4.3 Placental met, pregnancy and nutrition - Part 2

Question 1

FROM SCHÉMA: during pregnancy, name:
- 6 things ish that increase
- 1 thing that changes
- 1 thing that slows down

Answer 1

INCREASE:
- blood volume and RBC mass
- uterus expands
- heart rate increase by 20%
- curvature of spine increases (bc abdomen increases)
- fat stores increase to provide more nutrient to fetus
- hormones promote growth
CHANGES in:
- breast tissue
SLOWS DOWN:
- gastrointestinal motility, to give more food to baby

Question 2

what happens during pregnancy (increase or decrease)
- GFR, tubular reabsorption, renal loss of glu/folate/iodine/aa
- histamine and pepsin
- excretion of fetal waste products, GI motility, risk of constipation, efficiency of nutrient absorption
- cardiac output
- ventilation, oxygen demands
- plasma lipids, lipolysis
- blood glucose
- muscle breakdown, placental uptake of alanine, alanine availability for mother
- hepatic gluconeogenesis

Answer 2

(I) = increase
(D) = decrease
- (I) GFR, (D) tubular reabsorption, (I) renal loss of glu/folate/iodine/aa
- (D) histamine and pepsin
- (I) excretion of fetal waste products, GI motility, (I) risk of constipation, (I) efficiency of nutrient absorption
- (I) cardiac output
- (I) ventilation, (I) oxygen demands
- (I) plasma lipids, (I) lipolysis + mild ketosis
- (D) blood glucose in 3rd trimester
- (D) muscle breakdown, (I) placental uptake of alanine, (D) alanine availability for mother
- (impaired) hepatic gluconeogenesis

Question 3

what are 5 symptoms that happen to pregnancy mothers? relating to GI tract ish

Answer 3

1. changes in smell and taste
2. nausea/vomiting
3. heartburn
4. gastroesophageal reflux disease (GERD)
5. constipation

Question 4

changes in smell and taste during pregnancy
- impact ________ behavior during pregnancy
- food ______ and _______ common due to changes in smell and taste
- 2/3 pregnant women report heightened sense of _________ –> hypothesized to be associated with what?

Answer 4

• impact dietary behavior
• food cravings and aversions –> may have preference for fruits, dairy products and sweet/salty foods
• heightened sense of smell –> associated with natural changes in hormones

Question 5

• what does “morning sickness” refer to?
• cause?
• starts at which week? stops at which week?
• harmful?
• predictor of pregnancy outcomes?
• how to prevent and treat?

Answer 5

• nausea and vomiting –> common during pregnancy
• cause not clear
• start at 6th week, stops around 12 wks
• not harmful unless too many skipped meals –> ketosis and hypoglycemia + could have deficiencies
• nausea/vomiting: positive predictor for pregnancy outcome & decreased risk of fetal death
• avoid foods and smells that trigger nausea + small frequent high fat, low bulk meals

Question 6

Heartburn:
- occurs in which trimester(s) in pregnancy? but mostly in which one?
- causes (2)

Answer 6

• can occur in all trimesters –> mostly in 3rd trimester
  1. increase in estrogen and progesterone –> relaxation of GI muscles + of lower esophageal sphincter –> stomach contents move into esophagus, causing heartburn, or more severely, gastroesophageal reflux disease (GERD)
  2. cause also be caused by pressure from uterus and fetus

Question 7

Gastroesophageal reflux disease (GERD)
- caused by what?
- triggers (6)
- how to help manage symptoms?

Answer 7

• caused by impact of fluctuating hormones (estrogen/progesterone) on lower esophageal sphincter –> stomach acid easily refluxes into esophagus (hearburn)
  TRIGGERS:
• eating before bed
• intake of fatty or spicy foods
• caffeine, mints, chocolate
• side effects of medication
  MANAGE SYMPTOMS: lifestyle modifications addressing triggers: no food before bed, decrease caffeine, mints, chocolate, no fat/spicy food + drug therapy may be warranted for severe cases

Question 8

constipation
- occurs in which trimester? common?
- due to 5
- can be reduced by (2)
- laxative recommended?

