Chapter 20: Pregnancy & Lactation

Question 1

What are the IOM recommended weight gain goals? BMI <18.5 BMI 18.5 to 24.9 BMI 25 to 29.9 BMI >30

Answer 1

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

Question 2

(TRUE/FALSE) For women with preexisting obesity, it is recommended to limit weight gain to amounts below the IOM recommendations.

Answer 2

FALSE. This choice may have detrimental consequences for the fetus.

Question 3

(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.

Answer 3

TRUE.

Question 4

What are the AND recommendations for calculating energy requirements in pregnancy? (Hint: Based on BMI)

Answer 4

• 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

Question 5

(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.

Answer 5

TRUE.

Question 6

(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.

Answer 6

TRUE.

Question 7

What is the IOM RDA for CHOs in pregancy?

Answer 7

175 grams/day.

Question 8

What is poor maternal glucose control associated with?

Answer 8

• 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.

Question 9

**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

Answer 9

**

• 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.

Question 10

(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.

Answer 10

TRUE.

Question 11

What is the fat intake recommendation for pregnant women?

Answer 11

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

Question 12

Why does DHA play an important role in pregnacy?

Answer 12

• 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.

Question 13

**What is the current recommendation for DHA supplementation for pregnant and lactating women?

Answer 13

** At least 200 mg DHA in the diet

Question 14

How much are serum triglycerides and serum cholesterol expected to increase in pregnant women?

Answer 14

• Serum TG: May rise 150%
• Serum cholesterol: May rise from 125 to 150%

From prepregnancy levels.

Question 15

What are the fluid recommendations for pregnant women?

Answer 15

AI for fluid is 3 L/day (with 2.3 L from beverages, and the rest from food)

Question 16

What are the energy and protein requirements for lactating women?

Answer 16

• 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.

Question 17

What is the daily recommendation for DHA in lactating women?

Answer 17

At least 200 mg/day

Question 18

Define hyperemesis gravidarum.

Answer 18

• 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.

Question 19

What are the treatment steps for hyperemesis gravidarum?

Answer 19

1. Initial: SFM compromised of low-fat, high-CHO foods and the avoidance of trigger foods and foods with strong odors.
2. If unsuccessful: Supplemental vitamin B12, ginger and acupressure
3. Next: Combined vitamin B6/doxylamine, antihistamines, dopamine antagonists, serotonin antagonists, and IV fluid with or w/o diazepam.
4. Lastly: Corticosteroids, EN, PN (in severe cases), gabapentin, or transdermal clonidine.

Question 20

(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.

Answer 20

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).

Question 21

**When IC is not available, how would you recommend energy needs for a critically-ill, pregnant woman?

Answer 21

**

• 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.

Question 22

**How would you calculate protein needs for a critically-ill, pregnant women?

Answer 22

**By the same method for nonpregnant patients, beginning with 1.5 to 2.0 g/kg/day pregravid weight.

Question 23

What are the other important nutrition recommendations for pregnant women?

Answer 23

• MVI with minerals should be provided daily, as well as additional folic acid
• Consider additional iron (may be necessary)
• Glucose control should be managed!!!