Prenatal Nutrition: Background, Weight Gain and Pregnancy, Diet in Pregnancy 30/09/15 4:27 p.m.

Prenatal Nutrition
Author: Serdar H Ural, MD; Chief Editor: Christine Isaacs, MD more...

Updated: Mar 06, 2015

Background
The fields of obstetrics and nutrition have changed over the last few decades,
greatly affecting the field of prenatal nutrition. The importance of nutrition in
pregnancy cannot be overstated. It maintains maternal energy requirements,
provides substrate for the development of new fetal tissues, and builds energy
reserves for postpartum lactation. Recommendations for prenatal nutrition have
traditionally been directed at 2 clinical arenas, weight gain in pregnancy and
dietary intake in pregnancy.

For patient education resources, see the Women's Health Center and Pregnancy
and Reproduction Center, as well as Prenatal Planning and Breastfeeding.

Weight Gain and Pregnancy

An infant's birth weight is affected by many factors, including the mother's
prepregnancy weight-for-height value and weight gain during pregnancy.
Prepregnancy weight-for-height value is expressed as body mass index (BMI). BMI
is defined as weight in kilograms divided by the square of height in meters. In
1959, the Metropolitan Life Insurance Company defined its weight-for-height
standards by BMI. These standards are in common use today.

Underweight is defined as a BMI of less than 19.8. Normal weight is defined as a

BMI of 19.8-26, which corresponds to between 25% and 75% of the expected
weight-for-height value. Overweight is defined as a BMI of 26-29. Lastly, obesity is
defined as a BMI that exceeds 29. Birth weight is affected by prepregnancy BMI
independent of actual weight gain during pregnancy. Women who are underweight
are at increased risk for low birth weight babies; women who are overweight or
obese are at increased risk for macrosomic infants. Macrosomia is variably defined
as weight exceeding 4000 g, 4500 g, or the 90th percentile. Macrosomic infants
are at increased risk for shoulder dystocia and brachial plexus injuries.

Morbid obesity is defined by a BMI exceeding 35. Morbidly obese patients are at
increased risk for preeclampsia, nonreassuring fetal heart tracings, meconium
aspiration, late intrauterine fetal death, and early neonatal death.[1]

Of course, birth weight is also affected by weight gain during pregnancy. Although
weight should be gained throughout pregnancy, it is most critical in the second
trimester. Even if overall weight gain is poor, birth weight is usually acceptable with
appropriate second-trimester weight gain. The following table relates low birth
weight to both prepregnancy weight and pregnancy weight gain.

The Institute of Medicine’s pregnancy weight gain recommendation guidelines for

2009 are as follows[2] :

Underweight - 28-40 lbs

Normal weight - 25-35 lbs
Overweight - 15-25 lbs
Obese - 11-20 lbs

Dieting during pregnancy is never recommended, even for patients who are
morbidly obese. Severe restriction of energy (caloric) intake is associated with a
250-g decrease in average birth weight. Because of the expansion of maternal
blood volume and construction of fetal and placental tissues, some weight gain is
essential for a healthy pregnancy.

Weight gain within these parameters is associated with a lower rate of cesarean
delivery, fewer infants with growth restriction or macrosomia, and a decreased
incidence of postpartum obesity. Nevertheless, only 30-40% of pregnant women
achieve appropriate weight gain.[3] Further evaluation is needed if weight gain is
persistently slow or does not equal 10 lb by mid pregnancy.

Diet in Pregnancy

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The demands of pregnancy necessitate additional dietary requirements. Obviously,

additional energy (caloric) intake is required to support recommended weight gain.
Because energy requirements in pregnancy are increased by 17% over the
nonpregnant state, a woman of normal weight should consume an additional 126
kJ/d (300 kcal/d); however, this energy should be of high nutrient density. Nutrient
density reflects the amount of protein, vitamins, and minerals per 418 kJ (100 kcal)
of food.

Protein should comprise 20% of a normal pregnancy diet. The recommended daily
allowance (RDA) in pregnancy is 60 g. Fortunately, most American diets already
contain more than enough protein. Pregnant women should be aware that many
animal sources of protein are very high in fat and might contribute to excessive
weight gain; therefore, animal proteins should be taken sparingly. Fat should only
comprise 30% of a normal pregnancy diet. Carbohydrates should comprise the
remaining 50%.

