Chapter 5

Nutrition During Pregnancy:

Conditions and Interventions
 Introduction

• Health conditions impacting pregnancy &

interventions are covered to include:
– Obesity
– Hypertensive disorders of pregnancy
– Preexisting & gestational diabetes
– Multifetal pregnancies
– Eating disorders
– Fetal alcohol spectrum
– Adolescent pregnancy
 Obesity and Pregnancy

Associated with unfavorable metabolic changes:

•  blood glucose levels
•  C-reactive protein levels
•  blood levels of insulin & insulin resistance
•  blood pressure
• High Total-LDL cholesterol & Triglycerides
• Low HDL cholesterol

• Obesity associated with higher rates of gestational

diabetes and hypertensive disorders
 Obesity and Infant Outcomes
• Obesity associated with higher rates of
– Stillbirth
– Large for gestational newborns
– Cesarean-section delivery
– May increase risk of child becoming overweight or
having Type 2 diabetes later in life
• The risks associated with obesity are related to gene
variants parents transfer to the egg at fertilization
• Other in utero exposures experienced by the rapidly
developing embryo and fetus
 Nutritional Recommendations and
Interventions for Obesity in Pregnancy
• Meet nutrient needs
• Consume healthy dietary patterns
– Low in sugar and refined carbohydrates, highly
processed foods, and red meats; and highlight
vegetables, fruits, low-fat dairy products, poultry,
fish, and seafood; nuts and seeds, vegetables oils,
whole grains, and whole grain products.
• Participate in physical activity
• Maintain appropriate rates of weight gain
 Pregnancy After Bariatric Surgery
• Bariatric surgery for weight loss has increased
• Weight rapidly lost due to
– Limited food intake
– Fat malabsorption
• Dumping syndrome
• Persistence in pregnancy
• Deficiencies of many nutrient stores
– Thiamin, Vitamins D, B12 and Folate
– Iron and calcium
 Pregnancy After Bariatric Surgery
• It is recommended that pregnancy be
postponed for several years after bariatric
surgery, when body weight is stable and
nutrient stores have been established
Bariatric Surgery
 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
– Chewable forms of vitamin and mineral supplements
– Nutrient biomarker status
– Women with a history of bariatric surgery generally qualify
as “at risk” for gestational diabetes
– Weight gain
– Physical activity
– Gastrointestinal symptoms
 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
Hypertensive Disorders of Pregnancy
 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
Ways to Decrease/Increase Oxidative
Stress
 Chronic Hypertension
• HTN present before pregnancy or diagnosed <20
weeks
• 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
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 consuming
too little that could impair fetal growth
 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
 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
 Characteristics of Preeclampsia-
Eclampsia
• Oxidative stress, inflammation, & endothelial dysfunction
• Blood vessel spasms & constriction & increased blood clots
– Most affected organ: the placenta and the mother’s kidney, liver, and
brain
• 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
 Characteristics of Preeclampsia-
Eclampsia
• Signs, symptoms and consequences of preeclampsia
range from mild to severe
• Preeclampsia during pregnancy doubles the risk of
cardiovascular disease development and increases
the risk of developing gestational diabetes, type 2
diabetes, and hypertension later in life
• Cause is unknown – appears to originate from:
– Abnormal implantation & vascularization of
placenta with poor blood flow.
Characteristics of Preeclampsia-
Eclampsia
Characteristics of Preeclampsia-
Eclampsia
Vitamin and Mineral Supplementation and
the Risk of Preeclampsia
• Vitamin C & E  did not decrease oxidative
stress
• Vitamin D risk in women with low vitamin D
status only
 Nutritional Recommendations
and Interventions for Preeclampsia
• Dietary interventions should begin prior to
pregnancy
– Decrease body weight and stores of central body
fat
– Become physically fit
– Consume a diet that reduces inflammation and
oxidative stress
 Nutritional Recommendations
and Interventions for Preeclampsia
• Regular intake of colorful vegetables and fruits
• Frequent inclusion of good sources of fiber
• Water replacement of sugar-sweetened beverages
• Use of low-fat dairy products
• Use of vegetable oils (such as olive oil)
• Selection of poultry, fish, and seafood over
processed and red meats
 Nutritional Recommendations
and Interventions for Preeclampsia
• Dietary recommendations & interventions
should begin in at-risk women as early in
pregnancy as possible
– Moderate exercise (i.e, walking,
swimming, or dancing for 30 minutes)
daily unless medically contraindicated
– Weight gain that follows
recommendations based on pre-
pregnancy weight
– Iron supplements not recommended
except in specific conditions
 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
 Gestational Diabetes
• The prevalence varies from 2 to
12% 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, HbA1C,
triglycerides, fatty acids, & blood
pressure
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
Adverse Outcomes Associated
with Gestational Diabetes
Risk Factors for Gestational Diabetes
 Diagnosis of Diabetes During
Pregnancy
• Pregnant women should be screened at the
first prenatal visit for diabetes:
– Hemoglobin A1c (A1c) ≥6.5%
– Fasting plasma glucose ≥126 mg/dL
– 2-hour glucose ≥200 mg/dL after a 75-gram oral
glucose load
– Classic symptoms of hyperglycemia present
– A random plasma glucose level ≥ 200 mg/dL (11.1
mmol/L)

