Maternal Nutrition and Pregnancy: Stages, Symptoms, and Recommendations, Study notes of Nutrition

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SECTION 3

MATERNAL HEALTH AND NUTRITION

TABLE OF CONTENTS

3.0 Maternal Nutrition 3.0.1 Introduction 3.0.2 Purpose 3.0.3 Objectives 3.1 Pregnancy 3.1.1 Signs of Pregnancy 3.1.2 Prenatal Care 3.1.3 Stages of Pregnancy

3.2 Changes During Pregnancy 3.2.1 Breast Changes 3.2.2 Swelling 3.2.3 Mouth and Tooth Changes 3.2.4 Heartburn and Indigestion 3.2.5 Nausea and Vomiting 3.2.6 Constipation and Gas 3.2.7 Hemorrhoids 3.3 Prenatal Nutrition 3.3.1 Prenatal Diet 3.3.2 Nutrient Needs During Pregnancy 3.3.3 Supplementation

3.4 Special Health Concerns During Pregnancy 3.4.1 Diabetes 3.4.2 Hypertension and Preeclampsia 3.4.3 Overweight and Underweight

3.5 Special Dietary Concerns During Pregnancy 3.5.1 Adolescence 3.5.2 Pica and Unusual Cravings 3.5.3 Special Diets 3.5.4 Food Safety

3.6 Prenatal Weight Gain 3.6.1 Recommendations 3.6.2 High Maternal Weight Gain 3.6.3 Low Maternal Weight Gain 3.6.4 Where Does The Weight Go? 3.6.5 Exercise

3.7 Lifestyle Risks During Pregnancy 3.7.1 Smoking 3.7.2 Alcohol 3.7.3 Caffeine 3.7.4 Drugs

3.8 Postpartum Care 3.8.1 Postpartum Sadness and Depression 3.8.2 Postpartum Nutrition 3.8.3 Weight Control 3.8.4 Dietary Supplements

3.0 MATERNAL NUTRITION

3.0.1 Introduction

A mother’s nutrition status and health both before and during pregnancy have significant effects on the outcome of her offspring. A baby's birth weight, rate of postnatal growth and chances of survival are all influenced by the mother’s health and dietary intake. Good nutritional status before, during and after pregnancy optimizes maternal health and reduces the risk of pregnancy complications, birth defects and chronic disease in her children in later adulthood. A healthy, well-nourished woman is more likely to have a healthy pregnancy, which increases her chances of having a healthy baby. A healthy baby has a better chance of growing into a healthy child and then growing into a healthy adult.

In this module you will learn about the special nutrition concerns and needs for prenatal, breastfeeding and non-breastfeeding postpartum women.

3.0.2 Purpose

The purpose of the Maternal Health and Nutrition Section is to provide information on the stages of fetal development and basic nutrition concepts pertinent to pregnant and postpartum WIC participants.

3.0.3 Objectives

Upon completion of Section 3, you will be able to:

1. Identify the stages of pregnancy and vulnerable periods of fetal development.
2. State several physiological adjustments during pregnancy.
3. State the recommended ranges of maternal weight gain during pregnancy.
4. Specify gestational nutrient needs and nutrition-related concerns.
5. Identify counseling recommendations for common pregnancy-related problems such as nausea, edema, heartburn, hemorrhoids and constipation.
6. Identify the risks and counseling recommendations for use of caffeine, alcohol, drugs and tobacco during pregnancy.
7. Compare a woman’s nutritional needs as she transitions from pregnancy to lactation.

3.1 PREGNANCY

3.1.1 Signs of Pregnancy

Pregnancy is an exciting time of major change. Pregnancy symptoms differ from woman to woman and pregnancy to pregnancy; however, one of the most significant pregnancy indicators is a delayed or missed menstrual cycle. Some women experience signs or symptoms of pregnancy within a week of conception. Other women may develop symptoms over a few weeks or may not develop any symptoms at all.

Some of the most common pregnancy signs and symptoms include:  Spotting or a very light menstrual period  Nausea or queasiness  Tender or swollen breasts  Frequent urination  Feeling very tired  Being moody  Feeling bloated

Symptoms listed above are normal for pregnancy, however, some symptoms may not be normal and could be indicators of early pregnancy loss or ectopic pregnancy—a pregnancy that occurs outside the uterus.

