1. HUN 3403 Wk1 D3b Chapter 5 Nutrition During Pregnancy: Conditions and Interventions

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. Obesity and Pregnancy
Obesity associated with higher rates of gestational diabetes and hypertensive disorders
Associated with unfavorable metabolic changes:
 blood glucose levels
 C-reactive protein levels
 blood levels of insulin & insulin resistance
 blood pressure
High Total, LDL-cholesterol & Triglycerides
Low HDL-cholesterol

4. Obesity and Infant Outcomes
Obesity associated with higher rates of
Stillbirth
Large for gestational newborns
Cesarean-section delivery
May increase risk of child becoming overweight or having Type 2 diabetes later in life

5. Nutritional Recommendations and Interventions for Obesity in Pregnancy
Meet nutrient needs
Consume a variety of basic foods
Participate in physical activity
Maintain appropriate rates of weight gain
Weight loss is not recommended

6. 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

7. 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

8. 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”

9. Hypertensive Disorders of Pregnancy

10. Hypertensive Disorders of Pregnancy, Oxidative Stress, and Nutrition
HTN in pregnancy is related to:
Chronic inflammation
Oxidative stress
Damage to the endothelium of blood vessels
Consequences of endothelial dysfunction:
Impaired blood flow
Increased tendency to clot
Plaque formation

11. Ways to Reduce Oxidative Stress
Regular intake colorful fruits and vegetables, dried beans and whole-grain products
Adequate intake of vitamin D
Ample physical activity
See Table 5.3

12. Chronic Hypertension
HTN present before pregnancy or diagnosed <20 weeks
Estimated incidence is 3%
More common in:
African American, obese, >35 years of age, or history of HTN with previous pregnancy
Associated with increased risk of:
preterm delivery, fetal growth retardation, placenta abruption, Cesarean delivery

13. 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
Continue Na reduction required for blood pressure control without too little that could impair fetal growth

14. Gestational Hypertension
Hypertension diagnosed for first time after mid-pregnancy
No proteinuria
Tend to be overweight or obese with excess central body fat

15. 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

16. Characteristics of Preeclampsia-Eclampsia
Oxidative stress, inflammation, & endothelial dysfunction
Platelet aggregation & blood coagulation due to deficits in prostacyclin relative to thromboxane
Blood vessel spasms & constriction
Increased blood pressure
Insulin resistance
Adverse maternal immune system responses to the placenta
Elevated blood levels of triglycerides, free fatty acids and cholesterol

17. 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.

18. Characteristics of Preeclampsia-Eclampsia

19. Characteristics of Preeclampsia-Eclampsia

20. Recommendations and Interventions for Preeclampsia
Adequate calcium intake
Adequate vitamin D status
Use of multi-vitamin/minerals if needed
>5 servings of colorful vegetables and fruits daily
Adequate fiber intake (>21 grams/day)
Basic foods from MyPlate recommendations
Moderate exercise
Recommended weight gain

22. 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

23. Gestational Diabetes
In about 2-12% of pregnant women (increases with obesity)
Women developing gestational diabetes appear to be predisposed to insulin resistance, and have impaired insulin production
Related to metabolic changes favoring oxidative stress and elevated blood glucose

24. 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

25. Adverse Outcomes Associated with Gestational Diabetes

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

27. Risk Factors for Gestational Diabetes

28. Diagnosis of Gestational Diabetes
All pregnant women should be screened at first prenatal visit.
Confirm positive result for any of following for diagnosis:
Hemoglobin A1c (A1c) >6.5%
Fasting plasma glucose >126 mg/dL (7.0 mmol/L)
2-hour glucose >200 mg/dL after 75 g oral load
Classic symptoms of hyperglycemia present
Random plasma glucose >200 mg/dL

29. Diagnosis of Gestational Diabetes
All pregnant women without diabetes should be tested for GDM by a 75-gm oral glucose tolerance test at weeks.
Diagnosis cutpoints:
Fasting plasma glucose >92 mg/dL
1-hr plasma glucose >180 mg/dL
2-hr plasma glucose >153 mg/dL

30. Management of Gestational Diabetes
First approach is medical nutrition therapy to normalize blood glucose levels with diet & exercise
Blood glucose levels can be brought down with low calorie intake – avoid elevated ketones
Oral medication metformin (glyburide) used to decrease insulin resistance

32. Exercise Benefits & Recommendations
Regular aerobic exercise decreases insulin resistance & blood glucose in gestational diabetes
Recumbent bicycle at moderate intensity 45 min 3 x week
Weight lifting with arms 20 min 3 x week
Brisk walking 30 minutes every day
Exercise to make women slightly sweaty but not overheated, dehydrated or exhausted

33. 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

34. 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
Unsaturated fats
Three regular meals & snacks
Based around calculated level of calories

35. 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.
See Table 5.11 for menu examples

