Nutrition, supplementation and exercise in pregnancy — structured SAQ (15 marks)

(a) Folic acid dose for this woman (2 marks)

• 5 mg daily, peri-conceptionally. (1 mark)^[2][6]
• She is high-risk: pre-existing diabetes and a BMI of 30 or more both place her in the high-risk folate group (RANZCOG C-Obs 25). Start before conception because the neural tube closes by about day 28; the MRC Vitamin Study showed a 72% protective effect (RR 0.28) in high-risk women. (1 mark)^[2]

(b) Routine and targeted supplementation (5 marks)

One mark per element, max five; doses must be stated. ^[1][6]

• Folic acid — 5 mg for this woman (high-risk); 400 micrograms (0.4 to 0.8 mg) for low-risk women, peri-conceptionally through the first trimester (USPSTF, A recommendation).^[1]
• Iodine — 150 micrograms daily for all women who are pregnant, breastfeeding or planning pregnancy (Teratology Society position paper; NHMRC), continued throughout.^[3]
• Iron — targeted to deficiency or risk (low ferritin under 30 micrograms per litre, vegetarian diet, multiple pregnancy); daily or intermittent oral iron, intravenous for intolerance or severe late-pregnancy deficiency.^[6]
• Vitamin D — test at-risk women (dark skin, limited sun, veiling, obesity, malabsorption) and supplement the deficient; not routine for all.^[6]
• Vitamin B12 and calcium — B12 for vegetarians and vegans; calcium for low intake; avoid high-dose vitamin A (retinol).^[6]

(c) Weight-gain target and exercise advice (5 marks)

• Weight-gain target — with a BMI of 30 (obese), the IOM range is 5 to 9 kg total (about 0.22 kg per week in the second and third trimester). (2 marks)^[7]
• Exercise prescription (FITT) — most, preferably all, days; at least 30 minutes moderate at a time; 150 to 300 minutes per week; strengthening on two non-consecutive days. (2 marks)^[4]
• Specifics for her — she can continue recreational running as it is her established routine, but should avoid the supine position after the first trimester, avoid overheating, and monitor intensity (rating of perceived exertion 12 to 14, or the talk test). Pregnancy is not the time to chase peak fitness. (1 mark)^[4]

(d) Caffeine advice (3 marks)

• Limit — keep caffeine under 200 mg per day (ACOG Committee Opinion 462). (1 mark)^[5]
• Her intake — four espressos a day is roughly 300 to 400 mg, above the limit; advise reduction to under 200 mg (about one to two espressos). (1 mark)^[5]
• Evidence — moderate caffeine (under 200 mg/day) does not appear to be a major contributor to miscarriage or preterm birth; higher intake (200 mg/day or more) is associated with miscarriage (Weng: adjusted hazard ratio 2.23). (1 mark)^[5]