1. Nutrition through the Lifecycle
Chapter 1: Nutrition during Pregnancy
Objectives and Learning outcome: At the end of this chapter,
you should be able to-
1. List major physiological changes that occur in the body
during pregnancy and how nutrient needs are altered
2. Understand and discuss modifiable and non-modifiable risk
factors in the successful outcome of a pregnancy
3. Specify optimal weight gain during pregnancy and plan an
adequate / balanced diet for the same
4. Identify nutrients that may need to be given as supplements
and explain the reason / justification for the same
5. Discuss typical discomforts and complications of pregnancy
and explain how they can be minimized by dietary and
lifestyle modifications
6. Effectively counsel a pregnant woman
2.
3. Nutrition during Pregnancy:
The Impact on the Future
• The woman who is
pregnant, or soon will
be, must understand that
her nutrition is critical to
the health of her future
child throughout life
• The nutrient demands of
pregnancy are
extraordinary
4. Preparing for Pregnancy
• Adequate Food Intake
during Pregnancy is
important but a good “pre-
pregnancy nutritional
status” has many
advantages, providing a
margin of safety.
• Before she becomes
pregnant, a woman must
establish eating habits that
will optimally nourish both
the growing foetus and
herself
5. • Ideally, Pregnancy SHOULD BE PLANNED
because many practices or conditions of
the mother that can harm the developing
foetus are modifiable, such as-
• Alcohol consumption
• Smoking
• Use of certain medications / illegal drugs
• Heavy caffeine use
• Poorly controlled ongoing diabetes,
hypertension, etc.
• Inadequate diet / poor nutritional status
• Stress – Job related, family, etc.
6. • Many factors affect the development of a fetus
into a healthy child, some which are beyond the
mother’s control and others that are within her
control. Here are ten of the most common
pregnancy risk factors that can be controlled or
influenced:
• Smoking – Smoking is not only bad for the mother,
but it is worse for the baby. Smoking during
pregnancy reduces the amount of oxygen that the
baby receives and increases the risk of miscarriage,
bleeding, and morning sickness. Pregnant women
should also avoid second hand smoke.
• Alcohol – Drinking can cause fetal alcohol
syndrome, including symptoms like low birth weight,
medical problems, and behavior abnormalities.
7. • Caffeine – There are many conflicting studies about caffeine
and pregnancy and some believe that caffeine is not as
harmful as it was once thought to be. Nevertheless, the FDA
warns against caffeine consumption during pregnancy and
suggests quitting or reducing consumption at the very least.
Caffeine has been shown to affect fetal heart rates and
awake time (fetuses grow when sleeping).
• Drugs and Herbal Remedies – A pregnant woman needs to
be careful about drugs or herbal remedies that are not
prescribed by a doctor. These substances may affect the
development of the unborn child.
• Nutrition – Good nutrition is crucial to a developing child,
particularly getting enough folic acid. Lack of folic acid can
cause birth defects.
• Exercise – Moderate exercise is helpful as it improves the
mother’s mental state and can increase oxygen flow to the
fetus. However, over-exertion can be dangerous.
8. • Prenatal Care – Regular doctor visits are important to the
baby’s development. The body undergoes many changes
during pregnancy. Some side effects may be completely
normal, whereas others may not be.
• Multiple sex partners – Multiple sex partners can increase
risk of STD’s, which in turn may lead to birth and pregnancy
complications, like low birth weight or premature birth.
• Exposure to chemicals – During pregnancy, reduce
exposure to unnatural chemicals, particularly pesticides in
food. The simplest precaution to take before consuming
vegetables or fruits is to wash them thoroughly.
• Other factors – Many other factors can affect fetal
development, including heart disease, the mother’s age
(less than 15 years and over 35 years is a risk), asthma,
excessive stress or depression, etc.
9.
10. • This time period in the human experience-
creating a new human being – sets the
stage for the health of future generations.
The quality and quantity of
nourishment on the developing
in-utero
zygote,
then fetus, then neonate, then adult
emerges as one explanation for diseases
that manifest in adulthood. This concept
is known as fetal origins of disease or
developmental origins of health and
disease .
• (Niljand, 2008; Solomons, 2009)
11. “Basically, what a mother eats or does during pregnancy,
can affect even future generations. So a child’s health
depends on not only potentially what the mother ate, but
possibly even what the grandmother ate.” – Randy Jirtle in
Epigenetics (July 24, 2007)
The
Intergenerational
Effect
12. • Manel Esteller in Epigenetics on PBS (July 24, 2007)- “One of the
main findings of our research is that epigenomes can change in
function of what we eat, of what we smoke, of what we drink. And
this is one of the key differences between epigenetics and genetics.”
• From the Dr. Oz website:
• As DNA, the blueprint of the body, is rolled out during development,
it gets copied. And while that copying occurs, the things you are
experiencing – what you eat, the toxins you are exposed to – can
stop that copy machine from working properly. This basic principle
of epigenetics means that, while we can’t control what genes we
pass on to our children, we may be able to control which genes get
turned on or turned off.
• …Here’s another example that will help put epigenetics in
perspective. We share 99.8 percent of the same DNA as a monkey,
and any two babies share 99.9 percent of the same DNA. Not only
that, we even have 50 percent of the same DNA as a banana!!! So
genes alone cannot explain the diversity in the way we look, act,
behave, and develop. How those genes are expressed plays a huge
role in how vastly different we are from monkeys and how explicitly
and subtly different we are from each other.
13. Pregnancy- Phase of Rapid Growth
• The newly fertilized ovum i.e. the Zygote begins as a single
cell. Zygote represents the first 2 weeks of the phase of
human gestation.
• Divides into many cells during the days after fertilization
• Within two weeks, the zygote implants, and the placenta
begins to grow inside the uterus
– Minimal growth takes place at this time, but it is a crucial
period in development
– Adverse influences such as smoking, drug abuse, and
malnutrition at this time lead to failure to implant or to
abnormalities such as neural tube defects that can
cause the loss of the zygote
• The Embryo and Fetus
– During the next 6 weeks, the embryo registers
astonishing physical changes
14. • Embryo: The stage of human gestation from th
e
third to eighth week after conception
• Foetus (9-40weeks) - The stage of human
gestation from the 9th week after conception
until the birth of an infant
• The woman must be well nourished at the outset
because early in pregnancy the embryo undergoes
rapid and significant developmental changes that
depend on good nutrition
• Gestation: The period of about 40 weeks (three
trimesters) from conception to birth. The term of a
pregnancy
• The mother’s nutrition before pregnancy determines
whether her uterus will be able to support the growth
of a healthy placenta during the first month of
gestation
15. • Uterus
– The muscular organ within which
the infant develops before birth
• Placenta
– The organ of pregnancy in which
maternal and fetal blood circulate
in close proximity and exchange
nutrients and oxygen (flowing into
the fetus) and wastes (picked up
by the mother’s blood)
• If the placenta works perfectly, the
fetus also develops perfectly
• If the placenta does not work
efficiently, no alternative source of
sustenance is available and the
fetus will fail to thrive
17. • Placenta
• The placenta produces several hormones responsible
for regulating fetal growth and development of maternal
support tissues. It is the conduit for exchange of
nutrients, oxygen, and waste products. Placental insults
compromise the ability to nourish the fetus, regardless
of how well nourished the mother is.
• Placental insults can be the result of poor placentation
from early pregnancy or small changes associated with
preeclampsia or hypertension disorders.
• Average placental weight at term is about 500gms
• Placental size can be 15% to 20% lower than normal in
fetuses with intrauterine growth restriction (IUGR). A
small placenta has a smaller surface area of placental
villi, with a reduced functional capacity.
18. Mechanisms of Nutrient Transport across the Placenta
Mechanism Examples of nutrients
Passive diffusion
(also called simple diffusion)
Nutrients transferred from blood with
higher concentration levels to blood
with lower concentration levels
Water, some amino acids and
glucose, free fatty acids, ketones,
vitamins E and K*, some minerals
(sodium, chloride), gases.
Facilitated diffusion Some glucose, iron, vitamin A and
Receptors (“carriers”) on cell vitamin D
membranes increase the rate of
nutrient transfer
Active transport
Energy(from ATP) and cell membrane
receptors
Water- soluble vitamins, some
minerals (calcium, zinc, iron,
potassium) and amino acids
Endocytosis (also called pinocytosis)
Nutrients and other molecules are
engulfed by placental membrane and
released into fetal blood supply
Immunoglobulins, albumin
* Vitamin k crosses the placenta slowly and to a limited degree
19. • If the mother’s nutrient stores are inadequate
during the period when her body is developing
the placenta, then the placenta will never form
and function properly
– As a consequence, no matter how well the mother
eats later, her fetus will not receive optimal
nourishment, and a low birth weight baby with all
of the associated risks is likely
• The amniotic sac surrounds and cradles the
foetus- Cushioning it with fluids
• The umbilical cord is the pipeline from the
placenta to the fetus
20. • The umbilical cord contains two large arteries, which
deliver oxygen and nutrients to the fetus from the placenta,
and one large vein, which carries carbon di oxide and other
wastes from the fetus to the placenta.
• Transferred to the bloodstream, most of these wastes are
soon eliminated through the mother’s excretory system.
• As the fetus approaches birth, the umbilical cord is about
50cm (20in) long and has a diameter of 1.5cm (0.5in).
21. • The amniotic sac is the fluid-filled balloon like
structure that holds the fetus.
• The umbilical cord delivers nutrients and oxygen;
removes wastes.
• Placenta – respiration, absorption and excretion for
fetus.
22. • MATERNAL UNDERNUTRITION INFLUENCES PLACENTAL-FETAL
DEVELOPMENT: Louiza Belkacemi, et.al. Department of Obstetrics
and Gynecology, Washington University School of Medicine, USA
• Maternal nutrition during pregnancy plays a pivotal role in the
regulation of placental and fetal development and thereby
affects the life-long health and productivity of offspring. Sub-
optimal maternal nutrition yields low birth weights, with
substantial effect on the short-term morbidity of the newborn.
• The placenta is the organ through which gases, nutrients, and
wastes are exchanged between the maternal and fetal circulations.
The size, morphology and nutrient transfer capacity of the placenta
determine the prenatal growth trajectory of the fetus to influence
birth weight. Trans-placental exchange depends on uterine,
placental and umbilical blood flow.
• Importantly, maternal nutrition influences factors associated
not only with placental homeostasis but with optimal fetal
development as well. This review relates fetal growth with
maternal nutrition during pregnancy, placental growth and vascular
development, and placental nutrient transport.
23. • SUMMARY: Maternal nutrition during pregnancy is an important
determinant of optimal fetal development, pregnancy outcome and
ultimately, life-long health as an adult.
• Normal placental function facilitates maternal-fetal transfer of
nutrients that are critical for the development of a healthy fetus.
MUN reduces fetal growth in part by impairing placental
development and function.
