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Title: WEEK 5


1
Lecture 4, 2006
High Risk Pregnancies Counseling the Pregnant
Woman
2
High Risk Pregnancies
  • Disordered Eating
  • Hypertensive Disorders
  • Gestational Diabetes

3
Disordered Eating Pregnancy Prevalence
  • Few data on prevalence of disordered eating in
    pregnancy
  • Difficult to adequately capture this information
    from women. Women may have needs for secrecy and
    denial so information about history of eating
    disorders is often not given to health care
    providers during pregnancy
  • Some published numbers for disordered eating in
    the population ((Mitchell et al. J midwifery
    womens health, 2006)
  • Prevalence of binge eating disorder 1.2-4.5
  • Prevalence of anorexia nervosa in young females
    is 0.03
  • About 25 of individuals with anorexia nervosa
    develop a chronic course.

4
Diagnostic Criteria Anorexia Nervosa (American
Psychiatric Association)
  • Refusal to maintain body weigh at or above normal
    weight for age and height
  • Intense fear of gaining weight or becoming fat,
    even through underweight
  • Disturbance in the way in which ones body weigh
    or shape is experiences,
  • Undue influence ob body weigh or self-evaluation
    or denial of the seriousness of current low body
    weight
  • In postmenarcheal females, amenorrhea (absence of
    at least three consecutive menstrual cycles)

5
Diagnostic Criteria Bulimia Nervosa (American
Psychiatric Association)
  • Recurrent episodes of binge eating. An episode of
    binge eating is characterized by both of the
    following
  • In a discrete period of time, eating an amount of
    food definitely larger than most people would eat
  • A sense of lack of control over eating during the
    episode
  • Recurrent inappropriate compensatory behavior
    such as self-induced vomiting, misuse of
    laxatives, diuretics, enemas or other
    medications.
  • Binge eating and inappropriate compensatory
    behaviors occur at least twice a week for 3
    months
  • Self-evaluation is unduly influenced by body
    shape and weight
  • The disturbance does not occur exclusively during
    anorexia nervosa.

6
Diagnostic Criteria Not otherwise specified
(American Psychiatric Association)
  • For females, all the criteria for AN are met,
    except that the individual has regular menstrual
    cycles.
  • All criteria for AN is met, except the weight is
    WNL, despite significant weight loss
  • Regular use of inappropriate compensatory
    behaviors in an individual of normal weight after
    eating small amounts of food
  • Repeated chewing and spitting out food, but not
    swallowing
  • Binge-eating disorder recurrent episodes of
    binge eating in the absence of regular use of
    compensatory behaviors characteristic of BN

7
Disordered Eating Pregnancy
  • Results of published studies are inconsistent
  • Developmental tasks of pregnancy are often about
    the same issues that arise in some women with
    eating disorders
  • Body changes
  • Alterations in roles
  • Concerns about a womans own mothering and needs
    for psychological separation.

8
Pregnancy and Eating Disorders A review and
clinical Implications (Franko and Walton, Int.J.
Eating Disorders, 1993)
  • British report on 6 of 327 women who had attended
    eating disorder clinic and got pregnant
  • Median BMI was 16.8 (range 14.9-18.1)
  • Median length of time with AN was 15 years (range
    11-17)
  • Average weight gain was 8 kg (range 5-14)
    -recommendations for low BMI are 13-18
  • Poor third trimester fetal growth was found in
    all 5 babies who were monitored
  • Babies had some catch up in infancy

9
Pregnancy Outcome and Disordered Eating (Abraham
et al J Psychosom Obstet Gynecol, 1994)
  • 24 women reported previous problems with
    disordered eating.
  • These women had higher rates of antenatal
    complications such as IUGR, PIH, edema, GDM,
    vaginal bleeding (plt0.05)
  • These women also were more likely to have infants
    with birthweights lt 25th ile (plt0.02)

10
Bulimia Symptoms and other risk behaviors during
pregnancy in women with Bulimia Nervosa (Crow et
al, Int J Eat Disord, 2004)
  • 129 participants in a long-term follow up study
    of women who had been treated for BN at the
    University of Minnesota
  • 322 pregnancies

11
Crow et al., 2004
12
2 Studies from Sweden.
13
Pregnancy and neonatal outcomes in women with
eating disorders (Kouba et al. Obstet Gynecol,
2005)
  • Recruited women from 13 Swedish prenatal clinics
    screened and diagnosed eating disorders.
  • 68 controls 49 nulliparous, nonsmoking women
    diagnosed with
  • 24 AN
  • 20 BN
  • 5 NOS
  • Mean duration of eating disorders was 9 years
    (range 3-15)
  • 16 (33) of women with hx of eating disorders had
    received TX
  • 11 (22) of women with eating disorders had a
    relapse during pregnancy that led to contact with
    a psychologist or psychiatrist.

