Chapter 15

Nutrition in Pregnancy
And
Lactation
 Pregnancy
 It is the most critical and unique period In
human life.
 The foundation of a new life is being laid that
will influence the future of succeeding
generation.
 Has a social importance affecting not only
individual but also their families and society as
a whole.
 During this stage the
mother and child have
an intimate and
inseparable relationship.

 It is the period from

conception to birth and
for human being last
from 38-42 weeks.
 Physiological basis of nutritional
needs in Pregnancy

Stages of Pregnancy
 Implantation
 Organogenesis
 Growth
 Implantation
 The period in which the
fertilized ovum implants
itself in the uterus and
being develop.

 Occurs during the first

to second week of
conception.
 Organogenesis
 The embryo undergoes
differentiation or rapid
cell division that occurs
during 2-8 weeks after
conception
 This is a critical period
when organs are being
formed and most
vulnerable to adverse
influences.
 If cell division and the final cell number achieved
in an organ are limited during this period, it will
have irreversible effects on later developmental
stage.
 Growth

 Occurs during on the

remaining 7 months.
 Blood Volume and Composition
 The plasma volume begin to increase towards
the end of the first trimester and by 34 weeks.
It is 50% greater at conception, if nutrients and
blood constituents do not keep up with the
expansion in plasma volume, their
concentration will decrease even the total
amounts may rise.
 It will lead to a condition called
“Physiological anemia of pregnancy”
 Circulatory System
 There is a slight cardiac hypertrophy or
dilation due to increased blood volume and
cardiac output.
 As the diaphragm is displaced upward, the
heart is elevated upward and to the left, pulse
increases slowly up to the 10-15 bpm between
14-20 and persist to term.
 Bradycardia and palpitation may occur after
delivery and persist for one week.
 There is decreased in systolic and diastolic
blood pressure of 5 to 10 mm Hg due to
peripheral vasodilatation from hormonal
changes in pregnancy during the first half of
pregnancy.
 During the third trimester, blood pressure
should return to the values obtained during the
first trimester.
 Cardiac output increases from 30-50% by the
32nd week of pregnancy and declines to about
20% increase at 40 weeks.

 This is due to the increased stroke volume and

response to increased tissue demands for
oxygen.
 Respiration
 Maternal oxygen
requirements increases due
to acceleration in basal
metabolic rate and the need
to add tissue mass in the
uterus and breast.
 There is increased
vascularization in the
respiratory tract due to
elevated levels of estrogen.
 Edema and Hyperemia
- occurs during
elevation of the
capillaries.
 Tympanic membrane and Eustachian tube swell,
giving rise to symptoms of impaired hearing
earaches of a sense of fullness in the ear.

 Thoracic breathing replaces abdominal breathing

with advancing pregnancy.

 The pregnant women breaths more deeply but

increases her respiratory only slightly (2bpm)
 Renal Function
 Blood flow through the kidneys and the
glomerular filtration rate are increased during
pregnancy to facilitate the clearance of waste
production of fetal and maternal metabolism.
 Glucose
 Amino-acid
 Water soluble vitamins
 - they appears in the urine instead of being
reabsorbed by the kidneys to preserve body
balance.

The reason is that high glomerular filtration rate

offers the tubules greater quantities of nutrient
that they can possibly absorb.
 Gastrointestinal function
 Loss of appetite, nausea and vomiting may
occur during the 1st trimester of pregnancy due
to hormonal changes. There may be alteration
in the sense of taste such as preference for
stronger salt solution compared with non
pregnant women.
 Smooth muscle of GI
- decreased tome of the gallbladder and this
condition together with hypercholesterolemia
Due to increased progesterone, may be the cause
of frequent gallstone during pregnancy.

some cause of discomfort due to

intro- abdominal alteration
 Pelvic pressure
 flatulence
 distention
 Bowel cramping
 Venous pressure increases in the pelvic organ
due to the displacement of the intestines and
pressure from expanding uterus
 Hormones

 The pregnant women secretes more than 30

different hormones during the pregnancy.
 Placenta
 The function is the
production of
hormones to
regulate the activity
of pregnancy.
 Progesterone
 Causes relaxation of the
smooth muscles of the
uterus and other smooth
muscles in the body.
 Effect of this is to favor
maternal fat deposition
and increased renal
sodium excretion.
 Estrogen
 Promote growth and control the
function of the uterus
 It changes the structure of
mucopolyssacharides in connective
tissues increasing its affinity to water.
 Changes in the cardiovascular system
cause extra cellular fluid to accurate in
the feet and legs.
 Mild edema
- physiological in pregnancy and the usual
measures commonly use to prevent it such as
using diuretics and restricting dietary sodium
is not recommended because it imposes
unnecessary risk.
 Insulin

 Affects blood glucose

level by facilitating its
transport into cells to
be used for energy or
fat synthesis.
 Weight gain
 All women need to gain weight during
pregnancy for fetal growth and maternal
health.

