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Date Created: 01/19/15
Chapter 4 The status of reproductive outcomes in the United States and other economically developed countries is routinely assessed through examination of a particular set of vital statistics data called natality statistics natality means related to birth Natality statistics summarize important information about the occurrence of pregnancy complications and harmful behaviors in addition to infant mortality death and morbidity illness rates within a specific population These data are used to identify problems in need of resolution and to identify progress in meeting national goals for improvement in the course and outcome of pregnancy Infant mortality reflects the general health and socioeconomic status of a population The reason for this is because so many of the socioeconomic and environmental factors that influence the health of pregnant women and newborns also affect the health of the rest of the population Liveborn Infant a liveborn infant is the outcome of delivery when a completely expelled or extracted fetus breathes or shows any sign of life such as beating of the heart pulsation of the umbilical cord or definite movement of voluntary muscles whether or not the cord has been cut or the placenta is still attached HEALTHY LIFESTYLE DURING PREGNANCY Appropriate weight gain Appropriate physical activity Consumption of a variety of food that mirror the current Dietary Guidelines Appropriate and timely vitamin and mineral supplementation Avoid alcohol tobacco and other harmful substances Safe food handling EVALUATING OBSTETRICAL HISTORY Gravida number of pregnancies a woman has experienced Para parity number of liveborn infants a woman has produced Gravida 3 Para 1 She has had three pregnancies and one liveborn infant ndicates two prior miscarriagesspontaneous abortions andor stillbirths EVALUATING OBSTETRICAL HISTORY Gestational Age Time from Conception Menstrual Age Time from Last Menstrual Period PREGNANCY DEFINITIONS Preterm born before 37 weeks Post term born after 42 weeks Perinatal pertaining to the period immediately before and after birth LOW BIRTHWEIGHTI PRETERM INFANTS Low birthweight or preterm babies Most likely to die in first year of life Higher rate in US born to African Americans Due to factors other than genetics and race 82 of all births are low birth weight Infants weighing 35004500 grams 77 lbs 99 lbs at birth are least likely to die within first year FT healthy baby is 6879 lbs Also less likely to develop heart disease DM lung disease or hypertension WHAT AFFECTS LOW BIRTHWEIGHT AND PRETERM DELIVERY Maternal undenNeight Maternal obesity Low pregnancy weight gain Smoking during pregnancy Iron Deficiency Anemia VARIATION IN FETAL GROWTH Small for Gestational Age SGA Newborn weight is lt10th percentile Disproportionately Small dSGA Newborn weight is lt10th percentile Length and head circumference normal Proportionately Small pSGA Newborn weight length and head circumference are all lt10th percentile VARIATION IN FETAL GROWTH Large for gestational age LGA Newborn weight gt90th percentile or gt45OO g 10 lbs 2 Affects 12 related to maternal obesity uncontrolled diabetes excessive weight gain LGA infants have lower morbiditymortality rates Mothers have more delivery complications Appropriate for Gestational Age AGA Weight length and head circumference are between the 10th and 90th percentiles for gestational age Placenta a diskshaped organ of nutrient and gas interchange between mother and fetus at term the placenta weighs about 15 percent of the weight of the fetus Edema Swelling usually of the legs and feet but can also extend throughout the body due to an accumulation of extracellular fluid Steroid Hormones hormones such as progesterone estrogen and testosterone produced primarily from cholesterol Glucogenic Amino Acids amino acids such as alanine and glutamate that can be converted to glucose Ketones Metabolic byproducts of the breakdown of fatty acids in energy formation b hydroxybutyric acid acetoacetic acid and acetone are the major ketones or ketone bodies Key placental hormones and examples of their roles in pregnancy Human chorionic gonadotropinhCG Maintains early pregnancy by stimulating the corpus