• Placental alterations vary with the nutritional setting, and include
either decreases or increases in placental weight, altered vascular
development, diminished growth factor expression and reductions
in placental glucose, amino acid and lipid transport.
• The plasticity of the placenta allows this pivotal tissue to respond
to exogenous insults and compensate for varying nutritional status
of the mother. When this response is not sufficient to maintain fetal
growth, IUGR results and sub-optimal outcomes may appear in
newborns and persist into adult life
• Maternal under nutrition affects the placental weight, modifies
the nutrient transfer capacity, nutrient levels and fetal growth.
28. Fetal development at 4 weeks
At this point of development the
structures that eventually form the face
and neck are becoming evident. The
heart and blood vessels continue to
develop. And the lungs, stomach, and
liver start to develop.
Fetal development at 8 weeks
The baby is now about the size of
a grape - almost an inch in size.
Eyelids and ears are forming and
even the tip of the nose is visible.
The arms and legs are well
formed. The fingers and toes
grow longer and more distinct.
29. The First Trimester (0-12 weeks)
• At 8 weeks, the fetus has
– A complete central nervous system
– A beating heart
– A fully formed digestive system
– Well-defined fingers and toes
– The beginnings of facial features
• By the end of first trimester:
• Most organs are formed and the fetus can move
• Very Critical period as nutritional deficiencies or harmful
substances (eg. Certain medications, illicit drugs, radiation,
trauma, injury, etc.) transmitted from mother to embryo or
foetus can alter or arrest the progressing phase of
development.
• Most ‘spontaneous abortions’ or miscarriages occur during
this time.
• Very early miscarriages usually result from a genetic defect
or fatal error in development.
30. •NUTRITION:
Recommend a well balanced diet
and mineral/vitamin supplements to
help in Hyperplasia and
Hypertrophy
•WEIGHT GAIN:
About 1.5 to 2kgs in the entire first
trimester
•EXERCISE/PHYSICALACTIVITY:
Helps to tone muscles. Light work
or activity, as advised by the doctor
•INITIAL CHANGES:
Lethargy/tiredness,
nausea/vomiting, food cravings,
etc..
•CHANGES IN LIFESTYLE:
Rest and relaxation, no smoking
/alcohol, reduce caffeine, no drugs
without the doctor’s approval
31. The Second Trimester (13-28 weeks)
• Arms, Hands, Fingers, Legs, Feet, Toes are fully formed
• The foetus has ears and begins to form tooth sockets in
its jawbones
• Meconium develops in the baby's intestinal tract. This
will be the baby's first bowel movement.
• The baby makes sucking motions (sucking reflex).
• Mother can appreciate the foetal movements and the
heartbeat can be detected by a stethoscope
• Foetus can still be affected by exposure to toxins but
less than the 1st trimester.
• Under nutrition during second trimester has a greater
effect on the mother than the foetus, because, the
developing foetus will freely draw upon the mother’s
body reserves of nutrients
32.
33. Fetal development at 16 weeks
The fetus now measures about 4.3
to 4.6 inches and weighs about 2.8
ounces (90gms). The baby's eyes
can blink and the heart and blood
vessels are fully formed. The baby's
fingers and toes should have
fingerprints.
Fetal development at 20 weeks
The baby weighs about 9 ounces
(280gms) and is about six inches
long. The baby can suck a thumb,
yawn, stretch, and make faces.
Soon – the mother can feel her
baby move, which is called
"quickening."
34. Fetal development at 24 weeks
The fetus weighs about 1.4 pounds
(635gms) now. It responds to
sounds by moving or increasing its
pulse. Mother may notice jerking
motions if it hiccups. With the inner
ear fully developed, it may be able
to sense being upside down in the
womb.
Fetal development at 28 weeks
The fetus weighs about 2 pounds 6
ounces (~1kg). It changes position
frequently at this point in pregnancy.
There's a good chance of survival if
the baby was born prematurely now.
....YouTube Video
DownloadsNUTRITION through the
LIFECYCLENational Geographic - In
The Womb 8-10.avi
35. The Third Trimester (29-40 weeks)
• The third trimester is again a crucial phase.
• In the last months of pregnancy:
– The fetus grows 50x heavier and 20x longer
– Critical periods of cell division and development occur in
organ after organ
– The amniotic sac fills with more fluid
– The uterus and its supporting muscles increase in size
– The breasts may become tender and full
– The nipples may darken in preparation for lactation
– The mother’s blood volume increases by half to
accommodate the added load of materials it must carry
• The baby's body begins to store vital minerals, such as iron
and calcium.
• “Lanugo” begins to fall off.
36. • Lanugo begins to
fall off. Real hair
begins to grow on
the baby's head.
• Appearance of
“Lanugo” – fine hair
all over the body
37. • Bone marrow begins to make
blood cells.
• Taste buds form on the baby's
tongue.
• Footprints and fingerprints have
formed.
• Real hair begins to grow on the
head.
• The lungs are formed, but do not
work.
• The baby sleeps and wakes
regularly.
• If the baby is a boy, his testicles
begin to move from the abdomen
into the scrotum. If the baby is a
girl, her uterus and ovaries are in
place, and a lifetime supply of eggs
have formed in the ovaries.
• The baby stores fat and has gained
quite a bit of weight.
38. Fetal development at 36 weeks
Babies differ in size, depending on many factors (such as gender, the
number of babies being carried, and size of the parents), so the baby's
overall rate of growth is as important as the actual size. On average, it's
about 12.5 inches and weighs 5.5 pounds (2.5kgs). The brain has been
developing rapidly. Lungs are nearly fully developed. The head is usually
positioned down into the pelvis by now. A pregnancy is considered 'at term'
once 37 weeks has been completed; and the baby is ready!
39. • A healthful diet and good habits are vital during pregnancy to
ensure the health of both the offspring and the mother.
• Gestation lasts approximately 40 weeks and ends with the
birth of the infant
• An infant born after at least 28-32 weeks of gestation has a
good chance of survival, if it is cared for in an “NICU” –
(neonatal intensive care unit)…such a child is called “ Very
Pre-term infant”.
• However, a preterm infant will not contain the mineral (Fe
and Ca mainly) and fat stores normally accumulated during
the last month
• They also exhibit poor ability to suck & swallow – which
complicates the nutritional care of preterm babies
• The Foetus is very selfish with regard to Iron and
will deplete the iron stores of the mother to fulfill
its own needs. So, if a mother is not taking
adequate iron, she can end up severely anemic
after delivery.
40. Critical Periods Preprogrammed time periods during
embryonic and fetal development when specific cells,
organs, and tissues are formed and integrated, or
functional levels established. Also called sensitive periods.
41.
42. • A Note about Critical Periods
• Critical Period: specific time when a given event, or
its absence, has the greatest impact on development
– Each organ and tissue type grows with its own
characteristic pattern and timing
• If the development of an organ is limited
during a critical period, recovery is
impossible
• The effects of malnutrition during critical periods of
pregnancy are seen in
– Defects of the nervous system of the embryo
– The child’s poor dental health
– The adolescent’s and adult’s vulnerability to
infections and possibly higher risks of diseases
43.
44. • Whatever nutrients and other environmental
conditions are necessary during this period must be
supplied on time if the organ is to reach its full
potential.
• The effects of malnutrition during critical periods
are irreversible. Abundant and nourishing food,
fed after the critical time, cannot remedy harm
already done
• If the development of an organ is limited during a
critical period, recovery is impossible. For example,
the fetus’s heart and brain are well developed at 14
weeks; the lungs, 10 weeks later. Therefore, early
malnutrition impairs the heart and brain; later
malnutrition impairs the lungs.
45. Critical periods
Times of intense
development and
rapid cell division
Adverse influences
on organ and tissue
development
Neural tube defects
17-30 days gestation
Anencephaly affects
brain development
Spina bifida can lead
to paralysis or
meningitis
48. • Birth Defects Statistics
• Although the infant mortality rate is showing a downward trend
worldwide; there is a constant rise in the percentage of infant
deaths due to birth defects (March of Dimes Global Report 2006).
• Worldwide about 7.9 million children (6%) annually are born with a
• serious birth defect i.e. about 2-6 per 100 children are born with
birth defects around the world
• 2.5/1000 babies are born with Neural Tube Defects
• 2.7/1000 babies are born with Club foot, Gastrointestinal tract
abnormalities and defective diaphragm
• 1.9/1000 babies are born with Cleft lip, Cleft palate and Congenital
Heart Defects
• Various risk factors that are associated with birth defects are
status, infections,
advanced maternal age, maternal nutritional
medical illnesses such as diabetes, maternal exposure to
teratogenic drugs, and consanguinity.
49. • Birth Defects Registry of India (BDRI) was instituted in 2001 by Fetal
Care Research Foundation, a not-for-profit charity trust based in Chennai,
to document incidences of congenital abnormalities in the Indian
population. From a modest beginning, BDRI has now enrolled more
than 700 hospitals across 28 states and 3 Union territories and has
so far analyzed over 10 lakh births of which the most common
anomaly has been Neural Tube Defects (NTD).
• Birth defects incidence in India has not reduced over the last 8-10years
• Various hospital-based prospective Indian studies have shown a
prevalence of birth defects ranging from 1.6-3.2% in live births and 5-
16.4% in stillbirths
• Most of the available Indian studies, including the data available from Birth
Defect Registry of India (BDRI) show that the common systems involved in
birth defects are central nervous system, musculoskeletal system and
cardiovascular system, with neural tube defects being the commonest
• Birth Defects Registry of India aims to measure baseline prevalence of
birth defects, reduce the incidence of birth defects and enable families to
establish Support Groups for congenital disorders.
• Read more: Birth Defects Registry of India - A ‘Saving Babies’ Project | Medindia
http://www.medindia.net/news/healthwatch/Birth-Defects-Registry-of-India-A-Saving-Babies-
Project-78389-1.htm#ixzz2LzldZJTv
50. Teratogens & Congenital Defects
• Teratogen: a chemical or physical agent which
can lead to malformations in the fetus
• Congenital Defect: a defect present at birth
caused by a teratogen.
• Categories of Teratogens
• Metabolic (Diseases)
• Chemicals
– Drugs
– Alcohol, Heroin, Narcotics, Nicotine
• Maternal malnutrition
• Radiation
51. • What are some influences that impact on healthy prenatal
development?
• Teratogens are the broad range of substances (such as drugs
and pollutants) and conditions (such as severe malnutrition
and extreme stress) that increase the risk of prenatal
abnormalities.
• These abnormalities include obvious physical problems (such
as missing limbs) and more subtle impairments such as brain
damage that first appears in elementary school.
• A specific teratogen may damage the body structures, the
growth rate, the neurological networks, or all three.
• Teratogens that harm the brain, and therefore make a child
hyperactive, antisocial, retarded and
behavioural teratogens; their effects
so on, are
can be far
called
more
damaging over the life of a person than physical defects.
