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Lecture 5, 2005

Lecture 5, 2005. Nausea and vomiting Lifestyle concerns with nutritional implications: alcohol caffeine smoking drugs artificial sweeteners oral health exercise. Nausea & Vomiting: Cochrane Library, 2003 Quinlan et al, Am Fam Phys, 2003. Background.

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Lecture 5, 2005

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  1. Lecture 5, 2005

  2. Nausea and vomiting • Lifestyle concerns with nutritional implications: • alcohol • caffeine • smoking • drugs • artificial sweeteners • oral health • exercise

  3. Nausea & Vomiting:Cochrane Library, 2003 Quinlan et al, Am Fam Phys, 2003

  4. Background • 70-85% of women experience nausea with pregnancy • ~ ½ experience vomiting • 35% of women with employment lose time from work due to nausea – an average of 62 hours • Almost 50% of women report that their work efficiency is reduced by n&v

  5. Etiology • Unknown • Nausea less common in those who subsequently experience miscarriage • More common in twin pregnancies • Recent studies implicate helicobacter pylori • H pylori infections more common in women with n&v • Case reports that eradication of infection with antibiotics ameliorates symptoms

  6. Hyperemesis Gravidarum • Severe nausea and vomiting • Affects one in 200 pregnancies • Most common reason for hospitalization in early pregnancy • Clinical features: Persistent vomiting, dehydration, ketonuria, electrolyte disturbances, weight loss • 159 per million pregnant women died in England between 1931-1940 (before IV fluid replacement therapy was available) • (Charlotte Bronte died of hyperemesis in her fourth month of pregnancy)

  7. Cochrane Conclusions • B6 “appears to be effective in reducing the severity of nausea.” • Results of P6 acupressure trends are “equivocal.” • “No trials of treatment for hyperemesis gravidarum show evidence of benefit.”

  8. Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting(Borelli. Obstet Gynecol. 2005) • Six double-blind RCTs with a total of 675 participants and a prospective observational cohort study (n = 187) met all inclusion criteria • Four of the 6 RCTs (n = 246) showed superiority of ginger over placebo; the other 2 RCTs (n = 429) indicated that ginger was as effective as the reference drug (vitamin B6) in relieving the severity of nausea and vomiting episodes.

  9. Borelli, cont. • absence of significant side effects or adverse effects on pregnancy outcomes • CONCLUSION: Ginger may be an effective treatment for nausea and vomiting in pregnancy. However, more observational studies, with a larger sample size, are needed to confirm the encouraging preliminary data on ginger safety.

  10. Nausea and vomiting of pregnancy: an evidence-based review(Davis,J Perinat Neonatal Nurs. 2004) • n&v rates less in women taking perinatal multivitamin • Mild to moderate n&v reduced by P6 acupuncture site pressure wristband (new battery operated electrical nerve stimulator) • First step is dietary & lifestyle changes

  11. Davis, cont…. • If diet/lifestyle fail to bring relief drug therapy may be indicated. • Most drugs will not be tested in pregnant women • Pharmacologic treatments include: • B6 (pyradoxine) • B6 plus doxylamine (aka Bendectin)

  12. Stress Associated with Nausea and Vomiting…. • Lack of understanding and support from others • • Inability to take vitamins or eat healthy • • Taking medications perceived as risky • • Missing out on the “fun” of being pregnant • • Loss of a “normal” pregnancy • • Lost work days or quitting work • • Putting life “on hold” • • Longing to eat and drink normally • • Money expended on care and support • • Lack of energy, fatigue • • Irritability and lack of enjoyment of life • • Memory loss or inability to think clearly • • Burden of care and time on others • • Lack of socialization, isolation

  13. Stress, cont…. • • Inability to prepare for birth and arrival of baby • • Inability to care for family and home • Wanting pregnancy over or to end the misery • • Others’ perception that hyperemesis is only in her mind • • Reluctance of doctors to treat because of cost or liability • • Weight loss or inadequate weight gain for gestational age of baby • • Sense of inadequacy and failure at being unable to cope or function • • Difficulty bonding with infant • • Lack of energy and socialization with other children • • Lack of excitement about infant’s arrival

