Lewis

Provides science-based, national goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all people in the United States

• Increase the proportion of women delivering a live birth who received preconception care services and practiced key recommended preconception health behaviors
• Increase the proportion of women of childbearing potential with intake of at least 400 μg of folic acid from fortified foods or dietary supplements
• Reduce the proportion of women of childbearing potential who have low red blood cell folate concentrations
• Reduce the proportion of persons aged 18 to 44 years who have impaired fecundity 

• One of a pair of primary reproductive organs in which oocytes form and mature
• Produces hormones estrogen and progesterone which stimulate maturation of oocyte
• Formation of corpus luteum
• Preparation of the uterine lining for pregnancy

• Chamber in which embryo develops
• Secretes mucus that helps sperm move into it and bars many bacteria

Thick muscle layers of uterus that stretch enormously during pregnancy

• Inner lining of uterus
• Site of implantation of blastocyst (early embryonic stage) becomes thickened, nutrient-packed, highly vascularized tissue during a pregnancy
• Gives rise to maternal portion of placenta

• One of a pair of primary reproductive organs
• Packed with sperm-producing tubules and cells that secrete testosterone and other hormones

One of a pair of glands that secrete fructose and prostaglandins which become part of the semen

• One of a pair of ducts in which sperm complete maturation
• The portion farthest from testis stores mature sperm

• Source: hypothalamus
• Stimulates release of FSH and LH

• Source: pituitary gland
• Stimulates the maturation of ova and sperm

• Source: pituitary gland
• Stimulates secretion of estrogen, progesterone, and testosterone and growth of the corpus luteum

• Source: ovaries, testes, fat cells, corpus luteum, and placenta
• Stimulates release of GnRH in follicular plase and inhibits in luteal phase
• Stimulates thickening of uterine wall during menstrual cycle

• Source: ovaries and placenta
• Prepares uterus for fertilized ovum and to maintain a pregnancy
• Stimulates uterine lining buildup during menstrual cycle
• Helps stimulate cell division of fertilized ova
• Inhibits action of testosterone

• Source: testes
• Stimulates maturation of male sex organs and sperm, formation of muscle tissue and other functions

• LH and FSH increase during this time
• Estradiol decreases 

• The lack of conception after one year of unprotected intercourse
• 40% of couples diagnosed with this will conceive a child within 3 years without technology

Corpus luteum secretes progesterone to help with the potential of a fertile egg and prepares body for pregnancy

• Weight loss >15%
• Inadequate body fat
• Extreme levels of exercise
• High alcohol intake
• Endocrine disorders
• Celiac disease
• Severe stress
• Diabetes

• Recent oral contraceptive use
• Anorexia or bulemia
• High caffeine intake
• High fiber intake
• Age >35 years
• Pelvic inflammatory disease
• Endometriosis

• Inadequate zinc status
• Heavy metal exposure
• Halogen and glycol exposure
• Estrogen exposure
• Sperm defects
• Excessive heat to testes
• Steroid abuse

• Acute undernutrition is associated with a dramatic decline in fertility
• Weight loss >10-15% of usual weight decreases estrogen, results in amenorrhea
• Decreased fertility is seen with low or high body fat

The lack of a menstural cycle

• Implants, patches and injections are used and carry a slight risk for thromboembolism
• Oral contraceptives, combinations of estrogen and progesterone may increase serum TG, TC, and HDL, decrease serum B-12 and increase serum copper
• Injections and patches have reported weight gain as an adverse effect

• Increased blood levels of HDL cholesterol
• Increased blood levels of triglycerides and LDL cholesterol
• Increased risk of venous thromboembolism, cervical cancer, and cardiovascular disease
• Decreased blood levels of vitamins B12 & B6
• Increased blood lvels of copper

• Weight gain
• Increased blood levels of LDL cholesterol and insulsin
• Decreased blood levels of HDL cholesterol
• Decreased bone density

Weight gain

• Neural tube closes within the first few weeks of pregnancy
• Need to get women this before they know they’re pregnant
• -Needed to prevent neural tube defects

• Too much vitamin A before pregnancy is bad
• Iron deficient results in poor pregnancy outcome
• Lead exposure

• Provide nutritional counseling
• Have to have a nutritional risk to participate
• Funded by the USDA
• Target low-income, nutritionally at-risk populations with supplemental foods and nutrition education
• Pregnant, breastfeeding, and non-breastfeeding, postpartum
• women, infants and children up to 5 years of age

• Developed to prevent and treat micronutrient deficiencies among young children and other vulnerable groups at risk
• Sachets (like small packets of sugar) containing a blend of micronutrients in powder form
• Coating of the iron prevents changes to the taste, color or texture of the food to which they are added
• Used to fortify foods that lower income families consume

• Published a report highlighting recommendations for improving preconception health
• Preconception health care should be delivered at regular primary care visits
• Focus of care should be on vaccinations, weight, iron and folate status, assessment of alcohol use and management of disorders such as diabetes

You are an RD and your patient is a 22 year old college student.  She is healthy, takes oral contraceptives, and is interested in becoming pregnant in the next couple of years. She takes no supplements, but says she eats healthy. What are the key nutrition recommendations you would discuss with her?

