Nutrition and

Pregnancy

Cleonara Yanuar Dini, S.Gz., M.Sc., RD

Nutrition Department
Brawijaya University
The Status of Pregnancy Outcomes

 At no other time in life are the benefits of optimal nutritional

status more obvious than during pregnancy

 How well these processes go depends on many factors, most

of which are modifiable nutritional status stands out.
 The Status of Pregnancy Outcomes
Natality statistics
(natality means “related to birth”)

Summarize important information about the occurrence of pregnancy

complications and harmful behaviors in addition to infant mortality (death) and
morbidity (illness) rates within a specific population.

to identify problems in need of
resolution
T
to identify progress in meeting
national goals for improvement
in the course and outcome of
pregnancy
Maternal Mortality
 Infant Mortality

population-wide improvements in social circumstances, infectious

disease control, and availability of safe and nutritious foods have
corresponded to greater reductions in infant mortality than have
technological advances in medical care.
 Maternal Physiology

 Occur in a specific sequence.

 The order of the sequence is absolute
 They begin in earnest within a week after conception
 Abnormalities  modify subsequent fetal growth and development
Maternal Physiology during Pregnancy
• Maternal plasma volume: To provide the fetus with sufficient energy,
nutrients, and oxygen for growth,
20 week
• Maternal nutrient stores: they will be needed to support large gains
in fetal weight.
20 week
• Placental weight: ensures that the placenta is fully prepare for the high level
of functioning that will be needed as fetal weight increases most rapidly.
31 week

• Uterine blood flow

37 week

• Fetal weight: Fetuses depend on the functioning of multiple systems,

established well in advance of their maximal rates of growth and development.
37 week
 Physiological changes in pregnancy

“Maternal Anabolic” “Maternal Catabolic”

(1st half of pregnancy/ accomplish 10%
of fetal growth)
Build the capacity of the mother’s body to
deliver relatively large quantities of blood,
oxygen, and nutrients to the fetus in the
second half of pregnancy.
(2nd half of pregnancy/ accomplish
90% fetal growth)\
Energy and nutrient stores, and the
heightened capacity to deliver stored
energy and nutrients to the fetus,
predominate
 Body Water Changes
 Plasma volume begins to increase
 Increased volumes of plasma, within a few weeks after
extracellular fluid, amniotic fluid. conception and reaches a
maximum at approximately 34
 Total body water increases in weeks women feel tired and
pregnancy range from 7 to 10 become exhausted easily when
liters undertaking exercise performed
routinely prior to pregnancy.
 About two-thirds of the
 Fatigue associated with plasma-
expansion is intracellular (blood
and body tissues) and one-third is volume increases in the second
extracellular (fluid in spaces and third months of pregnancy
between cells). declines as other compensatory
physiological adjustments are
made.
 Body Water Changes
 Gains in body water vary a good deal among women during
normal pregnancy  increasing degrees of edema and weight
gain. If not accompanied by hypertension, edema generally
reflects a healthy expansion of plasma volume.

 Birth weight is strongly related to plasma volume: generally, the

greater the expansion, the greater the newborn size.

 The increased volume of water in the blood is responsible for the

“dilution effect” of some vitamins and minerals.

 Blood levels of fat-soluble vitamins tend to increase in pregnancy,

whereas levels of the water-soluble vitamins tend to decrease.
Vitamin supplement use can modify these relationships.
Hormonal Changes
 Maternal Nutrient Metabolism
 Adjustments in maternal nutrient metabolism are apparent within
the first few weeks after conception and progress throughout
pregnancy ensuring that nutrients will be available to the fetus
during periods of high nutrient need.

 Fetal nutrient needs are driven by genetically timed sequences of

fetal tissue growth and development  nutrients must be available
at the same time that genes controlling fetal growth and
development are expressed

 The amount and types of nutrients required depend on the type and
amount of nutrients needed for specific metabolic pathways to
function and for fetal structures to develop.
 Carbohydrate Metabolism
First Half Of Pregnancy
• estrogen- and progesterone-stimulated increases in insulin production and
conversion of glucose to glycogen and fat

Second Half Of Pregnancy

• Rising levels of hCS and prolactin from the mother’s pituitary
gland inhibit the conversion of glucose to glycogen and fat

Insulin resistance builds in the mother, increasing her reliance on

fats for energy.

