Pregnant and underweight: How to get the nutrients you need

Abstract

Aim: Data analyzing risks during pregnancy and neonatal outcome in Caucasian women with pre-conceptional underweight are scarce.
Patients and Methods: We conducted a retrospective cohort study in Northern Germany comparing pregnancy risks and neonatal
outcomes in nulliparous women with either pre-conceptional underweight or normal weight. Results:

The data of 3,854 nulliparous
women with either underweight (n=243; BMI ≤18.5 kg/m2) or normal weight (n=3611; BMI 18.5-24.9 kg/m2) were screened. The risks for preterm birth (23.3 vs. 18.6%; p=0.

004) and neonatal underweight were significantly higher
in women with underweight prior to conception (p{amp}lt;0.0001). The risk for secondary caesarean sections was significantly lower
in underweight patients. Conclusion:

To our knowledge, the present retrospective cohort study constitutes the largest sub-group
analysis on delivery and maternal and neonatal outcome in pre-conceptionally underweight mothers.

There are significantly
more preterm deliveries in underweight mothers, while maternal outcome and birth-associated trauma (lacerations, caesarean
section) is not disadvantageously influenced by maternal underweight.

Further investigations are required in order to specify
nutritional deficits in underweight pregnant women and to optimize medication in cases where nutritional balance cannot be
achieved in order to improve the neonatal status at birth.

Did we answer your question about weight, fertility, and pregnancy?

This is not another installment of «Skinny Girl Humble Complains.» I won’t be whining about all the milkshakes I have to consume or how hard it is to find size 0 maternity jeans. No, this is a recognition that the way people experience pregnancy varies. Some get gestational diabetes or have to navigate a pre-existing condition. It’s helpful for women to know they’re not alone and for the rest of us to understand and empathize. It’s no different for women who go through pregnancy with a low body mass index (BMI), and I’m here to tell you what that’s like.

I’ve always been thin, with the exception of when I was born. I weighed almost 9 pounds and was 22.5 inches long. However, it wasn’t long before I was below the 5th percentile on the growth charts. Later, I wasn’t even on it. My stepdad remembers that when he met me at age 7, I was wearing size 2T shorts. By high school, I didn’t technically weigh enough to sit in the front seat of my mom’s van. It was around that time that so-called «friends» found it necessary to report me to the school counselor for possible anorexia.

Courtesy of Kimmie Fink

I didn’t have nor have I ever had an eating disorder. I was a late bloomer, getting my period about six months after I turned 16, but I started to fill out in college. I hit a growth spurt that lasted from my junior year in high school to my freshman year is college and ended up taller than average as well, which no one (especially the pediatrician who predicted I’d be 5’2″) expected. As an adult, I’m a comfortable weight for my frame, but with a BMI less than 18.5, I’m considered underweight. Maybe it was naive of me, but I never really considered how having a low BMI might affect a future pregnancy.

If and when you do get pregnant, you will automatically be labeled high risk.

For one, it can be a challenge to get pregnant in the first place. I got pregnant with my firstborn right away, but trying to conceive a second time was much more challenging. According to the Southern California Reproductive Center, a low BMI can mean fertility issues. The fact is, you need a certain amount of body fat to conceive. That’s because sex hormones are stored in the body’s fat layers. Low BMI can also affect how much estrogen you produce. If you have an abnormal (or absent) menstrual cycle due to reduced estrogen, you’re obviously going to have problems conceiving. Not all underweight women will struggle to get pregnant, but many will have to make some lifestyle adjustments, including a higher-fat diet and curtailing their exercise regimen.

Courtesy of Kimmie Fink

If and when you do get pregnant, you will automatically be labeled high risk. When it happened to me, I assumed it had something to do with my age rather than my weight, but not so. According to Livestrong, women with a low BMI are 72 percent more likely to miscarry in the first trimester, although this can be mediated with nutritional supplements. In a study published in the International Journal of Epidemiology, researchers found that underweight mothers are at higher risk of both pre-term birth and low birth weight. What this all means is that your doctor or midwife will be watching you a little more closely than they otherwise might.

