Nutrition in

Pregnancy and Lactation

Astiti Dwi Arumbakti
Eleonora Mitaning Christy
Patricia Amanda
Kurnia Sitompul
Adventia Natali

Physiology of Pregnancy
Pregnancy averages 38 weeks, or 266
days, in length
Commonly, pregnancy duration is given as
40 weeks (280 days) because it is
measured from the date of the first day of
the last menstrual period (LMP)

Normal Physiological
Changes During Pregnancy
First half : maternal anabolic deliver relatively
large quantities of blood, oxygen
10% of fetal
growth in the first half of pregnancy
Second half : maternal catabolic, which energy
and nutrient stores, deliver stored energy and
nutrients to the fetus, fetal growth90% occurs in the
second half

1. Body Water Changes

A womans body water during
pregnancy = increased volumes of plasma
and extracellular fluid, as well as amniotic
fluid
Total body water increases in
pregnancy from 7 to 10 liters
(2-2,5 gallons)

Two-thirds of the
expansion is
intracellular
(blood and body
tissues)

One-third is
extracellular
(fluid in spaces
between cells)

Body water (2)

Plasma volume begins to increase after
conception and reaches a maximum at
34 weeks
Plasma-volume increases : primary
reason that pregnant woman feel tired and
become exhausted easily, make pregnant
woman fatigue in second and third
trimester

Body water (3)

Birth weight 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 pregnancy
decreased levels of
hemoglobin, serum albumin, other serum
protein and water soluble vitamin

2. Cardiovascular and Pulmonary

Function
Increased cardiac output and cardiac size
Pressure of the expanding uterus on the inferior
vena cava
Mild lower extremity edema
Blood return to the heart decrease cardiac
output , fall in blood pressure , and lowerextremity edema
Maternal oxygen requirements increase

3. Gastrointestinal function
First trimester : Nausea and Vomiting
Increased Progesterone level
Increased Progesterone
concentration
Relax the uterine
muscle

Decreasing GI motility with

increased reabsorption of
water

Constipation

Allow for fetal growth

Relaxed lower esophageal sphincter and pressure on the

stomach from the growing uterus---regurgitation and
gastric reflux
Gall bladder emptying becomes less efficient

4. Renal Function
The Glomerular Filtration Rate increases
by 50%
Renal tubular resorption is less efficient
than in the nonpregnant state
Glucosuria (+) increase the risk for
urinary tract infections

5. Hormonal Changes
The placenta serves many
roles, but a key one is the
production of steroid
hormones
such as
progesterone and
estrogen.
The placenta : main
supplier of hormones
needed to support the
physiological changes of
pregnancy

Hormonal Changes (2)

6. Maternal Nutrient Metabolism

Carbohydrate Metabolism
Glucose is the fetuss preferred fuel
Carbohydrate metabolism in the first half of
pregnancy is characterized by estrogen- and
progesterone-stimulated increases in insulin
production and conversion of glucose to
glycogen and fat.

Carbohydrate Metabolism
In the second half, rising levels of hCS and
prolactin from the mothers pituitary gland
inhibit the conversion of glucose to glycogen
and fat
At the same time, insulin resistance builds
in the mother, increasing her reliance on fats
for energy

Protein Metabolism
Nitrogen and protein needed >> for
synthesis of new maternal and fetal
tissues
To some extent the increased need for
protein is met through reduced levels of
nitrogen excretion and the conservation of
amino acids for protein tissue synthesis

Fat Metabolism
Plasma triglyceride = three times non
pregnant levels
Cholesterol containing lipoprotein,
phospolipid, and fatty acid also increase, but
lesser than triglycerides
Cholesterol supply used by placenta for
steroid hormone synthesis and by the fetal
for nerve and cell membrane formation

Mineral Metabolism
Calcium metabolism characterized by
increased rate of bone turnover and
reformation
levels of body water and tissue synthesis
-- increased requirements for sodium
Sodium metabolism delicately balance by
changes in the kidneys that increase
aldosterone secretion and the retention of
sodium

7. The Placenta
Placenta derived from Latin word for cake.
Functions of the placenta include:
Hormone and enzyme production,
Nutrient and gas exchange between
the mother and fetus
Removal of waste products from the
fetus

Placenta cont..

LACTATION PHYSIOLOGY
Mammary Gland
The functional units : alveoli
Each alveolus is composed of a cluster of cells
(secretory cells) with a duct in the center
Each smaller duct leading to six to ten larger
collecting ducts.
Myoepithelial cells surround the secretory cells
can contract under the influence of oxytocin and
cause milk to be ejected into the ducts.

