Maternal Nutrition During Pregnancy

CHAPTER 11
Nutrition During Pregnancy and Lactation

Sharon M. Nickols-Richardson

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Maternal Nutrition
and the Outcome of Pregnancy

Early Medical Practice
 Two assumptions, now known to be false,
governed practice:
 1. The parasite theory: whatever the fetus needs, it
draws from maternal stores despite the maternal diet
 2. The maternal instinct theory: whatever the fetus
needs, the pregnant woman instinctively craves and
consumes

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2

Maternal Nutrition
and the Outcome of Pregnancy – Cont’d

Healthy Pregnancy
 A healthy pregnancy has often been defined by
the birth weight of the newborn


Maternal Nutrition

Factors Determining Nutritional Need
 Maternal nutrition is critically important to both
the mother and newborn
 Age, gravida, and parity determine nutritional
requirements of the woman during her
pregnancy


Maternal Nutrition

Complex Physiologic Interactions
of Gestation
 Three distinct biologic entities are involved
during gestation:
 1. The woman
 2. The fetus
 3. The placenta, which nourishes fetal growth


Basic Concepts Involved

 Three basic concepts form a fundamental
framework for assessing maternal nutritional
needs and for planning supportive prenatal
care for the woman:
 1. Perinatal concept
 2. Synergism concept
 3. Life continuum concept


Preconception Nutrition

 Preconception counseling and optimal
preconception nutrition may increase the
odds for a healthy pregnancy and desirable
infant outcome


Preconception Nutrition – Cont’d
Exercise
 Women who exercise before pregnancy
should continue a reasonable exercise
regimen during pregnancy
 Kilocalories (kcalories or kcal) must be
consumed to meet the energy cost of
exercise and to promote appropriate maternal
weight gain and fetal growth and
development
 Adequate hydration is also vital

Nutritional Demands of Pregnancy

 Kcalories must be sufficient to perform the
following two functions:
 1. Supply the increased energy and nutrient
demands created by the increased metabolic
workload, including some maternal fat storage and
fetal fat storage to ensure an optimal newborn size
for survival
 2. Spare protein for tissue building


Nutritional Demands of Pregnancy –
Cont’d

 Approximately 340 additional kcal/day are
needed during the second trimester
 Approximately 450 additional kcal/day during the
third trimester


Cont’d

Protein
 Approximately 71 g/day is needed
 More protein is necessary for the following:
• Rapid fetal growth
• Enlargement of the uterus, mammary glands, and placenta
• Increase in maternal circulating blood volume


Cont’d
Protein – cont’d
 Approximately 71 g/day is needed – cont’d
 More protein is necessary for the following: –
cont’d
• Formation of amniotic fluid
• Storage reserves for labor, delivery, and lactation
 Milk, egg, cheese, and meat are complete protein
foods


Cont’d

 An adequate supply of essential fatty acids is
needed
 Linoleic acid: 13 g/day
 Alpha-linolenic acid: 1.4 g/day


Cont’d
Carbohydrates
 At least 175 g/day during pregnancy
 Whole grain breads, cereals, fresh fruits, and
vegetables should be consumed


Cont’d

 Total daily dietary kcalorie intake should
comprise:
 15% protein
 30% fat
 55% carbohydrate


Cont’d
Calcium
 1000 mg of calcium per day
 Essential element for the construction and
maintenance of bones and teeth
 An important factor in the blood-clotting
mechanism and normal muscle action


Cont’d

Iodine
 70 µg/day during pregnancy
 Vital for thyroid hormone synthesis and
prevention of goiter


Cont’d
Iron
 27 mg of iron per day
 A daily supplement of 30 to 60 mg of iron may
be prescribed
 Maternal iron is needed to supply iron to the
developing placenta and fetal liver


Cont’d
Iron – cont’d
 Major food source of iron is liver
 Other food sources include meat, legumes,
dried fruit, green leafy vegetables, eggs, and
enriched bread and cereals


Cont’d
Zinc
 Increases from 8 to 11 mg/day
 Vital for enzymatic reactions
 Essential to growth and development due to
its role in deoxyribonucleic acid (DNA) and
ribonucleic acid (RNA) synthesis and protein
production
 Seafood, eggs, and meat are primary sources
of zinc


Cont’d
Vitamin A
 770 µg of retinol activity equivalents (RAE)
 Essential factor in cell differentiation, organ
formation, maintenance of strong epithelial
tissue, tooth formation, and normal bone
growth