A condition occurring among women of reproductive age that includes a group of physical, psychological, and behavioral symptoms with the onset of the luteal phase and subsiding with menstrual bleeding

Severe form of PMS with mood swings, depressed mood, irritability, anxiety, and physical symptoms

• Fatigue
• Bloating
• Swelling of hands of feet
• Headache
• Tender breasts
• Nausea

• Craving of sweet or salty foods
• Depression
• Irritability
• Mood swings 
• Anxiety
• Social withdrawal

• A high total vitamin D (700 IU) intake had a relative risk of 0.59 for PMS symptoms compared to those in the lowest quintile (100 IU)
• Those with a high intake of dietary calcium (1200 mg) had a relative risk of 0.7 for PMS symptoms compared to those with a low intake (500 mg)

• Use selective serotonin-reuptake inhibitors
• GnRH agonist-reduce the release of FSH and LH, prevent ovulation and result in decreased estrogen levels
• Both significantly reduce symptoms

• Energy deficits disrupts the release of GnRH and LH and leads to anovulation and loss of menstrual cycles
• Related to underweight, weight loss or weight loss accompanied by intense exercise

• Disordered eating
• Amennorhea
• Osteoporosis
• Gymnastics is an activity which places high strains on the skeleton, however adolescent gymnasts have been investigated as having a risk for premature bone loss
• Gymnasts, by nature of the sport, strive for a lean body type

• Energy availability: optimal vs low
• Menstrual function: amenorrhea vs eumenorrhea
• Bone mineral density: osteoporosis vs optimal bone health

• One symptom of anorexia is amenorrhea; this is manifested by irregular release of GnRH and low levels of estrogen
• Losing 15% of body mass
• Weight gain can bring the menstrual period back and increase fertility

• Sex hormone binding globulin (SHBG)- levels are decreased
• -Transfers estrogen and testosterone
• -Availability of sex hormones depends on the level of SHBG
• Hyperandrogenism in some women and reduced androgens in men
• Central body fat (waist circumference > 38 inches) increases risk for infertility
• Weight loss significantly increases fertility
• Have low vitamin D levels
• Increased chance for gestational diabetes and preeclampsia
• Need less weight gain
• Post-partum weight gain is a leading cause

• The most common endocrine disorder in women of reproductive age (10% of women)
• Leading cause of infertility
• Strong genetic component that interacts with environmental factors (e.g., insulin resistance)

• The ovary does not make the hormones it needs for an egg to fully mature
• Since no egg is released, ovulation does not occur and progesterone is not made (i.e., a woman's menstrual cycle becomes irregular/absent)
• The cysts produce male hormones, which also prevent ovulation

• Menstrual irregularities
• Common signs are low HDL and high triglycerides
• Induces metabolic issues
• Major signs: insulin resistance and high testosterone
• -Treat insulin resistance first
• -If you can improve insulin sensitivity, you don’t have to rely on medication

• Based on symptoms, and lowering chances of heart disease and diabetes
• Many women will need a combination of treatments to meet these goals:
• -Birth Control Pills
• -Diabetes Medications
• -Fertility Medications (to stimulate ovulation)
• -Surgery
• -Lifestyle Modifications

• Exercise can increase insulin sensitivity in type II diabetes
• Begin moderate exercise program before pregnancy and continue low-impact activities throughout
• Key is to control blood glucose levels
• Shouldn’t get pregnant until the woman has lost an adequate amount of weight

• The baby being small, or growing too large and making delivery difficult for baby and mother
• Increased risk of pre-eclampsia (high blood pressure and excess protein in the urine)
• Increased risk of premature birth
• Increased risk of the baby suffering respiratory distress syndrome when born

• Genetic defect
• Lack the enzyme phenylalanine hydroxylase and cannot convert phenylalanine to tyrosine
• Get build up of serum phenylalanine

• Mental retardation
• Heart defects
• Low birth weight
• Women maintaining normal phenylalanine levels can have healthy infants 