(Berger, 2000)
52. • What are the factors that influence the degree of affect?
• One crucial factor is when the developing organism is exposed to
which teratogen. Some teratogens cause damage only during specific
days or weeks early in pregnancy, when a particular part of the body is
undergoing formation. Others can be harmful at any time, but how
severe the damage is depends on when the exposure occurred. The
time of greatest susceptibility is called the critical period. Each body
structure has its own critical period. As a general rule, for physical
defects the critical period is the entire period of the embryo/foetus.
• A second important factor is the dose and/or frequency of exposure to
a teratogen.
• A third factor that determines whether a specific teratogen will be
harmful, and to what extent, is the developing organism's genes. In
some cases, genetic vulnerability is related to the sex of the
developing organism. Generally, male embryos (XY) and fetuses are at
a greater risk than female in that more male embryos are more often
aborted spontaneously. In addition, newborn boys have more birth
defects, and older boys have more learning disabilities and other
problems caused by behavioural teratogens. (Berger, 2000)
58. Zika virus infection and pregnancy
• Zika virus can be spread from a pregnant woman to her unborn baby.
There have been reports of a serious birth defect of the brain called
microcephaly in babies of mothers who had Zika virus while pregnant.
• Knowledge of the link between Zika and birth defects is evolving, but
until more is known, CDC recommends special precautions for pregnant
women. Pregnant women in any trimester should consider postponing
travel to any area where Zika virus is spreading.
• Does Zika in pregnant women cause birth defects?
• Brazil has been having a significant outbreak of Zika virus since May
2015. Officials in Brazil have also noted an increase in the number of
babies with congenital microcephaly (a birth defect in which the size of a
baby’s head is smaller than expected for age and sex) during that time.
Congenital microcephaly is often a sign of the brain not developing
normally during pregnancy. Health authorities in Brazil, with assistance
from the Pan American Health Organization, CDC, and other agencies,
have been investigating the possible association between Zika virus
infection and microcephaly.
http://www.cdc.gov/zika/pregnancy/question-answers.html
59. Increased nutrient needs to
support Pregnancy
• All nutrients required by the developing foetus must be
supplied by the mother’s diet or her body reserves
• Also, the mother herself needs extra for increases in her
tissues, fat deposits, blood, etc.
• So, maternal needs during pregnancy must be met for all
essential nutrients to ensure a healthy outcome.
• Nutrient requirements during pregnancy are not static. They
vary during the course of pregnancy depending on pre-
pregnancy nutrient stores, body size and composition,
physical activity levels, stage of pregnancy & health status.
• For the most part, nutrient needs can be and are optimally
met by consuming well balanced, adequate, and healthful
diets consisting of basic foods. Healthful diets established
during pregnancy can last well beyond pregnancy and benefit
the health of both the mother and child for life
60. • Where babies are born dramatically influences their
chances of survival
• Almost 99% of newborn deaths occur in the developing
world. In part because of their large populations, more than
half of these deaths now happen in just five large countries –
India, Nigeria, Pakistan, China and Democratic Republic
of the Congo. India alone has more than 900,000
newborn deaths per year, nearly 28% of the global total.
• Nigeria, the world’s seventh most populous country, now
ranks second in newborn deaths up from fifth in 1990. This is
due to an increase in the total number of births while the risk
of newborn death has decreased only slightly.
• China: In contrast, because the number of births went down
and the risk of newborn death was cut in half (23 to 11 per
1000), China moved from second place to fourth place.
• With a reduction of 1% per year, Africa has seen the slowest
progress of any region in the world.
61.
62.
63.
64. Nutrient Normal
adult
woman
Pregnant
woman
(ICMR 1989 RDA)
Pregnant woman
(ICMR 2010 RDA)
Pregnant woman
(RDA as per various
international sources)
Energy:
Sedentary 1900 kcal
+300 kcal +350 kcal
+350 (2nd trimester)
+ 450 (3rd trimester)
Energy:
Moderate 2230 kcal
Energy:
Heavy 2850 kcal
Protein
gms/day
1gm/kg
body wt
+15 gm +23 gm +25gms
Visible Fat
gms/day
20 to 30
gm
30 gm 30gm 25 to 30
Dietary Fiber
gms/day 20-35gm -- 20gm/1000kcals 25 to 40
Linoleic Acid
gms/day
2.5-3% of
Energy
-- 2.5-3% of Energy 13
Linolenic
Acid (g/day)
>0.5% of
Energy
-- >0.5% of Energy 1.4
Recommended Dietary Allowances for Macronutrients
65. Nutrient Normal
adult
woman*
Pregnant
woman
(ICMR 1989 RDA)
Pregnant woman
(ICMR 2010 RDA*)
Pregnant woman
(RDA as per various
international sources)
Calcium
mg/day 600 mg 1000 mg 1200 mg 1000mg
Iron
mg/day 21 mg 38 mg 35 mg 27
Iodine
mcg/day 150 175-200 250 220 to 250
Zinc
mg/day 10mg 10 12mg 11
Magnesium
mg/day 310mg 350 310mg 350
Recommended Dietary Allowances for Minerals
66. Nutrient Normal
adult
woman
Pregnant
woman
(ICMR 1989 RDA)
Pregnant woman
(ICMR 2010 RDA)
Pregnant woman
(RDA as per various
international sources)
Vitamin A
(Retinol)
µg/day
600 600 800 770
Vitamin A
(β-carotene)
µg/day
4800 2400 6400 --
Vitamin C
mg/day 40 40 60 85
Vitamin D
IU/day 400 400 400
5mcg/day or
200IU/day
Folic acid
µg/day 200 400 500 600
Vitamin B6
mg/day 2.0 2.5 2.5 1.9
Vitamin B12
µg/day 1.0 1.0 1.2 2.6
Recommended Dietary Allowances for Vitamins
67.
68.
69. • Energy requirement during pregnancy comprises the normal requirement
for an adult woman and an additional requirement for foetal growth plus
the associated increase in body weight of the woman during pregnancy,
most of which occurs during the second and the third trimesters.
• The total energy requirement during pregnancy for a woman weighing 55
kg is estimated to be 80,000 kcal of which 36,000 kcal is deposited as fat,
which is utilized subsequently during lactation.
• Based on these estimates, FAO/WHO Consultants recommended
additional daily allowance of150kcal/day of energy during first trimester
and 350 kcal/day during the second and the third trimesters
• Energy requirement during pregnancy comprises body weight gain
consisting of protein, fat and water.
• Protein is predominantly deposited in the fetus (42%) but also in the
uterus (17%), blood (14%), placenta (10%) and breasts (8%).
• Fat is predominantly deposited in fetus and maternal tissues and
contributes substantially to the overall energy cost of pregnancy.
• Protein and fat gain associated with gestational weight gain of 12 kg,
would be 597g and 3.7 kg respectively
ENERGY
70. Over the entire pregnancy, recommended weight gain:
Normal weight pregnant woman: 11-16kgs (ICMR: 10-12kgs)
Overweight woman: 7-11kgs
Underweight woman: 13-18kgs
71. ENERGY
•
• The following figures can be recommended as additional energy
requirements of an Indian woman with pre-pregnancy weight of 55 kg.
• Note that the average value for the 2nd and 3rd trimester is taken fora
single recommendation value.
12 kg increase 10 kg increase
• 1st trimester 85 70
• 2nd trimester 280 230
• 3rd trimester 470 390
• During 2nd & 3rd trimester 375 310
• Hence, an average recommendation of +350 kcal/day through the
second and third trimesters, as additional requirement during pregnancy
for an Indian woman of 55 kg body weight and pregnancy weight gain
between 10 -12 kg may be recommended (ICMR; RDA2010)
• Therefore, RDA specifies an increase of about +350 calories per
day from the 2nd trimester onwards to meet additional energy
demands of pregnancy
• This will ensure adequate weight gain during pregnancy
72. • The Pattern of weight gain is more important than total
weight gain. The recommended pattern is-
• 1.5kgs in the first trimester, and then
• 2kgs per month till full term (i.e. 0.5kg or 1 pound per
week)
• Sharp increase in weight in the third trimester may be
due to excess fluid retention – a potential sign of P.I.H.
(pregnancy induced hypertension)
78. Carbohydrates
• Extra carbohydrate is necessary to fuel the fetal brain
and spare the protein needed for fetal growth
• Minimum of 60-65% of energy should be supplied by
carbohydrates, mostly from the complex type.
• Women should consume a minimum of 175 grams
carbohydrates to meet the fetal brain’s need for glucose.
• Fiber can help alleviate the constipation that many
pregnant women experience (20gm/1000kcals)
• Basic foods such as vegetables, fruits, and whole-grain
products containing fiber and a variety of other nutrients
are good choices for high-carbohydrate foods.
• These foods also provide beneficial phytochemicals,
such as plant antioxidants, and protection against
constipation.
79. PROTEIN
• Additional RDA for pregnancy is higher than
for non pregnant women by 23-25grams/day.
• During pregnancy additional protein is required
for,
– Development of placenta
– Growth of the fetus
– Enlargement of maternal tissues
– Increased maternal blood volume
– Formation of amniotic fluid
– Protein reserves prepare the mother for labour,
delivery and lactation
80. PROTEIN
• Infants born to mothers with adequate protein
intake are taller, have better brain development
and can resist infections better.
• Physiological adaptations in protein metabolism
during pregnancy shift in the direction of meeting
maternal and fetal needs for protein.
• Consequently, less protein is used for energy
and more is used for protein synthesis
• P.I.H. is more common in women with a low
protein intake
81. • Fat:
• The high nutrient requirements of pregnancy leave
little room in the diet for excess fat, but a slight
increase ensures that the pregnant mother meets
the increased energy demands.
• It is estimated that pregnant women consume, on
average, 25% of total calories from fat. Fat
consumed in foods is 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.
82. • Essential Fatty Acids:
• The essential long-chain polyunsaturated fatty acids are
particularly important to the growth and development of the
fetus.
• The brain is composed mainly of lipid material and depends
heavily on long-chain omega-3 and omega-6 fatty acids for
its growth, function, and structure ( they also provide DHA).
• It is recommended that pregnant women consume 9 to
13 grams of the EFA linoleic acid (omega-6) daily, and
1.2 to 1.4 grams of the other essential fatty acid, alpha
linolenic acid (omega-3).
• Omega-3 fatty acids during pregnancy are essential for,
– brain development and preventing preterm birth
– fetal visual development
– reduced incidence of heart diseases & heart disease
related deaths in infants.
83. How the brain develops
• Development of the brain and nervous system of the embryo
begins shortly after conception
• Neural tube spinal cord & brain (2-4 weeks)
• At birth, the brain already has all the neurons it will need for
life
• An infant’s brain is 25% of its adult weight at birth in full term
babies
• By the age of 2, the brain will be 75% of its adult weight (90%
by age 6)
• Between birth and age 2, children will go through several
stages of cognitive development including sensory
development & language development
– Eg. 8-18 months = first words
– Approx. 2 years = combining words
– 6 years = 10,000 word vocabulary
84. Prenatal Brain Development
During peak periods of
brain development, new
neurons are being
generated at the rate of
250,000 per minute.
