Nutritional Guidelines for Pregnancy

You may not like that your OBGYN is so keenly interested in the seemingly boring details of nutrition and weight during your pregnancy, but as your baby grows, you can be certain that you will be put up on the scale each and every time you have a prenatal checkup. You will also be asked many questions regarding the content and quality of your diet.

While pregnancy is to be enjoyed, many women believe that they can eat without regard to calorie count. Some women may want to remain thin and eat too little nutritious food. Others may feel it is their right to feast on sweets any time they feel the urge.

Maintaining proper nutrition and weight throughout pregnancy is very important. However, it is a daunting task to try and rummage through the plethora of nutritional information available. A well balanced diet, proper weight gain and special consideration to the individual’s needs will contribute greatly to the well being of both the mother and child. The mother’s adaptation to the hormonal and physical changes of pregnancy is aided by a proper diet. Similarly, the rapidly developing fetus needs the proper nourishment provided by the mother’s well balanced diet to allow proper organ and brain development.

Recommended Weight Gain in Pregnancy

The intent of this article is not to cause undue worry… but to simply offer a few guidelines regarding what researches have found to be true regarding weight, the size of your own pre-pregnancy physique, and the healthy development of your baby during pregnancy.

Pregnant women should have a 25–40 lbs. gain depending on their pre-pregnancy weight. The pre-pregnancy weight gain is calculated as BMI (Body Mass Index). the definition is weight (pounds) divided by height (inches) squared an then multiply by 703.

To determine BMI (Body Mass Index):

Divide weight (pounds) by height (inches) squared and multiply by 703

e.g.(140 lbs/(68 inches x 68 inches) x 703 = 21.3

BMI Chart (Body Mass Index)

Multiple Pregnancies (based on pregravid weight)

Other:

Young adolescents and black women should aim for gains at upper end of range.

Short women should aim for gains at lower end of range.

Weight gain in early pregnancy is due to increased blood volume and deposition of maternal fat. In the second and third trimesters weight gain is related to growth of the fetus, placenta, and to an increase in amniotic fluid volume.

Maternal weight gain should be monitored throughout the pregnancy, as adequate gain is generally an indicator of proper nutrition.

The Baby’s birth weight is directly related to birth weight of the mother. Both excessive and insufficient weight gain can lead to pregnancy complications and affect the health of the growing fetus and newborn baby.

Excessive weight gain in pregnancy can increase a mother’s chances of developing gestational diabetes, pre-eclampsia. It also can lead to difficult deliveries, birth trauma and a higher incidence of cesarean deliveries. Overweight women are also at a higher risk of infection in the postpartum period

Inadequate weight gain puts a baby at risk of reduced birth weight, intrauterine growth retardation (developmental delays), and higher risk of pre-term delivery. Short women should aim for gains at lower end of range.

Energy

Pregnant women should increase their caloric intake by anywhere from 300 to 700 calories a day. The total number of calories should probably range from 2200 to 2900 calories per day. However, due to individual differences in basal metabolic rate and energy output the range of acceptable intakes is vast.

In general the extra energy needed:

1st Trimester calories are not increased from pre-pregnancy needs.

2nd Trimester add approximately 340–360 calories per day.

3rd Trimester add approximately 452 calories per day.

Fluids

Drinking 8 to 10 cups of fluid a day will maintain adequate hydration. Some of the fluid needs are met through milk, juice and the water in foods such as fruit and vegetables.

Supplements

1. Folic Acid: 400 μg synthetic folic acid daily from fortified foods or supplements in addition to 200 μg food and beverage forms of folate in a varied diet.
2. Fortified foods (must state on the label): breakfast cereals, rice, noodles, and bread. Food/beverage forms: liver, mushrooms, spinach, asparagus, lean beef, potatoes, orange juice and dried beans.
3. Iron: 27 mg iron daily is recommended. Anemic women may need 60 mg a day until the anemia is resolved. In addition, for optimal absorption, the iron supplement should ideally be taken between meals and not with milk, coffee or tea but with a beverage containing vitamin C as it enhances absorption of the iron.
4. Vitamin D: Supplementation with amounts greater than the RDA of 200 IU/d does not appear to provide additional benefit to pregnant women.
5. B-12: vegans and some vegetarians should take a B-12 supplement if they don’t already.
6. Multivitamin vitamin: The Institute of Medicine has not found sufficient evidence to recommend routine use of most vitamins except for those with high-risk pregnancies (e.g., undernourished females, teenagers, females with substance abuse problems, females with a short interval between pregnancies, females with history of delivering low body weight infant, females with multiple gestation).