14
Kouba, 2005
15
Kouba, 2005
16
Birth outcomes and pregnancy complications in
women with a history of AN (Ekeus et al, BJOG,
2006)
  • Birth register study
  • 1000 primiparous women who were discharged from
    hospital with dx of AN from 1973-1996 who gave
    birth 1983-2002
  • All non AN births (827,582)
  • Birthweights lower (p0.005) in AN group
  • Mean AN, 3387
  • General population mean, 3431
  • Longer hospital say for AN (gt 6 months) not
    associated with different outcomes
  • No difference in SGA and any other negative birth
    outcomes for mother or baby

17
Birth outcomes and pregnancy complications in
women with a history of AN (Ekeus et al, BJOG,
2006)
  • Authors explanation of findings
  • Our findings may be a result of gradual
    improvement in the care process, both AN and
    maternity care.
  • A country with a satisfactory maternity
    surveillance, outcome of pregnancy and delivery
    may be just as good for women with a hx of AN as
    for the general population.
  • OR..the fertility problems associated with AN
    mean that pregnancy will only occur in less
    severe cases

18
Postpartum eating and Body Image for all Women
  • It is of note that in a general population of
    postpartum women, eating disorder behaviors
    increase markedly in the first 3 months
    post-partum and remain high for the next 9
    months.
  • Some women actually first experience clinical
    eating disorders during this time.

19
Eating Habits and Attitudes in the Post Partum
Period (Stein et al. Psychosomatic Med., 1996)
  • N97, prospective cohort study of primip. women
    followed during pregnancy and at 3 and 6 mos pp.
  • Eating Disorder Examination (EDE) restraint,
    eating concern, shape concern, weight concern and
    global scores about state over last 28 days
  • Repeated measures ANOVA indicated that changes in
    eating disorder pathology pp were largely due to
    changes in body weight.

20
Eating Habits and Attitudes in the Post Partum
Period (Stein et al. Psychosomatic Med., 1996)
p lt0.05, plt 0.01, plt0.001
21
An observational study of mothers with eating
disorders and their infants ( Stein et al., J
Child Psychol Psychiat, 1994)
  • 2 groups of primips
  • Index group, women who had met EDE criteria for
    disordered eating during pp period, n34
  • Control group, balanced for SES, age, and childs
    gender, n24
  • At one year
  • EDE
  • Childs growth
  • Structured observation of child and mother at
    task and mealtime

22
Mealtime Behaviors ( Stein et al., J Child
Psychol Psychiat, 1994)
23
Play Behaviors ( Stein et al., J Child Psychol
Psychiat, 1994)
24
Discussion ( Stein et al., J Child Psychol
Psychiat, 1994)
  • Index mothers were more intrusive than control
    mothers
  • About 1/3 of the index infants and one of the
    control infants had growth faltering
  • Regression analysis models to predict infant
    weights were best fit when included
  • maternal height,
  • infant birthweight
  • conflict during meals
  • mothers concern about own body shape

25
www.anred.com
  • You could become depressed and frantic because of
    weight gain during pregnancy. You might feel so
    out of control of your life and body that you
    would try to hurt yourself or the unborn baby.
    You might worry and feel guilty about the damage
    you could be causing the baby.

26
  • Some women with eating disorders welcome
    pregnancy as a vacation from weight worries. They
    believe they are doing something important by
    having a baby and are able to set aside their
    fear of fat in service to the health of the
    child. Others fall into black depression and
    intolerable anxiety when their bellies begin to
    swell. Most fall somewhere between these two
    extremes.

27
  • You might underfeed your child to make her thin,
    or, you might overfeed her to show the world that
    you are a nurturing parent. Power struggles over
    food and eating often plague families where
    someone has an eating disorder. You could
    continue that pattern with your child.

