Successful pregnancy outcome using total parenteral nutrition from the first trimester of pregnancy

Congenital midgut malrotation causing intestinal obstruction in midpregnancy managed by prolonged total parenteral nutrition: case report and review of the literature

Background: A review of the English literature from 1980 to 2010 revealed only six gravidas managed by total parenteral nutrition (TPN) for at least 16 weeks of pregnancy. We found only two gravidas with obstruction due to malrotation, both managed surgically.

Case: We report a unique case of bowel obstruction presenting in the second trimester due to congenital malrotation of the small intestine that was conservatively managed by prolonged TPN, with the delivery of a healthy term baby girl. Surgical correction was delayed until the patient was not pregnant.

Conclusion: Intestinal obstruction in pregnancy is rare, and malrotation of the small bowel as the cause is extremely rare. This is the first case of intestinal obstruction in midtrimester in which prolonged TPN was employed when surgery was contraindicated. TPN may be considered if surgery cannot be performed, with an excellent outcome likely.

Normal gestation after 5 years on home parenteral nutrition

A case of normal gestation after 5 years on HPN is reported. The patient had her entire jejunum and ileum and right colon resected because of gangrene and has subsisted normally on HPN ever since. From the second trimester on, her HPN formula was supplemented to meet the requirement for growth and development of the foetus. Anaemia, hypoalbuminaemia, low plasma zinc levels and jaundice became manifest in the final trimester. These responded readily to readjustment of her HPN formula. A normal baby weighing 2020 g was delivered by Caesarean section at 36 weeks. Long-term HPN, final trimester abnormalities and HPN formula adjustments are discussed.

Delivery of a normal newborn after intensive medical treatment for an acute exacerbation of ulcerative colitis during pregnancy: a case report

A 28-year-old woman developed an acute exacerbation of chronic ulcerative colitis in the second trimester of pregnancy. She was treated by intensive medical treatment with intravenous prednisolone, betamethasone enema, oral salazosulfapyridine, intravenous ceftazitim, and total parenteral nutrition. The acute relapse subsided after 73 days of the treatment and a normal female newborn weighing 2,208 g was delivered vaginally after 40 weeks' gestation. Our experience showed that the intensive medical therapy did not impair either the course of the pregnancy or the fetal outcome.

Total parenteral nutrition and its effects on bone metabolism

Total parenteral nutrition (TPN) may affect bone metabolism in a variety of ways. These may include potential indirect effects such as on gastrointestinal hormone secretion, liver function, especially cytochrome P450 isoenzymes, metabolic biorhythms where established, and the continuous compared with the intermittent supply of nutrients. More substantial evidence exists for the reduction of bone formation, parathyroid hormone secretion, and calcitriol production in TPN patients along with high urinary calcium excretion. This review considers both aluminum loading and vitamin D sensitivity as etiologic factors and suggests that aluminum may have played a primary role in the pathogenesis of these abnormalities in bone and mineral metabolism, but that vitamin D may have potentiated the deleterious actions of aluminum. While the sources of aluminum contamination of TPN solutions have been identified and efforts are under way to reduce its contamination of TPN solutions, the persistence of low bone mass measurement in TPN patients is a problem that has been identified repeatedly, does not have a current explanation, and requires further study.

A historical perspective and review of the safety of lipid emulsion in pregnancy

Total parenteral nutrition for pregnant patients is essential to maintain or restore optimal nutritional status for both the mother and fetus when adequate protein and caloric intake by the oral or enteral route is not feasible. This report reviews the safety of intravenous lipid emulsions in total parenteral nutrition programs for pregnant patients. Controversy regarding the adverse effects of intravenous lipid emulsion when administered to pregnant patients is based on early reports of the use of cottonseed oil lipid emulsions. The adverse effects reported included infarction of the placenta, ketonemia, increased myometrial activity, and induction of labor. In 32 subsequent case reports in which soybean oil- or soybean/safflower oil-based emulsions were used in total parenteral nutrition programs for pregnant patients, there was no relationship apparent between onset of labor and harmful maternal or fetal effects associated with the administration of lipid emulsion. It appears that the currently available soybean and soybean/safflower lipid-based emulsions can be safely administered to pregnant patients.

Parenteral nutrition in obstetric patients

PN is required to maintain or restore an anabolic state when oral enteral routes are not feasible. Despite 22 years of experience with PN, its use during pregnancy has only recently been reported. Most of this information is anecdotal but suggests that this mode of therapy is safe, effective, and occasionally lifesaving. PN during pregnancy has been used most often to provide adequate nutrition for those who suffer from prolonged hyperemesis or who have difficulty absorbing adequate nutrients because of such conditions as Crohn's disease. The proper selection and administration of dextrose, fat, protein, vitamins, trace elements, and electrolytes for pregnant women have been associated with favorable perinatal outcomes. Fat emulsion use does not appear to be associated with any abnormal outcomes. Preterm deliveries and intrauterine fetal growth retardation appear to relate to preexisting or coexisting medical or obstetric complications. Principles for PN with all patients would apply during pregnancy. As with any therapy, the benefits must be weighed against the risks and costs. Sufficient favorable clinical experience over the last 10 years suggests that PN is a relatively safe and effective method for reversing maternal malnutrition and promoting normal fetal growth and development.