Nutrition During Pregnancy PDF

Nutrition During Pregnancy Dr. Tasneem Ravat RD, CDE Ref: Nutrition Through Life Cycle, 4th Edition, Judith Brown  Pregnancy Introduction Physiology of Pregnancy Physiological changes during Pregnancy Maternal Nutrient Metaboli...

Nutrition During Pregnancy Dr. Tasneem Ravat RD, CDE Ref: Nutrition Through Life Cycle, 4th Edition, Judith Brown  Pregnancy Introduction Physiology of Pregnancy Physiological changes during Pregnancy Maternal Nutrient Metabolism Placenta Embryonic & Fetal Growth& Development Fetal Body Composition Fetal- Origin Hypothesis of Later Disease Risk Pregnancy Weight Gain Nutrition in Pregnancy Exercise Common Health problems during Pregnancy  Pregnancy Most intense period of growth and development. Process depends on various factors, NUTRITIONAL STATUS IMPORTANT!! STAGES OF PRENATAL DEVELOPMENT Preembryonic stage - first 2 weeks. Products of conception are called as conceptus. Embryonic stage - from the third week until the end of the eight week. From this period conceptus is called embryo. Fetal period starts from the beginning of the ninth week through the full 41 weeks of development. Products of conception are called as fetus.  Preembryonic Stage fertilization zygote formation division of fertilized ovum morula formation formation of free blastocyst implantation of the ovum in the uterine wall Primitive chorionic villi formation Initial folding into layers – gastrulation beginning. Chorion and amnion begin to form during this period also. Fertilization  Fertilization Fertilization in the ampulle of the FT. Prostaglandins Oxytocin Ectopic (extrauterine) gravidity  A SPERM FERTILIZING AN OVUM File:Sperm-egg.jpg Fertilization Transport into the uterus - 3-5 days Contraction of the FT isthmus Relaxation - progesteron Fertilization Implantation 5-7 days after fertilization Proteolytic enzymes of the trophoblast cells Implantation- attachment of the blastocyst on the 7th day into uterine wall called implantation.  AN EMBRYO IS ABOUT 5 WEEKS OLD 200px-Tubal_Pregnancy_with_embryo Pregnancy  Physiology of Pregnancy Changes in maternal body composition and function: SEQUENCE (absolute)  Normal Physiological changes during Pregnancy 1st Half: MATERNAL ANABOLIC (building capacity to deliver) 2nd Half: MATERNAL CATABOLIC (utilization) Maternal-Fetal Metabolism 2 phases of pregnancy: 1st - 20th week - mother´s anabolic phase: - anabolic metabolism of the mother - quite small nutrition demands of the conceptus - normal or increased sensitivity to insulin - lower plasmatic glucose level - lipogenesis, glycogen stores increases - growth of breasts, uterus,weight gain 21 - 40 week (esp. last trimester): - high metabolic demands of the fetus - accelerated starvation of the mother - maternal insulin resistance - increased transport of nutrients through placental membrane - lipolysis Insulin resistance caused by HCS, cortisol and growth hormone  Physiological Changes 1. Body water changes 2. Blood volume expansion 3. Hemodilution 4. Blood lipid levels 5. Blood glucose levels 6. Maternal Organ and tissue enlargement 7. Circulatory System 8. Respiratory System 9. Food intake 10. Gastrointestinal changes 11. Kidney Changes 12. Immune system 13. Basal metabolism 14. Hormones  1. Body water changes Increased volume of plasma and ECF and amniotic fluid 7 to 10 litres 2/3rd expansion is ICF and 1/3rd is ECF Fatigue increases as plasma volume increases 2nd and 3rd trimester: fatigue associated with increase in plasma volume declines since other compensatory physiological adjustments are made. High water content: edema (If no HTN, then healthy) Birth weight strongly related to plasma volume.  