Nutrition, Health & Pregnancy

• Body Mass & Health Mesurements
  • BMI does not distinguish fat from lean muscle
  • Waist to Hip ratio: Max-0.8 (Cardiovascular health)
  • FBS (fasting blood sugar) , TG’s (Triglycerides), HDL
• Weight Charts
  • Set to correspond with the lowest mortality rates
  • Not factored for lifestyle
  • Optimum BMI: 19.8-24.5 (2 fold risk); 21-27 
• Mortality & Weight
  • Positive correlation between weight and mortality. Controlled for smoking. (one goes up/other goes up)
  • Mortality rates up to 35% or higher with BMI greater than 25.
• Chronic Disease & BMI
  • Type 2-diabetes
  • Hypertension
  • Chronic Heart Disease
  • Cholelithisais
  • Postmenopausal breast cancer–all breast cancer
  • Cancer
• Even a gain of 11-22 lbs. can result in an increased RR-Relative Risk of 1.5 to 3 for Chronic Heart Disease, Diabetes, & Hypertension
  • Relative Risk:
    • 1.0 = no increase risk; standard
    • 1.5 = 50% risk over population
    • 2.0 = 100% risk over population
• MyPyramid.gov
• Pre-Pregnancy BMI & (Weight gain recommendations)
  • less than 19.8 = underweight (28-40lbs)
  • 19.8-24.9 = normal weight (25-35lbs)
  • 25.0-29.9 = overweight (15-25lbs)
  • equal to/above 30 = obese (less than/equal to 15lbs)
    • Twins range= 35-45lbs
    • Higher end of range for young/black/S.Asian women
• High risk for poor weight gain groups
  • Smokers
  • Substance users
  • Very young adolesants
  • Poor
  • Busy professional women
  • Multiple gestation
• Pregnancy Risk Related to Overweight
  • hypertension
  • diabetes
  • Cesarean
  • Macrosomia (too big)
  • Shoulder Dystocia (baby shoulder caught)
  • NTD (neural tube defect)
  • Late intrauterine death
  • Infection
• Distribution of weight in pregnancy:
  • 7.5-8.5lbs = fetus
  • 7.5lbs = fat & protein
  • 4.0lbs = blood
  • 2.7lbs = tissue fluids
  • 2.0lbs = uterus
  • 1.8lbs = amniotic fluid
  • 1.5lbs = placenta & umbilical cord
  • 1.0lbs = breasts
  • TOTAL = 28-29lbs
• Weight gain & birth weight
  • when weight gain is within IOM (Institute of Medicine) recommendations incidence of SGA or LBW is reduced.
• Calorie Requirements:
  • After 20 weeks, ADD 300 CALORIES, and 25 GRAMS of PROTEIN to the woman’s non-preg calorie and protein requirements.
• Risk associated with LBW
  • Mortality
  • Mental retardation
  • Cerebral palsy
  • Learning disabilities
  • Neurologic defects
  • Vision/Hearing impairments
  • Stunted growth and development
• Brain growth
  • malnutrition during hyperplasia leads to a decrease in the number of brain cells that is irreversible.
  • BW of 3000 grams is critical
• Alcohol: No known safe level. Avoid all alcohol including beer and wine
• Caffine & Pregnancy: Half-Life prolonged in the fetus; fine, but do not overdue it; 300mg-400mg/day = SAFE amount of coffee and soft drinks
• Pregnancy Requirements:
  • 300Kcal/day
  • 25-60grams protein/day
  • Iron 30mg/day beginning at 12th week
  • Folate 400mcg/day
  • Calcium 1200mg/day (dairy, spinich, supplements)
• Sources of IRON:
  • not enough can cause–anemia
  • Liver, meats, whole grain or enriched breads and cereals, deep green leafy vegetables, legumes, dried fruits
  • take on an empty stomach
  • may cause stools to be black/green
• Sources of CALCIUM:
  • Milk & Yogurt –rich in Ca+
  • Milk, cheese, yogurt, sardines or other fish eaten with bones left in, deep green leafy vegetables except spinach or Swiss chard, calcium-set tofu, baked beans, tortillas
  • Daily Recommendations During Pregnancy
• Nutrition & Prenatal Care
  • 24hr recall
  • Cultural sensitivity
  • Consistancy weighing
  • Set weight goal at initial visit
  • Additional time with high risk groups
• Morning Sickness:
  • Dry crackers/starches
  • Upright after meals
  • Eat slowly
  • Small frequent meals
  • Ginger

