NUTRITION SUPPORT IN OBSTETRIC PATIENTS Less than 75 cases have been reported, despite the clinical availability of this modality for over 25 years, of parenteral nutrition being used during pregnancy. Even large tertiary perinatal centers treat only a few suitable candidates annually. Obstetricians and perinatologists remain relatively unsophisticated in their use of parenteral nutrition, and members of nutritional support teams continue to be ill at ease when asked to participate in the care of pregnant women. The important effects of maternal nutrition on pregnancy outcome are well recognized. Clearly, there are poorly nourished pregnant women who would benefit from this form of therapy. In this issue, Dr. Rayburn succinctly summarizes the current state of knowledge regarding the use of parenteral nutrition during pregnancy. He also provides concise guidelines for the evaluation, treatment, and monitoring of pregnant women requiring this modality. These should be of great benefit to health care personnel involved in the care of seriously ill pregnant women. Several questions remain to be answered regarding the optimal use of parenteral nutrition during pregnancy. Most investigators have calculated the caloric needs of their pregnant patients by using the HarrisBenedict equation (intended for nonpregnant individuals) and then making theoretical corrections based on National Research Council guidelines for pregnancy. This approach has often been retrospectively justified by observations that either the mother gained weight while on parenteral nutrition or that the infant’s birth weight was normal. Two recent publications using more precise methods to evaluate the adequacy of maternal caloric intake have suggested that the above calculations may provide less than an appropriate number of calories.1,2 Further studies employing more objective techniques such as indirect calorimetry are required to further define the best method for calculating maternal caloric requirements while on parenteral nutrition. While it is clear that some pregnant women with severe gastrointestinal injury or disease will experience prolonged inadequate nutrition, justifying parenteral nutrition, newer reports have suggested the use of this therapy in patients suffering from hyper-

emesis. Many patients suffer from nausea and vomiting in pregnancy. Until recently, subjective criteria

employed to select those patients suffering from hyperemesis who were to be treated with parenteral nutrition. Recently, more objective criteria have been proposed.’ However, no controlled studies have been undertaken either to test the appropriateness of the suggested selection criteria or to compare maternal and neonatal outcome among hy-

were

peremesis patients receiving parenteral

nutrition

with outcomes for those treated in a more traditional fashion. Although a multicenter approach may be required, such studies are urgently needed. While the outcomes in the cases reported to date have been reassuring, the safety of parenteral nutrition, particularly during the period of organogenesis, remains a concern. Even a several fold increase in most congenital abnormalities is unlikely to be detected among the small number of reported patients who have been treated in the first trimester. Therefore, there remains a need for clinicians to report

and journals

to

publish

outcome statistics.

evidenced by Ms. Barclay’s publication in this issue, other forms of therapy for nutritionally deprived pregnant women need to be evaluated and compared with parenteral nutrition. This will lead to the selection of modalities to optimize the treatment of pregnant women suffering from a wide variety of disorders.

Finally,

as

References

CG, Meis PJ. Total parenteral nutrition in pregnancy. Gynecol 1985;66:585. 2. Levine MG, Esser D. Total parenteral nutrition for treatment 1. Hatjis

Obstet

of severe hyperemesis gravidarum: maternal nutritional effects and fetal outcome. Obstet Gynecol 1988;72:102. 3. Lee RV, Rodgers BD, Young C, et al. Total parenteral nutrition during pregnancy. Obstet Gynecol 1986;68:563.

Justin P. Lavin, Jr.,M.D. Chief, Division of Obstetrics Akron City Hospital Professor of Obstetrics and Gynecology Northeastern Ohio Universities College of Medicine

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