2. Blood volume expansion Blood volume increases 20% Plasma volume increases 50% Edema  3. Hemodilution Concentrations of most vitamins and minerals in blood decrease  4. Blood lipid levels Increased: Cholesterol LDL TG HDL  5. Blood glucose levels Increased insulin resistance ( increased plasma levels of glucose and insulin)  6. Maternal Organ and tissue enlargement Heart Thyroid Liver Kidney Uterus Breasts: lactation Adipose tissue  7. Circulatory System Cardiac output (CO) 30 -50% above normal placental circulation increased metabolism skin - thermoregulation renal circulation decreases in last 8 weeks (uterus compresses vena cava) incr. 30% more during labor Heart rate (HR) increases up to 90/min Blood pressure (BP) drops, periferal resistance decreases with twins CO increases more, BP drops more Supine hypotension related to Venal cava syndrome This leads to dizziness, air hunger, nausea  8. Respiratory system Increased tidal volume (30-40%) Increased oxygenRespiratory consumption (10%)Changes 50 % of this increase is required by the uterus  Respiratory capacity increases Diaphragm – pressure by the foetus on diaphragm - diaphragm  Shortness rises upto 4 cm - of breath uncomfortable – shallow breathing  Pulmonary reserve decreases Respiratory capacity increases  Increased risk of Shortness of breath muscle soreness Tendency to hyperventilate  Tendency to hyperventilate  9. Food intake Increased appetite Weight gain All the increase in maternal tissues lead to an increased weight gain. A healthy woman who enters pregnancy at normal weight gains 10-12 kgs. Taste and odor changes, modification in preference for some foods Increased thirst  10. Gastrointestinal changes Relaxed GI tract muscle tone Increased gastric and intestinal transit time Gastrointestinal motility slows, food moves more slowly through the intestinal tract Advantage-more nutrients could get absorbed. Gastric emptying time is prolonged→ nausea (70%), vomiting (40%) Relaxation of smooth stomach muscle Heartburn Motility of large bowel is diminished → constipation Prolonged gallbladder emptying time may lead to gall stones Bile salt buildup may lead to itching.  11. Kidney changes Kidneys grow and filter more blood as the blood volume increases GFR increases (50-60%) Volume of plasma filtered by kidney increases by 75%-Could lead to urinary urgency in pregnancy. Bladder becomes compressed causing frequent urination and incontinence Increased sodium conservation Increased reabsorption of ions and water - placental steroids - aldosterone Increased nutrient spillage into urine; protein conserved Smooth muscle of bladder relaxes/stasis : Increased risk of UTI  12. Immune system Suppressed immunity Increased risk of UTI and reproductive tract infection  13. Basal metabolism Increased BMR in second half Increased body temperature  14. Hormones Normal pregnancy physiology shows – “lower lows and higher highs” Placental secretions of large amounts of hormones needed to support physiological changes: Key- Progesterone and estrogen Hormonal changes HCG HCS  Hormonal changes Progesterone Estrogens  chloas1-s Other changes 01-before Integumentary System: These result from stretching of the skin and hormonal changes Chloasma/ melasma – “mask of pregnancy” Dermatlas: ABDOMEN - linea nigra Straie: stretch marks of abd, breasts, thighs and buttocks Linea nigra: pigmentation down middle line of abdomen Sweating Musculoskeletal system Joint relaxation Posture changes -lordosis/center of gravity Back ache Neurological & Sensory Decreased intraoccular pressure Altered sense of smell Decreased attention span Problems with memory Altered CNS physiology leading to mood disturbance.  Maternal Nutrient Metabolism Ensures nutrient availability during high nutrient need to the fetus:: depends on genetic expression for fetal growth and development  Carbohydrate metabolism Glucose: preferred fuel for energy for fetus Maternal insulin resistance: Diabetogenic effect of pregnancy (CHO intolerant in third trimester of pregnancy)  Carbohydrate metabolism First half: Estrogen & progesterone stimulated increases in insulin production & conversion of glucose to glycogen and fat Second half: Inhibition of the above conversion with increase in prolactin and hCs + Insulin Resistance (Maternal reliance on fats for energy) Decreased conversion of glucose to Constant supply of glycogen and fat glucose for Lowered maternal utilization of glucose fetal growth and Increased liver production of glucose development Third trimester: FBG is low & PPBG is high  Accelerated Fasting metabolism Glucogenic amino acid utilization Fat oxidation Increased production of ketones with fats (fast >12 hours) Women use fat sparing amino acids