• Autoimmune disease in people with genetic susceptibility to protein gliadin found in gluten component of wheat, rye, barley, which causes malabsorption & flattening of intestinal lining
• Linked to infertility in some women and men

• Eliminate gluten in diet
• Look for “gluten free” labels
• Gluten found in many non-grain foods like hot dogs, deli meats, supplements, chips, bouillon, salad dressing, etc.
• Correction of vitamin & mineral deficiencies

• Depends on the mother's nutrient intake to meet its nutritional needs
• Gets iron, calcium, vitamin D, and most importantly glucose from the mother

The number of pregnancies a woman has experienced

• The number of previous deliveries a woman has experienced
• Nulliparous
• Primiparous
• Multiparous

No previous deliveries

One previous delivery

• From conception: gestational age- 38 wks
• From last menstrual period: menstrual age- 40 wks

• Weeks 0-12
• Embryo: weeks 0-8
• Miscarriage: weeks 0-20

• Weeks 12-27
• Fetus: weeks 8-40
• Fetal death/stillbirth: weeks 20-40 

• Weeks 27-birth
• Very pre-term: <34 weeks
• Pre-term: <37 weeks
• Term: 38-42 weeks
• Neonatal: <42 weeks
• Postneonatal: 1 week after birth to months

• From 20 weeks gestational up to 1 month after birth
• Death, generally from low birth weight and lack of nutrients

• Index of the population’s health status
• Congenital malformations, low birthweight and sudden infant death syndrome are main causes
• 1995- 7.6
• 2006/2007- 6.8

• Changes in maternal body composition & functions occur in specific sequence
• Plasma volume is important to transfer all of the nutrients
• -Also used to exchange gases and remove waste
• Nutrient stores iron, calcium, fat

• Plasma volume: week 20
• Nutrient store: week 20
• Placental weight: week 31
• Uterine blood flow: week 37
• Fetal weight: week 37

• Takes place in the 1st half of pregnancy
• Synthesizing
• Blood volume expansion, increased cardiac output
• Buildup of fat, nutrient, and liver glycogen stores
• Growth of some maternal organs
• Increased appetite, food intake
• Decreased exercise tolerance
• Increased levels of anabolic hormones
• 10% of fetal growth

• Takes place in the 2nd half of pregnancy
• Releasing
• Mobilization of fat and nutrient stores
• Increased production and blood levels of glucose, triglycerides, and fatty acids
• Decreased liver glycogen stores
• Accelerated fasting metabolism
• Increased levels of catabolic hormones
• 90% of fetal growth
• Heightened ability to deliver nutrients to fetus

• Maintains early pregnancy by stimulating the corpus luteum to produce estrogen and progesterone
• Stimulates the growth of the endometrium
• Placenta produces estrogenand progesterone after the first 2 months of pregnancy
• Increase around 10 weeks 

• Increases maternal isulin resistance to maintain glucose availability for fetal use
• Promotes protein synthesis and the breakdown of fat for energy for maternal use

May participate in the regulation of appetit and lipid metabolism, weight gain, and utilization of fat stores

The fetus prefers glucose over fat as fuel and needs a constant supply in the 2nd half of pregnancy

High estrogen & progesterone stimulate insulin which increases glucose conversion to glycogen & fat

• Human chorionic somatotropin (hCS) and prolactin inhibit the conversion of glucose to glycogen and fat
• “Diabetogenic effect of pregnancy:” insulin resistance increases

• About 925 g of protein accumulate during gestation
• Protein & amino acids are conserved
• No evidence the body stores protein early in pregnancy
• Needs must be met by mother’s intake of protein

• Accumulate in first half of pregnancy
• Enhanced fat mobilization in last half
• Blood lipid levels increase
• Increased cholesterol (LDL and HDL); substrate for steroid hormone synthesis
• -High need of cholesterol for hormones
• Increase in serum triglyceride levels (unrelated to diet)
• -Occurs in prenatal state

• Increased bone turnover
• The process of bone being resorbed or lost
• Thinks mother stores some calcium for baby

• Accumulation in mother, placenta, & fetus
• Restriction of it potentially harmful

• Blood volume increases 20%
• Plasma volume increases 50%
• Cardiac output increases 30-50%
• -Goes up so you can get blood out to the increased tissues
• Heart rate increases up to 6 BPM
• Blood Pressure decreases 5-10 mmHg in the 1st half; then becomes normal during the 2nd half

• Increased tidal volume; i.e., amount of air inhaled and exhaled (30-40%)
• Increased oxygen consumption (~ 10%)

