Nutrition%20in%20pregnancy Management

Nutritional counseling ideally should begin before conception and should continue across pregnancy and during lactation in order to optimize maternal and child health

• Daily caloric intake increases in the 2nd and 3rd trimesters for appropriate weight gain; however, as energy requirements vary among women, recommendations must be individualized
  • A higher caloric requirement is indicated in pregnant adolescents, high physical activity or hard physical labor, multifetal pregnancy, and malabsorption disorders or infections
• A wide variety of food should be taken every day for a balanced diet in order to meet the gestational nutritional requirements: Different types and colors of fruits and vegetables, grains and cereals, preferably whole grain and high-fiber, moderate amounts of meat, fish, eggs, milk and milk products
  • Dietary fiber reduces constipation and may help decrease the risk of preeclampsia and gestational diabetes
  • Consider giving a maternal milk formula¹ or supplements if patient has difficulty in consuming other types of foods
    • Maternal macronutrient supplementation with fatty acids, eg alpha-linolenic acid (ALA), linoleic acid and docosahexaenoic acid (DHA), and complex lipids, eg gangliosides and phospholipids, enhances fetal brain development and later neurodevelopment
• Choose foods that are high in iron, folic acid, calcium, iodine, and omega-3 fatty acids
• Advise patients to remain hydrated
  • Adequate fluid intake for pregnant women is 3 L/day, which includes drinking water, beverages and foods; may be adjusted according to exercise level and weather
• Avoid or at least reduce consumption of foods and drinks rich in saturated fat, added sugar and salt, eg fried, processed or preserved foods, desserts, soft drinks, sweetened drinks
  • Boil, grill or steam food instead of frying or sautéing to reduce fat intake
• A vegetarian diet can be taken during pregnancy provided it contains adequate amounts of protein, calcium, iron and vitamin B12

Recommended Daily Servings of Food Groups for Pregnant Women
Food Group	Servings Per Day	Sample Serving*	Preferred Choice
Oil, fat, salt, sugar	In moderation	1 tsp oil 1 tsp salt 5 tsp sugar	Use vegetable oils and iodized salt for cooking
Lean meat, poultry, fish, eggs, tofu, nuts, seeds	3.5-7	30 g cooked meat (table tennis ball size) 1 chicken egg 4 tbsp of cooked soya beans	Meat or poultry with trimmed fat and without skin
Milk, cheese, yoghurt	1-2	1 cup of milk 2 slices of processed cheese	Low-fat or fat-free products
Vegetables, legumes, beans	3-5	½ bowl of cooked vegetables 1 bowl of uncooked vegetables	More dark green leafy vegetables
Fruits	2-3	1 medium-sized fruit 2 small fruits	Fruits of different colors
Grains	3-8	1 bowl of rice 2 slices of bread	Brown rice and whole-grain food
Fluids	6-8 cups	Includes soup	-

^*Serving: Bowl = 250-300 mL, Cup = 240 mL
List shown above is not exhaustive and as recommendations may vary between countries, please refer to available nutrition guidelines from local health authority.
Modified from:
Department of Health Hong Kong. Healthy eating during pregnancy and breastfeeding. Family Health Service, Department of Health, The Government of the Hong Kong Special Administrative Region. https://www.fhs.gov.hk. Dec 2019.
Florentino RF, Tee ES, Hardinsyah R, et al. Food-based dietary guidelines of Southeast Asian countries: part 2 - analysis of pictorial food guides. Mal J Nutr. 2016;22(Suppl):S49-S65.
¹Various maternal milk formula preparations are available. Please see the latest MIMS for specific formulations and prescribing information.

• Pregnant women may fast for a few hours during the day for >1 day during Ramadan
  • Fasting during pregnancy depends on the maternal health, pregnancy stage and when Ramadan is observed, ie risk of dehydration is high when Ramadan falls during summer
  • Studies have shown no adverse effects in the fetus of healthy women who fasted during Ramadan though further research is needed to determine the effects of fasting on fetal health and development and its consequences in later life
  • Healthcare provider should be informed if pregnant patient decides to fast in order to identify potential complications and for patient to be advised and guided during fasting
• Counsel patient regarding other unproven dietary practices during pregnancy such as:
  • Avoidance of potential food allergens (eg milk, peanuts, seafood, etc) to protect the infant from developing allergic diseases is not recommended due to lack of evidence 
  • Consumption of artificial sweeteners in moderation based on acceptable daily intake standards does not increase the risk of birth defects 
  • Prenatal fluoride supplementation does not reduce the risk of developing caries in the infant
  • Restricting water intake does not relieve hand and leg swelling
• Proper nutrition should be emphasized in order to obtain a healthy weight postpartum and promote lactation
  • Breastfeeding improves the short- and long-term health outcomes for both mother and child

