NUTRITION IN PREGNANCY

OBJECTIVES:
AT THE END OF THE UNIT THE STUDENT SHOULD BE ABLE TO:

1. Define terms in Pregnancy

2. Explain why maintaining a nutritious diet is important for prospective parents even before
conception.
3. Describe the stages and physiological changes during pregnancy.
4. Explore the relationship among fetal development, changes in the mother, and increasing
nutrient requirements during a pregnancy.
5. Identify the range of optimal weight gain for a pregnant woman in each trimester.
 NUTRITIONIN PREGNANCY
INTRODUCTION
Of all the periods in the human life cycle, the period of pregnancy is the most critical and
unique. It is critical because during pregnancy, the foundations of a new life is being laid that
will influence the future of succeeding generations.
It is unique in that at no other time in life does the well-being of an individual depends so much
on the well-being of another.
PURPOSE OF NUTRITION CARE
1. To meet the normal requirements of the mother.
2. To meet the nutrient needs of the growing fetus and other maternal tissues, and
3. For building reserves in preparation for delivery and lactation.

DEFINITION OF TERMS:
1. Conception – the union of the male sperm and the female ovum; fertilization.

2. Pregnancy
▪ Period from conception to delivery and for human beings last from 38 to 42 weeks.
▪ Condition of having a developing embryo (the developing organism from eight week
of gestation when most of cell differentiation takes place) into a fetus (the
developing human from three months after conception to birth) after the fertilization
of an ovum with a sperm (the fertilized egg, called a zygote), within the uterine
environment;
▪ Also known as gestation

3. Placenta - the organ that develops inside the uterus early in pregnancy, through which
the fetus receive nutrients and oxygen and returns carbon dioxide and other waste
products to be excreted.

4. Uterus – the muscular organ within which the infant develops before birth.

5. Amniotic sac – the “bag of waters” in the uterus, in which the fetus floats.

6. Umbilical cord – the ropelike structure through which the fetu’s veins and arteries
reach the placenta.

7. Ovum – the female reproductive cell, capable of developing into a new organism upon
fertilization; commonly referred to as an egg.

8. Sperm- the male reproductive cell, capable of fertilizing an ovum.

9. Blastocyst – the developmental stage of the zygote when it is about five days old and
ready for implantation.

10. Parturition – the act of giving birth, delivery of the fetus from the mother.
11. Low-birth-weight (LBW) infants – babies weighing – less than 2500 grams (<5.5
pounds).
 12. Small for Gestational Age (SGA) infants – full term babies who weigh less than 2500
grams (5.5 pounds).
13. Premature infants/ Preterm – babies born less than 37 weeks of gestation; also
called preterm infants.
14. Post term Infant – one who is born after 42 weeks or more of gestation
15. Very low birth weight infant (VLBW)- an infant who weighs less than 1500g (3–½ lb)
16. Extremely low birth weight infant (ELBW) – an infant who weighs less than 1000g (2
– ¼ lb)
17. Appropriate for gestational age (AGA) – an infant who has a birth weight between
the 10th to the 90th percentiles on the intrauterine growth chart.
18. Large for gestational age (LGA) - an infant whose birth weight is above the 90th
percentiles on the intrauterine growth chart.
19. Term Infant – one who is born between the 37th and 42nd week of gestation
20. Intrauterine Growth Retardation ( IUGR ) – the depressed growth of the fetus due to
poor nutrition during fetal growth;
Factors contributory to IUGR are:
1. Inadequate maternal nutrition status before conception
2. Short maternal stature (due to undernutrition)
3. Poor maternal nutrition during pregnancy (low gestational weight gain)
4. intrauterine infection
5. small/inefficient of placenta
6. maternal smoking, alcoholism, drug addiction, and/or severe malnutrition.

PLANNING FOR A HEALTHY PREGNANCY

IS NUTRITION IMPORTANT BEFORE CONCEPTION?
Maintaining a nutritious diet is important for prospective parents even before conception. Both
a man’s and a woman’s nutrition may affect fertility and possibly the genetic contributions they
make to their children, but it is the woman’s nutrition that has the most direct influence on the
developing fetus. In preparation for a healthy pregnancy, a woman can establish the following
habits.
1. Achieve and maintain a healthy body weight. Both underweight and overweight are
associated with infertility. Overweight and obese men have low sperm counts and
hormonal changes that reduce fertility. Excess body fat in women disrupts menstrual
regularity and ovarian hormone production. Should a pregnancy occur, mothers, both
underweight and overweight, and their newborns, face increased risks of
complications.
2. Choose an adequate and balanced diet. Malnutrition reduces fertility and impairs the
early development of an infant. In contrast, a healthy diet that emphasizes
monounsaturated fats instead of transfats, vegetable proteins instead of animal
proteins, and low glycemic carbohydrates instead of simple sugars can favourably
influence fertility. Men with diets rich in antioxidant nutrients have higher sperm
numbers and motility.
 Maintaining a balanced and nourishing diet before conception reduces a woman’s risk
of developing a nutrition-related disorder during her pregnancy.
▪ Some deficiency-related problems develop extremely early in pregnancy, typically
before the mother even realizes she is pregnant. Example, failure of the spinal cord
to close results in neural tube defects, theses defects are closely related to
inadequate levels of folate during the first few weeks following conception. For this
reason, all sexually active women of childbearing age capable of becoming
pregnant are encouraged to consume 400ug of folic acid daily, whether or not they
plan to become pregnant.

3. Be physically active. A woman who wants to be physically active when she is

pregnant needs to become physically active beforehand.