Answer 8

• especially in 3rd trimester. in 25-40% of pregnancies
  CAUSES:
• relaxed musculature of GI tract
• physiological and hormonal changes in GI system
• decreased maternal activity
• iron supplementation
• normal slowed GI transit with hormonal shifts (increase estrogen and progesterone)
  REDUCE:
• increase fiber intake to 30g per day
• increase fluid intake to 6-8 glasses per day
  + PA, bulk forming agents, probiotic supplements
• laxative generally not recommended during pregnancy bc can cause dehydration and nutrient deficiencies

Question 9

weight gain recommendations for mother based on what?
- should underweight or overweight mothers gain more weight?

Answer 9

based on BMI of mother!
- underweight: 28-40 lbs
- BMI 18.5-24.9: 25-35 lbs
- BMI 25.0-29.9: 15-25 lbs
- BMI > 30: 11-20 lbs

Question 10

pregnancy weight gain:
- woman needs ___% of body wt as fat
- avg weight gain of 12.5 kg –> 20% gain overall –> of which, 40% is (3)
- if BMI > 29: limit to ___ kg wt gain
- if twins, ___-____ lbs regardless of pre-pregnancy wt

Answer 10

• 22% fat
• 40% is fetal, placental tissues and amniotic fluid
• limit to 6 kg wt gain
• twins: gain 35-45 lbs

Question 11

what is the pattern of weight gain during pregnancy?
- what can cause concern?

Answer 11

• 3-4 lbs for 1st 10 weeks
• 1 lb/ week for the rest of pregnancy (most weight gain is during 2nd and 3rd trimester)
• > +1kg/week causes for concern –> likely excessive edema and risk for preeclampsia + increase risk of placental abruption, stillbirth, decreased blood flow to placenta, LBW

Question 12

if there’s less than 20 lbs weight gain during pregnancy = increased risk of what?

Answer 12

increased risk of being born premature or being small for gestational age

Question 13

obligatory weight gain = 5 things
- insufficient blood volume expansion increase risk of (3)
- increase (2) is directly related to feral size
- 2/3 of maternal weight gain is (4) (not related to fetus)

Answer 13

• fetus, placenta + enlarged uterine + enlarged breast tissue + expanded blood volume
• increase risk still births, LBW, spontaneous abortions
• 2/3 of maternal weight gain = maternal tissue accretion + expansion of maternal blood volume + extracellular fluid + fat stores

Question 14

• weight gained during 1st 20 weeks is mostly (2) –> for what?
• vs what composes most of weight gained during 2nd half of pregnancy?

Answer 14

1st half of pregnancy:
- gain in adipose tissue and protein stores
- 40% of energy needed to support pregnancy is deposited in 1st 20 weeks
- avg 3.8kg fat laid down by 30th week = increase subcutaneous fat to protect from energy deficit at the end of pregnancy and during lactation
2nd half of pregnancy:
- fetal tissues, placenta and amniotic fluid comprises most of wt gain
- rest of weight gain = extracellular fluid, fat and protein stores

Question 15

• what fraction of weight gained in normal-weight woman goest to fetus?
• fat storage increases most significantly during which semester? will decrease?
• body fat stores provide avg reserve of _______ cals for pregnancy and lactation

Answer 15

• 1/2
• during first several weeks of 2nd trimester and tends to decrease alter in pregnancy
• 30 000 cals –> increased body fat helps to meet the nutritional needs of mother and fetus

Question 16

avg weight distribution during pregnancy: (how many lbs)
- breast size
- uterus and muscles
- blood and fluids
- fetus, placenta
- maternal fat stores

Answer 16

• breast size: 1lb
• uterus and muscles: 2 lbs
• blood and fluids: 5.5 lbs
• fetus, placenta: 11 lbs
• maternal fat stores: 4-8 lbs

Question 17

entering pregnancy underweight:
- increase risks of (7 ish)
- mothers should focus on (3)