A sample diet for normal pregnancy is based on the food pyramid and should
include 6-11 servings of grains; 3-5 servings of vegetables; 2-4 servings of fruit; 3-
4 servings of dairy; 2-3 servings of meats, beans, or nuts; and 1 serving of sweets.
Total energy intake should vary by BMI, but the average recommendation is 10,460
kJ/d (2500 kcal/d).

One study suggests that eating up to 3 meals of fish per week prior to 22 weeks’
gestation may reduce recurrent preterm birth.[4] This level of fish consumption is
also supported by the American Dietetic Association (ADA) and the American
College of Obstetricians and Gynecologists (ACOG).

Vitamins in Pregnancy
The following recommendations are provided by the American Academy of
Pediatrics and the ACOG.[5]

Vitamin A

Vitamin A, a fat-soluble vitamin, is important for maintenance of visual function. Its

main influence is on the retina, but it also aids glycoprotein synthesis and promotes
cellular growth and differentiation in other tissues. Vitamin A is found in green leafy
vegetables and yellow-orange vegetables. The nonpregnancy RDA is 700 mcg, the
pregnancy RDA is 770 mcg. The lactation RDA is 1300 mcg. Well-balanced diets
provide the RDA for women who are pregnant or lactating; therefore, routine
supplementation is not recommended. Doses exceeding 15,000 IU/d, often used to
treat acne, are associated with an increased risk of birth defects and should not be
used in pregnancy; however, alpha-carotene, a vitamin A precursor, is not
teratogenic.

Vitamin B-1
Vitamin B-1, also known as thiamine, is a water-soluble B-complex vitamin. It is
involved in the release of energy from cells. Its food sources include milk and raw
grains. The RDA is 1.1 mg. In both pregnancy and lactation, the RDA increases to
1.4 mg. Well-balanced diets provide the pregnant and lactating RDA; therefore,
routine supplementation is not recommended.

Vitamin B-2

Vitamin B-2, also known as riboflavin, is a water-soluble B-complex vitamin. It is

also involved in the release of energy from cells. Vitamin B-2 is found in green
vegetables, milk, eggs, cheese, and fish. The RDA is 1.1 mg. In pregnancy, the
RDA increases to 1.4 mg; in lactation, it increases to 1.6 mg. Well-balanced diets
provide the RDA for women who are pregnant or lactating; therefore, routine
supplementation is not recommended.

Vitamin B-6
Vitamin B-6, also known as pyridoxine, is a water-soluble B-complex vitamin. It is
important in protein, carbohydrate, and lipid metabolism. It is also involved in the
synthesis of heme compounds. Vitamin B-6 is found mostly in vegetables. The
RDA is 1.2-1.5 mg. The pregnancy RDA is 1.9 and in lactation, the RDA increases
to 2 mg. Well-balanced diets provide the pregnant and lactating RDA; therefore,
routine supplementation is not recommended.

Vitamin B-12
Vitamin B-12, a water-soluble B-complex vitamin, is essential for DNA synthesis
and cell division. It is found in animal proteins. Deficiency is usually secondary to
compromised intestinal function. Dietary deficiency is rare, but it is occasionally

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encountered in persons who follow strict vegan diets. The RDA is 2.4 mcg. The
pregnancy RDA is 2.6 mcg. The RDA increases to 2.8 mcg with lactation. Well-
balanced diets provide the RDA for women who are pregnant or lactating;
therefore, routine supplementation is not recommended.

Vitamin C
Vitamin C, also known as ascorbic acid, is a water-soluble vitamin with numerous
functions. These include reducing free radicals and assisting in procollagen
formation. Vitamin C is found in fruits and vegetables. Chronic deficiency impairs
collagen synthesis and leads to scurvy. The RDA is 75 mg. The pregnancy RDA is
85 mg. The RDA increases to 120 mg with lactation. Well-balanced diets provide
the RDA for women who are pregnant or lactating; therefore, routine
supplementation is not recommended.

Vitamin D

Vitamin D, a fat-soluble vitamin, is found in fortified milk. Exposure to ultraviolet

light is necessary for vitamin conversion. Deficiency of vitamin D is associated with
tooth enamel hypoplasia. The RDA in both pregnancy and lactation is 5 mcg. Well-
balanced diets provide the RDA for women who are pregnant or lactating;
therefore, routine supplementation is not recommended.

