1. Chapter 5 Nutrition During Pregnancy: Conditions and Interventions
Nutrition Through the Life Cycle
Judith E. Brown

2. 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

3. 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”

4. Hypertensive Disorders of Pregnancy

5. 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

6. 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.

7. 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

8. 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

9. 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

10. 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

11. Characteristics of Preeclampsia-Eclampsia
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

12. Characteristics of Preeclampsia-Eclampsia
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.

13. Characteristics of Preeclampsia-Eclampsia

14. Characteristics of Preeclampsia-Eclampsia

16. 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 16

17. 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 17

18. 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

19. 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

20. 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

21. Adverse Outcomes Associated with Gestational Diabetes

22. Risk Factors for Gestational Diabetes
Linked to multiple inherited predisposition
Environmental triggers such as:
Excess body fat
Low physical activity levels

23. Risk Factors for Gestational Diabetes

24. 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

25. 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

26. 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

27. 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

29. 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

30. 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

31. 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

32. 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.

33. 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

34. Menus for Women with Gestational Diabetes

35. 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

36. 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

37. 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

38. 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)

39. 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

40. Note the Differences in Placentas and Amniotic Sacs

41. 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

42. Risks Associated with Multifetal Pregnancy

43. Complications Increase as Number of Fetuses Increases

44. Nutrition and the Outcome of Multifetal Pregnancy
Weight gain in multifetal pregnancy
IOM recommends 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

45. 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”

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. Fetal Alcohol Syndrome
First identified in 1973
Characteristics include:
Anomalies of eyes, nose, heart & CNS
Growth retardation
Small head
Mental retardation

54. 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

55. Nutrition and Adolescent Pregnancy

56. 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

57. 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

58. Nutritional Management of Adolescent Pregnancy
Multidisciplinary counseling services should include:
Individualized nutrition assessment
Intervention education
Guidance on weight gain
Follow-up birthweight outcomes

59. Nutritional Management of Adolescent Pregnancy
Services should focus on:
Psychosocial needs
Support/discussion groups
Home visits

60. 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