HYPERALIMENTATION, PARENTERAL

Fetal Risk Summary

Parenteral hyperalimentation (TPN) is the administration of an IV solution designed to provide complete nutritional support for a patient unable to maintain adequate nutritional intake. The solution is normally composed of dextrose (5%–35%), amino acids (3.5%–5%), vitamins, electrolytes, and trace elements. Lipids (IV fat emulsions) are often given with TPN to supply essential fatty acids and calories (see Lipids). A number of studies describing the use of TPN in pregnant women have been published (1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24 ,25 and 26). A report of four additional cases with a review of the literature appeared in 1986 (27), followed by another review in 1990 (28). This latter review also included an in-depth discussion of indications, fluid, caloric (including lipids), electrolyte, and vitamin requirements for gestation and lactation, and monitoring techniques (28).

Maternal indications for TPN have been varied, with duration of therapy ranging from a few days to the entire pregnancy. Eleven patients were treated during the 1st trimester (1,2,3,4 and 5). No fetal complications attributable to TPN, including newborn hypoglycemia, have been identified in any of the reports. Intrauterine growth retardation occurred in five infants, and one of them died, but the retarded growth and neonatal death were most likely caused by the underlying maternal disease (2,3 and 4,6,7,8 and 9,22). In a group of eight women treated with TPN for severe hyperemesis gravidarum who delivered live babies, the ratio of birth weight to standard mean weight for gestational age was greater than 1.0 in each case (5).

Obstetric complications included the worsening of one mother's renal hypertension after TPN was initiated, but the relationship between the effect and the therapy is not known (8). In a second case, resistance to oxytocin-induced labor was observed but, again, the relationship to TPN is not clear (9).

Maternal and fetal death secondary to cardiac tamponade during central hyperalimentation has been reported (29). A 22-year-old woman in the 3rd trimester of pregnancy was treated with TPN for severe hyperemesis gravidarum. Seven days after commencing central TPN therapy, the patient experienced acute sharp retrosternal pain and dyspnea (29). Cardiac tamponade was subsequently diagnosed, but the mother and the fetus expired before the condition could be corrected. Percutaneous pericardiocentesis yielded 70 ml of fluid that was a mixture of the TPN and lipid solutions that the patient had been receiving.

A stillborn male fetus was delivered at 22 weeks' gestation from a 31-year-old woman with hyperemesis gravidarum following 8 weeks of parenteral hyperalimentation with lipid emulsion (fat composed 24% of total calories) (30). The tan-yellow placenta showed vacuolated syncytial cells and Hofbauer cells that stained for fat (30).

In summary, the use of total parenteral hyperalimentation does not seem to pose a significant risk to the fetus or newborn provided that normal procedures, as with nonpregnant patients, are followed to prevent maternal complications.

Breast Feeding Summary

No problems should be expected in nursing infants whose mothers are receiving total parenteral hyperalimentation.

References

1. Hew LR, Deitel M. Total parenteral nutrition in gynecology and obstetrics. Obstet Gynecol 1980;55:464–8.
2. Tresadern JC, Falconer GF, Turnberg LA, Irving MH. Successful completed pregnancy in a patient maintained on home parenteral nutrition. Br Med J 1983;286:602–3.
3. Tresadern JC, Falconer GF, Turnberg LA, Irving MH. Maintenance of pregnancy in a home parenteral nutrition patient. J Parenter Enteral Nutr 1984;8:199–202.
4. Breen KJ, McDonald IA, Panelli D, Ihle B. Planned pregnancy in a patient who was receiving home parenteral nutrition. Med J Aust 1987;146:215–7.
5. Levine MG, Esser D. Total parenteral nutrition for the treatment of severe hyperemesis gravidarum: maternal nutritional effects and fetal outcome. Obstet Gynecol 1988;72:102–7.
6. Gineston JL, Capron JP, Delcenserie R, Delamarre J, Blot M, Boulanger JC. Prolonged total parenteral nutrition in a pregnant woman with acute pancreatitis. J Clin Gastroenterol 1984;6:249–52.
7. Lakoff KM, Feldman JD. Anorexia nervosa associated with pregnancy. Obstet Gynecol 1972;39:699–701.
8. Lavin JP Jr, Gimmon Z, Miodovnik M, von Meyenfeldt M, Fischer JE. Total parenteral nutrition in a pregnant insulin-requiring diabetic. Obstet Gynecol 1982;59:660–4.
9. Weinberg RB, Sitrin MD, Adkins GM, Lin CC. Treatment of hyperlipidemic pancreatitis in pregnancy with total parenteral nutrition. Gastroenterology 1982;83:1300–5.
10. Di Costanzo J, Martin J, Cano N, Mas JC, Noirclerc M. Total parenteral nutrition with fat emulsions during pregnancy—nutritional requirements: a case report. JPEN 1982;6:534–8.
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20. Stowell JC, Bottsford JE Jr, Rubel HR. Pancreatitis with pseudocyst and cholelithiasis in third trimester of pregnancy: management with total parenteral nutrition. South Med J 1984;77:502–4.
21. Martin R, Trubow M, Bistrian BR, Benotti P, Blackburn GL. Hyperalimentation during pregnancy: a case report. JPEN 1985;9:212–5.
22. Herbert WNP, Seeds JW, Bowes WA, Sweeney CA. Fetal growth response to total parenteral nutrition in pregnancy: a case report. J Reprod Med 1986;31:263–6.
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24. Adami GF, Friedman D, Cuneo S, Marinari G, Gandolfo P, Scopinaro N. Intravenous nutritional support in pregnancy. Experience following biliopancreatic diversion. Clin Nutr 1992;11:106–9.
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26. Teuscher AU, Sutherland DER, Robertson RP. Successful pregnancy after pancreatic islet autotransplantation. Transplant Proc 1994;26:3520.
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28. Wolk RA, Rayburn WF. Parenteral nutrition in obstetric patients. Nutr Clin Pract 1990;5:139–52.
29. Greenspoon JS, Masaki DI, Kurz CR. Cardiac tamponade in pregnancy during central hyperalimentation. Obstet Gynecol 1989;73:465–6.
30. Jasnosz KM, Pickeral JJ, Graner S. Fat deposits in the placenta following maternal total parenteral nutrition with intravenous lipid emulsion. Arch Pathol Lab Med 1995;119:555–7.