28
  • Motherhood is stressful. If you are not strong in
    your recovery, you will be tempted to fall back
    on the starving and stuffing coping behaviors
    that are so familiar to you. Ideally, as you
    begin raising a family, you will already have
    learned, and will have had practice using, other
    more healthy and effective behaviors when you
    feel overwhelmed.

29
  • Also, eating disordered women make poor role
    models. Your influence could lead your daughters
    to their own eating disorders and your sons to
    believe that the most important thing about women
    is their weight.

30
Clinical Implications
  • Careful screening and monitoring
  • Possible use of self administered, computer
    assisted screening tool
  • Psychotherapy may be indicated
  • Interventions are not evidence based at this
    time, but based on case studies individual
    counselors experiences

31
Clinical Interventions Psychosocial
  • Making the fetus as real as possible to the
    patient very early.
  • Empathetically addressing fears of weight gain
    and feelings of being out of control
  • Assurance about normal weight gain and patterns
    of pp weight loss
  • Education of significant others

32
Clinical Interventions Nutrition
  • Frequent weigh-ins, lectures about weight gain,
    and even well-meaning comments my clinical staff
    can be triggers for increasing the frequency of
    eating disordered behaviors. (Mitchell et al. J
    midwifery womens health, 2006)
  • If appropriate
  • Discuss and provide materials about nutrients and
    food in pregnancy
  • Design individual food plan
  • Determine optimal range of weight gain
  • Discuss hydration shifts in pregnancy and need
    for fluid

33
Clinical Interventions Exercise
  • Assess exercise level
  • Suggest joining exercise groups and new mothers
    groups to normalize experience of weight concerns

34
Clinical Intervention Infant Feeding
  • Offer assistance with parenting concerns
  • Offer information about infant feeding
  • infants ability to self regulate
  • attention to infant cues signals
  • use of food as reward or control mechanism

35
Bulik Hypothesis (Int J Eat Disord, 2005)
  • Preterm birth is associated with threefold
    increase in risk of AN
  • Neurodevelopmental insults in premature infants
    could contribute to delayed oral-motor growth and
    onset of early eating problems.
  • Women with low prepreg BMI inadequate nutrition
    during gestation have increased risk for preterm
    delivery cycle of risk is established.

36
Hypertensive Disorders During Pregnancy
  • Incidence
  • Definitions
  • Etiology/pathophysiology
  • Nutritional Implications

37
N A T I O N A L I N S T I T U T E S O F H E A
L T H N A T I O N A L H E A R T , L U N G , A N D
B L O O D I N S T I T U T E
WORKING GROUP REPORT ON HIGH BLOOD PRESSURE IN
PREGNANCY
July 2000
38
Incidence
  • Second leading cause of maternal mortality in US
  • 15 of maternal deaths (disseminated
    intravascular coagulation, cerebral hemorrhgae,
    hepatic failure, acute renal failure)
  • Hypertensive disorders occur in 6 to 8 of
    pregnancies
  • Contribute to neonatal morbitity and mortality

39
High risk
  • First pregnancy and under age 17 or over 35
  • Family history of hypertension
  • Poor nutritional status
  • Smoking
  • Overweight
  • Other health problems such as renal disease,
    diabetes
  • Multiple gestation
  • Some Fetal anomalies

40
Chronic Hypertension
  • Known hypertension before pregnancy or rise in
    blood pressure to gt 140/90 mm Hg before 20 weeks
  • Hypertension that is diagnosed for the first time
    during pregnancy and that does not resolve
    postpartum is also classified as chronic
    hypertension.

41
Gestational Hypertension
  • Hypertension in pregnancy is present when
    diastolic BP is 90 or greater, systolic BP is 140
    or greater
  • the use of BP increases of 30 mm Hg systolic and
    15 mm Hg diastolic has not been recommended -
    women in this group not likely to have increased
    adverse outcomes
  • ¼ of women with gestational htn advance to
    preeclampsia

42
Preeclampsia
  • Preeclampsia is defined as the presence of
    hypertension accompanied by proteinuria
  • In the absence of proteinuria the disease is
    highly suspect when increased blood pressure with
    headache, blurred vision, and abdominal pain, or
    with abnormal laboratory tests, specifically, low
    platelet counts and abnormal liver enzymes.

