Maternal Nutrition Flashcards
1
Q
Human Fetal Growth
A
- Ovum released from ovary
- Fertilization by sperm in fallopian tube
- Fertilized egg divides rapidly to form solid mass of cells which buries itself in endometrial lining of the uterus
- 1st Half - 10% growth
- 2nd Half - 90% growth
- Cell division complete **by 34-36 weeks **
- Last 4-6 weeks, growth continues by increase in cell size
- Normal full term gestation - **40 weeks **
2
Q
Stage 1
A
Blastogenesis Stage
- Fertilized egg divides into cell that fold in on one another
- Inner mass of cells gives rise to embryo
- Outer layer becomes the placenta
- Ends 2 weeks after fertilization
3
Q
Stage 2
A
Embryonic Stage
- Cells **differentiate into 3 layers **
- All major features of fetus achieved
- Embryonic growth = hyperplasia
By 60 days…
-
Ectoderm: outermost layer
- Brain, hair, nervous system, skin
-
Mesoderm: intermediate layer
- Voluntary muscles, bones, excretory system, cardiovascular system
-
Endoderm: innermost layer
- Digestive, glandular organs, respiratory
4
Q
Stage 3
A
Fetal Stage
- Period of most rapid growth
- Weight increases 6 g to 3.5kg
- Fetal growth = hyperplasia and hypertrophy
5
Q
Growth-Retarded Infants
A
Early Gestation Deficiency
- Can Cause
- Fetal malformations
- Teratogenic effects
- Death of embryo
- Quantitative requirements very small
- Severe deficiency necessary to cause malformation
Deficiency after 3 months
- No teratogenic effects
- Fetal growth impaired
In Last Trimester
- Highest nutrient requirements
- Even mild deficiency could have serious effects on growth
- Cell number and size reduced
6
Q
Small for Gestational Age (SGA)
A
<10 percentile
Type 1
- Disproportional
- Growth retardation affecting wt
- HC and length appropriate
- Poorly developed muscles
- Limited subcutaneous fat
- Results from inadequate nutrition during final stage
Type 2
- Proportional
- All <10%
- Diet deficient throughout gestation
7
Q
Appropriate for Gestational Age (AGA)
A
10-90th percentile
8
Q
Large for Gestational Age (LGA)
A
>90th percentile
9
Q
Nutritional Influences on Growth
A
- Most information from animal studies - some human studies on restricted food intake overall, and some for individual nutrients
10
Q
Caution with Animal Data
A
- Malnutrition consequences are greater in animals
- Relative Growth rates are faster
- Timing of max growth differs
- Number and size of animal fetuses are larger
- Magnitude of deprivation studied is rarely encountered in normal human circumstances
11
Q
Maternal Malnutrition
A
Can interfere with conception
Threatens pregnancy
Impairs cell metabolism
Most damaging when cells are undergoing rapid division
Timing and severity of deficiency are key factors
Different causes of growth failure
12
Q
Growth Failure
A
Can’t survive intrauterine insults without adverse effects
Fate of baby depends in part on nutrition after birth too
Effect on brain cells is biggest concern
Brain size may be permanently reduced
13
Q
LBW
A
LBW: <2.5kg at birth
VLBW: <1.5 kg at birth
7-8% of annual incidence of LBW due to intrauterine growth failure
14
Q
Pregnancy Assessment Tools
A
Weigth gain graphs **based on pregravid weight **
The higher your pregravid weight, the less you should gain during pregnancy