and glucose for fetus Fasting: fetus uses ketone bodies for energy: decreased growth & impaired intellectual development of offspring (poorly controlled DM, lose weight during part or all of pregnancy)  Protein metabolism Needs increase for synthesis of maternal and fetal tissues Needs met through decreased N2 excretion and conservation of amino acids for protein tissue synthesis Mothers intake important  Fat metabolism First half: Accumulation of maternal fat stores Second half: Increase in fat mobilization Increase in lipoproteins dramatically Increased cholesterol supply is used by, o placenta for steroid hormone synthesis o fetus for nerve and cell membrane formation  Mineral metabolism Ca met: Increased rate of bone turnover and reformation Changes in kidneys: Increase aldosterone secretion and retention of sodium Increase requirement for Na and other minerals Na restriction may overstress mechanisms : acts to conserve Na: leads to functional and growth impairments due to Na depletion  Placenta One of the major factors that determine fetal nutrition and growth. Develops from embryonic tissue Development precedes fetal development  Placenta Functions: 1. Hormone & enzyme production 2. Nutrient and gas exchange between mother and fetus 3. Removal of waste products from fetus 4. Barrier to some harmful compounds 5. Governs the rate of passage of nutrients 6. Barrier to the passage of maternal RBC, bacteria and many large proteins 7. Prevents mixing of fetal and maternal blood until delivery, when ruptures in blood vessels may occur.  Nutrient transfer through placenta Placenta uses 30-40% glucose delivered by maternal circulation. Functioning affected if requirement not met. Factors: Size & charge of molecules Lipid solubility of the particle being transported Concentration of nutrients in maternal and fetal blood blood flow, abundance of transporters  Small mol (H2O) and lipids pass easily Large mol (insulin & enzymes) aren't transferred Unregulated for some nutrients, O2, CO2; highly regulated for some  The placenta is a nutrient sensor. Able to modify its own transport function according to maternal nutrient supply and fetal needs. Fetus receives small amounts of water and other nutrients from ingestion of amniotic fluid Second half: able to swallow and absorb water, minerals, N2 waste products and other substances in amniotic fluid  Fetus is NOT a PARASITE It cannot take whatever nutrient it needs from mothers body at mothers expense Fetal growth & devp compromised when intake falls First nutrients will be used to support maternal nutrient needs for her health and physiological changes Second for devp of placenta Thirdly, it reaches fetus at optimum levels. If fetus: parasite, it would harm. BUT, fetus is harmed by poor nut status then the mother  Embryonic & fetal growth and development CRITICAL PERIODS Set time interval during which fetal growth & devp proceed along genetically determined pathways in which cells are programmed to multiply, differentiate, and establish long term functional levels. Preprogrammed time periods during embryonic and fetal development when specific cells, organs and tissues are formed and integrated or functional levels established.  1st 2 months important after conception (organ & tissue formation)! CRITICAL PERIODS----------”ONE WAY STREET” No reverse, no correction of error  CRITICAL PERIODS FOR THE DEVELOPMENT OF OBESITY “ Critical period is a developmental stage in which longterm growth may be substantially altered by events that occur in a relatively short period of time” Dietz,1996a FETAL LIFE INFANCY CHILDHOOD ADOLESCENCE  1. Hyperplasia Increase in cell multiplication, DNA  Excess or deficit in nutrients: lifelong defects in organ and tissue structure and function NTD: week 3 and 4 after conception. If B9 deficient- permanent damage to brain and spinal cord Hyperplasia continues: growth spurt 2. Hyperplasia-Hypertrophy Cell size increases due to accumulation of protein and lipids inside the cells. Production of digestive enzymes by cells within the SI or neurotransmitters by nerve cells along with increase in cell number and size  3. Hypertrophy Cells no longer multiply, BUT accumulation continues and functional levels gro. Unfavorable nutrient environment: Reduction in cell size, deficit in organ and tissue function like reduced mental capabilities or decline in muscular coordination  4. Maturation Stabilization of cell number and size Occurs after tissues and organs are fully developed later in life.  