Malnutrition & Dehydration

Do Women with Hyperemesis Gravidarum (HG) Have Malnutrition and Dehydration?

Ironically, nutrition is likely one of the most prolific topics related to pregnancy, yet when a woman has HG, she is often told malnutrition will not harm her unborn child or herself. While surgical patients are given nutritional therapy typically within one week if they are unable to eat, HG mothers may go weeks or months nearly starving without nutritional intervention.

Research finds that extreme weight loss (>15% of pre-pregnancy weight) is associated with numerous adverse fetal outcomes. These women should have aggressive treatment to promote a healthier outcome for both the mother and child.

As we unravel the genetics of HG, we learn the same proteins that cause cachexia syndrome are involved in HG. The associated genes also alter appetite and taste perception making intake very difficult.
Kimber MacGibbon, RN

Fear of Malnutrition | Fear of Medication

One of the most difficult challenges with HG is managing a mother's nutritional needs. Every book, newspaper, magazine, and friend or family member will tell her repeatedly that she must eat healthy or she will harm her unborn child. The fear of harming her unborn child through lack of nutrition is closely followed by a fear of harming her unborn child with medications.

Some women choose termination (elective abortion) rather than possibly face having a child who may have been harmed by malnutrition or medications.

Pregnancy Nutrition

Many nutrients are needed to form the placenta, to increase the size of the uterus and breast tissue, and to create amniotic fluid. A mother's blood volume increases by 25–50%, and more fluids, iron, B vitamins, folic acid, zinc and copper, calcium, magnesium, and proteins are needed to support this new blood. Storage levels of most nutrients must be obtained from the diet as well. A nutritional consult may be helpful both during and after pregnancy to ensure she sufficiently rebuilds her nutrient stores, especially while breastfeeding and before becoming pregnant again.

Food Aversions and Cravings

It is very typical for mothers with HG to have very strong cravings and aversions that prohibit a well-balanced diet for much of their pregnancies, and these preferences may change frequently until delivery. It may be the smell, texture, appearance or taste that leads to nausea and vomiting.

Triggers

The cause is likely a complex interaction of endocrine (hormone) changes related to pregnancy, nutrient deficiencies, mechanical changes in the body, gastrointestinal dysfunction (e.g. reflux), and changes in neurochemicals. The intensity of cravings and aversions can be very high and trigger repeated bouts of severe nausea and/or vomiting.

Thinking about foods, smelling them, or even just seeing food on the television is enough to trigger vomiting for many. She may crave very specific combinations of food characteristics, such as salty and crunchy, or sweet and soft.

Entering a grocery store, opening the refrigerator, or even contemplating food preparation are usually intolerable for at least the first trimester. There is very strong evidence this is caused by certain genes. This has a significant impact both on her and her family and is not something she can control. Finding foods that meet these criteria are crucial to prevent malnutrition.

Support and Understanding

These issues must be acknowledged, supported, and accepted by her family and care providers. It's impossible to fully understand the unusual dietary preferences of HG unless you have experienced it for yourself. Trying to force other foods that are aversive will typically result in vomiting and greater anxiety for the mother.

With HG, any calorie is a good calorie. Any food a mother can tolerate should be offered as soon as possible.

Nutritional Deficiencies and Hyperemesis

Women with HG may vomit or have severe nausea for months that will leave her exhausted and very depleted. It is imperative that women losing weight rapidly and not responding to medications be given nutritional support to prevent significant nutrient depletion in these women. Vitamins, especially B vitamins, are depleted very quickly and if not replaced can worsen her symptoms or put her at risk for life-threatening neurological disorders like Wernicke's Encephalopathy.

Deficiencies left uncorrected may have numerous adverse effects on the breastfeeding child, such as bleeding and neurodevelopmental disorders, especially if a mother had prolonged HG.

Rehydration

At a minimum, mothers requiring hydration should also receive vitamins and electrolytes. Those who continue to lose over 5-10% of their body weight in the early months should be considered for nutritional support to protect the well-being of both mother and child. These mothers are also at greater risk for complications such as pre-eclampsia, fetal loss, premature delivery, and more severe HG. Studies show that an inadequately nourished fetus may grow and develop more slowly, have chronic disease in later life, experience emotional/behavioral and sensory issues, and more likely be preterm.

Hydration Guidelines with Consideration of Weight Loss

Weight loss <5% - Rehydrate**, evaluate needed lifestyle & antiemetic changes. Check serum electrolytes. Prescribe 30-50 mg oral thiamin as tolerated.

Weight loss 5%-10% - Rehydrate**, review antiemetic options, evaluate need for nutritional support and consider midline IV for regular infusion of fluids. Check metabolic panel. Prescribe 30-50 mg oral thiamin as tolerated.

