Pregnancy Health Issues PDF

Changes in body water Body water increases 7–10 L during pregnancy Most goes toward building blood and tissues during the first trimester Plasma volume starts to increase within the first few weeks of pregnancy Continues until the 34th week with the steepest increase during the second trimester Wome...

Changes in body water Body water increases 7–10 L during pregnancy Most goes toward building blood and tissues during the first trimester Plasma volume starts to increase within the first few weeks of pregnancy Continues until the 34th week with the steepest increase during the second trimester Women with high gains in fluid experience more edema and greater weight gain Physiological Adjustments during Pregnancy Increased blood volume Altered stomach, cardiac, renal and pulmonary functions Hemodilution Altered plasma lipid profiles Altered appetite and thirst Altered digestion and assimilation of food ↑GFR and ↓ tubular re-absorption capacity ↑ excretion of fetal waste products but ALSO ↑renal loss of glucose, folate, iodine and aa’s. ↓ histamine & pepsin Relaxed cardiac sphincter heartburn ↓GI motility + insufficient fluids ↑ risk of constipation. ↑ efficiency of nutrient absorption Cardiac hypertrophy + ↑ cardiac output ↑ventilation due to ↑ oxygen demands. BMR ↑ by 15-20% ↑Plasma lipids (conserve glucose) Blood glucose falls in 3rd trimester but ↑lipolysis and mild ketosis Decreased muscle breakdown + ↑placental uptake of alanine ↓alanine availability impaired hepatic gluconeogenesis Changes in smell and taste Impact dietary behavior during pregnancy Food cravings and aversions common due to changes in senses of smell and taste Many have a preference for fruits, dairy products, and sweet or salty foods Two-thirds of pregnant women report a heightened sense of smell Hypothesized to be associated with natural changes in hormones Nausea and vomiting -Morning sickness: 6 weeks after last menstrual period (↑estrogen & human chorionic gonadotropin) -Nausea/vomiting: positive predictor of pregnancy outcome & decreased risk of fetal death -But: too many skipped meals ketosis & hypoglycemia (teratogenic risk) -Recommended: small frequent high fat, low bulk meals Common during pregnancy Often referred to as “morning sickness” Cause not clear Starts around the 6th week and stops around 12th wk Not harmful unless becomes severe Can help prevent and treat by: Avoiding foods and smells that trigger nausea Making certain dietary changes Heartburn Can occur during all trimesters of pregnancy Relaxation of GI muscles secondary to an increase in estrogen and progesterone Relaxation of the lower esophageal sphincter Stomach contents move into the esophagus, causing heartburn or more severely gastroesophageal reflux disease (GERD) Can also be caused by pressure from the uterus and fetus Gastroesophageal reflux disease (GERD) Caused by impact of fluctuating hormones on lower esophageal sphincter Stomach acid easily refluxes into esophagus Triggers: eating before bed, intake of fatty or spicy foods, caffeine, mints, chocolate, and side effects of medications Lifestyle modifications addressing triggers help manage symptoms Drug therapy may be warranted for severe cases. Constipation Common, especially in third trimester ~25–40% of pregnancies Likely due to relaxed musculature of GI tract Physiological and hormonal changes in the GI system Decreased maternal activity Iron supplementation Normal slowed GI transit with hormonal shifts Constipation Adequate fluid and fiber intake Physical activity in accordance with medical approval Bulk forming agents Probiotic supplements Laxatives as last resort Can be reduced by: Increasing fiber intake to approximately 30 g per day Increasing fluid intake to 6–8 glasses per day Laxatives generally not recommended during pregnancy Can cause dehydration and nutrient deficiencies Weight gain recommendations Based on the prepregnancy weight status and body mass index (BMI) of the mother Individualized care and clinical judgment necessary for most successful weight gain outcomes Can use weight gain charts when counseling and educating women Pregnancy Weight Gain Pregnancy Weight Gain Need 22% of body wt as fat Average wt gain of 12.5% = 20% gain overall; of which 40% = fetal, placental tissues & amniotic fluid BMI >29 = limit 6 kg wt gain Adolescents: 28-40 pounds (12.5-18 kg) Twins: 35-45 pounds regardless of pre-pregnancy wt Pregnancy Weight Gain Patterns of wt gain = important 3-4 lbs for 1st 10 weeks 1 lb/week for rest of pregnancy > + 1 kg/week cause for concern Likely excessive edema and risk for preeclampsia ↑ risk of placental abruption, stillbirth, decreased blood flow to placenta, LBW Rate of pregnancy weight gain Most weight gain occurs during the second and third trimesters May have difficulty gaining weight due to varying circumstances May experience slow rates of weight gain and possibly weight loss throughout pregnancy Less than a 20-lb weight gain during pregnancy = increased risk of being born premature or being small for gestational age Pregnancy Weight Gain Obligatory Wt gain = fetus, placenta, enlarged uterine & breast tissue, expanded blood volume Edema common Insufficient blood volume expansion ↑ risk still births, LBW, spontaneous abortions ↑Plasma volume & RBC directly related to fetal size 2/3 of maternal Wt gain = maternal tissue accretion, expansion of maternal blood volume, extracellular fluid, fat stores Pregnancy Weight Gain Gain in adipose tissue & protein stores 40% of energy needed to support pregnancy is deposited in 1st 20 weeks Av. 3.8 kg fat laid down by 30th week =↑ subcutaneous fat Fetal tissues, placenta & amniotic fluid Comprises most of Wt gain during 2nd half of pregnancy Rest of Wt gain = extracellular fluid, fat & protein stores Composition of weight gain ~ One-third of the weight gained in a normal-weight woman goes to the fetus Fat storage increases most significantly during the first several weeks of the second trimester and tends to decrease later in pregnancy Body fat stores provide an average reserve of 30,000 calories for pregnancy and lactation Increased body fat helps to meet the nutritional needs of the mother and the fetus. especially in 3rd trimester Pregnancy Weight Gain Average weight distribution during pregnancy. Inadequate weight gain during pregnancy and entering pregnancy underweight BMI < 18.5 considered underweight ~20% of women don’t gain enough weight Increases risk of: Maternal bone and muscle loss, vitamin and mineral deficiencies, anemia, and fatigue Preterm delivery, IUGR, and LBW Mother should focus on: Balanced diet of meals and snacks, listening to hunger and fullness cues, and engaging in physical activity regularly Entering pregnancy overweight or obese Weight loss during pregnancy not advised Weight gain goals vary based on BMI Increased risk of excessive weight gain during pregnancy Children of obese women face a greater risk of: Fetal death Congenital malformations Increased perinatal complications Entering pregnancy overweight or obese Gaining more weight than recommended correlated with short- and long-term health risks Gestational diabetes Hypertension Preeclampsia Dyslipidemia Cardiovascular disease for both baby and mother (rest only mom) Cesarean delivery Less likely to start and sustain breastfeeding Interventions to prevent excess weight gain Nutrition counseling and education Increased physical activity Improved diet Individualized care during preconception, prenatal, and postpartum care to assist with weight gain and obtaining a healthy postpartum weight Healthy Weight Gain Gestational diabetes mellitus (GDM) Glucose intolerance diagnosed for first time in pregnancy Usually second or third trimester Usually resolves after childbirth Increases risk for type 2 diabetes later in life Higher risk for pregnancy complications such as: C-section Macrosomia Neonatal hypoglycemia obesity increases risk to have GDM Gestational diabetes mellitus (GDM) Incidence increasing likely due to rising obesity rates Poorly controlled GDM can be harmful to baby Women with GDM more likely to experience it again in future pregnancies Gestational diabetes mellitus (GDM) Prevented with dietary and exercise-related interventions Treatment goal Maintain blood glucose levels to minimize risks Individualized medical nutrition therapy Insulin preferred choice of medication Self-monitoring of blood glucose mandatory Hypertension Systolic blood pressure of >140 mm Hg, diastolic pressure of >90 mm Hg, or both Hypertension in pregnancy classified into Chronic hypertension before 20 weeks Gestational hypertension second to third trimester Preeclampsia after 20 weeks Maternal hypertension prevents placenta from getting enough blood and can result in LBW The DASH diet is rich in vegetables, fruits and whole grains. It includes fat-free or low-fat dairy products, fish, poultry, beans and nuts. It limits foods that are high in saturated fat, such as fatty meats and full-fat dairy products. Preeclampsia Characterized by high blood pressure and protein in urine Occurs after 20th week of gestation Can lead to complications for mother and baby Routine screening recommended Most effective treatment is delivery of baby Adherence to DASH diet recommended Mental health Anxiety and depression in mother most common Increases risk for adverse outcomes in child Emotional problems Symptoms of ADHD Impaired cognitive development Several vitamins and minerals linked to improving depression and other mood disorders, including: Iron, folate, and vitamin B12 Important for clinicians to assist women in selecting nutrientdense foods and beverages Depression Common but often underdiagnosed and underreported Likely a result of multiple factors, including nutrition Can negatively influence mother and child Linked to: Preeclampsia Birth difficulties, Reduced breastfeeding Risk of developmental and behavioral issues in offspring Depression multifactor during pregnancy 80% hormonal after pregnancy, supposed to go away after 6 weeks Must identify and address as early as possible Signs of depression Depressed mood Loss of interest Guilt or low self-worth Disturbed sleep or appetite Low energy Poor concentration Eating disorders Place mother and baby at risk for negative health outcomes Three common forms: anorexia nervosa, bulimia nervosa, and binge eating disorder Amenorrhea also common with anorexia May not gain enough weight during pregnancy Eating disorders Risk of dehydration if mother is bulimic Higher risk of gestational diabetes if overweight Likely contributing factors: bc vomit Genetics, emotional and psychological health, and societal pressure Meal planning and patient monitoring essential Pica Cravings for nonnutritive substances Potential complications such as: like clay, dirt, gravel, ice, etc. weight gain Iron-deficiency anemia, lead poisoning, and other toxicities Multifactorial in origin ethology = we don’t really know Pica Increases risk of