Hyperemesis gravidarum: feed the mother, feed the child.

The article “Hyperemesis Gravidarum and Fetal Outcome” by Paauw et al in this issue represents a fresh look at the effect of hyperemesis on maternal complications and fetal outcome. In this study, they found that infants born to women who had significant hyperemesis were more likely to be born prematurely and to have a significantly increased hospital length of stay. Of particular interest are those portions of the statistical analysis that compared outcomes in infants of mothers who were well nourished vs those who were clinically malnourished, and those who received nutrition support vs those who did not. Although the numbers were small, there were no significant differences in fetal outcome in any of the groups. This result raises an interesting question: if there are no statistically significant differences in the maternal and infant outcome in either of the groups regardless of nutritional status or nutrition therapy, then at what point should nutrition therapy be started in these patients? The risks of maternal malnutrition are well known, and the lists of both maternal and fetal complications, which can occur with this malnutrition, have been well documented in the literature. These include neural tube and other developmental defects that affect the infant long after birth, prematurity, and small-for-gestational-age infants. The American Society of Parenteral and Enteral Nutrition clinical guidelines strongly encourage the use of nutrition support in pregnant women who are at increased nutritional risk to prevent these complications and improve both maternal and infant outcome. Other sources recommend nutrition support only in those patients who fail conventional medical management without addressing nutritional status as an independent factor for starting nutrition support. With these recommendations in mind, a review of the current literature reveals a paucity of prospective studies on the effect of nutrition support on the outcome of hyperemetic patients. Most retrospective studies discuss various methods of nutrition support for these patients, including the use of enteric feeding tubes and parenteral nutrition (PN), and discuss the safety and efficacy of these methods without commenting on the effect of improved nutrition on either maternal or fetal outcome. Of interest is a recent article in the Journal of Reproductive Medicine that compared outcome and complications of hyperemetic patients who received PN vs those who received conventional nutrition therapy (antiemetics and encouragement of a bland diet). This study failed to demonstrate any benefit from PN and showed a 16% complication rate related to the central lines used for administration of the PN. The study was limited by its retrospective nature and the uncontrolled nature of the usage of PN, but it raises the specter that in some cases PN may do more harm than good. Other studies and literature reviews have also documented the use of PN without clearly demonstrating a benefit to the patient or infant. In our own institutional experience, over 15 years, many patients were treated for nutritional complications of hyperemesis with PN with a complication rate similar to that of nonpregnant patients (ie, a complication rate of approximately 1–2%). Upon review of our data, there was never any evidence to show a clear benefit to PN in the hyperemetic patient; however, similar to other studies, the data were prejudiced by selection criteria in that PN was ordered at the discretion of the obstetrician and not by the hospital nutrition service. This led to a wide variability in nutritional status of the patients, making the data unsuitable for risk-benefit analysis. In these days of evidence-based medicine and the reluctance of insurance companies to provide any treatment without proven benefit, it is of vital importance that research continue into the usage and effects of nutrition support in the hyperemetic patient. It should be noted that both enteral nutrition (EN) and PN, by providing nutrients and fluids for hydration, may make it possible for the patient to be discharged home sooner, because it will no longer be necessary for the mother to be kept in the hospital until her nausea subsides and oral intake can be resumed. The safety of PN and EN in the hyperemetic patient is well documented at this point, and research should concentrate more on the timing of nutrition support, as well as the nutrients needed by both the mother and developing fetus, and less on the methods of administration. It will be necessary to overcome the prejudice of the obstetrician against PN and EN and to encourage them to Received for publication December 3, 2003. Accepted for publication December 6, 2004. Correspondence: Lillian H. Banchik, MD, FACS, 11 Gateway Drive, Great Neck, NY 11021. Electronic mail may be sent to LHBanchik@aol.com. 0148-6071/05/2902-0134$03.00/0 Vol. 29, No. 2 JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Printed in U.S.A. Copyright © 2005 by the American Society for Parenteral and Enteral Nutrition