Another unexpected part of a low BMI pregnancy is that you may have additional ultrasounds.

Your provider will likely recommend that you gain more weight than is standard. According to the American Pregnancy Association (APA), if you have a BMI of less than 18.5, you should aim for a weight gain of 28-40 pounds. For both my pregnancies, my midwife recommended that I gain 35-45 pounds (I gained 40 with my daughter). Adding 300 calories a day is a good way to accomplish this goal. Granted, that’s not permission to binge on ice cream and pizza. Expectant moms with a low BMI want to get the most bang for their nutritional buck. That means foods that are high in healthy fats, such as avocados and fish. My midwife has encouraged me to drink whole milk and real fruit juice.

Courtesy of Kimmie Fink

Gaining weight isn’t always that easy. If you’re underweight, you probably have a high metabolism, making packing on the pounds difficult in the first place. For many women, nausea and vomiting of pregnancy can wreak havoc on their appetite, too. I had hyperemesis gravidarum for both of my pregnancies, and it was extremely challenging to keep anything down. I focused on not losing weight and ate a spoonful of peanut butter as often as I could. Weight gain can bring up many feelings for women who suffer or have suffered from eating disorders. Whether or not this is the case for you, you should be prepared for the question and to answer honestly. Providers are trained for this and should be able to put women in touch with additional support, such as a dietician or mental health professional.

One of the most obnoxious things about being underweight during pregnancy isn’t medical at all. It’s the skinny shaming.

Another unexpected part of a low BMI pregnancy is that you may have additional ultrasounds. The American College of Obstetricians and Gynecologists only requires one, usually between 18 and 22 weeks, but that’s for an uncomplicated pregnancy. Your provider will likely want to check in more often to ensure that your baby is measuring correctly, and a sonogram is a good way to do that. I’m already scheduled for a 30-week ultrasound. The doctor admitted that this practice is more «voodoo» than science (his words), but I’m OK with any opportunity to check in on my baby’s growth.

Courtesy of Kimmie Fink

One of the most obnoxious things about being underweight during pregnancy isn’t medical at all. It’s the skinny shaming. If you think that’s not a thing, just ask Duchess Kate, whose pregnancies are already under the microscope but who also gets accused of «pregorexia.» Underweight moms hear everything from they’re not eating enough to they won’t be able to breastfeed. You’ll likely be told you’re «all belly,» but it’s not necessarily a compliment. In fact, it just sucks. Your weight is no one’s business but yours and your provider’s, and it shouldn’t be acceptable for a stranger to tell you it looks like you swallowed a basketball.

Everyone experiences pregnancy differently, and just because it’s more socially acceptable to be thin doesn’t mean we should diminish what underweight expectant moms go through. They deserve know what they can expect as much as the next person, and they have the right to own their experience.

Check out Romper’s new video series, Bearing The Motherload, where disagreeing parents from different sides of an issue sit down with a mediator and talk about how to support (and not judge) each other’s parenting perspectives. New episodes air Mondays on Facebook.

This study is a retrospective cohort analysis of all deliveries at the University Clinic of Schleswig-Holstein, Campus Luebeck
from January 1st 2000 to December 31st, 2009. Our hospital is the referral Centre for the Northern German coastal region with
more than 4 million inhabitants.

The region is characterized by a predominantly Caucasian population. We included all single
pregnancies of that period that met the following inclusion criteria: Based on maternal BMI calculated from the pregnant women’s
reported height and pre-pregnancy weight, all pregnant women were divided into two groups:

underweight pregnant women with
a BMI less than 18.5 kg/m2 at the time of conception formed group A, women with a normal weight at conception (BMI between 18.5 and ≤24.

9 kg/m2) formed group B. Pregnant women with a preconceptional BMI higher than 25 kg/m2 were excluded. Only nulliparous women were included in the study. Exclusion criteria were defined as preterm delivery before
24 completed weeks of gestation post-menstruation, confirmed multiple pregnancy and incomplete data sets (Figure 1).