• Brain begins as a fluid-filled
neural tube about three
weeks after conception
• The neural tube is lined with
stem cells
• Neural stem cells divide and
multiply, producing neurons
and glial cells
• Top of
three bulges that form
tube thickens into
the
and
hindbrain, midbrain,
forebrain
• Hindbrain structures are first
to develop, followed by
midbrain structures
• Forebrain structures develop
last, eventually surrounding
the hindbrain and midbrain
structures
85. The key component of fish
is omega-3 fatty acids,
which are critical to fetal
neural development.
Those who
fish, some
abstain
very
from
good
sources of omega-3 fatty
are flaxseed,
soybeans and
acids
walnuts,
eggs.
• Avoid swordfish, shark, king mackerel, etc.
86. Vitamins of Special Interest: Folate, Vitamin A,
Vitamin D and Vitamin B12
• FOLATE / FOLIC ACID: The RDA for folate during
pregnancy increases up to 500 micrograms/day
– RBC formation requires folate
– The body uses folate to manufacture new cells
and genetic material.
– Folate plays an important role in preventing neural
tube defects
– The early weeks of pregnancy are critical periods
for the formation and closure of the neural tube
that will later develop to form the brain and spinal
cord
– By the time a woman suspects she is pregnant,
usually around the sixth week of pregnancy, the
embryo’s neural tube has normally closed
87. • Ideally, Folate supplements and/or Folate
rich foods should be administered 1-3
months prior to conception to minimize risk.
• Generally, Folic acid supplements are given
in combination with Iron and started
immediately on pregnancy confirmation
• If the mother has a prior child affected by a
neural tube defect, supplementation in the
subsequent pregnancy should be increased
to 4-5mg/day (i.e. 4000-5000mcg/day)
91. • A neural tube defect (NTD) occurs when
the tube fails to close properly
– When the neural tube fails to close properly and
brain development fails, a rare but lethal defect
known as anencephaly occurs (i.e. the baby is
born without a brain)
• All such infants die shortly after birth
• In a more common NTD, the spinal cord and
backbone do not develop normally
– The result is spina bifida
• The membranes covering the spinal cord often
protrude from the spine sac, and sometimes a portion
of the spinal cord is contained within the sac
94. Types of Spina Bifida
• Meningo-myelocele: This is the most serious
type of spina bifida. With this condition, a sac of
fluid comes through an opening in the baby’s
back. Part of the spinal cord and nerves are also
in this sac and are damaged.
• This type of spina bifida causes moderate to
severe disabilities, such as loss of feeling in the
person’s legs or feet, and not being able to move
the legs, water in the brain (hydrocephalus),
learning disabilities, paralysis with bone and joint
abnormalities, decreased sensation of the skin,
and bowel and urinary problems.
95.
96. • Meningocele:
• In a meningocele, a sac of fluid comes through an
opening in the baby’s back. But, the spinal cord is
not in this sac. There is usually little or no nerve
damage. This type of spina bifida can cause minor
disabilities.
• Spina Bifida Occulta: Mildest type of spina bifida. It
is sometimes called “hidden” spina bifida. With it,
there is a small gap in the spine, but no opening or
sac on the back. The spinal cord and the nerves
usually are normal. Many times, spina bifida occulta
is not discovered until late childhood or adulthood.
This type of spina bifida usually does not cause any
disabilities.
97. • Screening for NTDs is recommended if the following are
present:
• A child with NTDs is already in the family OR a family history of
NTDs exists, especially a mother with NTDs.
• The mother has type I or II diabetes mellitus at the onset of
pregnancy (expression of Pax3, a gene required for neuraltube
closure, is significantly reduced by maternal diabetes).
• Maternal exposure to drugs, such as valproic acid, is associated
with NTDs.
• Ultrasound findings indicate the possibility of NTDs. Can detect
anencephaly from the 12th week and spina-bifida from 16-20
weeks
• Elevated level of MSAFP (maternal serum alpha-fetoprotein) is
present (greatest sensitivity between 16-18 weeks' gestation).
• For further confirmation, if the level of neuronal acetyl-
cholinesterase also rises along with MSAFP, it is suspected as
a condition of a NTD.
98. • A randomised controlled trial conducted by the Medical
Research Council of the United Kingdom demonstrated
a 72% reduction in risk of recurrence by peri-
conceptional (ie before and after conception) folic acid
supplementation @ 4mg daily.
• Other epidemiological research, including work done in
Australia, suggests that primary occurrences of neural
tube defects may also be prevented by folic acid either
as a supplement or in the diet.
• This has been confirmed in a randomised controlled
trial from Hungary, which found that a multivitamin
supplement containing 0.8mg folic acid was effective in
reducing the occurrence of neural tube defects in first
births.
• (Data excerpt from NHMRC Publication, Australia)
99. • The Lancet, Volume 366, Issue 9489, Pages 930 - 931, 10 September
2005
• Incidence of neural tube defects in the least-developed area of India:
a population-based study: Anil Cherian MBBS, et. al.
• Summary
• Hospital-based records from major cities of India, where roughly a
quarter of the population resides, identified the frequency of neural
tube defects (NTDs) as ranging from 3·9 to 8·8 per 1000 births, but
the incidence in rural areas is unknown. We did a population-based
door-to-door survey of mothers living in remote clusters of villages
in Balrampur District in Uttar Pradesh, a region ranked as the least-
developed area in India. The data showed that the incidence of NTDs
was 6·57—8·21 per 1000 live births, which is among the highest
worldwide. India's Ministry of Health needs to produce a strategy to
reduce the incidence of such defects.
• P.S. The Government of India has included folic acid prophylaxis for
pregnant mothers along with iron supplementation as part of
“National Anemia Control Prophylaxis Program”. All pregnant
mothers are given one tablet per day containing 60mgms elemental
iron and 0.5mg (500mcg) of folic acid.
100. Vitamin A
• Needs increase by 25 to 30% in pregnancy
• Vitamin A is needed to protect the fetus from immune
system problems, blindness, infections, and death
• Vitamin A is a key nutrient in pregnancy because it plays
important roles in reactions involved in cell
differentiation.
• Deficiency of this vitamin is rare in pregnant women in
industrialized countries, but it is a major problem in
many developing nations (night blindness in 3rd trimester).
• Deficiency linked to an increased risk of low birth weight,
intrauterine growth retardation, preterm births.
• Vitamin A deficiency that occurs early in pregnancy can
produce malformations of the fetal lungs, urinary tract,
and heart.
101. • Excess preformed vitamin A exerts teratogenic
effects. Can cause birth defects in high doses
• Intakes of Vitamin A in the form of Retinol and
Retinoic acid, in doses over 10,000 IU per day, and
the use of medications such as Accutane and Retin-
A for acne and wrinkle treatment, increase the risk
of fetal abnormalities. Effects are particularly striking
in infants born to women using Accutane or Retin-A
early in pregnancy.
• Fetal exposure to the high doses of retinoic acid in
these drugs tends to result in “retinoic acid
syndrome.” Features of this syndrome include small
ears or no ears, abnormal or missing ear canals,
brain malformation, and heart defects.
102. • Vitamin D: Calcium absorption increases during
pregnancy to distribute extra calcium for forming the
bones of the foetus. To help calcium absorption,
adequate Vitamin D is a must. Ensuring regular
RDA compliance and exposure to sunlight is
sufficient.
• B12: With increased Folate intake, the pregnant
woman needs a greater amount of B12 to assist
folate in the manufacture of new cells
• People who eat meat, eggs, or dairy products
receive all the vitamin B12 they need, even for
pregnancy
• Those who exclude all animal products from their
diet need vitamin B12 fortified foods / supplements
103. Minerals of special interest during
Pregnancy - Iron, Calcium, Iodine and Zinc
• Calcium – 1000 to 1200mg/day
• Intestinal absorption doubles in pregnancy, to
promote adequate mineralization of the foetal
skeleton and teeth. Requirement is greatest in
3rd trimester.
• The mineral is stored in the mother’s bones.
When fetal bones begin to calcify, the mother’s
bone calcium stores are mobilized, and there is
a shift of calcium across the placenta
• This leads to a promotion of progressive
calcium retention to meet the progressively
increasing fetal skeletal demands for
mineralization.
104. Role of Calcium in Pregnancy
• Adequate calcium decreases the risk of-
– Hypertension and Pre-eclampsia
– Low Birth Weight
– Chronic Hypertension in children
• Implications for the new-born and mother-
– Calcium is essential for fetal mineralization of bones
and teeth and also electrolyte acid base buffering
– Fetal bone and teeth calcification occurs primarily in
the last trimester
– Muscle contraction and blood clotting
– If serum calcium levels are low, this will happen at the
cost of demineralization of mothers bones and teeth.
Most affected is the spine.
105. • Approximately 30g of calcium is accumulated during
pregnancy, almost all of it in the fetal skeleton (25 g).
The remainder is stored in the maternal skeleton, held
in reserve for the calcium demands of lactation.
• Most fetal accumulation (80%) occurs during the last
trimester of pregnancy, at an average of 300 mg/day.
• Hormonal adaptations and increased intestinal
absorption protect maternal bone while meeting fetal
calcium requirements
• Efforts to ensure an adequate calcium intake during
pregnancy are aimed at conserving the mother’s bone
mass while supplying fetal needs
• Most women do not meet the RDA for calcium and
should increase their intakes. Encourage increased
consumption of milk and milk products like
curd/yoghurt, cheese, etc. Ragi is an excellent source.
• Supplements (600mg of calcium / day) are usually
recommended because dietary sources may not be
able to meet the daily demand.
108. • Magnesium
– Essential for bone and tissue growth
– So, during Pregnancy, magnesium RDA through
diet must be met.
• Zinc
– Required for protein synthesis and cell
development
– Supports normal growth and important for
sexual maturation
– Important for immunity as well
– Severe deficiency during pregnancy increases
the risk of having a Low birth weight infant
– Provided abundantly by protein-rich foods
– Most supplements for pregnancy provide zinc
109. • Iron – 35mg / day
• consumption may lead to poor
Inadequate iron
hemoglobin production, followed by compromised
delivery of oxygen to the uterus, placenta, and
developing fetus. The added workload of the heart from
maternal anemia with increased cardiac output can lead
to preterm delivery, fetal growth retardation, LBW or
neonatal death.
• Iron stores dwindle because the developing fetus draws
heavily on its mother’s iron stores
• Even women with inadequate iron stores transfer
significant amounts of iron to the fetus
• As per govt. regulations, iron supplements containing
60-100mg elemental iron and 0.5mg folic acid are given
free to all pregnant women.
110.
111.