43
Proteinuria
  • Proteinuria is defined as the urinary excretion
    of 0.3 g protein or greater in a 24-hour
    specimen.
  • This will usually correlate with 30 mg/dL (1
    dipstick) or greater in a random urine
    determination with no evidence of urinary tract
    infection.
  • because of the discrepancy between random protein
    determinations and 24-hour urine protein in
    preeclampsia it is recommended that the diagnosis
    be based on a 24-hour urine if at all possible

44
Findings that increase the possibility of
Eclampsia and indicate need for FU Severe
Preeclampsia
45
(No Transcript)
46
Edema
47
Dx of Preeclampsia Superimposed on Chronic Htn.
48
Eclampsia
  • Occurrence in a woman with preeclampsia, of
    seizures that can not be attributed to other
    causes
  • Rare 4 of women with preeclampsia advance to
    eclampsia

49
Etiology
  • Not fully understood
  • Primary pathophysiology is placental function
  • Secondary pathophysiology involves endothelial
    cell dysfunction due to factors released because
    of insufficient placental blood supply

50
Characterized by
  • Vasospasm
  • Activation of the coagulation system
  • Perturbations in systems related to volume and
    blood pressure control

51
Pathogenic Mechanisms
  • Delivery is only known cure - research has
    focused on placenta
  • failure of the spiral arteries (terminal branches
    of uterine artery) to remodel
  • alterations in immune response at the maternal
    interface
  • increase in inflammatory cytokines in placenta
    and maternal circulation, natural killer cells,
    and neutrophil activation

52
Pathophysiology
  • Decreased blood flow
  • Decreased renal blood flow, decreased GFR, Na
    retention
  • Tissue hypoxia
  • Damage to organs multi-organ disease affecting
    the liver, kidneys, and brain

53
Pathophysiology
  • Decreased blood volume
  • Decreased placental blood flow may occur 3-4
    weeks before increased BP
  • Hypoxia
  • Decreased nutrient delivery

54
Outcomes
  • Increased LBW and IUGR for infant
  • There is mounting evidence that children born to
    mothers whose blood pressure was elevated during
    pregnancy are at greater risk for elevated blood
    pressure during childhood and adolescence
  • Also long term maternal health may be affected by
    consequences of maternal damage to renal and CV
    systems.

55
Focus of Possible Interventions
  • Smooth muscle contraction
  • Prostaglandin synthesis

56
Calcium
  • Epi studies suggest inverse relation between
    dietary calcium and PIH
  • Intraerythrocyte calcium levels and intracellular
    calcium ion conc. increased in women with
    pre-eclampsia
  • HO Ca supplementation reduced serum parathyroid
    hormone reduced intracellular Ca conc. in
    vascular smooth muscle cells and reduces response
    to pressure stimuli
  • Several RCT have found reduced risk of PIH with
    Ca supplementation to prevent (not treat) PIH.

57
Calcium, cont.
  • Recent meta-analysis found Ca intake of 1.5-2 g
    associated with sig. reductions in systolic and
    diastolic BP without adverse effects.
  • Question remains does lowering BP have effect on
    pathophysiology of PIH?

58
Cochrane Calcium supplementation during
pregnancy for preventing hypertensive disorders
and related problems (2006)
  • 12 studies met criteria
  • Randomized trials comparing at least one gram
    daily of calcium during pregnancy with placebo.
  • RR of high blood pressure with Ca supplements
    0.70 (95 CI, 0.57-0.86)
  • RR of preeclampsia with Ca supplements 0.48
    (95 CI, 0.33-0.69)

59
Cochrane Calcium supplementation during
pregnancy for preventing hypertensive disorders
and related problems (2006)
  • 5 trials of Ca supplements in high risk women
  • RR 0.22 (95 CI, 0.12-0.42)
  • 7 trials in women with low baseline Ca
  • RR 0.22 (95 CI, 0.18-0.70)

60
Cochrane Calcium supplementation during
pregnancy for preventing hypertensive disorders
and related problems updated 2006
  • Reviewers conclusions
  • Calcium supplementation appears to almost halve
    the risk of pre-eclampsia, and to reduce the rare
    occurrence of the composite outcome 'death or
    serious morbidity'. There were no other clear
    benefits, or harms.