Primary outcome was defined as the mode of delivery. Additional maternal data and the neonatal outcome were reported (patient
clinical record files as primary data source). Neonatal outcome was determined by either a specially trained obstetrician
or paediatrician of the neonatal intensive care unit of the University hospital.

Every delivery was accompanied by a midwife
and an obstetrician who took responsibility for the course and outcome of labour. We categorized the mode of delivery in spontaneous,
vaginal operative and caesarean deliveries.

Vaginal operative delivery included forceps and vacuum extraction. Caesarean section
was differentiated in primary and secondary caesarean delivery. Emergency delivery was added to secondary caesarean section.

Primary caesarean section was defined as elective, whereas secondary Caesarean delivery was defined as non-elective operation.
High-grade lacerations were defined as third and fourth degree lacerations.

Demographic data were abstracted from the prenatal and inpatient records. Gestational age was determined from prenatal records
and calculated from last menstrual period or best obstetric estimate based on early prenatal ultrasound and obstetric examination.

Data were extracted from the electronic database of our hospital, PIA Fetal DatabaseTM (GE; City, County, USA). All statistical
analyses were performed with Prism 5.

0 for Windows (GraphPad Software, 2007, San Diego, CA, USA). Analysis included the Mann–Whitney
test for continuous data, Chi-square test and Fisher’s exact test for categorical data.

Most women who start off their pregnancies underweight are advised to gain between 28 and 40 pounds – a bit more than the standard recommendation of 25 to 35 pounds. The March of Dimes suggests that if you begin your pregnancy underweight you try to gain slightly over a pound a week in the second and third trimesters (assuming you gain between 1 and 4 1/2 pounds in the first trimester).

However, your doctor or midwife may make a different recommendation based on your individual situation, particularly if you have a history of eating disorders such as anorexia or bulimia.

If you need help gaining the extra weight, seek out a registered dietitian. (Ask your healthcare provider for a recommendation.)

Not sure if you were underweight before you were pregnant? View a body mass index (BMI) chart to find out. You’re considered underweight if you have a BMI of less than 18.5. (Your BMI reflects the relationship between your height and weight.)

cartoon weight scale

If you’re underweight at the start of your pregnancy, you have a greater risk of having a preterm birth or a small for gestational age (SGA) baby. This puts the baby at risk for a host of problems.

To begin with, like all pregnant women, you need to be taking a folic acid supplement to reduce your baby’s risk of a neural tube defect. In fact, experts recommend taking 400 micrograms (mcg) of folic acid per day, beginning at least a month before you start trying to get pregnant. Some experts advise raising the dose to at least 600 mcg per day once you’re pregnant.

Other than that, the bulk of your nourishment should come from whole foods, but a prenatal vitamin and mineral supplement can help make up for some shortcomings. Your doctor or midwife will probably recommend that you start taking one as soon as you find out you’re pregnant, if not before.

If you’re not sure you can stick to a healthy diet on your own, a registered dietitian can help you come up with a sensible meal plan and even provide you with simple recipes that include the foods rich in the vitamins and minerals that are essential to a healthy baby.

Use our handy pregnancy food diary to make sure you’re getting enough calories and nutrients and drinking plenty of water every day. The diary is also useful for tracking your mood and hunger levels, so you can spot patterns you may need to change.

Choose plenty of nutritious foods that contain some healthy fat and adequate calories. Here are four easy ways to get more calories:

  • Eat breakfast every day. Add some peanut butter or a slice of cheese to your morning toast for an extra protein boost.
  • Add a couple of slices of avocado and a handful of nuts or seeds to your salads for extra protein and healthy fat.
  • Eat two or three snacks between meals. Choose foods like yogurt (for protein and calcium), dried fruit (for vitamins, minerals, and fiber), or a fruit and yogurt smoothie (for protein, calcium, vitamins, and minerals).
  • Replace soda with milk (for protein and calcium) or juices that are high in vitamin C or beta carotene, an antioxidant. Grapefruit juice, orange juice, and papaya nectar are rich in vitamin C. Apricot nectar and carrot juice have lots of beta carotene.

