Chapter 20: Pregnancy & Lactation Flashcards
What are the IOM recommended weight gain goals? BMI <18.5 BMI 18.5 to 24.9 BMI 25 to 29.9 BMI >30
Based on pregravid:
- BMI: BMI <18.5: 28 - 40 lbs
- BMI 18.5 to 24.9: 25 - 35 lbs
- BMI 25 to 29.9: 15 - 25 lbs
- BMI >30: 11 - 20 lbs
(TRUE/FALSE) For women with preexisting obesity, it is recommended to limit weight gain to amounts below the IOM recommendations.
FALSE. This choice may have detrimental consequences for the fetus.
(TRUE/FALSE) Maternal obesity alone is a risk factor for infant mortality, but very low weight gain is also a risk factor for infant mortality.
TRUE.
What are the AND recommendations for calculating energy requirements in pregnancy? (Hint: Based on BMI)
- BMI <18.5: 42 to 50 kcal/kg pregravid weight
- BMI 18.5 - 24.9: 40 to 45 kcal/kg pregravid weight
- BMI > 25: 30 to 35 kcal/kg pregravid weight
(TRUE/FALSE)
Additional energy is generally not required in the first trimester, and increased energy goals for weight gain should be applied in the second and third trimesters.
TRUE.
(TRUE/FALSE)
Protein in pregnancy has a “sweet spot.” Inadequate protein intake may lead to poor growth and development, but excessive protein delivery may also be harmful.
TRUE.
What is the IOM RDA for CHOs in pregancy?
175 grams/day.
What is poor maternal glucose control associated with?
- Increased risk of macrosomia (meaning ‘larger than normal fetus’), which may result in birth trauma and an increased rate of C-sections.
- Increased risk of stillbirths
Hyperglycemia impairs oxygen delivery to the fetus.
**What is the recommended target BG levels for pregnant women with diabetes (type 1 or gestational)?
- Fasting BG
- 1-hour post-prandial BG
- 2-hour post-prandial BG
**
- Fasting BG: 95 mg/dL or lower
- 1-hour post-prandial BG: 140 mg/dL or less
- 2-hour post-prandial BG: 120 mg/dL or less
**THESE TARGETS ARE ALSO IMPORTANT TO FOLLOW FOR PREGNANT WOMEN REQUIRING NUTRITION SUPPORT.
(TRUE/FALSE)
Inadequate carbohydrate intake during pregnancy an also be harmful and may lead to ketonemia or ketonuria. Ketone bodies have a negative effect on embryogenesis and the behavior and intellectual developlement of offspring in childhood.
TRUE.
What is the fat intake recommendation for pregnant women?
There is no formal recommendation for total fat intake in pregnancy, but a reasonal starting point would be approximately 20 to 35% of energy, as suggested by the IOM DRIs.
- Linoleic acid: 13 g/day
- Alpha-linolenic acid: 1.4 g/day
Why does DHA play an important role in pregnacy?
- For fetal brain and CNS development, which occurs at a rapid pace during the third trimester.
- Proposed benefits of DHA supplementation FOR INFANTS include:
- Improved infant visual acuity
- Postnatal growth
- Cognitive dev
- Prevention of allergies and asthma
- FOR THE MOTHER:
- Potentially may lower incidence of gestational HTN and peripartum depression.
**What is the current recommendation for DHA supplementation for pregnant and lactating women?
** At least 200 mg DHA in the diet
How much are serum triglycerides and serum cholesterol expected to increase in pregnant women?
- Serum TG: May rise 150%
- Serum cholesterol: May rise from 125 to 150%
From prepregnancy levels.
What are the fluid recommendations for pregnant women?
AI for fluid is 3 L/day (with 2.3 L from beverages, and the rest from food)
What are the energy and protein requirements for lactating women?
- First 6 months postpartum: (EER + 330 kcals)
- Second 6 months postpartum: (EER +400 kcals)
- 1.3 g/kg/day OR add 25 g/day to maintenance protein requirements.
NOTE: Milk production actually ‘costs’ closer to 400-500 kcal/day, but IOM recommends a slight energy reduction to promote pregnancy weight loss.