 During puberty, the cyclic

release of estrogen and
progesteron governs pubertal
breast development and
usually complete within 12 to
18 months after menarche.
Estrogen : stimulates
development of the glands
Progesterone : elongate
tubules and duplicate the cells
that line the tubules (epithelial
cells)

Lactogenesis
Lactogenesis I, begins during the last
trimester of pregnancy untill first day
postpartum, milk begins to form, lactose and
protein content of milk increase
Lactogenesis II : 25 days postpartum,
increased blood flow to the mammary gland
Lactogenesis III. This stage of breast milk
production begins about 10 days after birth,
the milk composition becomes stable.

Hormonal Control of Lactation

Prolactin and oxytocin are necessary for
establishing and maintaining a milk supply.
Prolactin : stimulates milk production,
stimulates by suckling, stress, sleep, and
sexual intercourse
In the last 3 months of pregnancy, prolactin
activity is suppressed by a prolactin-inhibiting
factor that is released by the hypothalamus

Hormonal control lactation cont..

Oxytocin : main role is in letdown, or the

ejection of milk from the milk gland (acinus)
into the milk ducts.
Stimulated by suckling or nipple stimulation
Oxytocin also acts on the uterus, causing it
to contract, seal blood vessels, and shrink
its size.

The Letdown Reflex

The letdown reflex : stimulates

milk release from the breast

The stimuli -- through nerves to

the hypothalamus -- promoting
oxytocin release oxytocin :
contraction of the myoepithelial
cells -- milk is released through
the ducts

Other stimuli : hearing a baby cry,

sexual arousal, and thinking
about nursing, can also cause
letdown

Indicator of Nutrional Status in

Pregnancy
Several Indicator of Nutional Status in Pregnancy :
Upper arm muscle circumference, weight for height and
eating patterns (weight gain), Hemoglobin.

Weight Gain During Pregnancy

Weight Gain

Upper Arm Circumference

Nutrional Assesment for

Breastfeeding Women

Nutrition Requirement

Factors affecting nutrient requirements during

pregnancy:
- prepregnancy nutrient stores
- body size and composition
- physical activity levels
- stage of pregnancy
- health status.

The need for energy

Energy requirements increase during pregnancy,
mainly due to increased maternal body mass
and fetal growth.
The increased need for energy in pregnancy
averages 300 kcal a day.
The increased calorie need in pregnancy:
1/3 increased work of the heart
1/3 increased energy needs for respiration and
accretion of breast tissue, uterine muscles, and
the placenta
1/3 the fetus

The need for carbohydrate

Approximately 5060% of total caloric
intake during pregnancy should come
from carbohydrates.
Women should consume a minimum of
175 grams carbohydrates to meet the
fetal brains need for glucose.

The need for protein

The recommended protein intake for pregnancy is
+25 grams per day. Less protein is used for
energy and more is used for protein synthesis.
Approximately 925 grams of protein (2 pounds)
accumulated in protein tissues during pregnancy
- 440 grams are taken up by the fetus
- 216 grams are used for increases in maternal
blood and extracellular fluid volume
- 166 grams are consumed by the uterus
- 100 grams are accumulated by the placenta.

The need for fat

It is estimated that pregnant women consume
33% of total calories from fat.
Used as an energy source for fetal growth
and development and serves as a source
of fat-soluble vitamins.
Fat also provides essential fatty acids that
are specifically required for components of
fetal growth and development.

The need for water

On average, women consume about 9 cups of
fluid daily during pregnancy (+300 mL a day).
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.

Nutrition Problem in Pregnancy

Obesity and Pregnancy

Hypertensive Disorders of Pregnancy
Diabetes in Pregnancy
Multiple Pregnancies

Nutrition Problem in Pregnancy

(Indonesia)
Chronic Energy Impairment 38,5%
(LLA<23,5cm)
Anemia (37,1%) Hb<11
Eclampsia 24%
Malaria (1,9%) tend to increase risks of:
anemia, haemorrhage, LBW
Source: Riskesdas, 2013

Obesity and Pregnancy

Associated with : gestational diabetes &
hypertensive disorders
Increase risks of: stillbirth, large-for-gestational
newborns developing type 2 DM, Cesareansection delivery

Comparative Prevalence of
Obesity Prior to Pregnancy and
Outcomes Related to Pregnancy

Source: Brown JD., Nutrition Through The Life Cycle. 4th Ed. Belmont :
Wadsworth.2011.10 :135

