This document provides an overview of nutrition during pregnancy. It discusses topics like physiology of pregnancy, fetal growth and development, pregnancy weight gain recommendations, and nutrient needs. Key points include how the placenta functions in nutrient and gas exchange for the fetus, critical periods of fetal development, recommendations for adequate weight gain and composition of weight gain during pregnancy, and increased energy and nutrient needs including protein, fat, vitamins, minerals, and water. Nutrition is essential for reducing risks of complications like preterm birth and low birthweight.

1. NUTRITION DURING
PREGNANCY
DR. SHARIFAH WAJIHAH WAFA BTE SST WAFA
School of Nutrition and Dietetics
Faculty of Health Sciences
sharifahwajihah@unisza.edu.my
KNOWLEDGE FOR THE BENEFIT OF HUMANITY

2. Introduction
• Topics covered include:
– Status of pregnancy outcome
– Physiology of pregnancy
– Embryonic & fetal growth and development
– Pregnancy weight gain
– Nutrition and course/outcome of pregnancy
– Nutrient needs during pregnancy

3. Time-related Terms Before, During,
and After Pregnancy

4. The Status of Pregnancy Outcomes
• Infant mortality:
– Reflects general health and socioeconomic
status of a population
– Decreases in mortality related to
improvements in social circumstances,
safe & nutritious food availability, &
infectious disease control

5. Natality Statistics: Rates, Definitions, and
Trends in the Rates in Malaysia

6. Natality Statistics: Rates, Definitions, and
Trends in the Rates in Malaysia

7. Natality Statistics: Rates, Definitions, and
Trends in the Rates in Malaysia

8. Natality Statistics: Rates, Definitions, and
Trends in the Rates in Malaysia

9. Natality Statistics: Rates, Definitions, and
Trends in the Rates in Malaysia

10. Low Birthweight, Preterm Delivery,
and Infant Mortality
• Low birth weight or preterm infants at
high risk of dying in 1st year of life
– 8.2% of births are LBW yet comprise 66%
of infant deaths
– 12% are born preterm yet account for high
incidence of infant deaths

11. Reducing Infant Mortality and
Morbidity
• Improve birth weight of newborns
– Desirable birth weight = 3500-4500 g
• Infants born with desirable wt are less
likely to develop:
• Heart and Lung diseases
• Diabetes
• Hypertension

12. Physiology of Pregnancy
• Key terms:
– Gestational age
• Assessed from date of conception
• Average pregnancy is 38 weeks
– Menstrual age
• Assessed from onset of last menstrual period
• Average pregnancy is 40 weeks

13. Maternal Physiology
• Changes in maternal body composition
& functions occur in specific sequence

14. Normal Physiological Changes
during Pregnancy
– Two phases of changes:
– Maternal anabolic changes
• Takes place in the 1st half of pregnancy
– Maternal catabolic changes
• Takes place in the 2nd half of pregnancy

15. Maternal Anabolic and Catabolic
Phases of Pregnancy

16. Body Water Changes
• Body water increases from ~7 L to 10 L
– Results from increased blood and body
tissues & extracellular volume & amniotic
fluid
• Edema
– Swelling due to accumulation of
extracellular fluid

17. Key Placental Hormones and
Examples of their Roles
• physiological changes in pregnancy are
modulated by hormones produced by the
placenta.
• Human chorionic gonadotropin (hCG)
– Maintains early pregnancy by stimulating the
corpus luteum to produce estrogen and
progesterone.
– It stimulates growth of the endometrium.
– The placenta produces estrogen and progesterone
after the first 2 months of pregnancy

18. Key Placental Hormones and
Examples of their Roles
• Progesterone
– Maintains the implant;
– stimulates growth of the endometrium and its
secretion of nutrients;
– Relaxes smooth muscles of the uterine blood
vessels and GI tract;
– stimulates breast development;
– promotes lipid deposition
• Leptin
– May participate in the regulation of appetite and
lipid metabolism, weight gain, and utilization of fat
stores

19. Key Placental Hormones and
Examples of their Roles
• Estrogen
– Increases lipid formation and storage, protein
synthesis, and uterine blood flow;
– Prompts uterine and breast duct development;
– Promotes ligament flexibility
• Human chorionic somatotropin (hCS)
– Increases maternal insulin resistance to maintain
glucose availability for fetal use;
– promotes protein synthesis and the breakdown of
fat for energy for maternal use

20. Maternal Nutrient Metabolism
• Changes can be seen in the first few
weeks after conception.
• Ensures that nutrients will be available
to the fetus when needed.

