Renal Disorders. Advanced renal disease and chronic renal failure are conditions rarely seen among pregnant women. Nonetheless, women with these conditions require special nutrition services (see, for example, Fröhling and colleagues77 ) to balance the increased nutrient requirements of pregnancy, the impaired ability to excrete certain nutrients, and the increased losses of certain nutrients that may result from dialysis or drug treatment. Close monitoring is critically important to guide dietary adjustments.

Human Immunodeficiency Virus. Because women infected with human immunodeficiency virus (HIV) are at increased risk for problems with gastrointestinal function, weight loss, and anemia,78,79 it is prudent to provide a thorough initial nutritional assessment, to recommend vitamin-mineral supplementation, and to monitor the woman's nutritional status frequently. This is especially important for women with AIDS. Because the effect of the virus on the fetus appears to be quite varied and unpredictable, it seems advisable to provide dietary management that not only avoids maternal weight loss but encourages normal weight gain during pregnancy, provides the nutrients essential to the proper functioning of the immune system,80 and includes education concerning the prevention of foodborne diseases.81,82

Conditions Involving Unhealthy Behaviors

Cigarette Smoking. Maternal cigarette smoking poses a serious threat to both the health and the growth of the developing fetus.10,83,84 The high frequency of smoking (25 to 30%) among U.S. women85 makes smoking a national problem as well as an individual one. Women who smoke need strong encouragement to stop this behavior and assistance to do so before and during pregnancy. Attention to the use of smokeless tobacco products is also warranted among some populations (e.g., a substantial proportion of young females from some American Indian tribes use such products;86,87 S. Pelican, Indian Health Service, personal communication, 1991).

Windsor and colleagues88 estimate that the dissemination of available, tested, cost-effective smoking cessation methods (with quit rates of 12 to 14%) could lead to cessation by an additional 28,000 pregnant women who are served by the public sector and an additional 84,000 who are served by the private sector each year. Shipp and colleagues 89 present a method for estimating the break-even point for smoking cessation programs for pregnant women.

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