NUTRITION DURING PREGNANCY

PREGNANCY

FIRST,

THEN,

AND THEN

OBJECTIVES
Nutrition for Pregnancy

To produce, healthy, normal weight infants while minimizing health risks to the mother.
To determine appropriate weight gain during pregnancy for normal, under and overweight women. To recognize the additional energy, vitamin and mineral requirements for women during pregnancy.

To understand changing nutritional needs during pregnancy

PERUBAHAN PADA TUBUH APA YANG TERJADI

PADA SAAT HAMIL

Nesting instinct Sulit konsentrasi Perubahan mood Ukuran BH meningkat Kulit mengalami perubahan Rambut dan kuku berubah tekstur Ukuran sepatu berubah Mobilitas persendian lebih longgarPeningkatan hormon relaxin memang diperlukan oleh ibu hamil untuk elastisitas serviks. Pembesaran pembuluh darah, ambeien dan konstipasi Gusi berdarah

OVERVIEW

Masalah-masalah Kehamilan

INCREASED NUTRITIONAL RISK

Pregnant women who are:
Drug or alcohol abusers Vegetarians Smokers Anorexic or bulimic, underweight, or obese

Pregnant women with:

Hyperemesis Poor weight gain or weight loss Dehydration, constipation Pre-existing medical conditions

OBSTETRICAL HISTORY
Past medical history (wt gained in pregnancy) Current dietary intake patterns and ETOH Vitamin, mineral and herbal intake PICA: dirt, starch, clay, ice, detergent Caffeine and other fluids Nausea, vomiting, and heartburn Constipation

OBSTETRICAL PHYSICAL EXAM

Low pre-pregnancy weight and low

maternal weight gain are risk factors for: Intrauterine growth retardation Low birth weight baby Increased incidence of perinatal death

Need to asses: Pre-pregnancy weight (BMI) Current weight (BMI) Weight gain from previous visit

NAUSEA AND VOMITING

Associated with increased levels of HCG (Chronionic Gonadotropin)asal dari plasenta

Peaks at 12 weeks gestation

Strategies for managing morning sickness:

Eat small, low-fat meals and snacks Drink fluids between meals, avoid caffeine Reduce citrus, spearmint, peppermint Limit spicy and high-fat foods Avoid lying down after eating or drinking Take a walk after meals Wear loose-fitting clothes

CONSTIPATION

Constipation during pregnancy is associated with: increased progesterone levels and smoothmuscle relaxation of the GI tract.

This results in GI discomfort, a bloated sensation, increased hemorrhoids, and decreased appetite. Increase fluid and fiber intake to reduce constipation.

FAKTOR-FAKTOR YANG MEMPENGARUHI GIZI

IBU HAMIL Kebiasaan dan oandangan wanita terhadap makanan Status ekonomi Pengetahuan zat gizi dalam makanan Status kesehatan Aktifitas Suhu lingkungan Berat badan Umur

GENERAL OVERVIEW OF NINE MONTHS OF PREGNANCY

From Conception to Birth

THE FIRST TRIMESTER

Lasts from conception to the twelfth week of pregnancy 3 periods during the first trimester:

The Germinal Period

Fertilized egg travels and implants in wall of uterus Implantation occurs 10-14 days after conception

The Period of the Embryo

Lasts from third through eighth week of pregnancy Major organs and anatomical structures begin to form

The Period of the Fetus

Lasts from ninth week of pregnancy until birth All major organs continue rapid growth and become interconnected

THE SECOND TRIMESTER

Fetus assumes distinct human appearance The nails harden and skin thickens, as well as the eye lashes, eye brows, and scalp hair appear during fifth and sixth months Fetuss visual and auditory senses are functional

THE THIRD TRIMESTER

All organ systems mature rapidly Fetus prepares for birth Fetus reaches age of viability, the point at which the fetus can survive outside of the uterus Fetus shows better-organized gross motor activity, and sleepiness/ waking activity Towards end of ninth month, fetus is positioned head-down with limbs curled up in fetal position

TERATOGENS
External

agents such as viruses, drugs, chemicals and radiation that can harm a developing embryo or fetus. Time when organ system or body part is at highest risk of effects from teratogens is known as sensitive period. Effects of teratogens on a body part or organ system are worst during the period when that structure is forming and growing most rapidly.