In 2011, the ACOG reported insufficient evidence to support a recommendation for

screening all pregnant women for vitamin D deficiency.[6] Routine screening for
vitamin D levels is not currently a standard of care in the United States, and routine
vitamin D supplementation during pregnancy should be continued as it currently is.
More clinical trials are needed to support further evidence that routine vitamin D
screening should be considered as standard of care.

Vitamin E
Vitamin E, a fat-soluble vitamin, is an important antioxidant. It is found in animal
protein and fats. Deficiency is not a major issue in obstetrics but has been
implicated in newborn hemolytic anemia. The RDA is 15 mg. The pregnancy RDA
is 15 mg; the lactation RDA is 19 mg. Well-balanced diets provide the RDA for
women who are pregnant or lactating; therefore, routine supplementation is not
recommended.

Vitamin K
Vitamin K, a fat-soluble vitamin, is required for synthesis of clotting factors VII, IX,
and X. It is found in green leafy vegetables, tomatoes, dairy products, and eggs.
Transportation of vitamin K from mother to fetus is limited; nevertheless, significant
bleeding problems in the fetus are rare. However, newborn infants are often
functionally deficient in vitamin K and receive parenteral supplementation at birth.
The RDA is 90 mg. In pregnancy and lactation, the RDA stays at 90 mg. Well-
balanced diets provide the RDA for women who are pregnant or lactating RDA;
therefore, routine supplementation is not recommended.

Folic acid
Folic acid, a water-soluble B-complex vitamin, is important for DNA synthesis and
cell replication. It is found in fortified grains, dried beans, and leafy greens.[7] Much
has been written about folic acid and pregnancy. Deficiency in pregnancy has been
linked with maternal megaloblastic anemia and fetal neural tube defects. The RDA
is 0.4 mg. The pregnancy RDA is 0.6 mg; the RDA decreases to 0.5 mg in
lactation.

In 1998, the US Food and Drug Administration mandated fortification of grains with
folate. The degree of fortification was calculated to provide only 0.1 mg/d of dietary
folate. This was enacted to avoid having supplemental folate mask evidence of
vitamin B-12 deficiency in susceptible populations, especially elderly persons.
Cereal fortification has resulted in a 32% decrease in the prevalence of elevated
maternal serum alpha-fetoprotein values[8] and a 25% decline in the prevalence of
open neural tube defects.[9]

Despite fortification, sufficient folic acid is not provided by the average American
diet and routine supplementation of 0.4 mg/d is recommended for healthy women.
Folate supplements should be administered 3 months prior to conception and
throughout the first trimester. If the mother has a prior child affected by a neural
tube defect, supplementation in the subsequent pregnancy should be increased to
4 mg/d.

Niacin
Niacin is a water-soluble vitamin involved in the release of energy from cells. It is

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found in poultry, fish, and nuts. Deficiency results in pellagra. The RDA is 14 mcg.
In pregnancy, the RDA increases to 18 mcg, and to 17 mcg in lactation. Well-
balanced diets provide the RDA for women who are pregnant and lactating;
therefore, routine supplementation is not recommended.

Iodine

In 2015, the US Council for Responsible Medicine released the following new
guidelines for iodine in prenatal vitamins[10, 11] :

A call for all dietary-supplement manufacturers and marketers to begin

including at least 150 µg of iodine in all daily multivitamin/mineral
supplements intended for pregnant and lactating women in the United
States within the next 12 months.
The US recommended daily allowances (RDA) for iodine intake are 150 µg
in adults, 220-250 µg in pregnant women, and 250-290 µg in breastfeeding
women. Dietary sources such as iodized salt, dairy products, some breads,
and seafood usually contain enough to meet the RDA for most people who
are not pregnant or lactating.
However, there is an upper safety limit, with ingestion of more than 1100
µg/day not recommended because of the risk for thyroid dysfunction. In
particular, infants, the elderly, pregnant and lactating women, and people
with preexisting thyroid disease are at risk for adverse effects of excess
iodine on the thyroid.