Fetal Body composition Not due to genetic causes but environmental factors such as energy, nutrient, and oxygen availability, and to conditions that interfere with genetically programmed growth and development.  IGF-1: growth stimulator of fetus It promotes uptake of nutrients by the fetus and inhibits fetal tissue breakdown Levels decrease by undernutrition ->decrease muscle and skeletal mass and produce assymetrical growth Prepregnancy underweight and shortness, Low weight gain during pregnancy, Factors associated Poor dietary intakes, with Smoking, reduced fetal growth Drug abuse, and Certain clinical complications of pregnancy  Miscarriages Reabsorption into the uterus or expulsion before 20 weeks of conception Genetic, Uterine, or hormonal abnormalities, Reproductive tract infections, Tissue rejection due to immune system disorders, Underweight women Elevated blood cholesterol or TG Use multivitamins during early pregnancy  Preterm delivery death, neurological problems reflected later in low IQ scores, congenital malformations, and chronic health problems such as cerebral palsy. ❑ Problems related to growth, digestion, respiration, and other conditions due to immaturity. ❑ Low stores of fat, essential fatty acids, glycogen, calcium, iron, zinc, and other nutrients in very preterm infants may also interfere with growth and health after delivery ❑ Genitaltract infections, ❑ Insufficient uterine-placental blood flow, ❑ Placental abruption (bleeding into the uterus), ❑ Prepregnancy underweight, ❑ Low weight gain in pregnancy, ❑ Short interpregnancy interval (6 months) ❑ High levels of psychological or social stress ❑ Previously delivered preterm ❑ Obese ❑ Increased levels of cholesterol, triglycerides, or free fatty acids and elevated levels of markers of inflammation and oxidative stress in the first half of pregnancy Mutlivitamin and mineral supplement Exercise Fetal-Origins Hypothesis of Later Disease Risk Risk begin in utero  Fetal programming ⚫Fetal programming is the phenomenon whereby alterations in fetal growth and development in response to the prenatal environment bring long term or permanent effects. OR ⚫The process by which exposure to adverse nutritional or other conditions during sensitive periods of growth and development produces long term effects on body structures, functions and disease risk.  Barker’s hypothesis ‘fetal origins of adult disease” ⚫“An adverse nutritional environment in utero causes defects in the development, structure and functions of organs, leading to a programmed susceptibility, which interacts with later diet and environmental stresses to cause overt disease many decades later”  Genetics Environment Environmental exposures modify development through epigenetic mechanisms that program metabolic changes in gene activity and not DNA structure. Epigenetic mechanisms influence growth and development by silencing certain genes (or turning them off) and activating (turning on) others. For example, epigenetic mechanisms can develop in response to maternal undernutrition by reducing cell multiplication in the kidneys while sparing brain growth.  In utero critical periods of growth ⚫Early gestation: Hypothalamic centers are Susceptible to exposure to over or under nutrition Regulation of appetite and growth are affected Increased predisposition to later obesity ⚫Late gestation Differentiation and hyperplasia of adipocytes occur Over nutrition causes adipocyte hyperplasia Increased Fetal accumulation of fat results in later obesity  Reductive adaptations during foetal life “Physiological mechanisms to cope up with energy and nutrient shortages and excesses, and with harmful substances” Eg: Low glucose supply during fetal life Insulin receptors on muscle cells Glucose uptake by muscle Availability of glucose to CNS  SHORT TERM AND LONG TERM EFFECTS OF NUTRIENTS SHORT TERM LONG TERM FOETAL NUTRITION