A Treatment Guide for Clinicians
Chuck Gebhardt, M. D.
The following is the introduction to my monograph that discusses hyperemesis gravidarum along with a short discussion of the importance of properly managing this condition. The remainder of the text is now available as an eBook from Amazon.com (http://www.amazon.com/dp/B00DMJU0GK). For patients or clinicians who have questions about the recommendations in the book, just place your question on this site in the comment area and I will respond to it as soon as I am able.
This book is an updated version of an article I had written for obstetricians that was first published in 1994. At that time, I had summarized about ten years of my experience treating some of the most severe cases of hyperemesis gravidarum with total parenteral nutrition (TPN). In the interim, I have developed some new and very useful strategies that often make the use of invasive feeding, such as TPN, unnecessary. This revised version includes the content of the earlier version with the new strategies included.
First, you may want to know a little of my background. I began my formal training in nutrition with a BS in Nutritional Science from Drexel University in Philadelphia. Throughout my medical training at the University of Pennsylvania, my residency training in internal medicine, and my medical practice here in Albany, Georgia, I have focused on medical nutrition as a subspecialty to my internal medicine specialty. When I first arrived in Albany, our local obstetricians began to refer their hyperemesis patients to me because of my expertise in medical nutrition. Not a lot has changed in the fifteen years since I wrote my original article, but I have learned to be much more proficient in treating this problem in its earliest stages, making the need for TPN much less frequent.
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When nausea and vomiting develop early in pregnancy, most of the time it will be the typical “morning sickness” of pregnancy. This condition will usually resolve itself by the end of the first trimester and may even confer an improved prognosis compared to pregnancy without this problem.[i] However, for a small percentage of these women, nausea and vomiting will continue to worsen and will result in dehydration, electrolyte abnormalities and possibly significant malnutrition if not recognized and appropriately treated. Unfortunately, we do not have a test at present which will allow us to predict which of the women who appear to have typical “morning sickness” are actually in the early stages of hyperemesis gravidarum
Standard care for “morning sickness” is the appropriate initial management for all pregnant women who develop nausea and vomiting. For many women, no intervention is needed. For the more symptomatic women, separating the timing of the consumption of dry foods from liquids and/or minimizing the amount of the fat in the diet can be helpful. Restriction of activity can also be helpful.[ii] I now recommend starting vitamin B6 (pyridoxine hcl) 50 mg., three times a day, as soon as nausea and vomiting start. This vitamin is quite safe at this dosage and highly effective.[iii] If dietary adjustments, reduced activity, and vitamin B6 supplementation are not effective, oral Zofran, Phenergan and/or Reglan can be safely used and can be quite helpful. I add medications to control stomach acid if acid reflux symptoms develop due to vomiting.
When complications develop despite these conservative efforts, hyperemesis gravidarum is present and more intensive management is indicated. Before, I go into the specific management steps I recommend in this stage of the disease, let me very briefly review why we need to be concerned about malnutrition during pregnancy.
RISKS THAT RESULT FROM MALNUTRITION DURING PREGNANCY
A very high risk of poor outcomes has been extensively documented when a pregnant woman’s food intake is inadequate or of poor quality.[iv] Malnutrition, as indicated by inadequate weight gain, has been shown to dramatically increase perinatal mortality. The perinatal death rate for women with weight gain less than 25 percent of expected was 200 percent higher than women with appropriate weight gains in the Collaborative Perinatal Project. While maternal malnutrition results in only a small increase in pregnancy complications, once a serious disorder is established, large increases in fetal mortality are noted for women who are seriously malnourished. For example, in cases of abruptio placentae, fetal mortality rates in malnutrition are over 400 percent greater than in woman with optimal weight gain, and placenta previa confers a 700 percent increase in fetal mortality rates.
Maternal malnutrition has also been shown to result in fetal malformation. A high rate of severe malformations results from pregnancies complicated by acrodermatitis enteropathica, A form of zinc deficiency, have been clearly documented.[v] Neural tube .defects have also been shown to be linked to inadequate folic acid intake.[vi] Animal studies strongly suggest that deficiencies of numerous other nutrients play a role in fetal abnormalities.
Brain development has also been shown to be compromised in cases of maternal malnutrition. Autopsy studies of Chilean children of malnourished mothers who died in the perinatal period show a dramatic decrease in brain cellularity compared to children of well-nourished mothers. Animal studies and indirect evidence in humans suggest that catch-up brain development is incomplete after a period of malnutrition during pregnancy.[vii] This would imply that permanent cognitive defects can result from periods of maternal malnutrition.[viii]
Clearly, the available evidence suggests that malnutrition during pregnancy and the resulting increased mortality, fetal malformations, and impaired brain development should be avoided whenever possible. Studies of nutritional intervention in populations with high rates of malnutrition have shown improvements in both morbidity and mortality, confirming that malnutrition is the direct cause of these poor outcomes.[ix]