Prenatal Care.pptx

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Nutrition

By: Kathleen Balmilero



• European winter: 1944-1945, nutritional deprivation of known intensity prevailed in a well-circumscribed area

of the Netherlands occupied by the German military(Stein and associates, 1972).

• At the lowest point during the Hunger Winter, rations

reached 450 kcal/day, with generalized rather thanselective malnutrition.

• Smith (1947) analyzed the outcomes of pregnancies

that were in progress during this 6-month famine.Median infant birthweights decreased about 250 g androse again after food became available.



• This indicated that birthweight can be influencedsignificantly by starvation during later pregnancy.

• The perinatal mortality rate, however, was notaltered, nor was the incidence of malformationssignificantly increased.

• Interestingly, the frequency of pregnancy"toxemia" was found to decline.



• Evidence of impaired brain development has

been obtained in some animal fetuses whose

mothers had been subjected to intense

dietary deprivation.



• Conversely, there is evidence that maternal

weight gain during pregnancy influences

birthweight.

• Martin and colleagues (2002b): Maternal

weight gain had a positive correlation with

birthweight



Recommendations For Weight Gain

• First half of the 20th century: recommended

weight gain during pregnancy be limited to

less than 20 lb (9.1 kg).

• Why? -> prevent pregnancy hypertensive

disorders and fetal macrosomia resulting in

operative deliveries



• 1970s: gain at least 25 lb (11.4 kg) to prevent

preterm birth and fetal growth restriction



• 1990: Institute of Medicine recommended a

weight gain of 25 to 35 lb (11.5 to 16 kg) for

women with a normal prepregnancy body

mass index (BMI)



Pre-Pregnancy BMI Recommended Total

Gains (Kg)Low (BMI < 19.8) 12.5-18

Normal (BMI 19.8-26) 11.5-16

High (BMI >26-19) 7-11.5

Obese (BMI >29) <7



• Hytten (1991): reviewed data from over 20years and observed total weight gainthroughout pregnancy in healthy

primigravidas eating without restrictions is12.5kg (27.5lbs).

•

Hytten and Leitch (1971) and Petitti and coworkers (1991): 0.7 lb/wk from 8 to 20 weeksand 1 lb/wk thereafter



Recommended Dietary Allowances

Nutrient Non-pregnant Pregnant Lactating

Kilocalories 2200 2500 2600

Protein (g) 55 60 65

Fat soluble Vitamins

A (ug RE) 800 800 1300

D (ug) 10 10 12

E (mg TE) 8 10 12

K (ug) 55 65 65




Water soluble

vitamins

C (mg) 60 70 95

Folate (ug) 180 400 280

Niacin (mg) 15 17 20

Riboflavin (mg) 1.3 1.6 1.8

Thiamine (mg) 1.1 1.5 1.6

Pyridoxine B6 (mg) 1.6 2.2 2.1

CobaLamin B12 (ug) 2.0 2.2 2.6




Minerals

Calcium (mg) 1200 1200 1200

Phosphorus (mg) 1200 1200 1200Iodone (ug) 150 175 200

Iron (mg or ferrous

iron)

15 30 15

Magnesium (mg) 280 320 355

Zinc (mg) 12 15 19



Calories

• Pregnancy requires an additional 80,000 kcal,

which are accumulated primarily in the last 20

weeks.

• To meet this demand, a caloric increase of 100

to 300 kcal per day is recommended during

pregnancy



• Calories are necessary for energy, and

whenever caloric intake is inadequate, protein

is metabolized rather than being spared for its

vital role in fetal growth and development.



Proteins

• To the basic protein needs of the nonpregnant

woman are added the demands for growth

and repair of the fetus, placenta, uterus, and

breasts, and increased maternal bloodvolume.

• During the second half of pregnancy, about

1000 g of protein are deposited, amounting to5 to 6 g/day.



• The concentrations of most amino acids in

maternal plasma fall markedly, including

ornithine, glycine, taurine, and proline except

glutamic acid and alanine.



Minerals

• Iron

– approximately 300 mg of iron transferred to the

fetus and placenta and the 500 mg incorporated

– iron requirements imposed by pregnancy and

maternal excretion total about 7 mg per day

– at least 27 mg of ferrous iron supplement be given

daily to pregnant women (AAP and ACOG)



• Scott and co-workers (1970) established that

as little as 30 mg of elemental iron, supplied

as ferrous gluconate, sulfate, or fumarate and

taken daily throughout the latter half of pregnancy, provided sufficient iron to meet

the requirements of pregnancy and to protect

any preexisting iron stores.



• Calcium

– the pregnant woman retains about 30 g of

calcium, most of which is deposited in the fetus

late in pregnancy



• Phosphorus

– The distribution of phosphorus ensures an

adequate intake during pregnancy.

