Nutrition in Pregnancy

1. See Also
   1. First Trimester Education
   2. Second Trimester Education
   3. Third Trimester Education
   4. First Obstetric Visit
   5. Prenatal Visit
2. Physiology
   1. Weight gain distribution over multiple components
      1. Fetus
      2. Placenta, amnion, and Uterus
      3. Edema and Increased Blood Volume
      4. Breast engorgement
   2. Adequate Weight Gain in Pregnancy
      1. Prevents Intrauterine Growth Retardation (IUGR)
         1. Especially in third trimester
   3. Obesity in pregnancy associated risks (BMI 30 compared with BMI 20)
      1. Fetal death (RR 1.3)
      2. Stillbirth (RR 1.5)
      3. Perinatal death (RR 1.3)
      4. Johansson (2014) BMJ 349:g6572 [PubMed]
3. Approach: Weight Gain in Pregnancy
   1. Normal conception weight (BMI = 19.8 - 26)
      1. Total weight gain: 11.25 - 15.75 kg (25 - 35 lb)
      2. Gain 1st trimester: 1.35-2.25 kg (3-5 lb) per month
      3. Gain 2nd/3rd: 0.45-0.90 kg (1-2 lb) per week
   2. Low weight at conception (BMI < 18.5)
      1. Total gain: 12.7 - 18 kg (28 to 40 lb)
   3. Overweight at conception (BMI 27-29)
      1. Total weight gain: 6.75 - 11.25 kg (15 - 25 lb)
      2. Gain 1st trimester: 0.90-1.80 kg (2-4 lb) per month
      3. Gain 2nd/3rd: 0.45 kg (1 lb) per week
   4. Morbidly Overweight at conception (BMI >=30)
      1. Total weight gain: 5.0 to 9.1 kg (11 to 20 lb)
4. Indications: Intensive Nutrition Counseling
   1. Weight gain <0.90 kg (2 lb) per month
   2. Weight gain >2.92 kg (6 lb 8 oz) per month
   3. Weight gain < 4.5 kg (10 lb) by mid-pregnancy
5. Approach: Postpartum Weight Loss
   1. Plan for gradual weight loss
   2. Weight loss 0.36 - 0.45 kg (13 oz - 1 lb) per week
6. Guidelines: National Research Council RDA Recommendations
   1. Myths
      1. Women should not double their Caloric Intake in pregnancy
   2. Daily Caloric Intakes are estimates for a moderately active woman
      1. Individualize Caloric Intake for body habitus and activity level
   3. Non-Pregnant Women Example
      1. Daily Caloric Intake: 2200 KCals for moderately active woman (range 1800-2400 calories/day)
      2. Daily Protein intake: 55 grams
   4. Pregnant Women: First Trimester Example
      1. Daily Caloric Intake 2300 KCals (100 additional calories per day)
      2. Equivalent of 100 additional calories/day
         1. One and one half slices of bread per day
         2. One Cup of milk or fruit juice
         3. One Banana
   5. Pregnant Women (Second and third trimester) Example
      1. Daily Caloric Intake: 2500 KCals (300-400 additional calories/day)
      2. Daily Protein intake: 60 grams
      3. Equivalent of 300-400 additional calories/day
         1. Two slices of bread and one half avocado per day
         2. 1 cup blueberries and 2 hard boiled eggs
   6. Lactating Women Example
      1. Daily Caloric Intake: 2600 KCals (400 additional calories/day)
      2. Daily Protein intake: 65 grams
7. Guidelines: Vitamin Supplementation in Pregnancy
   1. See Prenatal Vitamins (PNV)
   2. See Folic Acid Supplementation in Pregnancy
   3. Vegetarian or Vegan Diet
      1. Consider Vitamin B12 Supplementation
      2. Consider Vitamin D Supplementation
   4. Calcium Supplementation
      1. See Dietary Calcium
      2. Calcium 1000 mg per day (PNV contains 200-300 mg Calcium)
   5. Elemental Iron
      1. See Dietary Iron
      2. Elemental Iron 30 mg per day (PNV contains 27 mg Elemental Iron)
   6. Folic Acid
      1. See Folic Acid Supplementation in Pregnancy
      2. Folic Acid 400 to 1000 mcg per day (PNV contains 600 mcg)
      3. Up to 4000 mcg Folic Acid recommended daily if increased risk for Neural Tube Defect
   7. Omega-3 Fatty Acids
      1. See Omega-3 Fatty Acid Supplement (use safe preparations without Mercury Poisoning risk)
      2. Omega-3 Fatty Acid 650 mg per day (PNV contains variable amounts up to 450 mg)
         1. Roughly Half of Omega-3 Fatty Acid should be Docosahexaenoic Acid
   8. Vitamin D
      1. See Vitamin D
      2. Vitamin D 600 IU per day (PNV contains 200 to 600 IU)
8. Guidelines: Specific Components and Additives
   1. Artificial Sweeteners
      1. Artificial Sweeteners are associated with Large for Gestational Age infants and Childhood Obesity
         1. Zhu (2017) Int J Epidemiol 46(5): 1499-508 [PubMed]
      2. Specific sweeteners
         1. Avoid Saccharin (crosses placenta and may deposit in fetal tissue)
         2. Sucralose and Acesulfame-K are likely safe in pregnancy
         3. Aspartame is likely safe in pregnancy
            1. Theoretical risk of exposing an undiagnosed fetus with PKU to phenylalanine
   2. Caffeine
      1. Association with Spontaneous Abortion, preterm delivery and low birth weight with Caffeine >350 mg/day
      2. Limit Caffeine to <200 mg/day (2 small cups of coffee)
   3. Herbal teas
      1. Avoid chamomile, licorice, peppermint, raspberry leaf (risk or Preterm Labor, Spontaneous Abortion)
   4. Vitamin A Toxicity
      1. Avoid liver products
   5. Toxins
      1. See Mercury Content in Fish
      2. Various pollutants in farmed salmon (polychlorinated biphenyls, dioxins)
9. Guidelines: Foodborne Illness Prevention
   1. Toxoplasosis risk
      1. Unpasteurized dairy and soft cheeses (e.g. Feta, Brie, Caembert, Blue cheese)
      2. Unwashed fruits and vegetables
   2. Listeria risk (Listeriosis risk in 18 fold higher in pregnancy; fetal mortality approaches 35%)
      1. Unpasteurized dairy and soft cheeses (e.g. Feta, Brie, Caembert, Blue cheese)
      2. Unwashed fruits and vegetables
      3. Deli meats or meat spreads
      4. Under cooked meats
      5. Bean Sprouts
      6. Left-overs
      7. Raw or Smoked seafood
   3. Salmonella risk
      1. Raw eggs
   4. Parasites and Norovirus
      1. Raw fish or shellfish
10. References
    1. Cogswell (1999) Obstet Gynecol 94:616-22 [PubMed]
    2. Zolotor (2014) Am Fam Physician 89(3): 199-208 [PubMed]