 Some are underweight, overweight, obese

underweight
 Laura at six months
pregnant.
 BMI <19.8
 Risk for having low birth
weight infant (< 5lbs)
 Pre- term infant (born
before 38 weeks)
 Higher infant mortality
rate.
overweight
 Higher risk for having
hypertension gestational
diabetes and post partum
infection.
 More likely to born post
term and weight more than
9lbs.
 Overweight women should
try to achieve healthy body
weight before pregnancy.
Avoid too much gaining
weight.
 Recommended Range
Healthy Under Over Obese Carrying Pregnant
weight weight weight twins adolescent

11- 15kg 13-18 8-13.5 15- 35- 35lbs

(25- kg (24- kg (18- 30lbs 45lbs
35lbs) 40lbs) 30lbs)
The Role of Placenta
 Plays an active role in reproduction and is not
a passive barrier between the mother and the
fetus.
 It is the principle site for the production of
several hormones that regulate maternal
growth and development
 The placenta supplies the fetus with maternal
nutrients, and allows fetal waste to be disposed
of via the maternal kidneys
Mechanism for nutrient transfer

 Simple Diffusion

 Facilitated diffusion

 Pinocytosis
 Simple diffusion – a passive process In which
nutrients move from high concentration in the
maternal blood to lower concentration in the
fetal capillaries until equilibrium is reached.
 Facilitated diffusion – involves a carrier in the
cell membrane so the rate of transfer is faster
than simple diffusion. A sugar are transferred
via facilitated diffusion.
 Pinocytosis – the uptake of fluid materials by a
living cell, by means of invagination of the cell
and vacuole formation.
Nutrient Requirements
 Two factors that
determine energy
requirements are the
mother usual
physical activity and
the increase in
metabolic rate to
support the work
required for growth
of the fetus and the
accessory motors.
Protein
 This nutrient is essential
as it forms the structural
basis for all new cells and
tissues in the mother and
fetus. it is based on the
needs of the non-pregnant
women used as a reference
plus the extra amounts
needed for growth. About
925gm of protein are
deposited in the normal
fetus and maternal tissues.
 Maternal and fetal growth
accelerates only during the
second month and
increases progressively
until just before terms.
Vitamins
 Important during
pregnancy, the most
importantly cited are
folic acid, ascorbic acid
and the B vitamins
Ascorbic Acid RDA
 For pregnancy is
80mgs/day,which is an
additional 10mg/day over the
needs of non pregnant state.
There had been studies
showing the role of vitamins
C in premature rupture of the
membranes. Low plasma
levels of vitamin C had been
observed in cases of pre-
eclampsia.
Thiamin,Riboflavin and Niacin
 Related to caloric
intakes, since
caloric allowances
increases during
pregnancy, the
caloric requirement
also automatically
increases during
pregnancy.
 Folic Acid
 Deficiencies of folic acid
around the time of
conception has been
associated with neural
tube defects (NTD), such
as spina bifida.
 Many babies born with
spina bifida grow into
adulthood with paralysis
of the lower limbs and
varying degrees of
bowel and bladder
incontinence
 Cause megaloblastic
anemia.
Vitamin B6
 May control nausea and
vomiting during
pregnancy is not
conclusive.
 Pyridoxal phosphate
(PLP) is the active form
and is a cofactor in many
reactions of amino acid
metabolism, including
transamination,
deamination, and
decarboxylation.
 Vitamin A
 Essential nutrient because of
its critical role in
reproduction.
 a bi-polar molecule formed
with bi-polar covalent bonds
between carbon and
hydrogen, is linked to a
family of similarly shaped
molecules, the retinoid,
which complete the
remainder of the vitamin
sequence.
 Vitamin D
 Has a positive effect on
calcium balance during
pregnancy.
 It may be involved in neonatal
calcium homeostasis.
 Poor enamel development and
neonatal hypocalcemia has
been associated with maternal
vitamin D deficiency.
 Minerals
 Needs during pregnancy are increased so
that if the mothers diet does not provide
what is required by the fetus, pregnant
women need to access their stores to
ensure that the fetus have adequate
support.
 On the other hand, excess mineral intakes
may adversely affect the fetus. Thus, on
appropriate balance is needed.
 Iron
 Needed for the manufacture of
hemoglobin in maternal and
fetal red blood cells. The fetus
accumulates most of its iron
during the third trimester.
 Iron deficiency in the mother
affects pregnancy outcome.
 A reduction is hemoglobin
increases her cardiac output to
maintain adequate oxygen
consumption by placental and
fetal cells.
Calcium
 Promote adequate mineralization of
the fetal skeleton and deciduoles teeth
during pregnancy.
 The fetus acquires most of its calcium
during the last trimester when skeletal
growth id maximum and teeth are
being formed.
 Dental carries is a common
occurrence in pregnancy and there is
a belief that calcium deficiency
causes demineralization of teeth.
 Magnesium
 The fetus accumulates
about one gram magnesium
during gestation. Hence, the
US-RDA recommends 360
to 400mg magnesium per
day for pregnant women,
which is an additional 40 to
90mg magnesium per day
over the needs for non
pregnant women.
 Iodine
 Should be adequately
provided during pregnancy
because of an increased basal
metabolic rate.
 Iodine injection in the form
of iodized oil before
pregnancy will prevent
cretinism. The adverse
consequence of iodine
overdose is mental
retardation in infants.
Zinc
 When severe reduction
of circulatory Zinc
occurs in the mother
blood, there is the
possibility of increases
risk of spontaneous
abortions and
congenital
malformation.
Fluoride
 Development of primary
dentition of the fetus starts
on the 10 to 12th weeks of
pregnancy.
 The 32 teeth are formed
during gestation. The
adequate intake of fluoride
is 3mg/day – 10mg/day
Common Nutrition-Related
concern during pregnancy
Nausea and Vomiting
 Morning sickness
 Most common discomfort during
the early part of pregnancy
 Nausea and vomiting occur after
getting up in the morning
 Caused by increase hormone
secretion
 Disappear after the first trimester
Nutrition expert recommends
 Frequent feeding of dry meals, instead of 3 large meals
 Food high in carbohydrate and low fat food can over