Minerals and Trace Elements in Pregnancy

Iron
Iron is essential to the production of hemoglobin. Its dietary sources include animal
protein, dried beans, fortified grains, and any food cooked in cast iron cookware.
Despite its numerous sources, women have difficulty maintaining iron balance
using only a healthy diet. A well-balanced diet with 10,460 kJ/d (2500 kcal)
contains approximately 15 mg of elemental iron; however, the absorption of iron is
very inefficient and only approximately 10% of this is absorbed. With each normal
menses, 12-15 mg of elemental iron is lost. Estimates indicate that a woman's diet
must include 1.5-2 mg/d of elemental iron to compensate for menstrual losses
alone. In pregnancy, 500 mg of additional iron is needed to expand maternal red
cell mass. Another 500 mg is needed to supply fetal and placental tissues. On
average, an additional 3 mg/d of elemental iron must be absorbed from dietary
sources.

The RDA for elemental iron reflects these increased requirements. The RDA for
women who are not pregnant is 15 mg, 1.5 mg of which is absorbed. In pregnancy,
the RDA is 30 mg, 3 mg of which is absorbed. During lactation, the RDA returns to
15 mg. Well-balanced diets do not provide the pregnancy RDA for elemental iron;
therefore, iron supplementation is recommended in normal pregnancy.

Various iron preparations are commercially available, and each delivers a slightly
different amount of elemental iron. These preparations include ferrous sulfate,
ferrous fumarate, ferrous gluconate, and polysaccharide iron complex. Pure
elemental iron is available in 50-mg caplets of carbonyl iron. Providers should be
aware of the elemental iron contained in any one specific preparation, and they
should understand that only 10% of this is absorbed from the maternal gut.
Absorption is enhanced by concurrent ingestion of foods containing vitamin C.
Usually, one dose of any preparation containing at least 30 mg of elemental iron
meets the RDA. Larger doses are required only to treat maternal iron deficiency
anemia and only serve to constipate patients without anemia. Physicians should
remember that iron competes with zinc at absorption sites. The clinical implications
of this are discussed below in the zinc section.

Iron deficiency anemia is one of the most common pregnancy complications.

Screening for iron deficiency anemia is recommended at the first prenatal visit and,
thereafter, as indicated. Iron deficiency anemia is suggested if the complete blood
cell count suggests a microcytic, hypochromic anemia. Confirmatory test results
include a reduced serum iron level, increased total iron-binding capacity,
decreased transferrin saturation, and reduced serum ferritin levels. If a provider is
unable to perform the complete battery of confirmatory tests, the serum iron and
ferritin levels usually suggest the correct diagnosis. Treatment is increased oral
iron supplementation.

Many studies have shown that high hemoglobin values are associated with
adverse pregnancy outcomes; however, iron supplementation cannot, in itself,
raise hemoglobin to these levels.[12] Any adverse outcomes are more likely
secondary to underlying conditions responsible for high hemoglobin values.

Calcium

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Calcium is a major component of bone; therefore, large quantities of calcium are

required in pregnancy for construction of fetal tissues, especially in the third
trimester. Pregnant women younger than 25 years also still require calcium for
maternal bone mass. Hormonal adaptations and increased intestinal absorption
protect maternal bone while meeting fetal calcium requirements. A well-balanced
diet provides adequate calcium to meet all of these needs, and supplementation is
not recommended. The RDA for nonpregnant, pregnant, and lactating women is
1000 mg.[13]

Calcium is found in dairy products and leafy green vegetables such as collard,
kale, turnip, and mustard greens. Vitamin D is required for calcium absorption.

Phosphorus

Along with calcium, phosphorus is required for bone formation. Maternal serum
inorganic phosphorus levels remain constant during pregnancy because of
maternal adaptations. The RDA for nonpregnant, pregnant, and lactating women is
700 mg. Well-balanced diets easily provide the RDA for nonpregnant, pregnant,
and lactating women; supplementation is not recommended. In fact, phosphorus is
not usually in vitamin supplements.

