Transcript document

Nausea, Lifestyle & Oral Health
2008
• Nausea and vomiting
• Lifestyle concerns with nutritional
implications:
– alcohol
– caffeine
– smoking
– drugs
– Non-nutritive sweeteners
– physical activity
• oral health
Nausea & Vomiting:
Cochrane Library, 2003
Quinlan et al, Am Fam Phys, 2003
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
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
n&v
– Case reports that eradication of infection with
antibiotics ameliorates symptoms
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)
Cochrane Conclusions: 2003
• 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.”
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.
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.
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
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
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
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 N&V in
pregnancy, but “unfounded” lawsuits
claiming risk of congenital
malformations forced company to stop
production in 1983.
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.
• >30 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.”
Mahadevan reply, 2007
• “We limited our scope to agents used by
physicians practicing in the United
States who treat women during
pregnancy.”
Stress Associated with N&V
•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…
• 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
Adverse effects of substance
use determined by:
•
•
•
•
•
•
Timing
Dosage
Duration
Number of substances
Environment (nutrition, health status)
Individual susceptibility
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
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
MMWR
December 24, 2004 / 53(50);1178-1181
BRFSS, 2002
MMWR
December 5, 2002
BRFSS
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.
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
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
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
Fetal Alcohol Spectrum Disorders
(FASD)
• Surgeon General’s 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.”
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
Pathophysiology
• Combination of
– Toxic effects of ethanol and it’s derivatives
– Nutritional factors
– Genetic predisposition
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.
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
Surgeon General’s 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
Surgeon General’s Advisory
(2005)
Recommendations:
1.
2.
3.
4.
5.
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.
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
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 99185 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
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
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.”
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.”
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)
Coffee and Health: A Review of Recent
Human Research (Higdon and Frei; Crit
Rev Food Sci and Nutrition, 2006)
Conception
• Many studies find > 300 mg/d associated with
delay in time to conception (some do not find
this effect)
• Author’s conclusions: “it may be prudent for
women who are having difficulty conceiving to
limit caffeine consumption to less than 300
mg/d in addition to eliminating tobacco use
and decreasing alcohol consumption.”
Spontaneous Abortion
• Conflicting studies
• Women who decrease Caffeine due to N&V,
more likely to have viable pregnancies.
• “Most studies that observed significant
associations between self-reported coffee or
caffeine consumption and the risk of
spontaneous abortion did so at intake levels
of at least 300 mg/d of caffeine.”
Fetal Growth
• “Several studies found that maternal caffeine
intakes ranging from 200-400 mg/d were
associated with decreases in mean birth
weight of about 100 g.”
• “A meta-analysis that combined the results of
eight epidemiological studies found that
maternal caffeine consumption greater than
150 mg/d increased the risk of low birth
weight by approximately 50%.”
Preterm Delivery
• “Most epidemiological studies have not
found coffee or caffeine consumption to
be associated with the risk of preterm
delivery.”
Birth Defects
• “At present, there is no convincing
evidence from epidemiological studies
that maternal caffeine consumption
ranging from 300-1000 mg/d increases
the risk of congenital malformations in
humans.”
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 pregnant
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.”
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.
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.
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
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
Norkus et al. FASEB, 1989 and Ann
NY Acad Sci 1987
Smokers
Non-Smokers
Cord vit. C (mg/dl)
0.61
1.68
Placental vit. C
10.1
20.9
(mg/dl)
0.2
0.3
Maternal plasma
carotene (g dl
Cord carotene
19
44
7
20
(mg/dl)
Cord vit. E
(g dl
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
Nutritional Risks Associated
with Smoking, cont.
• Increased carboxyhemoglobin in
smokers blood leads to requires
increased cutoff point for anemia in
smokers.
• Women who smoke may have lower
prepregnancy weights and may have
lower pregnancy weight gains.
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….
Annotation: Cigarette Smoking, Nutrition,
and Birthweight (Rasmussen & Adams, AJPH, 1997)
“…individualized nutrition counseling is
recommended in addition to smoking
cessation.”
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
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
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.
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.”
Exercise
• Benefits:
– improved or maintained fitness
– reduces anxiety and depression
– eases pregnancy discomforts such as
constipation, backache, fatigue and
varicose veins
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
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
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
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
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.
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.”
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
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)
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
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
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
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 gramnegative 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
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.
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
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
Periodontal Health and Birth
Outcomes (Xu et al. Ob Gyn Survey, 2007)
• Evidence of an association between
periodontal disease and increased risk of
preterm birth and low birthweight, especially
in economically disadvantaged populations,
but potential biases and limited number of
RCTs .
• “Currently, there is insufficient evidence to
support the provision of treatment during
pregnancy for the purpose of reducing
adverse birth outcomes.”
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
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