Alcohol

Should be avoided by pregnant women or women who may become pregnant.

Caffeine

Pregnant women should limit caffeine intake to below 300 mg a day. Caffeine content :

16 ounce coffee—range from 143–564 but the average is 188 mg

12 ounce can of soda—18–48 mg of caffeine

Herbal/Botanical/Alternative Remedies

There are very few randomized clinical studies that have examined the safety and efficacy of alternative therapies during pregnancy. All women, especially pregnant women, should Inform their health professionals of any supplements that are being taken that the doctor has not prescribed.

Food Borne Illness

Pregnant women and their fetuses are at a higher risk of developing food borne illness. The pathogens of particular concern are Listeria monocytogenes, Salmonella and Toxoplasma gondii. Pregnant women should adhere to the following guidelines:

• Do not eat or drink unpasteurized milk or milk products including soft cheeses, raw or undercooked meat and poultry, unpasteurized juice, raw sprouts, raw or undercooked fish or shellfish and raw or partially cooks eggs (or foods containing raw eggs).
• Avoid cold smoked fish and cold deli salads.
• Eat only deli meats, luncheon meats, bologna and hot dogs that have reheated to steaming hot.
• Do not handle pets when preparing food and keep them out of the food preparation areas. Do not clean cat litter boxes or wear plastic gloves when cleaning litter boxes.
• Do not eat shark, swordfish, king mackerel or tilefish. Consuming twelve ounces or less per week of fish and shellfish lower in mercury (such as shrimp, canned tuna, salmon, pollock and catfish) is safe. Limit albacore “white” tune to 6 ounces or less per week. Also, check local advisories about safety of fish in bodies of water.

Nutritional counseling can be helpful in establishing dietary guidelines. This is particularly helpful in the following categories:

• Overweight and underweight women
• Women with known food allergies
• Those with dietary restrictions (i.e. vegetarians)
• Women who suffer from specific medical problems (i.e. diabetes)
• Young women and adolescents with poor dietary habits.
• Pregnant women who suffer from nausea and vomiting and thus unable to maintain a normal diet.

A registered dietician should be consulted regarding the need for nutritional advise, especially in women with any of the the above named problems. In addition, more individualized plans can be seen on “My Pyramid for Moms” at www.mypyramid.org

Guidelines regarding specific foods

Pregnant women and their fetuses are at a higher risk of developing foodborne illness. The pathogens of particular concern are Listeria monocytogenes, salmonella and Toxoplasma gondii. Pregnant women should never handle pets when preparing food . animals should be kept away from food preparation areas. In addition, pregnant women should either not clean cat litter boxes or wear plastic gloves when cleaning the litter boxes.

Pregnant women should adhere to the following guidelines:

1. Fish and Shellfish: Due to the accumulation of mercury and other toxins, consumption of fish should be reduced during pregnancy and limited to no more than two weekly servings.
   • Avoid fatty fish that harbor high levels of mercury and other toxins. Avoid swordfish, shark, tilefish, king mackerel, striped bass, and bluefish.
   • Eat no more than 6 oz. of albacore white tuna, tuna steak, and halibut.
   • The following fish have lower levels of toxins and should be consumed preferentially; cod, flounder, salmon, light canned tuna, sardines, pollack, shellfish, atlantic mackerel, and haddock.
   • Avoid raw fish and shellfish due to the risk of bacterial contamination.
   • Avoid cold smoked fish and cold deli salads
2. Calcium and Vitamin D intake: Increase intake of calcium to about 1,000–1,300 mg per day. Vitamin D supplements should be approximately 800 IU to 1,000 IU per day.
   • Insufficient calcium and vitamin D can effect childhood skeletal development. Calcium and vitamin D are important building blocks for the developing fetal skeleton.
   • Proper calcium levels are essential for maintaining a normal pregnancy and can reduce the risk of pre-eclampsia and prematurity.
3. Milk and cheese: Dairy products are an excellent source of protein and calcium.
   • Avoid unpasteurized milk or milk products including soft cheeses due to the risk of Listeria, a bacteria that can have devastating effects on the growing fetus.
   • Some dairy products are high in fat and their consumption should be monitored.
4. Eggs, Poultry and Meat,etc.:
   • Avoid raw and undercooked eggs, poultry and meat due to the risk of Salmonella. Undercooked meat can harbor Listeria.
   • Eat only deli meats, luncheon meats, bologna and hot dogs that have been reheated to steaming levels.
   • Raw sprouts and unpasteurized juices should be avoided also.
5. Alcohol: Alcohol consumption has been linked to a condition, fetal alcohol syndrome that is characterized by facial anomalies, mental retardation and learning disabilities. This condition can occur even in women who consume small quantities of alcohol. Therefore there are no “safe” levels of alcohol allowed during pregnancy. Alcohol therefore should be avoided completely during pregnancy.
6. Caffeine: Excessive consumption of caffeine has been linked to low birth weight and miscarriage. Drinking more than two cups of coffee per day (more than 300 mg of caffeine) should therefore be avoided.
   • 16 ounce coffee—range from 143–564 but the average is 188 mg.
   • 12 ounce can of soda—18–48 mg of caffeine.
7. Fat Consumption: Trans-fats found in processed foods and junk food can decrease the levels of “good” cholesterol and increase the bad cholesterol. This will block the transport of omega 3 fatty acids across the placenta and affect the growing fetus
8. Folate supplementation: Folate is an important vitamin and its consumption must be monitored carefully during pregnancy. Low folate levels are linked to neural tube defects (spina bifida etc.)

   Dietary sources of folate include green leafy vegetables (spinach), asparagus, liver, mushrooms, lean beef,potatoes, beans,whole grains, nuts, and oranges. Fortified foods (must state on the label) include breakfast cereals, rice, noodles, and bread. Synthetic supplements are inexpensive and guarantee appropriate dosages

   • High risk (prior history of neural tube defect): 4 mg daily.
   • Low risk 0.8 to 1.0 mg daily.
9. Iron Supplementation: Iron rich foods are important to prevent low birth weight infants. Recommended amounts are 18–27 milligrams—generally the amount found in prenatal vitamins. Anemic women may need 60 mg a day until the anemia is resolved. Sources of iron include spinach, strawberries, eggs, meats, sardines, scallops, shrimp, and turkey. For optimal absorption the iron supplement should be taken between meals and not with milk, coffee or tea but with a beverage containing vitamin C since it enhances the absorption of the iron.
10. Prenatal Vitamins: Due to the fact that most diets do not provide adequate amount of most vitamins, supplements are recommended in pregnancy.
    • DHA and Omega-3 fatty acids
    • Iron
    • Folic Acid
    • Calcium
    • Vitamin D
    • Vitamin B-1
    • Vitamin B-2
    • Vitamin B-6
    • Vitamin B-12—vegans and some vegetarians should take this.
    • Vitamin C
    • Vitamin A
    • Zinc
    • Magnesium
    • Niacin

Of note: The Institute of Medicine has not found sufficient evidence to recommend routine use of most vitamins except for those with high-risk pregnancies (e.g., undernourished females, teenagers, females with substance abuse problems, females with a short interval between pregnancies, females with history of delivering low body weight infant, females with multiple gestation).

Herbal/Botanical/Alternative Remedies

There are very few randomized clinical studies that have examined the safety and efficacy of alternative therapies during pregnancy. All women, especially pregnant women, should Inform their health professionals of any supplements that are being taken that the doctor has not prescribed.

References

Position of the American Dietetic Association:Nutrition and Lifestyle for a Healthy Pregnancy Outcome. J Am Diet assoc. 2008;108:553–561

Jessica Shapiro MS, RD is a Clinical Dietitian at Montefiore Medical Center in New York City working in the Cardiology and Cardiac Care Units. She received her Masters of Science from NYU and is a member of both The American Dietetic Association and The Greater New York Dietetic Association. In addition to her work at the medical center she has a private practice in New York City and can be reached at JessicaShapiroNutrition@gmail.com.

