spontaneous abortion, mental retardation, microcephaly, and congenital heart disease seen in the offspring of these pregnancies.20,27 Because of changing protein and energy needs over the course of pregnancy, frequent, careful monitoring and evaluation are advisable to determine the need for dietary adjustments. Some women may need assistance to be able to obtain the expensive formula that is the foundation of the diet.

Gastrointestinal Disorders. The pregnant woman with preexisting primary disease of the gallbladder, pancreas, stomach, or intestine (including malabsorption syndrome and conditions that have led to extensive resection of the intestine) is likely to benefit from special nutrition services to promote optimal maternal and fetal outcomes, as will women with other conditions that interfere with food intake by mouth (e.g., see Granström and colleagues99 ). Special formulas, tube feeding, or parenteral nutrition may be required to provide sufficient nutrients to support both the mother and fetus. If the gastrointestinal tract can be used, many types of tube feeding mixtures and delivery methods can be considered. The type of feeding and the volume of it to be delivered must be individualized for the pregnant woman's needs.

Parenteral feedings generally contain a nonprotein energy source (glucose, fat emulsions, or both), amino acids, electrolytes (including calcium, magnesium, and phosphorus), trace elements, and both water- and fat-soluble vitamins in amounts individualized to the woman's needs. Total parenteral nutrition has been reported to reverse gestational weight loss and to promote fetal growth.100 This highly specialized feeding method may be used for a relatively brief or extended period either in the hospital or at home, during any trimester of pregnancy. 101105 Watson and colleagues106 support the use of peripheral as well as central routes of administration. Close monitoring of the patient and adjustment of the feeding regimen as needed are essential when alternative feeding methods must be used. Extensive training is required for home use of such methods. (See also Chart 3–3, Chapter 3.)

Cystic Fibrosis. Nutritional care for women with cystic fibrosis includes the use of pancreatic enzymes (in pancreatic-insufficient patients); a high-energy, nutrient-rich diet; and supplemental vitamins. Because women with cystic fibrosis may have difficulty consuming and absorbing enough nutrients, they are at increased risk of low weight gain during pregnancy.107 They may need extra nutritional support using alternative feeding methods such as parenteral nutrition, 108 especially if the work of breathing inter

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