– Plasma levels of inorganic phosphorus do not

differ appreciably from nonpregnant levels.



• Zinc

– Severe zinc deficiency may lead to poor appetite,

suboptimal growth, and impaired wound healing.

– Profound zinc deficiency: causes dwarfism and

hypogonadism.

– It may also lead to a specific skin disorder,

acrodermatitis enteropathica, as the result of arare, severe congenital zinc deficiency.



• Although the level of zinc supplementation

that is safe for pregnant recommended daily

intake during pregnancy is about 12 mg



• Iodine

– The use of iodized salt and bread products isrecommended during pregnancy to offset theincreased fetal requirements and maternal renal

losses.

– Interest in increasing dietary iodine was heightened byreports linking subclinical maternal hypothyroidism toadverse pregnancy outcomes and possible

neurodevelopmental defects in children studied at age7 years (Casey and associates, 2004; Haddow andcolleagues, 1999).



– Severe maternal iodine deficiency predisposes

offspring to endemic cretinism, characterized by

multiple severe neurological defects.



• Magnesium

– Deficiency of magnesium as the consequence of pregnancy has not been recognized.

–Undoubtedly, during prolonged illness with nomagnesium intake, the plasma level mightbecome critically low, as it would in the absence of pregnancy.

–Supplementation did not improve any measuresof pregnancy outcome. (Sibai and co-workers(1989))



• Copper

– Enzymes that contain copper, such as cytochrome

oxidase, play key roles in many oxidative

processes and hence in the production of most of the energy required for metabolism.

– Pregnancy has a major effect on maternal copper

metabolism, with marked increases in serum

ceruloplasmin and plasma copper (Reyes and

associates, 2000).



– Copper deficiency has not been documented in

humans during pregnancy.

– No studies of copper supplementation of pregnant

women have been reported, although severalprenatal supplements currently marketed provide

2 mg of copper per tablet.



• Selenium

– This mineral is an essential component of the

enzyme glutathione peroxidase, which catalyzes

the conversion of Hydrogen peroxide to water. – Selenium is an important defensive component

against free radical damage.

–

A severe Geochemical deficiency has beenidentified in a large area of china.



– Deficiency is manifested by a frequently fata

cardiomyopathy in young children and women of

childbearing age.

–Conversely, selenium toxicity resulting fromoversupplementation also has been observed.



• Chromium

– Trace amounts of chromium are believed to serve

as a co-factor for insulin by facilitating attachment

to peripheral receptors. – The extent to which chromium is important in

human nutrition remains uncertain, and there are

no data suggesting that supplementation is

advisable during pregnancy.



• Manganese.

– This mineral serves as a co-factor for enzymes

such as the glycosyltransferases, which are

necessary for the synthesis of polysaccharides andglycoproteins.

– Manganese deficiency has not been observed in

human adults, and supplements are not indicated

during pregnancy.



• Potassium

– The concentration of potassium in maternal

plasma decreases by about 0.5 meq/l by

midpregnancy (brown and Colleagues, 1986). – Potassium deficiency develops in the same

circumstances as when the woman is not

pregnant.

– Prolonged nausea and vomiting may lead to

hypokalemia and metabolic alkalosis.



• Sodium

– Deficiency during pregnancy is unusual unlessdiuretics are prescribed or dietary sodium intake isreduced drastically.

– A normal diet provides an abundance of sodium,although pregnancy is associated with increased totalaccumulation of sodium, the serum concentrationdecreases slightly due to the expanded plasma

volume. – Sodium excretion remains unchanged, and averages

100 to 110 meq/day (brown and colleagues, 1986).



•

Fluoride – The value of supplemental fluoride during

pregnancy has been questioned.

– Maheshwari and co-workers (1983) found that

fluoride metabolism is not altered appreciably

during the course of pregnancy.



– Horowitz and heifetz (1967) onvestigated theprevalence of caries in temporary and permanentteeth of children with the same postnatalexposure to optimally fluoridated water but

different patterns of prenatal exposure.

– They concluded that there were no additionalbenefits from maternal ingestion of fluoridatedwater if the offspring ingested such water frombirth.



• Fluoride supplementation during pregnancy

has not been endorsed by the american dental

association (institute of medicine,1990).

• Supplemental fluoride ingested by the

lactating woman does not increase the

fluoride concentration in her milk (Ekstrand

and colleagues, 1981).



Vitamins

• Folic acid.

– In the united states, approximately 4000 pregnancies areaffected by neural-tube defects each year; more than half of these defects could be prevented with daily intake of

400 ug of folic acid throughout the periconceptionalperiod (Centers for disease control and prevention, 1999).