Answer 17

RISKS:
- maternal bone and muscle loss
- vitamin and mineral deficiencies
- anemia
- fatigue
- preterm delivery
- intrauterine growth retardation (IUGR)
- low birth weight
FOCUS ON:
- balanced diet of meals and snacks
- listening to hunger and fullness cues
- engaging in physical activity regularly

Question 18

entering pregnancy overweight/obese:
- weight loss during pregnancy is advised?
- weight gain goals based on what?
- increased risk of (3) for fetus
- increased risks for mother (7)

Answer 18

• NOT advised
• based on BMI
  FETUS:
• fetal death + congenital malformations + increased perinatal complications (ie speaking, concentration)
  MOTHER:
• gestational diabetes
• hypertension
• preeclampsia
• dyslipidemia
• cardiovascular disease
• cesarean delivery
• less likely to start and sustain breastfeeding

Question 19

3 interventions to prevent excess weight gain

Answer 19

1. nutrition counseling and education
2. increased physical activity
3. improved diet

Question 20

4 tips for healthy weight gain during pregnancy

Answer 20

1. do not skip meals –> aim for 5-6 small meals each day
2. include snacks throughout the day –> go no longer than 3-4 hours without eating
3. add healthy oils, butter, cream cheese, sour cream, cheese or gravy to meals
4. consume more healthy fats, including nuts, avocado, oilce oil and fish

Question 21

• what is gestational diabetes mellitus?
• usually which trimester?
• usually resolves?
• increases risk for what later in life?
• higher risk for pregnancy complications (3)

Answer 21

• glucose intolerance diagnosed for first time in pregnancy
• usually 2nd or 3rd trimester
• usually resolves after childbirth
• T2D + experience it in future pregnancies
  1. C-section
  2. macrosomia (baby wt > 4 kg)
  3. neonatal hypoglycemia
  + can be harmful to baby
• incidence of GDM increasing likely due to rising obesity rates

Question 22

how to prevent GDM (2)
- treatment goal (2)
- what is preferred choice of medication?

Answer 22

• dietary and exercise-related interventions
• treatment:
  1) maintain blood glucose levels to minimize risk
  2) individualized medical nutrition therapy
• insulin + self-monitoring of blood glucose mandatory

Question 23

Hypertension:
- systolic vs diastolic BP more than what = HPT?
- hypertension in pregnancy classified into 3 groups: when?
- maternal hypertension prevents what?

Answer 23

• systolic BP > 140 mmHg
• diastolic BP > 90 mmHg or both
  1. chronic hypertension: 1st 20 weeks
  2. gestational hypertension: 2nd 20 weeks
  3. preeclampsia: mostly after 20 wks
• maternal hypertension prevents placenta from getting enough blood and can result in LBW

Question 24

preeclampsia:
- characterized by (2)
- occurs after ____th week of gestation
(can lead to complications for mother and baby –> routine screening is recommended)
- most effective treatment?
- adherence to which diet is recommended?

Answer 24

• by high BP and protein in urine (kidney fct is harmed)
• 20th week
• most effective treatment = delivery of baby
• DASH diet

Question 25

MENTAL HEALTH:
- (2) in mother are most common
- increases risk for adverse outcomes in child (3)
- which vitamins/minerals linked to improving mental health disorders? (3)

Answer 25

• anxiety and depression
• emotional problems + symptoms of ADHD + impaired cognitive development
• iron, folate and vit B12
  *important for clinicians to assist women in selecting nutrient-dense foods and bevs

Question 26

Depression:
- common but often under______ and under_______
- likely a result of multiple factors, including (2)
- linked to (4)
- signs of depression (6)

Answer 26

• underdiagnosed and underrepported
• nutrition and decreased physical activity (not only caused by hormones)
• preeclampsia, birth difficulties, reduced breastfeeding, risk of developmental and behavioral issues in offspring (learning, concentration, decision)
  1. depressed mood
  2. loss of interest
  3. guilt or low self-worth
  4. disturbed sleep or appetite
  5. low energy
  6. poor concentration