Weight Gain 

• Preconception BMI is an independent predictor of several adverse pregnancy outcomes, eg gestational DM, preeclampsia, infection, miscarriage and life-long risks of chronic disease
  • Health risks such as cardiovascular disease, diabetes, dyslipidemia, and obesity are related to being overweight during the reproductive years; however, if patient is overweight prior to conceiving, she should be advised to not lose weight during pregnancy as this can be harmful to her and the fetus but to have a healthy diet and be physically active
• Normal weight gain in pregnancy happens after 20 weeks gestation; a pregnant woman’s energy requirement is increased during the 2nd and 3rd trimesters of pregnancy but excess energy intake will lead to inappropriate gestational weight gain
  • Excessive gestational weight gain may have maternal effects such as difficult delivery, increased risk for cesarean delivery, difficulty in returning to pre-pregnancy weight, higher risk of developing diabetes, hypertension and cardiac disease in the long term if persistently overweight; effects on the infant are large size with related complications and increased risk of developing diabetes, obesity, hypertension, and cardio and cerebrovascular diseases later in life
• Gestational weight should be within the normal BMI range with subsequent weight gain within recommended ranges 
• Poor gestational weight gain may lead to poor fetal growth, low birth weight and increased health risk later in life
  • Though weight gain may be slow in the 1st trimester due to poor appetite and morning sickness, poor weight gain during the latter half of pregnancy requires further assessment
• Modest weight retained postpartum is associated with a high risk of adverse events (eg diabetes, hypertension, and stillbirth) in subsequent pregnancies
  
  • Risk of retaining excess weight from pregnancy is increased in obese women at 1 year postpartum

Recommended Weight Gain During Singleton Pregnancy
Pre-pregnancy BMI (kg/m2)	Rates of Weight Gain for 1st Trimester (total in kg)	Rates of Weight Gain for 2nd and 3rd Trimesters (kg/wk)	Total Weight Gain (kg)
Underweight (<18.5)	1.0-3.0	0.51 (0.44-0.58)	12.5-18.0
Normal weight (18.5-24.9)	1.0-3.0	0.42 (0.35-0.50)	11.5-16.0
Overweight (25.0-29.9)	1.0-3.0	0.28 (0.23-0.33)	7.0-11.5
Obese (≥30.0)	0.2-2.0	0.22 (0.17-0.27)	5.0-9.0

As recommendations may vary between countries, please refer to available BMI cut-off limits and gestational weight gain recommendations from local health authority.
Modified from: 2009 US Institute of Medicine and National Research Council Recommendations
WHO BMI categories for Asians are underweight <18.5 kg/m², normal weight 18.5-22.9 kg/m², overweight 23-27.4 kg/m², obese ≥27.5 kg/m²

Foodborne Illnesses 

• Hormonal changes during pregnancy results in reduced cell-mediated immune function predisposing pregnant women to foodborne illnesses
• Foodborne infections can cause maternal disease, miscarriage, preterm labor, severe health problems or early death of infant
• Common pathogens include Listeria monocytogenes, Toxoplasma gondii, Salmonella sp, Brucella sp, Campylobacter jejuni
• Foods that may be contaminated with Listeria include chilled ready-to-eat seafoods and cold meat, vegetables, refrigerated salads or pates, soft ice cream, soft cheeses, unpasteurized milk
• Toxoplasmosis can result from consuming food or water contaminated with soil or feces of pets that contain the organism
• Salmonella infection may come from eating raw egg
• Brucellosis may result from ingestion of contaminated food such as raw meat or milk, unpasteurized milk
• Safe food handling includes the following:
  • Hands, utensils and foods should be thoroughly washed
  • Foods grown in or near the ground are peeled and stored separately from other foods
  • Separate cooked from raw food
  • Food should be thoroughly cooked and eaten soon after being prepared
  • Refrigerate cooked and left-over food