Enteral Vs. Parenteral Treatment of Hyperemesis Gravidarum
Michele Healey Smith, RD, CNSD
Coram Healthcare, Salt Lake City
Adapted from: A.S.P.E.N. Dietetics Section Newsletter: Homecare Column (Nov. 2001) (a 29kb PDF)
Hyperemesis gravidarum (HEG) is a condition in pregnancy characterized by severe nausea and vomiting which lead to dehydration and nutritional compromise in the pregnant woman. Women who suffer from HEG may experience hypovolemia, starvation ketoacidosis, and electrolyte and acid-base abnormalities. Weight loss due to fluid depletion and lean body mass wasting is common. HEG adversely impacts nutritional status as well as everyday life, and if untreated can lead to fetal demise. However, the prognosis is good if fluids are aggressively replaced and nutrition support is provided. Home health care involving IV fluids, enteral or parenteral nutrition can be essential in the treatment of HEG.
It has been nearly a decade since women with HEG began receiving enteral feedings for nutrition support. Enteral nutrition has long been known to be physiologically beneficial when compared with parenteral nutrition in a variety of disease states. Tube feeding, at first glance, may seem contraindicated in HEG, but has been shown to be safe and effective in the treatment of severe nausea and vomiting associated with HEG. Feeding into the gut may decrease abdominal or sensory stimuli which induce vomiting, decreasing the symptoms of nausea and vomiting. Research has supported use of a variety of enteral feeding access devices. Nasogastric tubes are the least complicated to place, but are also at the highest risk of being dislodged with vomiting. In spite of this obvious challenge, Hsu et al were able to effectively treat the symptoms of HEG with NG Dobhoff tubes. Endoscopically placed NJ tubes have been safely and effectively used in HEG, as have percutaneous endoscopic gastrostomy (PEG) and jejunostomy (PEJ) tubes. However, PEG and PEJ access are only rarely used, and typically not first choices for treatment. In the research articles reviewed, symptoms of nausea and vomiting decreased or resolved with enteral feedings, and supported adequate maternal weight gain and fetal growth.
However, in spite of the many benefits of enteral feedings, many clinicians are reluctant to recommend tube feedings for patients with HEG. This reluctance may stem from patient resistance to tube feedings. Patients frequently refuse feeding tube placement due to aesthetics or physical discomfort of enteral access. A tube exiting from the nose may deter a woman from normal activities if she is self-conscious about questions or stares that the tube may evoke. A tube placed through an incision in the abdomen can be an equally offensive thought. As clinicians we tend to ignore the emotional side of therapies in our focus on the physiologic benefits of nutrition therapy.
However, it is important that we recognize the patient's feelings toward therapy. In some situations, a tube feeding may interfere with daily life as much as the condition itself. Nasojejunal (NJ) feedings are probably the most common enteral route used in HEG. Nasogastric tubes are more likely to be regurgitated, requiring frequent replacement, and gastrostomy and jejunostomy tubes are viewed as invasive, especially when the length of therapy is unknown. But verification of NJ tube placement can be of concern to physicians. Many facilities do not have access to endoscopically placed NJ tubes, and abdominal x-rays can be risky in pregnancy.
If enteral feedings are chosen as the mode of nutrition support, an iso-osmolar formula should be used. Initiating the feedings at 25 ml per hour and advancing slowly over 24 to 48 hours until the final goal is reached, has been well tolerated by most women. Anti-emetic therapy in conjunction with tube feedings also improves the likelihood of enteral feeding tolerance.
Clinicians rarely advocate parenteral nutrition in a patient with adequate gut function due to the high cost of the therapy, increased risk of infection, and suboptimal enteral stimulation. However, if enteral nutrition is not indicated for any reason, IV fluids or nutrition may be necessary.
Traditionally, IV fluids were used to treat HEG, and are frequently still used as a first line of defense against dehydration. For short term fluid needs, a peripheral IV can be placed and fluids can be administered with or without IV antiemetic therapy to rehydrate a patient. Often fluids alone will significantly decrease nausea and vomiting and allow the patient to tolerate adequate oral nutrition.
If initial treatment with IV fluids does not resolve the severity of nausea and vomiting however, multiple options are available. Peripherally inserted central catheter (PICC) lines have created a lower risk means of achieving IV access for longer periods of time versus surgically placed central lines. IV fluids can be altered as necessary to provide fluid, electrolytes, protein, vitamins, minerals and calories as needed by the individual patient. If a woman can tolerate carbohydrate foods such as dry toast and crackers, but is unable to consume adequate protein to support the growth of the fetus, Procalamine can be administered to meet protein and fluid needs. If net nutrient intake is negligible, total parenteral nutrition (TPN) is indicated. Studies have indeed shown TPN to be a safe and effective way to improve nutritional status for the mother and to support adequate fetal growth.
In addition to the higher risk of infection, cost, physiology of parenteral nutrition, significantly more monitoring is required when compared to enteral nutrition. If TPN is utilized, patients must have labs drawn at least weekly initially, and adjustments made to the TPN. Physicians are often reluctant to commit to this intense monitoring and wish to avoid the increased risks associated with TPN. It is important that a home health care clinician be experienced in TPN management in order to provide close monitoring of patient tolerance to IV nutrition, and recommend an appropriate TPN regimen.
The mode of nutrition support chosen for a particular patient should be based on physiological benefits weighed with patient and physician comfort level with the therapy. Regardless of the type of nutrition support determined to be appropriate for your patient, fluid and nutrition therapies can usually be safely initiated, advanced and monitored in the home. With proper patient education and close monitoring, enteral or parenteral nutrition can support a sound pregnancy and a healthy baby.
Cowan MJ. Hyperemesis gravidarum: Implications for home care and infusion therapies. J Intraven Nurs.1996; 19(1):46-58.
Godil A, Chen YK. Percutaneous endoscopic gastrostomy for nutrition support in pregnancy associated with hyperemesis gravidarum and anorexia nervosa. JPEN 1998; 23(6):367-8.
Gulley RM, Vander Pleog N, Gulley JM. Treatment of hyperemesis gravidarum with nasogastric feeding. Nutr Clin Pract 1993; 8(1):33-5.
Boyce RA. Enteral nutrition in hyperemesis gravidarum: a new development. J Am Diet Assoc 1992; 92(6):733-6.
Hsu JJ, Clark-Glena R, Nelson DK, Kim CH. Nasogastric enteral feeding in the management of hyperemesis gravidarum. Obstet Gyecol 1996; 88(3):343-6.
Serrano P, Velloso A, Garcia-Luna PP, Pereira JL, Fernandez Z, Ductor MJ, Castro D, Tejero J, Fraile J, Romero H. Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases. Clin Nutr 1998; 17(3):135-9.
Trovik J, Haram K, Berstad A, Flaatten H. [Nasoenteral tube feeding in hyperemesis gravidarum. An alternative to parenteral nutrition]. Tidsskr Nor Laegeforen 1996; 116(20):2442-4.
Greenspoon JS, Rosen DJ, Ault M. Use of the peripherally inserted central catheter for parenteral nutrition during pregnancy. Obstet Gynecol 1993; 81(5 pt 2):831-4.
Levine MG, Esser D. Total parenteral nutrition for the treatment of severe hyperemesis gravidarum: maternal nutritional effects and fetal outcome. Obstet Gynecol 1988; 72(1):102-7.
Stellato TA, Danziger LH, Burkons D. Fetal salvage with maternal total parenteral nutrition: the pregnant mother as her own control. JPEN 1998; 12(4):412-3.
Updated on: Apr. 18, 2013