TERATOGENS
The

same defect can be caused by different teratogens. A variety of defects can be caused by a single teratogen. The longer the exposure or the higher the dose of the teratogen, the more likely it is that serious harm will be done. The long-term effects of a teratogen often depend on the quality of the postnatal environment.

RECOMMENDED WEIGHT GAIN

BMI Weight (kg) Height (m2) Weight Gain (kg) 12.7-18.2 11.4-15.9 6.8-11.4 6.8 Weight Gain 2nd&3rd trimester (kg/week) 0.5 0,4 0,3 >0,2

Underweight BMI < 18.5

Normal Weight BMI 19-24.9 Overweight BMI 25-29.9 Obese BMI > 30.0

Twin

15.9-20.4

0,7

Institute of Medicine. Weight Gain During Pregnancy. National Academy Press. 1999.

RATE OF WEIGHT GAIN

Pattern of weight gain in pregnancy as important as total weight gain. Deviations from expected patterns of weight gain are signals for intervention.

Pre-term birth doubles when 3rd trimester weight gain is low or inadequate.
Pregnancy is an anabolic state, resulting in increased energy (300 kcal/day) utk wanita umur 25-50 thn dgn kebutuhan energi 2000kkal/hari and nutrient needs.

PROPORSI PERTAMBAHAN BB KEHAMILAN

Janin 25-27% Plasenta 5% Cairan amnion 6% Ekspansi volume darah 10% Peningkatan lemak tubuh 25-27% Pertambahan uterus dan payudara 11%

NUTRITIONAL NEEDS DURING PREGNANCY

Energy:

First Trimester - no changeindo +180 kkal/hari Second Trimester - increases 340 indonesia +300 kcal/daypertambahan darah, perkembangan uterus, pertumbuhan jaringan mamae dan penimbunan lemak Third Trimester - increases 450 indo +300kcal/daypertumbuhan janin dan plasenta

Karbohidrat

40 g glukosa/hari60% dari total energi atau 1500 kal karbo

Protein

dan asam amino:

Total Increases 68% atau +17 gr/hari menjadi 60-76 gr protein per hari

KEBUTUHAN PROTEIN UNTUK FETUS

Total protein yg dibutuhkan fetal selama masa gestasi: 350-450 g

Timester pertama sampai kedua: < 6g/hari

Pada usia 20 minggu fetus mulai menerima asam

amino esensial dari ibu, namun asam amino non esensial (arginin dan kristin) tidak dapat disintesis oleh fetus

Trimester akhir: 10 g/hari

LEMAK

Tidak lebih dari 25% dari seluruh kalori yang dikonsumsi sehari menjaga BB ideal agar tidak

menyulitkan persalinan
Lemak yang dikonsumsi sebaiknya mengandung asam lemak esensial (Omega 3/asam lemak linolenat dan Omega 6/asam lemak linoleat) Omega 6 otak janin dan jaringan lain. Sumber:

biji2an
Rasio omega 6:omega 3= 4:1

OMEGA-3 FATTY ACIDS

Reduces the incidence of heart disease and heart related death of the infant Recommended 300 milligrams per day Turunan omega 3: EPA dan DHA Important for brain development and preventing preterm birth and Essential for visual development

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GOOD SOURCES OF OMEGA-3 FATTY ACIDS

Fish oil capsules Certain fish such as salmon, trout, mackerel, sardines, and fresh tuna Vegetable oils such as sunflower, rapeseed, flaxseed, and walnut oils

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VITAMIN AND MINERAL REQUIREMENTS IN PREGNANCY

Pregnant women are at increased risk for
folic acid, iron, and calcium deficiencies.

