This document discusses nutrition recommendations during pregnancy. It covers recommended weight gain, dietary allowances, macronutrients including protein, carbohydrates, fat and seafood guidelines. It also discusses micronutrients including vitamin and mineral needs such as folate, iron, iodine and cautions around excess vitamin A intake. Habits around caffeine, pica and alcohol are also covered. The document is authored by Prof. Aboubakr Elnashar from Benha University Hospital in Egypt.

1. NUTRITION DURING
PREGNANCY
Prof. Aboubakr
Elnashar
Benha university hospital,
Egypt
ABOUBAKR ELNASHAR

2. CONTENTS
1.WEIGHT GAIN DURING PREGNANCY
2.RECOMMENDED DIATERY ALLOWANCE
3.MACRO NUTRIENTS
4.MICRO NUTRIENTS
5.Habits
1.Caffeine
2.Pica
3.ptaylism
ABOUBAKR ELNASHAR

3. 1. WEIGHT GAIN RECOMMENDATIONS
 The new guidelines
 relatively narrow range of recommended weight
gains for obese women.
 Obesity
 gestational hypertension
 Preeclampsia
 gestational diabetes,
 macrosomia,
 cesarean delivery
 The risk
 dose related" to prenatal weight gain.
ABOUBAKR ELNASHAR

4. ABOUBAKR ELNASHAR

5.  100,000 women with normal prepregnancy BMI,
 WG<11.5kg: lower risk for
 preeclampsia,
 failed induction,
 cephalopelvic disproportion,
 cesarean delivery
 large-for-gestational age neonates.
 This cohort, however, had an increased risk for small for- gestational
age newborns.
(De Vader et al, 2007)
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6.  Maternal weight gain during pregnancy
positively correlated with birth weight
 WG
 12 kg: 60% of women
 <7kg: 14%:
 Increased risk of Birth wt < 2500 g
 20% of births to women with such low weight gains were
preterm.
(Martin et al,2009)
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7.  Lifestyle intervention during pregnancy
 can result in less wt gain
(Sagedal, 2017) .
 Weight loss in obese women during pregnancy
 an increased risk for low-birth weight neonates
(Cox Bauer, 2016) .
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8. 2. Recommended Dietary Allowances(RDA)
Amount of nutrients/d needed
for maintenance of good health
recommended by the Food and Nutrition Board of the National Research Council.
Excessive supplements during pregnancy.
Potentially toxic :
Iron, zinc, selenium
vit A, B6, C, and D.
Teratogenic:
Excessive vit A≥10,000 IU/d
Vit and mineral intake more than twice RDA
should be avoided
(American Academy of Pediatrics and ACOG, 2007)
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9. ABOUBAKR ELNASHAR

10. 3. MACRO NUTRIENTS
 Energy
 I trimester:
69 kcal/d, No additional input I trimester
 II trimester
266–360 kcal/d,340 kcal/d II trimester
 III trimester
 437–496 kcal/d, 452 kcal/d III trimester
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11.  Protein
 Meats, poultry, seafood,
eggs, dairy products,
beans, lentils, nuts, and seeds
 10–35% of energy
 RDA 1.1 g/kg/d (~71 g/d)
 This should be doubled in late gestation
(Stephens, 2015) .
 Additional 1 g/d I trimester
8 g/d II trimester
26 g/d III trimester
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12.  Carbohydrates
 Whole grains, non starchy vegetables
fruits, beans, peas,
lentils, low-fat dairy products
 45–65% of energy
 175 g/d
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13.  Fat
 No Recommended Daily Intake(DRI)
 Suggest 25%–35% of total calories
 Emphasize
omega-3 (n-3) polyunsaturated fatty acids (PUFAs)
 Limit animal fat and saturated fat
 Avoid trans-fat
 High-fat diets: increase insulin resistance.
 A high saturated fat intake: glucose abnormalities
in pregnancy and an increased risk of GDM.
 Higher intakes of animal fat and cholesterol before
pregnancy: an increased risk of GDM
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14.  Docosahexaenoic acid (DHA) and n-3 fatty acids
are needed for brain and retinal development
throughout the third trimester of gestation and the
first year of life.
 The fetus needs 200 to 300 mg/d of DHA and 500
mg of DHA plus eicosapentaenoic acid (EPA) per
day.
 Good sources of n-3 fatty acids include
 fatty fish and
 seafood (recommendation of 12 oz/w),
 walnuts, and
 dietary supplements.
ABOUBAKR ELNASHAR

15.  Seafood Consumption
 Fish
 an excellent source of protein
 low in saturated fats
 contain omega-3 fatty acids.
 Beneficial effects on pregnancy outcomes in
women who consumed 340 g or more of seafood
weekly (Hibbeln, 2007) .
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16.  Because nearly all fish and shellfish contain trace
amounts of mercury,
 pregnant and lactating women are advised to
avoid specific types of fish with potentially high
methylmercury levels.
 Shark
 Swordfish
 king mackerel
 tile fish. ‫القرامٌد‬
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17.  Pregnant women ingest 8 to 12 ounces of fish weekly,
but no more than 6 ounces of albacore or "white" tuna
(U. S Environmental Protection Agency, 2014)‫الباكور‬ ‫تونه‬
 If the mercury content of locally caught fish is
unknown, then overall fish consumption should be
limited to 6 ounces per week
(ACOG, 20 1 7) .
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18.  Fibre
28 g/d
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19. ABOUBAKR ELNASHAR