come nausea and vomiting

 Liquids are better taken between meals rather than

meal time
 Avoid excessive mealtime

 Piece of candy helps curb the nausea.

* Severe prolonged episode of vomiting requires

hospitalization to administer IV fluid and electrolyte
replacements to avoid dehydration
HeartBurn
 Common complaint in latter part
of pregnancy
 Pressure of the enlarged uterus
on the stomach
 Esophageal sphincter- dilation
or relaxation results in
regurgitation of acidic stomach
contents into the esophagus.
Nutrition expert recommends
 Limit the amount of food consumed at one time
 Eating less spicy
 Less greasy food
 Drinks fluids between meals rather than with meals
 Eat slowly and sit upright for at least 2hrs.after eating
 Avoid lying down after meal
 Walk around the house after meal
 Loose clothing around the waist must be worn
Constipation
 Pressure exerted by the
developing fetus on the
digestive track.

 Due to lack of exercise and

insufficient bulk and fluid
intakes
Nutrition expert recommends
 Lots of fresh fruits, vegetables, and
fluids
 Regular exercise

 Do not use medication like laxatives

without the doctor’s advice

 Bulking stool softener is

recommended.
Edema
 Present in the extremities in
the 3rd trimester.

 Swelling of the lower

extremities may be cause by
the pressure of the enlarging
uterus on the veins that
return fluid from legs.
 Recommendation

 Does not require sodium restriction or other

dietary change
Leg Cramps
 Sudden contractions of
gastrocnemius muscle

 Occur usually at night

 Decline in serum calcium

levels related to a calcium-
phosphorus imbalance
Rapid weight gain or loss
 Excessive weight gain
 Increase of a kg or more
per month in the second
and third 3rd semester
 Sudden increase in
weight after about 20th
week of gestation is
cause for suspecting that
water is being retained at
an inordinate rate and
warning sigh of
impending eclampsia
 Excessive weight loss
 Gain of less than 500 g/month during
the 1st trimester of pregnancy and 250
g during the 2nd trimester is
considered a maternal risk factor
*Effects of seriously underweight on entering
pregnancy (<38kg) or show inadequate
weight gain (<40kg)at 20th week of
pregnancy:
• Low birth weight infant/premature deliveries

• Abortions

• Brain and nerve damage to the offspring

*Causes of rapid weight loss

• Limited food budget

• Unusual dietary habit

 Unwise choices in selection of foods
 An underlying condition impairing absorption

*Protein calories supplements

• Correct past nutritional deficits and depleted stores

as well as provides for pregnancy needs.

• Committee on Nutritional Status during Pregnancy

- Recommends weight gain of 13-18kg and
pregnant women carrying twins can gain 16-
20kg.
 Pregnancy- induced Hypertension
 Toxemia of pregnancy
 Rapid weight gain, edema, high blood
pressure, excretion of albumin in the urine and
convulsions are some clinical manifestation
 Classifications:
 Pre-eclampsia
 Eclampsia
Pre- eclampsia

 Hypertension
with
proteinuria/edema
Eclampsia
 Convulsion/coma,
usually both when
associated with
hypertension,
proteinuria, edema
 Calcium and
magnesium
deficiency may play
a role in the
development of pre-
