Nausea, Lifestyle

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Nausea, Lifestyle Oral Health2007
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• Nausea and vomiting
• Lifestyle concerns with nutritional implications
• alcohol
• caffeine
• smoking
• drugs
• Non-nutritive sweeteners
• oral health
• physical activity

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Nausea Vomiting Cochrane Library, 2003
Quinlan et al, Am Fam Phys, 2003
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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 nv

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Etiology

• Unknown
• Nausea less common in those who subsequently
  experience miscarriage
• More common in twin pregnancies
• Emerging findings recent studies implicate
  helicobacter pylori
• H pylori infections more common in women with nv
• Case reports that eradication of infection with
  antibiotics ameliorates symptoms

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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)

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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.

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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.

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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.

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Nausea and vomiting of pregnancy an
evidence-based review (Davis, J Perinat Neonatal
Nurs. 2004)

• nv rates less in women taking perinatal
  multivitamin
• Mild to moderate nv reduced by P6 acupuncture
  site pressure wristband (new battery operated
  electrical nerve stimulator)
• First step is dietary lifestyle changes

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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 (an antihistamine) Bendectin

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American Gastroenterological Association
Institute Medial Position Statement on the Use of
Gastrointestinal Medication in Pregnancy (2006)

• Metoclopramide, prochlorperazine, promethazine,
  trimethobenzamide and ondansetron are considered
  low-risk drugs based on studies in pregnant women
  and can be used for nausea and vomiting and for
  hyperemesis gravidarum. Granisetron and
  dolasetron have not been studied in human
  pregnancies.

Reglan, Compazine , Phenergan , Tebamide, Zofran
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Letter from Staroselsky et al., Gastroenterology,
2007 Re Bendectin

• AGA guideline missing doxylamine (with or without
  B6)
• Doxyamine-pyridozine (Bendectin) was approved by
  FDA for Tx of NV in pregnancy, but unfounded
  lawsuits claiming risk of congenital
  malformations forced company to stop production
  in 1983.

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Starokelsky letter, cont.

• Meta-analysis of studies found no differences in
  birth defects with Bendectin.
• Doxalamin-pyridoxine available in Canada and use
  associated with lower hospitalization for HG.
• gt30 million infants have been exposed without
  increased malformations.
• Failure to acknowledge the safety and
  effectiveness of this drug is against the
  principals of evidence-based medicine.

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Mahadevan reply, 2007

• We limited our scope to agents used by
  physicians practicing in the United States who
  treat women during pregnancy.

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Stress Associated with NV

• 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

cont
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• 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 infants arrival

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Adverse effects of substance use determined by

• Timing
• Dosage
• Duration
• Number of substances
• Environment (nutrition, health status)
• Individual susceptibility

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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

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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

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MMWR December 24, 2004 / 53(50)1178-1181
BRFSS, 2002
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MMWR December 5, 2002
BRFSS
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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.

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FAS Diagnostic Criteria- Fetal Alcohol Study
Group of the Research Society on Alcoholism

• Prenatal and/or postnatal growth retardation
  (lt10th 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 lt 3rd ile)
• Micoopthalmia and/or short palpevral fissures
• Poorly developed philtrum, thin upper lip, and or
  flattening of the maxillary area

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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

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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

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Fetal Alcohol Spectrum Disorders (FASD)

• Surgeon Generals Advisory (2005)
• FASD is the full spectrum of birth defects
  caused by prenatal alcohol exposure.
• The spectrum may include mild and subtle
  changes, such as a slight learning disability
  and/or physical abnormality, through full-blown
  Fetal Alcohol Syndrome, which can include severe
  learning disabilities, growth deficiencies,
  abnormal facial features, and central nervous
  system disorders.

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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
• FASD is leading cause of mental retardation in
  the western world

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Pathophysiology

• Combination of
• Toxic effects of ethanol and its derivatives
• Nutritional factors
• Genetic predisposition

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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.

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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

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Surgeon Generals Advisory (2005)

• Science
• Alcohol consumed during pregnancy increases the
  risk of alcohol related birth defects, including
  growth deficiencies, facial abnormalities,
  central nervous system impairment, behavioral
  disorders, and impaired intellectual development.
  
• No amount of alcohol consumption can be
  considered safe during pregnancy.
• Alcohol can damage a fetus at any stage of
  pregnancy. Damage can occur in the earliest weeks
  of pregnancy, even before a woman knows that she
  is pregnant.
• The cognitive deficits and behavioral problems
  resulting from prenatal alcohol exposure are
  lifelong.
• Alcohol-related birth defects are completely
  preventable

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Surgeon Generals Advisory (2005)

• Recommendations
• A pregnant woman should not drink alcohol during
  pregnancy.
• A pregnant woman who has already consumed alcohol
  during her pregnancy should stop in order to
  minimize further risk.
• A woman who is considering becoming pregnant
  should abstain from alcohol.
• Recognizing that nearly half of all births in the
  United States are unplanned, women of
  child-bearing age should consult their physician
  and take steps to reduce the possibility of
  prenatal alcohol exposure.
• Health professionals should inquire routinely
  about alcohol consumption by women of
  childbearing age, inform them of the risks of
  alcohol consumption during pregnancy, and advise
  them not to drink alcoholic beverages during
  pregnancy.