112. • Iron is essential to the production of hemoglobin. Its
dietary sources include animal protein, dried beans,
fortified grains, and any food cooked in cast iron
cookware. Despite its numerous sources, women have
difficulty maintaining iron balance using only a healthy
diet
• Also, the absorption of iron is very inefficient and only
approximately 10% is absorbed.
• So, even with an adequate diet, iron supplements are
prescribed and recommended from the beginning of 2nd
trimester till 40 days postpartum
• In pregnancy, 500mg of additional iron is needed to
expand maternal red cell mass. Another 500mg is
needed to supply fetal and placental tissues. On
average, an additional 3mg/day of elemental iron must
be absorbed from dietary sources.
113. During pregnancy iron is essential for
• Fetal growth
• Expansion of maternal tissues including the red blood cell
mass
• Maintaining additional iron content of placenta
• Building the iron stores in fetal liver
• Compensate blood loss during delivery
Group Pre
pregnancy
body weight
(kg)
Basal
losses
µg/kg
Iron requirement
Growth
µg/kg
Total
µg/kg
Total
µg/d
Dietary iron
requirement on
mixed cereal diet
(mg/d)
Pregnant
woman
50 14 46 60 3000
(3mg)
37.5
114. • Maternal blood losses are also inevitable at birth, further
draining the mother’s iron reserves
• The RDA for elemental iron reflects these increased
requirements. Even well-balanced diets do not provide the
pregnancy RDA for elemental iron; therefore, iron
supplementation is recommended in normal pregnancy.
• Various iron preparations are commercially available, and
each delivers a slightly different amount of elemental iron.
These preparations include ferrous sulfate, ferrous fumarate,
ferrous gluconate, and polysaccharide iron complex.
• Only 10% is absorbed from the maternal gut. Absorption is
enhanced by concurrent ingestion of foods containing vitamin
C. Usually, one dose of any preparation containing at least
30 mg of elemental iron meets the RDA. Larger doses are
only to treat maternal iron deficiency
they only serve to constipate patients
anemia
without
required
otherwise
anemia.
115. • Iron is a metal. It can send an electro-magnetic
charge through nerves and muscles in bowel. This
slows down motility of the bowel i.e. peristalsis is
affected and may lead to constipation.
• Iron supplements decrease appetite and may cause
nausea, etc.
• To enhance iron absorption, the supplement should
be taken between/after meals and with liquids other
than milk, coffee, or tea, which inhibit iron absorption
• Iron and calcium supplements should not be taken
together, as it affects the absorption.
• Iron also competes with zinc at absorption sites.
116. • Impairment of iron absorption
–Tannins (Found in tea and coffee)
–Calcium and phosphorus (Milk)
–Phytates & Oxalates
• Found in the fiber of lightly processed legumes
and whole-grain cereals + GLVs
–Black tea is exceptional in its efficiency in
reducing iron absorption.
–For those who need more iron, drink tea /
coffee / milk, between meals, not with food
117. • Absorbing Iron
• Heme Iron - found in meat, fish and poultry,
promotes the absorption of non-heme iron
from other foods eaten at the same time
• Adding a food rich in Vitamin C to a meal
containing iron rich foods, can increase non-
heme iron absorption up to six times!
118. • Cooking in an iron
pan adds iron to food
–This iron is in the
form of iron salts
somewhat like
those in the
supplements
–The iron content of
100 grams of
spaghetti sauce
• Simmered in a
glass dish = 3mg
• Cooked in a black
iron skillet = 87mg
119. • IODINE: 200 to 250mcg/day
• Iodine is extremely important for brain development
• Adequate gestational iodine is associated with a
higher intelligence quotient in the child
• Iodine deficiency is a preventable cause of mental
impairment
• Lack of iodine could contribute to stillbirth, birth
defects.
• Attention deficit may be associated with mild iodine
deficiency
• Iodine supplementation and fortification programs
have been largely successful in decreasing iodine
deficiency conditions
120. • Iodine deficiency in pregnancy and the effects of
maternal iodine supplementation on the offspring: a
review: Michael B Zimmermann: Am J Clin Nutr 2009;89
(suppl): 668S–72S.
• The World Health Organization (WHO) recently
increased their recommended iodine intake during
pregnancy from 200 to 250 mcg/d and suggested that a
median urinary iodine (UI) concentration of 150–249
mcg/L indicates adequate iodine intake in pregnant
women.
• Thyrotropin concentrations in blood collected from newborns
3–4 d after birth may be a sensitive indicator of even mild
iodine deficiency during late pregnancy; <3% frequency of
thyrotropin values >5mU/L indicates iodine sufficiency. New
reference data and a simple collection system may facilitate
use of the median UI concentration as an indicator of iodine
status in newborns.
121. • In areas of severe iodine deficiency, maternal and fetal
hypo-thyroxinemia can cause cretinism and adversely affect
cognitive development in children
• To prevent fetal damage, iodine should be given before or
early in pregnancy. Whether mild-to-moderate maternal
iodine deficiency produces more subtle changes in cognitive
function in offspring is unclear; not many controlled
intervention studies have measured long-term clinical
outcomes.
• Cross-sectional studies have, with few exceptions, reported
impaired intellectual function and motor skills in children from
iodine-deficient areas, but many of these studies were likely
confounded by other factors that affect child development. In
countries or regions where <90% of households are using
iodized salt and the median UI concentration in school-age
children is <100mcg/L, the WHO recommends iodine
supplementation in pregnancy and infancy.
122. • Fluids During Pregnancy
• The need for fluids increases to 2.5 to 3 liters/day
for--
• Increase in the mother’s blood volume
• Regulating body temperature
• Production of amniotic fluid to protect and cushion
the fetus
• Combat fluid retention and constipation
• Prevent urinary tract infections
123.
124. Prenatal Supplements
• Physicians often recommend daily
mulitvitamin-mineral supplements for
pregnant women
• These prenatal supplements typically
provide more folate, iron, and calcium
than regular supplements
• Prenatal supplements are especially
beneficial for women who do not eat
adequately and for those in high-risk
groups
– Women carrying twins or triplets
– Cigarette smokers
– Alcohol and drug abusers
125. Each Capsule Contains:
Carbonyl iron – 100 mg; Folic acid IP – 1.5 mg
Vitamin B 12 – 15 mcg; Vitamin C – 75 mg
Vitamin E – 15 IU; Selenium – 65 mcg
Zinc – 22.5 mg
126. Each Composite Film Coated Tablet Contains
Carbonyl Iron
Eq. To Elemental iron
: 100mg
Folic Acid : 1500mcg
Zinc Sulphate delayed release : 61.8mg
Vitamin B12 : 10mcg
127. Key Nutrients During Pregnancy
Nutrient (RDA) Why is it needed? Best Sources
Calcium (1000-
1200mg)
Helps build strong bones and
teeth.
Milk , Yogurt, Cottage cheese,
Ragi, etc..
Iron (35 milligrams) Helps red blood cells deliver
oxygen, essential for normal
infant brain development and
immunity
Lean red meat, eggs, dried
beans and peas, nuts,
raisins/prunes/dates, dark
green leafy vegetables,
fortified cereals, etc..
Iodine (250
micrograms)
Essential for brain development;
deficiency can cause still birth /
other birth defects
(mental/physical)
Iodized salt, certain sea fish
and sea weeds, vegetables,
cereals, etc.
Zinc (12milligrams) Helps in making proteins,
genetic material. Promotes
normal growth; improves
immunity
All protein rich foods
Vitamin C (60-
80milligrams)
Promotes healthy gums, teeth,
and bones. Helps to absorb iron,
aids synthesis of collagen
Citrus fruits, potatoes,
gooseberry, broccoli,
tomatoes, strawberries, etc..
128. Nutrient (RDA) Why is it needed? Best Sources
Vitamin D
(10micrograms) or
400IU
Helps build strong bones and
teeth by aiding Calcium
absorption
Sunlight exposure; vitamin D
fortified milk and milk products;
eggs, meat, fatty fish such as
salmon, tuna, etc.
Vitamin A (700-
800micrograms)
Forms healthy skin and helps
eyesight. Helps with bone
growth. Provides immunity and
prevents infections
Carrots; dark green leafy
vegetables; sweet potatoes; all
deep green, yellow and orange
colored fruits and vegetables
Vitamin B12 (1.2-2.5
micrograms)
Maintains nervous system.
Needed to form red blood cells.
Liver, meat, fish, poultry, milk
(found only in animal foods).
Vegans should take a
supplement
Folic Acid (500-600
micrograms)
Helps in formation of RBCs,
neural tube, new cells and
genetic material
Green leafy vegetables; liver;
orange juice; legumes and
nuts
129.
130.
131. Normal Physiological changes in Pregnancy
• Physiological changes in pregnancy can be divided into two
basic groups: those occurring in the first half of pregnancy
and those in the second half.
• In general, physiological changes in the first half are
considered “maternal anabolic” changes because they 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.
• The second half is a time of “maternal catabolic” changes in
which energy and nutrient stores, and the heightened
capacity to deliver stored energy and nutrients to the fetus,
predominate.
• Approximately 10% of fetal growth is accomplished in the
first half of pregnancy, and the remaining 90% occurs in the
second half.
132. Summary of maternal anabolic and catabolic
phases of pregnancy
Maternal Anabolic Phase
(till 20 weeks)
Maternal Catabolic Phase
(after 20 weeks)
Blood volume expansion,
increased cardiac output
Mobilization of fat and nutrient
stores from mother to foetus
Buildup of fat, nutrient, and
liver glycogen stores
Increased production and blood
levels of glucose, triglycerides, and
fatty acids; decreased liver
glycogen stores
Growth of some maternal
organs
Accelerated fasting metabolism
Increased appetite, food intake
(positive energy balance)
Increased appetite and food intake
(decline somewhat near Term)
Decreased exercise tolerance Increased levels of catabolic
hormones
Increased levels of anabolic
hormones
133. Normal changes in maternal physiology
during pregnancy
• Blood Volume Expansion
• Blood volume increases 20%
• Plasma volume increases 50%
• Edema (occurs in 60 -75% of women)
• Food Intake
• Increased appetite and food intake; weight gain
• Taste and odor changes
• Modification in preference for some foods
• Increased thirst
• Gastrointestinal Changes
• Relaxed gastrointestinal tract muscle tone
• Increased gastric and intestinal transit time
• Nausea (70%), Vomiting (40%)
• Heartburn; Constipation
134. • Blood Glucose Levels
• Increased insulin resistance
• Increased plasma levels of glucose and insulin
• Kidney Changes
• Increased glomerular filtration rate (50-60%)
• Increased sodium conservation
• Increased nutrient spillage into urine; protein is conserved
• Increased risk of urinary tract infection
• Maternal Organ and Tissue Enlargement
• Heart, thyroid, liver, kidneys, uterus, breasts, adipose tissue
• Circulatory System
• Increased heart rate (16% or 6 beats/min)
• Increased cardiac output through increased heart rate and stroke
volume (30-50%)
• Decreased blood pressure in the first half of pregnancy (-9%),
followed by a return to non pregnancy levels in the second half
135. • Immune System
• Suppressed immunity
• Increased risk of urinary and reproductive tract infection
• Blood Lipid Levels
• Increased concentrations of cholesterol, LDL cholesterol,
triglycerides, HDL Cholesterol (Physiological Dyslipidemia)
• Hemo-dilution
• Concentrations of most vitamins and minerals in blood decrease
• Basal metabolism
• Increased basal metabolic rate in second half of pregnancy
• Increased body temperature
• Respiratory System
• Increased tidal volume, or the amount of air inhaled and exhaled
(30 – 40%); Increased oxygen consumption (10%)
• Hormones
• Placental secretions of large amounts of hormones needed to
support physiological changes of pregnancy
136.