NEUROSENSORY COGNITIVE CAPACITY & DEVELOPMENT EDUCATION GROWTH IMMUNITY & GENES MUSCLE/BONE WORK CAPACITY BODY COMPOSITION DIABETES OTHER METABOLIC PROGRAMMING, OBESITY EPIGENETIC CHO, LIPIDS, PROTEINS, CVD FACTORS HORMONES, CELL RECEPTORS, STROKE GENES HYPERTENSION CANCER EARLY AGING Diseases & other conditions in adults associated with underweight at birth  Pregnancy Weight Gain Indicator of plasma volume expansion and positive calorie balance, and provides a rough index of dietary adequacy low-calorie diets and given diuretics and amphetamines and use saccharin to limit weight gain Relationship between maternal and foetal nutrition Inadequate food intake and poor nutrition utilization Maternal malnutrition Reduced blood volume Inadequate increase in cardiac output Decreased blood and nutrient supply to the foetus Reduced placental size Reduced nutrient transfer Foetal growth retardation  Pregnancy weight gain Recommendations based primarily on gains associated with the birth of healthy-sized newborns (approximately 3500–4500 g or 7 lb 13 oz to 10 lb) The higher the weight before pregnancy, the lower the weight gain needed to produce healthy-sized infants.  Underweight and Overweight women Duration of gestation, smoking, maternal health status, gravida, and parity also influence birth weight. Rates of LGA newborns, Caesarean-section deliveries, and postpartum weight retention tend to be higher  Underweight women: o increased infant death and low birth weight, o poorer offspring growth and development. o down-regulate fetal growth o reduced birth weight and thinness. o increase the risk that infants will develop heart disease, type 2 diabetes, hypertension, and other types of chronic disease later in life.  Rate of weight gain is generally highest around mid-pregnancy—which is prior to the time the fetus gains most of its weight  Some weight (3 to 5 pounds) should be gained in the first trimester, followed by gradual and consistent gains thereafter. Weight should not be lost until after delivery Composition of weight gain Increased weight of maternal tissues. Fetus 5 kg Mother 6 kg  Body Fat Changes Storage of body fat: o to meet their own and the fetus’s energy needs, o to prepare for the energy demands of lactation. increase the most between 10 and 20 weeks of pregnancy, or before fetal energy requirements are highest. decrease before the end of pregnancy. 0.5 kg of the approximately 3.5 kg of fat stored during pregnancy is deposited in the fetus.  Body composition Pregravidic weight– maternal BMI is the best indicator Maternal obesity-risks maternal underweight preterm labour Preclampasia IUGR Gestational diabetes maternal anaemia Cesarian section LBW Low Apgar scores Macrosomia NTD Fetal overgrowth Therefore it is fundamental that pregnant women must have optimum nutrition to avoid under an overnutrition  Postpartum Weight Reduction Increased weight after pregnancy: o high weight gain in pregnancy (over 45 lb, or 20.5 kg), o weight gain after delivery, and o low activity levels High blood levels of insulin early in pregnancy, and levels of leptin= increased weight gain during pregnancy. lose about 15 pounds the day of delivery Exercise and healthy-eating program Nutrition in Pregnancy  Pregnancy – a 3 compartment model Mother , placenta and fetus interact to guarantee fetal growth and development. Disturbance of this equilibrium may compromise pregnancy outcome  Maternal diet Major environmental factor Modifies the expression of the genome ---- endocrine programming ---- immunological programming ----- epigenetic programming Thus programming of human adult functions and diseases seems to be influenced by hormones, metabolites and neurotransmitters during critical development  Maternal diet Increased need for nutrients. Periconceptual period—a critical step Micronutrient imbalances may present the onset of several disorders ❖ congenital abnormalities ❖ fetal loss ❖ miscarriage ❖ insufficient fetal growth ❖ Premature birth ❖ preeclampsia  Energy o The growth of the fetus. o The increase in maternal body size. o The increase in BMR during pregnancy. o O2 consumption is high The total cost of full term pregnancy is 80, 000 kcals. This