A medical intervention may be needed if potential pregnancy is suspected and a woman presents with any of the following signs:  Cramps or severe abdominal pain  Spotting that lasts more than one day  Vaginal bleeding  Faintness or dizziness

3.1.2 Prenatal Care

Prenatal care is the health care women receive during pregnancy. A pregnant woman needs prenatal care. Prenatal care is important to keep the mother and her baby healthy. Babies of mothers who do not receive prenatal care are three times more likely to be born with a low birth weight and five times more likely to die than those born to mothers receiving care. When health c are providers see mothers regularly they can detect and treat health problems early, which can minimize many existing problems and prevent others. Further, prenatal care can provide opportunities to encourage women to adopt good health and eating habits, get emotional counseling or support if needed, find out about local family services and prepare for childbirth as well as being a parent.

3.2 Changes During Pregnancy

3.2.1 Breast Changes

For many women the first hint of being pregnant is the breast changes they experience. Women may notice an increase in breast size and some tenderness very early even before the pregnancy is confirmed. Breasts may grow a whole bra-cup size by the sixth week of the pregnancy. Breast growth is a positive sign that the breasts are preparing for breastfeeding.

Changes that take place in the breast include:  An increase in the number of milk glands as the body prepares for making milk.  Fat accumulates.  Bluish veins may appear as blood flow to breasts increases.  The nipples and areola darken. Nipples may stick out more and the areolas grow larger.  Montgomery’s tubercles, small glands on the surface of the areola, become raised and bumpy. These glands produce an oily substance that keeps the nipples and areolas soft.

Breasts may continue to grow in size and weight during the first three months of pregnancy. During the third month of pregnancy the first colostrum appears. Colostrum is the thick yellow, nutrient and immune component-rich milk the breast produces for the baby's first few days of life. Some women may notice slight drainage of colostrum from their nipples. In the last trimester the breast continues to expand from the enlargement of milk-making cells and engorgement with colostrum.

3.2.2 Swelling

Most pregnant women experience some edema or swelling in the hands, face, legs, ankles and/or feet. Edema which is caused by extra fluid in the body may worsen in late pregnancy and during the summer months.

To relief swelling:

• Avoid prolonged standing.  Elevate feet. You may try to sleep with legs propped up on pillows. This keeps fluid from building up in the lower half of the body.  Be physically active as exercise can improve circulation, which reduces edema.  Avoid garters, socks or stockings that constrict the leg.

3.2.3 Mouth and Tooth Changes

During pregnancy gums and teeth are more vulnerable to cavities and gum disease. Pregnancy hormones can make gums swell and bleed. A dental check up early in pregnancy is important to ensure that the mouth stays healthy. Putting off dental work can lead to more dental problems. When scheduling a

dental appointment it is important that the woman lets her dentist know about the pregnancy. It is the role of certifying WIC staff to find out if a woman has any dental issues and provide appropriate dental referrals when needed.

Questions to ask Possible dental risk conditions

Have you visited a dentist within the past 12 months?

There is diagnosis of dental problems by a dentist, physician or a health care provider working under the orders of a physician.

Do you have tooth decay, broken teeth, bleeding gums, gum infection, (periodontal disease), missing teeth and/or misplaced teeth that make chewing difficult?

Periodontal disease (gum infection) is evidenced by swollen, red, bleeding and inflamed gums.

Do you (or your child) avoid certain foods that you would otherwise eat, or choose softer foods, because of chewing problems?

Tooth decay, broken teeth, gum infection (periodontal disease), tooth loss and/or ineffectively replaced teeth that impair the ability to chew food in adequate quantity or quality.

Do your gums feel swollen, sensitive, bleed easily or have a reddened appearance?

Gingivitis is present in pregnant women.

Source: MO WIC Operations Manual. 2010 ER# 2.

