Home Enteral Feeding during Pregnancy | Hot Topic
Case details Mrs R is a 35-year-old lady with a jejunal balloon retained feeding tube. A stoma tract for feeding was formed following an oesophagectomy (diagnosis akinetic segment of oesophagus) in June 2007. Since the operation Mrs R has had persistent dysphagia and has
remained dependent on an overnight
enteral feed (1000ml of 1.5kcal feed). Oral intake on a good day is limited to tea, milkshakes, ice cream, lollies and chocolate. In February 2009, Mrs R contacted me with the
good news that she was five weeks pregnant (weight 54Kg). At this time she had a Mic-Key button tube in- situ, following her recent wedding and desire to wear a bikini on honeymoon. She was managing small amounts orally and was struggling with her overnight feed because she was not sleeping. We decided to try oral nutritional supplements (ONS) in small volumes throughout the day. These had been tried on previous occasions, with limited tolerance. The following month Mrs R had a stoma site
infection, but was not allowed antibiotic treatment because of the pregnancy. She was continuing with her overnight feed and usual oral intake as she was unable to tolerate ONS. At 12 weeks (weight 55Kg), Mrs R found that the button was getting tight so she was advised to change back to a standard balloon feeding tube, so that the external fixator could be adjusted as the baby grew. After changing the tube Mrs R started having pain internally near the stoma site and the site was continually ‘mucky’. At the same time she had low iron levels and was started on liquid iron medication. She was also not tolerating the overnight feed because of nausea. She was advised to reduce the feeding rate. At 22 weeks (weight 56.7Kg) she was managing
90 per cent of the feed and very small amounts orally. Mrs R was still experiencing pain at the stoma site and also suffering from reflux. A month later, Mrs R reported that the stoma site
was very painful and there was back pressure from the tube, making feeding very difficult. She was having topical cream applied at the stoma site but was still not allowed antibiotics. Mrs R was still unable to take ONS due to dumping syndrome symptoms, despite following advice to sip slowly and only have small volumes.
She was seen by her Surgical
Consultant who advised her that the uterus was pushing on the bowel which was pushing the tube and therefore causing the pain. He was unable to do anything as it would be a risk to the baby and advised that a caesarean section should be performed as soon as the baby was viable. A month later (weight 60.5kg), Mrs R was
admitted to hospital with acute abdominal pain. She was not having her overnight feed but was managing ice lollies, soup and chocolate orally. She was advised to reduce the feeding rate and increase the length of time on the feed. She was also seen by her local Obstetric Consultant and was advised that she would be booked in for a caesarean section at 34 weeks. She was feeling very tired because of her anaemia andwas unable to tolerate the iron medication.
At 31 weeks I was invited to a joint appointment
with Mrs R’s Obstetric Consultant. Mrs R was struggling to have her tube feed and had a minimal oral intake due to feeling full all the time. The decision was made to give Mrs R steroid injections over the next two days to strengthen the baby’s lungs in preparation for an early delivery. Mrs R was advised to keep feeding at a low rate for 24 hours and to reduce her intake of low calorie oral fluids. A few days later Mrs R was feeling sick and
unable to manage any feeds. We decided to trial a 2kcal/ml feed at reduced rate/volume.
Initially this
was tolerated better. However, after another few days Mrs R was admitted to hospital again. The feeding tube had been pulled further inside with only one inch visible on the outside and she was unable to feed. I expressed my concerns to her Consultant that the balloon may burst and replacement would be difficult because of the pregnancy. We also had concerns about Mrs R’s nutritional status and the fact that it was becoming increasingly difficult to provide adequate enteral nutrition. A decision was made to deliver the baby by caesarean section on the same day and Mrs R was advised to change her feeding tube as soon as she felt able to after the birth. Mrs R had a baby boy delivered by caesarean
section on 28 August 2009. He weighed 3lb 10oz and spent several weeks on the Special Care Baby Unit. The balloon burst the day following the
caesarean section and Mrs R was able to successfully replace it. The stoma site healed quickly and became less painful. Mrs R was then able to go back on full overnight feeds and returned to her usual small oral intake. At the most recent review, in August 2010
(weight: 51.3Kg), Mrs R had a Mic-Key button in situ and was tolerating an increased volume of feed. She continues to have persistent dysphagia and only has a limited oral intake.
Discussion The management of symptoms, whilst trying to maintain an adequate nutritional intake, is the challenge with pregnancy and tube feeding. Trying to achieve a healthy balanced diet, such as recommended by NICE,2
is difficult when oral
intake is limited and tolerance of enteral feeds is poor.
Some of the general measures usually
advised to help alleviate nausea and reflux, such as small frequent amounts of dry foods, were not an option for Mrs R.
The fact that her
nausea continued throughout the pregnancy, and the pain experienced at the stoma site severely compromised her nutritional intake and forced the decision of an early delivery. Frequent contact and liaison with the patient’s Obstetric Consultant was very useful as it was a first for both of us, and adapting the feeding regimen as often as necessary all helped to achieve a successful (if a little early) outcome.
‘
Trying to achieve a healthy balanced diet, such as recommended by NICE,2 is difficult when oral intake is limited and
tolerance of enteral feeds is poor.
’
References: 1. Javell D, Young G (2003). Interventions for nausea and vomiting in early pregnancy. Cochrane Database of systematic reviews; (4) CD000145. 2. NICE (2008). Maternal and Child Nutrition. Public Health Guidance II.
Complete Nutrition Vol.10 No.6 December/January 2010/11
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