycle, as do nutritional deficiencies.


If nutritional support is not offered and/or she is not responding to anti-vomiting medications, a second opinion with a specialist may be needed. She may need you to do this for her as it is very difficult to think clearly and advocate for yourself when you are ill. See our Referral Network for tips on finding a doctor experienced in treating HG.

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 may not adequately consider the risks of TPN. Serious complications are possible when central venous lines are placed, as well as metabolic and infectious complications. These are usually due to insertion techniques, improper care of the IV site or line, or inadequate monitoring of her metabolic and nutritional status with blood tests. However, these problems are estimated to occur in only a small percentage of women with HG, even when TPN is given at home.

Before TPN is begun, consideration should be given to aggressive anti-vomiting medications and home IV therapy with vitamins, which do not put her at risk for any life-threatening complications. A growing number of women report that drugs from the serotonin antagonist category (e.g. Zofran, Anzemet, Kytril) have been used in higher doses (and early in pregnancy) in their subsequent pregnancies, eliminating the need for TPN and even IV's in some cases. Many physicians (and midwives) are not familiar with the use of these drugs during pregnancy, and are reluctant to offer them in adequate doses to give mothers relief from incessant vomiting. Feel free to refer her health professionals to our site for assistance, or find a physician up-to-date on caring for mothers with hyperemesis.

Potential Complications of Parenteral Nutrition:
Metabolic complications:
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.
Mechanical complications:
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.

Updated on: Apr. 18, 2013

Copyright © 2000-2015 H.E.R. Foundation • 9600 SE 257th Drive • Damascus, OR 97089 USA