3.2.4 Heartburn and Indigestion

Often the words “heartburn” and “indigestion” are used interchangeably however they are not the same condition. Indigestion happens when the stomach takes hours to empty. Indigestion symptoms include: feeling full, bloated and gassy. Heartburn is a burning feeling in the throat and chest. Pregnancy hormones, which relax the muscle valve between the stomach and esophagus are often the cause of heartburn during pregnancy. When the valve does not close, stomach acids leak into the esophagus. As the baby grows, it may press up against the stomach and cause stomach acid to leak into the esophagus.

Tips to help relieve or prevent indigestion and heartburn are:  Eat five or six small meals per day instead of two or three big ones.  Eat slowly and chew food well.  Limit liquids with meals.  Sit upright for at least one hour after a meal.  Limit greasy, fried and fatty foods.  Limit caffeinated and carbonated drinks, citrus fruits and juices.  Do not eat or drink shortly before bedtime or napping.  Wear clothes that are loose around the waist.

 Toward the end of pregnancy, the weight of the uterus puts pressure on the rectum.

When this occurs, gas can build up in the abdomen and cause bloating and pain.

 Tips for managing constipation during pregnancy:  Drink plenty of liquids—especially water.  Eat high-fiber foods.  Eat meals at regular times each day.  Be physically active every day. Note: Laxatives are not recommended during pregnancy.

3.2.7 Hemorrhoids

Constipation during pregnancy can lead to hemorrhoids. Hemorrhoids are swollen blood vessels in and around the anus. These vessels are normally present but stretch under pressure. The two main causes of the swelling are the extra blood in the pelvic area and the pressure the growing uterus puts on veins in the lower body. The straining during bowel movements caused by constipation can lead to swollen veins as more blood is being trapped in the veins.

To avoid or relief this problem, it is recommended to:  Eat high-fiber foods and drink plenty of liquids.  Be physically active as standing or sitting for long time can put pressure on the veins in the pelvic area.  Keep prenatal weight gain within recommendations. Excess weight can aggravate hemorrhoids.  If hemorrhoids have already developed the discomfort can be alleviated by soaking in a tub few times a day or by applying an ice pack to the problem area.

Fiber-Rich Foods

Breads/Cereals Whole wheat bread, bran breads and cereals, oatmeal, shredded wheat, bran flakes, whole wheat, pita bread, whole wheat pasta

Grains (^) Barley, bulgur, cornmeal, whole grain, oat bran, brown rice, wheat bran

Fruits Apple with skin, dried apricots, dried figs, kiwi fruit, prunes, raisins, raspberries, strawberries

Vegetables Beans, broccoli, brussels sprouts, cabbage, carrots, cauliflower, corn, potatoes (with skin), peas, sweet potatoes, tomatoes (raw),turnip greens Other Nuts, almonds, coconut, hazelnuts, peanuts

3.3 PRENATAL NUTRITION

3.3.1 Prenatal Diet

Good nutrition is important during pregnancy. A pregnant woman must consume adequate nutrients and energy for her body functions and to support her developing fetus. A woman’s diet during pregnancy can significantly affect the outcome of the pregnancy. When a pregnant woman eats, the nutrients absorbed travel through her blood stream to the placenta. The nutrients cross the placenta and are taken up by the blood stream of the fetus.

The prenatal diet should include proteins, carbohydrates, vitamins, minerals and fat to fuel the body and help the baby grow. If the maternal diet does not contain adequate nutrients to meet the growing fetus needs, the mother will supply some of the nutrients at her own body’s expense. She may not produce a healthy placenta or make enough blood, causing her infant to grow more slowly.

Pregnant women need adequate fluid intake to prevent dehydration which can lead to miscarriage or premature labor. Pregnant women need a minimum of 2 quarts (64 oz) of fluids every day. Water should account for at least half of the fluids consumed. The remainder can come from milk, juice and other beverages.

