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Parenteral (Intravenous) Nutritional Therapy

In women with hyperemesis gravidarum (HG) who become very malnourished or have a history of moderate to severe HG, Total Parenteral Nutrition (TPN) may be initiated to ensure she receives adequate nutrition. Once a woman loses over 5% of her body weight (pre-conception), nutritional therapies are highly recommended, especially if she is continuing to have significant nausea and vomiting. Once she loses 8-10% of her body weight or has been vomiting for more than a month, it is imperative that she receive some sort of intervention to replace the many nutrients she has lost and to maintain her hydration. This also decreases the risk of adverse fetal effects. Dehydration perpetuates the vomiting cycle, as do nutritional deficiencies.

At a minimum, IV home therapy with added vitamins should be administered before she becomes too depleted. Ideally, this would be initiated after only a few weeks of frequent vomiting. Total Peripheral Parenteral Nutrition (TPPN) or TPN is the next choice for ongoing replacement. Numerous vitamins and nutrients are depleted in only a few weeks, exacerbating her symptoms and making them more resistant to medical interventions.

It is important to note that TPPN/TPN is not a complete formula and it should be evaluated to ensure sufficient calorie content for a pregnant woman, as well as appropriate levels of vitamins and minerals based on her gestational age. Added multivitamins are very important to avoid complications such as Wernicke's Encephalopathy which is related to thiamine deficiency. Multiple vials may be needed initially to replenish her deficits.

"According to the American Medical Association (AMA), the physician should not await the development of clinical signs of vitamin deficiency before initiating vitamin therapy. The use of a multivitamin product obviates the need to speculate on the status of individual vitamin nutriture.

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. M.V.I.-12® does not contain vitamin K, which may have to be administered separately. " aaiPharma®

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 fail to realize the serious risks involved. Life-threatening complications of catheter insertion such as pericardial tamponade, pneumothorax and subclavian artery laceration may occur. Also, metabolic and infectious complications are not uncommon, such as hyperglycemia and gram-negative septic shock with severe cellulitis requiring surgery. The liver may enlarge if too many calories, particularly from fats, are consumed. The excess fat in the veins may also cause backaches, fever, chills, nausea, and a low platelet count. Pancreatitis is also a frequent problem. However, these problems are estimated to occur in only a small percentage of those receiving total parenteral nutrition for HG. TPN should be offered to hyperemetic women when aggressive medical management has failed and the patient is at risk for malnutrition.

While some physicians are reluctant to utilize newer medications, which have yet to show adverse maternal or fetal effects, they are more willing to offer TPN which has a known history of complications which can be life-threatening. A growing number of women report that drugs from the serotonin antagonist class (e.g. Zofran, Kytril, Anzemet) have been used in higher doses in their subsequent pregnancies, eliminating the need for TPN and even IV's in some cases. These women report beginning these medications at the onset of symptoms and increasing the dose as needed, then gradually weaning off of them in later pregnancy. Not only are her symptoms better controlled, she is also less miserable and will likely recover faster. This results in a net savings as the cost for additional physician visits, treatment of complications, TPN, and repeated hospital visits are much greater than the cost of these drugs. Perhaps a change in perception of risk would decrease the need for TPN and repeated IV hydration in women with HG.

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.

Care of the Mother Receiving Parenteral Nutrition

  • Use strict aseptic technique and utmost caution when caring for a central line.
  • Perform routine blood studies similar to the following (based on your policy)
    • Perform serum glucose measurements daily for 4 days, then on Monday, Wednesday, and Friday.
    • Measure serum electrolytes and blood urea nitrogen levels on Monday, Wednesday, and Friday.
    • Perform complete blood count with differential, prothrombin time, partial thromboplastin time, platelet count, liver function tests, and phosphorus, calcium, albumin, total protein, magnesium and creatinine levels at the start of TPN and weekly thereafter.
    • If the patient is receiving lipids, determine triglyceride levels daily for 2 days, then weekly.
    • Determine urine urea nitrogen levels weekly (collect 24-hour urine Sunday for Monday).
  • Ensure family has adequate support and training to effectively and safely care for the mother.