137. Hormonal changes
HCG
HCS
Human ChorionicGonadotropin
• prevent involution of CL
(progesterone, estrogen)
• effect on the testes ofmale
fetus - development of sex
organs
Human Chorionic
Somatomammotropin (orHPL)
• Mammary gland growth: preparing
for lactation(lactogenic)
• growth hormone effects
• decreases insulin sensitivity -more
glucose for the fetus
• low levels will causeplacental
insufficiency.
138. Hormonal changes
Progesterone
Estrogens
• relaxes smooth muscles
• maintains the implant by
maintaining the endometrial
lining
• decreases uterus contractility
• preparation for thelactation
• enlargement of uterus
• mammary gland and
breastsdevelopment
• relaxation of ligaments
139.
140. Physiological Changes-Health Concerns &
Discomforts of Pregnancy
• 1. Heartburn, Constipation, Hemorrhoids:
• Heartburn:
• Hormones (progesterone) produced by the
placenta soften the ligaments, relax muscles in the
uterus and intestinal tract. This often causes
‘Heartburn’ as gastric contents and stomach acid
slip into the lower esophagus.
• Heartburn results from the upward displacement
and compression of the stomach by the uterus,
combined with relaxation of the lower esophageal
sphincter
• Relieved by
– a regimen of more frequent but smaller meals
and avoidance of bending over or lying flat
– Antacid preparations
141. • Constipation and Hemorrhoids:
• ‘Constipation’ often results as intestinal muscles
relax during pregnancy. More likely to develop late
in Pregnancy, as the foetus competes with the GI
Tract for space in the abdominal cavity
• Constipation during Pregnancy is due to :
• Reduced motility of large intestine (progesterone
effect).
• Increased water re-absorption from large
intestine (aldosterone effect).
• Pressure on the colon by the foetus in the uterus.
• Low fiber diet
• Prenatal Iron Supplements
• Sedentary lifestyle
142.
143. • Pregnant women have increased fluid requirements because their
extracellular volume increases by 4-6 litres, particularly as pregnancy
progresses (Davison 1997)
• Short periods of water restriction can lead to an 8% reduction in the
amniotic fluid index - a measurement that indicates how much fluid
surrounds the fetus. This can reduce the thickness of the protective
amniotic cushion surrounding the infant (Kilpatrick and Safford
1993)
• One study showed that women who were not constipated consumed
more water from beverages (2,036ml daily, excluding tea and coffee)
than constipated pregnant women (1,675ml daily) (Anderson 1986)
• Derbyshire et al (2006) found that the water intake of pregnant
women is lowest in the first trimester (2,182ml daily) and increases in
the third (2,466ml daily).
• A similar study also concluded that Pregnant women with constipation
consume statistically significantly less water in the first trimester than
those without constipation (1,917ml daily and 2,311ml daily
respectively).
Derbyshire E (2007) The importance of adequate fluid and fibre intake
during pregnancy. Nursing Standard. 21, 24, 40-43.
144. • ‘Hemorrhoids’ is a problem frequently accompanied with
constipation.
• Straining during waste elimination can lead to Hemorrhoids
(Piles). Risk is more during Pregnancy owing to hormonal
changes (veins get relaxed and swell).
• Hemorrhoids occur due to:
• increased pressure on the rectum and perineum due to
persistent constipation
• Mechanical pressure on the pelvic veins
• Laxity of the walls of the veins by progesterone
145. • As pressure builds from the growing uterus
Venous return of blood from the rectal area back to the heart is
impeded.
The vessels near the rectum stretch, and as they stretch, so will
the surrounding skin or mucosa (if it's internal).
• The skin contains a vein that may or may not have clotted blood
in it. If it's purple in color and extremely painful, it's a good
indicator that there's a lot of blood trapped in the hemorrhoid.“
• Barbara Dehn-nurse practitioner at Women Physicians
OB/GYN: Medical Group in Mountain View, California
146. Haemorrhoids appear around the anus. They can be very
uncomfortable as they are itchy and may even bleed slightly. If left
untreated they can become prolapsed, which means they protrude
through the anus, causing a good deal of pain.
Varicose veins - swollen, purple veins - are common in the legs and
around the vaginal opening during late pregnancy. In most cases,
varicose veins are caused by the increased pressure on the legs
and the pelvic veins, and by the increased blood volume
To relieve the pain of the swollen hemorrhoids, hot sitz bath can be
applied daily. This will help stop the pain and irritation without opting
for any medicines. Hot sitz bath can be coupled with ice pack which
can also relieve the swelling of the hemorrhoids.
147. • 2. Edema:
• Placental hormones cause various body tissues to retain fluid
during pregnancy. Blood volume also increases
• The extra fluid normally causes some edema.
• The normal edema of pregnancy is a response to gravity - fluid
from blood pools in the ankles
• In mild edema, there is no need to restrict salt or use diuretics
• Edema in feet may limit physical activity and can be painful at
times
• To control symptoms:
• feet should be kept in an elevated position while sitting or lying
down.
• Avoid standing for long periods of time
• Ensure adequate protein intake.
• Edema signals trouble only if the fluid retention is accompanied
by excess urinary protein excretion and hypertension.
148. • Cardiovascular and Pulmonary Function
• Increased cardiac output accompanies pregnancy, and
cardiac size increases by 12%. Diastolic blood pressure
the first two trimesters because of
decreases during
peripheral vasodilatation, but returns to pre-pregnancy
values in the third trimester.
• Mild lower extremity edema is a normal condition of
pregnancy resulting from the pressure of the expanding
uterus on the inferior vena cava. Blood return to the heart
decreases, leading to decreased cardiac output, a fall in
blood pressure, and lower-extremity edema.
• Mild physiologic lower extremity edema is associated with
slightly larger babies and a lower rate of prematurity.
Maternal oxygen requirements increase and the threshold
for carbon dioxide lowers, making the pregnant woman feel
dyspnic. Adding to this feeling of dyspnea is the growing
uterus pushing the diaphragm upward.
149. • Why does the fluid collect mostly in the legs and
feet?
• During pregnancy, the growing uterus puts
pressure on the pelvic veins and on the vena cava
- a large vein on the right side of the body that
receives blood from the lower limbs and carries it
back to the heart.
• The pressure slows down circulation and causes
blood to pool in the legs, forcing fluid from the
veins into the tissues of the feet and ankles.
• This increased pressure is relieved when the
pregnant mother is made to lie on her side. And
since the vena cava is on the right side of the
body, the left-sided rest works best.
150. • 3. Morning Sickness / Nausea / Vomiting
and Hyperemesis Gravidarum
• Unexplained nausea / morning sickness is
usually the first signal of pregnancy to a
woman
• Commonly called ‘morning sickness’, but
nausea may occur at any time and/or persist
all day
• Nausea and vomiting in pregnancy
(NVP), affects 50% to 90% of all pregnant
women during the first trimester and usually
resolves at approximately 14-17 weeks
gestation. Motion, loud noises, bright lights,
and adverse climate conditions may also
trigger the nausea (Erick, 2004).
• This may also be due to a heightened sense
of smell induced by hormones secreted
during pregnancy
151. • hCG: The very quick rise in serum levels of hCG
(human chorionic gonadotropin) and estrogen play a
part in the appearance of pregnancy nausea. As the
hormones start decreasing in the system, around the
14th-16th week, the pregnancy nausea also starts to
decrease. During the first trimester, serum hCG levels
will be extremely high.
• Estrogen: Levels rise in pregnancy. So, this is another
suspect leading to “an enhanced sense of smell and
sensitivity to odors”.
• It's not uncommon for a newly pregnant woman to feel
overwhelmed by the strong smell of cooking/food, even
from far away.
For example- certain aromas instantly trigger the gag
reflex. (Some researchers think this may be a result of
higher levels of estrogen, but no one knows for sure.)
152. • On the plus side, morning sickness / nausea is usually a
sign that the mother's body is producing an adequate
amount of hormones, leading to less chance of having a
miscarriage
• Fortunately, most women with NVP are functional, able to
work, do not lose weight, and are helped by simple dietary
measures. Small, frequent snacks of carbohydrate foods
reduce nausea for some, whereas protein foods may help
others.
• Diets high in ginger and protein can reduce symptoms of
nausea (Levine et al., 2008). Ginger reduces symptoms of
NVP better than vitamin B6 (Chittumma et al., 2007;
Ensiyeh and Sakineh, 2009).
• Other therapies suggested include crackers or potato chips,
special lollipops ("Preggie Pops"), green tea, noise
reduction, acupuncture, etc.
153. • Some women do not tolerate the odors from hot foods, so room-
temperature foods / cold foods are preferred. Smelling lemons may
help block noxious odors (Erick, 2004). Unfortunately, there is no
“one cure for all”. Women suffering with nausea should eat whatever
and avoid odors that trigger
reduces the sensation of nausea
nausea.
• To overcome nausea:
• Advise non-sweet biscuits / crackers / dry toast in the morning
before getting out of bed
• Avoid fluids along with meals. Select low fat foods, skim milk
• Eat smaller meals at frequent intervals and cook with open windows
/ proper ventilation to dissipate strong smells
• Iron supplements may also trigger nausea, so can be startedfrom
2nd trimester and that too at bedtime
• If nausea continues after 1st trimester, is severe and affects dietary
intake, consult the doctor to prevent nutrient deficiencies.
• May recommend VitB6 x 7.5 times the RDA
• Hospitalization is essential in some cases when there is significant
dehydration / weight loss
154. • HYPEREMESIS GRAVIDARUM
• When early pregnancy is characterized by excessive NVP and
weight loss, fluid and electrolyte imbalances can occur. Now,
"morning sickness" becomes “Hyperemesis Gravidarum (HG)”.
• About 1-2% of pregnant women suffer from “hyperemesis
gravidarum”. The symptoms of this disorder usually peak at 9
weeks of gestation and subside by approximately 20 weeks of
gestation.
• Hyperemesis gravidarum is characterized by persistent nausea and
vomiting associated with dehydration, ketonuria, muscle wastage
and weight loss (>5% of pre-pregnancy weight or ≥ 5kgs).