increased energy needs are averaged out to +350 kcals during pregnancy 340 additional calories recommended per day during the second trimester 452 additional calories recommended per day during the third trimester Active women- High need  Carbohydrates, Artificial Sweetners, Alcohol 50%-60% of the total daily calories main source of extra calories during pregnancy as well as to supply glucose continuously to the fetus. Minimum of 175 gms Sources: cereals, pulses, nuts, fruits and vegetables- phytochemical benefits; fiber Do not contain added sugar and fat Artificial sweeteners: NO evidence; but poor source of nutrients Alcohol:: o Abnormal mental development and growth in the offspring, and the deficits are lifelong. o No clearly defined safe level of alcohol intake o In utero alcohol exposure during the first, critical months of pregnancy may impair organ development. o Development of fetal alcohol syndrome.  Protein +25 grams per day, or 71 grams daily, and as 1.1 gram/ kg body weight protein tissue accretion. Of the approximately 925 grams of protein (2 pounds) accumulated in protein tissues during pregnancy, o 440 grams are taken up by the fetus, o 216 grams are used for increases in maternal blood and extracellular fluid volume, o 166 grams are consumed by the uterus, and o 100 grams are accumulated by the placenta. o Additional protein is also required to maintain the protein tissue developed  Vegetarian diets Poor in vitamins B12 and D, calcium, iron, zinc, and omega-3 fatty acids eicosapentaenoic and docosahexaenoic acids  Fat 33% of total daily calories o Energy source for fetal growth and development o Source of fat soluble vitamins 13 grams of the linoleic acid daily 1.4 grams of alpha linolenic acid.  Fat Linoleic acid: safflower, corn, sunflower, and soy oil. Alpha-linolenic acid: flaxseed, walnut, soybean, and canola oils, and leafy green vegetables 9% of alpha-linolenic acid is converted to EPA and DHA  Eicosanoid derivatives of EPA o reduce inflammation, o dilate blood vessels, and o reduce blood clotting. DHA found in: o membranes in the central nervous system, including retinal photo receptors o in sperm. Optimal functioning of the central nervous system higher levels of intelligence, better vision, more mature central nervous system functioning  Water 9 cups Physical activity in hot and humid climate Urine should be light colored and normal in volume Water, diluted fruit juices, iced tea, other unsweetened beverages  Folate Anemia, reduced fetal growth o Synthesis of DNA o Gene expression o Gene regulation o Conversion of homocysteine to methionine High homocysteine: o genetic abnormalities o rupture of the placenta, o stillbirth, o preterm delivery, o preeclampsia, o structural abnormalities (congenital defects) in the newborn, o reduced birth weight. Folic acid supplements (500–600 mcg per day) in the second and third trimesters of pregnancy decrease homocysteine Levels  Folate and congenital abnormalities NTDs, brain and heart defects, and cleft palate Spina bifida: spinal cord fails to close, leaving a gap where spinal fluid collects during pregnancy Anencephaly is the absence of the brain or spinal cord. Encephalocele is characterized by the protrusion of the brain through the skull. Folate defi between 21 and 27 days after conception (when the embryo is only 2–3 mm in length) can interrupt normal cell differentiation and cause NTDs Neural Tube Defects big_orange Select the orange to proceed.  Sources of folate Monoglutamate form of folate and foods that provide folic acid through fortification. Whole-grain products including breads and pastas, brown rice, oatmeal, and organic grain products may or may not be fortified with folic acid.  