Nutrition for Nausea and Vomiting during PregnancySOFIE RIFAYANI KRISNADI

Nausea Vomiting in Pregnancy (NVP) Nausea with or without vomiting

Occurs in 50-90% of all pregnancies

Symptoms occur at 5-6 wks GA, peak at 9 wks,

Ablate by 16 to 18 wks; 20% continues for the entire pregnancy

32% during late pregnancy

Symptoms can occur any time of day—80% persist throughout the day ,

usually worst in the morning ( morning sickness)

Mild or moderate, self limited, not disturb the patient’s health or fetus’s

Hyperemesis Gravidarum Persistent vomiting accompanied by weight loss exceeding 5% of body weight

Dehydration, ketonuria unrelated to other causes;

Onset usually 4 to 10 wks GA

Affects 1-4 in 200 (0.5-2%) pregnancies

Can persist until delivery

Symptoms tend to improve in last half of pregnancy

Can be Life threatening to fetus and mother

Risk Factors Primigravida , Young women, Houseworks

Obesity, Multiple/molar pregnancy, History of motion sickness,

Eating disorder

History of NVP/HEG, Sensitive to OC’s

Psychiatric issues (stress, emotional tension, fear to be a parent,

excessive bond to mother

Female fetus (Mylonas et al, 2007)

Pathophysiologyo Not fully understood, multifactorial

o Correlated with increasing hormone hCG /others (thyroid,

progesterone, estrogen, adrenal hormones)

o Dysmotility GIT

o Nutrition deficiencies

o Psychologic, Genetic

o Helicobacter pylori infection

Algorithm for diagnosis of hyperemesis gravidarum, according to Mylonas-2007

GOT, Glutamatoxalacetate transaminase; GPT, Glutamatpyruvate transaminase

Differential Diagnosis NVP

Nutrition During Pregnancy Most pregnant women need 2,200-2,900 calories

Energy Requirements No different than non- pregnant women until the 2nd trimester

340 kcal in the 2nd trimester

452 kcal in the 3rd trimester

Variety of foods

Choose nutrient-dense foods/ limit energy-dense foods

www.mypryamid.gov

Table Nutrient Requirements During Pregnancy

Nutrient RDA/DRI Key Considerations

Protein 0.8–1.0 gm/kg protein/d + 10 gm protein/d per fetus using pre-pregnancy weight

Individuals who are protein deficient at conception, a goal of 1.2 – 1.7 gm/kg protein/d is ideal

Carbohydrate 50%–60% total calories For gestational diabetes, CHO content may need to bedecreased to as low as 40% calories

Fat 30% total calories There is no established DRI for essential fatty acids duringpregnancy, however it has been suggested intake shouldbe at least 4.5%–6% of total calorie intake

Fluid 30 mL/kg With nausea and vomiting, pregnant woman will needadditional fluids to account for fluid losses with emesis

Folate 600 micrograms/d With 400 micrograms coming from supplements or syntheticfolic acid found in fortified foods

Iron 27 milligrams/d Center for Disease Control and Prevention recommends allpregnant woman initiate iron supplementation of 30 mg/dat the first prenatal visit

Calcium 1000 milligrams/d for woman aged19 to 50 years

1300 milligrams/d for women 18 years or younger

Nutrient Effects in Nausea of Pregnancy

• Saturated fat intake before pregnancy increase the risk of HEG (Signorello,1998)• Protein predominant meals reduce nausea and gastric dysrithmic activity (compare to carbohydrate, fat or noncaloric meals)• Meals consistency did not affect symptom responses (Jednak, 1999)

• Prophylaxis Vit.B6 reduce NVP (Niebyl,2002)

• Rates of NVP correlated with high intake of macronutrient (Kcal, carbohydrate, protein,fat sugar, meat, milk and egg) (Pepper,2006)

• NVP increase with low intake of cereals and pulses (Pepper,2006)

• Prenatal vitamins worsen nausea because of the iron content,large size and side effects (Einarson, 2007)

Management Considerations with NVP

Mild NVP(not interfering with work or

lifestyle)

Supportive measures (eg, dietary, lifestyle, reassurance)

Moderate NVP (interfering with work or lifestyle)

Consider pharmacologic treatment options

Severe NVP (significant weight loss and

dehydration)

Hospitalization (eg, fluid replacement, nutritional supplementation, IV medications)

• Outpatient TreatmentExtensive dietary advice:

Foods should be rich in carbohydrates and low in fat , Cold and dry foods is better

Should be consumed in many small meals (6-8 X or more).

Chew and swallow your food very slowly

Eat a small snack before sleep at night will prevent morning sickness.

