Chapter 11

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

CHAPTER 11

Nutrition During Pregnancy and Lactation

Sharon M. Nickols-Richardson

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

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


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

Health & Medicine

Chapter 11