4. Receive regular medical care. Regular health-care visits can help ensure a healthy
start to pregnancy.
5. Manage chronic conditions. Conditions such as diabetes, HIV/AIDS, phenylketonuria
(PKU), Poor control of ongoing diabetes or hypertension and sexually transmitted
diseases can adversely affect a pregnancy and need close medical attention to help
ensure a healthy outcome.
6. Avoid harmful influences. Both maternal and paternal ingestion of or exposure to
harmful substances (such as cigarettes, alcohol, drugs, or environmental
contaminants, herbal therapies, job related hazards and stresses, heavy caffeine use,
X-ray exposure, including dental X-rays) can cause miscarriage or abnormalities, alter
genes or their expression, and interfere with fertility.
PHYSIOLOGICAL STAGES OF PREGNANCY:
Physiological Stages of Pregnancy:
1. Period of Implantation
The first two weeks of gestation during which the fertilized ovum called zygote (about
the size of a period at the end of this sentence.) implants itself in the wall of the uterus and
begin to develop, receiving its nutrients from the secretions of the uterine glands, known as
uterine milk.
▪ Also called the period of blastogenesis and the period of ovum.
2. Period of Organogenesis
The embryo (about ½ inch long) undergoes differentiation or rapid cell division that
occurs from two to eight weeks after conception, this is called critical period. Critical
period is an interval of time during which cells of a tissue or organ are genetically
programmed to multiply.
The development of each organ and tissue is most vulnerable to adverse influences
(such as nutrient deficiencies or toxins) during its own critical period.
Neural tube development is most vulnerable to nutrient deficiencies, nutrient excesses,
or toxins during this critical time when most women do not even realize they are pregnant.
Neural tube defect is a malformation of the brain, spinal cord, or both during embryonic
development. The two main types are;
1. Spina bifida (literally, “split spine”). Characterized by incomplete closure of the
spinal cord and its bony encasement. The meniges membranes covering the spinal
cord often protrude as a sac which may rupture and lead to meningitis, a life
 threatening infection. Spina bifida is accompanied by varying degrees of paralysis,
depending on the extent of the spinal cord damage.
Mild cases may not even noticed, but severe cases lead to death. Common
problems include clubfoot, dislocated hip, kidney disorders, curvature of the spine,
muscle weakness, mental handicaps, and motor and sensory losses.
2. Anencephaly (“no brain”). An uncommon and always fatal type of neural tube
defect; characterized by the absence of brain. In anencephaly, the upper end of the
neural tube fails to close. Pregnancies affected by the anencephaly often end in
miscarriage; infants born with anencephaly die shortly after birth.
Factors that make NTD are :
▪ A personal or family history of a pregnancy affected by a neural tube defect
▪ Maternal diabetes
▪ Maternal use of certain antiseizure medications
▪ Mutations in folate-related enzymes
▪ Maternal obesity
Folate supplementation (400 micrograms or 0.4 milligrams daily) reduces the
risks.
Nourishment comes from within the uterine environment and maternal tissues; absence of
certain nutrients during this stage may be crucial to the growth of developing fetus.
At the end of this period, the embryo weighs approximately one ounce, measures more
than an inch long and shows many features of a newborn.
3. Period of Growth (also called period of the fetus or fetal period)
The remaining seven months of pregnancy during which the differentiated tissues are
nourished through the placenta and continue to grow until they reach a functional size
capable of supporting extrauterine life (life after birth).
THE ROLE OF PLACENTA
The Placenta –is the principal site for the production of several hormones that regulate
maternal growth and development. It weighs from 450 to 1000 gms at birth
Purposes of the placenta:
a) Supplying fetus with nutrients and oxygen;
b) Storing nutrients particularly vitamins;
c) Synthesizing hormones;
d) Removing fetal waste products.
The mechanisms for nutrient transfer are:
a) Simple diffusion. A passive process in which nutrients move from high
concentrations in the maternal blood to lower concentrations in the fetal
capillaries until equilibrium is reached. Oxygen, carbon dioxide, fatty acids,
steroids, nucleosides, electrolytes and fat-soluble vitamins are transported
actively.
A couple of common examples will help to illustrate this concept.
▪ Imagine being inside a closed bathroom. If a bottle of perfume were
sprayed, the scent molecules would naturally diffuse from the spot
where they left the bottle to all corners of the bathroom, and this
diffusion would go on until no more concentration gradient remains.
 ▪ Another example is a spoonful of sugar placed in a cup of tea.
Eventually the sugar will diffuse throughout the tea until no
concentration gradient remains. In both cases, if the room is warmer or
the tea hotter, diffusion occurs even faster as the molecules are
bumping into each other and spreading out faster than at cooler
temperatures. Having an internal body temperature around 98.6° F thus
also aids in diffusion of particles within the body.
b) Facilitated diffusion. Is the diffusion process used for those substances that
cannot cross the lipid bilayer (plasma membrane) due to their size, charge,
and/or polarity. It involves a carrier in the cell membrane so the rate of transfer
is faster than simple diffusion. A common example of facilitated diffusion is the
movement of glucose into the cell, where it is used to make ATP. Although
glucose can be more concentrated outside of a cell, it cannot cross the lipid
bilayer via simple diffusion because it is both large and polar. To resolve this, a
specialized carrier protein called the glucose transporter will transfer glucose
molecules into the cell to facilitate its inward diffusion.

Amino acids, some cations, i.e., calcium, iron, iodine and phosphate, and
water-soluble vitamins are transported actively.
c) Pinocytosis. Is the uptake of fluid materials by a living cell, by means of
invagination of the cell and vacuole formation.

MATERNAL PHYSIOLOGICAL CHANGES OF PREGNANCY

1. Hormonal changes
Hormone – chemical messenger that is secreted into the bloodstream by one of the many
glands of the body and acts as a regulator of the physiologic processes at a site remote from
the gland that secreted it.
The pregnant woman secretes more than 30 different hormones throughout pregnancy.
Some of the hormones that have major effects on maternal physiology and/or nutrient
metabolism are:

HORMONE PRINCIPAL EFFECTS

( Primary Source of
Secretion)
Progesterone causes relaxation of the smooth muscles of the uterus and
(Placenta and mammary other smooth muscle of the body. Relaxation of the muscles
glands) of the gastrointestinal tract causes slower movement in the
gut and is the cause of constipation experienced by many
pregnant women. Favors maternal fat deposition; and
increase renal sodium excretion.
Estrogen to promote growth and control of the uterus, hygroscopic
(Placenta and ovaries) effect that may lead to retention of water in the skin(edema).
Aldosterone promotes sodium retention and potassium excretion.
(Adrenal cortex)
Oxytocin Initiates uterine contractions of labor.
(Anterior pituitary gland) Aids in ejecting milk during lactation.
Prolactin Stimulates growth of mammary glands and milk synthesis
(Anterior pituitary gland)
Human Placental Elevates blood glucose from breakdown of glycogen
Lactogen
(Placenta)
Human Chorionic Stimulates production of thyroid hormones
Thyrotropin
(HCT)(Placenta)
Human Growth Hormone Elevates blood glucose; stimulates growth of long bones;
(Anterior pituitary) promotes nitrogen retention
Thyroid Stimulating Stimulates secretion of thyroxine; increase uptake of iodine
Hormone(Anterior Pituitary) by thyroid gland.
Thyroxine Regulates rate of cellular oxidation (basal metabolism)
(Thyroid)
Parathyroid Hormone Promotes calcium resorption from bone; and increases
(PTH) calcium absorption; promotes urinary excretion of
(Parathyroid) phosphate.
Calcitonin(Thyroid) Inhibits calcium resorption from bone.
Insulin Reduces blood glucose levels to promote energy production
(Beta cells of pancreas) and fat synthesis.
Glucagon Elevates blood glucose levels for glycogen breakdown.
( Alpha cells of pancreas,
Cortisone ( Adrenal cortex))
Renin-Angiotensin Stimulates aldosterone secretion; promotes sodium and
(Kidney) water retention; increases thirst.

2. In Gastrointestinal functions.
▪ Loss of appetite, nausea and vomiting may occur during the first trimester of
pregnancy due to hormonal changes.
▪ There may be alterations in the sense of taste, such as preference for stronger salt
solutions compared with non pregnant women.
▪ Decreased tone and motility of the smooth muscles due to the increased
progesterone levels leading to esophagealregurgitation,decreased emptying time
of the stomach and reverse peristalsis.
▪ Gastroesophageal reflux, disease (GERD) is known to occur in 33 to 40% in
pregnancy. The pregnancy women experience heartburn as a result of this. The
decreased smooth muscle tone also results in more water absorption in the colon
leading to constipation.
▪ Decreased secretion of hydrochloric acid which reduces gastric acidity and
depresses calcium and iron absorption;
▪ Decreased emitting time of the gallbladder together with hypercholesterolemia from
increased progesterone levels which may lead to development of gallstones.
3. In Blood Volume and Composition.
▪ Plasma volume begins to increase towards the end of the first trimester and by 34
weeks it is 50% greater than conception. If nutrients and blood constituents do not
keep up with the expansion in plasma volume, their concentration will decrease
even though the total amounts may rise. This explains decreased haemoglobin,
serum albumin, and other protein concentration and water soluble vitamin
concentration.
▪ The decline in serum albumin concentration may contribute to extra cellular water
concentration, or edema.
 ▪ Another example, red blood cells are stimulated during pregnancy so that their
numbers gradually rise but the increase is not as large as the plasma volume
expansion. This leads to a condition called “physiologic anemia of pregnancy.”
▪ The increase in plasma volume is correlated with obstetrical performance.
▪ Women who have a small increase compared with the average were more likely to
have stillbirths, abortions and low birth weight babies.
4. The Circulatory System.
▪ There is slight cardiac hypertrophy or dilation due to increased blood volume and
cardiac output.
▪ Pulse increases slowly up to 10-15 beats per minute between weeks 14 and 20 and
persists to term.
▪ Palpitations may occur and bradycardia (abnormal slowness of the heart rate and
pulse) may begin after delivery and persist for one week.
▪ Cardiac output increases from 30 to 50% by 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.
▪ As the fetus grows, the uterus compresses underlying pelvic blood vessels,
hampering venous return from the legs and pelvic region. As a result, many
pregnant women develop varicose veins or hemorrhoids.

5. In Respiratory.
▪ Maternal oxygen requirements increase due to acceleration in basal metabolic rate
and the need to add tissue mass in the uterus and breast.
▪ Maternal oxygen requirements increase due to acceleration in basal metabolic rate
and the need to add tissue mass in the uterus and breast; the fetus requires
oxygen, too.
▪ Pregnant woman breathes more deeply but increases her respiratory rate only
slightly (two breaths per minute).
6. Renal Function.
▪ Blood flow through the kidneys and the glomerular filtration rate are increased by
50% during pregnancy to facilitate the clearance of waste products of fetal and
maternal metabolism. Thus, substantial quantities of nutrients such as glucose,
amino acids and water-soluble vitamins appear in the urine instead of being
reabsorbed by the kidneys to reserve the body’s balance. The reason is that the
high glomerular filtration rate offers the tubules greater quantities of nutrients that
they can possibly absorb.
▪ The relaxation and dilation of the urinary tract with its higher nutrient concentration
may lead to urinary tract infections.
▪ The downward pressure of the uterus compresses the urinary bladder, leading to
frequent urination. The increased urine volume may cause some women to
experience pronounced thirst.
7. Metabolic Adjustments. Among the metabolic changes that occur during pregnancy are:
▪ The basal metabolic rate (BMR) is increased by 20 to 25% by the end of the term.
▪ The major adjustment in energy utilization is a shift in the fuel sources. Fat is the
major maternal fuel while glucose is the major fetal fuel.
8. Integumentary System Changes
The dermis stretches extensively to accommodate the growing uterus, breast
tissue, and fat deposits on the thighs and hips. Torn connective tissue beneath the
 dermis can cause striae (stretch marks) on the abdomen, which appear as red or
purple marks during pregnancy that fade to a silvery white color in the months after
childbirth.
▪ The linea nigra, a dark medial line running from the umbilicus to the
pubis, forms during pregnancy and persists for a few weeks following
childbirth.
9. An increase in melanocyte-stimulating hormone, in conjunction with estrogens,
darkens the areolae and creates a line of pigment from the umbilicus to the pubis
called the linea nigra ([link]). Melanin production during pregnancy may also darken
or discolor skin on the face to create a chloasma, or “mask of pregnancy.”

