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Chapter 5 Nutrition During Pregnancy: Conditions and Interventions Nutrition Through the Life Cycle Judith E. Brown Introduction • Health conditions impacting pregnancy & interventions are covered to include: – – – – – – – – Hypertensive disorders of pregnancy Preexisting & gestational diabetes Obesity Multifetal pregnancies HIV/AIDS Eating disorders Fetal alcohol spectrum Adolescent pregnancy Hypertensive Disorders of Pregnancy • Hypertension (HTN) is defined as blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic blood pressure – Affects 6 to 10% of pregnancies – Contributes to stillbirths, fetal & newborn deaths, & other adverse conditions • “Pregnancy-induced hypertension” is being replaced with “hypertensive disorders of pregnancy” Hypertensive Disorders of Pregnancy Hypertensive Disorders of Pregnancy, Oxidative Stress, and Nutrition • HTN in pregnancy is related to: – Inflammation – Oxidative stress – Damage to the endothelium (cells lining the inside of blood vessels) • Consequences of endothelial dysfunction: – Impaired blood flow – Increased tendency to clot – Plaque formation Ways to Reduce Oxidative Stress • Regular intake colorful fruits and vegetables, dried beans and whole-grain products • Adequate intake of vitamin D, & omega-3 fatty acids • Ample physical activity – Weight loss if overweight (not recommended during pregnancy) See Table 5.3. Chronic Hypertension • HTN present before pregnancy or diagnosed <20 weeks • Estimated incidence is 1 to 5% • More common in: – African American, obese, >35 years of age, or history of HTN with previous pregnancy • Blood pressure ≥ 160/110 mm Hg associated with increased risk of: – Fetal death, preterm delivery, & fetal growth retardation Nutritional Interventions for Women with Chronic Hypertension in Pregnancy – Intervention should aim to achieve adequate & balanced diets for pregnancy – Weight gain is same as for other pregnant women – If salt-sensitive, Na restriction required for blood pressure control without too little that could impair fetal growth Gestational Hypertension – Hypertension diagnosed for first time after 20 weeks of pregnancy – No proteinuria – Tend to be overweight or obese with excess central body fat Preeclampsia-Eclampsia – A pregnancy-specific syndrome occurring >20 weeks gestation accompanied by proteinuria • Proteinuria—urinary excretion of ≥0.3 gram protein in 24-hour urine sample (or >30 mg/dL protein or ≥2 on dipstick reading) • Eclampsia—occurrence of seizures not attributed to other causes Characteristics of PreeclampsiaEclampsia • • • • Oxidative stress, inflammation, & endothelial dysfunction Blood vessel spasms & constriction Increased blood pressure Adverse maternal immune system responses to the placenta • Platelet aggregation & blood coagulation due to deficits in prostacyclin relative to thromboxane • Insulin resistance • Elevated blood levels of triglycerides, free fatty acids and cholesterol Characteristics of PreeclampsiaEclampsia • Signs and symptoms of preeclampsia range from mild to severe • Health consequences also range from mild to severe • Cause is unknown – appears to originate from: – Abnormal implantation & vascularization of placenta with poor blood flow. Characteristics of PreeclampsiaEclampsia Characteristics of PreeclampsiaEclampsia Pregnancy After Bariatric Surgery • Bariatric surgery for weight loss has increased • Weight rapidly lost due to – Limited food intake – Fat malabsorption – Dumping syndrome • Deficiencies of many nutrient stores – Thiamine, Vitamins D, B12 and Folate – Iron and calcium Nutrition Care Post-Bariatric Surgery and Pregnancy • Nutrient deficiencies vary depending on type of bariatric surgery performed • Nutrition care includes: – Assessment of dietary intake – Supplement use – Nutrient biomarker status – Weight gain – Physical activity – Gastrointestinal symptoms Diabetes in Pregnancy • Diabetes: a leading complication in pregnancy • Forms of diabetes include: – Type 1 diabetes—Results from destruction of insulin-producing cells of pancreas – Type 2 diabetes—Due to body’s inability to use insulin normally, or produce enough insulin – Gestational—CHO intolerance with 1st onset during pregnancy Gestational Diabetes • See in about 7.5% of pregnant women (and increasing with obesity) • Women who develop gestational diabetes appear to be predisposed to insulin resistance & type 2 diabetes • Associated with increased levels of blood glucose, triglycerides, fatty acids, & blood pressure Potential Consequences