Routine GTT for Gestational DM
- BMI <18.5: 28-40 lbs
- BMI 18.5-25: 25-35 lbs
- BMI >25: 15-25 lbs
- BMI > 30: 11-20 lbs
15
Q
Blood Vol/Composition Changes
A
Total body water increases 7-10 L
Plasma vol increase (~50%) associated with good pregnancy outcome
RBC production increase, but not at the same rate as plasma volume, so *Hct actually decreases relative to plasma vol *
- Hct normally 33-43%
- Pregnancy HCT > 33%
Hgb levels decrease relative to plasma vol
- Normal: >12 g/dL
- 1st and 3rd trimester: >11 g/dL
- 2nd trimester: >10/5 g/dL
16
Q
Serum Nutrient Levels
A
Non Pregnant Pregnant
TP: 6.5 - 8.5 mg/dL ** 6.0 - 8.0** mg/dL
Albumin: 3.5 - 5 g/dL ** 3 - 4.5** g/dL
Glucose: <110 mg/dL ** <120** mg/dL
Chol: 120-190 mg/dL ** 200-325** mg/dL
Vit C: 0.2 - 2.0 mg/dL ** 0.2 - 1.5** mg/dL
Folate: 5 - 21 ng/mL ** 3.15** ng/mL
Fe: >50 mcg/dL ** >40** mcg/dL
17
Q
Cardiac Changes
A
Cardiac Hypertrophy
- Increased cardiac output, HR and SV
- Decreased BP during first half due to peripheral vasodilation from hormonal changes
18
Q
Respiratory Changes
A
- Displaced diaphragm
- Deeper Breathing
- increased tidal volume
- More efficient exchange of lung gases
- Increased oxygen-carrying capacity of blood
19
Q
Renal Changes
A
- Increased blood flow through kidneys
- Increased GFR, related to decreased oncotic pressure with decreased serum albumin
- Plasma components greater than renal capacity to reabsorb
- Kidneys must manage increased metabolic demands, as well as excretion of fetal waste products
- Caused by:
- Hormones
- Posture
- Nutritional intake
20
Q
GI Changes
A
- Increase appetite and thirst
- High progesterone -> lower GI motility and decreased intestinal secretion -> **increased nutrient absorption **
- Heart burn and reflux
- Nausea and vomiting
21
Q
Morning sickness
A
Occurs any time of day
Last longer than most expect
Average duration is 17 weeks
10-20% have NVP **until delivery **
Causes - Theories
- Phys response to hormone changes
- Dehydration
- Low levels of minerals lost through vomiting
- Psychological
22
Q
Morning Sickness Treatment
A
Management of Symptoms
- Avoid offensive odors - “Radar Nose)
- Limited medications due to potential teratogenic effects
23
Q
Morning Sickness Dietary Recommendations
A
- Avoid dehydration
- Eat whatever foods seem most appealing
- Eat small amounts frequently
- Eat in a relaxing, pleasant environment
- Avoid large meals
- Sometimes greasy, fried and spicy foods can be problematic
- Individualize diet plan based on individual intolerances, triggers
- Avoid overly warm temperatures
- Alternative therapies
- B6
- Acupuncture
- Ginger
- lemonade, fresh lemons
- Motion sickness bands
- hypnosis
24
Q
Hyperemesis Gravidarum
A
Severe, prolonged persistant vomiting
1-2%
Hospitalization usually required for hydration and electrolyte replacement
Sometimes IV nutrition required
25
Eating Behaviors
Changes based on
* Medical advice
* Superstitious food beliefs from family and friends
* Folk Lore
* Some want smaller babies for easier delivery so they eat less
Cravings
* Sweets, fruit, salty foods, dairy
Increased intake of: **calcium and calories **
26
Food Aversions
Meat and animal proteins
Alcohol
Coffee / Caffeinated drinks
Built in protective mechanism?