10. Weight Gain. All women need to gain weight during pregnancy for fetal growth and
maternal health.
▪ A normal weight gain for most healthy women that is consistent with good
reproductive performance is about 25 to 35 lb.
▪ If a woman is overweight at the beginning of the pregnancy, she should not diet,
but instead limit the amount of desserts and other “extras.”
▪ If a woman is underweight at the beginning of pregnancy, she should increase her
food intake.

NEW RECOMMENDATIONS FOR TOTAL AND RATE OF WEIGHT GAIN

DURING PREGNANCY, BY PREPREGNANCY BODY MASS INDEX (BMI)

Pregnancy BMI Total Weight Gain Rates of Weight Gain*

2nd and 3rd Trimester
Range in Range in Mean (range) Mean (range)
kg lbs In kg/week In lb/week
Underweight 12.5 – 18 28 – 40 0.51 1
(<18.5 kg/m2) (0.44 – 0.58) (1 – 1.3)
Normal- weight 11.5 – 16 25 – 35 0.42 1
(18.5 – 24.9 kg/m )
2
(0.35 – 0.50) (0.8 – 1)
Overweight 7 -11.5 15 – 25 0.28 0.6
(25.0 – 29.9 kg/m2) (0.23 – 0.33) (0.5 – 0.7)
Obese 5 -9 11 -20 0.22 0.5
2
(> 30.0 kg/m ) (0.17 – 0.27) (0.4 – 0.6)
* Calculations assume a 0.5 – 2 kg (1.1 – 4.4 lbs) weight gain in the first trimester.
Source: IOM 2009. Weight Gain During Pregnancy: Reexamining the guidelines,

COMPONENTS OF WEIGHT GAIN DURING PREGNANCY

Component Weight Gain (kg) Weight Gain (lbs)

Fetus 3.2 – 3.0 7– 8
Placenta and 1.4 – 2.5 3 – 5.5
Amniotic fluid 1.8 – 2.7 4–6
Tissue fluid 1.4 – 2.0 3 – 4.5
Maternal blood 0.9 – 1.4 2–3
Enlargement of 0.5 – 0.7 1 – 1.5
the uterus 1.8 – 3.0 4 – 6.5
Breast _______ _____
 Fat stores 11 to 16 kg 24 to 35 lbs

Total
➢ Based on weight, the cut off to determine if a Filipino pregnant woman is at risk is
95%

▪ The pregnant woman’s rate of weight gain should follow this trend:
➢ She should gain 0.9 – 1.8 kg (2-4 lbs) by the end of the first trimester and
approximately 0.45 kg (1 lb) a week thereafter. A sudden weight gain that
exceeds the usual rate especially during the 20th week of gestation is an
indication of toxaemia.
➢ The recommended range for total weight gain and pattern of gain is based on
pregnancy weight for height.

THE EFFECT OF WEIGHT AND GUIDELINES FOR WEIGHT GAIN AND EFFECT FOR
PREGNANCY

Category BMI Effect on Pregnancy Total weight Rate of

Gain Weight
Range in Weight Gain for
Gain kg 2nd and 3rd
(lbs) Trimesters
Underweight < 18.8 Have a risk of having a 12.5 - 28 – 40 Slightly > 1
low birthweight infant (< 18 lb/wk
5lbs), pre-term infant
(born before 38 weeks)
and higher infant
mortality rates.
Normal 18.5 – 11.5 – 25 – 35 1 lb/wk
weight 24.9 16
Overweight 25 – High risk for 7 -11.5 15 – 25 2/3 lb/wk
29.9 complications such as
hypertension,
gestational diabetes,
and postpartum
infections.

Infants of overweight
women are likely to be
born post term and
weight before
pregnancy.
(avoid gaining too much
weight during pregnancy
and postpone weight
loss after childbirth)
Obese > 30 Same in overweight 5–9 11 – 20 Aim for
 steady
weight gain

NUTRIENT REQUIREMENTS DURING PREGNANCY:

▪ Calories. The two factors that determine energy requirements are the mother’s usual
physical activity and the increase in metabolic rate to support the work required for growth
of the fetus and the accessory tissue. About 300extra kcal per day.
▪ Protein. Increases in order to meet the needs of developing maternal tissues and to
support the growth of the fetus. Protein requirements are based on the needs of the non-
pregnant woman used as a reference plus the extra amounts needed for growth. About
925 g of protein are deposited in the normal fetus and maternal tissues. If this figure is
divided by 280 days of pregnancy, an average of 3.3 g of protein should be added to the
daily requirements. Increases by an average of 9g of protein per day throughout
pregnancy (FAO/WHO) (1985) recommended an additional of 9g of protein per day)
▪ Fats. Linoleic and alpha linoleic acids (ALA) are the essential fatty acids (EFA). They are
the nutrients that the body then further processes to gamma-linoleic acid, dihomo-gamma-
linoleic acid, eicosapentaenoic acid (EPA) and docosapentaenoic acid (DHA) to form the
structural components of the central nervous system.
▪ Vitamin A. Is an essential nutrient because of its critical role in reproduction. The need for
vitamin A is increased bu the amount is relatively small and confined mostly to the third
trimester. Maternal reserves are generally adequate to meet the needs.
➢ The Philippine RENI is 800 mcg RE for pregnancy.
➢ Excess preformed Vit. A can cause fetal abnormalities particularly in the
kidneys & nervous system even it is not consumed in extremely high quantities.