Lowered maternal utilization of glucose, and increased liver

production of glucose help to ensure that a constant supply of
glucose for fetal growth and development is available

Diabetogenic effect of pregnancy make normal pregnant

women slightly carbohydrate intolerant in the third trimester
of pregnancy
 Protein Metabolism
Increased nitrogen Mother’s body Maternal and fetal
and protein stores of protein needs for protein
• For synthesis of There is no evidence primarily fulfilled by
new maternal and that the mother’s the mother’s intake
fetal tissues body stores of of protein during
• Met through protein early in pregnancy.
reduced levels of pregnancy in order
nitrogen excretion
and the to meet fetal needs
conservation of for protein later in
amino acids for pregnancy.
protein tissue
synthesis

It is estimated that 925 grams (2 pounds) of protein is accumulated during

pregnancy.
 Fat Metabolism

 Changes in lipid metabolism  accumulation of maternal fat

stores in the first half of pregnancy and enhance fat mobilization
in the second half

 Cholesterol-containing lipoproteins, phospholipids, fatty acids,

and triglycerides used by the placenta for steroid hormone
synthesis and by the fetus for nerve and cell membrane
formation.
 Mineral Metabolism
 Sodium metabolism is delicately balanced during pregnancy to
promote an accumulation of sodium by the mother, placenta, and
fetus.
 Changes in the kidneys that increase aldosterone secretion and the
retention of sodium ineffective and potentially harmful any
attempts to prevent and treat high blood pressure in pregnancy by
reducing sodium intake.
 Sodium restriction  sodium depletionoverstress mechanisms
that act to conserve sodium  functional and growth impairments
 Calcium metabolism is characterized by an increased rate of bone
turnover and reformation
Placenta

Functions :
● Hormone and enzyme production
● Nutrient and gas exchange
between the mother and fetus
● Removal of waste products from
the fetus
Structure:
• a double lining of cells separating
maternal and fetal blood,
• acts as a barrier to some harmful
compounds
• governs the rate of passage of
nutrients and other substances into
and out of the fetal circulation
Nutrient Transfer

 The placenta uses 30–40% of the glucose

delivered by the maternal circulation.
 Nutrient supply is low placenta fulfills its
needs before nutrients are made available to
the fetus.
 Nutrient supplies fall short of meeting
placental needs functioning of the placenta is
compromised to sustain the nutrient supply
and health of the mother.
Nutrient transfer across the placenta depends on a number of
factors, including:
● The size and the charge of molecules available for transport
● Lipid solubility of the particles being transported
● The concentration of nutrients in maternal and fetal blood
 Pregnancy Weight Gain

 Current recommendations for weight gain in pregnancy are based primarily on

gains associated with the birth of healthy-sized newborns (approximately 3500–
4500 g or 7 lb 13 oz to 10 lb).

 Prepregnancy weight  weight gain and birth weight. The higher the weight before
pregnancy, the lower the weight gain needed to produce healthy-sized infants.

 Recommended weight gains for women of all ethnicities and statures entering
pregnancy underweight, normal-weight, overweight, and obese
Rate of Pregnancy Weight Gain
 Rates at which weight is gained during pregnancy appear to be as
important to newborn outcomes as is total weight gain.
 Low rates of gain in the first trimester of pregnancy may down-
regulate fetal growth and result in reduced birth weight and
thinness
 For underweight and normalweight women, rates of gain of less
than 0.5 pound (0.25 kg) per week in the second half of pregnancy,
and of less than 0.75 pound (0.37 kg) per week in the third
trimester of pregnancy, double the risk of preterm delivery and
SGA newborns.
 For overweight and obese women, rates of gain of less than 0.5
pound (0.25 kg) per week in the third trimester also double the risk
of preterm birth
Composition of Weight Gain in Pregnancy
“Where does the weight gain go?”