21. Carbohydrate Metabolism
• Glucose is preferred fuel for fetus
• “Diabetogenic effect of pregnancy” results from
maternal insulin resistance

22. Carbohydrate Metabolism
• Early pregnancy:
– High estrogen & progesterone stimulate
insulin which increases glucose
glycogen & fat
• Late pregnancy:
– Human chorionic somatotropin (hCS) &
prolactin inhibit conversion of glucose to
glycogen & fat

23. Protein Metabolism
• About 925 g of protein accumulate during
pregnancy
• Protein & amino acids conserved during
pregnancy
• No evidence the body stores protein early in
pregnancy
• Needs must be met by mother’s intake of
protein

24. Fat Metabolism
• Fat stores
– Accumulate in first half of pregnancy
– Enhanced fat mobilization in last half
• Blood lipid levels increase
• Increased cholesterol is substrate for steroid
hormone synthesis

25. Mineral Metabolism
• Calcium
– Increased bone turnover & reformation
• Sodium
– Accumulation in mother, placenta, & fetus
– Restriction of sodium potentially harmful

26. The Placenta
• Functions:
– Hormone & enzyme
production
– Nutrient & gas
exchange
– Remove waste from
fetus
• Structure:
– Double lining of cells
separating maternal
& fetal blood

27. Structure of the Placenta

28. The Placenta
• Nutrient Transfer
– Factors that affect the transfer:
• Size and charge of molecules
• Small molecules pass through most easily
• Lipid solubility of particles
• Concentration of nutrients in maternal and fetal
blood

29. The Placenta
• Nutrient Transfer
– The fetus is not a parasite
– Nutrients first used for maternal needs,
then for placenta & last for fetal needed
– The fetus is harmed more than the mother
by poor maternal nutrition

30. Mechanisms of Nutrient Transport
Across the Placenta

31. Embryonic and Fetal Growth and
Development
• Growth and Development
– Is at the highest level during the 9 months
of gestation
– If rate gain continued at this level, at 1 year
of age the infant would be 160 lbs
– Table 4.12 provides an overview of
embryonic and fetal development during
pregnancy

32. Critical Periods of Growth and
Development
• Differentiation
– Cellular acquisition of one or more characteristics
or functions different from that of the original cell
• Critical Periods
– Preprogrammed time periods during
embryonic & fetal development when specific
cells, organs & tissues are formed & integrated or
functional levels established

33. Critical Periods of Growth and
Development
• Four periods of growth & development
1) Hyperplasia( cell multiplication)
2) Hyperplasia & hypertrophy
3) Hypertrophy( cell growth)
4) Maturation (stabilization of cell
number & size)

34. Fetal Body Composition

35. Variation in Fetal Growth
• Variations linked to:
– Energy, nutrient, & oxygen availability
– Genetically programmed growth &
development
– Insulin-like growth factor (IGF-1) is main
fetal growth stimulator

36. Newborn Weight Classifications
• Terms to describe newborn size
– SGA (small for gestational age)
– dSGA (disproportionately small for
gestational age)
– pSGA (proportionately small for gestational
age)
– AGA (appropriate for gestational age)
– LGA (large for gestational age)

37. Variation in Fetal Growth
• Small for Gestational Age (SGA)
–Newborn weight is<10th
percentile for
gestational age.
– Also called small for date (SFD)

38. Disproportionately Small for
Gestational Age (dSGA)
• Newborn weight is<10th percentile of weight for
gestational age; length and head circumference are
normal.
• experienced in utero malnutrition in the third trimester
of pregnancy
• Short-term episodes of malnutrition, such as maternal
weight loss or low weight gain late in pregnancy that
compromise energy, nutrient, or oxygen
• Infants generally have smaller organ sizes but the
normal number of cells in organs and tissues.

39. Proportionately Small for Gestational
Age (pSGA)
• Newborn weight, length, and head
circumference are <10th percentile for
gestational age.
• experienced long-term malnutrition in utero,
due to factors such as
– prepregnancy underweight,
– consistently low rates of maternal weight gain in
pregnancy
– corresponding inadequate dietary intake, or
chronic exposure to alcohol

40. Large for gestational
age (LGA)
• Newborns with weights > 90th percentile for
gestational age
• Factors:
– Pre-pregnancy obesity,
– poorly controlled diabetes in pregnancy,
– Excessive weight gain in pregnancy (over 20kg)
• Experience far lower illness and death rates
than do SGA infants,
• Tend to be taller later in life.