• Increase in BMR 15-20%; related to increased oxygen consumption of uterine-placental-fetal tissue and the increased cardiac work of mother
• Increase in fat utilization by the mother; to accommodate the high needs for glucose by the fetus (50 - 70%)

• Relaxed GI muscle tone
• Increased gastric and intestinal transit time
• Majority of women experience heartburn, nausea, vomiting, and constipation
• Some (1-2%) develop hyperemesis gravidarium- severe nausea and vomiting lasting throughout pregnancy

• Increased glomerular filtration rate (50-60%)
• Increased sodium conservation
• Increased nutrient loss into urine
• Increased risk of developing a UTI

• What’s used to measure kidney function
• The amount of blood that is being filtered by the kidneys on a rate basis
• Has to increase during pregnancy to remove uria, nitrogen, and other wastes

• Body fat increases (~ 6 kg)
• Fat-free mass increases, but not as much as fat mass
• Body water increases
• -Plasma
• Overall, total body bone mineral does not change
• Fat-free mass increases the energy expenditure

• There appears to be no net loss of bone during pregnancy; the calcium available to the fetus results primarily from enhanced calcium absorption
• Preliminary research suggests women with usual intakes of <500 mg/day may experience a calcium loss during pregnancy

• Organ that facilitates the exchange of nutrients and gases between the mother and fetus
• Maximal growth occurs around week 31 of gestation
• Makes up approximately 15% of the weight of the fetus
• Requires its own delivery shortly after the baby is born

• Separation of maternal and fetal blood
• Nutrient transfer
• Exchange of respiratory gases and waste products
• Production of Hormones (hCG, estrogen, progesterone, others)

• Oxygen
• Carbon dioxide
• Fatty acids
• Steroids
• Nucleosides             
• Electrolytes
• Fat-soluble vitamins             
• Sugars
• Amino acids
• Water-soluble vitamins*
• Some cations
• -(calcium, iron, iodine, phosphate)

• Nutrients transferred from blood with higher concentration levels to blood with lower concentration levels
• Water, some amino acids and glucose, free fatty acids, ketones, vitamins E and K, some minerals (Na, Cl), gases

• Receptors on cell membranes increase the rate of nutrient transfer
• Some glucose, vitamins A and D, iron

• Energy (from ATP) and cell membrane receptors
• Water-soluble vitamins, some minerals (Ca, Zn, Fe, K), and amino acids

• Nutrients and other molecules are engulfed by placenta membrane and released into fetal blood supply
• Immunoglobulins, albumin

Alcohol, excessive levels of vitamins, drugs, and certain viruses DO cross the placenta and get to the fetus

• Makes cholesterol
• Receives progesterone and estrogen

• Cannot make cholesterol
• Can convert cholesterol to progesterone
• Cannot convert progesterone to androgens
• Can convert androgens to estrogens

• Cannot convert cholesterol to progesterone
• Can convert progesterone to androgens

• Starts with maternal malnutrition
• Then reduced blood volume expansion
• Then inadequate increase in cardiac output
• Then decreased placental blood flow
• Then reduced placental size and reduced nutrient transfer
• Leading to this..

Acquisition of one or more characteristics or functions different from the original cells

Preprogrammed time periods during which embryonic and fetal cells, organs and tissues are developed 

• Blastogenesis
• Embryonic
• Fetal stage

• Fertilized egg divides and the inner mass becomes the embryo and the outer mass becomes the trophoblast
• The trophoblast becomes the placenta

• Cells differentiate and become ectoderm (brain, nervous system), mesoderm (muscles, bone, CV and excretory systems) and endoderm (digestive system, respiratory and glandular)
• By 60 days

• Most rapid growth
• Third month until term
• 6g to 3500g

Stabilization of cell number and size (occurs after tissues and organs are fully developed later in life)

Newborns with a weight < 10th percentile for gestational age

Newborns that weigh <10th percentile for weight for gestational age and have normal head circumference and length

Newborn’s weight, height and head circumference are all <10th percentile

Newborns with weights > 90th percentile for gestational age

Weight, length and head circumference are between the 10th and 90th percentiles

• Used to assess the appropriateness of newborn size:
• -Weight in grams/cm3 x 1000 
• Values between 23 and 25 are considered normal weight for length

• Theory that exposures to adverse nutritional & other conditions during critical or sensitive periods of growth & development can permanently affect body structures & functions
• Changes may predispose individuals to CVD, type 2 diabetes, hypertension, & other disorders in later life

• Influenced by genes and environment
• Developmental plasticity
• Concept that the development can be modified by particular environmental conditions experienced by a fetus or infant
• Epigenetic mechanisms-change gene function without changing DNA sequence

