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.

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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.

Proteins – Proteins are the building blocks that help promote fetal growth as well as support the changes in the uterine and breast tissue and blood supply in the mother. Most experts recommend between 75-100 grams of protein a day. This can be divided into three servings a day. Either three ounces of meat (size of a deck of cards) or a half cup of legumes (chick peas, black beans etc.) is considered one serving of protein. Other examples of foods that contain protein include milk, cottage cheese, yoghurt, eggs, cheese and fish. For vegetarians, consider recommending foods such as peanut butter, whole wheat grains which count as a half serving of protein, and nuts.

Fruits/Vegetables – Many fruits and vegetables contain vitamin A, which is important for cell growth and healthy skin, bones and eyes. As with non-pregnant women, the daily recommended intake is five to six servings daily. Examples include mango, canteloupe, broccoli, spinach, yams, tomatoes and bell peppers.

Whole grains and Legumes – There are a wide variety of whole grains which include whole wheat, rye, oats, bulgur and quinoa. Legumes such as peas, beans and peanuts are also dense with nutrients. Whole grains and legumes are the foundation of many meals. Six or more servings daily are typically recommended. This can be in the form of whole wheat toast, cereals, brown rice, whole grain pasta, and cooked beans.

Calcium – Calcium is necessary to help the development of the baby’s bones and tooth buds, in addition to muscle, heart and nerve growth. It is recommended that pregnant women take 1000-1200 mg of calcium a day, which can be divided into four servings daily. Calcium rich foods include cheese, milk, yoghurt, calcium fortified orange juice, salmon and cooked greens.

Iron – Iron is essential in helping to expand blood volume and preventing anemia. Eating iron with foods that contain a high amount of vitamin C helps the absorption by the body. The recommended daily amount of iron consumption during pregnancy is 27 milligrams. Some of this is in the foods that are eaten, and also in a pre-natal vitamin. However, some women with inadequate iron stores prior to pregnancy may need additional iron supplementation from that found in ingested food and a pre-natal vitamin. Examples of iron rich foods include spinach, beef, beans, soy products and seaweed.

Folate – Folate is instrumental in helping to prevent neural tube defects. Folic acid is found in a variety of foods including dark green leafy vegetables, fruit, whole grains and legumes. The recommended daily intake is 400 micrograms or 0.4 milligrams. Despite many foods containing folic acid, it may be difficult to consume the entire amount. Thus, a supplement is recommended to ensure adequate intake.

Vitamin C – Vitamin C is necessary to help aid in wound healing, tissue repair, tooth and bone development and general metabolic processes. Since the body cannot store vitamin C, it is important to ensure the recommended intake of three servings daily. Vitamin C is found in a variety of foods, namely fruits and vegetables. Some examples include orange and orange juice, strawberries, kiwis, raspberries, broccoli, and edamame.

Fats – While fats notoriously have a bad reputation as overindulgence can lead to excessive weight gain, it is equally important to recognize the importance of certain fats in the diet that support healthy brain and eye development. Some omega three fatty acids such as DHA are even being taken as supplements during pregnancy and lactation to help assist in brain growth. A pregnant woman needs 56 grams of fat a day, which is often found in foods eaten throughout the day. Examples of fat include olive oil, butter, mayonnaise, cream cheese and peanut butter.

Vitamin D – Low vitamin D in take can lead to slight reduction in birth weight. The recommended daily allowance is 5 micrograms, or 200 international units, often found in a prenatal vitamin.

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?

Seafood high in mercury- While seafood such as fish and shellfish are good sources of protein and omega 3 fatty acids, some fish contain a disproportionately high level of mercury, which can lead to severe central nervous system damage. The fish which have a higher incidence of mercury contamination and should thus be avoided during pregnancy includeshark,swordfish,king mackerelandtilefish

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.

Raw or undercooked seafood – Raw or undercooked seafood can harbor bacteria or microbes that can cause food poisoning. More concerning, however, is the possibility of being infected with a parasite, which is more difficult to treat in pregnancy. The parasites can take important nutrients away from the baby. Cooked sushi such as that made with eel, crab, anything tempura coated and vegetable sushi is considered safe to eat. Of note, “sushi grade” raw fish that has undergone a freezing process generally clears any potential bacteria or parasites and is generally safe to eat.

Undercooked eggs – There is a higher risk for salmonella and from other food borne illnesses from undercooked eggs and meat. The immune system is weaker during pregnancy so a simple food poisoning can lead to more severe vomiting, diarrhea and dehydration then when not pregnant.