  14. Adverse effects of substance use determined by: • Timing • Dosage • Duration • Number of substances • Environment (nutrition, health status) • Individual susceptibility

  15. Effects of substance abuse include: • Increased health problems, including risk of AIDS • Compromised nutritional status/weight gain • Higher rates of OB complications • Psychosocial/economic/legal problems • Parenting difficulties • Higher rates of child abuse/neglect

  16. Alcohol: Background • Per capita alcohol consumption has risen through the second half of this century in the US • 70% of individuals between the ages of 20 and 34 consume alcohol • Alcohol consumption peaks in the 20-40 year old group

  17. Alcohol: Background, cont. • Women are at disadvantage because less gastric first pass metabolism due to lower levels of alcohol dehydrogenate in intestinal mucosa • Fetus has no alcohol dehydrogenase activity • Alcohol crosses placenta easily by passive diffusion – fetal levels mimic maternal levels • The amniotic fluid acts as a reservoir for alcohol.

  18. FAS Diagnostic Criteria- Fetal Alcohol Study Group of the Research Society on Alcoholism • Prenatal and/or postnatal growth retardation (<10th % ca) • Central nervous system involvement (neurologic abnormality, developmental delay or intellectual impairment) • Characteristic facial dysmorphology with at least 2 of these 3 signs: • Microcephally ( OFC < 3rd %ile) • Micoopthalmia and/or short palpevral fissures • Poorly developed philtrum, thin upper lip, and or flattening of the maxillary area

  19. FAS, cont. Other organ systems often involved. Some with nutritional implications: • Cleft palate • Eustachian tube dysfunction • Array of cardiac, renal, and skeletal defects that may require surgical repair

  20. FAE – Fetal Alcohol Effects or PFAE • Exhibit some components of FAE, but not all • Most common sign is retarded growth both pre and postnatal • Can have significant developmental and behavioral components

  21. FAS/FAE Incidence • FAS – 1.9 per 1000 births, 25 per 1000 among women who drink heavily • FAE – 3 to 5 per 1000 births, 90 per 1000 among women who drink heavily • FAS is leading cause of mental retardation in the western world

  22. Pathophysiology • Combination of • Toxic effects of ethanol and it’s derivatives • Nutritional factors • Genetic predisposition

  23. Toxic effects • Both alcohol and derivative acetaldehyde directly damage developing and mature nervous systems • Impair nucleic acid synthesis • Disrupts protein synthesis • Cell membrane narcosis • High maternal alcohol levels associated with dehydration, fetal hypoxia and acidosis, placental pathology and dysfunction, and endocrine disturbances.

  24. Nutrition Related Effects of Alcohol • Poor nutritional status of mother • Reduced placental transfer of zinc and folic acid associated in animal models • Alcohol impairs absorption, utilization, and metabolism of nutrients • Poor zinc status has been associated with adverse effects of alcohol many studies

  25. Bottom Line No amount of alcohol can be said to be safe in pregnancy.

  26. Caffeine • History: • Rat based studies with high levels of caffeine found adverse pregnancy outcomes • Early 1980s US FDA issued advisory about adverse effects of caffeine in pregnancy • Further research found little association, FDA concludes that no strong evidence, urges moderation • 1996 IOM review for WIC advised removing excessive caffeine intake from WIC risk criteria • 1998 - USDA removed as WIC risk criteria

  27. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Consumption: • In US 70-95% of pregnant women consume caffeine - average intake is 99-185 mg/day • 5-30% of pregnant women consume >300 mg/day • Heavy caffeine intake more likely in women who smoke and those with lower education levels

  28. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Metabolism • methylxantines cross the placenta to the fetus where an equilibrium is achieved between maternal and fetal plasma • half-life of caffeine in pregnancy changes from 5.2 to 18.1 hours in T2 and T3 and returns to non-pg levels a few weeks pp

  29. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Birthweight: • consistent negative association across studies between birthweight and caffeine consumption > 300 mg/day. • This affect appears to be due to IUGR not preterm birth • Data for intakes between 151 and 300 mg are conflicting • Few adverse effects at intakes < 150 mg

  30. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Preterm Labor and Delivery • “Generally, there appears to be no relationship between caffeine consumption during pregnancy and premature labor and delivery in humans.”

