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. 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

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

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. 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

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. 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

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 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

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