Pregnancy

and lactation
Maternal Nutrition

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General terminology:

• Gravida- Number of pregnancies

• Parity- Number of deliveries
• Term Pregnancy- Baby born at 38-42 weeks of gestation
• 1st trimester- conception to week 12
• 2nd trimester- week 13 to week 26
• 3rd trimester- week 27 to week 40
Physiology of pregnancy:

• First half of pregnancy:

• Anabolic phase
• Increase in blood plasma volume
• Increase in nutrient stores
• Increase in placental size
• Second half of pregnancy:
• Catabolic phase
• Using extra stores to support fetal growth
Maternal Changes During Pregnancy:

• Body water
• 2-2 ½ gallon increase
• Begins a few weeks after conception
• Birth weight is strongly associated to plasma volume
• Hormonal increases
• Glucose is the preferred energy source for the fetus
Recommended Weight Gain During
Pregnancy:
5-6 lbs. first trimester
Underweight 1-2 lbs/wk. second trimester
1-2 lbs/wk. third trimester

3-5 lbs. first trimester

Normal Weight 1-2 lbs/wk. second trimester
1-2 lbs/wk. third trimester
1-2 lbs. first trimester
Overweight 1 lbs/wk. for last 6 months
Weight gain and Pregnancy:

• Low weight gain:

• Low birth weight
• Intrauterine growth restriction (IUGR): poor growth of a
baby while in the mother's womb during pregnancy
• Preterm births
• Small for Gestational Age (SGA)
• Can increase risk for obesity, heart disease, HTN and Type
2 diabetes later in life
Weight gain and Pregnancy:

• High weight gain:

• Higher risk for gestational diabetes
• Fetal macrosomia: any baby over 8 lbs and 13 oz. no matter the
gestational age
• Large for Gestational Age (LGA)
• Can cause shoulder dystocia: damage to shoulder during birth
• Can increase risk for obesity, cardiovascular disease, asthma,
and atherosclerosis later in life
Preterm Delivery:

• Babies born before 40 weeks

• Very preterm is a baby born before 34 weeks
• Can lead to:
• Increased mortality
• Malformations
• GI problems
• Respiratory problems
• Decreased growth/IQ
Preterm Delivery:

• Reasons for Preterm deliveries:

• Multiples
• Decreased uterine-placental blood flow
• Placental abruption
• Low folate during early pregnancy
• Underweight
• Low weight gain during pregnancy
• Obesity pre-pregnancy
Gestational Diabetes:

• GDM is diabetes that is diagnosed in the second or third trimester

of pregnancy that is preexisting type 1 or type 2 diabetes
• Women at increased risk are:
• Overweight or obese
• Previous history of GDM
• Family history of diabetes
• Presence of polycystic ovary syndrome (PCOS)
• Multiple fetuses
Gestational Diabetes:

• During the 2nd or 3rd trimester of pregnancy, insulin resistance is

increased due to an increase in insulin-antagonistic hormone levels
• GDM is developed when women are unable to overcome this
increased insulin resistance and produce adequate insulin to
maintain normal glucose concentrations
• Blood glucose levels will return to normal after delivery for most
women, but will be at increased risk for developing type 2 DM later
in life
Gestational Diabetes Diagnosis:

• Selective screening occurs at 24-28 weeks

• “One- step” approach
• Perform a 75 g 2-hour OGTT with a plasma glucose measurement
fasting at 1 and 2 hours. Performed morning after an 8 hour fast
• Fasting = >92 mg/dL
• 1 hour = >180 mg/dL
• 2 hour = >153 mg/dL
Gestational Diabetes Diagnosis:

• Two-Step approach:
• 1: Perform a 50 g glucose load (non-fasting) with plasma
glucose measurements at 1 hour. If test is >130 mg/dL
proceed to 100-g OGTT test.
• 2: perform a fasting 100-g 3-hour OGTT with plasma
glucose measurements at 1, 2, and 3 hours.
Preeclampsia:

• Characterized by:
• Oxidative stress and inflammation
• Blood vessels spams and constriction
• Increased blood pressure
• Adverse maternal immune response to placenta
• Platelet aggregation and blood coagulation
• Alterations in calcium regulation
Preeclampsia:

• Risk factors:
• Overweight/obese
• Preexisting diabetes
• Previous pregnancy
• Younger than 20 or older than 40
• Multiple fetuses
• HTN
• Genetic factors
Preeclampsia:

• Can lead to:

• Preterm delivery
• Low-birth weight
• Neonatal deaths
• Maternal morbidity/morality
• Increased risk of developing cardiovascular disease
• Main treatment plan: delivery or bed rest
Alcohol and Pregnancy:

• Baby can develop fetal alcohol syndrome

• Fetus does not have enzymes to break alcohol down
• If alcohol is consumed during critical period:
• Impaired organ and tissue formation
• Decreased growth
• Decreased mental development
• Increases risk for: miscarriage, still birth, infant death within first
month
Fetal Alcohol Syndrome:

• Facial characteristics:
• Epicanthal folds
• Small eye openings
• Flat midface
• Smooth philtrum
• Thin upper lip
• Small chin
• Abnormally shaped ears
Nutrition Assessment:

• Screen performed on all patients within 24 hrs of admission

• Anthropometrics-
• Wt., Ht., Wt. changes, Waist circumference, BMI, Ethnicity
• NFPE-
• Overall appearance
• Edema
• BP, HR
Nutrition Assessment:

• Biochemical data-
• Glycemic tests: glucose challenge test (GCT), OGTT, A1c, Fasting glucose,
random glucose
• Lipid profile
• Vitamin/mineral levels, as appropriate
• Maternal and fetal testing (ex. Ultrasounds, biophysical profile, non-stress
testing)
• GDM- should be tested 4-12 wks. After delivery with an oral glucose
tolerance test and subsequently have lifelong screening for prediabetes or
diabetes at least every 3 years
Nutrition Assessment:

• When obtaining food history from a client, note the following:

• Socioeconomic factors, including participation in the Special
Supplemental Nutrition Program for Women, Infants, and
Children; participation in the Supplemental Nutrition
Assistance Program; and financial constraints
• Psychosocial issues, including family dynamics (eg, more than
one parental or guardian residence) and family schedule
• Barriers to lifestyle changes
Nutrition Assessment:

• Food/nutrition related history:

• 24-hour recall or typical food intake
• Readiness to change nutrition-related behaviors
• Usual physical activity
• Usual sleep habits
• Appetite/GI issues
• Food allergies/food intolerance
• Current weight, weight history
Nutrition Assessment:

• Client History:
• Social history (socioeconomic status, social and medical
support, cultural and religious beliefs, and living situation)
• Medical/health history
• Personal history factors (age, sex, education level)
• Vitamin/mineral/supplement use
• Past pregnancy history
Nutritional Needs Assessment:

• Calories:
• 1st trimester- +85 kcal per day
• 2nd / 3rd trimester- +300 kcal per day
• These calorie recommendations are to support one fetus. If more
than one fetus: multiply that number by the above calories.
• Example- 4 fetuses= 85 x 4 = +340 kcal/day and 300 x 4 =
+1200 kcal/day
Nutritional Needs Assessment:

• Protein:
• At least 1.1 g/kg/day protein using prepregnancy weight
• Or an additional 25 g per day after the 1 st trimester
• Fat:
• Fatty acids, omega-3 and omega-6 are essential nutrients for fetal growth
• 300 mg/day of DHA and EPA
• DHA intake is most important in the 3 rd trimester
• Carbohydrates:
• 175 g/day to provide glucose for fetal brain development
Nutritional Needs Assessment:

• Fluid needs:
• 3 L/day total water (including drinks and food), which includes approximately
2.3 L as total beverages
• Zinc:
• 11 mg/day
• Deficiency can interfere with fetal development and can comprise the immune
system.
• Folate:
• 400 µg of folic acid with iron
• Most important during the 1st trimester to support the development of the
embryo and neural tubes.
Nutritional Needs Assessment:

• Vitamin B12:
• 2.6 mcg/day
• Important for DNA methylation
• Deficiency can cause preeclampsia, preterm births, low birthweight, neural
tube defects, and still births
• Vitamin D:
• 400 IU/day
• Deficiency can cause increased risk for SGA, preterm birth and low birth weight
• Deficiency can cause an increased risk for the baby to develop rickets later in
life and have poor skeletal growth
Nutritional Needs Assessment:

• Iodine:
• Recommend the use of iodized salt or supplementation of 250 µg/day
• Deficiency can lead to fetal hypothyroidism and goiter
• Choline:
• 450 mg/day
• Leading cause of choline deficiency during pregnancy is from alcohol
intake
Nutrition Diagnosis:

• Not ready for diet/lifestyle change (NB- • Excessive alcohol intake (NI-4.3)
1.3)
• Inadequate vitamin intake (NI-
• Undesirable food choices (NB-1.7 54.1)
• Limited adherence to nutrition-related • Inadequate mineral intake (NI-
recommendations (NB-1.6) 55.1)
• Physical inactivity (NB-2.1) • Breastfeeding difficulty (NC-1.4)
• Inadequate energy intake (NI-1.4) • Altered nutrition-related
• Excessive energy intake (NI-1.5) laboratory values (NC-2.2)

• Increased nutrient needs (NI-5.1) • Underweight (NC-3.1)

PES Examples:

• Food- and nutrition-related knowledge deficit related to lack of prior nutrition-

related education as evidenced by new diagnosis of GDM and questions asked.
• Excessive energy intake related to increased appetite with pregnancy as
evidenced by food intake increasing from 3 to 6 meals daily with double
portions and 10-pound weight gain over the last month.
• Excessive alcohol intake related to patient continuing to consume 4-5 drinks per
week while pregnant as evidenced by food frequency questionnaire.
• Underweight related to low intake of nutrient dense foods as evidenced by BMI
of 16 pregnancy weight and a daily intake of 1200 calories.
Nutrition Goals: Gestational Diabetes

• Nutrition education
• Implement lifestyle strategies (eating pattern and physical activity) that
will improve clinical outcomes
• Evenly space out a minimum of 175 g of carbohydrates daily
• Provide adequate energy and nutrient needs for optimal growth.
• Prevent and treat complications of gestational diabetes
• Improve health through healthy food choices and physical activity
• Respect the individuals wishes and willingness and ability to change
Nutrition Goals: Low weight gain

• Nutrition education
• Implement lifestyle strategies (eating pattern and physical activity)
that will improve clinical outcomes
• Increase calories and meal frequency to support optimal growth
• Encourage appropriate weight gain
• Prevent and treat complications of undernutrition during pregnancy
• Respect the individuals wishes and willingness and ability to change
Nutrition Goals: Excessive weight gain

• Nutrition education
• Implement lifestyle strategies (eating pattern and physical activity)
that will improve clinical outcomes
• Maintain calories and meal frequency to support optimal growth
• Encourage appropriate weight maintenance
• Prevent and treat complications of overnutrition during pregnancy
• Respect the individuals wishes and willingness and ability to change
Nutrition Interventions:

• General:
• Healthy food choices
• Physical activity
• Nutrition education
• Nutrition counseling
• Gestational diabetes
• Carbohydrate counting
• Consistent carbohydrate intake
• Decrease body weight
• Low weight gain:
• Increase calories/meals
• Excessive weight gain:
• Decrease calories/meals
Nutrition Intervention: Gestational
Diabetes

• Carbohydrate counting
• Consistent carbohydrate intake
• Decrease body weight (at a healthy rate to still support pregnancy)
• Teach what foods contain carbohydrates, and how many 15 g servings each meal
should contain
• Encourage spacing out meals with snacks in between to evenly distribute
carbohydrates throughout the day
• Individuals should start a physical activity program gradually and increase activity
level gradually. Accumulating 30 minutes nearly every day is recommended for fitness
Nutrition Monitoring and Evaluation:

• The registered dietitian nutritionist (RDN) should monitor:

• Medications
• Lab values
• Anthropometric measurements
• Physical activity
• Food/Fluid intake
• Supplement use
• Symptoms of pregnancy (nausea, vomiting, pain)
Lactation:

• Exclusive breastfeeding is recommended for approximately 6 months and continued

breastfeeding for at least 12 months (AAP section on breastfeeding, 2012).
• Any milk not specifically designed for an infant (including cow’s milk, rice milk, soy milk,
almond milk, or goat’s milk) is not recommended during the first 12 months (AAP,
2014c; Basnet, 2010).
• Until approximately 9 months of age, cow’s milk consumption is associated with
intestinal blood loss (AAP, 2014c; ESPGHAN, 2008; Udall, 1999; Zeigler, 1999).
• Cow’s milk provides inadequate iron, vitamin E, and linoleic acid and excessive amounts
of sodium, potassium, and protein (AAP, 2014c; ESPGHAN, 2008). Proteins in cow’s milk
—especially casein, calcium, and phosphorus – inhibit iron absorption. Cows milk protein
is 80% casein.
Benefits of Breastfeeding:

• Mother:
• Stimulates Oxytocin
• Lower risk of breast and ovarian cancer
• Postpartum weight loss
• Decreased hypertension
• Improved mother-infant bonding
Benefits of Breastfeeding:

• Infant:
• Decrease in the incidence and severity of a wide range of
infectious diseases
• Decreases post-neonatal infant mortality
• Reduction in type ½ diabetes
• Decreases risk of obesity
• Enhanced performance on cognitive development tests
Breast Milk Composition:

• Colostrum
• 1-3 days after birth (first human milk produced)
• Provides more protein and lower in fat and carbohydrates than mature milk
• Higher electrolyte concentrations: sodium, chloride and magnesium
• Immune protection: contains IgA, lactoferrin, leukocytes and epidermal growth
factor
• Transitional Milk
• 5 days to 2 weeks
• Higher in lactose
• Lower in sodium and higher in potassium
• By 1 month milk is fully mature (less fluctuation of composition)
Lipid Composition:

• Consists of about 44% fat

• Hind milk is 2-3x higher in fat content then foremilk
• Maternal diet effects lipid profile:
• Very low-fat diet= more medium chain fatty acids
• Mothers should be consuming 200 mg DHA to increase amount in
breast milk
• DHA is important for brain and retinal development
Other Macronutrients in Breast Milk:

• Protein:
• Highest in mothers who deliver preterm babies
• Not influenced by maternal diet
• Divided into Whey and Casein constituents
• Contains non-protein nitrogen
• Includes nucleotides, amino acids, urea, uric acid, creatine, and
creatinine
• Carbohydrates:
• Main source is Lactose
Micronutrients in Breast Milk:

• Maternal Diet does alter breast milk amounts of vitamins A, D, B1,

B2, B3, B6, B12 and iodine
• Healthy balanced diet is important for optimal outcomes
• It is recommended for breastfeeding mother to take a multivitamin
to ensure adequate amount of vitamins are transferred to the infant
• Breast feed infants should be supplemented with Vitamin K and D
Maternal Diet:

• Things to avoid/limit:
• Alcohol
• Should not breastfeed until alcohol is cleared from body
• Drugs/prescriptions
• Caffeine
• Smoking
• Decreased amount of milk produced
• Changes in flavor and smell
Nutritional needs during breastfeeding:

• Calories:
• +330 first 6 months
• +400 second 6 months
• Carbohydrates:
• Minimum of 210 g/day
• Protein:
• +25 g/d or 1.1 g/kg/day
• Fat:
• 200 mg/day DHA
• High intake of PUFAs
Nutritional needs during breastfeeding:

• Vitamin A: 1300 • Choline: 550 mg/day

µg/day • Copper: 1300 mg/day
• Vitamin C: 120 mg/day
• Iodine: 290 µg/day
• Riboflavin: 1.6 mg/day
• Selenium: 70 µg/day
• Vitamin B6: 2 mg/day
• Zinc: 12 mg/day
• Vitamin B12: 2.6
• Potassium: 5100 mg/day
µg/day