▪ Ascorbic Acid. RDA for pregnancy is 80 mgs/day to maintain the integrity of fetal
membranes and for tissue structure.
.
▪ Thiamine, Riboflavin and Niacin. The requirement are related to caloric intake. To
maintain maternal stores; to meet fetal demands.
▪ Folic Acid .It is recommended that all women of childbearing age who are capable
becoming pregnant should take 0.4 mg (400 mcg) of folic acid daily.
➢ To prevent NTD. Because NTD is the most common and severe birth defects.
▪ 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) is the most common and severe birth defects.
➢ Folic Acid Deficiencies causes megaloblasticanemiain women and reduces fetal
growth, it is important that women of childbearing age should receive folic acid as
soon as possible.
Foods containing folacin:
Green leafy vegetables, Legumes, Liver, Orange juice and cantaloupe, Other
vegetables, Whole wheat products.
▪ Vitamin B6. Vitamin B6 or pyridoxine requirements increase in pregnancy because of the
greater need for nonessential amino acids for growth and also because the body is making
more niacin from trypthopan.
➢ The Philippine RNI recommends 1.9 mg vitamin B6 per day during pregnancy. The
possibility that vitamin B6 may control nausea and vomiting.
▪ Vitamin B12. The low maternal vitamin B12 status is associated with intrauterine growth
retardation in infants.
➢ The Philippine RNI recommends 2.6 mcg vitamin B12 per day during pregnancy,
which is an additional 0.2 mg/day over the RNI for non-pregnant women.
➢ Folate&B12 .Nutrients required in higher amounts during pregnancy due to their
roles in the synthesis of red blood cells.
▪ Vitamin D. This vitamin has a positive effect on calcium balance during pregnancy.
Evidence shows that it may involved in neonatal calcium homeostasis. Poor enamel
development and neonatal hypocalcemia have been associated with maternal vitamin D
deficiency. Maternal ingestion of large amounts of vitamin D is link to neonatal
hypercalcemia, calcification of soft tissues and craniofacial abnormalities.
➢ Philipine RENI is 200 IU or 5mcg vitamin D per day.
▪ Calcium. Calcium and phosphorus promote adequate mineralization of the fetal skeleton
and deciduous teeth during pregnancy. The fetus acquires most of its calcium during the
last trimester when skeletal growth is maximum and teeth are being formed.
➢ If the mother is not consuming adequate calcium in her diet, the baby will get its
calcium from her bones. Additional 400 mg/day.
▪ Iron. The Philippine RNI for iron is 34 -38 mg/day during the second and third trimester of
pregnancy compared to only 27 mg for-non pregnant women and during the first trimester.
. Usually this amount cannot be met by usual diets, hence supplementation is
recommended. During pregnancy, iron is needed for the manufacture of hemoglobin in
maternal and fetal red blood cells.
➢ Considered the most difficult to meet during pregnancy.
➢ The fetus ensures its own production of haemoglobin by drawing iron from the
mother. Maintenance of erythropoiesis (process of synthesizing red blood cells) is
one of the few instances during pregnancy when the fetus acts as a true parasites.
Maternal iron deficiency does not cause anemia in the infant. The most common
cause of iron deficiency in infants is prematurity as the fetus has a short gestation
and does not have time to accumulate enough iron during the last trimester.
➢ Pregnant women with anemia are at a higher risk for perinatal mortality and
morbidity.
➢ She is also more prone to development of puerperal infection.
▪ Iodine. Iodine should be adequately provided during pregnancy because of an increased
basal metabolic rate (BMR).
➢ The Philippine RNI recommends an additional 50 mcg/day of iodine throughout
gestation.
▪ Zinc.When severe reduction of circulating zinc occurs in the mother’s blood, there is the
possibility of increased risk of spontaneous abortions and congenital malformation.
➢ The Philippine RENI recommends 1.5 to 9.6 mg zinc/day for all pregnant women
compared to 4.5 mg zinc/day for non-pregnant women.
➢ Important roles in DNA & RNA synthesis and protein synthesis.
▪ Fluoride. The development of primary dentition of the fetus starts on the 10 to 12th week of
pregnancy. The 32 teeth are formed during gestation.
➢ The Philippine RNI for fluoride is suggested at 2.5 mg/day.
▪ Fluid Needs of Pregnant Women. AI for fluid intake which includes drinking water,
beverages and food is 2.3 liters (10 cups) of fluid as total beverages, including drinking
waters.
➢ It allows for the necessary increase in the mother’s blood volume
➢ Acts as lubricant
➢ Aids in regulating body temperature
➢ Necessary for many metabolic reactions.
➢ Helps maintain the amniotic fluid that surrounds, cushion and protect the fetus in
the uterus.
EFFECTS OF GOOD NUTRITION
1. On the mother
a. Increased chances of normal pregnancy leading to normal delivery
b. Absence or reduced chances of complications during pregnancy;
c. Reduced incidence of premature deliveries;
d. Reduce incidence of maternal depletion
e. Reduced incidence of morbidity and mortality
f. Increased chance on successful lactation;
2. On the child
a. Normal growth and development; normal birtweight and length;
b. Reduced incidence of intrauterine growth retardation (IUGR);
c. Reduced chances of stillbirths, congenital malformations and neonatal deaths;
d. Reduced incidence of illness and stronger resistance to infections;
e. Adequate nutrient reserves.
RELATIONSHIP BETWEEN FETAL AND MATERNAL NUTRITION
1. Fetal growth and development is dependent upon the utilization by the fetus of
adequate energy and nutrients, the gene expression of the factors promoting tissue
growth and the hormonal framework. The failure of the maternal-placental nutrient
supply to match fetal nutrient demand causes restriction of fetal growth.

Relationship Between Fetal and Maternal Malnutrition(Rosso,1981)