Nutritional Recommendations and

Interventions for Obesity During
Pregnancy
Meeting nutrient needs + variety of basic
foods
Changes in calorie intake and physical
activity weight gain (same as those for
women of other sizes)
Monitoring and evaluation

Hypertensive Disorders of
Pregnancy

Source: Brown JD., Nutrition Through The Life Cycle. 4th Ed. Belmont : Wadsworth.2011.10 :137

Hypertensive Disorders of
Pregnancy
Related to chronic inflammation (oxidative
stress, and damage to the endothelium)
Affect 6 to 10% stillbirths, fetal and
newborn deaths

Nutritional Recommendations
and Interventions for Preeclampsia
Adequate Calcium (recommendation: 1000-2000 mg

daily 3x500 mg daily) and Vitamin-D (RDA intake for

pregnant women)
Intake of anti-oxidants (ex: Vit.E,vit.C)
Five or more servings of colorful vegetables and fruits
daily
Consumption of the assortment of other basic food
Moderate exercise (walking, swimming, noncompetitive
tennis, or dancing for 30 minutes) daily unless
medically contraindicated
Weight gain

Diabetes in Pregnancy
7.5% of pregnant women, increasing
along with obesity
Gestational diabetes accounts for 88% of
all cases of diabetes in pregnancy

Diets developed for women with

gestational diabetes
Whole-grain breads and cereals,
vegetables, fruits, and high-fiber foods
Limited intake of simple sugars and foods
and beverages that contain them
Low-GI foods, or high fiber carbohydrate
foods that do not greatly raise glucose
levels
Unsaturated fats
Three regular meals and snacks daily

Estimating Levels of Caloric

Need in Women with Gestational
Diabetes

Source: Brown JD., Nutrition Through The Life Cycle. 4th Ed. Belmont : Wadsworth.2011.10 :137

Multiple Pregnancy

Source: Brown JD., Nutrition Through The Life Cycle. 4th Ed. Belmont : Wadsworth.2015.5 :149

Recommendation of
Nutrition
During Multiple
Pregnancy

Source: Brown JD., Nutrition Through The Life Cycle.

4th Ed. Belmont : Wadsworth.2015.5 :152

Anemia in pregnancy
Hb concentration <11 g/dL
-Increased maternal morbidity & mortality
-Increased fetal morbidity & mortality
-Increased risk of low birth weight
Therapy :
Adequate intake of daily nutrition (heme-iron)
Iron supplement 3x/daily (ferrous sulphate
@300 mg metal element tablet @65 mg ), 2-3
months (+/- 90 tablets)

Nutrition Problem in
Breastfeeding Women
Weight Loss During Breastfeeding
Common Breastfeeding Conditions (ex:
Hyperlactation, Plugged Duct, Mastitis,
Engorgement)
Low Vitamin and Mineral Intakes
clinical manifestation based on those
vitamin & mineral deficiency

Weight Loss During Breastfeeding

Current DRIs assuming a weight loss of
0.8 kg/month
Postpartum weight changes are smaller in
developing countries (0.1 kg/mo) than in
industrialized nations (0.8 kg/mo)
Requirement of Energy, Vitamin, and
Mineral based on RDA / AKG for
Lactation Women

Common Breastfeeding
Conditions
Sore Nipples: proper positioning of
the baby on the breast (nipple in
junction of the hard and soft palate)
Flat or Inverted Nipples
Plugged Duct : pain
Mastitis : inflamation

Low Vitamin and Minerals Intake

Intervention :
Optimal diet
Calcium, phosphate, folate, thiamin, vitamin
A, vitamin Drich foods such as: dairy
products, fruit, vegetables, and whole-grain
Requirement Vitamin and Mineral based
on RDA / AKG

CASE
Energy

Protein

Fat

Carbs

Water

AKG (Usia
25 thn)

2250 kkal

56 gr

75 gr

309 gr

2300 ml

Ibu
Menyusui

2580 kkal

76gr x 4 =
304 kkal

86gr x 9 =
774 kkal

354gr x 4 =
1416 kkal

3100 ml

Breakfast 20 % :
Energy
= 20% x 2580 kkal = 516 kkal
Water
= 20% x 3100 ml = 620 ml