What is the daily recommendation for DHA in lactating women?
At least 200 mg/day
Define hyperemesis gravidarum.
- Severe, intractable N and V complicated by dehydration, electrolyte imbalance, ketosis, nutrition deficiencies and at least 5% weight loss
- Affects 0.3 to 3% of total pregnancies.
- Symptoms start at 6 to 8 weeks gestation and often resolve by 20 weeks, but N/V can persist into the third trimester in ~1/3 pregnancies.
- At Risk For: Wernicke’s encephalopathy, AKI, liver dysfunction, esophageal rupture, and malnutrition.
What are the treatment steps for hyperemesis gravidarum?
- Initial: SFM compromised of low-fat, high-CHO foods and the avoidance of trigger foods and foods with strong odors.
- If unsuccessful: Supplemental vitamin B12, ginger and acupressure
- Next: Combined vitamin B6/doxylamine, antihistamines, dopamine antagonists, serotonin antagonists, and IV fluid with or w/o diazepam.
- Lastly: Corticosteroids, EN, PN (in severe cases), gabapentin, or transdermal clonidine.
(TRUE/FALSE)
Severe vomiting has been associated with thiamin depletion; therefore, it is essential that patients are given IV thiamin along with IV fluids (particularly if dextrose-containing IV fluids are used) to prevent Wernicke’s encephalopathy.
TRUE.
Wernicke’s encephalopathy is the presence of neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves, in particular thiamine (vitamin B1).
**When IC is not available, how would you recommend energy needs for a critically-ill, pregnant woman?
**
- Traditional equations that estimate the needs of critically ill patients can be used with 200 to 300 kcal/day added for pregnancy
- NOTE: This pregnancy energy deposition is slightly below the recommendations to support weight gain in a healthy pregnancy because the energy expenditure from activity while recovering from trauma would most likely be LOW and it is important to AVOID OVERFEEDING the critically ill patient.
**How would you calculate protein needs for a critically-ill, pregnant women?
**By the same method for nonpregnant patients, beginning with 1.5 to 2.0 g/kg/day pregravid weight.
What are the other important nutrition recommendations for pregnant women?
- MVI with minerals should be provided daily, as well as additional folic acid
- Consider additional iron (may be necessary)
- Glucose control should be managed!!!
pregnant females with these conditions have increased energy needs
hyperemesis gravidarum
IBD
Cystic Fibrosis
excessive weight gain in pregnant women who are obese increases the risk of
gestational diabetes
gestational HTN
pre-eclampsia
macrosomia
women with multiple’s (twins/triplets) are at risk for
giving birth to low weight/premature babies
nutrition assessment for pregnant women includes assessment of
pre gravid nutrition status
current nutrition status
pre gravid weight
assess metabolic conditions such as diabetes, obesity and IBS
inadequate maternal weight gain is associated with
LBW and SGA infants
what is the most common micronutrient deficiency in pregnancy
iron deficiency
which micronutrients should be assessed in pregnancy
iron, folate, B12, calcium, zinc
to assess energy and protein needs for pregnant female use____ ir ___ weight
pre-gravid
ideal body weight
extra calories are not needed in the ____ trimester
first
closely monitor weight gain of the fetus to assess for possible
intrauterine growth restriction
on average ___ extra calories are needed in the second trimester and ___ kcal extra are needed in the third trimester
340 kcals
452 kcals
protein turnover is at the highest during what trimester(s) of pregnancy
2nd & third trimesters
for a singleton, ___ g/kg/protein/day is needed in early pregnancy and ___g/kg for late pregnancy
- 2g/kg/day
1. 52 g/kg/day
target fasting blood glucose in T2DM and GDM is
95 mg/dL
1 hour Prost prandial target blood glucose for T2DM and GDM is
140mg/dL or less
__to___% of total calories should come from fat in pregnancy
20-35%
_____ fatty acids especially _____ &___ are important in fetal brain and central nervous system development
alpha linoleic acids (omega 3’s) DHA and EPA