2 Most Important Factors Determining Birthweight

• Underweight: 28-40 lbs
• Normal weight: 25-35 lbs
• Overweight: 15-25 lbs
• Obese: 11-20 lbs

• Gains of < 0.5 lb (0.25 kg)/week in the 2nd trimester and 0.75 lbs (0.37 kg) in the 3rd trimester in under- or normal weight women increases risk for preterm and SGA infants
• Gains of < 0.5 lbs in overwt/obese in the 3rd trimester increases risks

Third trimester gains greater than 1.5 lbs/week (0.7 kg) in normal and obese women adds little to birthweight and may increase postpartum weight retention

• Increase in basal metabolism
• Changes in physical activity
• Dietary induced thermogenesis
• Cumulative costs is estimated to be 85,000 kcal
• 300 additional cal/d; (340 2nd trimester to 452 in 3rd trimester)

• Adaptive responses in nitrogen metabolism occur to retain more nitrogen for protein synthesis for the mother and fetus
• Requirement is based on nonpregnant woman plus the needed amounts for growth during gestation (~ 925 gms)
• Add 25 grams/day for women ≥14 years of age (1.1 grams/kg/day)

• Need about 33% fat calories in diet
• Linoleic acid (18:2, n-6) - primarily vegetable oils; synthesizes arachidonic acid (20:4 n-6)
• Linolenic acid (18:2 n-3) - some oils, greens; converted to docosahexaenoic acid (DHA; 20:5 n-3), a fatty acid found in cold water fish
• DHA is important for retinal development; incorporated into retina at a high rate late in pregnancy and first 6 months following delivery

• EPA dilates blood vessels, reduces blood clotting and reduces inflammation
• DHA is an structural component of phospholipids in cell membranes of the CNS, including the retina
• Infants from pregnant women who consume adequate amounts may have health benefits
• Recommend 250 mg/day; 500 mg is safe
• Consume no more than 12 ounces of fish per week 
• Eat no more than 6 ounces of albacore tuna per week
• Most pregnant women are getting EPA and DHA from supplements, which are safe

• High needs during pregnancy
• Increased significantly with exercise
• Need approximately nine cups of H20/day
• Monitor urine color

• A methyl group donor and enzyme cofactor in metabolic reactions involved in the synthesis of DNA
• Deficiency of folate impairs these processes, leading to abnormal cell division and tissue formation
• Consume 600 mg /day of Dietary Folate Equivalents (DFE), and include 400 mg from supplements or fortified foods and 200 mg from fruits and vegetables (these foods provide ~40 mcg of folate per serving)
• One DFE = 1 mg food folate, 0.6 mg folic acid fortified in foods or supplement taken with foods and 0.5 mg folic acid supplement taken on an empty stomach

• Use RBC folate vs serum folate to assess status; measures long-term rather than short-term intakes
• RBC values > 300 ng/ml or 680 nmol/L are associated with low risks
• Achieved by intakes of 400 mcg/day of folic acid; hard to achieve by diet alone

Recommendation is to consume no more than 5000 IU as retinol from supplements

• Deficiency during pregnancy poses a risk for the neonate and infant
• The fetus may be abnormal
• The neonate and infant may develop rickets
• Linked to functioning of the immune system and inflammation
• Policy by the WIC program to increase breastfeeding may have contributed to increased cases of rickets
• The recommendation for supplementation to infants of exclusively breastfed infants is now higher (400 IU)

• RDA is 15mg/d (600 IU/d; IOM 2010)
• Poor intakes; fortified foods
• Limited sun exposure and use of sun block
• Dark skin
• Poor maternal vitamin D status may linked to long-term human health conditions

• In the first trimester significantly increases the risk of low-birth weight and pre-term infants
• In the 3rd trimester significantly increases the risk of low intelligence scores, language problems

• Need iron for red blood cell synthesis
• -To carry oxygen to the fetus
• -A lot is transferred to the fetus in the 3rd trimester
• For fetus and placenta: 300mg
• Blood lost (delivery): 250mg
• For increase in RBC: 450mg

• Increases by the 30th week of gestation
• Increases with lower levels of iron supplements
• Increases when supplements are given by itself (<5% vs >10%)
• Increases in women with poor iron status

• Needed for fetal skeletal mineralization
• Calcium absorption and bone remodeling increase during pregnancy
• May be beneficial with respect to hypertensive disorders of pregnancy, especially in those with low intakes (<500 mg/day)
• RDA - 1300 mg/day for 14-18 yrs and 1000 for 19-50 yrs
• Needs can be met by drinking 4 c milk/day or 2 c fortified OJ + 2 cup milk/day