American Diabetes Association

 Diagnosis of Gestational Diabetes
• Routine testing for GDM should be undertaken
between 24 to 28 weeks of pregnancy
• Women should be tested for GDM using one of
two diagnostic approaches:
– 75 g oral glucose tolerance test, or
– 50 g non-fasting glucose screen. If positive, follow-up
with an 100-g glucose tolerance test
 Diagnosis of Gestational Diabetes
• Acceptable blood glucose concentrations are
defined as:
– Fasting glucose < 95 mg/dL
– 1-hour postprandial < 140 mg/dL
– 2-hour postprandial <120 mg/dL
• Women with one elevated plasma glucose level
based on the above cut-points, receive a
diagnosis of GDM

American Diabetes Association

 Diagnosis of Gestational Diabetes
• The use of HbA1c for monitoring blood
glucose levels is not recommended for
diabetes management
– The values don’t reflect current blood glucose
levels
• Urinary glucose cannot be used to diagnose or
monitor gestational diabetes because the
results do not accurately reflect blood glucose
levels
 Treatment of Gestational Diabetes
• Restriction of pregnancy weight gain is not advised.
• Aggressive treatment of gestational diabetes that excessively
limits caloric intake and weight gain increases the risk of SGA
newborns.
• Excessively high caloric balances and weight gains are of
concern because they increase the risk of macrosomia.
 Management of Gestational
Diabetes
• First approach is to normalize blood glucose levels
with diet & exercise
• If postprandial glucose remains high within few
weeks after adhering to diet & exercise,
metformin/insulin injections could be initiated
along with medical nutrition therapy and exercise
• Unlike insulin, metformin is transferred to the fetus and
increases the risk that newborns will experience
hypoglycemia after birth
Exercise Benefits & Recommendations
• Regular aerobic exercise decreases insulin
resistance & blood glucose in gestational
diabetes
• Exercise is recommended 3 times per week
– Levels of exercise should make women become
slightly sweaty but not overheated, dehydrated, or
exhausted
 Nutritional Management of Women
with Gestational Diabetes
• Assess dietary & exercise habits
• Develop individualized diet & exercise plan
• Monitor weight gain
• Interpret blood glucose levels
• Ensure follow-up during & after pregnancy
 THE DIET PLAN
• Whole-grain breads & cereals, vegetables,
fruits, & high-fiber foods (28g/d)
• Limited intake of simple sugars
• Low-GI foods, or carbohydrate foods that do
not greatly raise glucose levels
• Monounsaturated fats
• Three regular meals & snacks
 Estimating Levels of Caloric Need in
Women with Gestational Diabetes
• Distribute calories among 3 meals & several snacks
– 10-20% for breakfast
– 20-30% for lunch
– 30-40% for dinner
– 30% for snacks
 Macronutrient Distribution of Total
Calories
• The following percent distributions of total
calories from carbohydrate, protein, and fat
have been established for gestational diabetes:
– Carbohydrates: 40-50% (complex CHOs and high
fiber foods)
– Protein: 20%
– Fat: 30-40% (unsaturated fats)
 Macronutrient Distribution of Total
Calories
• The relatively low-CHO, high-fat diet the need
for insulin by lowering the amount of glucose
absorbed from food, and blunts postprandial
increases in blood glucose and insulin levels
• Benefits of low-GI foods has been debated and
is controversial
– Healthy diet taking into account low GI foods
Other Topics on Diabetes in Pregnancy
• Postpartum Follow-Up
– 15% will remain glucose intolerant postpartum
– 10-15% will develop Type 2 diabetes in 2-5 yrs
– Women requiring insulin for glucose management should
be tested for fasting and 2-hour postprandial blood