  31. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Spontaneous Abortions • High caffeine intake prior to and during pregnancy was associated in several studies. Many studies failed to control for smoking, alcohol intake or parity • Study results are inconclusive and contradictory • Further research needed to determine if a true causal relationship exists.

  32. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Congenital Malformations • Finnish registry of congenital malformation study found no increased incidence even when women consumed < 6 cups of coffee a day. • No association is supported by current research

  33. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996 • Clinical applications • Caffeine intake should be limited to between 150 mg and 300 mg per day • Women in the last trimester and those who smoke are most susceptible to adverse effects.

  34. Maternal Caffeine Consumption and Spontaneous Abortion: Review of Epidemiologic Evidence(Epidemiology, 2004) • Most studies find positive association between maternal caffeine intake and sp ab. • All studies have limitations: • selection and recall bias • poor exposure measurements • issues related to timing of exposure and fetal demise

  35. Caffeine Metabolism, Genetics and Perinatal Outcomes(Ann Epidemiol 2005) • Wide individual variation in caffeine metabolism • Due to variation in CYP1A2 enzyme activity • “Measuring maternal, fetal and neonatal caffeine metabolites may allow for a more precise measure of fetal caffeine exposure.”

  36. Smoking • 25-30% of US women smoke during pregnancy; down from 40% in 1967 • Cochran review found that 30 trials of intensive intervention programs in pregnant women lead to smoking cessation in 6.6-9.2% of women.

  37. Adverse Outcomes of Smoking • Twice the risk of LBW • Lower birthweight (~200g) • Perinatal: Moderately increased risk of preterm delivery, perinatal mortality, spontaneous abortion • Long term: modest reduction in long term growth and intellectual development of fetus.

  38. Nutritional Risks Associated with Smoking • No breakfast (38% of smokers vs. 18% of non-smokers) • Lower dietary intakes of fruits and vegetables, protein, zinc, riboflavin, thiamin, iron

  39. Nutritional Risks Associated with Smoking, cont. • Smoking appears to: • decrease the availability of dietary energy • increase requirement for iron • reduce availability of B12, amino acids, vitamin C, folate, and zinc • Lower serum vitamin C, B6, E, folate, beta carotene

  40. Norkus et al. FASEB, 1989 and Ann NY Acad Sci 1987

  41. Vitamin C and PROM • PROM occurs in 8-10 % of all pregnancies • Vitamin C is required for collagen synthesis • Maternal plasma and placental vitamin C is lower in women with PROM

  42. Nutritional Risks Associated with Smoking, cont. • Increased carboxyhemoglobin in smokers blood leads to increased cutoff point for anemia. • Women who smoke may have lower prepregnancy weights and may have lower pregnancy weight gains.

  43. Annotation: Cigarette Smoking, Nutrition, and Birthweight(Rasmussen & Adams, AJPH, 1997) • “Smoking and maternal weight gain are independent, additive predictors of birthweight.” • “It does not appear that encouraging smokers to gain more weight than nonsmokers with a similar BMI will eliminate the negative effects of smoking on birthweight.” • Women who quit smoking in pregnancy are at increased risk of excessive weight gain. • Women who smoke are at increased risk of poor dietary intake. • Therefore….

  44. Annotation: Cigarette Smoking, Nutrition, and Birthweight(Rasmussen & Adams, AJPH, 1997) “…individualized nutrition counseling is recommended in addition to smoking cessation.”

  45. Illicit Drugs: Nutritional Implications • Estimates of 10% of US newborns exposed to one or more illicit drugs in utero • Illicit drug use strongly associated with inadequate weight gain, anemia, poor dietary habits • Knight et al. (FASEB, 1992) found lower serum ferritin, folate, vitamin C and B12 levels in women when cord blood reflected illicit drugs

  46. Illicit Drugs: Nutritional Implications • Cocaine: • associated with fewer meals, increased alcohol and caffeine and fat intake • 32% also classified as eating disordered • Methadone • diarrhea, constipation, nausea, anorexia, and dry mouth • Heroin • altered glucose tolerance - delayed glucose response

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