41. Nutrition, Miscarriages and Preterm
Delivery
• Miscarriages
– Thought to be caused by chromosome
abnormalities, thyroid disorders, hormone
imbalances, infections
• Underweight increases risk
• Elevated blood cholesterol or triglycerides
increase risk
• Multivitamin use reduces risk

42. Nutrition, Miscarriages and Preterm
Delivery
• Preterm Delivery
– Infants born preterm are at risk for death,
neurological problems, congenital
malformations, & chronic health problems
• Multivitamin supplements or folate intake
decrease risk
• 1-3fish meals per week are protective
• Underweight and obesity increase risk
• Elevated blood lipids increase risk

43. Pregnancy Weight Gain
• Weight gain during pregnancy is related
to the weight and health status of the
newborn infant
• Recommendations for weight gain are
influenced by the pre-pregnancy status
of the mother

44. Pregnancy Weight Gain Recommendations

45. Composition of Weight Gain
• The fetus is only about 1/3 of the total weight gain
• The balance of the weight gain is related to body
fat changes, placenta, amniotic fluid, increase of
extracellular fluids, and blood supply of the mother

46. Postpartum Weight Retention
• Much concern over pregnancy weight
gain and long-term obesity
– 6kg lost at delivery
– Wt loss difficult in women who gained
>20kg
– Women with recommended wt gain in
pregnancy are ~1 kg heavier at 1 yr
postpartum
– Lactating women lose slightly more

47. Energy and Nutrient Needs During
Pregnancy
• Nutrient needs vary during the course
of the pregnancy
• Overall, nutrient needs can be met with
well balanced, adequate and healthful
diets consisting of basic foods

48. Energy and Nutrient Needs During
Pregnancy
• Energy requirements in pregnancy
– +360/d in 2nd trimester
– +470/d in 3rd trimester
• Assessment of caloric intake
– Most easily assessed by pregnancy weight
gain
– As long as there is no noticeable edema

49. Carbohydrates
• Carbohydrate intake (50-60%)
• Functions
– Main energy supply
– Promotes weight gain of the fetus
• Basic foods such as
– vegetables, fruits, and whole grains with fibers =
best choice
• Precautions
– Limit refined sugar intake (sweet beverages and
foods) that can increase risk of GDM

50. Protein
• Protein requirements (15-20%)
– 55 g + 7.5 = 62.5 g
– Average intake of typical female ~78 g
• Function:
– For growth and maintenance of tissue and
overall metabolism
• Precaution
– Commercial protein supplements are not
recommended

51. The Need for Fat
• Fat requirements (20-30%)
– 2nd
trimester: 54-82 g/day
– 3rd
trimester: 57-85 d/day
– SFA: <30%
– MUFA: 12-15%
– PUFA: 5-7%
• Fat consumed in food is used as an
energy source for fetal growth and
development

52. Omega-3 Fatty Acids, EPA, and DHA
During Pregnancy
• Omega-3 (PUFA): important for fetal’s
brain and eye development
• Adequate EPA & DHA during
pregnancy & lactation linked to higher
intelligence, better vision & more
mature CNS

53. Vitamins
• Folate and pregnancy outcome
– Folate background
• Known to be associated with anemia and
reduced fetal growth
• Folate requirements  - extensive organ and
tissue growth
– Recommended intake: 600 mcg DFE
(dietary folate equivalents)
– Functions of folate
• Metabolic reactions
• Deficiencies lead to abnormal cell division and
tissue formation

54. Vitamins
• Folate and pregnancy outcome
– Folate and congenital abnormalities
• NTDs = Neural Tube Defects
• Malformations of the spinal cord and brain
• Three major types
– Spina bifida
– Anencephaly
– Encephalocele

55. A Newborn Child with Spina Bifida

56. Vitamins
• Choline
– Fetal brain growth
– Intellectual development
• Vitamin A
– Needed for cell differentiation
• Vitamin D
– Supports fetal growth
– Supports immune system

57. Minerals
• Calcium requirements in pregnancy
– RNI: 1000mcg
– Needed for fetal skeletal mineralization and
maintain maternal bones
– Calcium and release of lead from bones
• Low intakes of calcium are related to increased release
of lead—harmful to fetus
– Needs can be met with 3 cups of milk or calcium-
fortified soymilk or other adequate sources of
calcium.