eclampsia
 Recommendations
 Protein foods of high biological value
 Sources of iron, calcium and other minerals
 Salt intake is restricted to edema
 Under go physician's care
 Anemia
 Combine deficiency
of iron and folic acid
 Effect:
 Newborn becomes
anemic
 Increased chance of
premature birth

*Preventive measure
under physician’s
care is safe.
 Gestational Diabetes Mellitus
 Diabetes may occur as a
temporary response to the stress
of pregnancy and it disappears
after the baby is born

 Effects
 Risk of perinatal death

 Prematurity

 Macrosamia of the infant

 Physiology of Lactation
 Is the period of milk production by the
mammary glands
 Its starts during adolescence when hormonal
changes brings about development and
increase;
 Breast
 Areola
 Nipple
 Prolactin and oxytocin – two main hormones
responsible for milk production.
 Colostrums- The first milk is a thick, yellowish
fluid that comes out on the 2nd to the 5h day
after delivery.
 It is very important that the baby is fed third
first milk because it contains antibodies and
immune cells.
 Rich in protein and lower in carbohydrates and
fats.
 It is laxative, which initially cleans out the
baby’s digestive organs.
 Nutritional Requirements during
Lactation
 Energy
 Water and other fluids
 Protein
 Lipid
 Minerals
 Vitamins
Advantages of Breast Feeding
1. Human milk is nutritionally superior to other kinds of milk.
2. Breast milk is bacteriologically safe.
3. Breast milk is always fresh and the right temperature for the
body.
4. It contains immune cells and antibodies that will give
natural immunity for the baby.
5. It is the least allergenic of any infant food.
6. It is inexpensive compared to commercial milks.
7. Breast-feeding is convenient.
8. It promotes closer mother-baby ties or contact.
9. Babies are least likely to be overfed with breast-feeding.
10. Breast-feeding promotes good tooth and jaw development.
 Ten steps to successful breast-
feeding
 Have a written breast-feeding policy that Is
routinely communicated to all health care staff
in the hospital
 Train all health care staff to acquire the skills
necessary to implement this policy.
 Inform all pregnant women about the benefits
and management of breast-feeding
 Help the mother initiate breast-feeding within
30 minutes after birth.
 Show mother how to breast feed and how to maintain
lactation, even if they are separated from the infants.
 Give new born infants no food or drink. Other than
breast milk, unless medically indicated.
 Practice rooming-in; allow mothers and infants to
remain together 24 hours a day.
 Encourage breast-feeding on demand.
 Give no artificial teats or pacifiers to breast-fed
infants.
 Foster the establishment of breast-feeding groups and
refer mother to them upon discharge.
 Breast-Feeding Problems
 Medical advances have permitted breast-
feeding to mothers with chronic diseases,
which were not allowed in the past years to
nurse their babies.
 Retracted or invert nipples, sore nipples,
plugged milk ducts, breast abscess in one side,
baby has narrow mouth, baby fall asleep
during feeding, engorged breast, poor milk
production, poor let-down reflex.
 The end

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