Criteria for a Healthy Prenatal Diet

 Provides adequate calories for appropriate weight gain  Is well-balanced and follows MyPlate  Tastes good and is enjoyable to eat  Spaces eating at intervals throughout the day  Provides adequate amounts of high fiber foods  Includes 8 cups of fluid daily  Limits beverages that contain caffeine (2-3 servings or fewer daily)  Has moderate amounts of fat, saturated fat, cholesterol, sugar and sodium  Stable and continuous food supply  Excludes alcohol

Source: Story M, Stang J (eds). (2000). Nutrition and the Pregnant Adolescent: A Practical Reference Guide. Minneapolis, MN: Center for Leadership, Education, and Training in Maternal and Child Nutrition, University of Minnesot

3.3.2 Nutrient Needs During Pregnancy

All of the nutrients needed to support a healthy pregnancy, except for iron and folic acid can be obtained from a healthy diet. One way to make sure that all nutrient needs are met is to follow the MyPlate food plan developed by the U.S. Department of Agriculture (USDA). MyPlate gives guidelines to help mothers get the nutrients they need. For more information visit the MyPlate web page at

Calories

It is difficult to specify precise energy requirements during pregnancy because these vary with pre-pregnancy weight, amount and composition of weight gain, stage of pregnancy and activity level. Most pregnant women will probably need a total of 2,200 to 2,900 kcals per day. More research is needed to establish calorie requirements for women carrying more than one fetus.

Women, even obese women, should not decrease their calorie intake during pregnancy. If energy needs are not met, the protein the pregnant woman consumes will be used to meet her caloric requirements. If protein intake is not adequate, the mother’s muscle stores may be utilized to provide needed calories. This is a potentially dangerous situation since the protein used to meet energy requirements is then not available for building new cells and tissues in the mother and fetus.

Protein

Protein needs during pregnancy are variable, increasing as pregnancy progresses. The greatest demand for protein occurs during the second and third trimesters. Good sources of protein include lean meats, poultry and fish. These sources also supply other necessary nutrients, such as iron, B vitamins, and trace minerals. Other high-protein foods include dry beans, lentils, nuts, eggs and cheese.

Iron

The RDA for iron increases from 18 mg per day to 27 mg per day during pregnancy. Iron is used to make hemoglobin, a protein in red blood cells that carries oxygen to all organs and tissues as well as the baby. The fetus also stores enough iron to utilize in the first few months of life.

Certain foods are good iron sources, including lean beef and pork, organ meats, dried fruit and beans, whole grains and dark leafy greens. Vitamin C enhances iron absorption from plant sources whereas calcium can block iron absorption. For this reason calcium and iron should not be taken together. A good practice is to take supplements with iron in the morning and supplements with calcium at night. Iron supplements should be taken only with a health care provider’s recommendation. Section 6 provides more information on iron sources and prevention of iron deficiency anemia.

Folic Acid

The RDA for folic acid increases to 600 micrograms during pregnancy. Folic acid is necessary for normal cell division and the formation of certain major fetal structures. Consuming recommended amounts of folic acid before conception and especially during the early months of pregnancy can help prevent neural tube defects. Women who might get pregnant are advised to consume 400 micrograms of folic acid daily.

Folate is naturally present in certain foods such as leafy dark green vegetables, citrus fruits and beans. Additionally, almost all breads, cereals, pasta, rice and flour are fortified with folic acid. Section 6 provides more information about folic acid and preventing folic acid deficiency anemia.

Calcium

The calcium recommendation during pregnancy is 1,000 mg/day for women 19 to 50 years of age, and 1,300 mg/day for teens. Calcium is essential during pregnancy. It is an important structural component of fetal bones and teeth and is needed for the bone health of the mother during and after pregnancy. When a woman does not get enough calcium from her diet, the body takes it from her bones. Over time, this loss may weaken bone and lead to osteoporosis, a disorder characterized by abnormal bone mineral density.

In general, non-pregnant women consume only about 75 percent of the recommended amount of calcium therefore most pregnant women need to add calcium-rich foods to their diet. Calcium from plant sources is not as well absorbed as calcium from dairy sources. The best sources of calcium are milk and other dairy products such as cheese and yogurt. Calcium-fortified orange juice and other fortified foods, sardines, salmon with bones and collard, kale, mustard, spinach, and turnip greens are good sources of calcium from outside the dairy group.