Eat 2-3 saltine crackers or dry toast before getting out of bed

Do not et high fat foods (fried food, heavy sauces, rich desserts)

Lie down after eating with head raised on 1-2 pillows

Outpatient TreatmentFluids: Fluid intake prevent dehydration. Use your nausea-free intervals to their best advantage alternately with solids if you cannot take both at the same time. Drink any nonalcoholic fluid you like, avoid soft drinks and not more than a total of three cups of coffee or tea per day. Many women find lemonade or fruit drinks very acceptable. Water is excellent, if necessary as ice cubes or frozen fluids. Drink plenty of fluid, in small frequent quantities between meals

Outpatient TreatmentNaturally you will avoid all odours and tastes that make your NVP worse.

Your sensitive nose is possibly your worst enemy at present.

The smell of cooking, especially fatty foods, coffee, tea, cigarette smoke, or perfume are the most common items stated by NVP suffers to make their symptoms worse.

Normal odours can become unpleasantly nauseous. So, you may need to get extra help from your family and friends.

Rest adequately since nausea tends to worsen when a woman is tired.

Get plenty of fresh air and avoid warm places, as this can aggravate the nausea.

Patient’ education Reminding yourself as often as necessary that:

This condition is not your fault.

You have not done anything to cause NVP or HG.

There is nothing you could have done to prevent the onset of NVP or HG.

Keeping a daily diary of your symptoms may enable you to be prepared to eat.

Most importantly, drink at those nausea-free times.

Sometimes you may even feel hungry, but the hunger is often quickly followed by the onset of nausea.

Either feeling hunger or a nausea-free interval gives you a chance to eat straightaway.

If you cannot face a meal, keep nibbling your favourite food, especially when nausea threate

First-line therapy for NVPnot associated with teratogenicity, with proven effectiveness

Pyridoxine (Vit. B6). 10-25 mg TID. Few side effects. Preg. Category: A

Ginger root. 250 mg QID. Few to no side effects.

Preg. Category: not rated

Antihistamines - more sedating. Preg. Category: B◦Diphenhydramine(Benadryl) 25-50 mg po Q 4-8 hrs.◦Meclizine 25 mg po Q 4-6 hrs.◦Dimenhydrinate (Dramamine) 50-100 mg po Q 4-6 hrs.

Metoclopramide 5-10 mg po TID. Category: B

Second-line choices for NVP:considered safe but clinically unproven, Category B or C

Anti-emetics◦Chlorpromazine (Thorazine): 10-25 mg po BID to TID.◦Prochlorperazine (Compazine): 5-10 mg po TID to QID.◦Promethazine (Phenergan): 12.5 to 25 mg po Q 4-6 hrs.◦Trimethobenzamide (Tigan): 250 mg po TID to QID.◦Ondansetron (Zofran): 8 mg po BID to TID.

Category B, very expensive, only studied with hyperemesis

Steroids◦Methylprednisolone (Medrol) 16 mg po TID then taper. Could be a small teratogenic risk. Only studied with hyperemesis.

Initial Treatment of Severe NVP/HEG

Hospitalization

Intravenous fluids, electrolytes, and multivitamins

Intravenous antiemetics / antinauseants

Enteral or parenteral nutrition for severe cases

Gradual reintroduction of PO fluids and solid foods

Psychological support

Inpatient procedure in hyperemesis gravidarum, adapted from Mylonas-2007

OTHER THERAPY (Non Pharmacological)Nutritional Therapy

Complementary and Alternative Medicine

Sensory Deprivation Therapy (SDT)

Behavioural therapy

Bedrest

Psychotherapy

Therapeutic Abortion

.

NUTRITIONAL THERAPY- is the most important issues.

Pregnant women require a variety of nutrients for

- their own healing and normal development of the fetus

- to form the plasenta, amniotic fluid,

- increase the size of the uterus and breast tissue

- support mother's blood ( increases by 25–50%) which need more fluids, iron, Vit. B12, folic acid, zinc and copper, calcium, magnesium, and protein

The baby's requirements for minerals, vitamins, and other nutrients come first and are taken from the mother's bones, organs, tissues, and other storage areas.

This can leave the mother depleted very quickly, which can take months, or even years, to correct.

ENTERAL NUTRITION IN HEG EN allows the infusion of nutrients and fluid without the associated cephalic

phase (visual cues, food aromas and flavors) that stimulates salivary and

gastric secretions inducing nausea and vomiting in HEG.

If a woman with HEG has not responded to dietary manipulation and oral

antiemetics, EN should be considered.

EN, ideally via the gastric route, is anapproach that has been shown to offer

significant relief from nausea and vomiting, prevent hospitalization and lead to positive fetal outcomes

Nasojejunal feeding in hyperemesis gravidarum--a preliminary study.

Vaisman N, et al.Journal Clin Nutr. 2004 Feb;23(1):53-7.

• 11 pregnant women with hyperemesis gravidarum

• Consented to have a nasojejunal feeding tube inserted endoscopically.

• A clear reduction of vomiting apparent within 48 h after tube insertion,

• Vomiting ceased completely after a mean of 5+/-4 days (range 1-13 days).