Zinc

Zinc is involved in nucleic acid and protein metabolism; therefore, zinc is important
in early gestation. The RDA is 8 mg. The RDA for pregnant women is 11 mg, which
increases to 12 mg during lactation. Well-balanced diets provide the RDA for
women who are pregnant and lactating, and supplementation is not recommended.
Both iron and copper compete with zinc at absorption sites; therefore, zinc
supplementation is recommended when elemental iron supplementation exceeds
60 mg/d. Likewise, whenever zinc supplements are used, copper should also be
supplemented. Different prenatal vitamin formulations contain different amounts of
copper and zinc. Usually, copper or zinc supplementation can be accomplished by
careful selection of a prenatal vitamin formulation.

Sodium

Sodium is present in large quantities in the average American diet. It has received
much attention. The RDA is 1.5 mg during pregnancy, lactation, and the
nonpregnancy state. Whether pregnant or not, sodium should neither be restricted
nor used excessively. Well-balanced diets "salted to taste" satisfy sodium
requirements and obviate any need for supplementation. Pregnant women should
remember that most processed and pre-prepared foods are high in sodium.

Prenatal Vitamin Supplements

A standard prenatal vitamin formulation contains the following supplements:

Iron - 30 mg
Zinc - 15 mg
Calcium - 250 mg
Vitamin B-6 - 2 mg
Folate - 0.4 mg
Vitamin C - 50 mg
Vitamin D - 5 mcg

Of course, contents vary by individual formulation, and nutrient supplementation

should be chosen with attention to individual patient needs. A normal pregnancy
and a well-balanced diet generally provide the RDA of all nutrients except
elemental iron and folate, both of which must be supplemented. Prenatal vitamins
are not otherwise necessary for every patient; however, these supplements are
routinely prescribed to most patients for various important reasons. A major reason
is that a nutritionally compromised pregnancy can be difficult to identify, and the
potential benefits of routine supplementation overshadow any risk that can be
attributed. Also, the psychological impact of supplementation cannot be
overlooked. Many patients are uncomfortable with the idea of foregoing prenatal
vitamins and are reassured by their prescription.

Shah et al conducted a systematic literature review of prenatal multimicronutrient

supplementation on pregnancy outcomes. A significant reduction in risk of low birth
weight was observed for mothers taking the mulitmicronutrients compared those
taking with placebo or iron-folic acid supplementation. Birth weight was significantly
higher in newborns in the multimicronutrient group compared with the iron-folic
acid supplementation group. No significant differences were noted between
multimicronutrients, iron-folic acid supplementation, or placebo on the risk of
preterm birth or small-for-gestational-age infants.[14]

A randomized controlled trial by Hauth et al studied the effect of maternally

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administered vitamins C and E on risk of spontaneous preterm birth in low-risk,

nulliparous women.[15] Study participants were given either vitamin C 1000 mg and
vitamin E 500 IU or placebo starting between 9 and 16 weeks' gestation until
delivery. Supplementation with vitamin C and E did not reduce spontaneous
preterm births in this population.

Special Considerations
Lactose intolerance

Lactose intolerance is especially common among women of African, Asian, and

Middle Eastern descent. These women may have a difficult time getting adequate
calcium in their diet. Encourage these women to drink lactose-free dairy products
or calcium-enriched orange juice or soy milk; however, if their daily calcium intake
is less than 600 mg (one serving of calcium-rich food), they will benefit from
calcium supplementation. Many over-the-counter preparations are readily
available. The total daily divided dose should be 500-1000 mg. The maximum
tolerable daily divided dose is 2500 mg. If a woman is unable to tolerate any dairy
products and has limited exposure to sunlight, she may also require supplemental
vitamin D (400 IU/d). This scenario may arise in women who live in extreme
northern latitudes. It may also occur in women who wear purdah, as is common
among Muslims and women of Middle Eastern descent.

Vegetarian and vegan diets

Vegetarian diets are becoming increasingly prevalent. Well-balanced vegetarian

diets that include dairy products provide adequate energy and nutrient intake and
do not require special supplementation; however, vegan diets include no animal
products whatsoever, including, meat, dairy, and eggs. A vegan diet, even if well
balanced in all other respects, may be deficient in vitamins D and B-12. It may also
be extremely low in fat, making satisfaction of energy requirements a challenge.
Pregnant women who follow vegan diets require 400 IU/d of supplemental vitamin
D, 2 mcg/d of supplemental vitamin B-12, and careful attention to energy intake.