• Teratogenic
• Does not mobilize zinc from bone
• Associated with an increased malformation rate and other poor pregnancy outcomes
• Low serum and leukocyte zinc is associated with lower birth weight babies and pregnancy complications

• Zinc supplementation trials are mixed in response to pregnancy outcomes
• Most favorable results are seen in women with low serum zinc values
• The RDA for zinc during pregnancy is 11 mg

• Increases heart rate, acts as a diuretic, stimulates the CNS
• Easily passes through the placenta to the fetus
• Lingers in the fetus longer because the fetus excretes it more slowly

• There is no clearly defined safe level of alcohol intake during pregnancy; therefore it is strongly advised that pregnant women do not drink
• “Fetal Alcohol Spectrum” is used to describe the harmful effects of gestational alcohol exposure
• Alcohol easily crosses the placenta and the fetus does not have adequate enzymes to degrade the alcohol

• Due to alcohol exposure during critical periods of fetal development
• Approximately 40% of infants born to women who drink heavily (≥ 4 drinks/ day) will develop it
• Permanent alterations in facial features
• Poor coordination, short attention span, behavioral problems, growth retardation

• Show impaired rates of learning
• Experience poor memory
• Have trouble generalizing behaviors and information
• Act impulsively
• Exhibit reduced attention span or is distractible
• Display fearlessness and are unresponsive to verbal cautions

• More subtle features
• Have mental and behavioral features, but not the malformations

• Compulsive food behavior or craving during pregnancy due to changes in taste and smell
• Eat clay and dirt (geophagia), laundry starch (amylophagia), ice (pagophagia)
• More likely to be iron deficient, have gestational diabetes, lead poisoning, intestinal obstruction, and parasitic infestation of the GI tract
• Substitute for food = poor nutrition

• Definitely causes low birth weight babies
• Most likely due to poor transfer of oxygen and nutrients across the placenta
• Negative effects on fetal growth are greater in older women
• Doubled the risk for Sudden-Infant Death Syndrome (SIDS)
• Cessation should be one of the highest priorities in preconceptual care

• Nausea & vomiting
• Hyperemesis gravidarium
• Heartburn
• Constipation
• Hypertensive Disorders of Pregnancy
• Diabetes Mellitus
• Phenylketoneuria

• Small percent (1-2%) have a more serious disorder that requires IV fluid and electrolyte replacement
• These women may have trouble gaining appropriate weight and may be at risk for nutritional deficiencies and dehydration

• ~10% of all pregnancies; 2nd leading cause of maternal mortality in the US
• Pre-existing chronic hypertension 
• Gestational hypertension
• Pre-eclampsia 
• Eclampsia

• Blood pressure 140/90 before pregnancy or before 20 weeks gestation (1-5%)
• Continue medical therapy; try to minimize drug use
• Avoid excessive weight gain and use moderate sodium

Abnormal rise in blood pressure after the 20th week of gestation

• Hypertension with proteinuria and/or edema after 20 weeks gestation
• Hypertension: 140/90 mmHg or an increase of 30 mmHg in systolic and 15 mmHg diastolic over normal; 160/110 in severe cases
• Proteinuria: urinary excretion of 0.3 grams or more in 24 urine
• collection; 5 gm/24 hr in severe cases
• Edema

More advanced; life threatening situation evidenced by seizures and coma

• Hypertension
• Insulin resistance
• Increased urinary protein
• Decreased plasma volume expansion
• Persistent headaches
• Sensitivity of eyes to bright light
• Blurred vision
• Abdominal pain

• 1000-2000 mg calcium
• Adequate vitamin D status
• Use of multivitamin-mineral supplement
• Five or more servings of fruits and vegetables
• Consume foods based on MyPlate
• Moderate exercise, unless contraindicated
• -Some women are on bedrest
• Weight gain recommendations based on prepregnancy weight

Develops during pregnancy; ~ 7.5% of pregnant women

• Insulin-dependent diabetes mellitus (IDDM)
• Insulin deficient

• Insulin resistant-usually doesn’t require insulin
• Requires insulin during pregnancy

• Early in pregnancy insulin requirements are lower because of increased glucose going to fetus and nausea/vomiting that sometimes occurs
• Later in pregnancy, insulin requirements are increased 65 70% (because of placental hormones) and sensitivity is diminished; ketosis can occur

• The body relies on fat
• Fatty acid is oxidized and acetyl coA is being generated so much, and it builds up from fatty acid synthesis that it  leaves ketones in the body
• Ketones are used for energy, but if you generate too much, it changes acid/base balance