glucose values before hospital discharge
Other Topics on Diabetes in Pregnancy
• Prevention of Gestational Diabetes
– Reduce excessive weight and obesity
– Increase physical activity
– Decrease insulin resistance prior to pregnancy
– Use of a probiotic supplement such as Lactobacillus
rhamnosus early in pregnancy appears to reduce insulin
resistance and plasma insulin levels in women
Type 2 Diabetes during Pregnancy
• Care should be individualized and follow
protocol
• Primary goal – maintain normal blood
glucose
– Hyperglycemia and hypoglycemia are possible
– Challenging: insulin requirements change throughout
pregnancy and requires that women be closely
monitored and that care providers remain alert and
ready to modify care plan
• Medical nutrition therapy recommended
Type 2 Diabetes during Pregnancy
 Type 1 Diabetes during Pregnancy
• Mother with type 1 is at risk during pregnancy 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
• Blood glucose control from the beginning of pregnancy is
important because the fetal growth trajectory may be
largely determined in the first half of pregnancy
 Nutritional Management of Type 1
Diabetes during Pregnancy
• Control of blood glucose levels
• Nutritional adequacy of diet
• Achieve recommended weight gain
• Healthy mother & baby
• Careful home monitoring of glucose levels &
dietary intake, exercise and insulin dose
Case study
 Multifetal Pregnancies
• U.S. rates of multifetal pregnancies have
increased
– Linked to assisted reproductive technologies
– Spontaneous multifetal pregnancy  after 35
years of age
– Multifetal pregnancies  with obesity
• Incidence highest in women 45 to 54 y/o (1 in
5 are multifetal)
 Background Information
About Multifetal Pregnancies
• Dizygotic • Monozygotic
– 2 eggs are fertilized – 1 egg is fertilized
– AKA Fraternal – AKA Identical
– ~70% of twins • (or almost identical)
– Different genetic – Always same sex
“fingerprints” – ~30% of twins
– Incidence increased by – Rates appear not to be
perinatal nutrient influenced by heredity
supplements
 Rates of Fetal Weight Gain in
Singleton, Twin, and Triplet Fetuses
 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 weeks.
Risks Associated with Multifetal
Pregnancy
 Complications Increase as Number of
Fetuses Increases
From TABLE 5.14 – Average birthweight and gestational age at
delivery and low-birthweight rates, of singleton, twin, and triplet
newborns
 Nutrition and the Outcome of
Multifetal Pregnancy
• Institute of Medicine makes these provisional
recommendations for weight gain during twin
pregnancy:
– Normal-weight women should gain 17–25 kg
– Overweight women should gain 14–23 kg
– Obese women should gain 11–19 kg
– No recommendation for underweight women
• Weight gain in triplet pregnancy
– Gain of 23 kg based on studies
 Nutrition and the Outcome of
Multifetal Pregnancy
• Increased weight gain+ quicker onset of
starvation metabolism  Higher caloric need
• Levels of energy balance and nutrient intake
associated with optimal outcomes of
multifetal pregnancy have not been
quantitated
• Results of a large prospective study indicate
that women with twins consume an average
of 265 cal/d more than women with singleton.
 Nutrition and the Outcome of
Multifetal Pregnancy
Extrapolation
• Theoretically, to achieve a 40-pound (18.2 kg)
weight gain,
– Women with twins would need to consume
approximately 35,000 cal more during pregnancy
than do women with singleton pregnancies
– This increase would amount to about 150 cal per
day above the level for singleton pregnancy, or an
average of 450 cal more per day than pre-
pregnancy
 Nutrition and the Outcome of
Multifetal Pregnancy