Exercise
Although regular exercise in pregnancy is encouraged, athletes must give special
attention to the nutritional demands of pregnancy. Both during exercise and at rest,
women use carbohydrates faster when they are pregnant. Thus, they are prone to
hypoglycemia. Exercise stimulates glucose use, which might further limit fetal
access to nutrients. Pregnant women who exercise regularly are advised to
increase their carbohydrate intake to compensate for their increased use.

Adolescents
The pregnant adolescent may also require careful attention to energy intake.
Younger women may have increased energy requirements to satisfy the demands
of ongoing maternal growth. At the same time, body image concerns may deter
younger women from gaining the weight needed to support a healthy pregnancy.
Consultation with nutritionists and social workers (eg, counselors) may be helpful if
these dietary issues arise.

Multiple gestations
Women carrying multiple gestations have increased nutritional requirements. The
recommended weight gain for twin gestations is 16-20 kg (35-44 lb). This amount
of weight gain requires approximately 630 additional kJ/d (150 kcal/d) over the
dietary requirements of singleton pregnancies. Women with triplets should gain 50
lb.[16] Of course, these recommendations should be adjusted for prepregnancy
BMI. Nutrient requirements are also increased in multiple gestations. Routine
prenatal vitamin and mineral supplementation is recommended. The suggested
amount of folic acid supplementation is 1 mg/d. Elemental iron requirements are
often increased, requiring more frequent doses of iron supplements. Lastly, vitamin
B-6 requirements are increased. The recommended supplementation for women
with multiple pregnancies is 2 mg/d.

Hyperemesis gravidarum

Hyperemesis gravidarum is a common complication of early pregnancy. In the first

trimester, when weight gain is not yet essential to fetal growth, mild hyperemesis is
unlikely to affect fetal development. The initial therapy is avoidance of large
boluses of food. Frequent, small meals and snacks are preferred. If this fails,
patients may respond to vitamin B-6, 25 mg 3 times a day. When hyperemesis
precludes all oral intake, severe dehydration and ketosis may result, which
requires inpatient management and intravenous rehydration with a glucose-
containing solution. In rare instances when starvation is prolonged, patients must

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be fed parenterally, by total parenteral nutrition or peripheral parenteral nutrition.

Eating disorders
Eating disorders are common in women during their reproductive years. Anorexia
nervosa commonly results in amenorrhea and is not often observed in pregnancy.
However, bulimia may complicate pregnancy. As in hyperemesis, bulimia is
unlikely to affect fetal development in the first trimester. If it becomes persistent,
the severe energy restriction may compromise fetal growth. Consultation with a
psychiatrist is essential.

Malabsorption syndromes

Likewise, malabsorption syndromes and inflammatory bowel disease may

compromise fetal growth. Increased ultrasonographic surveillance may aid in early
detection of a growth-impaired pregnancy. Special diets and supplements may be
required; therefore, these patients must be treated in conjunction with a
gastroenterologist.

Bariatric surgery

The prevalence of obesity, and therefore bariatric surgery, has increased

dramatically over the last 20 years, leading to an increased number of pregnancies
following bariatric/gastric bypass surgery.

Several types of procedures are performed. In general, the classes include gastric
restriction such as banding, combined gastric restriction, and bypass such as the
roux-en-Y gastric bypass (RGB) and the combined gastric restriction and intestinal
malabsorption such as the biliopancreatic diversion (BPD). In general, gastric
restriction limits the amount of food eaten, causing early satiety by decreasing the
size of the stomach and decreasing the size of the outlet. The RGB has 2
components, the gastric restriction and also bypassing the duodenum and directly
connecting the stomach to the jejunum, thus creating early satiety, mild
malabsorption, and causing dumping syndrome when a large sugar load is
ingested. The BPD combines gastric restriction and a greater degree of
malabsorption. The frequency of the RGB is 70%, BPD 12% and gastric banding
16% (but includes several forms of banding).

Nutritional complications are not seen in purely restrictive procedures, whereas the
malabsorption procedures cause most of the nutritional complications seen in
patients undergoing bariatric surgery. Patients undergoing BPD and RGB often
develop protein malnutrition, anemia, and deficiencies of iron, folate, calcium,
vitamin B-12, and the lipid soluble vitamins such vitamins D, K, E and A.

