Nutrition Management During Pregnancy and LactationManual of Clinical Nutrition Management A- 19 Copyright © 2013 Compass Group, Inc.
Treatment of hyperemesis gravidarum depends on the risk level of the patient and the severity of
symptoms, such as dehydration and the inability to meet nutrition needs orally. Intensive nutrition
counseling and individualized meal planning is the first line of treatment (24, 25 ). If nutrition and behavior
modification does not alleviate symptoms, medications, such as metoclopramide (Reglan) and ranitidine
(Zantac), or antiemetic drugs, such as prochlorperazine (Compazine) and ondansetron (Zofran), are often
prescribed ( 26 ). Patients with severe symptoms may require hydration with intravenous fluids, electrolyte
replacement, or vitamin replacement with vitamin B 6 (pyridoxine) and vitamin B 1 (thiamin) (25,26). If patients
do not achieve the DRIs for thiamin (1.4 mg/day) and pyridoxine (1.9 mg/day) during pregnancy, dietary
supplementation should be provided (25). A small percentage of patients with hyperemesis gravidarum may
require nasogastric, gastrostomy, or jejunostomy feedings or total parenteral nutrition to ensure adequate
nutrition support. Only 2% to 5% of women with hyperemesis gravidarumrequire total parenteral nutrition
( 25 ). Nearly all of the literature regarding nutrition support during pregnancy is anecdotal, consisting of case
studies. Treatment and intervention strategies are based on experience and patient needs. If nutrition
support is indicated, treatment should be consistent with standards outlined for nonpregnant adults or in
managing coexisting medical conditions or risks (eg, refeeding syndrome). Refer to Section IB: Specialized
Nutrition Support and to Specific Nutrient Requirements During Pregnancy earlier in this section.
Obesity
Obesity in pregnancy not only increases risks for pregnant women during gestation, but also increases risks
for the future health of the child (27). Obesity during pregnancy has been associated with gestational diabetes,
gestational hypertension, pre-eclampsia, birth defects, Cesarean delivery, fetal macrosomia, perinatal deaths,
postpartum anemia, and childhood obesity (27,28). More women are beginning pregnancy with high BMI’s, and
more are gaining weight in excess of the 1990 Institute of Medicine (IOM) recommendations for gestational
weight gain (27). Overweight and obese women are more likely to maintain excess weight with each
successive pregnancy. Those who gain more are more likely to retain it and continue at a higher weight
throughout their lifetime, as compared to women who gain less weight during pregnancy (27, 28). Weight gain
during pregnancy has also been shown to have implications for the child’s future risk of being overweight (1,
27,28). It is the position of The Academy of Nutrition and Dietetics and the American Society for Nutrition that
all overweight and obese women of reproductive age should receive counseling prior to pregnancy, during
pregnancy, and in the interconceptional period on the roles of diet and physical activity in reproductive
health (27). During pregnancy overweight and obese clients should target IOM gestational weight gain targets,
be advised not to lose weight during pregnancy, and counseled about healthful eating habits (27). In addition
encouragement should be given to breastfeed and be made aware of the benefits for both the mom’s and her
child’s health (27).
Gestational Hypertension (3)
Gestational hypertension is defined as systolic blood pressure of 140 mm Hg or greater or diastolic blood
pressure of 90 mm Hg or greater with onset after 20 weeks’ gestation ( 29 ). About 25% of women with
gestational hypertension will develop preeclampsia, which is characterized by proteinuria (> 300 mg in a 24 -
hour urine sample). Preeclampsia occurs more often in primigravid women and in women older than 35
years with chronic hypertension or renal disease.
Gestational hypertension is associated with marked changes in renal function that may lead to excessive
extracellular fluid retention. Preeclampsia accompanied by grand mal seizures is a condition called eclampsia
(3,2 9 ). Preeclampsia usually occurs after the 20th week of conception. Preeclampsia is more common in
women with chronic hypertension and renal disease, adolescents, underweight women with inadequate
weight gain, women who are older than 35 years, obese women, women with a history of preeclampsia, and
women who are carrying multiple fetuses (3).
No specific nutrition therapy has been proven to be effective in preventing or delaying preeclampsia and
improving pregnancy outcomes (3, 29 ). Adequate calcium, protein, energy, and potassium may be necessary. A
meta-analysis of 17 randomized controlled trials concluded that calcium supplements (1 to 2 g/day) reduced
blood pressure and the risk of preeclampsia but had no significant effect on reducing maternal and infant
morbidity and mortality ( 30 ). Studies of other nutrients, such as vitamins C and E, have yielded inconclusive
results. The efficacy of dietary modifications, including sodium restriction, magnesium supplements, zinc
supplements, and consumption of fatty fish oils, has not been proven (3, 31 ). Diuretics should be avoided unless
strict medical supervision is provided.