Recommended intake of Folate One DFE equals any of the following: o 1 mcg food folate o 0.6 mcg folic acid consumed in fortified foods o or a supplement taken with food o 0.5 mcg of folic acid taken as a supplement on an empty stomach  Choline component of phosopholipids in cell membranes precursor of intracellular messengers. Choline converted to betaine, which, like folate, serves as a source of methyl groups used to regulate gene function, neural-tube and brain development, and the conversion of homocysteine to methionine 450 mg daily eggs and meat  Vitamin A cell differentiation with excessive intakes of vitamin A in the form of retinol or retinoic acid (but not beta-carotene): o malformations of the fetal lungs, o urinary tract infection, and heart disease o “retinoic acid syndrome’’: small ears or no ears, abnormal or missing ear canals, brain malformation, and heart defects. no more than 5,000 IU of vitamin A as retinol from supplements High intakes of beta-carotene have not been related to birth defects.  Vitamin D fetal growth, the addition of calcium to bone, and tooth and enamel formation, immune system and can inhibit inflammation smaller than average, low blood calcium levels (hypocalcaemia) at birth, poorly calcified bones and abnormal enamel. develop dental caries in childhood.  Vitamin D 5 mcg (200 IU) vitamin D daily o consume 3 cups of vitamin D–fortified milk a day, or by exposing the skin to sunshine  Calcium fetal skeletal mineralization and maintenance of maternal bone health. Fetal demand for calcium peaks in the third trimester when fetal bones are mineralizing at a high rate. Absorption of calcium from food increases, excretion of calcium in urine decreases, and bone mineral turnover takes place at a higher rate. Inadequate calcium intake: o increased blood pressure during pregnancy, o decreased subsequent o bone remineralization, o Increased blood pressure of infants, o decreased breast-milk concentration of calcium.  Calcium & Lead Lead in maternal blood can cross the placenta and be taken up by the fetus miscarriage, preterm birth, low-birth-weight infants, impaired central nervous system development, and subsequent developmental delays in children. Bone tissues contain about 95% of the body’s lead content, and the lead is released into the bloodstream when bones demineralize. Bone tissues de mineralize to a greater extent in pregnant women who fail to consume adequate calcium. Source: 3 cups of milk or calcium-fortified soymilk, or 2 cups of calcium- fortified orange juice plus a cup of milk, or by choosing a sufficient number of other good sources of calcium daily.  Flouride Teeth begin to develop in utero Limited amount transferred from the mother’s blood to the developing enamel of the fetus. Major gains in the fluoride composition of enamel occur in the years after birth when enamel in primary and permanent teeth fully develops and hardens  Iron 1000 mg (1 g) of additional iron for pregnancy. 300 mg is used by the fetus and placenta. 250 mg is lost at delivery. 450 mg is used to increase red blood cell mass.  Iron increases the risk of preterm delivery and low-birth-weight infants lower scores on intelligence, language, gross motor, and attention tests in affected decreased oxygen delivery to the placenta and fetus, increased rates of infection, or adverse effects of iron deficiency on brain development.  Iron Iron deficiency and iron-deficiency anemia are related to reduced iron stores in newborns. Preterm infants are at risk for iron deficiency in infancy because they have less time to accumulate iron in late pregnancy.  Iron Red cell mass increases substantially (30%) in pregnancy. Plasma volume expands more (by about 50%). The higher increase in plasma volume compared to red cell mass makes it appear that amounts of hemoglobin, ferritin, and packed red blood cells have decreased. They have not decreased but rather have become diluted by the large increase in plasma volume.  Iron Low levels of hemoglobin or serum ferritin may be associated with high plasma volume expansion (hyper volemia), and high hemoglobin levels are related to low plasma volume expansion (hypovolemia). Low levels of plasma volume expansion are associated with reduced fetal growth, and vice versa  Iron By trimester, hemoglobin levels indicative of iron deficiency anemia are: 11.0 g/dL in the first and third trimesters 10.5 g/dL in the second trimester  Iron No single test of iron status is totally accurate because (1) many factors, including infection and inflammation, affect iron status; and (2) Each test measures a different aspect of iron status. It is best to base the diagnosis of iron-deficiency anemia on results of several tests.  