58. Minerals
• Fluoride
– Teeth begin to develop in utero
– Limited amount of fluoride transferred from
mother
– Not recommended to supplement

59. Minerals
• Iron
– RDA: 27mg/day
– Function: carry oxygen to cells development and
infants iron storage
– Iron deficiency:
• a condition marked by depleted iron stores with
weakness, fatigue, short attention span, poor appetite,
increased susceptibility to infection and irritability
– Iron deficiency anemia:
• a condition marked by low hemoglobin with signs of iron
deficiency plus paleness, exhaustion and rapid heart rate

60. Minerals
• Iron-deficiency anemia in pregnancy
– Early pregnancy-risk of preterm delivery,
LBW
– Late pregnancy-lower scores on
intelligence, language, gross motor and
attention tests

61. Iron Supplementation
• Recommendations related to iron
supplementation in pregnancy
– Supplement with 30-mg iron daily after the
12th week of pregnancy
– 60-180 mg/day for iron deficiency anemia
– Women with ferritin >30 ng/mL will not
need supplement
– UL during pregnancy is 45 mg/day

62. Iron Supplementation
• Pros & Cons of Iron Supplementation
– Iron is absorbed better from supplements
containing iron only than when mixed with
other minerals
– Amount absorbed depends on the need
and the amount of iron in the supplement
– Side effects-nausea, cramps, gas &
constipation

63. Iron Supplementation
• Pros & Cons of Iron Supplementation
– >free radicals in GI tract- cause
inflammation & mitochondrial damage to
cells
– May interfere with zinc absorption

64. Other Mineral Concerns
• Iodine
– Required for thyroid function & energy
production and for fetal brain development
• Sodium
– Plays a critical role in maintaining body’s
water balance
– Restriction not indicated in normal
pregnancy or for control of edema or high
blood pressure

65. Bioactive Components of Food
• Bioactive food components are foods or
dietary supplements other than those
needed to meet basic human nutritional
needs that are responsible for changes
in health status
– Include phytochemicals and antioxidant
pigments
– Are not considered essential nutrients but
influence health

66. Caffeine Use in Pregnancy
– No apparent long-term consequences for
children of coffee intake during pregnancy
– Moderate intake: <300 mg/day
– High intake: >500 mg/day

67. The Need for Water
• Met by increased levels of thirst
– Average consumption ~9 cups fluid per day
– Recommend water, diluted fruit juice, iced
tea, and other unsweetened beverages

68. Factors Affecting Dietary Intake
During Pregnancy
• Effect of taste and smell changes
during pregnancy on intake
– May lead to changes in taste and smell
– Pica may result
• Pica
– Eating disorder: Eat non-food substances
• Cultural considerations

69. Dietary Supplements During
Pregnancy
• Multivitamin and Mineral Prenatal
Supplements
– Nutrient needs should be met by a well-
balanced diet
– Iron is considered to be the exception
– Recommended for inadequate diets,
multifetal pregnancy, smokers, drinkers,
vegans, or diagnosed nutrient deficiencies

70. Herbs to Avoid in Pregnancy

71. Food Safety Issues During
Pregnancy
• Foodborne illness
– Listeria monocytogenes
– Toxoplasma gondii
• Mercury contamination
– High levels in large, long-lived predatory fish
– Lower content in bottom feeders
– Avoid shark, swordfish, king mackerel, tile fish,
albacore tuna, walleye, pickerel, bass

72. Assessment of Nutritional Status
During Pregnancy
• Dietary assessment – usual intake,
supplement use, weight gain progress
• Nutrition biomarker assessment – iron
and other vitamins and minerals,
triglycerides

73. Exercise and Pregnancy Outcome
• No evidence that moderate or vigorous
exercise undertaken by healthy women
is harmful
• Exercise recommendation for pregnant
women
– 3-5 times each week for 20-30 minutes at
60-70% VO2 max

74. Common Health Problems During
Pregnancy
• Nausea and vomiting
– Hyperemesis gravidarum
• Severe N/V during most of pregnancy
– Management of nausea and vomiting
• Separate liquid & food intake
• Avoid odors and foods that trigger N/V
– Dietary supplements for the treatment of
nausea and vomiting
• Vitamin B6, multivitamins, & ginger

75. Common Health Problems During
Pregnancy
• Heartburn
– Management of heartburn
• Ingest small meals frequently
• Do not go to bed with a full stomach
• Avoid foods that make heartburn worse
• Constipation
– Prevention
• Consume dietary fiber (30 grams/day)
• Drink water along with the fiber
• Laxative pills are not recommended

76. THANK YOU
KNOWLEDGE FOR THE BENEFIT OF HUMANITY