61
Cochrane Magnesium supplementation in
pregnancy updated 2001
  • There is not enough high quality evidence to show
    that dietary magnesium supplementation during
    pregnancy is beneficial.

62
Omega-3 Fatty Acids In Maternal Erythrocytes and
Risk of Preeclampsia (Williams et al,
Epidemiology, 1995)
  • Theory
  • Ratio of omega 6 and omega 3 fa may modify
    processes related to PIH such as platelet and
    leukocyte reactivity, vasodilation, and
    inflammatory processes.
  • Study design
  • small case control, n22 cases, 40 controls
  • adjusted for parity and pre-pregnancy BMI

63
Omega-3 Fatty Acids In Maternal Erythrocytes and
Risk of Preeclampsia (Williams et al,
Epidemiology, 1995)
  • Results
  • Women with the lowest tertile of n-3 in
    erythrocytes had odds ratio of 7.6 (95
    CI1.4-40.6) for developing preeclampsia.

64
Cochrane Marine oil, and other prostaglandin
precursor, supplementation for pregnancy
uncomplicated by preeclampsia or intrauterine
growth restriction (2006)
  • 6 trials
  • No clear difference in the RR of preeclampsia
    between groups
  • 2 trials, lower risk of giving birth before 34
    weeks
  • RR 0.69 (95 CI 0.49-0.99)

65
Antioxidants and Preeclampsia Definitions
  • Antioxidants any substance that, when present in
    low concentrations compared to that of an
    oxidizable substrate, significantly delays or
    inhibits oxidation of that substrate
  • Free radical scavengers include vitamin C
    (ascorbate), vitamin E (tocopherols), carotenoids
  • Antioxidant enzymes include glutathione
    peroxidase, superoxide dismutase and catalase,
    which are dependent on the presence of co-factors
    such as selenium, zinc and iron

66
Antioxidants and Preeclampsia Possible Mechanisms
  • Placental underperfusion may mediate a state of
    oxidative stress.
  • Oxidative stress, coupled with an exaggerated
    inflammatory response, may result in the release
    of maternal factors that result in inappropriate
    endothelial cell activation and endothelial cell
    damage
  • Supplementing women with antioxidants may
    increase their resistance to oxidative stress,
    and hence could limit the systemic and
    uteroplacental endothelial damage seen in
    pre-eclampsia

Cochrane, 2005
67
Cochrane Antioxidants for preventing
pre-eclampsia (2005)
  • 7 trials involving 6082 women
  • Only 3 of 7 were rate high quality
  • All randomized and quasi-randomized trials
    comparing one or more antioxidants with either
    placebo or no antioxidants during pregnancy for
    the prevention of pre-eclampsia, and trials
    comparing one or more antioxidants with another,
    or with other interventions.

68
Cochrane Antioxidants for preventing
pre-eclampsia (2005)
  • Supplementing with any antioxidants during
    pregnancy compared to control
  • RR of preeclampsia 0.61 (95 CI, 0.50,0.70)
  • RR SGA 0.64 (95 CI, 0.47,0.87)
  • Increased risk of preterm birth RR 1.38 (95 CI,
    1.04,1.82)

69
Cochrane Antioxidants for preventing
pre-eclampsia (2005)
  • These results should be interpreted with
    caution, as most of the data come from poor
    quality studies. Nevertheless, antioxidant
    supplementation seems to reduce the risk of
    pre-eclampsia. There also appears to be a
    reduction in the risk of having a
    small-for-gestational-age baby associated with
    antioxidants, although there is an increase in
    the risk of preterm birth. Several large trials
    are ongoing, and the results of these are needed
    before antioxidants can be recommended for
    clinical practice.

70
Other Nutrition Related Factors
  • Na Pregnant women with proteinuric hypertension
    have lower plasma volume Na. restriction is
    associated with accelerated volume depletion
    not recommended
  • Energy and Protein intake increases not found
    to be useful
  • Weight reduction or limited gain in pregnancy
    not found to be useful

71
Position StatementGestational Diabetes Mellitus
American Diabetes Association2004
72
Definition
  • Gestational diabetes mellitus (GDM) is defined as
    any degree of glucose intolerance with onset or
    first recognition during pregnancy. The
    definition applies whether insulin or only diet
    modification is used for treatment and whether or
    not the condition persists after pregnancy. It
    does not exclude the possibility that
    unrecognized glucose intolerance may have
    antedated or begun concomitantly with the
    pregnancy.