Diagnosis of Pregnancy

Signs & Symptoms of Pregnancy:

**Objective 1: Identify the presumptive, probable and positive signs of pregnancy 

• Presumptive Signs:[Pregnant woman notices] Maternal physiological changes that a woman may experience.
  • Abrupt cessation of menses
  • Nausea and vomiting
  • Tingling, tenseness, nodularity, and enlargement of breasts and nipples
  • Increased frequency of urination
  • Fatigue
  • Color changes of breast:  darkening of nipples; primary and secondary areolar changes
  • Appearance of Montgomery’s tubercles (glands, breast-around nipple)
  • Continued elevation of BBT in the absence of infection
  • Expression of colostrom from nipples (3rd trimester)
  • Excessive salivation
  • Quickening (first feel the baby move)
  • Skin pigmentation and conditions, e.g. chloasma, breast and abdominal striae, linea nigra, vascular spiders, palmar erythema
• Probable Signs: [RN Notices] Maternal physiological and anatomical changes detected upon examination (other than presumptive signs)
  • Chadwick’s sign
  • Enlargement of abdomen
  • Change in the shape of the uterus
  • Ballotment (pateller test)
  • Palpation of fetal outline
  • Fetal movement palpated (probable or positive)
  • Piskacek’s sign
  • Hegar’s sign
  • Goodell’s sign
  • Palpation of Braxton Hicks contractions
  • Positive pregnancy test
• Positive Signs: Directly attributed to the fetus as documented by the examiner
  • *ONLY* Fetal heart tones
  • Ultrasound confirmation

 **Objective 2: Differentiate between quantitative and qualitative pregnancy tests

• Ask ahead of time: “How would you feel about being pregnant right now?”
• Pregnancy Tests: 
• Detect HCG(corpus luteum) in blood or urine; Recognition of hCG (or a subunit) by an antibody to the hCG molecule usually the $-subunit of hCG 
  • Qualitative:  positive or negative
    • Urine: morning sample is the best; but any will do
  • Quantitative:  provides an amount for hCG
    • Blood test: will give an amount (hCG can be detected in the serum 8-9 days after fertilization; and somewhat later in the maternal urine) –3 days after pregnancy
  • Clinical tests: sensitive at the time of missed menses

**Objective 3: Describe how to determine last menstrual period and estimated date of delivery

• Dating: LMP – 3months + 7 days 
• Nagele’s Rule: first day of LMP, minus three months, plus one week and one year.  This equal 280 days from LMP.  No research supports 280 days as the length of pregnancy.
• Example: Dec.1st (so,) Dec.1st-3months=Sept.1st + 7days=Sept.8th
• Research has shown that the pregnancy mean is closer to 283-284 days from LMP or 269-270 days from ovulation
• Always determine if LMP was a normal period for the woman. Spotting at the time of implantation is not uncommon.  This scanty bleeding may be interpreted as a period unless a through menstrual history is obtained.  Remember, LMP refers to the first day of her last NORMAL period.  If a woman is a poor historian and has difficulty determining her LMP, it may be useful to use holidays or other events to help her focus her memory.
• Gestational Wheel: At the beginning of the wheel is the 1st day of menses; outside of wheel calendar year. middle wheel months; also, 280 marker (40weeks) ex. Sept.10-June 17
• 

DATING METHODS Level 1 – most reliable

• 1.  LMP which is normal, regular, & certain (1-2 wk range of accuracy)
• 2.  Basal body temperature with coital record, showing ovulation & sustained temperature elevation. (2-5 days range of accuracy)
• 3. Ultrasound between 7 & 10 weeks of menstrual age, using crown-rump length to calculate gestational age. (accurate to within  3-5 days)
• 4. Serum hCG levels <10,000 on two separate occasions one week apart, rising appropriately. . (accurate to within  3-5 days)
• 5. Urine pregnancy testing, which may initially be negative, but becomes positive as soon as detectable levels of hCG are present in maternal urine. This timing will vary according to the type of urine test used.
• 6. Two ultrasounds <26 weeks gestational age, which estimate dates of delivery within 2.6 weeks of each other.  Use the EDD based upon the earlier ultrasound, unless obtained between 10 & 13.     