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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

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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 gt300 mg/day
• Heavy caffeine intake more likely in women who
  smoke and those with lower education levels

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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

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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 gt
  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 lt 150 mg

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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.

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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.

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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 lt 6 cups of coffee a day.
• No association is supported by current research

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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.

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Maternal exposure to caffeine and risk of
congenital anomalies (Brown, Epidemiology, 2006)

• Review of 7 (of 25 published) studies that met
  inclusion criteria
• Conclusion There is no evidence to support a
  teratogenic effect of caffeine in humans.
  Current epidemiologic evidence is not adequate to
  assess the possibility of a small change in risk
  of congenital anomalies resulting from maternal
  caffeine consumption.

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Maternal Caffeine Consumption and Spontaneous
Abortion Review of Epidemiologic Evidence
(Epidemiology, 2004)

• Most studies find positive association between
  maternal caffeine intake and sp ab, but causality
  has not been established
• All studies have limitations
• selection and recall bias
• poor exposure measurements
• issues related to timing of exposure and fetal
  demise
• (Lively discussion in other venues Are women who
  have strong coffee aversion due to nausea early
  in pregnancy more likely to sustain pregnancy?
  Ann Epi, 2006)

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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.

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Coffee and Health A Review of Recent Human
Research (Higdon and Frei crit rev food sci and
nutrition, 2006

• Currently available evidence suggests that it
  may be prudent for pregnancy women to limit
  coffee consumption to 3 cups/d providing no more
  than 300 mg/d of caffeine to exclude any
  increased probability of spontaneous abortion of
  impaired fetal growth.

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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.

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Adverse Outcomes of Maternal Smoking

• Cigarette smoking is the single most important
  factor affecting birthweight in developed
  countries (DiFranza, Pediatrics, 2004)
• 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.

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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

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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

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

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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.

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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.

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Annotation Cigarette Smoking, Nutrition, and
Birthweight (Rasmussen Adams, AJPH, 1997)

• individualized nutrition counseling is
  recommended in addition to smoking cessation.

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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

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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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Position of the American Dietetic Association
Use of nutritive and nonnutritive sweeteners
(Affirmed 2000, in effect until 2009)

• Toxicity testing during reproduction is required
  for FDA approval.
• The safety of acesulfame-K, aspartame,
  sucralose, and neotame in pregnancy has been
  determined with rat studies.
• Saccharin can cross the placenta and may remain
  in fetal tissues because of slow fetal clearance
  - It has been suggested that women consider
  careful use of saccharin during pregnancy.

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Position of the American Dietetic Association
Use of nutritive and nonnutritive sweeteners

• Aspartame issue relates to fetal exposure to
  aspartic acid, phe, or methanol.
• Animal models show no changed fetal exposure to
  aspartic acid with aspartame
• Maternal bolus of aspartame at the 99th ile of
  intake results in peak plasma phe level in both
  normal (1.85 mg/dl) and PKU heterozygote subjects
  (2.67 mg/dl) below levels associated with
  neurological problems (18 mg/dl)
• Plasma response of methanol and formate are not
  significant after aspartame load
• Use of aspartame within FDA guidelines appears
  safe for pregnant women.

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Exercise

• Benefits
• improved or maintained fitness
• reduces anxiety and depression
• eases pregnancy discomforts such as constipation,
  backache, fatigue and varicose veins

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Exercise

• Contraindications
• previous experience of preterm labor
• ob complications including vaginal bleeding,
  incompetent cervix, ruptured membranes,
  compromised fetal growth
• Hx of medical problems (hypertension, heart
  disease, etc.) requires health care provider
  approval

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Exercise

• Changes with pregnancy
• tolerance for strenuous exercise decreases as
  pregnancy progresses
• work of breathing increases as enlarging uterus
  crowds the diaphragm
• oxygen needs increase
• if lying flat on back after the 4th month, risk
  of compression of vena cava with dizziness and
  interference with blood flow to the uterus

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Exercise

• Changes with pregnancy, cont.
• may have increased efficiency of heat dissipation
• altered sense of balance with shift in center of
  gravity
• high hormonal levels associated with lax
  connective tissue and increased joint
  susceptibility

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Cochrane Aerobic Exercise for Women During
Pregnancy (2006)

• 11 trials involving 472 women
• The trials were not of high methodologic
  quality.
• Results
• Regular aerobic exercise during pregnancy appears
  to improve (or maintain) maternal physical
  fitness
• Non significant, but concerning increased risk of
  preterm birth in exercise groups. From 7 trials
  Pooled RR 1.82 (95 CI 0.35-9.57).
• Data insufficient to infer important risk or
  benefits for mother or infant

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Continuous, Strenuous, Vigorous Activity
Throughout Pregnancy (Gunderson, Clin Obstet
gynecology, 2003)

• Can reduce birth weight length of gestation
• Additional carbohydrate recommended before
  activity
• Increased need for B vitamins
• Careful screening for nutritional herbal
  supplements
• Athletes at higher risk for Fe depletion.