of Gestational Diabetes • Elevated glucose from mother – risk of adverse outcomes. – Spontaneous abortion, stillbirth, neonatal death – Congenital anomalies – insulin glucose uptake & triglyceride formation in fetus • Fetal changes likelihood later in life: – Insulin resistance and/or Type 2 diabetes – High blood pressure – Obesity Adverse Outcomes Associated with Gestational Diabetes Risk Factors for Gestational Diabetes • Linked to multiple inherited predisposition • Environmental triggers such as: – Excess body fat – Low physical activity levels Risk Factors for Gestational Diabetes Diagnosis of Gestational Diabetes • Glucose screening recommended for women at high risk • Risk factors are listed below: – – – – – Marked obesity Diabetes in a parent or sibling History of glucose intolerance Previous macrosomic infant Current glucosuria Glucose Screening • First screen is a 50-g oral glucose challenge test • If elevated, 3-hour, 100-g oral glucose tolerance test (OGTT) is given • Gestational diabetes diagnosed if ≥2 of the following levels are exceeded: – Overnight fast 95 mg/dL – 1-hour after glucose load 180 mg/dL – 2-hours after glucose load 155 mg/dL – 3-hours after glucose load 140 mg/dL Low Risk Women Not Needing Glucose Screens • Age <25 years • Not Hispanic, African American, South or East Asian, Pacific Islander, Native American, or Indigenous Australian • No diabetes in first-degree relatives • Normal prepregnancy weight & normal weight gain during pregnancy • No history of glucose intolerance • No prior obstetrical outcomes Treatment of Gestational Diabetes • First approach is to normalize blood glucose levels with diet & exercise • If postprandial glucose remains high 2 weeks after adhering to diet & exercise, insulin injections are added • Medical nutrition therapy decreases risk of adverse perinatal outcomes Exercise Benefits & Recommendations • Regular aerobic exercise decreases insulin resistance & blood glucose in gestational diabetes • Exercise should approximate 50-60% of VO2 max, 3 times per week • • • • Nutritional Management of Women with Gestational Diabetes Assess dietary & exercise habits Develop individualized diet & exercise plan Monitor weight gain Interpret blood glucose & urinary ketone results • Ensure follow-up during & after pregnancy THE DIET PLAN • Whole-grain breads & cereals, vegetables, fruits, & high-fiber foods • Limited intake of simple sugars • Low-GI foods, or carbohydrate foods that do not greatly raise glucose levels • Monounsaturated fats • Three regular meals & snacks Estimating Levels of Caloric Need in Women with Gestational Diabetes • Distribute calories among 3 meals & several snacks • Caloric levels & meal/snack plans are starting points and my need modifications. Consumption of Foods with Low Glycemic Index • Benefits of low-GI foods has been debated and is controversial • Blood glucose response with type 2 diabetes from meals of white bread or spaghetti is shown in graph • Note Lower-GI spaghetti improves blood glucose levels Menus for Women with Gestational Diabetes Other Topics on Diabetes in Pregnancy • Urinary Ketone Testing – Monitored with dipsticks • Postpartum Follow-Up – 15% will remain glucose intolerant postpartum – 10-15% will develop Type 2 diabetes in 2-5 yrs • Prevention of Gestational Diabetes – Reduce excessive weight and obesity – Increase physical activity – Decrease insulin resistance prior to pregnancy Type 1 Diabetes during Pregnancy • Potentially, a more hazardous condition than most cases of gestational diabetes • Mother with type 1 is at risk of: – Kidney disease – Hypertension – Other complications • Newborn born to her is at risk of: – Mortality – Being SGA or LGA – Hypoglycemia within 12 hours after birth Nutritional Management of Type 1 Diabetes during Pregnancy • • • • Control of blood glucose levels Nutritional adequacy of diet Achieve recommended weight gain Careful home monitoring of glucose levels & dietary intake, exercise, insulin dose, & urinary ketone levels Multifetal Pregnancies • U.S. rates of multifetal pregnancies have increased – Linked to assisted reproductive technologies • Spontaneous multifetal pregnancy after 35 years of age • Incidence highest in women 45 to 54 y/o (1 in 5 are multifetal) Background Information About Multifetal Pregnancies • Dizygotic – – – – 2 eggs are fertilized AKA Fraternal ~70% of twins Different genetic “fingerprints” – Incidence increased by perinatal nutrient supplements • Monozygotic – 1 egg is fertilized – AKA Identical • (or almost identical) – Always