Iron Absorption of iron from multimineral supplements is lower Nausea, cramps, gas, and constipation are associated with the presence of free iron in the intestines, and these side effects increase as doses of supplemental iron increase  Iron Recommendations Related to Iron Supplementation in Pregnancy: 30-mg iron supplement daily after the twelveth week of pregnancy. Women with iron-deficiency anemia are often given 60–180 mg of iron per day. Recommended Intake of Iron During Pregnancy: Additional 3.7 mg absorbed iron per day on average throughout pregnancy The Upper Limit for iron intake during pregnancy is set at 45 mg per day  Iodine Additional 25μg to the adult requirements of 100-200 μg. There is an increase in BMR of the mother. There is an increased activity of the thyroid gland and secretion of thyroid hormones. Adequate iodine intake leads to proper mental health of the fetus. Iodine deficiency in mother leads to still birth and cretinism.  Sodium Maintaining the body’s water balance. Requirements increase markedly during pregnancy due to plasma volume expansion. Sodium restriction during pregnancy may exhaust sodium conservation mechanisms and lead to excessive sodium loss  Bioactive components 1. Antioxidant pigments 2. Caffeine help protect fetal DNA from damage due to exposure to oxygen and other oxidizing chemicals produced in the body. Antioxidants also reduce maternal tissue damage associated with inflammation and oxidation. Vitamins C and E, o Reduce risk of asthma o Reduce lung inflammation 5 cups of vegetables and fruits  Caffeine Increases heart rate, Acts as a diuretic, and Stimulates CNS It is generally concluded that intake of up to 4 cups of coffee per day during pregnancy is safe. Healthy diets for Pregnancy  Dietary Supplements With the exception of iron, nutrient needs during pregnancy should be met by the consumption of a well-balanced and adequate diet Do not ordinarily consume an adequate diet Have multifetal pregnancy Smoke, drink, or use drugs Are vegans Have iron deficiency anemia Have a diagnosed nutrient deficiency vitamin B6, folic acid, vitamin D, iron, iodine, and EPA, DHA  Herbal Remedies 1/3rd: unsafe for use by pregnant women Some herbs considered safe based on traditional use have been found to produce malformations in animal studies heart failure in the baby. Ginseng: malformations in rat embryos, Ginkgo: excessive bleeding. Peppermint tea and ginger root, taken for nausea, appear to be safe  Benefits of Exercising Mother Fetus –Improved cardiovascular –Decreased fat mass function –Improved stress tolerance –Limited pregnancy weight –Advanced gain neurobehavioral –Decreased maturation musculoskeletal discomfort –Reduced muscle cramps –Reduced lower limb swelling –Mood stability Recommendations Exercise Three to five times a week for 20–30 minutes at a heart rate that achieves 60–70% VO2 max Exercise should begin with about 5 minutes of warm-up movements and end with the same length of cool down  Types of exercise Beginners –Walking –Cycling –Swimming –Aerobics Exercisers –Running –Strength training  Exercises to avoid Contact sport –Football –Basketball –Ice Hockey –Soccer Scuba Diving Gymnastics Horseback riding Standing for long periods of time  Food Safety issues Listeria monocytogenes: o spontaneous abortion o stillbirth o mild infection in mothers Not eat raw or smoked fish, oysters, unpasteurized cheese, raw or undercooked meat, or unpasteurized milk, hot dogs, and other processed meats should be stored correctly, and foods such as hot dogs heated thoroughly  Food Safety issues Toxoplasma gondii:: o mental retardation, o blindness, o seizures, and o death. raw and undercooked meats, the surface of fruits and vegetables, and cat litter. Cats that eat wild animals and undercooked meats can become infected and transfer the infection through the air and via stools left in their litter boxes  Food Safety issues Mercury Contamination: fetal brain development. mental retardation, hearing loss, numbness, and seizures. Present in the muscles of large, long-lived predatory fish such as sharks, swordfish, tilefish, albacore tuna, walleye, pickerel, and bass. Thank you