Adapted from Van Way III, Allen JA. Intravenous nutrition. In: Van Way III, ed. Handbook of Surgical Nutrition. Philadelphia: JB Lippincott , 1992: 73–77 and other sources

Other Resources:

  • Hankins, J et al., editors. Infusion Nurse Society: Infusion Nursing in Clinical Practice, WB Saunders. 2001
  • Phillips, Lynn. Manual of IV Therapeutics. 3rd ed. FA Davis. 2001
  • Weinstein, S. editor. Plumer's Principle & Practice of IV Therapy, 7th ed. Lippincott Williams, Wilkins. 2000

Offsite Research:

Pregnancy outcome and total parenteral nutrition in malnourished pregnant women.
Caruso A, De Carolis S, Ferrazzani S, Trivellini C, Mastromarino C, Pittiruti M.
Department of Obstetrics and Gynecology, Catholic University, Rome, Italy.
Fetal Diagnosis & Therapy 1998 May-Jun;13(3):136-40.

We evaluated pregnancy outcome and fetal growth in women requiring total parenteral nutrition (TPN). The duration of TPN ranged from 14 to 220 days. Maternal nutritional state was well preserved and no complications were related to treatment. A gestational age of 35+/-3 weeks at delivery (mean +/- SD), birth weight of 2,251+/-670 g (mean +/- SD) and birth percentile of 29+/-16 (mean +/- SD) were observed. One intrauterine death occurred. The comparison between the sonographic findings, before and 2 weeks after starting TPN, showed a fetal percentile gain with a statistically significant increase in the abdominal circumference percentile (p < 0.05) from a median percentile of 2 (range 2-32) to 33 (range 2-78). CONCLUSIONS: TPN proved to be helpful and lifesaving in malnourished pregnant women and promoted fetal growth, as shown by the longitudinal ultrasonographic evaluations.
 

Use of the peripherally inserted central catheter for parenteral nutrition during pregnancy.
Greenspoon JS, Rosen DJ, Ault M.
Department of Obstetrics-Gynecology, Cedars-Sinai Medical Center, Los Angeles, California.
Obstetrics & Gynecology 1993 May;81(5 ( Pt 2)):831-4.

The peripherally inserted central catheter was successfully placed, and central venous administration of hyperosmolar solutions was accomplished without complication for periods of 28-137 days. Maternal weight gain and fetal growth were adequate. The peripherally inserted central catheter avoids some of the risks related to obtaining central venous access and permits long-term administration of parenteral nutrition into the central venous circulation.
 

Total peripheral parenteral nutrition in pregnancy.
Watson LA, Bommarito AA, Marshall JF.
Department of Obstetrics and Gynecology, Saginaw Cooperative Hospitals, Inc., Michigan.
JPEN Journal of Parenteral & Enteral Nutrition 1990 Sep-Oct;14(5):485-9.

Twenty pregnant patients needing nutritional support for various indications received hypercaloric, hyperosmotic, "3 in 1," peripheral parenteral nutrition as a bridge to enteral therapy. This system, named total peripheral parenteral nutrition, was evaluated as to tolerance and efficacy in pregnant patients. Patients were in various stages of pregnancy and had an average weight loss of 10.4 pounds prior to admission. Patients were maintained on total peripheral parenteral nutrition for an average of 5 days and gained an average of 4.1 pounds. Good tolerance with minimal side effects of the treatment was noted. Intravenous sites were changed an average of 1.1 times per patient during the course of therapy and only one serious complication was noted in 20 patients. Patients were followed through delivery and this information is presented. Total peripheral parenteral nutrition appears to be an acceptable alternative to conventional total parenteral nutrition to pregnant patients needing nutritional support. These hypertonic solutions can supply total caloric/metabolic needs without unacceptable side effects.
 

Updated on: Apr. 18, 2013

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