same sex – ~30% of twins – Rates appear not to be influenced by heredity Note the Differences in Placentas and Amniotic Sacs The Vanishing Twin Phenomeon • It is estimated that 6 to 12% of pregnancies begin as twins with only 3% born as twins • Most fetal losses silently occur by absorption into the uterus within the 1st 8 months Risks Associated with Multifetal Pregnancy Complications Increase as Number of Fetuses Increases Nutrition and the Outcome of Multifetal Pregnancy • Weight gain in multifetal pregnancy – IOM recommends 25-54 pounds • Rate of weight gain in twin pregnancy – 0.5 pounds per week in 1st trimester – 1.5 pounds per week in 2nd & 3rd trimesters • Weight gain in triplet pregnancy – Gain of ~50 pounds or 1.5 pounds per week Nutrition and the Outcome of Multifetal Pregnancy • Dietary intake in twin pregnancy – Benefits from increases in essential fatty acids, iron & calcium • Vitamin and mineral supplements – Needs unknown • Nutritional recommendations – Based on logical assumptions & theories – Table 5.16 indicates “Best Practice” HIV/AIDS during Pregnancy • Treatment of HIV/AIDS – Needed before, during & after pregnancy • Consequences of HIV/AIDS during pregnancy – Infection does not appear to be related to adverse pregnancy outcome • Nutritional factors and HIV/AIDS during pregnancy – Nutritional needs increase the most in advanced stages of HIV/AIDS Nutritional Management for Women With HIV/AIDS during Pregnancy • Goals for nutritional management include: – Maintenance of positive nitrogen balance & preservation of lean muscle & bone mass – Adequate intake of energy & nutrients to support maternal physiological changes & fetal growth & development – Correction of elements of poor nutritional status identified by nutritional assessment – Adoption of safe food-handling practices – Delivery of a healthy newborn Fetal Alcohol Spectrum • “Fetal alcohol spectrum” describes range of effects that fetal alcohol exposure has on mental development & physical growth • Effects include: – – – – – Behavioral problems Mental retardation Aggressiveness Nervousness & short attention span Stunting growth & birth defects Fetal Alcohol Spectrum • Fetal exposure to alcohol is a leading preventable cause of birth defects – ~1 in 12 American pregnant women drink alcohol – 1 in 30 consume ≥5 drinks on 1 occasion at least monthly – 1 in 1000 newborns are affected by fetal alcohol syndrome Effects of Alcohol on Pregnancy Outcome • Alcohol easily crosses placenta to fetus • Alcohol remains in fetal circulation because fetus lacks enzymes to break down alcohol • Alcohol exposure during critical periods of growth & development can permanently impair organ & tissue formation, growth, health and mental development Effects of Alcohol on Pregnancy Outcome • Heavy drinking (4-5 drinks/day) increases risk of miscarriage, stillbirth, & infant death • ~40% of fetuses born to women who drink heavily will have fetal alcohol syndrome • Because a “safe” dose of alcohol consumption during pregnancy has not been identified, it is recommended that women do not drink alcohol while pregnant Fetal Alcohol Syndrome • First identified in 1973 • Characteristics include: – Anomalies of eyes, nose, heart & CNS – Growth retardation – Small head – Mental retardation Nutrition and Adolescent Pregnancy • Growth during adolescent pregnancy – Teen growth in height & weight at expense of fetus – Infants born to teens average 155g less than those born to older adults Nutrition and Adolescent Pregnancy Obesity, Excess Weight Gain and Adolescent Pregnancy • Overweight & obese adolescents are at increased risk for: – – – – Cesarean delivery Hypertensive disorders of pregnancy Gestational diabetes Delivery of excessively large infants Dietary Recommendations for Pregnant Adolescents • Young adolescents may need more calories to support their own growth as well as that of fetus • Caloric need should be from nutrient-dense diet • Calcium DRI for pregnant teens is 1300 mg Nutritional Management of Adolescent Pregnancy • Multidisciplinary counseling services should include: – – – – Individualized nutrition assessment Intervention education Guidance on weight gain Follow-up birthweight outcomes Nutritional Management of Adolescent Pregnancy • Services should focus on: – Psychosocial needs – Support/discussion groups – Home visits Evidence-Based Practice “Enormous amounts of new knowledge are barreling down the information highway, but they are not arriving at the doorsteps of our patients.” − Claude Lenfant, National Institutes of Health