luteum to produce estrogen and progesterone It stimulates growth of the endometrium The placenta produces estrogen and progesterone after the first 2 months of pregnancy Progesterone Maintains the implant stimulates growth of the endometrium and its secretion of nutrients relaxes smooth muscles of the uterine blood vessels and gastrointestinal tract stimulates breast development promotes lipid deposition Estrogen Increases lipid formation and storage protein synthesis and uterine blood flow prompts uterine and breast duct development promotes ligament flexibility Human chorionic somatotropin hCS Increases maternal insulin resistance to maintain glucose availability for fetal use promotes protein synthesis and the breakdown of fat for energy for maternal use Leptin May participate in the regulation of appetite and lipid metabolism weight gain and utilization of fat stores Amniotic Fluid the fluid contained in the amniotic sac that surrounds the fetus in the uterus Growth Increase in an organism s size through cell multiplication hyperplasia and enlargement of cell size hypertrophy Development progression of the physical and mental capabilities of an organism through growth and differentiation of organs and tissues and integration of functions Differentiation Cellular acquisition of one or more characteristics or functions different from that of the original cells Critical Periods preprogrammed time periods during embryonic and fetal development when specific cells organs and tissues are formed and integrated or functional levels established Also called sensitive periods Shoulder Dystocia Blockage or difficulty of delivery due to obstruction of the birth canal by the infant s shoulders Cerebral Palsy a group of disorders characterized by impaired muscle activity and coordination present at birth or developed during early childhood Developmental programming of later disease risk a process by which adverse nutritional and other exposures during critical periods of growth and development modify gene function Such changes may predispose individuals to develop cardiovascular diseases type 2 diabetes hypertension obesity and other disorders later in life also called fetal origins hypothesis developmental programming developmental origins of adult health and disease and the Barker hypothesis Developmental Plasticity the concept that development can be modified by particular environmental conditions experienced by a fetus or infant Epigenetic epi over above alterations in gene activity that do not change the structure of DNa Gene activity can be shut off or turned on or slowed or spedup by epigenetic mechanisms epigenetic mechanisms are affected by environmental factors RATE OF WEIGHT GAIN First trimester 45 pounds Second and third trimesters 1 lb per week Rate of gain highest around midpregnancy WHERE DOES THE WEIGHT GO 13 fetus 13 maternal fat stores 13 fluids placenta uterus and breast tissue Where does the weight go postpartum 15 lb day of delivery Weight retention less with breastfeeding PHYSICAL ACTIVITY DURING PREGNANCY 30 minutes or more of PA most days of the week 50 lower risk of GD and 40 risk reduction for preeclampsia Dempsey 2005 Women should be evaluated for conditions that may PA Avoid any activity with high risk of falling or trauma to abdomen NUTRITION REQUIREMENTS DURING PREGNANCY Nutrient requirements can vary by woman or change during pregnancy based on Pre pregnancy nutrient stores Body size and composition Physical activity levels Stage of pregnancy Health status NUTRITION REQUIREMENTS DURING PREGNANCY Energy 300 additional calories on avg Due to increases in maternal body mass and fetal growth 22002900 kcal daily Depends upon prepregnancy BMI rate of weight gain maternal age and appetite Eat a variety of foods within calorie range httpwwwchoosemyplategovpregnancybreastfeedinghtml NUTRITION REQUIREMENTS DURING PREGNANCY Energy Needs Increase 1st trimester 013 weeks 21002300 kcal per day should be sufficient 2nd trimester 1426 weeks 340 extra kcal per day for each age group 3rd trimester 2740 weeks 452 extra kcal per day for each age group EXAMPLE OF 340 AND 450 ADDITIONAL CALORIES 340 additional calories Medium apple with 2 Tbsp of Peanut Butter and 8 oz of skim milk 1 cup of vanilla lowfat