Raw or undercooked meat – Ingestion of undercooked meat can lead to Toxoplasmosis, which can also be caused by unwashed fruits and vegetables, soil contaminated fruits and vegetables or ingestion of undercooked or cured meat. Raw and undercooked meat can also cause Brucellosis.

Anything that can contain Listeria – Listeria is found in processed deli meats, pate, hot dogs, soft cheeses, smoked seafood and meat spreads. Listeria is usually killed off during the heating process, but these foods are often kept at room temperature and thus pose a higher risk to the pregnant woman.

Unpasteurized Foods – Soft cheeses such as feta, goat cheese, Brie, Camembert, blue cheese, and Mexican queso fresco or queso blanco are more likely not to have undergone the pasteurization process, which kills of the potential pathogen Listeria. Listeria infection carries a higher risk of miscarriage and pre-term delivery.

Unwashed Fruits and Vegetables – These can cause toxoplasmosis, as mentioned above.

What lifestyle habits should a woman modify before and during pregnancy?

Substance Abuse – Alcohol, cigarettes and illegal drugs can seriously affect the health of the fetus. When a woman drinks alcohol it interferes with a fetus’ ability to get enough oxygen and nourishment for normal cell development in the brain and other body organs.

Alcohol – At this time, there is no known ‘safe’ amount of alcohol consumption during pregnancy. Alcohol can interfere with the fetus’ ability to get enough oxygen and nourishment for proper growth and can result in Fetal Alcohol Syndrome (FAS). FAS is a syndrome with a wide range of manifestations including physical deformities, mental deficencies and developmental and behavioral problems. In addition to problems with the baby, excessive alcohol consumption can also increase risk of miscarriage, premature labor, low birthweight, stlilbirth and problems with labor and delivery.

Cigarette smoking – Smoking is known to cause miscarriages and even infant death. The fetus does not have enough oxygen and it cannot grow appropriately. Low birthweight is a major cause of infant morbidity and mortality. These babies are at increased risk of SIDS (sudden infant death syndrome).

Marijuana – Marijuana use can have a wide range of effects on both the fetus and the pregnancy as a whole. Marijuana use can cause genetic damage leading to birth defects or cancer, as well as behavioral problems and a fetal alcohol type syndrome.

Cocaine – The main effect of cocaine is the restriction of blood flow to the fetus and subsequent retardation of fetal growth. It can also cause miscarriage, premature labor and stillbirth. Ultimately, it is responsible for long term sequelae on a child including neurological and behavioral problems, motor deficits and cognitive impairments. Any woman who continues to engage in cocaine or other illicit drug use is threatening the well being of her child and should seek help immediately.

What else may a pregnant woman be concerned about?

Caffeine – More than two to three cups of coffee per day can lead to miscarriage, pre-term delivery and low birth weight infants. It is important to keep in mind that caffeine is also found in sodas, tea and chocolate, and dark brews may contain more caffeine than a home made cup. It is important to keep consumption below 200 milligrams per day.

Herbal Tea – The effects of herbs in pregnancy have not been well studied. Herbs can act like medicine on the body, and there is no way to regulate the amount found in herbal teas. For this reason, the FDA suggests steering clear of any herbal teas, especially any with chamomile and hibiscus as they can lead to pre-term labor. It is better to drink black (caffeine free) tea and add fresh fruits to achieve the desired flavor.

Sugar Substitutes – While there is no evidence that aspartame (Nutrasweet), sucralose (Splenda), acesulfame-K (Sunnette), sorbitol, mannitol or lactose increases the risk of pregnancy related complications or birth defects, they are generally not a healthy choice compared to other alternatives. Saccharin (Sweet ‘N Low) has been shown to increase the risk of bladder cancer in the offspring of pregnant rats, but it is unclear if a similar risk if present among humans. In addition, this sweetener crosses the placenta and is eliminated very slowly from fetal tissue, suggesting it is best to avoid it if possible.

Vegetarian Diets – Generally vegetarians and vegans can have healthy pregnancies. Few key dietary components such as adequate protein, calcium, vitamin B12 and vitamin D need to be ingested in non-meat forms, or a vitamin supplement can be taken if dietary sources are deemed to be insufficient.

Spicy foods – There is no risk to the pregnancy by eating spicy foods. However, ingestion can lead to significant heartburn and indigestion, which can compound these already increased symptoms during pregnancy.

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.