27
Pica
Compulsion for persistent ingestion of unsuitable substances that have little or no nutritional value
Cause not understood, but not a new practice
Not limited to any one geographic area, race, culture or social status
More common in African Americans
Not limited to pregnancy
28
Types of Pica
**Geophagia**: dirt or clay
**Amylophagia**: laundry starch
**Pagophagia**: ice, freezer frost
Other
* Paper
* Burnt matches
* Coffee grounds
* Cigarette ashes
* Antacids, MOM
* Moth balls
* Toilet air fresheners
* Flip flops
* Cardboard
* Rubber
29
Pica Theories
* Relieves nausea and vomiting
* Calms hunger pains
* Triggered by a deficiency of an essential nutrient
* Tradition carried on from prior generations
* Perception that it has benefiial effects
* Prevents birth marks, makes skin lighter
* Relieves nerves of mother
* Helps baby "slide out"
30
Pica Negative Effects
* Nutrient deficiencies
* Malnutrition - nonfood substances replace foods
* Malabsorption
* Intestinal obstruction
* Obesity
* Lead poisoning
* Irritable uterus - related to fecal impaction
* Anemia
* Infection
* Can lead to death
31
Hormonal Changes
More than 30 different hormones secreted throughout gestation
Two main: progesterone and estrogen
32
Progesterone
* Smooth muscle relaxation
* Uterine expansion
* **Decrease gastric motility** -\> **increase nutrient absorption**
* Induces maternal fat deposition
* Facilitates gas exchange
* Increase renal sodium excretion
* **Interferes with folic acid metabolism**
33
Estrogen
* **Decrease serum proteims**
* Promotes growth of uterus
* Enhances **flexibility of uterus at birth**
* **Hydroscopic** effect
* **Interferes with folic acid** metabolism
34
Metabolic Changes
Increased **BMR in 2nd half** of pregnancy
* usually rises **by 4th month**
* Increases **15-25% by term**
Maternal **fat use** increases to conserve glucose for fetus -\> maternal **glucose levels fall as fetal demands increase**
Maternal **lipolysis** increases
35
Placenta
Joins mother and offspring
**Nourishment and endocrine secretions** for development and growth of embryo and fetus
Active role in reproduction
Major **pregnancy hormones produced**
Facilitates exchange of nutrients, oxygen and waste - efficiency of transfer determines fetal health
Contains fetal and maternal components
Fetal and maternal **blood** are **separated by placental membrane** and never mix
**Transfer** of nutrients **impeded by insufficient vascularization **
36
Nutrient Transfer
Simple/passive diffusion
* Nutrients move from high -\> low concentrations in fetal blood
* Water, O2, CO2, **fatty acids**, **steroids**, electrolytes, **Vit E and K**
Facilitated Diffusion
* Rate of transfer faster than passive diffusion
* **Monosaccharides, Vit A, D and Fe**
Active Transport
* Requires both carrier proteins and energy (ATP)
* **Amino acids, water soluble vitamins, Ca, Fe, PO4**
37
Respiratory and Excretory Exchange
Fetus cannot tolerate variation in rate of oxygen supply, so mother compensates by **adjusting cardiac output**
**Urea, creatinine, and uric acid** move through placenta by **diffusion and active transport**
38
Maternal Malnutrition
* Reduced blood vol expansion
* Inadequate increase in Cardiac Output
* Decreased placental blood flow
* Decreased placental weight, size
* Reduced nutrient transfer
* Results in fetal growth retardation
39
Historical Practices
**Casual observation between diet and outcome**
Imitative magic
* "You are what you eat"
* "if you eat sour foods you'll have a sour baby"
Obstetrical problems influenced dietary recommendations
40
Rickets
* **Impaired mineralization** of bones due to **Vit D, Ca and Phos deficiencies**
* Carried serious risk
* Death of mom and child was common
* **Contracted pelvis**
* **Restricted diet was recommended** so the baby would be smaller and easier to deliver
41
Historical Development '60's - 70's
**1960**'s: **renewed interest** in infant mortality -\> reevaluation of influence of diet
1969 - **White House Conference on Food, Nutrition and Health**
* Prompted by **widespread hunger and malnutrition in US**
* Pregnancy and infants studied
1970: Benchmark National Research Council report
* "Maternal Nutrition & Course of Pregnancy"
* identified that there were limited studies available
* **Recommended long term longitudinal studies**
1973: **NRC** guidelines for **supplementary food during pregnancy** and for public health workers
42
WIC 1970's
Special supplemental food program for at risk women, infants and children
Foods include:
* Infant cereal with Fe
* Certain cereals
* eggs