elevated blood lead levels and iron deficiency Low hemoglobin, hematocrit, and plasma zinc associated with pica Direction of relationship is unclear Impossible to predict and prevent Birth Weight Determined by duration of gestation & rate of fetal growth Most important determinants of birth weight Gestational age Maternal weight gain Preconception weight Mortality rates are lowest for infants between 2.5 kg and 4 kg High perinatal morbidity & mortality related to LBW Low Birth Weight Premature (Gestational age ≤ 37 wks) Intrauterine growth retardation < 2 SDs in weight for gestational age < 10th percentile in weight for gestational age < 2500 g and gestational age > 37 wks Preterm Birth Causes: Genitourinary infection Multiple pregnancies Pregnancy-induced HTN Low prepregnancy BMI Prior history Smoking Strenuous physical labor Prematurity Mildly preterm (32-36 wks) Somewhat elevated risk of RDS, infection, mortality Extremely preterm infants Severe morbidity in infancy & childhood Retinopathy of prematurity Chronic lung disease (e.g. bronchopulmonary dysplasia) Most serious: neurocognitive (cerebral palsy, mental retardation, seizure disorders & other) Intrauterine growth restriction Proportionate Extreme fetal malnutrition Congenital infection Disproportionate Decreased growth potential Genetic disorder Uteroplacental insufficiency Environmental toxins LBW: preterm birth or SGA (proxy for IUGR) Maternal malnutrition Intrauterine growth retardation Associated with Congenital anomalies Low energy intake Low prepregnancy BMI Short maternal stature Pregnancy-induced HTN Smoking Alcohol Malaria Intrauterine growth retardation Developing countries Typically shorter & lighter women, more physical labor Malaria is a major cause of anemia in women with first offspring Hypoglycemia, hypocalcemia in early neonatal period Most IUGR infants survive this period; but risk of infection Catch-up growth is incomplete in many children Mild neurocognitive deficits & behavioral problems Abnormal Patterns of Fetal Growth Linked to Adult Disease Symmetrical small babies of LBW Babies thin at birth but undergo catch-up later in infancy Disproportionately large head & narrow waist (i.e. low ponderal index = birth weight/length 3) Average birth weight infants but abnormally small in proportion to their placental weight Tend to grow below average during infancy IUGR recently associated with adult disease (HTN, DM2, CHD) Developing countries: shift from energy scarcity to plenty rise in obesity + fetal growth deficits contribution to insulin resistance & DM2 (e.g. India) loss weight normal in first trimester, not on second or third ones Fetal weight gain follows S-shaped curve Wt maintenance or slight losses: normal in the 1st trimester. Little effect on embryonic wt gain. Short- and Long-Term Effects from Adverse Intrauterine Environment Risks of LBW include 1. 2. 3. 4. Decreased lung capacity during childhood x2 risk of CVD x6 risk of diabetes & impaired glucose metabolism Increased blood pressure risk, abnormal high TG, insulin and low HDL Excessive birth weight (> 9 lbs) linked with ↑ risk of hormonally related cancers Improved postnatal nutrition cannot correct metabolic abnormalities in adulthood Mechanisms of Pregnancy Undernutrition and Adult Disease of Offspring Under-nutrition ⇒↑ maternal corticosteroid production ⇒ ↑ fetal maturation of lungs & other organs Advantageous in providing ↑ maturation of organs  ↑ shortterm survival Inadequate development of placenta ⇒ ↓ ability to break down corticosteroids, insulin and thyroxine Cortisol exposure in early gestation linked with ↑ risk of HTN later in life Exercise recommendations Moderate-to-vigorous exercise both mentally and physically beneficial for mother and fetus Helps maintain approximate gestational weight gain and appropriate fetal weight gain May reduce hypertensive disorders and gestational diabetes Recommendation: at least 30 minutes five times each week, or for a total of 150 minutes a week Exercise recommendations Strength training and aerobic activity positively impact maternal and fetal health Should be accompanied by well-balanced diet, proper hydration, and adequate rest Exercise recommendations Possible contraindications Low-lying placenta Severe anemia Persistent second or third trimester bleeding Preeclampsia Pregnancy with more than one baby at a time Previous history of miscarriage Food insecurity Inability to obtain nutritious and safe foods in socially acceptable ways More common among low-income women during pregnancy Increases the risk of Low birth weight Poor brain development Infections Certain congenital disabilities Categories for Nutritional Risk for Pregnancy Poverty Low pre-pregnancy and pregnancy weight Short interconception interval Chronic systemic illness Unusual dietary patterns History of anemia or obesity Poor reproductive history Adolescence Poverty – poorer nutritional intake/status, increased smoking 2x LBW (↓ by 200-300 g) Adolescence – high nutritional demands/food fads/ poor financial status, obstetric and nutritional support, increased use of drugs and smoking Short inter-conception interval –high physiological/nutritional demands on body stores of nutrients Chronic systemic illness – diabetes, chronic infection, cancer, alcoholism, malabsorption Unusual dietary patterns – food faddism, pica History of anemia or obesity –long term imbalanced or inappropriate diet Poor reproductive history – prior LBW/ premature labour/spontaneous abortions