Inadequate food intake Poor nutrient utilization

Maternal malnutrition

Reduced blood volume expansion

Inadequate increase in cardiac output

Decreased blood and nutrient supply to fetus

Reduced nutrient transfer

Reduced placental size

Fetal growth retardation

COMMON NUTRITION-RELATED CONCERNS DURING PREGNANCY AND DIETARY

INTERVENTIONS
1. Nausea and Vomiting “ Morning Sickness”
During the early part of pregnancy, the most common discomfort is “morning sickness”, so
called because nausea and vomiting usually occur immediately after getting up in the
morning. Due toincreased hormone production resulting in disturbed physiologic and
biochemical process.
For most pregnant women, morning sickness disappears after the first trimester.
Intervention:
▪ Small frequent feedings
▪ Eat diet high in protein & complex carbohydrates and low fat food such as crackers
and jelly, rice and little brown sugar.
▪ eat diet high in protein & complex carbohydrates and low fat food such as crackers
and jelly, rice and little brown sugar.
▪ drink plenty of fluids.
▪ avoid excessive greasy foods, hot, spices and gas formers, e.g., cabbage family &
beans.
▪ eat early and often, and get some extra sleep and relaxation.
▪ brush your teeth, or rinse your mouth after each about vomiting.
2. Hyperemesis gravidarumor severe and prolonged vomiting throughout pregnancy can be
life threatening if not controlled; it is characterized by dehydration, acidosis, weight loss,
avitaminosis, and jaundice.
▪ Intravenous feeding can help prevent dehydration and provide nutrients.
▪ If tolerated, enteral feeding of an appropriate formula through nasogastric tube may
be given and this can be followed by a dry diet in six small feedings with clear
liquids between feedings.
2. Heartburn. This is caused by increased levels of progesterone and rise of gastric
secretions into the esophagus (gastroesophageal reflux or GERD) and the growing fetus
that places pressure on the stomach.
Intervention:
▪ don’t wear clothing that is tight around your abdomen or waist.
▪ eat six meal rather than three big ones and eat slowly.
▪ drink fluids between meals rather than with meals.
▪ stays upright for several hours after eating.
▪ eat less spicy, less greasy foods.
▪ avoid lying down after meals’ walk around the house leisurely.
▪ Drinks nourishing less acidic liquids between meals.
3. Constipation. Due in part to the pressure exerted by the developing fetus on the digestive
tract, lack of exercise, and insufficient bulk(dietary intake). With chronic or habitual
constipation, one experiences headaches and much discomfort.
Intervention:
▪ drink 8 to 12 glasses of water every day.
▪ fight back with fiber like lots of fresh fruits and vegetables
▪ don’t hold bowel movement.
▪ Regular exercise
▪ Do not use medication like laxatives without doctor’s advice.
4. Edema(swelling of the ankles and feet). Mild, physiologic edema is usually present in the
extremities in the third trimester and should not be confused with the pathologic,
generalized edema associated with pregnancy-induced hypertension (PIH). The swelling of
the lower extremeties may caused by the pressure of the enlarging uterus on the veins that
 return fluids from the legs. It does not require sodium restriction or other dietary change.
Extravascular fluid is often mobilized in the evening when the woman is lying down,
resulting in a tendency to urinate at night.
Intervention:
▪ Avoid extend period of standing
▪ Elevate your legs if possible when you’re sitting, lie down briefly when you can,
preferably on your left side.
▪ Wear comfortable shoes/slippers, avoid elastic socks/ stockings.
5. Leg Cramps. Occurs usually at night, manifested by sudden contractions of
gastrocnemius muscle. It was thought to be related to a decline in serum calcium levels
related to calcium-phosphorus imbalance, but double- blind studies are nor definite that
there is correlation between leg cramps and either the intake of dairy products or calcium
supplementation.
Intervention:
▪ Provide phosphorus and magnesium need according to RENI recommendation.
▪ Straighten your leg and flex your ankle and toes slowly up toward your nose.
▪ Proper exercises with supervision from a clinician help relieve leg cramps.
6. Rapid weight gain or Loss. The popular concept of “eating for two” is not valid among
well-nourished mothers. It may lead to overweight with consequent toxemias or PIH
(Pregnancy-induced hypertension), difficulties of labor and birth of large, sickly babies.
Excessive weight gain during pregnancy is defined as an increase of 3kg or more/
month in the second and third trimesters. A sudden increase in weight after about the
twentieth week of gestation is a cause for suspending that water is being retained at an
inordinate rate and should be regarded as a warning sign of impending eclampsia.
A gain of less than 500 grams per month during the first trimester of pregnancy and
250 grams during the second trimester is considered a maternal “at risk” factor.
Underweight on entering pregnancy(<38kg)or show inadequate weight gain (<40kg) at the
20th week of pregnancy are more likely to deliver a low-birth-weight infant, or to have
premature deliveries, abortions, brain nerve damage to the offsprings.
7. Pregnancy-Induced Hypertension (PIH). Rapid weight gain, edema, high blood
pressure, excretion of albumin in the urine, and convulsions are the clinical manifestations
of PIH “Toxemia of pregnancy”- old terminology
Classifications are:
▪ Pre-eclampsia-hypertension with proteinuria and/ or edema developing after the 20th
week of gestation.
▪ Eclampsia-convulsions or coma; usually both when associated with hypertension,
proteinuria, edema; occurs after 20th week of gestation.
PIH complicates about 5% of pregnancies is among the leading causes of maternal
deaths, pre-natal deaths, and low birth-weight infants. Several studies have indicated that
calcium and magnesium deficiency may play role in the development of pre-eclampsia.
Who are at Risk?
➢ High levels of blood triglycerides (associated with high sugar diets)
➢ Women who are obese (BMI>35)
➢ Women who are already have chronic high blood pressure
➢ Women with diabetes
➢ Women carrying multiple fetus