* Peanut butter
* 100% fruit juice
* Cheese
* Infant formula with Fe
* Milk
* Dried beans/peas
* Tuna
* Vegetable juice
* Farmer's Market vouchers
43
WIC 2009
Food packages "time for a change"
* Aligned with **2005 DGA**
* **Infant guidelines** aligned with **AAP**
* promote and support **long-term breastfeeding**
* Accomodates cultural food preferences
* **Wider variety** of food
* Soy-based beverages, tofu, fruits, vegetables, baby foods, whole wheat bread, other whole grains
44
WIC Eligibility
1. _Women_
- Pregnant and post partum
- Up to **6 months** coverage for mom **if bottle feeding**
- Up to **12 months** coverage for mom if **breast feeding**
- Infants of eligible women
- Children **under the age of 5**
2. _Low Income_
- 1 person: \<$21,257 annually
- If pregnant, each **unborn infant counts as an extra person** in the household size, so income **eligibility gets easier **
3. _At **nutrition risk** according to health professional_
- medically-based risk
- Dietary risk
4. _Must be **resident of the state **_
45
WIC Overview
* Administered by state health departments
* **Must** **offer nutrition education and health services** directly or provide referral for services
* Strong congressional support
* **Reaches 93% of eligible**
* Most _**thoroughly evaluated** publically funded program_
46
WIC Positive Impact
WIC eligible who receive services vs. WIC eligible who do not receive services
* Increased
* Birth weight
* **Prenatal and med care**
* Head circumference
* Decreased
* LBW or VLBW
* Premature Births
* **Fe deficiency** anemia - during pregnancy, post-partum and in low income children
* **Improved Maternal Intake** of...
* Protein and kcals
* Fe
* Ca, P, Mg
* Vit C, B6, B12
* Thiamin, Riboflavin, niacin
* Cost Effective
* **Nutrition education** component has the **most positive effect **
47
WIC- Associated Services
* Immunization
* Drug screening
* Medicaid eligibility determination
*
48
Historical Development 1980's-90's
**1981: ACOG-ADA Guidelines**
* *Guidelines for Assessment of Maternal Nutrition*
* National **consensus** on the **relavant risk factors** before and after pregnancy
1981: **NRC Perinatal Guide issued**
* *Nutrition Services for Perinatal Care*
* Addressed **infant feeding issue**
* Raised **concerns about substance abuse **
**1990: National Academy of Sciences**
* *Nutrition during Pregnancy: Weight Gain and Nutrient Supplements*
* **Most recent landmark document available**
* Frequently cited in pregnancy literature
49
Malnutrition Natural Experiments
Evaluation of birth statistics before, during and after famine/war
* _WWII_ - Russia, Holland, Japan and GB
* _Siefe of Sarajevo_ (1990's)
* Famine → Increased...
* **infertility** rates
* Infant **mortality**
* **LBW** rates
* Famine during _early pregnancy_ → Increased **teratogenicity**, **still births**
* Famine during l_ate pregnancy _→ **LBW**
* After war, *trends reverse within 1 year *
50
Malnutrition Organ Studies
**Organs** and **still born infant size** from **low income women** **\<** those of *higher income women *
**Placenta** is always available for study
_Decreased **placental size** and **cell number** in:_
* **IUGR** (Intrauterine Growth Retardation) babies
* **Needy/Poor** populations
* Maternal **anorexia nervosa**
51
Nutritional Correlates of BW
* **Plasma vol expansion**
* Greater vol expansion → **greater BW**
* Maternal body size **(ht & pregravid wt)**
* Bigger mom = bigger baby
* Maternal **pregnancy wt gain**
* **Underwt** mom → higher incidence of **LBW** and **prematurity**
* **Obese** women → higher risk for **HTN**, **gestational DM, UTI**
52
Maternal Weight Gain
* Best wt. gain amount still debated
* **Recommended: 25-35 lbs**
* **1/3** wt. gain **d/t Fetus**
* 2/3 wt. gain d/t Maternal tissue
* **~40%** US women **gain recommended** amount
* **Underweight**: retain some of weight gained for own needs
* **Overweight**: can use some of own stores to support fetal growth
53
Excessive Maternal Weight Gain
Bad for mother and fetus
* Increase **risk for HTN and C-section**
* Increase risk for **long-term weight control problems** later in life
**Young** mothers and **first time mothers usually gain more** than older or multigravidae women
**Rate of wt gain** is as **important** as total wt gain
**Sudden** wt gain **= fluid retention **
54
Low Weight Gain
* Restriction of body fat development can be detrimental
* Can **increase risk for heart dx, DM, HTN** **later** **in child's life**
* **Risk** of chonic disease **may begin in-utero**
55
Calorie Requirements
* Increases d/t...