Antepartal Care: Teratology

• Teratogens (birth defects) any agent or non-genetic factor that produces permanent abnormal embryonic physical development of physiology.
• Historical Events:
  • 1941: Rubella (blindness, Congenital Heart defects)
  • 1950’s: Methylmercury (neurotoxicity)
  • 1960’s: Thalidomide (phocomelia)
  • 1970’s: Alcohol (fetal alcohol syndrome)
• Principles of Teratology:
  • All or none phenomenon (from conception to implantation)-prenatal death
  • Dose dependency
  • Critical periods for certain effects
  • Duration of exposure
  • Host suseptibility
  • Drug interactions
    • BEST: Single drug; lowest dose
• Critical periods during human development:
• Embryonic 3-8weeks; Gestational age 5-10weeks
• 
• Effect of teratogen by (gestational) week exposure:
  • 1-6 weeks: CNS
  • 2-7 weeks: Heart
  • 3-8 weeks: Extremities
  • 3-8 weeks: Eyes
  • 5-8 weeks: Palate
  • 6-10 weeks: External Genitalia
• Thalidomide:
  • Introduced in 1956 as a seditive & anti-nausea agent
  • Withdrawn in 1961
  • Discovered to be human teratogen causing absence of limbs or limb malformations in newborns
  • 5000-7000 infants effected
  • Resulted in new drug testing rules
• Pre-Embryonic Stage:
  • Time of fertilization & up to implantation
  • First 2 weeks of gestation
  • Exposure to teratogens in this period may lead to improper implantation & spontaneous abortion, Also called “All or None”.
• Critical Period- Embryonic Period:
  • From day 14-18 to day 54-60 post-conception (this is the critical period)
  • Period of most extensive organ differentiation (the heart-first 38days; arms/legs-first 49days; teeth-first 56days, etc.)
  • Exposure to teratogens during this period can cause structural and functionatl birth defects.
• Fetal Period:
  • From day 56 of gestation to delivery
  • Differentiation of the palate, external genitalia, and ear are examples for this period. Structural defects as well as fetal growth retardation can occur.
• Known or strongly suspected Teratogens (Drugs & Chemicals)
  • Alcohol
  • Androgens (testosterone)
  • ACE Inhibitors (hypertensive medications)
  • Antithyroid medications
  • Coumadin
  • Carbamezepine, Phenytoin, Valproic Acid (cleft palate)
  • Folic Acid Antagonist (Hyper/Hypobilrubemia
  • Cocaine
  • Lead, Mercury+
  • Lithium (Bipolar meds. -cardiac defects)
  • NSAID’s
  • Tetracycline (discolor teeth/effect bone growth)
  • Thalidomide
  • NO Sulfa-drugs
• Known or Strongly Suspected Teratogens (INFECTIONS)
  • CMV-cytomet.virus
  • Rubella
  • Syphilis (Treat w/ PCN-not for babies/PCN desensitizes preg.women) baby bleeds to death
  • Toxoplasmosis
  • Varicella
• SSRI’s and Birth Defects (To treat depression)
  • Paxil, after 20th.wk, 1st trimester
    • Persistant Pulmonary Hypertension; taken after 20th wk; respiratory problems; 6 times greater risk
    • RR of atrial and ventricular septal defects w/ 1st trimester use; fetal echocardiography to screen in women exposed
  • Prozac, third trimester use
    • preterm delivery, respiratory difficulty, admission to NICU, jitteriness
  • JAMA, May 2008: SSRI’s-late in preg-3times greater risk-respiratory prob. in newborns (including Effexor)
  • FDA Category D
• FDA Categories:
  • A: Controlled studies in humans/ but not shown an increased risk for BD’s
  • B: Animal studies show negative for BD’s/no adequate human studies OR animal/human studies not available
  • C: Animal Studies show risk/ lack in human data
  • D: Human data-show risk (benefit may outweigh)
  • X: Animal/Human data positive
• Smoking in Pregnancy
  • Associated with reduced birth weight (IUGR & LBW), pematurity, stillborn, placental abruption
• Fetal Alcohol Syndrome (FAS)
  • First described in 1970s
  • Facial abnml, growth retardation, CNS effects, reduced intelligence
  • Facial effects: microcephaly, flat face, thin lips, missing groove above lip, short nose
  • Effects 4-12 thousand infants per year
  • Fetal Alcohol effects: (FAE) milder form but still CNS involvement