Iodine

Iodine is an essential element that is needed for the production of thyroid hormone. The body does not make iodine. The RDA for iodine during pregnancy is 220 μg per day and 290 μg per day during lactation. According to The American Thyroid Association, severe iodine deficiency in the mother has been associated with miscarriages, stillbirth, preterm delivery, and congenital abnormalities in their babies. Children of mothers with severe iodine deficiency during pregnancy can have mental retardation and problems with growth, hearing, and speech. In the most severe form, an underactive thyroid can result in cretinism. Even mild iodine deficiency during pregnancy may affect cognitive development in children. The American Thyroid Association has recommended that all pregnant and breastfeeding women in the U.S. take a prenatal multivitamin containing 150 μg iodine per day. Not all prenatal vitamins contain

pregnant women take a vitamin and mineral supplement every day. Prenatal formulations have the appropriate amount and balance of nutrients needed during pregnancy.

Prenatal vitamins are most effective when taken with water or juice. Taking vitamin supplements with milk, tea or coffee can reduce iron absorption. Toxic levels of vitamins and minerals can be reached quickly, especially for vitamin A. Large doses of vitamin A and zinc may cause birth defects. All women should be tell their health care provider about any supplements they may already be taking, including herbals or botanicals and follow his or her advise to protect themselves from taking too much.

3.4 Special Health Concerns During Pregnancy

3.4.1 Diabetes

Pre-Diabetes

Pre-diabetes is defined by impaired fasting glucose (IFG) and/or impaired glucose intolerance (IGT). IFG is diagnosed for individuals with fasting glucose level between 100-125 mg/dl. IGT is diagnosed for individuals with plasma glucose levels of 140-199 mg/dl after a 2-hour oral glucose tolerance test. Women diagnosed with pre-diabetes are at increased risk for developing type 2 diabetes and cardiovascular disease. The American Diabetes Association recommends testing for pre-diabetes in adults who are overweight or obese and who have one or more additional risk factors- see table below.

Diabetes Risk Factors

• Physical inactivity
• Members of a high-risk ethnic population (e.g. African American, Latino, Native American, Asian American, Pacific Islander)
• Women who delivered a baby weighting > 9 lb or were diagnosed with gestational diabetes mellitus
• Hypertension (blood pressure > 140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level < 35 mg/dl and/or a triglyceride level > 250 mg/dl
• Women with polycystic ovarian syndrome (PCOS)
• IGT or IFG on previous testing
• Other clinical conditions associated with insulin resistance (e.g. severe obesity and acanthosis nigricans)
• History of CVD

Source: United States Department of Agriculture (USDA). Food and Nutrition Service. WIC Policy Memorandum 98-9, Revision 10 Nutrition Risk Criteria.

Gestational Diabetes

During pregnancy, IFG and IGT are diagnosed as gestational diabetes. Women who are diagnosed with gestational diabetes (GDM) during pregnancy are more likely to develop diabetes later in life. Additionally, women with a history of GDM are at higher risk for GDM diagnosis in a subsequent pregnancy. Risk factors associated with subsequent GDM include: obesity, insulin use in previous pregnancy, weight gain between pregnancies, and unhealthy BMI. All women with a history of GDM but without postpartum diagnosis of diabetes should be advised to talk with their doctor about having a Glucose Tolerance Test (GTT) at 6-12 weeks postpartum. Obese women with a history of GDM should be encouraged to lose weight before subsequent pregnancy.

Diabetes Mellitus

Diabetes mellitus is a group of metabolic diseases characterized by inappropriate hyperglycemia. Diabetes mellitus is further characterized by abnormalities in the metabolism of insulin, protein, fat and carbohydrates as well as by abnormalities in the structure of blood vessels and nerves. There are three classifications of diabetes: Type 1 and Type 2 Diabetes and Maturity Onset Diabetes of the Young or MODY.

Type 1 is associated with beta-cell destruction that leads to absolute insulin deficiency. Type 2 diabetes ranges from predominantly insulin resistance with relative insulin deficiency to a predominantly insulin secretory defect with insulin resistance. MODY is a series of familial disorders characterized by early onset and mild hyperglycemia, often diagnosed before the age of 25.The long- term complications of diabetes include:

 Retinopathy and potential vision loss  Nephropathy and renal failure  Peripheral neuropathy with risk of foot ulcers, amputations and Charcot joints  Autonomic neuropathy causing gastrointestinal, genitourinary, cardiovascular symptoms and sexual dysfunction.