• C-section delivery
• Increased risk of preeclampsia
• Increased risk of type II diabetes, high blood pressure and obesity later in life
• Increased risk of gestational diabetes in subsequent pregnancy

• Stillbirth
• Spontaneous abortion
• Macrosomia (> 10 lbs or > 4500 g)
• Neonatal hypoglycemia
• Increased risk of type II diabetes, high blood pressure and obesity later in life

• Should be conducted at the initial visit if the woman is high risk
• Test at 24-28 weeks gestation
• Use a 50 gm 1-hour test; if the blood glucose value is >130 mg/100 ml, a complete 3-hour glucose tolerance test (GTT) should be conducted

• If two or more values are higher, then gestational diabetes is the diagnosis
• Fasting- >95/100
• 1 hr- >180/100
• 2 hr- >155/100
• 3 hr- >140/100

The critical objective is to maintain good glycemic control before and during pregnancy; if this is achieved there will be minimal risks, similar to the non-diabetic pregnant women

• Energy needs – 20-40 kcal/kg bw depending on weight status
• Carbohydrate 40 - 50% of total calories (focus on complex carbohydrates and limit simple sugars)
• Fat 30 - 40% of total calories (limit saturated fat)
• Protein 20% of total calories
• Regular meals and snacks should be distributed throughout the day to maintain blood glucose levels
• Use ADA Diabetic Exchange Lists
• Develop an individualized diet and exercise plan; regularly assess
• Monitor weight gain
• Help interpret blood glucose and urinary ketone values

• Increases oxytocin levels:
• -Stimulates contraction of the uterus
• -Minimizes postpartum blood loss
• -Brings uterus back to pre-pregnancy size
• Delays fertility (doesn’t prevent)
• Positive for countries with high birthrates to promote breastfeeding
• Promotes self-confidence and bonding with mother and infant
• Lowers risk for breast and ovarian cancer, if start nursing at a younger age and for longer duration
• Data on weight loss are mixed

• Nutritionally superior to human milk substitutes (HMS); optimal milk for the infant
• No need for dilution; same ionic concentration as plasma
• Lower protein content; whey protein
• Essential fatty acids (DHA) and bioavailable minerals
• Protect against infection; contains T- and B-lymphocytes, immunoglobins, neutrophils, macrophages, epithelial cells
• Reduced acute and chronic illness in the infant

• Puberty- a system of ducts, lobes, and alveoli develop
• Stage 2- stimulated by insulin growth factor I and estrogen
• During pregnancy- stimulated by prolactin and estrogen

• Lobe -> lobule -> alveoli -> alveolus -> secretory cells
• Alveoli are the functional units and each is composed of secretory cells with a duct in the center
• Myoepithelial cells, that line the alveoli, contract during letdown causing milk ejection into lactiferous ducts
• Milk is stored in lactiferous sinuses

• Ductal growth
• Mammary gland diffferentiation with menstruation

• Alveolar development
• After onset of menses and during pregnancy

• Alveolar development and milk production
• Pregnancy and breastfeeding ( from 3rd trimester to weaning)
• Steadily rising during pregnancy
• Released in response to suckling, stress, sleep, & sexual intercourse

• Letdown; ejection of milk from myopithelial cells
• From the onset of milk secretion to weaning
• Tingling of the breast may occur corresponding to contractions in milk duct
• Causes uterus to contract, seal blood vessels, and shrink in size

• Estrogen and progesterone remain low
• Prolactin remains high
• Oxytocin increases depending on if there's stimulation for breastfeeding

• 48 hours after:
• -Prolactin increases in normal women after 30 minutes
• -Prolactin decreases in overweight women after 30 minutes
• 7 days after:
• -Prolactin still increases in normal women
• -Prolactin increases in overweight women after 30 minutes

The diet of the mom affects her breastmilk composition?

If a woman breastfeeds for 6 months, does the baby need supplemental food?