73
Prevalence
  • 7 of all pregnancies are complicated by GDM in
    US
  • more than 200,000 cases annually in US
  • prevalence may range from 1 to 14 of all
    pregnancies, depending on the population studied
    and the diagnostic tests employed.

74
Diagnosis
  • Assess risk at first visit
  • If high risk (marked obesity, personal history of
    GDM, glycosuria, or a strong family history of
    diabetes) GTT ASAP
  • Women of average risk should have testing
    undertaken at 2428 weeks of gestation
  • Low-risk status requires no glucose testing

75
Low Risk Criteria
  • Age lt25 years
  • Weight normal before pregnancy
  • Member of an ethnic group with a low prevalence
    of GDM
  • No known diabetes in first-degree relatives
  • No history of abnormal glucose tolerance
  • No history of poor obstetric outcome

76
Non GTT dx
  • A fasting plasma glucose level gt126 mg/dl (7.0
    mmol/l) or a casual plasma glucose gt200 mg/dl
    (11.1 mmol/l) meets the threshold for the
    diagnosis of diabetes, if confirmed on a
    subsequent day, and precludes the need for any
    glucose challenge

77
One-step Approach
  • Perform a diagnostic oral glucose tolerance test
    (OGTT) without prior plasma or serum glucose
    screening
  • May be cost-effective in high-risk patients or
    populations (e.g., some Native-American groups).

78
Two-step approach
  • Initial screening by measuring the plasma or
    serum glucose concentration 1 h after a 50-g oral
    glucose load
  • Diagnostic OGTT on that subset of women exceeding
    the glucose threshold value on the GCT

79
Table 1 Diagnosis of GDM with a 100-g oral
glucose load
mg/dl mmol/l

Fasting 95 5.3
1-h 180 10.0
2-h 155 8.6
3-h 140 7.8
Two or more of the venous plasma concentrations
must be met or exceeded for a positive diagnosis.
The test should be done in the morning after an
overnight fast of between 8 and 14 h and after at
least 3 days of unrestricted diet ( 150 g
carbohydrate per day) and unlimited physical
activity. The subject should remain seated and
should not smoke throughout the test.
80
Infant Concerns in GDM
  • Higher risk of
  • neural tube defects
  • birth trauma
  • hypocalcemia
  • hypomagnsemia
  • hyperbilirubinemia
  • prematurity syndromes
  • subsequent childhood and adolescent obesity and
    risk of diabetes

81
Infant Concerns, cont.
  • Macrosomia in infant due to high glucose levels
    from mother and fetal insulin response leading to
    increased fat deposition, associated with
    complications at delivery.
  • Hypoglycemia of infant following delivery due to
    high fetal insulin levels at delivery and sudden
    withdrawal of maternal glucose transfer

82
Maternal Concerns
  • Higher risk of
  • hypertension
  • preeclampsia
  • urinary tract infections
  • cesarean section
  • future diabetes

83
Nutritional Therapy in GDM
  • Goals
  • prevent perinatal morbidity and mortality by
    normalizing the level of glycemia
  • prevent ketosis
  • provide adequate energy and nutrients for
    maternal and fetal health
  • dependent on maternal body composition

84
Monitoring
  • Daily self-monitoring of blood glucose (SMBG)
  • Urine glucose monitoring is not useful in GDM.
    Urine ketone monitoring may be useful in
    detecting insufficient caloric or carbohydrate
    intake in women treated with calorie restriction.

85
Monitoring
  • Blood pressure and urine protein monitoring to
    detect hypertensive disorders.
  • Increased surveillance for pregnancies at risk
    for fetal demise is appropriate
  • Assessment for asymmetric fetal growth by
    ultrasonography to assess need for insulin

86
Nutrition Management
  • All women with GDM should receive nutritional
    counseling, by a registered dietitian when
    possible
  • For obese women (BMI gt30 kg/m2), a 3033 calorie
    restriction (to 25 kcal/kg actual weight per
    day) has been shown to reduce hyperglycemia and
    plasma triglycerides with no increase in
    ketonuria
  • Restriction of carbohydrates to 3540 of
    calories has been shown to decrease maternal
    glucose levels and improve maternal and fetal
    outcomes