* 1/3 - increased **heart work**
* 1/3 - increased work of **respiration**, **accretion of breast tissue**, **uterus** and **placenta**
* 1/3 - **fetus**
* DRI does not apply to all women - wide range of differences in BMR
* \*\*Always use pregravid wt\*\*
* Add extra kcals after multiplying basal \* AF
1st Trimester
* **equation** = **same** as pregravid
* **30 kcal/kg**
2nd trimester
* Pregravid Equation **+ 340 kcal/day **
* **36 kcal/kg**
3rd Trimester
* Pregravid equation **+ 452 kcal**
* **36 kcal/kg**
56
Protein Requirements
DRI 2002
* **Additional 25g** protein/day
or
* **1.1g protein/kg** (pregravid wt)
57
Fluid Requirements
* **1 mL / 1 kcal** - this is more personalized
or
* **9 cups/day**
58
Vitamins
Prenatal Vitamin for Low income women
* Decreased **preterm delivery, LBW and congenital defects**
Huge variation in PNV content
59
Folate
* Received most attention
* Required for cell division
* Requirements increase due to extensive organ and tissue growth
* Deficiency causes megaloblastic anemia and production of abnormal RBC
* Importnat role in preventing neural tube defects
Folate Supplementation
* All women of childbearing age
* DRI: **0.4 mg/day** (400 mcg)
* UL: **0.8 mg/day (14-18 yo)**
* *1.0 mg/day (\>18)**
* Pregnancy
* **DRI: 0.6 mg/day**
* UL: same
60
Neural Tube Defects
* Malformations of spinal cord and brain
* **Neural tube closes by 28 days of gestation**
* Genetic and environmental causes as well
* *Most common congenital defect* in US
**70%** of cases can be **prevented with folate**
* Impaired metabolism of folate may be involved
* Connection with B12
* Excess folate can mask B12 deficiency
* Recommended folate intake can be obtained through diet alone
* Most eat diet with inadequate folate
* **1998** → **FDA mandate for folic acid fortification** of enriched flour, bread, corn meal, rice, noodles, macaroni and other grains
61
Encephalocele
Protrusion of brain through skull
62
Ancephaly
Absense of the brain or spinal cord
Baby dies before or shortly after birth
63
Spina Bifida
**Spinal cord fails to close**, leaving a gap
**Spinal fluid collects in gap**
Children grow into adulthood
**Paralysis of lower limbs**
Varying degrees of **bowel/bladder incontinence **
64
B12
Important for cell division
Deficiency is rare
Can contribute to **megaloblastic anemia**
**High risk in vegetarian** women
**Recommended** supplementation: **2 mcg/day**
65
B6
Importnat for **AA metabolism** and **protein synthesis**
May help with **NVP**
Controversial
**Dose tested 30 mg/day**
66
Vit C
Recommended intake easily met
Associated with **premature rupture of membranes**
**Large intakes** may → **fetal dependency **
67
Thiamin, Riboflavin, Niacin
**Requirements relate to caloric intake** since they play a **role in metabolic pathways**
The more you eat, the **more vitamins you need**
Animal studies not applicable
68
Vit D
Maternal **deficiency** may → **neonatal hypocalcemia and poor bone formation**
**Excess** amounts are **harmful**
69
Vit A
\*\*The **most concern for toxicity** during pregnancy\*\*
**Maternal reserves adequate for preg**
Megadoses = teratogenic
**Vit A analogs** (acne and wrinkles) are very **teratogenic**
* Accutane, Retin A
**Highest Risk**: **2 weeks prior to conception and throughout first 2 months of gestation**
* Dermatologists won't recommend acne meds unless woman is on relaiable BC
**"Retinoic Acid syndrome"**
* Small/missing ears or ear canals
* Flat nasal bridge
* Brain malformations
* Heart defects
70
Iron
Fetus is a parasite regarding Fe
**Additional 1000mg** required during pregnancy
* **300** mg - **fetus** and placenta
* **250** mg - **lost** at delivery
* **450** mg - increase **RBC** **mass**
Supplementation
* **30 mg/day during 2nd and 3rd trimester**
* Divide doses between meals
* Vit C containing juice to enhance absorption
For **Fe deficiency** anemia...