 Intervention:
▪ Management of pre-eclampsia focuses mainly on blood pressure control.
▪ Typical treatment includes bed rest, emphasis is given protein foods of high
biologic value, sources of iron, calcium and other minerals.
▪ Salt intake is restricted for edema, there is no evidence that mild sodium restriction
is harmful.
8. Anemia. Iron deficiency anemia is the most common nutritional deficiency during
pregnancy. A screening should be performed as early in the pregnancy as possible.
▪ Choose foods rich in iron and B-vitamins using the Nutritional Guide Pyramid
recommended for pregnancy.
▪ Iron supplementation
▪ A 15% prevalence of anemia in pregnant woman can be described as mild anemia.
9. Gestational Diabetes Mellitus
For some women, diabetes may occur as a temporary response to the stress of pregnancy
and it disappear after the baby is born. Usually begins in the 5th or 6th month of
pregnancy(bet. 24th& 28 weeks).About 10% experience. If blood glucose not controlled,
there is risk of perinatal death, prematurity, and other complications during delivery. e.g.
macrosomia of the infant.
Dietary Measures/Intervention for GDM:
▪ Lower caloric intake by 30% but not lower than 1600kcal
▪ Limit carbohydrate intake to 40-45% of total daily kcal.
▪ Space carbohydrates evenly throughout the day, but less for the breakfast meal.
▪ Plan 3 smaller meals and add snacks.
What causes Gestational Diabetes?
▪ Changing hormones (estrogen, cortisol and human placental lactogen) and weight
gain are part of a healthy pregnancy. But both changes make it hard for your body
to keep up with its need for hormone called insulin.
▪ Production of insulin is not enough to overcome the effect of the placental
hormones, blood sugar level rises and gestational diabetes results.
What are the risk factors associated with GD?
▪ Obesity
▪ Family history of diabetes
▪ Multiple pregnancy
▪ Having given birth previously to a very large infant
▪ Having too much amniotic fluid
▪ Women who are older than 25 years.
How is GD diagnosed & treated ?
▪ Drinking a glucose drink followed by measurement of blood sugar level after one
hour.
Treatment for GD focuses on keeping blood glucose levels in the normal range.
Treatment includes:
▪ Special diet
▪ Exercise
▪ Daily blood glucose monitoring
▪ Insulin injections
 What are the risks for the mother and the baby?
Maternal Risks
Fetal Risks
▪ High blood pressure during pregnancy
▪ Higher chance of caesarean section ▪ Large babies weighing more than 8.5
▪ Risk of developing type 2 DM later in life. pounds
▪ Low sugar levels
▪ Yellowing of the skin (jaundice)
▪ Respiratory distress syndrome
10. Cravings And Aversions (Pica)
It Refers to the compulsion for persistent ingestion of unnatural foods or non-food items
such as clay, starch, ice, charcoal, etc.. Ingestion of pica substances can limit of nutritious
foods and/or interfere with the absorption of nutrients. Some pica substances may also
contain toxic compounds. In some cultures, pregnant women crave for non-nutritive items
like clay and dirt with the belief that if these are not consumed, the developing fetus will be
harmed.
The word pica is Latin for magpie which is a bird notorious for eating almost
anything.
What are typical pica cravings during pregnancy?
The most common substances craved during pregnancy are dirt, clay, and laundry starch.
Other pica cravings include: burnt matches, stones, charcoal, mothballs, ice, cornstarch,
toothpaste, soap, sand, plaster, coffee grounds, baking soda, and cigarette ashes.
11. TORCH Infections
TORCH is an acronym for Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes simplex.
If any of such infectious disease occur during pregnancy, the developing fetus suffers
harmful effects. An adequate balanced diet helps provide the nutrients needed to fight
infections.
13. Maternal Phenylketonuria
Spontaneous abortion, microcephaly, congenital heart disease, low birth weight, and
mental retardation have been associated with phenylketonuria (PKU). Many of these
women are unaware that they have this disease. It is believed that poor birth outcomes
associated with maternal PKU may be reduced if the woman can maintain a very low blood
phenylalanine concentration before and throughout pregnancy.
▪ Monitor plasma phenylalanine levels regularly
▪ Use Lofenalac in place of milk
▪ Avoid all products sweetened with aspartame.
▪ Allow low-protein food, such as fruits, vegetables, and certain cereals.
▪ Use dietary products completely free of phenylalanine.
PRACTICES INCOMPATIBLE DURING PREGNANCY
Alcohol, Caffeine, Smoking, and Substance Abuse
▪ Cigarette smoking. Nicotine and cyanide in cigarettes are toxic to the fetus. Smoking
restricts blood supply to the fetus and therefore limits nutrients and oxygen and removal of
waste products. The growth and development of the fetus is retarded. There is a risk of
genetic disorders, mental defects and respiratory problems.
➢ The more a mother smokes, the smaller the baby will be. Smokers tend to have
lower intakes of vitamin and dietary fiber.
➢ Milk production is reduced and has a lower fat content.
➢ Lactating mothers who breastfeed passes on the harmful effects of secondary
smoke to their baby and these include poor growth, impaired hearing, breathing
difficulties.
▪ Alcohol abuse. Excessive alcohol consumption causes adverse effects on fetal
development known as fetal alcohol syndrome (FAS). Infants with FAS exhibit:
a) Facial defects
b) Growth retardation
c) Abnormalities of the central nervous, cardiac, and genitourinary systems.
▪ Over the counter drug and herbal supplements- mega doses of vit. And minerals
supplement can be toxic and could cause defects to the fetus.
▪ Illicit drugs. Like marijuana, cocaine can cross the placenta and result in nervous system
disorder of the fetus. Growth and development is retarded.
▪ Caffeine. Caffeine crosses the placenta and the fetus has a limited ability to metabolize it.
Results are conflicting as to how much caffeine should be allowed. Recent evidences
suggest that drinking 3 cups of coffee a day increases the risk of fetal death. For safe
consumption, allow only 1 cup of 5-oz coffee or two 12-oz cola beverages a day.