Cont’d

Vitamin A – cont’d
 Good sources: Liver, egg yolk, butter and
fortified margarine, dark green and yellow
vegetables, and fruits


Cont’d
B Vitamins
 Special need for thiamin, riboflavin, niacin,
pyridoxine, cobalamin, pantothenic acid, and
folate during pregnancy
 Coenzyme factors in a number of metabolic
activities related to energy production, tissue
protein synthesis, and function of muscle and
nerve tissue


Cont’d

Folate
 600 µg/day during pregnancy
 500 µg/day during lactation


Cont’d

Vitamin C
 85 mg/day for the pregnant woman
 Essential to the formation of intercellular cement
substance in developing connective tissues and
vascular systems


Cont’d

Vitamin D
 5 µg cholecalciferol (200 IU/day)
 Used to promote the absorption and utilization of
calcium and phosphorus


General Daily Food Pattern

 Two useful general principles:
 1. Eat an appropriate quantity of food
 2. Eat regularly, avoiding fasting or skipping
meals, especially breakfast


Alternative Food Patterns

 With the increasing ethnic diversity in the United
States, it is especially important to use the
woman’s personal cultural food patterns in
dietary counseling


Dietary Supplements

 “Prenatal vitamins” are often prescribed for
pregnant women
 Supplements include a variety of vitamins
and minerals and are intended to add to
nutrient intake from foods rather than replace
food and nutrient consumption
 Herbal and botanical supplement use during
pregnancy is discouraged


Weight Gain During Pregnancy

 An average weight gain during normal
pregnancy is about 11 to 16 kg (25 to 35 lb)
 Normal weight women with body mass index
(BMI) of 19.8 to 26.0: 11.5 to 16 kg (25 to 35
lb)
 Underweight women with BMI of less than
19.8: 13 to 18 kg (28 to 40 lb)


Weight Gain During Pregnancy – Cont’d

 Overweight women with BMI of greater than
26.0 to 29.0: 7 to 11.5 kg (15 to 25 lb)
 Obese women with BMI of greater than 29.0:
minimum of 7 kg (15 lb)


Quality of Weight Gain

 Foods consumed should be nutrient dense,
not full of empty kcalories
 Analysis of the total tissue gained in an
average pregnancy shows that the largest
component, 62%, is water
 Fat accounts for 31% and protein for 7%
 Weight reduction should never be undertaken
during pregnancy


Rate of Weight Gain

 Approximately 1 to 2.3 kg (2 to 5 lb) is an
average weight gain during the first trimester
 An average weight gain of about 0.5 kg (1
lb)/week during the remainder of the
pregnancy is usual
 Some women may need to gain more


Rate of Weight Gain – Cont’d

Sodium Intake
 1.5 to 2.3 g/day
 Limiting sodium beyond this general use is
contrary to physiologic need in pregnancy
and is unfounded


Functional Gastrointestinal Problems
Nausea and Vomiting
 Usually mild and short term, the so-called
“morning sickness” of early pregnancy
 At least 50% of all pregnant women experience
this condition


Functional Gastrointestinal Problems –
Cont’d

Hyperemesis
 Approximately 3.5:1000 pregnancies
 Severe form of persistent nausea and vomiting
occurs that does not respond to usual treatment
 May develop into the more serious pernicious
form of hyperemesis gravidarum


Cont’d
Constipation
 Contributes to discomfort and concern
 Placental hormones relax the gastrointestinal
muscles
 The pressure of the enlarging uterus on the
lower portion of the intestine may make
elimination somewhat difficult


Cont’d

Constipation – cont’d
 Increased fluid intake, the use of naturally
laxative foods containing dietary fiber, and
exercise may help


Cont’d
Hemorrhoids
 Common complaint during the latter part of
pregnancy
 May cause considerable discomfort, burning,
and itching
 Problem is usually controlled by the dietary
suggestions given for constipation


Cont’d

Heartburn and Gastric Pressure
 Discomforts occur especially after meals and are
usually caused by the pressure of the enlarging
uterus crowding the stomach
 Usually remedied by dividing the day’s food into
a series of small meals


High-Risk Pregnancies

Plan Personal Care
 Once early assessment identifies risk factors,
practitioners can then give more careful
attention to these women
 A food plan can be developed with the
woman to ensure an optimal intake of energy
and nutrients to support her pregnancy