* **60-180 mg/day until Hgb \>11**
Major fetal accumulation during 3rd trimester
Premature infants have high risk of deficiency
Maternal deficiency may affect birth
**Absorption increases** during pregnancy
71
Calcium
**Fetus acquires most in last trimester**
Premature infants have low Ca reserve
Requirements *don't change *
**\>18 years: 1000 mg/day **
**\<18 years: 1300 mg/day**
Ca *absorption increases* during pregnancy
**Higher level** of Ca supplementation **may prevent pregnancy-induced HTN**
72
Magnesium
Mostly found in bones
Role in nerve and muscle function
Supplementation may **relieve leg cramps**, **decrease preeclampsia and IUGR**
**Slightly higher** recommendations during preg
**\<18** years: **400 mg/day**
**19-30** years: **350 mg/day**
**31-50** years: **360 mg/day**
73
Zinc
Important role in reproduction
Deficiency may correlate with **poor preg outcomes**
**Status** can be **decreased by Fe supplementation **
74
Iodine
Synthesis of **thyroid hormones**
American Thyroid Association: **Rec 150 mcg in PNV**
Deficiency causes ***neonatal cretinism***
* Mental **retardation**, **deafness**, dwarfism, goiter, **hypothyroidism**
* **China, Africa, Eastern Europe**
* **Atypical in US** due to iodine fortification
* Most common **preventable cause of mental retardation**
* **Subclinical** iodine deficiency may cause **developmental delay **
75
Fluoride
**Permanent Tooth formation begins** during pregnancy
Prenatal fluoride supplementation is controversial
Only **trace amounts** pass through placenta
**Supplementation not shown to alter rate of dental carries **
76
Sodium
Maintain body's water balance
**Metabolism is altered** due to changes in hormonal levels
**Increased requirements** due to **increase volume, increase body water and tissue synthesis**
Dietary _Na restriction not recommended _
* Has **not improved preeclampsia, edema, BP**
* may have detrimental effect if dietary quality otherwise affected
77
Alcohol
_Fetal Alcohol Syndrome (FAS)_
* Abnormalities, teratogenicity
* Recognized in **1973**
* New Term: **Fetal Alcohol Spectrum**
_2005 CDC Requirements for Diagnosis_ - Must have all
* Prenatal and postnatal **growth failure**
* **Thin upper lip**
* **Indistinct Philtrum** (vertical groove in upper lip)
* **Small eyelid** opening
* **Neurological** disorder
Non Diagnostic Characteristics
* Small teeth
* Cleft lip/palate
* **Micrognathia**: underbite and receeding chin
* Small jaw: interferes with feeding
* **Microcephaly**: (HC \<10%tile)
* **Epicanthal** **fold**: fold of skin over inner corner of eye
* Flat nasal bridge
78
Fetal Alcohol Effects
**Moderate ETOH consumption**/occasional binge drinking
Physical characteristics more subtle
**No facial characteristics ****→ **More difficult to diagnose
More *difficult to secure needed services*
**Cognitive** and **behavioral** problems can be **just as severe** as FAS
**\*\*Not just a mild form of FAS\*\***
79
Negative effects of Alcohol
Direct toxic effect on fetus
* ETOH crosses placenta
* Higher rate of **spontaneous abortion, PROM**
Maternal Malnutrition frequently associated with alcoholism
Altered nutrient metabolism
* Thiamin, folic acid, Vit A, B6, Magnesium, Zinc, phosphorus, calcium
Change in normal hormonal effect
**Diminished oxygen delivery** to fetus
Higher rate of **LBW** baby
Impaired **cell migration**
**Deleterious effects on sperm **
80
Cigarette Smoking
Higher risk of **perinatal morbidity and mortality**
Sometimes **lower food/calorie intake and utilization** by mom
Fetal **growth** retardation
**CO and nicotine decrease placental perfusion and O2 transport to fetus**
Increased incidence of **LBW** - especially in older, smoking women