• Milk begins to form
• Begins in last trimester until 2 days postpartum

• l2-5 days postpartum until 10 days
• Increased blood flow to mammary gland; significant changes in milk composition and quantity
• Production of milk starts to increase

• After day 10
• Maintenance of milk supply

• 600 ml increasing to ~ 750 - 800 ml
• Depends on infant weight, caloric density of milk, infant age, infant demand (more removed -> more produced)
• Does not matter about breast size; more likely to affect milk storage
• Feedback Inhibitor of Lactation (a protein), and nitric oxide, appear to influence milk production

• Prolactin stimulates milk production and inhibits ovulation
• Oxytocin stimulates milk ejection and promotes uterine contractions
• Both are high during breastfeeding, but are negative on nutrients for bones
• -Lose 5-6% of bone
• Sucking stimulus -> triggers release of oxytocin -> causes milk ejection
• Can be triggered by other factors:
• -Baby cry
• -Sexual arousal
• -Thinking about nursing

• Birth to 1-3 days
• Thick, yellowish and high in carotene
• Higher protein content than mature milk (2.0 vs 1.1 g/100ml)
• Lactoferrin is a primary protein-has antimicrobial activity
• Higher in IgA (0.5g vs 0.1g/100ml)-antibody that provides protection in the gut mucosa
• Lower in sugar and fat
• Lower in calories (55 vs 67 kcal/100ml)
• Higher is sodium, vitamin A

3-10 days

• 10 days on
• Fore milk
• Hind milk

• Major component in human milk
• Isotonic with maternal plasma

• Calories may vary with fat, protein and carbohydrate composition
• Lower in calories than human milk substitute (HMS)

• Provide ½ the calories in human milk
• Effect of maternal diet on fat composition
• Fatty acid profile reflects dietary intake of mother
• Very low fat diet with adequate CHO & protein, milk is higher in medium-chain fatty acids 

• Essential for retinal development
• Associated with higher IQ scores

Present in human milk from maternal diet

• Higher in human milk than HMS
• -Part of the membranes in the neural tissue to help develop brain
• Early consumption of cholesterol through breast milk appears to be related to lower blood cholesterol levels later in life

• Total proteins are lower than in whole cow’s milk (0.32 vs. 0.98 g/oz)
• Have antiviral & antimicrobial effects
• Casein
• Whey
• Advantage to have lower protein
• -Excess protein needs to get rid of the excess nitrogen
• Non-protein nitrogen
• ~20-25% nitrogen in human milk
• -Used to make non-essential amino acids

• Main protein in mature human milk
• Facilitates calcium absorption

• A soluble protein that precipitates by acid or enzyme-fluid after milk coagulates
• Some mineral, hormone & vitamin binding proteins are part of it

• Lactose
• Oligosaccharides

• Dominant carbohydrate
• Enhances calcium absorption

• A medium-length carbohydrate
• Prevent binding of pathogenic microorganisms to gut, which prevents infection & diarrhea

• Level linked to milk’s fat content
• Level not adequate to meet needs of preterm infants

• ~5% of breastfed infants at risk for deficiency based on clotting factors
• Infants who did not receive injection at birth may be deficient
• The gut microbes synthesize it
• -Brand new gut so aren’t able to synthesize it

• Content in colostrum is ~double that of mature milk
• Yellow color from beta-carotene

• 25-(OH)D
• Content reflective of mother’s exposure to sun
• You don’t measure the active metabolite because it has a really short half-life
• 25 reflects how much sunlight you get and in your diet
• Regulated by calcitonin, parathyroid hormone

• Caused by vitamin D deficiency and severe protein and energy (caloric) deficiency
• Melanin in skin competes with 7-DHC for UV light, thus decreasing vitamin D synthesis 
• Vitamin D content of human milk is low, however, among most breastfed infants, the combination of breast milk and sunlight exposure provides sufficient vitamin D 

• Occurs mostly in offspring from African-American women who breastfed for an average of 12.5 months
• Growth failure was common as indicated by low height-weight percentiles
• Skin synthesis of vitamin D is less per UV exposure in dark-skinned vs light skinned individuals; requires more UV exposure

• Infants should receive 400 IU of vitamin D in the first few days after birth
• The old requirement was 200 IU by 2 months of age 

• Content reflective of mother’s diet
• Vitamin most likely to be deficient is B6

• Bound to whey proteins
• Low B12 seen in women who:
• -Are vegans or malnourished
• -Have had gastric bypass 

• Contribute to osmolality
• Content related to growth of infant
• Concentration decreases over 1st 4 months, except for magnesium
• Bioavailability
• Most have high bioavailability
• Exclusively breastfed infants have very low risk of anemia despite low iron content of human milk

Bound to protein & highly available

In general, they are not altered by mother’s diet, excepting fluoride

• Protein is lower (9 g vs 35 g/liter)
• Higher in vitamins A, E, C
• Lower in calcium, phosphorus, sodium
• Low in vitamin K and iron
• Higher in immunoglobulins and linoleic acid

Collective number and concentration of solute particles in solution, carried to the kidney for excretion in the urine, usually nitrogen and electrolytes (primarily sodium and potassium)