nutrition%20in%20pregnancy
NUTRITION IN PREGNANCY

Nutrition is the intake of food necessary for optimal health.

Choices regarding maternal nutrition & lifestyle affect maternal & child health.

The World Health Organization (WHO) recommends that women develop healthy dietary behaviors prior, during & after their pregnancy for optimal maternal & infant health outcomes.

The goal of prenatal nutrition is to provide for the optimal development of the fetus & to support maternal health.

History

  • Patient may present with symptoms of paleness, bruising, hair loss, poor vision, loss of taste or appetite, mouth ulcers, constipation, diarrhea, heart palpitations, difficulty breathing, weakness, fatigue, muscle cramps, tingling and numbness of the joints, muscle wasting, loss of height, poor concentration, sleepiness, irregular menses
  • Inquire regarding patient’s previous and current illnesses, current medications, social history eg use of alcohol, cigarettes, or illicit drugs, diet composition, nutrition beliefs and practices, physical activity
    • Conditions such as HIV, tuberculosis, malaria, or gastrointestinal infections or a previous bariatric surgery can cause malabsorption and metabolism alteration resulting in weight loss and vitamin and mineral deficiencies
    • Patient’s obstetric history may reveal a previous offspring with a neural tube defect which would warrant a folic acid supplementation at a higher dose for reduction of risk recurrence

Physical Examination

  • Assess patient’s blood pressure, height, weight, BMI, waist circumference, gestational weight gain
    • BMI upper limit of normal for Asians is <23 kg/m2
  • Perform a complete physical and dental examination
  • Examine for signs of nutritional deficiency or medical disease, eg anemia or eating disorders, such as pallor, dry skin, yellow discoloration of skin, brittle or spoon-shaped nails, cracking of lips and mouth, gingival hypertrophy, erosion of tooth enamel, goiter, bradycardia, muscle tenderness, bowed legs, unsteady movement or gait, depression, etc

Laboratory Tests

  • Check hemoglobin and hematocrit to assess for anemia during the 1st prenatal visit and in the late 2nd to early 3rd trimester of pregnancy
    • Iron deficiency, with or without anemia, may be tested using serum iron and total iron binding capacity (TIBC), serum ferritin, red cell indices, reticulocyte count, reticulocyte hemoglobin concentration (CHr), or soluble (serum) transferrin receptor level
    • As zinc is also needed for hemoglobin synthesis, maternal zinc level may also be determined if indicated 
  • Measurement of 25-hydroxyvitamin D levels is not routinely performed but may be done in women with history of malabsorption or fractures, obesity, little sunlight exposure, or other risk factors for vitamin D deficiency, eg dark skin, vegan diet, as low levels of vitamin D have been associated with adverse health outcomes both in the mother and child

Screen for Pregnancy Complications

  • Assess patient’s risk for developing gestational diabetes, preeclampsia
    • If glycosuria was found on dipstick testing, consider doing an oral glucose tolerance test (OGTT) to screen for gestational diabetes
    • Antenatal screening for preeclampsia includes checking maternal blood pressure and for presence of proteinuria
  • Referral for medical nutrition therapy may be needed in patients with hyperemesis, poor dietary patterns and practices, multiple gestation, overweight and obesity, inappropriate gestational weight gain, or diseases such as diabetes, hypertension, gastrointestinal or metabolic disorders
  • Please see Anemia – Iron-Deficiency, Gestational Diabetes Mellitus, Hypertension in Pregnancy and Nausea & Vomiting in Pregnancy Disease Management Charts for details

Factors for Nutritional Assessment at Various Stages of Pregnancy

Factors for Nutritional Assessment at Various Stages of Pregnancy
Pregnancy Stage
Assessment Considerations
Issues to Address
Pre-pregnancy
  • Composition of diet
  • Physical activity
  • Height, weight, BMI
  • Anemia
  • Risk of obesity
  • Risk of nutritional problems: Folic acid, iron, calcium, iodine, PUFAs, vitamin B12, vitamin D, zinc
  • Significance of a healthy diet and exercise
  • Sedentary behavior
  • Counsel regarding weight loss
  • Alcohol, smoking and recreational drugs use
  • Screening for and management of chronic diseases
  • Supplementation with folic acid and other nutrients as required
Pregnancy
  • Composition of diet
  • Physical activity
  • Height, weight, BMI, waist circumference
  • Gestational weight gain
  • Blood pressure
  • Anemia
  • Risk of gestational diabetes
  • Risk of nutritional problems:
    • 1st trimester: Folic acid, iodine, PUFAs, vitamin B12
    • 2nd and 3rd trimesters: Folic acid, iron, calcium, copper, iodine, PUFAs, B vitamins, vitamin D, zinc, energy (340-450 kcal/day)
  • Appropriate exercise
  • Sedentary behavior
  • Counsel regarding dietary intake
  • Management of weight changes
  • Alcohol, smoking and recreational drugs use
  • Avoidance of food-borne infection
  • Screening for and management of pregnancy complications, eg gestational diabetes, preeclampsia
  • Supplementation with folic acid, iron and other nutrients as required
Post-pregnancy
(Lactation)
  • Composition of diet
  • Status of weight and postpartum weight loss
  • Diabetes screening
  • Risk of nutritional problems: PUFAs, vitamins/minerals, protein, energy (approximately +330 kcal/day)
  • Physical activity
  • Sedentary behavior
  • Healthy diet and weaning foods
  • Targeting healthy weight
  • Breastfeeding
  • Spacing of pregnancy and contraception
  • Screening for and management of chronic diseases, eg type 2 diabetes, hypertension
  • Supplementation with folic acid and iron during the first 3 months after delivery
Modified from: Hanson MA, Bardsley A, De-Regil LM, et al. The International Federation of Gynecology and Obstetrics (FIGO) recommendations on adolescent, preconception, and maternal nutrition: “Think Nutrition First”. Int J Gynaecol Obstet. 2015 Oct;131 Suppl 4:S213-253.
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