81
Caffeine
**Animal** studies: **teratogenic** effects, congenital malformations at high intake
**Human**: *no relationship to birth defects*, moderate consumption advised
FDA and ACOG **recommend \<300 mg/day**
Generally **up to 4 cups coffee/day is safe **
82
Saccharin
Sweet 'n Low
**Not teratogenic**
Weakly carcinogenic in rats
Crosses placenta
**Low/moderate consumption** advised
83
Aspartame
Equal, Nutrasweet, Nutra-taste
Compound: **L-aspartyl-L-phenylalanine methyl ester**
Metabolized into aspartic acid, phenylalanine and methanol
**Phenylalanine** → **tyrosine** (rapid break down)
**High circulating levels** of phenylalanine is known to **damage fetal brain **
84
Phenylketonuria (PKU)
Condition **lacking phenylalanine hydroxylase**
Can't convert phenylalanine to tyrosine
**Women without PKU have extremely low circulating amounts** of phenylalanine
Huge consumption necessary to raise serum levels - 12 oz soda every 8 minutes for 24 hours
**Aspartame** - no risk for non-PKU mothers
* FDA and American Academy of Pediatrics Committee on Nutrition consider it a **safe substance for pregnant women and developing infant**
* *Moderation recommended* due ot limited data
* Consumption of diet soda should not replace intake of other nutritious beverages
85
Heavy Metals
Embryotoxic
**Permanent brain damage** from prenatal and neonatal exposure
**Cadmium, nickel, selenium** shown to cause **malformations** in **animal** studies
**Lead** associated with **spontaneous abortion** and **menstrual disorders**
Mercury poisoning in humans
86
Mercury in Fish
Hg:
* Paper and cement manufacturing
* Coal burning and incineration
Drifts into waterways → converted into *toxic form*: **methylmercury**
Fish absorb methylmercury
Large predator fish have more
High levels of **Hg can accumulate in brain** → neurological problems
Greatest risk:
* unborn
* breast fed babies
* very young children
87
Safe Fish
Flounder
Cod
Haddock
Whitefish
Pollack
Salmon
Sole
Canned light or chunk light tuna
Farm-raised freshwater fish
88
Recommended Fish Consumption
2010 DGA
Consume **8-12 oz of variety of seafood/wk**
Albacore limited to 6oz/week
**No tilefish, shark, swordfish, king mackeral**
US FDA safety limit = 2x Canada's limit
89
Pesticides
Public health professionals concerned
EPA - **many registered pesticides are toxic, mutagenic and/or carcinogenic**
EPA limits some chemical residues in food
Chemicals are difficult to eliminate from food chain once deposited
**Effect of low level exposure not known**
No real pesticide-free control population to study
90
PCB's
Polychlorinated biphenyls
Birth Defects
* SGA
* dark skin
* Eye abnormalities
**Breast and cow milk** most significant route of exposure
91
Food Safety
Progesterone decreases body's ability to resist infection, so pregnant women are more prone to food poisoning
92
Listeria
Bacteria found in soil, ground water, on plants, uncooked meats, soft cheese, deli cold cuts, raw milk
**Listeriosis**: bacterial infection caused by eating food contaminated with liisteria
At risk
* pregnant
* very young and very old
* immunocompromised
Babies can be born with it if mother at contaminated food
Killed by pasteurization, heat
Symptoms:
* fever, chills, GI, headache, stiff neck, confusion, seizures
Onset: **2-30 days after ingestion**
93
Avoiding Listeria
Avoid uncooked, soft cheeses
Keep cold foods cold and warm foods warm
Thoroughly cook and reheat everything
Wash hands and food
No advantage to washing poultry and fish
94
Constipation
Decreased GI from progesterone
Increased abdominal pressure from enlarging uterus