Extra weight can make it hard for you to get pregnant. For example, polycystic ovary syndrome, or PCOS, is one of the most common reasons for infertility in women and can also cause obesity. Overweight and obesity affect fertility by:1″{amp}gt;1

  • Preventing ovulation. Your ovaries make the female hormone estrogen. Fat cells also make estrogen. As you gain weight, your fat cells grow and release more estrogen. Too much natural estrogen can cause your body to react as if you are taking hormonal birth control with estrogen (like the pill, shot, or vaginal ring) or are already pregnant. This can prevent you from ovulating and having a monthly period. 
  • Preventing fertility treatments from working. Obesity may lower your chances of getting pregnant with certain fertility treatments, such as in vitro fertilization (IVF).

If you are underweight (your BMI is 18.5 or less), you may have problems getting pregnant. Being underweight can cause your body to stop making estrogen. This can cause irregular menstrual cycles.

You may stop ovulating and getting your period. This is especially true if you are losing weight because you are not eating enough or because you are exercising too much, which may be signs of an eating disorder like anorexia nervosa.

In order to get pregnant, you need to ovulate or release an egg from the ovary so it can be fertilized by a man’s sperm. Then your body needs to be able to support a developing baby in the womb.

Yes. Every woman is different, but studies show that for women who have overweight or obesity, losing weight raised their chances of getting pregnant. Losing weight also helped menstrual cycles return to normal.1″{amp}gt;1 Talk to your doctor or nurse about how to lose weight safely.

Women who need to gain weight before getting pregnant should gain weight gradually and talk to their doctor or nurse about how to gain weight safely.

How much weight you should gain during pregnancy depends on your body mass index (BMI) before getting pregnant.

If you have:2″{amp}gt;2

  • Underweight (BMI of less than 18.5), you should gain 28 to 40 pounds
  • Normal weight (BMI of 18.5 to 24.9), you should gain 25 to 35 pounds
  • Overweight (BMI of 25 to 29.9), you should gain 15 to 25 pounds
  • Obesity (BMI of 30 or greater), you should gain no more than 11 to 20 pounds

Talk to your doctor, nurse, or midwife about how much weight is safe to gain during pregnancy.

Having overweight or obesity during pregnancy raises your risk for problems during pregnancy. Also, even if you do not have overweight or obesity, gaining more weight than recommended can cause the same problems.

These include:

  • Gestational hypertension (high blood pressure during pregnancy). If not controlled during pregnancy, gestational hypertension may lead to a more serious condition called preeclampsia.
  • Gestational diabetes (diabetes that starts during pregnancy). Having overweight or obesity raises the risk for gestational diabetes. Women who have had gestational diabetes also have a higher lifetime risk for obesity and type 2 diabetes. Gestational diabetes can cause low blood sugar in the infant. Unborn babies may also be larger, which could injure the baby or the mother during birth.
  • Increased risk for C-section3″{amp}gt;3

Talk to your doctor, nurse, or midwife about healthy weight gain during pregnancy to help lower your risk for these health problems.

Learn more about pregnancy complications.

Babies born to mothers with overweight or obesity are at higher risk for health problems, including:3″{amp}gt;3

  • Neural tube defects, such as spina bifida
  • Heart defects
  • Low blood sugar and larger body size, if the mother has gestational diabetes
  • Obesity, type 2 diabetes, and high cholesterol

Babies born to mothers who are underweight (women with BMIs lower than 18.5) are at higher risk for health problems, including:4″{amp}gt;4

  • Premature birth (also called preterm birth), or childbirth before 37 weeks of pregnancy
  • Low birth weight (smaller than 5 1/2 pounds). These infants are at risk for health and development problems as they get older.

For more information about weight, fertility, and pregnancy, call the OWH Helpline at 1-800-994-9662 or check out the following resources from other organizations:

Women with a low body mass index are underweight and must gain weight for their pregnancy. Underweight women are at a higher risk of suffering from miscarriage during the first trimester of pregnancy.

  1. An increased risk of preterm delivery or the infant born with a low birth weight.
  1. It also increases the possibility of pregnancy complications like obstetric surgical interventions.
  1. Your infant may suffer from postpartum hemorrhage, which can lead to a sudden death.
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