NUTRITION DURING PRGNANCY In the cycle of life, pregnancy marks a new beginning that has lifelong effects, for

both mother and baby. Pregnancy is one of the most nutritionally demanding periods of a woman’s life. Gestation involves rapid cell division and organ development. An adequate supply of nutrients is essential to support this tremendous fetal growth. Energy needs increase only about 15 percent. Most pregnant women need 2,200 to 2,900 kcal a day, but pre-pregnancy body mass index, rate of weight gain, maternal age, and appetite must be considered when tailoring these needs to the individual. Women of childbearing potential should maintain good nutritional status through a lifestyle that optimizes maternal health and reduces the risk of birth defects, suboptimal fetal growth and development, and chronic health problems in their children. The key components of a health-promoting lifestyle during pregnancy include appropriate weight gain; consumption of a variety of foods; appropriate and timely vitamin and mineral supplementation; avoidance of alcohol, tobacco, and other harmful substances; and safe food-handling. Definition and Assessment of a Healthy Pregnancy A healthy pregnancy is without physical or psychological pathology in the mother or fetus and results in the delivery of a healthy baby. During pregnancy, maternal metabolism adjusts dramatically, mediated by changes in key reproductive hormones—human chorionic gonadotropin, human placental lactogen, progesterone, estradiol, estrone, estriol, prolactin, and cortisol. This is important for maintaining the flow of nutrients to the fetus, stimulating uterine growth, and promoting mammary development, among many other functions. By reducing maternal energy intake, the early nausea and vomiting associated with these hormonal changes may play a role in partitioning nutrients to the placenta and fetus. Progesterone also relaxes the smooth muscle in the gastrointestinal tract, contributing to decreased gut motility. Absorption of iron and calcium are increased during pregnancy. Blood volume expands in the course of a normal, healthy pregnancy, mainly due to a 35% to 40% increase in plasma volume.

There is postprandial hyperglycemia: To ensure sustained glucose levels for fetus. Insulin resistance promotes hyperglycemia. Accelerated starvation: Early switch from glucose to lipids for fuels. Mild fasting hypoglycemia occurs with elevated FFA, triglycerides, and cholesterol. Metabolic changes of Pregnancy: Maternal anabolic phase: 0-20 weeks. “building up” of mother’s body to supply increased needs of fetus later 10% of fetal growth occurs in this phase. Maternal catabolic phase: 20 weeks – Birth. Delivering stored energy & nutrients to growing fetus 90% of fetal growth occurs in this phase. Why is nutrition so important? TO: Meet increased nutrient demands, Provide needed energy. Prevent or minimize common pregnancy-related problems. Reduce risk of birth defects, Supply needed nutrients for baby’s growth. Ensure healthy birth weight, Maintain a healthy weight . Maternal weight gain during pregnancy: Maternal weight gain must support the products of conception (fetus, placenta, and amniotic fluid) and (expansion of blood volume and extracellular fluid, uterine and mammary glands, and maternal fat stores). Weight-for-height category Low (BMI 19.8) Normal (BMI of 19.8 to 26.0) High (BMI 26.0 to 29.0) Recommended total weight gain 12.5–18 kg 11.5–16 kg