Pregnancy can be emotionally stressful due to the hormonal and physical changes that women experience during this special time. Mental changes that women experience can result in anxiety, depression, fear, and frustration which can have adverse effects on their infants. Poor eating and sleeping patterns can limit overall functioning which can be associated with a higher risk of prematurity and low birth weights along with delayed infant development and negative temperaments in children. Drug therapy in pregnancy to control stress always has risks of side-effects to both mother and child, making non-pharmacologic intervention a safer alternative.

Music has always been used as a form of therapy to reduce stress, pain, and anxiety by promoting relaxation through creation of a healing environment for physical, emotional, and spiritual well being. As early as 555 BC, a well known Greek philosopher and mathematician named Pythagorus felt that music was an important therapy in medicine to maintain good health and often recommended music to maintain harmony and healing in the body.

Stress can effect the hypothalamus, pituitary, and adrenal cortex arousing the sympathetic nervous system. Music can cause a pituitary response with release of hormones and endorphins which are natural opiates that can relieve pain. It stimulates the thalamus and limbic areas of the brain, stimulating good feelings and emotions. Music has been shown to effect blood pressure, heart rate, and respiration along with emotional balance in adults.

Pregnancy, delivery, and newborn care are likely areas to complement and expand conventional medical care by using alternative therapy such as music to reduce stress, anxiety, and pain. Music has been found to stimulate pleasure response and distract from labor pains. Sidorenko published a paper in 2000 showing that music improved relaxation in pregnant women by decreasing heart rates, blood pressure, breathing patterns, and pulse. In addition there was a a reduction in the need of pain killers and improved sleep patterns, and reduction in the number of premature births. Women who listen to music during labor and delivery had reduced anxiety and decreased pain during childbirth for both vaginal and cesarean deliveries. It also allowed for decreased labor time and shortened hospital stay.

The choice of music has been found to be important to its success. The most beneficial responses occur when the music is familiar, desirable and meaningful. Browning in Canada conducted a study demonstrating that music can be an important adjunct to pain and stress management during labor when the music was chosen by the mother, with emphasis on pieces that have significant meaning to both mother and her partner. Daily listening should begin by the third trimester to gain familiarity prior to labor in the hopes of promoting a positive conditioned response during labor.

Music has also been found to be therapeutic to infants. Studies on premature and low birth weight infants have shown shorter hospital stays, less weight loss and fewer apnea episodes when taped music was played in intensive care unit settings. (Casino 1992, Stardley and Moore 1995) A study by Keith in 2009 showed significant reduction in frequency and duration of inconsolable crying in infants as result of music intervention, as well as improved heart rate, respirations, oxygen saturation and mean arterial pressure. Other studies showed an increase in head circumference and decreased heart rate in premature infants in the newborn intensive care unit between 28 and 32 weeks when listening to music. (Cassidy 2009)

A newborn infant has a predilection for the maternal voice and also to musical pieces to which they have been exposed to in utero indicating that the fetus may have a capacity to learn in utero. (Gerhardt, 2000) It is believed that the fetus can hear by late gestation. Studies from Canada have shown heart rate increases in response to Brahms’ Lullaby starting at 28 weeks.

Some additional guidelines published in the Journal of Perinatology in 2000 by the Physical and Developmental Environment of the High Risk Infant Center Study Group on Neonatal Intensive Care Unit Sound and the Expert Review Panel recommend that:

1. Pregnant women avoid prolonged exposure to low frequency sound levels (<250 Hz) above 65 dB during pregnancy.
2. Earphones and other devices for sound should not be attached directly to the gravid abdomen.
3. The fetus does not require supplemental auditory experience for normal auditory development.
4. Infant neonatal intensive units should develop a system of noise control since exposure to loud background noise will interfere with auditory development and frequency discrimination.
5. Earphones and other devices should never be attached to the infants ears.