yogurt with one ounce of almonds 452 additional calories Peanut butter and banana sandwich Fruit smoothie with 1 cup of 1 milk 1 cup of berries and 1 tsp of sugar 4 oz of lean beef and 2 slices of whole grain breadCarbohydrate 5060 of total kcals Carbohydrates 5060 of total kcals Energy antioxidants and relieve constipation 175 gm minimum per day each trimester 28 gm total dietary fiber per day Protein Production of new cells enzymes and hormones maternal Growth and to achieve healthy birth wt baby 25 gmday all 3 trimesters 1 1gkg BWFat Fat Omega6 linoleic acid 13 gmday all age groups all 3 trimesters Safflower corn sunflower and soy oil Omega3 alphalinolenic acid 14 gmday Flaxseed walnut soybean canola and leafy green vegetables All age groups all 3 trimesters EPA and DHAAI gt250 mgday important in vision development and learning abilityWater Eicosanoids Molecules synthesized from essential fatty acids they exert complex control over many bodily systems mainly in inflammation and immunity and act as messengers in the central nervous system Water Total water approx 9 cupsday Vitamin and Mineral Needs During Pregnancy Increase during pregnancy due to Metabolic demands of placenta and fetal growth Expansion of maternal tissues and plasma volume Increased nutrient need for tissue maintenance Needs should be met by an adequate and wellbalanced diet however MVls are beneficial to many women and are typically recommended or prescribed to pregnant women FOLATE DFE Dietary Folate Equivalents amount of folate available from natural sources fortified foods and supplements pregnancy RDA 600mcg DFE 400 mcg folic acid 200 mcg DFE from fruits veggies Food sources listed Table 423 Folate in foods naturally is one for one Folic acid in fortified foods has a 17 conversion for DFE Ex 200 mcg of folate from foods 150 mcg of folic acid from fortified foods DIETARY FOLATE EQUIVALENTS DFE How many Dietary Folate Equivalents is your patient consuming Below is a list of her daily intake W cup of cooked black beans 180 mcg folate 1 fresh orange 60 mcg folate 1 cup of fortified cereal 200 mcg folic acid Gene variant an alteration in the normal coding sequence of a gene the different forms of the same genes are considered alleles NUTRITION REQUIREMENTS CONTINUED Vitamin D 5 mcgday 200 IU 3 cups of Vit D fortified milk or 25 hour of good sunlight per week Calcium 300 mg per day during last quarter May be met by increased absorption amp release of calcium from bone IRON 12 of women enter pregnancy irondeficient lrondeficiency anemia increases risk of preterm and low birthweight 23x RDA for iron in pregnancy is 27 mg UL is 45 mgday 30 mg iron supplement recommended after 12th week of pregnancy Anemic women may need 60 mg IRON Serum Ferritin ngldmL Normal gt35 ngmL Depleted Stores lt20 ngmL lt15 ngmL Hemoglobin levels anemia lt110 gdL 1st and 3rd trimesters lt105 gdL 2nd trimester Pica compulsion to eat nonfood substances Geophagia dirt clay Pagophagia ice freezer frost o Amylophagia Compulsive consumption of laundry starch or cornstarch NUTRITION CONCERNS Artificial Sweeteners Classified as Generally Recognized as Safe Poor sources of nutrients Alcohol No known safe intake Vitamin A Deficiencies rare in developed countries Concern is excessive intake retinol retinoic acid NUTRITION CONCERNS Caffeine Considered safe up to 200300mgday FishMercury Consume no more than 12 oz fishweek No more than 6 ozweek albacore tuna labeled white tuna FOOD SAFETY amp ENVIRONMENTAL CONCERNS Food Safety Listeria Monocytogenes Associated with undercooked or cold deli meats hot dogs blueveined cheeses any unpasteurized cheeses Environmental Concerns Toxoplasmosis Gondii T Gondii Associated with infected cat litter Encourage client to have spouse empty cat litter or wear long gloves mask COMMON HEALTH PROBLEMS DURING PREGNANCY Nausea and Vomiting Not uncommon but do monitor for extreme nv such as in Hyperemesis Gravidarum commonly called hyperemesis Monitor weight to ensure wt gain occurs May require hospitalization for IV electrolytes and tube feeding Heartburn Rec smaller more frequent meals avoid lying down immediately following a meal Constipation Encourage fiberrich foods and increase fluid intake
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