36. Consumption of Foods with Low Glycemic Index
Low GI carbohydrate foods helps sustain modest improvement in blood glucose levels
Blood glucose response with diabetes from meals of white bread or spaghetti is shown in graph

37. Gestational Diabetes 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

38. Type 2 Diabetes during Pregnancy
Care should be individualized and follow protocol
Primary goal – maintain normal blood glucose
Hyperglycemia and hypoglycemia are possible
Routine testing for urinary ketones not recommended
Medical nutrition therapy recommended

39. Type 1 Diabetes during Pregnancy
Potentially, a more hazardous condition than most cases of gestational or type 2 diabetes
Mother with type 1 is at risk of:
Kidney disease
Hypertension
Other complications
Newborn is at risk of:
Mortality
Being SGA or LGA
Hypoglycemia within 12 hours after birth

40. Nutritional Management of Type 1 Diabetes during Pregnancy
Control of blood glucose levels
Caloric and nutritional adequacy of diet
Achieve recommended weight gain
Careful home monitoring of glucose levels & dietary intake, exercise, insulin dose, & urinary ketone levels

41. Multifetal Pregnancies
U.S. rates of multifetal pregnancies have increased
Linked to assisted reproductive technologies
Spontaneous multifetal pregnancy  after 35 years of age, and  weight status

42. 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

43. Note the Differences in Placentas and Amniotic Sacs

44. The Vanishing Twin Phenomenon
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 weeks

45. Risks Associated with Multifetal Pregnancy

46. Complications Increase as Number of Fetuses Increases

47. Nutrition and the Outcome of Multifetal Pregnancy
Weight gain in multifetal pregnancy based on prepregnancy weight
IOM recommends pounds
Rate of weight gain in twin pregnancy
5-7 pounds in 1st trimester
1-2 pounds per week in 2nd & 3rd trimesters
Weight gain in triplet pregnancy
Gain of ~50 pounds or 1.5 pounds per week

48. Nutrition and the Outcome of Multifetal Pregnancy
Dietary intake in twin pregnancy
Higher caloric need
Benefits from increases in essential fatty acids, iron & calcium
Vitamin and mineral supplements
Needs unknown
Nutritional recommendations
Table 5.17 indicates “Best Practice”

50. 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

51. Nutritional Management for Women With HIV/AIDS during Pregnancy
Goals for nutritional management include:
Insure adequate intake of calories and essential fatty acids
Facilitate access to food assistance programs
Correction of elements of poor nutritional status identified by nutritional assessment
Treatment of iron deficiency
Multivitamin and mineral supplementation in moderation
Adoption of safe food-handling practices
More guidelines in Table 5.18

52. Eating Disorders in Pregnancy
Eating disorders are rare in pregnancy since most females with disorders are subfertile or infertile
Bulimics more likely to become pregnant than those with anorexia nervosa
Eating disorder symptoms subside in 2nd & 3rd trimester but return postpartum

53. Eating Disorders in Pregnancy
Consequences of eating disorders in pregnancy  risk
Spontaneous abortion
Hypertension
Difficult deliveries
Smaller newborns
Higher rates neonatal complications

54. Eating Disorders in Pregnancy
Treatment of women with eating disorders during pregnancy
Refer to eating disorders clinic
Nutritional interventions for women with eating disorders
Behavioral changes
Improve nutritional status
Appropriate weight gain

55. Fetal Alcohol Spectrum Disorders
“Fetal alcohol spectrum disorders” (FASD) 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

56. Fetal Alcohol Spectrum Disorders
Fetal exposure to alcohol is a leading preventable cause of birth defects
~12% of American pregnant women drink alcohol once a month
2% consume ≥5 drinks on at least 1 occasion
1% of Americans have symptoms related to alcohol consumption during pregnancy

57. Fetal Alcohol Spectrum Disorders
Fetal alcohol syndrome (FAS)
Most severe form
Abnormal facial features
Growth problems
CNS abnormalities
Problems with social skills, learning, memory, attention span, communication, vision, hearing

58. Fetal Alcohol Spectrum Disorders
Alcohol-related neurodevelopment disorder (ARND)
No overt physical features
Intellectual disabilities
Problems with behavior, learning, coping, impulse control, attention

59. Fetal Alcohol Spectrum Disorders
Alcohol-related birth defects (ARBD)
Abnormalities of the heart, kidneys, bones, or hearing
Estimated that 44% of children with FASD have CNS impairments resulting in behavioral and intellectual disabilities
Although there is no firm evidence that small amounts of alcohol cause harm, not drinking during pregnancy is recommended

60. 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

61. Nutrition and Adolescent Pregnancy

62. 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

63. 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 RDA for pregnant teens is 1300 mg

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

65. Nutritional Management of Adolescent Pregnancy
Services should focus on:
Psychosocial needs
Support/discussion groups
Home visits
Referral to assistance programs