The fetus actually comprises only about a third of the total weight gained
during pregnancy in women who enter pregnancy at normal weight or
underweight.
Most of the rest of the weight is accounted for by the increased weightof
maternal tissues.
 Postpartum Weight Retention
 Increased weight after
pregnancy appears to be
related to a variety of factors,
including excessively high
weight gain in pregnancy
(over 45 lb, or 20.5 kg), weight
gain after delivery, and low
activity levels
 High blood levels of insulin
early and levels of leptin 
related to dietincreased
weight gain during pregnancy.
 Postpartum weight retention
tends to be slightly less in
women who breastfeed for at
least 6 months after pregnancy
 Postpartum weight can be
reduced by identifying high
weight gainers during
pregnancy and getting the
women identified involved in an
exercise and healthy-eating
program.
 Nutritional Requirement during
Pregnancy
 Nutrient requirements  For the most part, nutrient
during pregnancy are not needs can be and are
static. optimally met by
consuming well balanced,
 They vary during the course adequate, and healthful
of pregnancy depending on diets consisting of basic
prepregnancy nutrient foods.
stores, body size and
composition, physical  Healthful diets established
activity levels, stage of during pregnancy can last
pregnancy, and health well beyond pregnancy and
status. benefit health for life.
 The Need for Energy

 Increased maternal body mass

and fetal growth energy
requirements increase during
pregnancy
 The increased need for energy
in pregnancy averages 300 Respiration and accretion of breast tissue,
Increased workandof the
uterine Fetus
muscles, the heart
placenta
kcal a day (210–570 kcal a day).
 Caloric intake
recommendations represent a
rough estimate that by no
means applies to every
woman.
 The need for additional calories during pregnancy may be a
good deal lower in women who perform little exercise, and
higher in women who are very active.

 Low levels of energy expenditure from physical activity are

common in the first trimester of pregnancy and the energy
savings may produce a positive caloric balance even though a
woman’s caloric intake hasn’t changed much.

 Adequacy of calorie intake is most easily assessed in practice

by pregnancy weight gain. Rates of gain in women who do not
have noticeable edema are a good indicator of caloric balance.
 The Need for Carbohydrates
 50–60% of total caloric
 Consume a minimum of 175 grams
carbohydrates to meet the fetal  There is no evidence that
brain’s need for glucose. consumption of aspartame or
acesulfame K is harmful in pregnancy.
 Source: Vegetables, fruits, and
whole-grain products containing fiber  Diet soft drinks and other artificially
and a variety of other nutrients are sweetened beverages and foods are
good choices for high-carbohydrate often poor sources of nutrients,
foods. however, and may displace other,
more nutrient-dense foods in the diet
 Sources of carbohydrates that do not
contain added sugars and fat tend to
be less energy-dense than foods that
do and may help women manage
pregnancy weight gain.
The Need for Protein
Increases in
maternal blood &
extracellular fluid
volume (216 gr)
 +25 grams/ day (71 grams daily;
1.1 gram/ kg body weight) for Taken up accumulat
females aged 14 and older by the ed by the
 Physiological adaptations in
fetus placenta
protein metabolism during ( 440 g) Protein (100 g)
pregnancy shift in the direction 925 g
of meeting maternal and fetal
needs for protein less protein maintain
is used for energy and more is the consumed by
used for protein synthesis protein the uterus
tissue (166 g)
developed
Vegetarian Diets in Pregnancy

 Diets of pregnant vegetarians are sometimes low in vitamin B12

and D, calcium, iron, zinc, and omega-3 fatty acids
eicosapentaenoic and docosahexaenoic acids

 In pregnant women who consume no animal products, the

variety of plant protein sources needs to include complementary
sources of protein daily. Protein sources that complement each
other, or provide a complete source of protein include and grains.

 Protein requirements in vegetarians whose main source of

protein is cereals and legumes may be 30% higher than for non-
vegetarians due to the low digestibility of protein in these foods.
The Need for Fat
 33% of total calories
 13 grams of the essential
 Used as an energy source for
fatty acid linoleic acid daily
fetal growth and
(safflower, corn, sunflower,
development and serves as a
and soy oil)
source of fat-soluble
vitamins.
 1.4 grams of the other
 Provides essential fatty acids essential fatty acid,
that are specifically required alphalinolenic acid (flaxseed,
for components of fetal walnut, soybean, canola oils,
growth and development. and leafy green vegetables).
 Omega-3 Fatty Acids EPA and DHA
During Pregnancy
 Linoleic and alpha-linolenic:
structural components of cell
membranes. The brain, retina,
and other neural tissues of the
fetus are particularly rich in these
fatty acids.
 Derivatives of linoleic acid and
alphalinolenic acid serve as
precursors for eicosanoids that
regulate numerous cell and
organ functions
 Two members of the alpha-
linolenic acid family of fatty acids:
eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA)
 EPA reduce inflammation, dilate
blood vessels, and reduce blood
clotting.
 DHA is a major structural
component of phospholipids in
cell membranes in the central
nervous system, including
retinalphoto receptors.
 Fish consumed should be good sources of EPA and DHA and contain low amounts
of mercury and other contaminants.

