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

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

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

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

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

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

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: Chronic inflammation Oxidative stress Damage to the endothelium 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 Ample physical activity See Table 5.3

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

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

Gestational Hypertension Hypertension diagnosed for first time after mid-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 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

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

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

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 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

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 Unhealthful diets Low physical activity levels

Risk Factors for Gestational Diabetes

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

Diagnosis of Gestational Diabetes All pregnant women without diabetes should be tested for GDM by a 75-gm oral glucose tolerance test at 24-28 weeks. Diagnosis cutpoints: Fasting plasma glucose >92 mg/dL 1-hr plasma glucose >180 mg/dL 2-hr plasma glucose >153 mg/dL

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

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

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

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

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

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

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

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

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

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

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 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

Risks Associated with Multifetal Pregnancy

Complications Increase as Number of Fetuses Increases

Nutrition and the Outcome of Multifetal Pregnancy Weight gain in multifetal pregnancy based on prepregnancy weight IOM recommends 25-54 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

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”

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: 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

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

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

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

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

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

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

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

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

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 RDA 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 All enhance birthweight outcomes

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