▪ Exercise/Physical Activity. In the absence of medical or obstetrical complications,

regular mild to moderate physical activity does not affect the fetus and can benefit the
pregnant woman.
➢ Women can continue to exercise with mild to moderate exercise routines. Regular
exercise (at least 3 times per week) is preferred to intermittent exercise.

▪ Food Safety. General principles of food safety should be followed by pregnant women to
decrease the risk of foodborne illness.
➢ Listerosis. Can cause miscarriage during the first 3 months of pregnancy and
acute illness or stillbirth later in pregnancy. Avoid unpasteurized or raw milk
products.

➢ E. coli. Bacteria normally found in the alimentary canal of humans and animals.
When even a small amount of this bacteria is ingested, in can produce deadly
toxins that can cause severe damage to the intestinal tract and kidneys. In
pregnant women, the infection can spread to the fetus and cause early-onset
neonatal sepsis with nongroup B streptococcal organisms that are resistant to
antibiotics.

➢ Methyl mercury ,PCBs and Lead. Exposure during pregnancy is associated with
increased rates of miscarriage and stillbirth, decreased birthweight, and adverse
cognitive, genitive behavioral, and neuro-physical development in the fetus.

➢ Sugar Substitutes. Can be used during pregnancy, however, pregnant women

should be advised to moderate their intake of products containing artificial
sweeteners if these food are replacing more nutrient-dense foods.

➢ Herbs. At this time there is not enough scientific information about the safety of
various herbs and herbal products to recommend their general use during
pregnancy and lactation.

SPECIAL CONCERNS
 A. TEENAGE PREGNANCY
A biologically mature female is the first requisite for a healthy pregnancy. Many
pregnant adolescents have not reached this stage, which is at least 5 years post-menarche.
▪ Adolescent pregnancies are at risk of complications because of biological,
psychosocial and economic factors.
▪ Pregnant adolescents are more likely to be emotionally, financially, and socially
immature.
▪ Pregnant adolescents give low priority to nutrition and tend to have erratic patterns
and practices.
▪ Pregnant adolescents seek parental care later.
Significant nutrient- related risk Factors for Pregnant Teenagers include:
▪ Low pregnancy weight gain
▪ Low pregnancy weight for height
▪ Excessive pre-pregnancy weight for height.
▪ Low gynecological age ,ie. Age of onset of pregnancy minus age of menarche.
▪ Unhealthy lifestyle such as the use of drugs, alcohol, or cigarettes.
▪ A history of eating disorders.
▪ The presence of anemia, toxemia, and other chronic diseases.
To ensure optimal fetal development and growth, and at the same time provide for the needs
of a growing adolescent, a pregnant teenager requires increased intakes of calories and
nutrients that exceed the dietary allowances for a mature pregnant woman.
An appropriate weight gain for a pregnant adolescent is 14 to 15 kg (about 30 lb)
throughout the gestation period, or a rate of 500g/week.
Intervention for Pregnant Teenagers
▪ Proper health nutrition counselling and encouragement should be given to
teenage mothers.
➢ Realistic goals for weight gain should be set.
➢ Healthy lifestyle – adequate diets, plenty of exercise and rest, and not to
smoking, alcohol drinking and use of drugs – should be practiced.
➢ Emotional and socioeconomic care and support should be given.
B. VEGETARIANISM
Well-planned vegetarian diets can be adequate during pregnancy. Weight gain of pregnant
vegetarians is usually sufficient and should follow the recommended weight gains for
pregnancy
▪ If weight gain is low, concentrated sources of calories and small, frequent meals
can be recommended.
▪ B12 is recommended for vegans during pregnancy.
▪ Vitamin D supplementation, if exposure to sunlight is inadequate
▪ Zinc supplementation if dietary zinc is inadequate
▪ Calcium supplementation if dietary calcium intake is inadequate.
SUMMARY OF NUTRITIONAL CARE DURING PREGNANCY
To ensure a healthy pregnancy, it is important for the expectant mother to:
▪ Gain sufficient weight to support the demands of the pregnancy.
▪ Consume a variety of nutritious foods
▪ Take a daily multivitamin/multi-mineral as prescribed by her healthcare provider
▪ Abstain from alcohol, tobacco, and other harmful substances
▪ Handle foods safety.
 MYTH ON PREGNANCY
Eating for Two
Helping yourself to double servings of potato salad or ice cream? Not so fast. Yes, you're eating for two
-- but that doesn't mean two adult-sized servings are necessary.
The average woman with a normal weight pre-pregnancy needs only about 300 extra calories per day to
promote her baby's growth, according to the American Congress of Obstetricians and Gynecologists
(ACOG). That's roughly the number of calories in a glass of skim milk and half a sandwich. A woman of
normal weight should gain 25 to 35 pounds during pregnancy -- less if she's overweight.
Also, women who gain more than 50 pounds when they're carrying just one child have a higher risk of a
cesarean section or a difficult vaginal birth, and babies who are "overgrown" at birth, are more likely to be
obese when they're adults.

NUTRITION ASSESSMENT
The following should be considered in the nutrition assessment of pregnant women. This
global evaluation can help to ensure that nutrition intervention is adequate and pertinent to the
prenatal woman.
▪ Anthropometrics – height, pre-pregnancy weight, and weight gain in pregnancy are
important determinants of infant birth weight. Weight is usually measured at each prenatal
visit and plotted on a prenatal weight chart to monitor the progress of weight gain. Weight
gain should be assessed over time. Rapid weight gain may indicate fluid retention. Even
though total weight gain may appear to be within the acceptable range, consistent gains at
the low end of the range may result in an inadequate weight gain.

▪ Biochemical indicators –blood glucose levels (at 24 to 48 weeks), standard CBC,

haemoglobin and or haematocrit, and others (eg, ferritin, transferrin) as indicated.

▪ Previous obstetric performance – history of low-birth-weight infant (<2500 g), small for
gestational-age infant, high-birth-weight infant (>4500 g), preterm labor and/or delivery,
repeated pregnancies or lactation within 1-year interval, pregnancy involving an infant or
fetus with a neural tube defect, hyperemesis gravidum, gestational diabetes, pre-
eclampsis, >2 spontaneous abortions, inadequate weight gain, anemia, excessive weight
gain, neonatal death, stillbirth, congenital anomaly, and an infant born with fetal alcohol
syndrome or fetal alcohol effects.

▪ Current medical/obstetric complications – gynaecological history, diabetes,

hyperemesis, hypertension, thyroid disease, fibroids, urinary infection during pregnancy,
sexually transmitted infections, metabolic disorder, etc.

▪ Food and diet history – appetite, usual eating habits (including cultural or ethnic
practices), vegan diet, nutritional supplements, physical activity, etc.

▪ Psychological history – age, gynaecological age of adolescent, number of previous

pregnancies, marital status, income, economic situation, work/occupation, culture, religion,
educational level, living arrangements, family or support system, language barriers,
attitude toward pregnancy, history of abuse, and mental illness.

Braxton Hicks contractions, also called false labor. These contractions can often be relieved
with rest or hydration.