In summary: With the holiday season rapidly approaching, listening to music can have physiologic effects on the pregnant woman which can result in positive effects on mood, stress and anxiety. This can enhance a strong sense of well-being and create a happier atmosphere which can promote fetal and maternal well-being.

Pregnant Woman with Fatty Food

With the holiday season upon us, pregnant women have to be especially vigilant about not eating large, fatty meals. Pregnancy predisposes women to gallstones. Approximately 2.5 to 4.5% of pregnant women have gallstones. Approximately 81% of women that develop signs of gallbladder disease had their initial attack within the first year of pregnancy. Most gallbladder attacks occur during the second or third trimester of pregnancy. The risk of developing gallstones increases with the number of pregnancies. Pregnant patients with symptomatic gallstones have a high rate of relapse of symptoms during their pregnancy.

What causes gallbladder disease in pregnancy?

The combination of increasing volume of the gallbladder during the second and third trimester, along with decreased motility due to elevated progesterone levels, and increased cholesterol and bile acids can lead to the development of gallstones. Women that have obesity or diabetes with a hereditary tendency to gallstones are especially susceptible.

What are the symptoms of gallbladder disease in pregnancy?

About 50% of women with cholelithiasis, (gallstones alone) have no symptoms at all. Symptoms, if present, can include right upper quadrant colicky pain or mid-epigastric pain which can radiate to the back or the right shoulder. The pain often occurs after consuming a large fatty meal. The pain can be accompanied by nausea and vomiting, fever and/or chills. Laboratory values of leukocytes, hepatic functions, amylase, lipase, and alkaline phosphatase may also be elevated.

What causes the symptoms of gallbladder disease?

The gallstones, or sludge (precursor to gallstones) induces a chemical inflammation. This can cause obstruction and swelling in the gallbladder with decreased blood flow. This allows bacteria to enter with resultant infection. The most common bacteria is Escherichia coli, a common bowel bacteria. Other bacteria can include Klebsiella, Proteus, Enterococci, and Streptococci, Bacterioides, and Clostridia.

How do you make the diagnoses?
History of symptoms along with increase in pain in the right upper quadrant when taking a deep breath (Murphy’s sign) helps make the diagnoses. Ultrasound is the one diagnostic test that is safe, and 93% accurate in diagnosing gallbladder disease. Visualizing a stone in the gallbladder duct can be impossible to see. However, seeing thickening of the gallbladder wall, swelling of the gallbladder, and experiencing pain when pressing the gallbladder are also helpful in making the diagnoses.

What are the treatment options for gallbladder disease?

• Antibiotics
  A penicillin and an aminoglycoside are generally first line medical therapies for women who develop pain and symptoms during first, second, or third trimester.
• Resting the bowel
  Not eating and giving hydration
• Correcting any abnormal lab values
• Pain medication
• Surgery

Unfortunately there is a high rate of recurrence of symptoms throughout the pregnancy. Generally if a woman is known to have gallbladder disease, she should have surgery for removal of the gallbladder prior to becoming pregnant.

For recurrent episodes, or refractory pain in the first trimester, surgery should be delayed, if possible, to the second trimester. Recurrent episodes in third trimester should be delayed till postpartum but if patients have deteriorating status or refractory pain, surgery should be done. Laparoscopic removal of gall bladder is preferred method in pregnancy because of reduced morbidity and mortality and decreased hospitalization costs.

Laparoscopy is preferred because

• Patients return to normal activity quicker
• Bowel function resumes faster
• Less requirement for pain medication in pregnancy
• Lower risk of spontaneous abortion, preterm labor, and premature delivery.

If this is not possible, traditional laparotomy can also be done.

In summary

Pregnancy is a risk factor for the formation of biliary sludge or gallstones which can lead to cholecystitis, or gallbladder inflammation. Eating a large, heavy fatty meal can precipitate symptoms. Ultrasound is the best way to make a diagnoses. Relapse rates of disease are high in pregnancy. Surgical management by laparoscopy is warranted if conservative medical management fails.

Nausea and vomiting often referred to as “morning sickness” are common and extremely distressing symptoms of pregnancy. The term “morning sickness” is a misnomer as most women suffer from these symptoms throughout the day.
(more…)