Nutrition In Pregnancy Authors Jan S Eperjesi MD

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Nutrition In Pregnancy Author(s): Jan S. Eperjesi, MD, MHSc, BEd. Academic Affiliation : Duke

Nutrition In Pregnancy Author(s): Jan S. Eperjesi, MD, MHSc, BEd. Academic Affiliation : Duke University Medical Center, OB/GYN Resident Level: Basic / Intermediate / Advanced Version No: 1. 0 Submitted: 5/1/2012 Editors’ Review:

2 Disclaimer/Liability • The information provided in the VAP is made available in good

2 Disclaimer/Liability • The information provided in the VAP is made available in good faith and is derived from sources believed to be reliable and accurate at the time of release. • The materials presented on the VAP may include links to external Internet sites. These external information sources are outside the control of Duke-NUS. The user of the Internet links is responsible for making his or her own decision about the accuracy, reliability and correctness of the information found. • In no event shall Duke-NUS be liable for any indirect, special, incidental, or consequential damages arising out of any use of reliance of any information contained in the VAP. Nor does Duke-NUS assume any responsibility for failure or delay in updating or removing the information contained in the VAP. • Moreover, information provided on the VAP does not constitute medical advice or treatment nor should it be considered as a replacement of the patient/physician relationship or a physician’s professional judgment. Duke-NUS expressly disclaims all liability for treatment, diagnosis, decisions and actions taken or not taken in reliance upon information contained in the VAP. This work is licensed under a Creative Commons Attribution-Non. Commercial-No. Derivs 3. 0 Unported License To view a copy of this license, visit [http: //creativecommons. org/licenses/by-nc-nd/3. 0/]

3 Financial Disclosures (past 3 years) • No Disclosures

3 Financial Disclosures (past 3 years) • No Disclosures

4 Learning Objectives • Recommendations for weight gain in pregnancy • Maternal and fetal

4 Learning Objectives • Recommendations for weight gain in pregnancy • Maternal and fetal risks associated with excessive or inadequate weight gain in pregnancy • Typical weight loss timeline after pregnancy • Information about caloric intake, protein sources, mercury toxicity from certain fish, iron requirements, calcium, folic acid, vitamin A, caffeine, and pica

5 Recommended Weight Gain in Pregnancy Weight-for-Height Category BMI Recommended Total Weight Gain (kg)

5 Recommended Weight Gain in Pregnancy Weight-for-Height Category BMI Recommended Total Weight Gain (kg) Recommended Total Wight Gain (lb) Low < 19. 8 12. 5 -18 28 -40 Normal 19. 8 -26 11. 5 -16 25 -35 High 26 -29 7 -11. 5 15 -25 Obese >29 ≥ 7 ≥ 15 From the Institute of Medicine (1990)

6 Maternal/Fetal Risks Associated with Excessive or Inadequate Weight Gain in Pregnancy Inadequate weight

6 Maternal/Fetal Risks Associated with Excessive or Inadequate Weight Gain in Pregnancy Inadequate weight gain: • Low-birthweight infant Excessive weight gain: • macrosomia, gestational hypertension, preeclampsia, gestational diabetes, cesarian delivery, failed induction, cephalopelvic disproportion

7 Timeline of Weight Loss/Retention After Pregnancy • Most maternal weight lost at delivery

7 Timeline of Weight Loss/Retention After Pregnancy • Most maternal weight lost at delivery (~12 lbs) • Next 2 weeks ~9 lbs • Between 2 wks-6 months postpartum 5. 5 lbs • Overall, the more weight gained during pregnancy, the more lost during postpartum • Interestingly, there is no relationship between pre-pregnancy BMI or prenatal weight gain and weight retention

8 Protein • Most protein should be supplied from animal sources e. g. meat,

8 Protein • Most protein should be supplied from animal sources e. g. meat, milk, eggs, poultry and fish because amino acids provided in optimal combinations • Ingestion of specific fish (e. g. Mackerel)-> methylmercury toxicity risk

9 Iron & Calcium After mid-pregnancy iron requirements total approximately 7 mg per day

9 Iron & Calcium After mid-pregnancy iron requirements total approximately 7 mg per day Few women have sufficient Fe stores or dietary Fe intake to supply this amount ACOG endorses at least 27 mg of ferrous iron supplement given daily to pregnant women; this amount is contained in most pre-natal vitamins Ingestion of iron at bedtime or on an empty stomach aids absorption and appears to minimize the possibility of an adverse gastrointestinal reaction Calcium: most maternal calcium is in bone and can be readily mobilized for fetal growth.

10 Folic Acid—Prevention of Neural Tube Defects • >50% of all neural-tube defects can

10 Folic Acid—Prevention of Neural Tube Defects • >50% of all neural-tube defects can be prevented with daily intake of 400μg of folic acid throughout the periconceptional period (CDC). • Putting 140μg of folic acid into each 100 g of grain products may increase the folic acid intake American woman of childbearing age by 100μg/day. • Because nutritional sources alone are insufficient, however, folic acid supplementation is still recommended. • A woman with a prior child with a neural-tube defect can reduce the 2 to 5% recurrence risk by >70% with daily 4 mg folic acid supplements in the month before conception and during the 1 st trimester • This higher dose should be consumed as a separate supplement, that is, not as multivitamin tablets, to avoid excess intake of fat-soluble vitamins.

11 Vitamin A • Association with birth defects at very high doses (10000 -50000

11 Vitamin A • Association with birth defects at very high doses (10000 -50000 IU daily) • Beta-carotene precursor of vit. A found in fruits and vegetables no vit. A toxicity • vit. A deficiency is an endemic nutrition problem in developing countries causes night blindness in pregnant women; associated with increased risk of anemia and preterm birth

12 Caffeine • American Dietetic Association recommends that caffeine intake in pregnancy be limited

12 Caffeine • American Dietetic Association recommends that caffeine intake in pregnancy be limited to <300 mg/day or ~ 3 5 -oz cups of coffee • increased risk for fetal growth restriction if caffeine >200 mg/day throughout pregnancy versus <100 mg/day (CARE Study 2008).

13 Pica • Cravings of pregnant women for strange foods or non-foods e. g.

13 Pica • Cravings of pregnant women for strange foods or non-foods e. g. ice, starch, or clay • 4% prevalence in 2 nd trim. • Most common nonfood items: starch (64%), dirt (14%), sourdough (9%), ice (5%) • May be triggered by severe iron deficiency, but not all women with pica are necessarily iron deficient • Interestingly, preterm delivery <35 wks twice as high in women with Pica

14 References 1) Williams Obstetrics 23 rd Edition. Chapter 8: Prenatal Care. 2) Institute

14 References 1) Williams Obstetrics 23 rd Edition. Chapter 8: Prenatal Care. 2) Institute of Medicine: Nutrition During Pregnancy, 1. Weight Gain; 2. Nutrient Supplements. Washington, DC, National Academy Press, 1990. 3) Kiel DW et al. Gestational weight gain and pregnancy outcomes in obese women: How much is enough. Obstet Gynecol 110: 752, 2007 4) De. Vader et al. Evaluation of gestational weight gain guidelines for women with normal prepregnancy body mass index. Obstet Gynecol 110: 745, 2007 5) CARE study group: Maternal caffeine intake during pregnancy and risk of fetal growth restriction: A large prospective observational study. BMJ 337: a 2332, 2008.

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