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Exercise during pregnancy and the postpartum
period. ACOG Committee on Obstetric Practice.
January 2002
The current Centers for Disease Control and
Prevention and American College of Sports
Medicine recommendation for exercise, aimed at
improving the health and well-being of
nonpregnant individuals, suggests that an
accumulation of 30 minutes or more of moderate
exercise a day should occur on most, if not all,
days of the week. In the absence of either
medical or obstetric complications, pregnant
women also can adopt this recommendation.
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Exercise during pregnancy and the postpartum
period. ACOG Committee on Obstetric Practice.
January 2002

• Exercise may be beneficial in primary prevention
  of GDM
• Avoid
• supine position (may result in obstruction of
  venous return)
• motionless standing
• exertion above 6,000 feet altitude

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Avoid

• Sports with high potential for trauma ice
  hockey, soccer, basketball
• Increased risk of falling gymnastics, downhill
  skiing, vigorous racket sports, horseback riding
• Scuba diving (increased risk of decompression
  sickness)

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Postpartum

• Physiological changes persist 4 to 6 weeks
  postpartum
• Return to vigorous exercise should be gradual
• Return to physical activity may be protective
  against postpartum depression if exercise is
  stress relieving- not inducing

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Oral Health Major Concepts (Academy of General
Dentistry)

• Increased risk for gingivitis (red,swollen,
  tender gums that are more likely to bleed)
  associated with increased estrogen and
  progesterone
• Frequent consumption of high cho foods may be
  used to combat nausea
• Cariogenic bacteria may be passed from mother to
  infant
• Periodontal disease is associated with preterm
  birth

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Pregnancy Gingivitis

• 30-75 of women experience gingival changes such
  as edema, hyperplasia, redness, and bleeding
• Hormonal changes cause greater reaction to dental
  plaque
• Women who are plaque and inflammation-free at
  beginning of pregnancy have only 0.03 chance of
  gingivitis

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Periodontitis

• Definition an infection caused by specific
  bacterial plaque that involves loss of bone,
  fiber, and gum tissue attachment for the tooth.
• Smoking associated with increased prevalence and
  severity of periodontitis
• Periodontal infections caused by gram-negative
  pathogens are associated with increase in preterm
  delivery and/or PROM - one mediating factor is
  prostaglandin production triggered by bacterial
  products.
• Women with diabetes are at higher risk

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Periodontitis (cont.)

• Pathogens and bacterial products may translocate
  and inhibit normal clearance of enteric organisms
  from genitourinary tract.
• Overgrowth of gram negative bacteria and
  infection can be associated with preterm birth.

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Periodontal Health and Birth Outcomes (report on
a policy and practice forum held Dec. 2006)

• There is evidence of an association between
  periodontal disease and increased risk of preterm
  birth and low birthweight, especially in
  economically disadvantaged populations, but
  potential biases (especially in terms of
  inconsistent definitions) and the limited number
  of RCTs prevent clear conclusions.
• Currently, there is insufficient evidence to
  support the provision of treatment during
  pregnancy for the purpose of reducing adverse
  birth outcomes.

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Can preterm birth be prevented by periodontal
treatment?

• NIDCR funded two large RCT women assigned to
  treatment or no treatment
• Oral Therapy to Reduce Obstetric Risk (OPT)
  results published in 2006
• Maternal Oral Therapy to Reduce Obstetric Risk
  (MOTOR) results due in 2008

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OPT Treatment of Periodontal Disease and the
Risk of Preterm Birth (Michalowicz et al. NEJM,
Nov. 2006)

• 823 women with periodontal disease, enrolled
  between 13-17 weeks gestation, randomized to
• Scaling and root planing before 21 weeks monthly
  polishings
• Scaling and root planing after delivery
• Major Outcomes
• no difference in rates of preterm birth or low
  birthweight
• no adverse outcomes associated with treatment

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American Academy of Periodontology Statement
Regarding Periodontal Management of the Pregnant
Patient (2004)

• Achieve a high level of oral hygiene prior to
  becoming pregnant and throughout pregnancy
• Periodonal treatment (eg scaling and root
  planing) is usually scheduled in second trimester
  
• Emergencies such as acute infection and abcess
  may require immediate treatment regardless of
  stage of pregnancy)
• Consultation with prenatal care provider

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Oral Health Recommendations

• Frequent dental cleanings (3 to 6 months)
• Daily oral care routines including brushing and
  flossing at least twice daily and after eating
• Use of toothpastes and rinses with fluoride
• Consider cariogensis in food choices and
  patterns.
• Offer smoking cessation programs