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A case report demonstrating successful use of prolonged total parenteral nutrition in a diabetic pregnancy complicated by severe gastroparesis
  1. A Basu Sanyal,
  2. S Winfield,
  3. R W Bilous,
  4. M Bilous
  1. The James Cook University Hospital, Middlesbrough, UK

Abstract

Introduction Gastroparesis is a complication of autonomic neuropathy, which in turn is a complication of poorly-controlled diabetes mellitus. In pregnancy, gastroparesis is associated with increased maternal morbidity and poor perinatal outcome, and it also limits the ability to correct hypoglycaemia with oral glucose.1

Case report A 29-year-old para 2 with previously poorly-controlled Type 1 diabetes, advanced retinopathy and autonomic neuropathy, developed intractable vomiting at 18 weeks gestation and was hospitalised. Glycaemic control was maintained by glucose-potassium-insulin infusion. Despite regular intravenous ondansetron and subcutaneous metoclopramide, poor oral intake continued and total parenteral nutrition (TPN) was commenced at 20 weeks via a Hickman line until delivery. Intractable vomiting, psychological distress and concerns for fetal wellbeing in-utero (small for dates) necessitated a caesarean section at 28 weeks after steroids, delivering a female infant (1150 g) who did well on the neonatal unit. TPN was stopped at 7 days postnatal and the patient recovered and was discharged.

Discussion Prolonged TPN has been used in the management of severe digestive disease in pregnancy before, with good fetomaternal outcomes.2,3 In this case, severe vomiting, two episodes of ketoacidosis and concerns for fetomaternal malnutrition necessitated its use. Management of gastroparesis involves attention to precipitating factors, optimisation of nutritional support and pharmacological intervention.4 Drugs used are prokinetics to improve gastric emptying (e.g., metoclopramide), antiemetics and intravenous erythromycin, all safe in pregnancy. Early delivery was performed after multidisciplinary discussion with the aim to improve gastroparesis in a mother who was extremely unwell and not coping with intractable vomiting.

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