High-Risk Pregnancies – Cont’d

Recognize Special Counseling Needs
 Several special needs require sensitive
counseling
 Include the age and parity of the woman; any
use of harmful agents such as alcohol,
cigarettes, drugs, or pica; and socioeconomic
problems



Age and Parity
 Nulligravida (no prior pregnancy) who is 15
years of age or younger
 Especially at risk because her own growth is
incomplete
 Sufficient weight gain and the quality of her diet
are particularly important



Age and Parity – cont’d
 Primigravida (first pregnancy) older than 35
years also requires special attention
 May be more at risk for hypertension and need
more attention to the rate of weight gain and
amount of sodium used



Social Habits
 Alcohol
 Fetal alcohol syndrome (FAS), which is currently a
leading cause of mental retardation
 Cigarettes
 Cause fetal damage and special problems of
placental abnormalities



Social Habits – cont’d
 Drugs
 Abnormal fetal heart rate
 Fetal damage
 Poor prenatal weight gain
 Very short (less than 3 hours) or prolonged labor
 Operative delivery
 Other perinatal problems


Complications of Pregnancy

Anemia
 Associated with the normal maternal blood
volume increase of 40% to 50% and a
disproportionate increase in red cell mass of
about 20%


Complications of Pregnancy – Cont’d

Iron Deficiency Anemia
 Iron requirement typically exceeds the available
reserves in the average woman
 Daily supplement or higher therapeutic dose
may be required



Folate Deficiency Anemia
 Fetus is sensitive to folate inhibitors and
therefore has increased metabolic requirements
for folate
 Dietary Reference Intake (DRI) standard
recommends 600 µg of folate per day during
pregnancy



Hemorrhagic Anemia
 Anemia caused by blood loss is more likely to
occur during labor and delivery than during
pregnancy


Pregnancy-Induced Hypertension

 Disease that principally affects young women
with their first pregnancy
 Diets poor in kcalories, protein, calcium,
magnesium, potassium, and dietary fiber
have been associated with risk of pregnancy-
induced hypertension (PIH)


Pregnancy-Induced Hypertension –
Cont’d

Clinical Symptoms
 Abnormal and excessive edema, albuminuria,
and, in severe cases, convulsions or coma, a
state called eclampsia


Pregnancy-Induced Hypertension –
Cont’d

Treatment
 Regular diet with adequate dietary protein and
calcium and one that is rich in fruits and
vegetables, providing magnesium, potassium,
and dietary fiber


Multiple Fetuses

 Energy intake must be increased beyond the
needs of a singleton pregnancy such that the
recommended weight gain for multiple
fetuses is achieved
 Adequate folate intake is critical to reduce
risks of low birth weights


Multiple Fetuses – Cont’d

 Supplemental iron may be necessary
 Additional calcium and vitamin D are needed
 Zinc, copper, and pyridoxine supplementation
may also be required


Maternal Disease Conditions

 Some of these problems can be prevented by
initial screening and continued monitoring by
the prenatal nurse, with referral to the clinical
nutritionist for a plan of care:
 Hypertension
 Diabetes mellitus
 Phenylketonuria (PKU)
 Acquired immunodeficiency syndrome (AIDS)
 Eating disorders


Nutrition During Lactation

 Approximately 71% of mothers initiate breast-
feeding
 Exclusive breast-feeding by well-nourished
mothers can be adequate for periods ranging
from 2 to 15 months


Nutrition During Lactation – Cont’d

 The basic nutritional needs for lactation
include the following additions to the mother’s
prepregnancy needs:
 Energy: Caloric increase is 330 kcal/day (plus
170 kcal/day from maternal stores) for first 6
months and 400 kcal/day in the second 6 months
 Protein: 71 g/day during first 6 months
 Calcium: 1000 mg/day



prepregnancy needs: – cont’d
 Vitamins: DRI for Vitamin C during lactation is
120 mg/day
 Fluids: A pale yellow color of the urine suggests
adequate fluid intake
 Dietary supplements: Continue the woman’s
prenatal nutrient supplements during lactation



prepregnancy needs: – cont’d
 Rest and relaxation: Both parents may benefit
from counseling focused on reducing the stresses
of their new family situation
 Maternal medical conditions: Some conditions
exist for which it is recommended that women in
the United States not breast-feed


Maternal Nutrition During Pregnancy

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