Carbohydrate = 20% x 354 gr = 70, 8 gr

Protein
= 20% x 76 gr = 15,2 gr
Fat
= 20% x 86 gr = 17,2 gr

Snack 10 % :
Energy = 10% x 2580 kkal = 258 kkal
Water = 10% x 3100 ml = 310 ml

Carbohydrate = 10% x 354 gr = 35,4 gr

Protein
= 10% x 76 gr = 7,6 gr
Fat
= 10% x 86 gr = 8,6 gr

Lunch 30 % :
Energy = 30% x 2580 kkal = 774 kkal
Water = 30% x 3100 ml = 930 ml

Carbohydrate = 30% x 354 gr = 106,2 gr

Protein
= 30% x 76 gr = 22,8 gr
Fat
= 30% x 86 gr = 25,8 gr

Snack 10 % :
Energy = 10% x 2580 kkal = 258 kkal
Water = 10% x 3100 ml = 310 ml

Carbohydrate = 10% x 354 gr = 35,4 gr

Protein
= 10% x 76 gr = 7,6 gr
Fat
= 10% x 86 gr = 8,6 gr

Dinner 20% :
Energy = 20% x 2580 kkal = 516 kkal
Water = 20% x 3100 ml = 620 ml

Carbohydrate = 20% x 354 gr = 70, 8 gr

Protein
= 20% x 76 gr = 15,2 gr
Fat
= 20% x 86 gr = 17,2 gr

Snack 10 % :
Energy = 10% x 2580 kkal = 258 kkal
Water = 10% x 3100 ml = 310

Carbohydrate = 10% x 354 gr = 35,4 gr

Protein
= 10% x 76 gr = 7,6 gr
Fat
= 10% x 86 gr = 8,6 gr

Schedule

Nutrient Percentage

Variety of food

Breakfast
Energy 516
kkal

Carbohydrate 106,2 gr
Protein 22,8 gr
Fat 25,8 gr
Water 930 ml

Nasi putih 100 gr

Telur ayam rebus 1btr
55gr
Tempe goreng 1 ptg gr
Sayur sop 100 gr
Pepaya 2 ptg bsr

180 kkal
95,7 kkal
87,5 kkal
27 kkal
100 kkal
Total : 490,2 kkal

Snack
Energy 285
kkal

Carbohydrate 35,4 gr
Protein 7,6 gr
Fat 8,6 gr
Water 310 ml

Lapis legit 50 gr
Susu skim cair 1 gls

194,5 kkal
75 kkal
Total : 269,5 kkal

Lunch
Energy 774
kkal

Carbohydrate 70,8 gr
Protein 15,2 gr
Fat 17,2 gr
Water 620 ml

Nasi 150 gr
Ayam goreng kalasan
paha 40 gr
Gado-gado 50 gr
Kerupuk udang goreng
20 gr
Semangka 3 ptg bsr

270 kkal
110 kkal
68.5 kkal
95,4 kkal
150 kkal
Total : 693,9 kkal

Schedule

Nutrient Percentage

Variety of food

Snack
Energy 258
kkal

Carbohydrate 35,4 gr
Protein 7,6 gr
Fat 8,6 gr
Water 310 ml

Roti putih 2 ptg

Keju 1 ptg 35 gr
Madu 1 sdm

117 kkal
125 kkal
50 kkal
Total: 292 kkal

Dinner
Energy 516
kkal

Carbohydrate 70,8 gr
Protein 15,2 gr
Fat 17,2 gr
Water 620 ml

Nasi 100 gr
Tahu goreng 1 ptg bsr
Tumis bayam
bersantan 100 gr
Yogurt non fat 2/3 gls
Pear 1 bh

180 kkal
115 kkal
48 kkal
75 kkal
100 kkal
Total: 518 kkal

Snack
Energy 258
kkal

Carbohydrate 35,4 gr
Protein 7,6 gr
Fat 8,6 gr
Water 310 ml

Pastel 80 gr

245,6 kkal

TOTAL : 2509,2 kkal

Human Milk
Composition

colostrum, first milk, thick, often

yellow fluid produced
Infants may drink only 2 to 10 mL
(1.52 tsp) of colostrum per
feeding in the first 23 days.
Colostrum higher in
immunoglobulin A and lactoferrin
(the primary proteins present in
colostrum), mononuclear cell,
sodium, potassium, and chloride
than more mature milk.

References
Padilha PC, Accioly E, Libera BD, Chagas C,
Saunders C. Anthropometric assessment of
nutritional status in Brazilian pregnant women.
Rev Panam Salud Publica. 2009;25(2):1718
Brown,E.Judith. Nutrition During Pregnancy
(chapter4).In: Nutrition Through The Life Cycle
(4th edition). USA: Wadsword, CA. 2011. Pg: 87130
Mahan, L. Kathleen., Escottt-Stump, Sylvia. 2008.
The Nutrients and Their Metabolism. In: Krauses
Food and Nutrition Therapy, International edition
12nd. Missouri : Saunders El Savier.