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 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

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.

Characteristics of Preeclampsia-Eclampsia

Characteristics of Preeclampsia-Eclampsia

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

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

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