Chapter 5 Nutrition During Pregnancy: Conditions and Interventions

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

2. Key Nutrition Concept #1 • Some complications of pregnancy are related to women’s nutritional status.

3. Key Nutrition Concept #2 • Nutritional interventions for a number of complications of pregnancy can benefit maternal and infant health outcomes.

4. Key Nutrition Concept #3 • Nutritional interventions during pregnancy should be based on scientific evidence that supports their safety, effectiveness, and affordability.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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”

12. Hypertensive Disorders of Pregnancy

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.

21. Characteristics of Preeclampsia-Eclampsia

22. Characteristics of Preeclampsia-Eclampsia

24. 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

25. 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

26. 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

27. Adverse Outcomes Associated with Gestational Diabetes

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

29. Risk Factors for Gestational Diabetes

30. 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

31. 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

32. 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

33. 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

35. 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

36. 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

37. 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

38. 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.

39. 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 Consumption of Foods with Low Glycemic Index

40. Menus for Women with Gestational Diabetes

41. 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

42. 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

43. 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

44. 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)

45. 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 Background InformationAbout Multifetal Pregnancies

46. Note the Differences in Placentas and Amniotic Sacs

47. 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

48. Risks Associated with Multifetal Pregnancy

49. Complications Increase as Number of Fetuses Increases

50. 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