• Weight gain was recorded in six patients (tube feeding for more than 4 days)

• Patients encouraged to start drinking and eating along tube feeding after 3-4 days.

• Ceasing vomiting and a sufficient oral intake of at least 1000 kcal/day resulted in the decision to remove the tube after 4-21 days.

• In three cases, the tube was expelled by recurrent vomiting after 1-4 days, or was blocked as in one case.

PARENTERAL/ INTRAVENOUS NUTRITIONAL THERAPY

Parenteral nutrition (PN) is sterile intravenous solution of protein, dextrose and fat in combination with electrolytes, vitamins, trace elements and water.

Total Parenteral Nutrition (TPN),

- no significant nutrition is obtained by other routes.

Peripheral parenteral nutrition (PPN) when administered through vein access in a limb, rather than through a central vein (Central PN)

High cost and Increased risk of infection.

PROGNOSIS NVP usually improve (18-20 weeks of pregnancy)

13% persisted beyond 20 weeks' gestation

NVP reduced risk of miscarriage (6 studies, 14,564 women; OR 0.36, 95% CI 0.32 to 0.42)

Morbidities (mother)

- including Wernicke's encephalopathy,

- Oesophageal rupture, Splenic avulsion

- Pneumothorax,

- Postpartum depression/ Posttraumatic stress disorder

POTENTIAL FETAL COMPLICATIONTHEY CAN RESULT FROM SEVERE HEG, INADEQUATELY TREATED, OR THERE IS A DELAY IN

MEDICAL INTERVENTIONS

Early delivery,

Congenital heart disease

Integumentary (skin) abnormalities

Low birth weight

Shorter length

Undescended testicles

Perinatal death

Hip dysplasia

Neurodevelopmental sequelae

Neural tube defects

Central nervous system malformations

Skeletal malformations

Testicular cancer

Behavioral/emotional problems

"fetal programming" Prolonged stress, malnutrition and dehydration in the mother can potentially put an unborn child at risk for chronic disease

Increase glucose intolerance, disease of lifestyle, heart disease, DM, obesity, hypertension (Roseboom et al, 2006)

Increase coronary disease, altered clotting, raise lipids, obesity

Increase breast cancer, obstructive airway disease

Increase schizophrenia, antisocial personality (Kyle& Pritchard,2006)

Multigeneration effect (Stein & Lumey, 2000)

Increase Gallblader disease, Liver dysfunction, muscle pain, renal failure, retinal hemorrhage (Fejzo e al., 2009)

CONCLUSIONS Preconception diet is important (Folat, Piridoxine, Low fat)

The first choice in NVP treatment generally involves changes in diet or lifestyle.

Early treatment of NVP might decrease the risk of HG.

Pyridoxine and metoclopramide (category A) are first-line in treatment of HG followed by prochlorperazine (category C), prednisolone (category B), promethazine (category C) and ondansetron (category B1).3

When NVP is very severe and the patient is unable to tolerate oral fluids, she has to hospitalized and intravenous fluids, medications or/and enteral/ parenteral nutrition should be started.

REFERENCES1. Latva-Pukkila U et al, 2010. Dietary and clinical impacts of nausea and vomiting during

pregnancy. J of Human Nutr & Dietetics, Vol 23, Issue 1:69-77

2. Noel M. Lee, M.D. Nausea and Vomiting of Pregnancy.Gastroenterol Clin North Am. 2011 June; 40(2):309-38.

3. Gill SK, Maltepe C and Koren G. The effectiveness of discontinuing iron-containing prenatal multivitamins on reducing the severity of nausea and vomiting of pregnancy. Journal of Obstetrics and Gynaecology, January 2009; 29(1): 13–16

4. Ioanis Mylonas, Andrea Gingaimaier, Franz Kainer.Dtsch Arztebl 2007; 104(25): A 1821-6

5. Jednak MA, Shadigian EM, Kim,SM., et al., Protei meals reduce nausea and gastric slow wave dysrhytmic activity in first trimester pregnancy. Am J Physiol. 277/Gastrointest.Liver Physiol 40: G855-61,1999)

6. Niebyl JR, Goodwin TM. Overview of nausea and vomiting of pregnancy with an emphasis on vitamins. AJOG 2002, May;186:S253-5.

REFERENCES7. Signorello LB, Harlow BL, Wang S, Erick MA. Saturated Fat intake and the Risk of Severe

Hyperemesis Gravidarum. (Epidemiology 1998;9:636-40)8. Einarson A, Boskovic CMR, Koren G.nTreatment of nausea and vomiting in pregnancy An updated algorithm. Canadian Family Physician. Vol 53: december 2007 , 2109-2111.9.Pepper GV, Roberts C. Rates of nausea and vomiting in pregnancy and dietary characteristics across populations. Proc.R.Soc. B(2006) 273, 2675-79