increased need for this micronutrient is essential for forth and fetal development. Deficiency increases the risk for the development of neural tube defects therefore should be supplemented early in pregnancy
folic acid
____ deficiency in the fetus is associated with vision impairment and growth restriction
vitamin A
_____ toxicity has bee linked to spontaneous abortion and birth defects
vitamin A
_____ deficiency can contribute to neonatal hypocalcemia and or rickets
vitamin D
in addition to omega 3 fatty acids and folic acid, ___ and ___ are micronutrients necessary for brain development and nervous system development
zinc and iodine
indications for EN in pregnancy include
hyperemesis gravidarum
non functioning GI tract
trauma
critical illness
what type of artificial nutrition method is preferred in hyperemesis gravidarum, IBD and intestinal stricture
Enteral Nutrition
when providing parenteral nutrition, hyperglycemia risk is elevated in pregnancy. a target blood glucose of ____ will avoid complications
140mg/dL
if a pregnant female is not allergic to fish ILE’s with ___ should be use in long term PN
Fish oil ILE with DHA
severe intractable nausea and vomiting with dehydration, electrolyte imbalance, ketosis, nutrition deficiency and at least 5% weight loss are symptoms of
hyperemesis gravidarum
before EN or PN is considered in hyperemesis gravidarum what methods can be used
small, frequent melas anti emetics low fat, high carb foods avoid trigger foods with strong odors Vitamin B6 supplementation
True/False: the fetus is unaffected in obese women who lose weight during pregnancy
False. Obese women who lost weight during pregnancy had twofold greater odds of having a LBW infant and 1.8 greater odds of having an SGA infant
How many additional kcals are added for 1st, 2nd, and 3rd trimester?
0 kcal for 1st trimester
340 kcal for 2nd trimester
452 kcal for 3rd trimester
Protein recommendations for pregnancy
Singleton: maintenance protein requirements +25 gm/day
Multiples: maintenance protein requirements +50 gm/day or 20% total kcal
Factors that contribute to the development of gestational diabetes
During the 2nd trimester, progesterone, estrogen, human placental lactogen, growth hormone, and cortisol levels all rise, which may lead to increased insulin resistance and decreased insulin sensitivity
Glucose control goals for women with T1DM or gestational diabetes
Target fasting BG = 95 mg/dL or lower
1-hour postprandial BG = 140 mg/dL or less
2-hour postprandial BG = 120 mg/dL or less
Examples of situations when EN might be used in pregnancy
Hyperemesis gravidarum, multiple gestation, trauma, critical illness
Why does a nasoenteric tube carry the risk of reflux and aspiration in pregnant women?
Gastric emptying is delated and lower esophageal sphincter tone is decreased in pregnancy. Nasoenteric tube will prevent the LES from closing completely, allowing for reflux of gastric contents into the esophagus
How does the process for selecting an enteral formula for the pregnant patient differ from nonpregnant patients?
It doesn’t. Polymeric formula is appropriate for patient with adequate digestive and absorptive capacity. Consider fiber containing formula since constipation is often a problem in pregnancy
Should peripheral or central PN be used in pregnancy?
Central, allows for provision of full energy and protein needs in a reduced volume
Micronutrients of concern in PN?
IV preparations of standard multivitamins and trace elements may not be adequate to meet 100% of pregnancy requirements. Nutrients of concern include vitamin D, vitamin K, folic acid, calcium, magnesium, iron, iodine, and selenium
What normal acid-base changes should clinicians be aware of during pregnancy while monitoring EN/PN tolerance?
A chronic state of compensated respiratory alkalosis exists and buffering capacity is decreased in pregnancy.
Energy and protein requirements for lactation:
Energy: Pre-pregnancy EER + 330 kcal for first 6 months postpartum; Pre-pregnancy EER + 400 for 2nd 6 months postpartum
Protein: 1.3 gm/kg or add 25 gm/day to maintenance requirements
What conditions are women with hyperemesis gravidarum at risk for?
Wernicke’s encephalopathy, AKI, liver dysfunction, esophageal rupture, malnutrition
