Surgery is lifesaving for certain gastrointestinal conditionsperforative appendicitis being the most common example. Laparoscopic procedures have replaced traditional surgical techniques for many abdominal disorders during pregnancy. hese are shown in detail with descriptions of surgical technique in Chapter 46 (p. 903) and in Cunningham and Gilstrap 5 Operative Obstetrics, 3rd edition (Kho, 2016). Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy have been provided by the Society of American Gastrointestinal and Endoscopic Surgeons-SAGES (Pearl, 2017).
Specialized nutritional support can be delivered enteraly, usually via nasogastric tube feedings, orparenteraly with nutrition given by venous catheter access, either peripherally or centrally.
When possible, enteral alimentation is preferable because it has fewer serious complications (Bistrian, 2012; Stokke, 2015). In obstetrical patients, very few conditions prohibit enteral nutrition as a first efort to prevent catabolism. For extreme cases, such as recalcitrant hyperemesis gravidarum, percutaneous endoscopic gastrostomy with a jejunal port (PEG-J tube) has been described (Saha, 2009).
he purpose of parenteral eeding, or hyperalimentation, is to provide nutrition when the intestinal tract must be quiescent. Central venous access is necessary for total parenteral nutrition because its hyperosmolarity requires rapid dilution in a highflow vascular system. hese solutions provide 24 to 40 kcall kg/ d, principally as a hypertonic glucose solution.
Not surprisingly, gastrointestinal disorders are the most common indication, and in the many studies cited, feeding duration averaged approximately 33 days.
Importantly, complications of parenteral nutrition are frequent, and they may be severe (Guglielmi, 2006). n early report of 26 pregnancies described a 50-percent rate of complications, which included pneumothorax, hemothorax, and brachial plexus injury (Russo-Stieglitz, 1999). he most frequent serious complication is catheter sepsis, and Folk (2004) reported a 25-percent incidence in 27 women with hyperemesis gravidarum. Although bacterial sepsis is most common, Candia septicemia has been described (Paranyuk, 2006). he Centers for Disease Control and Prevention has updated its detailed guidelines to prevent catheter-related sepsis, and these serve to lessen the dangers of serious infections (O'Grady, 2011). Perinatal complications are
TABLE 54-1. Some Conditions Treated with Enteral or Parenteral Nutrition During Pregnancya aOisorders are listed alphabetically.
Data from Folk, 2004; Guglielmi, 2006; Manliadevan, 2015;
Ogura, 2003; Porter, 2014; Russo-Stieglitz, 1999; Saha, 2009;
Spiliopoulos, 201n3 .
uncommon, however, fetal subdural hematoma caused by mater nal vitamin K deiciency has been described (Sakai, 2003).
Appreciable morbidity is also associated with long-term use of a peripheraly inserted central catheter (PICC). Infection is the most common serious long-term complication (Holmgren, 2008;
Ogura, 2003). In a series of84 such catheters inserted in 66 preg nant women, Cape and coworkers (2014) reported a 56-percent complication rate, of which bacteremia was the most frequent.