Weight loss >10% - Rehydrate**, run comprehensive labs to determine nutritional status, give parenteral vitamins including B complex daily, reevaluate antiemetic strategy & tolerability, consult with nutritional support regarding increasing protein and vitamins, esp. B vitamins. Consider midline for PPN, enteral nutrition (NG/NJ, PEG/PEJ), or a PICC for TPN. Prescribe oral thiamin after discontinuing PN/EN.

REMEMBER: Check thiamin content of parenteral multivitamins. MVI only has 6 mg thiamin. Parenteral B-complex usually has 100 mg of thiamin.

**Rehydrate using D5NS with an ampule of MVI plus 100 mg thiamin and folic acid, or Myer’s Cocktail + 1 ampule of MVI and folic acid, or a Banana Bag with B-vitamins. Additional nutrients such as vitamins K & D, zinc, selenium, iron, magnesium and calcium are likely deficient, replenishment benefits mother and baby and may preempt additional complications.

How Starvation Affects Body Systems

System:	Effects:
Digestive	Low acid production by the stomach. Frequent, sometimes serious diarrhea.
Cardiovascular (heart and blood vessels)	Reduced heart size, reduced amount of blood pumped, slow heart rate, and low blood. pressure. Ultimately, heart failure.
Respiratory	Slow breathing, reduced lung capacity. Ultimately, respiratory failure.
Reproductive	Reduced size of ovaries in women. Loss of sex drive (libido).
Nervous	Apathy and irritability.
Muscular	Low capacity for exercise or work because of reduced muscle size and strength.
Hematologic (blood)	Anemia.
Metabolic	Low body temperature (hypothermia), frequently contributing to death. Fluid accumulation in the skin, resulting mainly from disappearance of fat under the skin and low protein diet.
Immune	Impaired ability to fight infections and repair wounds.
Adapted from the Merck Manual.

Metabolic Response to Starvation

Energy Needs	Decreased
Primary Fuel (RQ)	Lipids (0.75)
Insulin	Decreased
Ketones	Usually Present
Total Body Water	Decreased
Proteolysis	Decreased
Glycogenolysis	Increased
Body Stores (Skeletal Muscle)	Reduced
Body Stores (Fat)	Reduced
Body Stores (Visceral Protein)	Preserved
Refeeding Response	Net Anabolism
Weight (lean tissue) Loss	Gradual
(RQ: respiratory quotient)
Adapted From: Zaloga G, ed. Nutrition in Critical Care. St. Louis: Mosby-Year Book Inc.; 1994.

Research & Reference Info

Refeeding Syndrome

Patients at Risk for Refeeding Syndrome

Poor nutritional intake
Weight loss >15%
Prolonged IV hydration
Significant stress
Electrolyte & nutrient depletion

Weight Loss

Weight loss is influenced in part by genetics, and occurs in most cases of HG unless effective medications and nutritional support are offered early in pregnancy. Weight loss may be rapid until the mother becomes emaciated and her metabolism slows. The more weight a mother loses, the greater the risks to her and her child, and the longer her recovery.

Swelling (Edema)

Edema may develop in some patients due to fluid shifts, low protein intake and refeeding syndrome. Monitor weight changes often until patients are asymptomatic and stable.

Genetics and Weight Loss

Given new genetic findings associating GDF15 with HG, as well as research identifying inflammatory markers are often elevated in HG, nutritional risk may be greater still. ASPEN and other experts state a weight loss over 7.5% in 3 months is considered severe malnutrition. Our research finds weight loss exceeding 15% is not uncommon, and women may lose over 25% of their preconception body weight due to HG. Regardless of BMI, these women need nutritional intervention, at a minimum micronutrient repletion.

Monitor: even when weight loss slows

It should not be assumed that slowing of weight loss after several weeks signals improvement. Rapid weight loss early on is partly due to loss of muscle and fat, which will eventually slow down when body mass and activity level drop below normal. Any woman experiencing unintentional weight loss during pregnancy should be assessed and monitored closely until she maintains her weight and her BMI (body mass index) is within normal limits.

Weight Loss and Postpartum Recovery

It should also be remembered that insufficient weight gain in pregnancy can result in a prolonged recovery for the mother. This can also put her at great risk for postpartum depression, debility, and other difficulties. Consideration should be given to nutritional intervention if she is unable to make up for early weight loss by mid-pregnancy, as well as gain enough weight in later pregnancy. Monitoring BMI and net weight change from pre-pregnancy weight throughout pregnancy is important. Women using the HG Care App can share their app Insights Report with this information.

WEIGHT LOSS CALCULATOR

Calculate your Percent Weight Change by entering your usual weight and actual (current) weight below.

NOTE: These scales are based on non-pregnant subjects.
* Percent Weight Change = [(Usual Weight - Actual Weight) ÷ (Usual Weight)] x 100

Is your weight loss severe?