87
Insulin
  • Insulin therapy is recommended when MNT fails to
    maintain self-monitored glucose at the following
    levels
  • Fasting whole blood glucose 95 mg/dl (5.3
    mmol/l)
  • Fasting plasma glucose 105 mg/dl (5.8 mmol/l)
  • 1-h postprandial whole blood glucose 140 mg/dl
    (7.8 mmol/l)
  • 1-h postprandial plasma glucose 155 mg/dl (8.6
    mmol/l)
  • 2-h postprandial whole blood glucose 120 mg/dl
    (6.7 mmol/l)
  • 2-h postprandial plasma glucose 130 mg/dl (7.2
    mmol/l)
  • Oral glucose-lowering agents have generally not
    been recommended during pregnancy

88
Exercise
  • Programs of moderate physical exercise have been
    shown to lower maternal glucose concentrations in
    women with GDM

89
Long Term
  • Reclassification of maternal glycemic status
    should be performed at least 6 weeks after
    delivery
  • If glucose levels are normal post-partum,
    reassessment of glycemia should be undertaken at
    a minimum of 3-year intervals
  • education regarding lifestyle modifications that
    lessen insulin resistance, including maintenance
    of normal body weight through MNT and physical
    activity.

90
Long Term
  • Avoid medications that worsen insulin resistance
    (e.g., glucocorticoids, nicotinic acid)
  • Seek medical attention if develop symptoms
    suggestive of hyperglycemia.
  • Use family planning to assure optimal glycemic
    regulation from the start of any subsequent
    pregnancy

91
Counseling the Pregnant Woman
92
General strategies for providing effective
nutritional care
  • Assess nutritional status
  • anthropometric
  • biochemical
  • social
  • medical
  • dietary

93
Dietary Assessment Selection of Methods
  • Avoid collecting information that wont be used
  • What is the language skill and literacy level of
    the woman?
  • How will I use the information? How accurate and
    detailed does it need to be?
  • What is the standard that will be used for
    comparison?
  • What resources do I have for collecting,
    analyzing and interpreting the data?

94
Essential Steps for Patient Education (IOM
Implementation Guide)
  • Identify the problem(s)
  • Develop a tentative clinical objective
  • Discuss objective with the woman
  • If woman does not perceive as a problem offer
    personalized information

95
Essential Steps for Patient Education (IOM
Implementation Guide) Cont.
  • With the woman
  • Identify behaviors that support or impede
    achievement of the clinical objective
  • Assess barriers to behavioral change strategize
    about removing barriers
  • Plan one or two behavior changes
  • Help to reduce barriers with referrals or
    information
  • Offer feedback and reinforcement for success

96
Referrals to Food and Nutrition Programs
  • WIC
  • Temporary emergency food assistance program or
    food banks
  • Food stamp program
  • Cooperative Extension- Expanded Food and
    Nutrition Program

97
Family Food Hotline
  • http//www.familyfoodline.org/
  • Order outreach cards
  • 1-888-4-food-wa

98
Cultural factors affecting diet and pregnancy
outcome in Mexican-Americans (Gutierrez, J. J
Adolesc Health. 1999 Sep25(3)227-37.
  • N48 primigravida adolescents aged 13-18 who self
    identified as Mexican-American.
  • Questions
  • In some parts of Mexican culture food is
    classified into hot such as pork or cold such
    as fruit juices to balance good health. Do you
    practice or follow such classification?
  • Some people believe that cravings during
    pregnancy should be satisfied or the infant may
    be marked by whatever food was craved. What do
    you think?

99
Cultural factors affecting diet and pregnancy
outcome in Mexican-Americans (Gutierrez, J of
Adolescent health, in press)
  • Questions (cont.)
  • Some people believe that nausea and vomiting
    during pregnancy should be treated by drinking
    flour and water, cornstarch and lemon juice, or
    chamomile tea. What do you think?
  • Do you believe that heartburn is caused by eating
    chili?
  • Some people believe that during pregnancy, if the
    woman sleeps too much it causes the baby to stick
    to the uterus. What do you think?

100
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101
Seven Domains of Cultural Competence
  • Cultural Competence A Journey
    http//www.bphc.hrsa.gov/culturalcompetence/Defaul
    t.htm1

102
1. Values and attitudes
  • Promoting mutual respect . . . awareness of
    the varying degrees of acculturation . . . a
    client-centered perspective . . . acceptance that
    beliefs may influence a patients response to
    health, illness, disease and death. . .