• Most of these patients also have hyponatremia, hypokalemia, and a
low serum urea level.
• Ptyalism is also a typical symptom of hyperemesis.
• Hyperemesis gravidarum may cause volume depletion, electrolytes
and acid-base imbalances, nutritional deficiencies, and even death.
Severe hyperemesis requiring hospital admission occurs in 0.3-2%
of pregnancies. (Goodwin TM. Hyperemesis gravidarum. Obstet
Gynecol Clin North Am. Sep 2008;35(3):401-17, viii)
155.
156. • The pathogenesis of Hyperemesis gravidarum is
not fully understood, but may be attributed to
gastrointestinal
serotonin, nutritional
dysfunction,
deficiencies,
pylori infection, psychosomatic
hormones,
thyrotoxicosis,
Helicobacter
causes, etc.
• Hyperemesis itself is not a risk factor for adverse
outcomes, but these outcomes are the
consequence of the low weight gain associated
with hyperemesis.
• Patients who have > 5% weight loss and are
malnourished experience adverse pregnancy
outcomes, such as low birth weight, antepartum
hemorrhage, preterm delivery, and an association
with fetal anomalies.
157. • Also, some research suggests that women with a stomach bacterium
called Helicobacter pylori are more likely to have severe or long-
lasting nausea and vomiting.
• Helicobacter pylori infection of the stomach is one of the main cause
of acute gastritis. H.pylori destroys the mucosal lining and an acidic
environment is created, regurgitation of acid occurs and thus the
pregnant mother feels nauseated.
• In such cases, the lack of food, fluids and nutrients may be harmful to
their health and also the well-being of the foetus.
• If left untreated, severe cases can lead to dehydration, ketonuria and
malnutrition.
• Hospitalization for nutrition support and hydration is usually indicated.
Appropriate weight gain for pregnancy; correction of fluid and
electrolyte deficits; avoidance of ketosis; control of HG symptoms; and
achievement of nitrogen, vitamin, and mineral balance are the goals in
management (Austin, 2010).
• Thiamine should be a routine supplement in women with HG or severe
NVP. Pregnant women should ingest a total of 1.5 mg/d.
158.
159. Eur J Obstet Gynecol Reprod Biol. 2011 May;156(1):56-9. Maternal characteristics
largely explain poor pregnancy outcome after hyperemesis gravidarum.
Roseboom TJ, et. al.
In The Netherlands Perinatal Registry, we used all data on singleton pregnancies of at
least 24 weeks and 500 g without congenital anomalies in the years 2000-2006. We
examined the characteristics of women who suffered from hyperemesis gravidarum and
their children.
RESULTS: Women who suffered from hyperemesis gravidarum were slightly
younger; more often primiparous, of lower socio-economic status, of non-
Western descent and substance abusers; had more often conceived through
assisted reproduction techniques and more often had pre-existing
hypertension, diabetes mellitus and psychiatric diseases than women who did
not suffer from hyperemesis gravidarum. Also, their pregnancies were more
often complicated by hypertension and diabetes and they more often carried a
female fetus. Pregnancies complicated by hyperemesis gravidarum significantly more
often had an adverse outcome (prematurity or birth weight below the 10th percentile). The
increased risk of adverse pregnancy outcomes after hyperemesis gravidarum was largely
explained by the differences in maternal characteristics (crude OR 1.22 (95% CI 1.10-
1.36), adjusted OR was 1.07 (95% CI 0.95-1.19)).
CONCLUSION: Hyperemesis gravidarum is associated with adverse pregnancy
outcomes. This is largely explained by differences in maternal characteristics. Given the
impact of the early environment on later health (which is independent of size at birth),
studies that aim to assess the long-term consequences of hyperemesis gravidarum need
to be given high priority.
160. • Management of HG includes:
• Maternal diet and lifestyle alterations
• Administration of intravenous fluids (rehydration)
• Thiamine supplementation
• Vitamin B6 and Vitamin C supplementation
• Antiemetic drugs if required (doxylamine,
metoclopramide and chlorpromazine being the first-
line choices)
• In severe cases, nasogastric or parenteral nutrition
• Psychological support is often necessary
• Ginger (1gm for 4days)
• Alternative therapies such as acupuncture and
hypnosis.
161.
162. Key placental hormones and examples of their
roles in pregnancy
• Human chorionic gonadotropin (hCG)
• Maintains early pregnancy by stimulating the corpus
luteum to produce estrogen and progesterone. It
stimulates growth of the endometrium. The placenta
produces estrogen and progesterone after the first 2
months of pregnancy
• Progesterone
• Maintains the implant; stimulates growth of the
endometrium and its secretion of nutrients; relaxes
smooth muscles of the uterine blood vessels and
gastrointestinal tract; stimulates breast
development; promotes lipid deposition
163. • Estrogen
• Increases lipid formation and storage, protein
synthesis, and uterine blood flow; prompts uterine
and breast duct development; promotes ligament
flexibility
• Human chorionic somatotropin (hCS) / hPL
• Increases maternal insulin resistance to maintain
glucose availability for fetal use; promotes protein
synthesis and the breakdown of fat for energy for
maternal use
• Leptin
• May participate in the regulation of appetite and lipid
metabolism, weight gain, and utilization of fat stores
164. 4. PICA
• The name “Pica" comes from the Latin
word for Magpie, a bird known to eat
voraciously and eat almost anything!!
• Pica is the persistent craving and
compulsive eating of nonfood substances
like Clay, Lime, Laundry Starch, burnt coal,
etc.
• In the Diagnostic and statistical manual of
mental disorders fourth edition (DSM-IV),
PICA is described as persistent eating of
non-nutritive substances for a period of at
least 1 month which is inappropriate to the
developmental level and not part of a
culturally sanctioned practice (American
Psychiatric Association, 1994).
165. Types of Pica disorders
• Amylophagia: A compulsive consumption of purified starch
in excessive amounts. Mostly seen among pregnant women.
• Pagophagia: Consumption of excessive amounts of ice
cubes or freezer ice is known as pagophagia. This condition
is associated with iron deficiency. Common in pregnancy.
• Geophagia: An abnormal craving for earthy or soil-like
substances e.g. clay, chalk, sand, soil etc. It is common
among children and pregnant women.
LESS COMMON IN PREGNANCY
• Trichophagia: This condition is characterized by eating hair,
mostly one’s own. The long hair is first chewed without
pulling them from the scalp and then swallowed. Sometimes
the patient might also eat other people’s hair. They may even
burn the hair before eating.
166. • Xylophagia: Consumption of wood. People usually eat things
made of wood like pencil, paper, wood bark etc. This is seen
mostly among children.
• Hyalophagia: The person eats glass objects. This is usually
used as a performance technique by performers.
• Urophagia: The practice of consuming urine is called
urophagia. The reason for this might be health concerns as
urine is regarded, by some as earthy and with healing
properties.
• Mucophagia: A disorder of feeding on the mucus of the
invertebrates and fishes is called mucophagia.
• Self-cannibalism: It is the self-eating practice. Self-
cannibaliam is also called auto cannibalism or auto
sarcophagy.
• Coprophagy: An eating disorder characterized by eating feces
is called coprophagy. It is seen among animals and is
uncommon in human beings.
167. • The incidence of pica is not limited to any one
geographic area, race, sex, culture, or social status;
nor is it limited to pregnancy. It’s cause in pregnancy is
poorly understood. One theory suggests that pica
relieves nausea and vomiting.
• Pica occurs throughout the world. Geophagia is the
most common form of pica in people who live in
poverty and people who live in the tropics and in tribe-
oriented societies.
• Pica is a widespread practice in western Kenya,
Southern Africa, and India.
• Pica has been reported in Australia, Canada, Israel,
Iran, Uganda, Srilanka, Wales, Turkey, Jamaica, etc.
• In some countries, for example, Uganda, soil is
available for purchase for the purpose of ingestion.
168. Prevalence of PICA Practice among Pregnant Women in and
around Manipal, Udupi District, Karnataka
Garg, Meenakshi and Sharma , Richa (2012) Prevalence of PICA
Practice among Pregnant Women in and around Manipal, Udupi
District, Karnataka. Health and Population-Perspectives and
Issues, 33 (2). pp. 86-95. ISSN 0253-6803
ABSTRACT
This study was designed to define characteristics and factors
influencing the practice of pica. The study group consisted of
180 pregnant women who were interviewed regarding pica
practice, general information and dietary pattern. Prevalence of
Pica was found among 5% of the study subjects. The common
substances consumed were ice, raw rice, tamarind seeds and
chalk. Statistically significant association was found between
pica practice with hemoglobin levels (p<0.005) and socio
economic status (p<0.001). There is a need to routinely screen
pregnant women for pica during pregnancy. Further studies are also
needed to establish possible health consequences of pica on mother
and child.
169. ETIOLOGY
• The reason that some women develop pica cravings during
pregnancy is not known for certain. However, there are a
number of theories as to why the disorder may develop:
• Nutritional Deficiency According to the Journal of
American Dietetic Association there may be a connection
to iron deficiency. Pica may be the body’s natural
response to a nutritional depletion and may cause strange
dietary cravings. However, not every person with pica has a
nutritional deficiency.
• Cultural Factors Pica is accepted in some cultures as a
way of increasing spirituality or treating certain physical
illnesses, like morning sickness.
• Psychological Reasons Mental illness or psychological
trauma can trigger pica in some women. Pica is often a
hallmark of extreme stress, fear, or abuse.
170. • Some theories suggest that these strange cravings may
occur in women with nutrient-poor diets
– A pregnant woman who is deficient in iron, zinc, or other
nutrients may crave and eat soil, clay, ice, cornstarch,
and other non-nutritious substances like Dirt, Paint,
Plaster, Chalk, Rocks, Cigarette Ashes, Sand, Gravel,
Laundry starch, coffee grinds, rust, hair, baking soda,
glue, freezer ice, etc..
• However, the substances the woman craves do not
deliver the nutrients she needs!
– Clay and other substances can cling to the intestinal wall
and form a barrier that interferes with normal nutrient
absorption
– If the soil or clay contains environmental contaminants
such as lead or parasites, health and nutrition suffer
– Common complications: Malnutrition, Intestinal
obstruction, Intestinal infections, Anemia, Mercury
poisoning, Liver and Kidney damage, Constipation, Lead
poisoning, etc.
171. Prevalence of pica and its different types
Percentage
distribution of
different types of pica
among urban (filled
bars) and rural (open
bars) pregnant
women. (Bars
indicate ± Standard
error; n = 188, i.e.,
women practicing
pica).
• Pica practices could be influenced by genetic factors or could be a
learned behavior.
• Pica practice according to this article is not influenced by
educational background or place or residence of the individual.
• Women should be screened for pica and educated about the
potentially serious effects on the fetus and mother.
172. .
