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Volume 6, No. 7, July 2008
Abstract of the Month
Does a PICC line facilitate treatment of hyperemesis gravidarum?
OBJECTIVE: The objective of the study was to evaluate the use of interventions such as a peripherally inserted central catheters (PICC) line or nasogastric (NG)/nasoduodenal (ND) tube with the use of medications alone in the management of pregnancies with hyperemesis. STUDY
DESIGN: Subjects were identified with confirmed intrauterine pregnancy, admitted with hyperemesis gravidarum (HEG) between 1998 and 2004. Medical records were then abstracted for information with regard to therapy. Subjects were assigned on the basis of the management plan: medication alone, PICC line, or NG/ND tube. Outcomes were compared between groups.
RESULTS: Ninety-four patients met study criteria and had complete outcome data available. Of those, 33 had a PICC line placed (35.1%), 19 had a NG/ND placed (20.2%), and 42 were managed with medication alone (44.7%). These groups were similar with respect to gestational age at delivery, Apgar score, and mean birthweight. Maternal complications were significantly higher among those with PICC lines. Of patients managed with PICC lines, 66.4% (P < .001) required treatment for infection, thromboembolism, or both. Adjusted odds ratio for a PICC line complication was 34.5 (5.09, 233.73).
CONCLUSION: Maternal complications associated with PICC line placement are substantial despite no difference in neonatal outcomes, suggesting that the use of PICC lines for treatment of HEG patients should not be routinely used.
OB/GYN CCC Editorial comment:
66.4% of women managed with a PICC line required treatment for thromboembolism or infection, or both
Holmgren et al conclude that enteral feeding for women with hyperemesis gravidarum is safer than parenteral feeding and is accepted by patients. Obstetricians should make every effort to use enteral feeding for women with hyperemesis gravidarum and persistent weight loss.
For a more complete discussion about management options for hyperemesis gravidarum, please review the answer to this month’s Medical Mystery Tour. Another possible resource can be found in T. Murphy Goodwin, MD’s discussion, link below.
Holmgren et al expands on the observations of previous authors who have pointed out the numerous complications of PICC line access for parenteral nutrition during pregnancy. The vast majority of such interventions during pregnancy are for the diagnosis of HEG.
That some form of nutritional supplementation is needed for women who experience persistent weight loss with hyperemesis is clear. Although it is rare, maternal mortality still does occur and comes almost exclusively from this group of women. The same is true for major maternal morbidity such as Wernicke’s encephalopathy.
Fetal effects such as growth restriction are limited to women who have HEG who also lose weight. Apart from growth restriction, which can be recognizable at birth, substantial data in both humans and experimental animals suggest adverse consequences later in life as a result of maternal calorie restriction for even a few months of pregnancy.
Interestingly, in this study, there were no SGA infants in either the group treated with medication alone or the group managed with NG/ND tube placement.
Main complications are thrombosis, infection
The major complications of peripheral and central venous access for nutrition in pregnancy are thrombosis and infection, and the prevalence is now well established to be around 50%. Maternal death from complications of line access has also been reported.
A confirmation of case reports and small series
This study is important because it represents the largest report of women who have received total nutritional support via an enteral feeding tube. Previous reports were limited to single cases or small series.
There is little evidence indicating that the better safety record of enteral feeding and greater efficacy compared with parenteral feeding via a PICC line have led to increased usage. In our own survey of 792 women who self-reported hyperemesis gravidarum from 2000 to 2004, 16.7% reported parenteral nutrition, compared with only 2.3% who reported enteral tube feeding. It is hoped that this study will help reverse this ratio.
Have you taken advantage of the free Perinatology Corner CME / CEU Module we offer on this topic? If not, this next part is definitely low hanging fruit. Just go to this module, review the material, answer a few quick questions, hit the submit button and voila free CME credits…..plus the module offers a great set of materials for future reference.
Resources:
Nausea and Vomiting in Pregnancy: Perinatology Corner Module
http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/NVP01.cfm
Holmgren C, Aagaard-Tillery KM, Silver RM, Porter TF, Varner M. Hyperemesis in pregnancy: an evaluation of treatment strategies with maternal and neonatal outcomes. Am J Obstet Gynecol. 2008;198:56.e1–56.e4
http://www.ncbi.nlm.nih.gov/pubmed/18166306
Goodwin TM. Does a PICC line facilitate treatment of hyperemesis gravidarum?
OBG Management May 2008 · Vol. 20, No. 05
http://www.obgmanagement.com/article_pages.asp?aid=6143
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