7–11.5 kg

Young adolescents should strive for gains at the upper end of the recommended range. Short women (157 cm, or 62 inches) should strive for gains at the lower end of the range. The recommended target weight gain for obese women (BMI 29.0) is at least 6.8 kg. Risk of complications during pregnancy or delivery is lowest when prenatal weight gain is adequate. Low weight gain in second or third trimester increases risk of intrauterine growth retardation. Low weight gain in third trimester increases risk preterm delivery . Higher maternal BMI in the first trimester and a greater change in BMI during pregnancy were associated with longer gestation and an increased risk of postdates pregnancy. Higher maternal BMI during the first trimester was also associated with decreased likelihood of spontaneous onset of labor at term and increased likelihood of complications. Increased maternal BMI is associated with increased risk of developing minor complications during pregnancy; use of medications associated with treating these conditions and has significant NHS costs. Energy Requirements: Energy utilization during pregnancy: Maternal gain: breast tissue, uterine muscles and placenta (27,000 kcal).Fetal tissues (27,000 kcal). Increased work of maternal heart (27,000 kcal). Result: BMR ↑ 60% 2nd and 3rd trimesters (catabolic phase). Need for 80,000 kcal positive balance over pregnancy. The additional energy needs during the second and third trimesters of pregnancy are approximately [300 kcal/day], in adults and older adolescents, and 500 kcal a day in young adolescents (< 14 years). This is approximately the same number of calories as supplied by 21⁄2 cups of skim milk, or one cup of ice cream, or a bagel with cream cheese, or a tuna fish sandwich. This additional calorie requirement may seem small. However, it is enough to supply the extra energy essential to support pregnancy.

Some expectant mothers may be tempted to “eat for two,” or double the amount of food they normally eat. This practice is likely to result in excessive weight gain. Food requirements during pregnancy are not drastically different from a normal well-balanced diet. Nutrient needs are higher, but the general principles of sound nutrition variety, balance, and moderation-still apply. Physical Activity: Some evidence suggests that pregnant women who engage in recreational physical activity have a 50% lower risk of gestational diabetes and 40% risk reduction for preeclampsia. Increased physical activity will control excess weight gain, in addition to the normal beneficial physical and emotional effects. Thus, healthy women with uncomplicated pregnancies may continue moderate exercise on a regular basis, but they should be advised about appropriate activities and contraindications.

(Proper nutrition): Major Nutrients: Carbohydrates , Protein , Fat , Vitamins , Minerals , Water. Carbohydrates : • • Should make up 60-70% of total daily calories Not less than 175gm/day for pregnant female which equal to 700 calories i.e. 35% of 2000 calories/day .

Protein : • • Need ~10 grams more per day in pregnancy i.e. 1.1gm/kg/day . 10-20% of total calories

Fat: • • 20-25% of total calories (use sparingly) . Choose healthy fats .

Water: • • 60-75% of body weight 8-10 cups/day.

Suboptimal hydration predisposes to pre mature labor pain and reduced amniotic fluid optimal hydration reduces UTI ,kidney stones and constipation.

Fiber: • 25-35 grams/day.

Vitamins and Minerals: Body does not make most vitamins Good source: Deep colored fruits and vegetables Multivitamin/Multi-mineral supplements and Iron .

Appropriate and Timely Vitamin and Mineral Supplementation Dietary Assessment: Routine assessment of dietary practices is recommended for all pregnant women to allow evaluation of the need for improved diet or vitamin or mineral supplements. Iron: For the general population of pregnant women, supplements of 30 mg of ferrous iron are recommended daily during the second and third trimesters. This amount of ferrous iron is provided, for example, by approximately 150 mg of ferrous sulfate, 300 mg of ferrous gluconate, or 100 mg of ferrous fumarate. Administration between meals or at bedtime on an empty stomach will facilitate iron absorption, but taking ascorbic acid with supplements containing ferrous iron does not enhance iron absorption. Folate: Although routine folate supplementation of pregnant women is not recommended, a supplement of 300μg/day may be given when there are doubts about the adequacy of dietary folate. Women who ingest fruit, juices, wholegrain or fortified cereals, and green vegetables infrequently are likely to have low folate intake. Multivitamin Mineral Supplements For pregnant women who do not ordinarily consume an adequate diet and for those in high-risk categories, such as women carrying more than one fetus, heavy cigarette smokers, and alcohol and drug abusers, a daily multivitamin-mineral preparation containing the following nutrients beginning in the second trimester is recommended:

Iron 30 mg Zinc 15 mg Copper 2 mg Calcium 250 mg

Vitamin B6 2 mg Folate 300μg Vitamin C 50 mg Vitamin D 5μg

Nutrient Supplementation in Special Circumstances Vitamin D: 10μg (400 IU) daily for complete vegetarians (those who consume no animal products at all) and others with a low intake of vitamin D fortified milk. Vitamin D status is a special concern for women at northern latitudes in winter and for others with minimal exposure to sunlight and thus reduced synthesis of vitamin D in the skin. Calcium: 600 mg daily for women under age 25 whose daily dietary calcium intake is less than 600 mg. To enhance absorption and limit interaction with iron supplements, the calcium supplement should be taken at mealtime. There is no evidence that older pregnant women (i.e., those over age 35) have a special need for supplemental calcium. Vitamin B 12: 2.0μg daily for complete vegetarians. The RDA for preformed vitamin A is 2700 IU/day or 8000 IU of betacarotene. Limiting vitamin A in prenatal vitamins to 5000-8000 IU and vitamin A content of all multivitamins to 10,000 IU; therein suggesting women should not ingest more than 10,000 IU prior to consulting a physician. These were made because teratogenicity appears to occur at some undetermined level above 8000 IU. Zinc and copper: When therapeutic levels of iron (>30 mg/day) are given to treat anemia, supplementation with approximately 15 mg of zinc and 2 mg of copper is recommended because the iron may interfere with the absorption and utilization of those trace elements. Foods to Avoid during pregnancy: Fish containing high levels of mercury (shark, swordfish, king mackerel and tuna) not more than 120gm/week . Raw or undercooked fish . Raw or undercooked shellfish Raw eggs or dishes containing raw or partially cooked eggs. Unpasteurized cheeses and juices . Things to Avoid During Pregnancy:

Alcohol , Cigarettes , Recreational drugs. Over-The-Counter Medications or Herbal Supplements Caffeine : allowed in moderation Smoking during Pregnancy: Limits oxygen supplied to the fetus. Reduces birth weight of the infant Increases the risk of pre-term delivery. Increases the risk of perinatal mortality Passive exposure to tobacco smoke may also reduce infant growth Associated with mental retardation and nicotine addiction in the fetus. Complication during pregnancy Constipation: Hormonal changes slow down the intestine to overcome this effect. Drink 8-12 glasses of water every day. Eat high-fiber foods Try dried plums, prune juice, or figs. Be as physically active as possible Do not use laxatives unless prescribed by health care provider.

Heartburn: Eat small meals frequently. Cut down on caffeinated and carbonated beverages Eat slowly in a relaxed environment. Do not lie down after eating Prop head of bed up. Wear loose-fitting comfortable clothes Avoid gaining too much weight. Talk to doctor before taking antacids. Edema : As blood supply increases, legs, feet, and arms may swell. Drink plenty of fluids, especially water. Avoid diuretics, unless prescribed by health care provider. Elevate your feet whenever possible. Gestational Diabetes:

Some women develop diabetes during pregnancy. Gestational diabetes occurs in the latter half (after 24 weeks) in 7% of pregnancies. Increases risk of delivering infants large for gestational age. Gestational diabetes can often be controlled through medical nutrition therapy and moderate exercise, but insulin is recommended in women who do not improve glycemic control through lifestyle changes alone. Oral glucose lowering agents are generally not recommended during pregnancy. Pregnancy-induced Hypertension: Risk factors include: Chronic Hypertension. Preeclampsia in a previous pregnancy. Obesity especially who practices bad dieting just before pregnancy. Old or young primigravidae. Genetic factors . No specific therapy has been proven effective in preventing or delaying preeclampsia and improving pregnancy outcomes. A meta-analysis of 17 randomized controlled trials concluded that calcium supplements (1-2 g/day) reduce blood pressure and risk of preeclampsia but had no significant effect on reducing maternal and infant morbidity and mortality. Calcium supplementation may only be beneficial where calcium intakes are very low.

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