Question 27

• what are 3 common forms of eating disorders?
  (place mother and baby at risk for negative health outcomes, ie not gain enough weight during pregnancy)
• likely contributing factors (3)
• risk of ________ if _______
• risk of _______ if ________
• _____ ______ and patient monitoring essential

Answer 27

• anorexia nervosa (also common with amenorrhea), bulimia nervosa, binge-eating disorder
• genetics, emotional and psychological health, societal pressure
• risk of dehydration if bulimic
• risk of gestational diabetes if overweight (binge eating)
• meal planning and patient monitoring = essential

Question 28

• what is pica?
• potential complications (3)
• low (3) associated with pica
• possible to prevent?

Answer 28

• craving for nonnutritive substances (ie chalk, dirt, clay, laundry powder, ice, paint)
• iron-deficiency anemia, increased risk of elevated blood lead levels/lead poisoning, and other toxicities
• low hemoglobin, hematocrit and plasma zinc associated with pica –> direction of relationship is unclear
• impossible to predict and prevent

Question 29

• birth weight determined by (2) (concepts ish)
• 3 most important determinants of birth weight
• mortality rates are lowest for infants btw ___ and ___ kg
• high perinatal _____ and ______ related to LBW

Answer 29

• duration of gestation and rate of fetal growth
  1. gestational age
  2. maternal weight gain
  3. preconception weight
• 2.5 and 4 kg
• morbidity and mortality

Question 30

what are 2 main problem/causes of low birth weight?

Answer 30

1. premature: gestational age <= 37 weeks
2. intrauterine growth retardation
   - < 2 SDs in weight for gestational age
   - < 10th percentile in weight for gestational age
   < 2500 g and gestational age > 37 wks

Question 31

7 causes of preterm birth

Answer 31

1. genitourinary infection
2. multiple pregnancies
3. pregnancy induced hypertension
4. low prepregnancy BMI
5. prior history
6. smoking (strong risk factor for IUGR)
7. strenuous physical labor

Question 32

MILDLY PRETERM
- ___-____ weeks
- somewhat elevated risks of (3)
EXTREMELY PRETERM INFANTS
- < ___ weeks
- severe morbidity in infancy and childhood –> 3 examples

Answer 32

MILDLY PRETERM
- 32-36 weeks
- somewhat elevated risk of respiratory disorder syndrome (RDS), infection, mortality
EXTREMELY PRETERM INFANTS:
- < 25 weeks
- severe morbidity:
1. retinopathy of prematurity (blindness)
2. chronic lung disease (increase need for O2) –> ie bronchopulmonary dysplasia
3. most serious: neurocognitive (cerebral palsy, mental retardation, seizure disorders…)

Question 33

intrauterine growth retardation associated with/caused by (8 things from the mother)

Answer 33

1. congenital anomalies
2. low energy intake
3. low prepregnancy BMI
4. short maternal stature
5. pregnancy-induced hypertension
6. smoking
7. alcohol
8. malaria

Question 34

schéma thingy of IUGR causes:
- IUGR separates into (2)
1. separates into 2 and one branch separates into 3
2. separates into 2

Answer 34

1. proportionate: more severe, long term, since the 1st trimester
   a) extreme fetal malnutrition (right at beginning of pregnancy and continues on during
   b) decreased growth potential
   - congenital infection
   - genetic disorder
   - environmental toxins
2. disproportionate (less severe health risk)
   a) uteroplacental insufficiency: issues in placental dev more towards end of pregnancy (infections, malaria…)
   b) maternal malnutrition (ie placenta can’t grow properly)

Question 35

• what characteristics in developing countries lead to IUGR? (2)
• effects of IUGR for the child? (4)

Answer 35

• typically shorter & lighter women (more physical labor) + malaria is a major cause of anemia in women with first offspring
  1. hypoglycemia + hypocalcemia in early neonatal period
  2. most IUGR infants survive this period, but risk of infection
  3. catch-up growth is incomplete in many children
  4. mild neurocognitive deficits and behavioral problems

Question 36

what are 2 abnormal patterns of fetal growth linked to adult disease?