• To be diagnosed with Pica, a person must exhibit or show
signs for at least one month.
• There is no specific medical test that can confirm Pica.
• Quite often, Pica is only seen and recognized when it results
in complications that leads someone to obtain medical
attention.
• There is no specific prevention of Pica
.
• Most nutritionists believe that PICA is triggered by severe
iron deficiency but not all pregnant women with pica are
necessarily iron deficient
• Prevalence of anemia : 15% in women with pica
: 06% in women without pica
• Rate of preterm birth (<35 weeks) is twice as high in women
with pica.
173. Complications of Pica
Lead Poisoning: Eating substances that contain lead, such
as soil, clay, or paint.
Bowel Obstruction: Eating rocks, hair, and dirt can cause
the bowel to become obstructed.
(Constipation, bowel inflammation, infection, ulcerations,
perforations).
Parasitic Infection: Earthy items including clay, soil, and
grass, can be home to parasites.
(Infection in gastrointestinal tract causing pain, weight loss,
soil-borne parasitic infections, such as toxoplasmosis,
ascariasis and other side effects).
174.
175. • Dental Injury: Teeths are not made to process non-
food items. Hard substances like rocks, clay, and
ice can cause serious damage to the teeth like
tooth abrasion and surface tooth loss.
• Starch in excessive amounts can contribute to
obesity and it can be worse with diabetes mellitus.
176. Effects of Pica on Foetus
• Unfortunately, pica cravings can cause serious harm
to the foetus.
• Eating non-food items can actually prevent the body
from absorbing the proper minerals and nutrients.
• This could mean that the baby is not receiving the
proper nutrition leading to risk for a variety of
complications, such as- low birth weight, preterm
labor, and stillbirth.
177. • Treatment
• Depends on the cause and type of pica.
• Conventional medical treatment may be appropriate in
certain situations. For example, if the pregnant woman is
iron deficient, supplementation with iron has shown to
cause the unusual cravings to subside in some cases.
• Medical complications and health threats, including high
lead levels, bowel perforation or intestinal obstruction, will
require additional medical management, beyond
addressing the underlying issue of pica.
• Alternative treatment
• Because most cases of pica do not have an obvious
medical cause, treatment with counseling, education, and
nutritional management is often more successful and
more appropriate than treatment with medication.
• Some therapists specializing in eating disorders may
have expertise in treating pica.
179. • 5. Nutritional Anemia:
• To supply fetal needs, mother’s blood volume expands to 150%
of normal. But the RBCs expand only 20-30% and that too
gradually.
• Resultantly, there are fewer RBCs in a pregnant woman’s
bloodstream. The low ratio of RBC:Total Blood Volume is a
condition known as “Physiological Anemia”. This is a normal
response to Pregnancy rather than an inadequate nutrient
intake.
• A disproportionate increase in plasma volume results in hemo-
dilution (hydremia of pregnancy): Hct decreases from between
38 and 45% in healthy women to about 34% during single
pregnancy and to 30% during multifetal pregnancy. Thus during
pregnancy, anemia is defined as Hb<10g/dL (Hct < 30%).
• Despite hemodilution, O2-carrying capacity remains normal
normally increases immediately
throughout pregnancy. Hct
after birth.
180. Changes in cardiac output, plasmavolume and red blood cell (RBC) volume during pregnancy and the
puerperium (modified from Obstetric Analgesia and Anesthesia: 1980 Bonica JJ. World Federation of
Anaesthesiologists,Amsterdam.)
Blood volume - plasma volume increases by 45% while the red cell mass
increases by only 20%. This results in the physiological anaemia of pregnancy
(the haemoglobin falling from 15 g/dl to 12 g/dl at 34 weeks). The blood volume
returns to normal 10 - 14 days post partum
181. Criteria for Diagnosis of Anemia in Pregnancy
WHO definition
Severe anemia
Mild-Moderate anemia
: Hb. < 7 g/dL
: Hb. 7–11 g/dl
182. Magnitude and Prevalence of the problem
• Anaemia (defined by the World Health Organization as
haemoglobin levels of ≤ 11 g/dl ) is one of the world's
leading causes of disability, and thus one of the most
serious global public health problems / concerns.
• Anaemia is one of the most prevalent nutritional
deficiency problems affecting pregnant women.
• The prevalence of anaemia in pregnancy varies
considerably because of differences in socioeconomic
conditions, lifestyles and health-seeking behaviours
across different cultures.
• Anaemia affects nearly half of all pregnant women in the
world: 52% in developing countries compared with 23%
in the developed world.
183. • WHO ( World Health Organization) statistics in 2001
indicated a worldwide anemia prevalence of about two
billion with higher rates in developing countries.
• The WHO estimates that anemia contributed to
approximately 20% of the 515,000 maternal deaths
worldwide in 1995-2005.
• The high prevalence of iron and other micronutrient
deficiencies among women during pregnancy in
developing countries is of concern and maternal anaemia
is still a cause of considerable perinatal morbidity and
mortality.
http://apps.who.int/rhl/pregnancy_childbirth/medical/anaemia/cfcom/en/index.html
184. 57.1%
24.1%
48.2%
25.1%
44.2%
30.7%
41.8%
South-East
Asia
Europe Eastern
Mediterranean
Western
Pacific
Global
Prevalence of Anemia in Pregnant women (WHO region)
Africa
Americas
South-East Asia
Europe
Eastern Mediterranean
Western Pacific
Global
Africa Americas
Source: (de Benoist B, 2008).
41.80%
59% 57.10%
48.20%
14%
51%
65%
75%
Worldwide prevalence of anemia among pregnant women (WHO
1993-2005)
Global (1993-2005)
Global -1998
African Region
Southeast Asia
Developed
Developing
India (Urban)
India (Rural)
Source: (WHO, 1993-2005).
185.
186. CAUSES
• Increased demand during pregnancy:
During gestation, the maternal need for iron induced by
pregnancy changes. Extra iron is needed for the growth and
development of the fetus.
Hence, the requirement of iron rises from 21mg in non- pregnant
state to 35mg/day, especially in third trimester of pregnancy.
This can be met by additional supplementation of iron with
dietary iron intake and prenatal supplements.
• Poor intake of dietary iron:
Diet deficient in iron containing food.
The iron content in the diet of women in the lower
socioeconomic group is very low, these women exist on a diet
which gives them little opportunity to store iron.
Pregnant women who are vegetarian.
187. • Ignorance and Socio-demographic causes:
Poor knowledge / awareness; SES; Literacy; Poor ANC record
• Poor absorption/bioavailability:
Iron from animal sources are more easily absorbed than iron derived
from vegetable sources.
Presence of phytates, oxalates in the diet.
Increased pH of gastric juice (achlorhydria).
Ferric ions in the gut instead of ferrous form.
Lack of vitamin C in the diet.
• Excessive iron loss (Physiological / Pathological):
Repeated pregnancies, especially at short intervals with consequent
inability of the body to make up the blood losses in short periods.
Menorrhagia prior to pregnancy.
Pathological causes of hemorrage eg. Parasitic infestations
Pregnant women with morning sickness causing frequent vomiting are
more prone.
PICA ?!
188. 75
35
61
19
29
52
44
23
37
3+ ANC IFA for 90+ days Postnatal care within 2
days
Urban Rural Total
(for most recent birth in the last 5 years)
NFHS 3 (2005-06)
189. Clinical Features of Iron Deficiency Anemia
10-11g/dl: Usually Asymptomatic
8-10 g/dL: Weakness, easy fatigability, exhaustion, giddiness,
breathlessness, loss of appetite, poor work capacity…
7-8g/dL: impaired immune function, increased morbidity due to
infections..
5-7g/dL: Palpitations, tachycardia, increased cardiac output,
increased morbidity and maternal mortality due to
inability to withstand even small amount of bleeding
during pregnancy /delivery and increased risk of
infections..
<5g/dL: about 1/3rd develop severe congestive cardiac failure and
many with congestive failure succumb either during
pregnancy or during labour..
There is 8 to 10 fold increase in MMR when the Hb is <5g%
190. • Consequences of Nutritional Anaemia
• Impaired cognitive performance at all stages of life
• Significant reduction of physical work capacity & productivity
• Increased morbidity from infectious diseases
• Greater risk of death of pregnant women during the perinatal
period
• Anemic pregnant mother poorly tolerates hemorrhage with
delivery, which increases cardiac stress
• Negative foetal outcome: intrauterine growth restriction
(Decreased delivery of oxygen to the uterus, placenta and
developing fetus that causes IUGR), low birth weight infants
with high mortality risk, Those who survive have greater
rates of morbidity and poorer neurological development.
• Child with impaired brain function
• Premature births
• http://www.unicef.org/rosa/Anaemia.pdf
191. Iron deficiency anemia: Impact on pregnancy
risk of preterm labour
2.6 fold in postpartum haemorrage
3.1 fold in low birth weight
risk of inter-current infections
risk of preeclampsia (31.2%)
risk of obstetric shock (these women withstand hemorrhage
poorly)
small for gestational age (SGA) newborn
devastating effect on newborn child’s motor & intellectual
development.
192. • Daily supplement during pregnancy: 100mg elemental iron
with 0.5mg of folic acid for a minimum of 100 days (second
trimester onwards+40 days postpartum) as
Anemia Prophylaxis Program/National Iron
per National
Plus Initiative
under the National Nutrition Policy of Govt. of India
• As hook worm infestation is common, 400mg single dose
Albendazole or Mebendazole 100mg B.D. for 3days therapy is
also recommended (second trimester, after uterus palpable).
• Sources: In addition to iron supplements, include DFS, Liver,
meat, legumes, poultry, dark green leafy vegetables, broccoli,
peas, nuts, dried fruits, eggs, whole grain cereals, jaggery,
etc..
Management of Pregnancy Anemia
193. Dietary iron exist in two forms: heme iron, which is found in haemogolobin and
myoglobin, and non – heme iron, Although heme iron accounts for only 5 – 10% of
dietary iron, 25% is actively absorbed, compared to 5 % absorption of non – heme
iron. Compared to non – heme iron, heme iron is less affected by dietary
inhibitors.
194. • What affects iron absorption?
• Iron absorption refers to the amount of dietary iron that the
body obtains and uses from food. Healthy adults absorb
about 10% to 15% of dietary iron, but individual absorption is
influenced by several factors.
• Storage levels of iron have the greatest influence on iron
absorption. Iron absorption increases when body stores are
low. When iron stores are high, absorption decreases to help
protect against toxic effects of iron overload. Iron absorption is
also influenced by the type of dietary iron consumed.
• Absorption of heme iron from meat proteins is efficient.
Absorption of heme iron ranges from 15% to 35%, and is not
significantly affected by diet. In contrast, 2% to 20% of
nonheme iron in plant foods such as rice, maize, black beans,
soybeans and wheat is absorbed. Nonheme iron absorption is
significantly influenced by various food components.