No research has established weight loss amounts that are safe during pregnancy. Our research finds that there is significant risk to the baby’s long-term health when a woman’s weight loss exceeds 15% of her pre-pregnancy weight.

Other factors need consideration such as the pre-pregnancy weight, which if low, puts mother and baby at greater risk by weight loss. Conversely, a mother who is overweight prior to pregnancy may be able to lose a little more weight without significant risk, provided she gets adequate essential nutrients like vitamins B1, folic acid, and vitamin K.

According to ASPEN, for non-pregnant women, severe weight loss is >2% in a week or >5% in a month. Severe malnutrition is less than 50% of you needed dietary intake for over a week. Pregnancy is an accelerated state of starvation so women likely qualify sooner. Many women with HG would easily be considered malnourished and should be screened carefully and given nutritional intervention.

"White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275–283." FROM-Adult Nutrition Support Core Curriculum, Third Edition, 9. Malnutrition Screening and Assessment

Nutritional Intake

It is common to find aversions to protein foods and vegetables for much of the first trimester, if not longer. Even when women can eat, it might be less than healthy foods with little variety. This can cause guilt and frustration, as well as significant nutritional deficiencies. Women should be reassured and encouraged to make the best decisions possible but focus on increasing fluid and calorie intake any way possible.

HER believes with HG, “Any calorie is a good calorie when you have severe nausea and vomiting!�?

A dietary consult can sometimes be helpful, especially for tips on creative inclusion of nutritional foods or increasing calories with nutrient dense foods (e.g. peanut butter).

Nutritional Assessment

For most women with HG, intake of adequate food and fluids is practically impossible for weeks or even months. Standardized nutritional assessment tools are not scaled for pregnant women, yet many women with HG would still show severe risk of malnutrition. However, less than 20% of women get nutritional support.

Malnutrition Universal Screening Tool (MUST)

Subjective Global Assessment (SGA)

Importantly, mothers with poor nutritional intake for more than 10 days, weight loss exceeding 15% of preconception weight, electrolyte loss, and low serum magnesium levels are at high risk for refeeding syndrome. Methodical and gradual initiation of nutritional support, starting at 25% of needed nutrition and slowly increasing to goal as tolerated at a controlled rate, is imperative to prevent severe electrolyte and fluid shifts that can be life-threatening.

Monitoring

Daily monitoring of laboratory results, such as phosphorus, magnesium, sodium, calcium, glucose, and potassium, are important over the first week of refeeding. Close monitoring should be continued for at least 10 days, or until electrolytes are stable.

Nutritional Therapy

Being pregnant, women are in a state of accelerated starvation, meaning the adverse effects of starvation occur more quickly. Significant malnutrition can occur as many nutrients are depleted in a relatively short time frame, especially water-soluble vitamins, such as thiamin. Within just 2 weeks, nutritional deficiencies (e.g., B1) can cause neurological and cardiac symptoms that may be fatal. If HG is left untreated, numerous complications can result.

Offsite Research: PubMed Research on Nutrition and HG

IV Nutrition (Parenteral)

IV Nutrition

In women that do not respond to medications, IV nutrition is imperative. Women with HG often have delayed gastric emptying, reflux, and hypersensitive gag reflexes that increase their risk of complications, and many benefit greatly from a brief period of gut rest. It cannot be overemphasized that the longer a woman vomits, the more likely the complications, and the more difficult it is to stop the vomiting cycle. Early intervention is key, especially in women with a history of HG.

Tube Feeding (Enteral)

Parenteral (IV Nutrition)

Enteral (Tube Feeding)

Neurological Complications Due to Malnutrition

Neurological Conditions like Wernicke's Encephalopathy and Central Pontine Myelinolysis may be prevented in most cases by careful and proactive repletion of micronutrients. They may be fatal for the mother and unborn child if left untreated. Increasing numbers of cases are being reported each year. Symptoms differ in non-alcoholic patients like mothers with HG.

Our Case Study on HG and WE/CPM/EPM

Find recommendations on identification, prevention and treatment.

WE is typically identified by the symptom triad of ataxia, confusion and oculomotor abnormalities. However, 10-47% of patients lack these signs, especially with ... non-alcoholic [HG] patients... Persistent or prolonged vomiting, confusion, and unintentional weight loss are red flags indicating a high risk of WE. Additional WE signs ... include weakness, dysarthria, confabulation, akinetic mutism, aphasia, cardiac failure, seizures, abdominal pain and nausea. Mental status changes are nearly universal and exhibited as dizziness, drowsiness, apathy, and cognitive impairment. Gait abnormalities range from weakness to inability to stand...

Usual Weight:	Actual Weight:	Percent Weight Change:
lbs. or kgs.	lbs. or kgs.	%

Malnutrition & Dehydration