No standard of care has been set related to the frequency of monitoring nutritional
deficiencies of patients who become pregnant after undergoing bariatric surgery.
However, in a recent review of bariatric surgery patients were advised to not get
pregnant during the more rapid phase of weight loss because of an increased risk
for micronutrient and macronutrient deficiencies during this period.[17] General
surgeons have a wide range of practice for monitoring micronutrient and
macronutrient deficiencies.

The American College of Obstetrics and Gynecology recommends that all patients
have preconceptional counseling and prenatal assessment of their nutritional
status and, where appropriate, replacement of vitamin B-12, folic acid, iron, and
calcium.[18] In addition, the assessment of other potential nutritional deficiencies
should be based on the practitioner’s clinical judgment. Pregnancy outcomes are
favorable overall. Researchers have determined that pregnancies after bariatric
surgery are less likely to be complicated by gestational diabetes, hypertension,
macrosomia, and cesarean delivery than are pregnancies of obese women who
have not had the surgery but can be associated with adverse perinatal outcomes.
Consultation with a perinatologist may be helpful.

Poverty
Poverty nearly doubles the rate of insufficient weight gain. Nutritional counseling
may assist patients who are impoverished in identifying low-cost foods with high-
nutrient density. The federal Women, Infants, and Children (WIC) program,
administered through the US Department of Agriculture Food and Nutrition
Service, is a valuable resource for women who are impoverished (see Food and
Nutrition Service).

International issues

In the United States, the vast majority of pregnant women enjoy good nutrition;
however, in much of the developing world, pregnant women may experience
nutritional deficiencies not commonly observed in the United States.

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For example, diets that are severely deficient in calcium have been associated with
an increased prevalence of hypertensive disorders of pregnancy. Zinc deficiency,
which can occur with poor dietary intake or increased dietary iron or copper intake,
is associated with an increased risk of congenital anomalies, pregnancy loss,
intrauterine growth restriction, and preterm delivery. Iodine deficiency is associated
with fetal loss and cretinism. Vitamin A deficiency is widespread in developing
nations and is associated with night blindness, intrauterine growth restriction, and
preterm delivery. Vitamin D deficiency, which occurs mainly in women who have
limited exposure to sunlight, is associated with neonatal tetany, rickets, and
abnormal tooth development.

Thus, micronutrient supplementation may be beneficial to the public health of

developing nations.[19] When administering large doses of supplemental iron,
remember that the increased serum hemoglobin level associated with iron
supplementation can result in a greater attack rate of clinical malaria. Thus,
malarial prophylaxis is indicated when large doses of elemental iron are given to
pregnant women in endemic areas.

Contributor Information and Disclosures

Author
Serdar H Ural, MD Associate Professor of Obstetrics and Gynecology and Radiology, Director, Division of
Maternal-Fetal Medicine, Medical Director, Labor and Delivery Suite, Pennsylvania State University College of
Medicine

Serdar H Ural, MD is a member of the following medical societies: American College of Obstetricians and
Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of
Professors of Gynecology and Obstetrics, AAGL, Society for Maternal-Fetal Medicine

Disclosure: Received honoraria from GSK for speaking and teaching; Received honoraria from J&J for speaking
and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General
Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School
of Medicine

Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and
Gynecologists

Disclosure: Nothing to disclose.

Chief Editor
Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General
Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School
of Medicine

Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and
Gynecologists

Disclosure: Nothing to disclose.

Additional Contributors
Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of
Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and
Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American College of
Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, International Society for Clinical
Densitometry, AAGL, North American Menopause Society, American Medical Association, Association of
Reproductive Health Professionals

Disclosure: Nothing to disclose.

Acknowledgements
Corenthian J Booker, MD Staff Physician, Department of Obstetrics and Gynecology, Penn State Hershey
Medical Center

Corenthian J Booker, MD is a member of the following medical societies: American College of Obstetricians and
Gynecologists, National Medical Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Dominic Marchiano, MD Assistant Professor of Obstetrics and Gynecology, Division of Maternal Fetal

http://emedicine.medscape.com/article/259059-overview Página 8 de 9
Prenatal Nutrition: Background, Weight Gain and Pregnancy, Diet in Pregnancy 30/09/15 4:27 p.m.

Medicine, Pennsylvania Hospital

Disclosure: Nothing to disclose.

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