General dietary recommendations for diabetes include high fiber consumption, calorie monitoring and reduced carbohydrate intake. The WIC Food package provides high fiber and low fat foods. It emphasizes consumption of whole grains, fruits and vegetables, and dairy that may assist WIC clients in reducing their risk for diabetes.

3.4.2 Hypertension and Preeclampsia

Hypertension is defined as having blood pressure reading with systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg. Prehypertension is diagnosed with blood pressure readings between 130/80 to

Certain lifestyle modifications- such as early prenatal care, taking prenatal vitamin, and physical activity- have shown to have protective effect against preeclampsia. Vitamin D may also be important in prevention of preeclampsia because of its role in blood pressure regulation and influence on vascular structure and function.

3.4.3 Overweight and Underweight

Among the various prenatal nutritional counseling goals in WIC- one is to achieve recommended weight gain during pregnancy. The overweight woman should be encouraged to make food selections that are of high nutritional quality and to avoid calorie rich foods. For the underweight emphasis should be on increased consumption and inclusion of calorie dense foods. Prepregnancy overweight and underweight have been associated with a higher incidence of various pregnancy complications.

Pregnancy Complications Associated with Prepregnancy Weight Weight Status Before Pregnancy Potential Complications

Overweight

 Higher rates of cesarean delivery  Gestational diabetes mellitus  Preeclampsia  Other pregnancy-induced hypertensive disorders  Postpartum anemia

Underweight

 Higher risk for delivery of LBW infants, retarded fetal growth and perinatal mortality.  Higher rates of cesarean delivery  Antepartum hemorrhage  Premature rapture of membranes  Anemia  Endometriosis Source: United States Department of Agriculture (USDA). Food and Nutrition Service. WIC Policy Memorandum 98-9, Revision 10 Nutrition Risk Criteria.

The Institute of Medicine (IOM) prenatal weight gain recommendations are associated with improved maternal and child health outcome. See section 3. 1 Prenatal Weight Gain for more information.

3.5 Special Dietary Concerns During Pregnancy

3.5.1 Adolescence

Adolescence is a time of intense physical, intellectual, emotional and social growth. Peer pressure, concern about appearance, and an active lifestyle can have a negative influence on the types and amounts of foods a teen eats. National surveys reveal that the diets of teens are often low in vitamins A and E, folate, vitamin B 6 , calcium, iron, zinc, and fiber and high in fat and sugar. Pregnancy in adolescence is associated with higher risks for preeclampsia,

anemia, premature birth, low-birth weight, infant mortality and sexually transmitted diseases. If a pregnancy occurs within two years of the onset of menstruation or if the adolescent is younger than 16 years of age, she may still be growing and could compete with her fetus for nutrients. By learning to make healthy food choices pregnant adolescents can increase their baby’s chance of being born healthy. Nutritional care for pregnant adolescents begins with the determination of daily caloric needs.

3.5.2 Pica and Unusual Cravings

Pregnant women often have food cravings. For most, giving into these cravings causes no harm. The cravings can become a problem if only one type of food is consumed and the rest of the diet is neglected. Variety in the diet is important to ensure nutrient needs are being met.

Pica is the practice of eating non-food items or substances having little or no nutritional value. Women at risk for pica behavior are more likely to be African American, live in rural areas and have a family history of pica. Reasons for pica are not known. Proposed explanations include: it is due to a deficiency of an essential nutrient; it is related to hormonal changes; or it is a family tradition to consume a non-food item during pregnancy.

The potential risks associated with pica in pregnancy include fetal and maternal toxicity as well as medical complications.

Potential complications from pica include:  Constipation and gastric or intestinal obstruction  Low intakes of iron, zinc and energy, which may lead to nutrient deficiencies and/or inadequate weight gain  Appetite depression, particularly with ice eaten before and instead of meals  Malabsorption of minerals caused by them binding to substances ingested  Delivery of an infant that is irritable, cries often and has smaller head circumference (especially associated with ice, freezer frost and starch consumption)  Tooth fractures from chewing hard substances  Congenital lead poisoning in infants if mothers ingested lead-containing substances

The extent of the risk is dependent on the type, quantity and frequency of the substances ingested. Pregnant woman who experience pica should be counseled on the possible effects and monitored for anemia and poor fetal development.