Recommendations are:
Iron indonesia 30-60 mg/hari Folate indo 400 mg/hari Calcium -indo 1200mg/hari Magnesium - indo 320 Vitamin C indo 70 mg/day Iodineindonesia 175mg/hari

CALCIUM AND VITAMIN D

Calcium

and vitamin D are needed for strong bones and teeth Vitamin D is needed for the formation of the fetal bones Recommended 10 micrograms of Vitamin D per day
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GOOD SOURCES OF CALCIUM AND VITAMIN D

Milk and other dairy products Eggs Meat Certain fish such as salmon, trout, mackerel, sardines, and fresh tuna

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CALCIUM REQUIREMENTS

DRI Calcium Recommendations

9 - 18 y/o: 1300 mg/day 19 - 50 y/o: 1000 mg/day (adults, pregnant and lactating) >51 y/o: 1200 mg/day Increased requirements during the third trimester Supplementation shown to reduce hypertension during pregnancy

Dietary sources

Milk, yogurt (8 oz), cheese (1 oz) ~ 300 mg calcium Orange juice- fortified (1 cup = 300 mg) Broccoli, kale (1 cup cooked = 90 mg) Bok choy, mustard green (1 cup cooked =180 mg) Tofu (made with calcium citrate- ( cup =260 mg) Canned salmon (3 oz = 180 mg)

NEURAL TUBE DEFECTS (NTD) PREVENTION: ROLE OF FOLATE

Folate deficiency is the most common deficiency during pregnancy Functions:

Serves as a co-factor in one-carbon transfers, (nucleic acids and amino acids) and therefore required during periods of rapid growth. Increased maternal erythropoesis causes increased folate needs during second and third trimesters.

Role in Prevention:

NTD are thought to result from a dietary deficiency of folate and/or a genetic defect affecting folate metabolism.

During pregnancy, the neural tube is formed from the 18th to the 26th DAY of gestation.

NEURAL TUBE DEFECTS

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FOLATE REQUIREMENTS IN PREGNANCY

Adequate folate is critical before and during the first 4 weeks of pregnancy. Since 50% of pregnancies are unplanned and most women do not seek prenatal care until 8 weeks gestation, folate supplements prior to conception are critical to prevent NTD. Folate Antagonists (taken during 2nd or 3rd trimester doubles fetal CV defects): Phenobarbiotic Phenytoin Primidone Carbamazepine Trimethoprin Triamterene

KNOWLEDGE THAT FOLATE PREVENTS BIRTH DEFECTS: STILL LOW

50% 40% 30% 20% 10% 0% 1995 1997 1998 2000 2001 2004

Source: March of Dimes Survey 1995-2004: Based on 2000 Non-pregnant Women Age 18 to 45.

WOMEN TAKING A DAILY MULITVITAMIN CONTAINING FOLATE

50% 40% 30% 20% 10% 0% 1995 1997 1998 2000 2001 2002 2003 2004

Source: March of Dimes Survey 1995-2004: Based on 2000 Non-pregnant Women Age 18 to 45.

FOLATE REQUIREMENTS IN PREGNANCY

DRI=600 g pregnancy or 500 g lactating female, 400 g for non-pregnant woman.

Beans, peas, orange juice, green leafy vegetables, fortified cereals are good sources. Prenatal vitamins contain 1000 g folate.

FOLATE INTAKE IN NON-PREGNANT WOMEN (16-39 Y/O): US 1988-1994

300 261 250 200 150 100 50 0
White nonBlack nonHispanic Hispanic Adapted from The Department of Health and Human Services Center of Disease Control and Prevention, July 2002. Total population Mexican American

234

238 202

(ug/day)

FOLIC ACID KNOWLEDGE AND BEHAVIOR 1995 - 2004

Aware of folic acid Knew folic acid can prevent birth defects Knew folic acid should be taken before pregnancy Take folic acid daily

52

80 77

20 24 10 12 28 33

1995 2002 2004

40 60 80 100

20

40

Percent
Source: March of Dimes Survey 1995-2004: Based on 2000 Non-pregnant Women Age 18 to 45.