• To achieve higher rates of gain, underweight
women may need a higher level of intake, and
overweight and obese women lower levels.
• Energy needs will also vary by energy
expenditure levels.
• As for singleton pregnancy, adequacy of caloric
intake can be estimated by weight-gain
progress
 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
 Best practice
recommendations
for nutrition during
multifetal
pregnancy
 Eating Disorders in Pregnancy
• Eating disorders are rare in
pregnancy since most females
with disorders are subfertile or
infertile
• Bulimics more likely to become
pregnant than those with
anorexia nervosa
• Eating disorder symptoms
subside in 2nd & 3rd trimester
but return postpartum
 Eating Disorders in Pregnancy
• Consequences of eating disorders in
pregnancy  risk
– Spontaneous abortion
– Hypertension
– Difficult deliveries
– Smaller newborns
– Higher rates neonatal complications
 Eating Disorders in Pregnancy
• Treatment of women with eating disorders
during pregnancy
– Refer to eating disorders clinic
• Nutritional interventions for women with
eating disorders
– Behavioral changes
– Improve nutritional status
– Appropriate weight gain
 Eating Disorders in Pregnancy
• Pregorexia
– Emerging term in clinical practice as an unofficial term
for women with restrictive eating behaviors during
pregnancy
– The term refers to women with eating disorders who
fail to gain weight during pregnancy and are at high
risk of intrauterine growth retardation and early
delivery
• In order to stress the importance of eating right and
gaining weight, some dietitians will supply the women
with ketosticks and ask them to check their urine several
times a day.
 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
 Effects of Alcohol on Pregnancy
Outcome
• Alcohol easily crosses placenta to fetus
• Alcohol remains in fetal circulation because
fetus lacks enzymes to break down alcohol
• Alcohol exposure during critical periods of
growth & development can permanently
impair organ & tissue formation, growth,
health and mental development
 Fetal Alcohol Syndrome
The syndrome has two major diagnostic
categories: • Characteristics include:
1. Fetal alcohol syndrome (FAS) – Anomalies of eyes, nose,
characterized by the presence of heart & CNS
three specific facial features:
– Growth retardation
a. A smooth ridge between the nose
and upper lip – Small head
b. Narrow openings between the – Mental retardation
upper and lower eyelids
c. A thin border on the upper edge
of the lip
2. Partial fetal alcohol syndrome (PFAS)
- Presence of two of the three
characteristic facial features
 Nutrition and Adolescent
Pregnancy
• Growth during adolescent
pregnancy
– Teen growth in height &
weight at expense of fetus
– Infants born to teens
average 155g less than
those born to older adults
Risks associated with adolescent
pregnancy
 Obesity, Excess Weight Gain and
Adolescent Pregnancy
• Overweight & obese adolescents are at
increased risk for:
– Cesarean delivery
– Hypertensive disorders of pregnancy
– Gestational diabetes
– Delivery of excessively large infants
 Dietary Recommendations for
Pregnant Adolescents
• Young adolescents may need more calories to
support their own growth as well as that of
fetus
• Caloric need should be from nutrient-dense
diet
• Calcium DRI for pregnant teens is 1300 mg
 Nutritional Management of
Adolescent Pregnancy
• Multidisciplinary counseling services should
include:
– Individualized nutrition assessment
– Intervention education
– Guidance on weight gain
– Follow-up birth weight outcomes
 Nutritional Management of
Adolescent Pregnancy
• Services should focus on:
– Psychosocial needs
– Support/discussion groups
– Home visits