A 26-year-old primigravid woman at 14 weeks gestation comes to the office to establish prenatal care. The patient has had no vaginal bleeding or cramping. She has no chronic medical conditions, and her only medication is a daily prenatal vitamin. The patient follows a vegan diet and drinks 2 cups of coffee each morning. She is an avid runner and runs 5 miles most days. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Prepregnancy BMI was 22 kg/m². Physical examination is normal. Transvaginal ultrasound shows a single intrauterine gestation with a heart rate of 155/min. The patient asks about possible lifestyle modifications needed during pregnancy. Which of the following is the most appropriate recommendation for this patient?

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Explanation: 11ec25c8_d991_f215_bc81_5904d5859197_MD0003_00 Nutrition in pregnancy is addressed at the initial prenatal visit. Appropriate weight gain: Women with a normal prepregnancy BMI (18.5-24.9 kg/m²) should gain 11.4-15.9 kg (25-35 lb) during pregnancy (Choice E). This weight gain is equivalent to increasing caloric intake by 350 kcal/day during the second trimester and 450 kcal/day during the third. Patients following specific diets (eg, vegan) can continue the diet throughout pregnancy as long as it has well-balanced quantities of protein, carbohydrates, and fats (Choice B). Vitamin and mineral supplementation: A single, daily prenatal vitamin is recommended for the majority of pregnant women because it fulfills most of the daily vitamin and mineral supplementation requirements. Patients with vitamin or mineral deficiencies require specific supplementation (eg, iron) rather than multiple prenatal vitamins to avoid consuming harmful amounts of other vitamins (eg, vitamin A). Vegans, who are at risk for some vitamin and mineral deficiencies (eg, vitamin B₁₂, calcium, iron) secondary to lack of meat consumption, may require supplementation. Avoidance of harmful substances: Patients are counseled on substance abuse (eg, alcohol) and substances to avoid in pregnancy (eg, fish with high mercury levels). Although high caffeine doses can be harmful during pregnancy, moderate intake (ie, 1 or 2 cups of coffee daily) is not (Choice C). Safe handling of food: Some food products are associated with congenital infection and intrauterine fetal demise. Patients are counseled to avoid undercooked meat, fish, and eggs; to thoroughly clean raw fruits and vegetables; and to avoid unpasteurized dairy products. By maintaining proper maternal nutrition in pregnancy, patients provide appropriate fetal nutrition and decrease the risk of pregnancy complications (eg, low birth weight, preterm delivery). (Choice A) Patients with an uncomplicated pregnancy who are already conditioned for long-duration, high-intensity exercise (eg, running 5 miles/day) can typically continue their regimen as tolerated. Pregnant patients are counseled to avoid exercises that increase the risk of abdominal trauma (eg, contact sports, downhill skiing) due to the increased risk of placental abruption. Educational objective: Proper nutrition in pregnancy includes appropriate weight gain, vitamin and mineral supplementation, avoidance of harmful substances, and safe handling of foods. Patients with a normal prepregnancy BMI should gain 11.4-15.9 kg (25-35 lb) during pregnancy and increase caloric intake by 350 kcal/day in the second trimester and 450 kcal/day in the third. References: ACOG committee opinion no. 548: weight gain during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/23262962)

A 26-Year-Old Primigravid Woman at 14 Weeks Gestation Comes to the Office