WHY WOMEN MIGHT BE ENCOURAGED TO TAKE A DAILY MULTIVITAMIN

Advised by a health care provider Change in health Feeling run down Needed vitamins Remembered to take More info about benefits Someone to remind me If pregnant

34 11 4 4 4 3 3 3 0 10 20
Percent

30

40

Source: March of Dimes Survey 2002

IRON IN PREGNANCY

Iron is an essential element in all cells of the body.

During pregnancy, maternal blood volume increases 20-30%.

Iron needs increase from 18 to 27 g/day during pregnancy.

Deficiency increases risk of maternal and infant death, preterm delivery, and low birth weight babies.

DIAGNOSIS OF IRON DEFICIENCY ANEMIA

The CDC reference criteria for anemia during pregnancy: First trimester Hgb <11.0 g/dl or Hct <33% Second trimester Hgb < 10.4 g/dl or Hct <32% Third trimester Hgb <11.0 g/dl or Hct <33%

IRON DEFICIENCY ANEMIA

Susceptible

Populations:

Pregnant women who have not been taking iron supplements Infants and children Menstruating females Teens Low income women

Etiology:

Poor iron intake - only 25% of females 12 - 49 meet needs Diet with low bioavailable iron

IRON DEFICIENCY ANEMIA

Weakness, fatigue, poor work performance, and changes in behavior. Physical signs include pallor, fatigue, coldness and paresthesia of the extremities, greater susceptibility to infections. Infants and young children with iron deficiency may have low IQ levels, poor cognitive and motor development, learning, and behavioral problems.

IRON TREATMENT RECOMMENDATIONS

Iron-rich foods:

Meat, fish, poultry, eggs Organ meats Peas and beans Dried fruit Whole grain and enriched cereal

Therapeutic dose/supplements
30 mg TID but can be constipating IV iron, but may cause a reaction

PREVALENCE OF ANEMIA
BY

TRIMESTER OF PREGNANCY, 1989-1996 PNSS

35 30 25 20 15 10 5 0 1989 1990 1991 1992 1993 1994 1995 1996

1st trimester 2nd trimester 3rd trimester

Adapted from Pregnancy Nutrition Surveillance, 1996 full report

VITAMIN A AND IODINE

Vitamin A is needed in small(indo +300 mg/hari) amounts to protect the fetus from immune system problems, blindness, infections, and death

Can cause birth defects in high doses

Lack of iodine could contribute to stillbirth, birth defects, and decreased brain development Iodine is important for brain development

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NO ALCOHOL AND LIMITED CAFFEINE

Protect the infant from fetal alcohol syndrome and other birth defects

Avoid alcohol, including all wines, beers, hard liquor, and wine coolers

High caffeine intake linked to low birth weight and spontaneous fetal death

Avoid food and beverages such as teas, coffee, colas, energy drinks, and chocolate

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FOOD BORNE ILLNESS

Raw and highly carnivorous fish should be avoided.

Including: fresh tuna, shark, tilefish, swordfish, king mackerel

All dairy foods and juices should be pasteurized. Food contaminated with heavy metals can have neurotoxic effects for the fetus. (Mercury) Minamata disaster Listeria monocytogenes contamination in pregnancy develop into a serious blood borne, transplacental infection.

Wash vegetables and fruits Cook meats Avoid processed, precooked meats (cold cuts) Avoid soft cheeses (brie, blue cheese, etc.)

EXERCISE DURING PREGNANCY

Benefits of exercise during pregnancy: Helps reduce backaches, constipation, bloating, and swelling May help prevent or treat gestational diabetes Increases energy, improves mood and sleep Improves your posture, promotes muscle tone, strength, and endurance Acceptable activities: Walking, dancing, biking Swimming, Yoga Exercises to avoid: Downhill Skiing, Scuba Diving, Trampoline Contact Sports (Ice Hockey, Basketball, Amusement Slides) Hot tubs Warning Signs to stop exercise: Vaginal bleeding, uterine contractions, decreased fetal movement, fluid leaking from the vagina Dizziness or feeling faint, increased shortness of breath Chest pain, headache, muscle weakness, calf pain or swelling