 Fish known to generally contain high levels of mercury (swordfish, king mackerel,
tilefish, and shark) should not be consumed. No more than 6 ounces per week of
albacore tuna (labeled as “white tuna” on cans) should be consumed each week.

 Due to the presence of mercury and other contaminants in some types of fish, it is
recommended that women who are pregnant or breastfeeding consume no more
than 12 ounces of fish per week.
 The Need of Water

 The large increase in water need during pregnancy

is generally met by increased levels of thirst.
 On average, women consume about 9 cups of fluid
daily during pregnancy.
 Women who engage in physical activity in hot and
humid climates should drink enough to keep urine
light-colored and normal in volume.
 Water, diluted fruit juice, iced tea, and other
unsweetened beverages are good choices for
staying hydrated
Angka Kecukupan Gizi (2013)
 The Need for Vitamins and Mineral
Pregnancy
 Folate is a methyl group (CH3) donor
and enzyme cofactor in metabolic
reactions involved in the synthesis of
DNA, gene expression and gene
regulation

 Inadequate Deficiency Anemia

inpregnancy,reduced fetal growth,
abnormal cell division Neural tube
defects /NTDs (malformations of the
spinal cord and brain
NTD
Anencelophaty: Encephalocele:
Spina bifida:
absence of the protrusion of the
spinal cord
brain or spinal brain through
failing to close
cord the skull
 Other Nutrient Concerns
Vitamin A • For cell differentiation

• Support fetal growth

Vitamin D • Support immune systems

• Teeth begin to develop

Flouride • Not recommended to supplement

• Fetal skeletal mineralization and maintain

Calcium maternal bones

• Low intake of calcium are realted to increase
release of Lead harmful to fetus

• Thyroid function
Iodine • energy production
• Fetal brain development
• Restriction not indicated in normal pregnancy
Sodium or for control edema or high blood pressure
• Maintaining body’s water balance
 Iron Status and the Course and
Outcome of Pregnancy
Assessment of iron status Recommendations
•Iron deficiency: a condition marked by • Intake iron during preganncy upper limit is
depleted iron stores with weakness, fatigue, set at 45mg/day
short attention span, poor appetite, increased
susceptibility to infection and irritability •Iron supplementation in pregnancy: 30 mg
iron/day after the 12th week of pregnancy
•Iron deficiency anemia: a condition marked by
low hemoglobin with signs of iron deficiency
plus paleness, exhaustion and rapid heart rate

Additional Iron Needs Iron deficiency anemia in pregnancy

•300 mg for fetus •Early pregnancy risk of pretem delivery
•250 mg lost at delivery •Late pregnancy lower scores on intelegence,
•450 mgfor increasing RBC language, gross motor and attention tests
Iron Status and the Course and
Outcome of Pregnancy
 Health Concerns during
Pregnancy
Nausea: Eat dry toast or crackersbefore arising; drink fluids between meals only; eat no
fats and oils; use skim milk

Constipation: Eat high fiber foods (fresh foods, vegetables , whole grain breads and cereals

Anemia: Increase intake of iron and the vitamins associated with red blood cells formation
(folacin, B6,B12 and C)

Pica (the practice of eating non-food items): education the patient about the need to
discontinue the practice

Heartburn: Eat bland foods; take antacids if prescribed; plan small andfrequent meals

Urinary urgency: Generally avoid consuming tea, coffee, spices, and alcoholic bavarages

Muscle cramps: Increase calcium and decrease phosphorus intake

Bloating/ cramping: Plan frequent and small meals ; eat no grasy foods; reduce roughage and
cold