NUTRITION DURING PREGNANCY

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Nutrition before conception

Risk

assessment, health promotion, intervention Weight Maintain a healthy weight Vitamins Folic acid/day Avoid high doses of retinol Substance use Eliminate prior to pregnancy
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Effect of nutritional status on pregnancy outcome

1. Maternal size - maternal size ~ placental size indicator of placental health determines the amount of nutrient available to the fetus birth weight - prepregnancy weight << lighter weight placenta risk for LBW

2. Weight Gain During Pregnancy

Recommended weight gain during pregnancy based on BMI

Total weight gain Underweight (BMI < 19.8) Normal weight (BMI 19.8 26) Overweight (BMI 26 29) Obese (BMI > 29) Twins Triplets/multiples 12.5 18 1st trim 2.3 2nd & 3rd weekly gain 0.49

11.5 16.0
7.0 11.5 6.0 15.9 20.4 >22.7

1.6
0.9

0.44
0.3

Normal components of maternal weight gain during pregnancy

Organ, tissue or fluid Uterus Breasts Blood Water Fat Maternal components Fetus Placenta Amniotic fluid Non-maternal components Total (g) 970 450 1250 1680 3350
= 7700 3400 650 800 = 4850 = 12550

3. Obesity

risk - Gestational DM - Pregnancy induced hypertension - Cesarean section - IUFD Hesitant to gain weight during pregnancy Should be told that pregnancy is not a time for weight loss

4. Adolescence
Risk factor for poor pregnancy outcome in teenagers Maternal age 15 yrs - Pregnancy < 2 yrs after onset of menarche - Poor nutrition & low prepregnancy weight - Poor weight gain - Infection - STD infection - preexisting anemia
-

Substance abuse : smoking, drinking, drugs Poverty Lack of social support Lack of education Rapid repeat pregnancies Lack of access to ageappropriate prenatal care Late entry into the health care system

Deficiencies of : - folic acid - other vitamins - calcium - vitamin D - energy - micronutrients

Clinical findings : - poor weight gain during pregnancy - LBW - premature birth

Physiologic changes in the GI tract

Primarily as a result of the relaxation of smooth muscle Esophageal regurgitation, emptying time of the stomach, reverse peristalsis heart burn water absorption from the colon constipation Hormonal changes nausea & vomiting

Nutritional requirements

Energy

- additional energy is required - metabolism by 15% - 2002 DRI : - 1st trim : = not pregnant - 2nd trim : + 340 360 kcal/day - 3rd trim : + 112kcal/day

Protein

Additional protein is required support the synthesis of maternal & fetal tissues RDA : 71 g (> 25 g than not pregnant) Deficiency adverse consequences

Specific nutrients to consider

Folic acid Calcium Iron Zinc

Folic acid

req, for - maternal erythropoiesis - fetal & placental growth - prevention of NTD RDA : 600 g 400 g from fortified foods or supplement & 200 g from foods Deficiency : - megaloblastic anemia - congenital malformations

The Centers for Disease Control & Prevention :

all female of childbearing age their intake of folic acid, because : - 50% of all pregnancies in US are unplanned - neural tube closed by 28 days of gestation Supplementation should begin before conception

US Public Health Service : - all women of childbearing age capable of becoming pregnant should consume 400 g folic acid /day

The American College of OG : - women who are planning a pregnancy & have previously had a child with NTD take 4 mg of folic acid/day beginning 1 mo prior to conception 3 mo of pregnancy

Three major type of Neural Tube Defects

Anencephaly

Spina bifida

Encephalocele

PHYSICAL IMPACT
Spina bifida often causes lifelong disabilities: paralysis

NTDs can require complex medical management, often including multiple surgeries.

Folate-rich Foods
Orange juice, oranges Liver Avocado Dried beans and peas; lentils Dark green leafy vegetables (spinach, mustard, turnip, collard greens) Broccoli Asparagus

Fortified Foods

Good way to get synthetic folic acid with minimal behavior change Blood levels are increasing

Pasta fortified with 140 micrograms per 100 grams flour (FDA, January 1998)

Folic acid

30%

Iron

RDA 27 mg/day (18 mg for non pregnant) Many women start pregnancy with poor iron stores & target iron intake is often not achieved from diet alone supplementation is often necessary 30 mg in divided doses of ferrous iron supplements daily during the 2nd & 3rd trim

Calcium
AI 1000 1300 mg Supplementation is necessary for those who do not drink milk or eat dairy products Daily intake < AI calcium loss from maternal skeleton

Increased Requirements

Nonnutritive substances in food

Caffeine - risk of 1st trim spontaneous abortion as consumption from 100 mg to > 500 mg /day

Food beliefs

Most change their diets medical advice, beliefs, food preferences, appetite May be idiosyncratic or culturally patterned Harmful : - elimination of animal protein - attempt to limit weight gain to produce smaller fetus easier delivery

Pica

Consumption of substance with little or no nutritional value (dirt, clay, ice, chalk, baking soda, hair, stone, cigarette ashes) Some reasons : - relief of nausea or nervous tension - a deficiency of an essential nutrient - pleasant sensation when chewing Possible risks : gastrointestinal disorders

Nausea & Vomiting

Common during 1st trim, resolves 13th 14th wk Vomit excessively deficit in protein, energy, vitamins & minerals Fluid & electrolyte imbalance (+) hospitalized for rehydration & prevent ketosis

Recommendation for nausea & vomiting

Eat crackers or dry cereal before getting out of bed in the morning Eat small, frequent meals Liquids are best consumed between meals Avoid drinking coffee and tea Avoid or limit intake of fatty and spicy foods

Heartburn
Common during the latter part of pregnancy Often occurs at night Effect of pressure from the enlarged uterus on the intestine & stomach, relaxation of the esophageal sphincter regurgitation

Recommendation for heartburn

Eat small low-fat meals, slowly Drink fluids between meals Avoid spices Avoid lying down for 1 to 2 hours after eating or drinking Wear loose-fitting clothing

Constipation & hemorrhoids

Usually occurs in the 3rd trim Causes : - gut motility - physical inactivity - pressure exerted on the bowel by the enlarged uterus

Recommendation for constipation

Drink 2 to 3 quarts of fluids daily Eat high-fiber foods, including cereals, whole grains, legumes and fresh fruits and vegetables Be physically active Avoid taking laxatives

Gestational DM

Goal : - provide all required nutrients - prevent hyperglycemia & ketosis - insure appropriate weight gain Meal plan is individualized & expert care is needed

Summary

Energy intake to meet nutritional needs and allow for about 0.4kg weight gain /wk during the last 30 wk of pregnancy Protein intake to meet nutritional needs Mineral & vitamin intakes to meet RDA ( For folic acid requires supplementation and for iron it is also likely that is required) Alcohol omitted Caffeine in moderation

HEALTHY BABIES START WITH HEALTHY MOMS