– Since 1992, the public health service has recommendedthat all women capable of becoming pregnant consume400 ug of folic acid daily throughout their childbearing

years. – Folic acid supplementation is still recommended (american

college of obstetrician and gynecologists, 2003b).



• A woman with a prior pregnancy complicated

by a neural-tube defect can reduce the 3-

percent recurrence risk by more than 70

percent if she supplements her daily diet with4 mg of folic acid for the month before

conception and for the first trimester of

pregnancy.



• Vitamin A – Dietary intake of vitamin A appears to be adequate,

and routine supplementation during pregnancy is notrecommended (american college of obstetricians andgynecologists, 1998b).

– A small number of case reports suggest an association

of birth defects with very high doses during pregnancy10,000 to 50,000 IU daily.

– These malformations are similar to those produced bythe vitamin A derivative isotretinoin (accutane), whichis a potent teratogen in Humans.

– Beta-carotene, the precursor of vitamin A found infruits and vegetables, has not been shown to producevitamin A toxicity.



• Vitamin B12

– The level of vitamin B12 in maternal plasmadecreases variably in otherwise normalpregnancies

– This decrease is mostly from a reduction in plasma

transcobalamins and is thus prevented only in partby supplementation.

– Vitamin B12 occurs naturally only in foods of animal origin.

– Ingestion of vitamin C also can lead to a functionaldeficiency of vitamin B12.



• Vitamin B6

– Most clinical trials in pregnant women have failed

to demonstrate any benefits of vitamin B6

supplements (Institute of medicine, 1990). – For women at high risk for inadequate nutrition

(e.G., Substance abuse, adolescents, and those

with multifetal gestations), a daily supplement

containing 2 mg is recommended.



• Vitamin C

– The recommended dietary allowance for vitamin C

during pregnancy is 80 to 85 mg/day, or about 20

percent more than when nonpregnant – A reasonable diet should readily provide this

amount. The maternal plasma level declines

during pregnancy, whereas the cord level is higher,

a phenomenon observed with most water-soluble

vitamins.



Pragmatic Nutritional Surveillance

• 1. In general, advise the pregnant woman to eat what she

wants in amounts she desires and salted to taste.

• 2. Make sure that there is ample food to eat in the case of

socioeconomically deprived women.

• 3. Monitor weight gain, with a goal of about 25 to 35 pounds

in women with a normal BMI.



• 4. Periodically explore food intake by dietary recall todiscover the occasional nutritionally absurd diet.

• 5. Give tablets of simple iron salts that provide at least27 mg of iron daily. Give folate supplementation beforeand in the early weeks of pregnancy.

•

6. Recheck the hematocrit or hemoglobinconcentration at 28 to 32 weeks to detect anysignificant decrease.



Common Concerns

• Exercise. – In general, it is not necessary for the pregnant woman

to limit exercise, provided she does not becomeexcessively fatigued or risk injury.

–Clapp (1989) reported that 18 conditioned pregnantwomen actually improved their metabolic efficiencyduring exercise.

– Oxygen consumption, heart rate, stroke volume, andcardiac output all increased appropriately in response

to exercise. Pivarnik and associates (1994) latershowed that pregnant women who exercised regularlyhad significantly larger blood volumes.



• With some pregnancy complications, the

mother and her fetus may benefit from a

sedentary existence. For example, some

women with hypertensive disorders, multiplepregnancy, those suspected of having a

growth-restricted fetus, or those with severe

heart disease.



• Employment

•

Travel

• Bathing – Hot tub and Jacuzzi: 100F – miscarriaged and neural

tube defect

• Clothing – One clothing designer stated: "It used to be about

covering it up, and now it's about showing it off.Today's maternity chic is body-hugging not bodyhiding."



• Bowel habits

– Constipation is common, presumably because of

prolonged transit time and compression of the lower

bowel by the uterus or by the presenting part. – There is also greater frequency of hemorrhoids and,

much less commonly, prolapse of the rectal mucosa.

– Women whose bowel habits are normal before

pregnancy may prevent constipation duringpregnancy.



• Coitus

– Whenever abortion or preterm labor threatens,

coitus should be avoided.

– Otherwise it has been generally accepted that inhealthy pregnant women, sexual intercourse

usually is not harmful.



• Dentition• Immunization

• Caffeine

•

Medications• Nausea and vomiting

• Backache

• Varicosities

• Hemorrhoids• Heartburn



• PICA

• Ptyalism

• Fatigue

• Headache

• Leukorrhea - response to hyperestrogenemia

•

Bacterial vaginosis• Candidiasis



_EnD_

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Prenatal Care.pptx