Answer 36

1. symmetrical small babies of LBW:
   - babies thin at birth but undergo catch-up later in infancy: disproportionately large head & narrow waist (ie low ponderal index = birth weight/length^3)
2. average birth weight infants but abnormally small in proportion to their placental weight
   - tend to grow below average during infancy

Question 37

difference between proportionate IUGR and disproportionate IUGR?

Answer 37

PROPORTIONATE:
- both length and weight of baby are affected
- more severe consequences
DISPROPORTIONATE:
- ie length grows normally but weight growth is slow in second trimester and becomes normal again ish in 3rd trimester

Question 38

4 risks for child who is LBW?
- vs excessive birth weight (> ___ lbs) linked with increase risk of what?

Answer 38

1. decreased lung capacity during childhood
2. x2 risk of CVD
3. x6 risk of diabetes and impaired glucose metabolism
4. increased blood pressure risk, abnormal high TG, insulin and low HDL
   - > 9 lbs –> linked with increase risk of hormonally related cancers

Question 39

mechanisms of pregnancy undernutrition:
1. undernutrition –> increase maternal ________ production –> increase fetal maturation of _____ and ______ ________
- advantageous in providing increase maturation of ______ –> increase short/long-term survival
2. inadequate development of _______ –> decrease ability to break down (3 hormones ish)
- exposure to one of the 3 hormones in early gestation is linked with increase risk of what later in life

Answer 39

1. undernutrition –> increase maternal corticosteroid production –> increase fetal maturation of lungs and other organs
   - advantageous in providing increase maturation of organs –> increase short-term survival
2. inadequate development of placenta –> decrease ability to break down corticosteroids, insulin and thyroxine
   - exposure to cortisol in early gestation is linked with increase risk of hypertension later in life

Question 40

exercise recommendations for pregnancy women:
- rec?
- benefits (6 ish)

Answer 40

• at least 30 minutes, 5 times each week OR a total of 150 minutes per week
  1. moderate to vigorous exercise both mentally and physically beneficial for mother and fetus
  2. helps maintain approximate gestational weight gain and appropriate fetal weight gain
  3. may reduce hypertensive disorders and gestational diabetes

Question 41

should pregnancy women do strength training? aerobic activity?
- should be accompanied by what? (3)

Answer 41

• yes! strength training and aerobic activity positively impact maternal and fetal health
• should be accompanied by well-balanced diet, proper hydration and adequate rest

Question 42

possible contraindications to pregnant women exercise recommendations (6)

Answer 42

1. low-lying placenta
2. severe anemia
3. persistent second or third trimester bleeding
4. preeclampsia
5. pregnancy with more than 1 baby at a time
6. previous history of miscarriage

Question 43

• what is food insecurity?
• more common among which women during pregnancy?
• increases risk of (4)

Answer 43

• inability to obtain nutritious and safe foods in socially acceptable ways
• more common along low-income women during pregnancy
  1. low birth weight
  2. poor brain development
  3. infections
  4. certain congenital disabilities

Question 44

8 categories for nutritional risk for pregnancy

Answer 44

1. poverty: poorer nutritional intake/status, increased smoking –> 2x risk LBW (decrease by 200-300g)
2. low pre-pregnancy and pregnancy weight
3. short interconception interval: high physiological/nutritional demands on body stores of nutrients
4. chronic systemic illness (cancer, CVD, diabetes, chronic infection, alcoholism, malabsorption)
5. unusual dietary patterns (food faddism, pica)
6. history of anemia or obesity (long term imbalanced or inappropriate diet)
7. poor reproductive history (prior LBW, premature labour, spontaneous abortions, miscarriage…)
8. adolescence (high nutritional demands/food fads/poor financial status, obstetric and nutritional support, increased use of drugs/smoking) OR pregnancy > 35 yo