103
2. Communications styles
  • Sensitivity . . awareness . . . knowledge . .
    . alternatives to written communication .

104
3. Community/consumer participation
  • Continuous, active involvement of community
    leaders and members . . . involved participants
    are invested participants, health outcomes
    improve. .

105
4. Physical environment, materials, resources
  • Culturally and linguistically friendly
    interior design, pictures, posters, and artwork
    as well as magazines, brochures, audio, videos,
    films. . . literacy sensitive print information .
    . . congruent with the culture and the language .
    . .

106
5. Policies and procedures
  • Written policies, procedures, mission
    statements, goals, objectives incorporating
    linguistic and cultural principles . . . clinical
    protocols, orientation, community involvement,
    outreach. . . multicultural and multilingual
    staff reflecting the community . .

107
6. Population-based clinical practice
  • Culturally skilled clinicians avoid
    misapplication of scientific knowledge . . .
    avoid stereotyping while appreciating the
    importance of culture . . . know their own world
    views . . . learn about populations . . .
    understand sociopolitical influences . . .
    practice appropriate intervention skills and
    strategies . .

108
7. Training and professional development
  • Requiring training . . . nature of cultural
    competence training . . duration and frequency of
    professional development opportunities . . .

109
Ethnomed
  • http//healthlinks.washington.edu/clinical/ethnome
    d/

110
Southeast Asian
Traditional practices are heavily based in
concepts of "hot" and "cold" conditions. Younger
women may no longer follow traditional practices
but the family (mother or mother-in-law) may
insist on following traditions and it is
important to understand how an individual woman
and the greater family compromise.
111
Southeast Asian Pregnancy Foodways - Ethnomed
  • "Cold" foods are needed for the "hot" condition
    of pregnancy according to Chinese categories.
  • There are a wide range of foods which are felt
    beneficial or harmful between cultural groups.
  • Bean sprouts/green peas avoided - thought to
    cause SAB (Vietnamese)
  • Homemade rice wine, herbal medicines, coconut
    juice are taken to help give the baby good
    quality skin. Beer is thought to make the
    delivery easier (Cambodian)
  • Drinking milk and gaining too much weight will
    make baby fat and difficult to deliver (all SE
    Asian)

112
Southeast Asian Postpartum Foodways - Ethnomed
  • Maternal diet balanced between "hot" (alcohol,
    ginger, black pepper some high protein) and
    "cold" (fruits, vegetables, some seafood). No
    sour foods (cause incontinence), no raw foods.
    Pork felt very nutritious.
  • Cold ice water offered post delivery in the
    hospital may be seen as unhealthy.
  • Inability to follow traditional post-partum
    practices is thought to cause later health
    problems, especially abdominal pain in women
    (which may occur months or even years later).
    Once a woman becomes sick from symptoms thought
    due to violation of "d'sai kchey", she is sick
    for the rest of her life. (Cambodian)

113
East Africa Pregnancy Foodways- Ethnomed
Related women and women within a neighborhood
have very strong ties among each other in East
African communities. In some cultures, such as
that of ethnic groups from Ethiopia, women have a
daily coffee ritual where they gather each day in
homes to share coffee and talk. This daily
gathering of women established support networks
for pregnancy, postpartum help, and child care.
114
East Africa Pregnancy Foodways- Ethnomed
  • Women try to have good nutrition and particularly
    may increase meat in their diet.
  • Flax seed flour is mixed with warm water before
    delivery and drunk by the woman to help produce
    an easy delivery.

115
East African Post-Partum Foodways - Ethnomed
  • Traditionally women rest in bed for 40 days
    postpartum and are attended by other women who
    prepare nutritious food and do housework.
  • Special teas, soups, and porridge are provided
    for the mother.
  • Flax seed porridge with honey is commonly given
    to mothers post-partum.

116
Adolescent Development (Drake P. J Obset.
Gynacol. Neonatal Nursing, 1996)
117
Adolescent Development (Drake P. J Obset.
Gynacol. Neonatal Nursing, 1996)
118
Responding to Developmental Differences of
Adolescence Goal Setting
119
Responding to Developmental Differences of
Adolescence Professional Approaches
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