Hospital Medicine
Nutrition and Pregnancy
I. Problem/Challenge.
As hospitalists, we often care for patients who do not have regular follow up with primary care providers. As part of an admitted patient's evaluation, we may uncover an underlying pregnancy that a patient may or may not have been aware of. It is important that we are familiar with the basics of pre-natal counseling. In particular, a general approach to a patient's nutrition during pregnancy will not only prove to be practical, but the information provided can also help bridge the patient from their hospital admission to when they are able to obtain an appointment to see an obstetrician.
Eating healthy should be a part of every woman's life, and is especially important during pregnancy. Good nutrition with special dietary modifications should ideally begin prior to conception and continued throughout pregnancy and lactation. All women of child-bearing age should be educated on the importance of certain key nutrients. In addition, women should be counseled to avoid potential toxins in the event of pregnancy, as the fetus is most at risk in the first trimester, when women may not recognize that they are pregnant.
II. Identify the Goal Behavior.
The hospitalist can play a key role prior to and during a woman's pregnancy. By focusing on a few key areas of interest, a patient can make drastic changes to help ensure a healthy pregnancy.
Firstly, pregnancy can be determined with either a home or office pregnancy test, which measures HCG, human chorionic gonadotropin.
Once the desire to become pregnant or actual pregnancy is confirmed, the hospitalist's main contribution will focus on counseling on basic nutritional health. This includes the basics of a healthy diet, foods that should be avoided, key nutrients, substance abuse and general other concerns that arise during pregnancy.
III. Describe a Step-by-Step approach/method to this problem.
What are the basics of a healthy diet?
Eating healthy foods during pregnancy is one of the main ways to help ensure adequate birth weight, brain development and reduced risk for birth defects. During pregnancy, a balanced diet should include carbohydrates, proteins, fat, minerals and vitamins.
Telling patients to "drink more milk" or "eat more protein" tend to be less effective ways to improve nutritional intake. Concrete examples such as "1 cup of milk is one serving of calcium" or "3 ounces of meat, which is the size of a deck of cards, is one serving of protein" can help patients achieve their nutritional goals.
How much weight should a woman gain during pregnancy?
This is one of the most frequently asked questions to obstetricians. The answer depends on the patient's pre-pregnancy weight status. An underweight woman (BMI less than 18.5), should gain an average of 28-40 pounds. A normal weight woman (BMI 18.5-24.9) should gain between 25-35 pounds. An overweight woman (BMI 25-29.9) should gain between 15-25 pounds. Finally, the recommendations for an obese woman (BMI 30 or greater), are to gain no more than 11-20 pounds. These are general guidelines and may vary from case to case, but ideally the large range within each weight class is representative of the variations that may occur.
While it is important to eat well to accommodate a growing baby and the physiological changes that are taking place during pregnancy, it is a common misconception that women should now be eating for two people. In reality, increasing nutrient intake by 300 calories a day in the second and third trimester should be adequate in most cases.
A typical woman will gain 3-4 pounds during the first trimester, a pound a week during the second trimester for a total of 12-14 pounds and finally about a pound a week in the third trimester until the ninth month when there may be very little weight gained for total of 8-10 pounds during the third trimester.
Which foods should a pregnant woman avoid?
Albacore (white) tuna has more mercury than light canned tuna, so consumption should be limited to no more than six ounces per week (one meal). Tuna steaks should also be limited to six ounces per week, although some physicians recommend that tuna steaks be avoided all together as large tuna can have higher mercury levels. This is in contrast to canned tuna, which is typically made from smaller fish.
Fish considered to have low levels of mercury contamination and thus be safe for consumption during pregnancy include shrimp, salmon, pollock, and catfish.
What lifestyle habits should a woman modify before and during pregnancy?
What else may a pregnant woman be concerned about?
IV. Common Pitfalls.
Hospitalists often feel ill equipped to care for and counsel women who are considering pregnancy or are already pregnant. Recognizing that there are a few main points to consider, hospitalists can be key to establishing proper nutritional habits early on when it can make the most difference.
V. National Standards, Core Indicators and Quality Measures.
According to the American Congress of Obstetricians and Gynecologists, women of child bearing age who are considering pregnancy would ideally be taking 400 micrograms of the B vitamin folic acid prior to conception and for at least the first 12 weeks of pregnancy to help reduce the risk of neural tube defects.
In addition, ACOG has general recommendations for adequate weight gain based on a woman's weight prior to pregnancy.
The United States Preventative Task Force recommends that women take a folic acid supplement of 0.4 to 0.8 mg per day preconceptionally and during the first trimester. For women at increased risk for a child with neural tube defects (prior offspring with a neural tube defect or maternal use of anticonvulsants) should take 4 milligrams per day.
The Institute of Medicine supports an increased total calorie intake of 340 calories per day in the second trimester and 452 calories in the third trimester.
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