inadqueate fluid
Iron supplementation
95
Hemorrhoids
Enlarged veins in mucous membrane
Causes
* Decreased GI muscle tone
* weight of fetus
* Constipation
* Straining to have a bowel movement
Treatment
* Prevent and treat constipation
* Avoid excessive weight gain
96
Heart Burn
Enlarging uterus crowds digestive organs and causes reflux, esophageal burning
Relaxation o**f Lower Esophageal Sphincter (LES) - 30-50%**
Recommendations:
* avoid large meals
* Eat slowly in relaxed environment
* Avoid caffeine, greasy, spicy foods
* Tums or antacids
97
Gallstones
Decreased emptying of GB
Increased cholesterol
98
Chronic HTN
1-5% pregnancies
Dx before pregnancy or during 1st half
Underlying - does not resolve after birth
99
Gestational HTN
Dx after 20 weeks
No proteinuria
Resolves within 3 months
100
Preeclampsia
"Toxemia"
Usually occurs in 3rd trimester
Signs and Symptoms
* HTN
* Proteinuria
* Edema
* Decreased plasma vol expansion and urine output
* headaches
* vision changes
Severe: coma, convulsions
Treatment is delivery
Prevention:
* Adequate dietary protein
* Adequate Vit E and C, Na, Ca and Mg
101
HTN Risk Factors
African american, american indian
First pregnancy
DM, insulin resistence
Multiple gestation
Low socioeconomic status
Prior pregnancy HTN
Obesity
Lack of prenatal care
Dietary deficiencies
Age \<20 or \>35
Large fetus
Preexisting HTN, renal or vascular dx
Family hx of HTN or vascular dx
102
Gestational DM
7.5% of all pregnant women
Screening: 24-28 weeks
High risk: screen at initial prenatal visit
Screening - 1 hour GLT
* +/- fasting levels checked **(\>95)**
* **50g** glucose drink → **1 hour check (\>135)**
Diagnosis
* **3 hour OGTT**
* Fasting level checked \>95
* **100g** glucose drink →
* 1 hr check **\>180**
* 2 hr check **\>155**
* 3 hr check **\>140**
* If two values are high, diagnose
103
Gestational DM Treatment
Oral meds not used during pregnancy because meds cross placenta, so babies pancreas starts making more insulin → hypoglycemia
Risk Factors
* Obesity
* Hx and FHx of GDM and DM
* Hx and FHx of large BW delivery
* Excess wt gain
* Wt gain between pregnancies
* History of stillbirths, miscarriages, congenital abnormalities
* Mother SGA at her own birth → more likely to develop gestational DM when she has a child
* Low fiber diet
* Age \> 35
Outcome Goals
* Well controlled BG
* Hgb A1c \<7% (long term check)
Post-partum
* many women return to normal glucose tolerance
* 10-15% develope DM within 2-5 years
104
Adolescent Pregnancy
Nutrient needs affected by...
* Gynecologic age - how soon she becomes pregnant after onset of menses
* Preconception nutritional status
* Nutrient stores of mother
* Maternal growth requirements if mother is still growing
* Smaller babies because mother's body still needs calories for growth
Risks
* LBW or SGA
* Premature delivery
* Perinatal and infant deaths
* Physical deformities
* C-section
* Cephalopelvic disproportion
* Fe deficiency
* Preeclampsia
* Morbidity and mortality
Risk Factors for Poor Outcome
* \<15 years old
* Conception \<2 years after onset of menses
* Low pregravid weight
* Poor wt gain
* lack of access to HC
* Infection, STD's
* Preexisting anemia
* Substance abuse
* Rapid repeat pregs
105
Multifetal Pregnancy
Twins
* 1980: 1 in 56
* 2006: 1 in 32
* \>45 years: 1 in 5 births
Triplets
* 1980: 1 in 3000 births
* 2006: 1 in 650 births
Optimal Wt Gain
* Singleton: 25-35 lbs
* Twins: 35-45 lbs
* Triplets: ~50 lbs
Calories
* Twins: +150 kcals/day
* Triplets: intake level to promote 1.5 lbs/week throughout pregnancy
Protein
* + 10g protein/fetus
* Singleton: 25g for the first
* Triplets: add 10g/fetus
