Examining the Evidence
Does a PICC line facilitate treatment of hyperemesis gravidarum?
No. In fact, it may be dangerous. In this study, 42 women hospitalized with hyperemesis gravidarum (HEG) were assigned to treatment with medication alone, 33 to a peripherally inserted central catheter (PICC) line, and 19 to a nasogastric (NG) or nasoduodenal (ND) tube. Of those managed with a PICC line, 66.4% (P<.001) required treatment for infection, thromboembolism, or both. In addition, neonatal complications including small for gestational age (SGA), admission to neonatal intensive care, termination of pregnancy because of HEG, and fetal loss were increased in the women who had a PICC line.
This important study 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.
What this evidence means for clinical practice
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.—T. Murphy Goodwin, MD