Malnutrition & Starvation
One of the most difficult challenges with HG is managing a mother's nutritional needs. It must be remembered that every book, newspaper, magazine and friend or family member will tell her repeatedly that she has to eat healthy or it will harm her unborn child. This fear is one of the greatest for these women and should be discussed. Some may choose termination (elective abortion) rather than face having a child who has potentially been harmed by their limited intake.
Further, even when women can eat, it might be less than healthy foods and little variety. It is not uncommon to find aversions to protein foods and vegetables for much of their first trimester, if not longer. This can cause guilt and frustration. She should be reassured and encouraged to make the best decisions possible, but keep her focus on increasing her fluid and calorie intake any way possible. A dietary consult can sometimes be helpful, especially for tips on hiding nutritional foods like vegetables or increasing calories by adding dense foods (e.g. peanut butter) to those she tolerates.
Treatment
According to the medical research, if women fail to gain weight for two consecutive trimesters, it can have detrimental effects on the baby. Further, women who lose large amounts of weight (>10% of their pre-pregnancy weight) are at greatest risk for maternal and fetal complications. Intervention to stop the vomiting, and thus decrease weight loss is critical.
In women that do not respond to medications, IV nutrition is imperative. Although NG tube feedings are often considered less invasive and better for the gut, they are not tolerated by many women with HG and have great potential for aspiration risks if the vomiting is also not controlled simultaneously. These women often have delayed gastric emptying and hypersensitive gag reflexes that increase their risk of complications. Further, many of these women benefit greatly from a period of gut rest. It cannot be overemphasized that the longer a woman vomits, the more likely the complications, and the more difficult it is to stop the vomiting cycle. Early intervention is key, especially in women with a history of HG.
Assessment
For most women with HG, intake of any food or sufficient fluids is practically impossible for weeks or even months. If left untreated, numerous complications can result. It should not be assumed that slowing of weight loss after several weeks signals improvement. Rapid weight loss early on is partly due to loss of muscle and fat, which will eventually slow down.
It should also be remembered that insufficient weight gain in late pregnancy can result in a prolonged recovery for the mother. This can also put her at great risk for postpartum depression and other difficulties. Consideration should be given to nutritional intervention if she is unable to gain sufficient weight in later pregnancy, as well as make up for early weight loss. Monitoring net change in weight throughout pregnancy is important.
Following is information on some of the possible effects on the body if a women is left without nutritional support. The effects vary based on a her overall health prior to pregnancy and the length of time a she is without sufficient intake (i.e. the time it takes for a body system to be affected by starvation).
| How Starvation Affects Body Systems | |
| System: | Effects: |
| Digestives | Low acid production by the stomach. Frequent, often fatal diarrhea. |
| Cardiovascular (heart and blood vessels) | Reduced heart size, reduced amount of blood pumped,
slow heart rate, and low blood pressure. Ultimately, heart failure |
| Respiratory | Slow breathing, reduced lung capacity. Ultimately, respiratory failure. |
| Reproductive | Reduced size of ovaries in women Loss of sex drive (libido) |
| Nervous | Apathy and irritability, although intellect remains intact. |
| Muscular | Low capacity for exercise or work because of reduced muscle size and strength. |
| Hematologic (blood) | Anemia. |
| Metabolic | Low body temperature (hypothermia), frequently contributing
to death. Fluid accumulation in the skin, resulting mainly from disappearance of fat under the skin. |
| Immune | Impaired ability to fight infections and repair wounds. |
| Adapted from the Merck Manual. | |
Severity of Weight Loss*
| Time: | Significant Weight Loss (%): | Severe Weight Loss (%): |
| 1 week | 1-2% | > 2% |
| 1 month | 5% | > 5% |
| 3 months | 7.5% | > 7.5% |
| 6 months | 10% | > 10% |
Reprinted from Blackburn GL, Bistrian
BR, Maini BS, Schlamm HT, Smith MF. "Nutritional and metabolic assessment
of the hospitalized patient." JPEN. 1977; 1:11-22.
* Percent Weight Change = [(Usual Weight - Actual Weight) ÷ (Usual
Weight)] x 100
NOTE: This scale is based on non-pregnant subjects.
| Metabolic Response to Starvation | |
| Energy Needs | Decreased |
| Primary Fuel (RQ) | Lipids (0.75) |
| Insulin | Decreased |
| Ketones | Present |
| Total Body Water | Decreased |
| Proteolysis | Decreased |
| Glycogenolysis | Increased |
| Body Stores (Skeletal Muscle) | Reduced |
| Body Stores (Fat) | Reduced |
| Body Stores (Visceral Protein) | Preserved |
| Refeeding Response | Net Anabolism |
| Weight (lean tissue) Loss | Gradual |
| (RQ: respiratory quotient) | |
| From: Zaloga G, ed. Nutrition in Critical Care. St. Louis: Mosby-Year Book Inc.; 1994. | |
Updated on: Sep. 15, 2022
The Chronicles of Nausea
Beyond Morning Sickness