20. 4. MICO NUITRIENTS
VITAMINS
 During pregnancy
 The increased requirements for most vitamins
 usually are supplied by any genera diet that
provides adequate calories and protein.
 The exception is folic acid during times of unusual
requirements, such as pregnancy complicated by
protracted vomiting, hemolytic anemia, or multiple
fetuses.
ABOUBAKR ELNASHAR

21.  In poor countries:
 Routine multivitamin supplementation
 reduced the incidence of
 low-birth weight
 growth-restricted fetuses
 did not alter
 preterm delivery or
 perinatal mortality rates
(Fawzi, 2007) .
ABOUBAKR ELNASHAR

22. 1. Folate
 Beans, peas, orange juice,
green leafy vegetables
 RDA 600 mcg/d
 Supplémentation
 0.4 mg/d
 start 3months before pregnancy
ABOUBAKR ELNASHAR

23. 2. Vitamin D
 Fatty fish, egg yolks,
fortified milk, margarine,
yogurt, orange juice
 RDA
 15 mcg (600 IU)/d, at least 600 IU/d
 1500–2000 IU/d to maintain the level above 30
ng/ml
 Supplementation:
 None additional supplementation in general
 in risk groups 2000 IU/d
 may supplement up to 1000–2000 IU/d
ABOUBAKR ELNASHAR

24.  Vitamin D deficiency
 common during pregnancy.
 especially in high-risk groups such
 limited sun exposure,
 vegetarians, and
 ethnic minorities particularly those with darker
skin
(Bodnar, 2007) .
 serum levels of 25-hydroxyvitamin D can be obtained.
 In women suspected of having vitamin D deficiency,
ABOUBAKR ELNASHAR

25. 3. Vitamin A
 Sources:
 plant: Sweet potatoes, carrots, dark leafy
greens
Beta-carotene, the precursor of vitamin A found
in fruits and vegetables, has not been shown to
produce vitamin A toxicity.
 Animal: liver
 RDA:
Pregnant: 750 ug/d
Lactating: 1300 ug/d
 No significant effects of supplementation in US
population
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26.  Toxicity:
10,000 IU/d: congenital malformations
(RCOG, 2011)
similar to those produced by vit A derivative isotretinoin (Accutane)
Most prenatal vit
contain vit A in doses considerably below the
teratogenic threshold.
 Avoid:
1. Supplements containing pre-formed vit A
(RCOG, 2011)
2. Eating liver and liver products
{contain high levels of vit A}.
e.g. cod liver oil
(NICE, 2008).
3. Overdosing
(Hovdenak , Haram, 2012)
ABOUBAKR ELNASHAR

27. ‫الكبدة‬ ‫من‬ ‫واحدة‬ ‫وجبة‬(ً‫حوال‬١٢٠)‫إلى‬ ‫ٌصل‬ ‫ما‬ ‫على‬ ‫تحتوي‬ ‫قد‬٢٠،٠٠٠
‫فٌتامٌن‬ ‫من‬ ‫دولٌة‬ ‫وحدة‬(‫أ‬)
‫خطٌرة‬ ‫مشاكل‬ ‫اي‬ ‫ألحداث‬ ‫كافٌة‬ ‫غٌر‬ ‫تزال‬ ‫ال‬ ‫الجرعة‬ ‫تلك‬ ‫لكن‬ ‫و‬.
‫الغنٌة‬ ‫األطعمة‬ ‫أو‬ ‫الكبدة‬ ‫من‬ ‫كبٌرة‬ ‫كمٌات‬ ‫تناول‬ ‫عند‬ ‫فقط‬ ‫تحدث‬ ‫الخلقٌة‬ ‫العٌوب‬
‫بفٌتامٌن‬(‫أ‬)‫من‬ ‫اكبر‬ ‫بكمٌات‬٢٥،٠٠٠‫وحدة‬/‫أشهر‬ ‫مدى‬ ‫على‬ ً‫ا‬ٌ‫ٌوم‬
‫من‬ ‫منخفضة‬ ‫جرعات‬ ‫ٌتناولن‬ ً‫الالت‬ ‫الحوامل‬ ‫السٌدات‬ ‫لدي‬ ً‫ا‬‫جد‬ ‫ضعٌف‬ ‫الخلقٌة‬ ‫العٌوب‬ ‫حدوث‬ ‫مخاطر‬
‫فٌتامٌن‬(‫أ‬)‫من‬ ‫أقل‬٢٥،٠٠٠ً‫ا‬‫ٌوم‬ ‫وحدة‬
‫المزمن‬ ‫التسمم‬ ‫تسبب‬ ‫ال‬ ‫االسبوع‬ ً‫ف‬ ‫واحدة‬ ‫مرة‬ ‫الكبدة‬ ‫من‬ ‫معتدلة‬ ‫كمٌات‬ ‫تناول‬
‫الخلقٌة‬ ‫العٌوب‬ ‫أو‬.
‫بٌن‬ ‫العالمٌه‬ ‫الصحٌه‬ ‫المنظمات‬ ‫بٌن‬ ‫االراء‬ ‫انقسمت‬
‫او‬ ‫التام‬ ‫الكبده‬ ‫اكل‬ ‫منع‬
‫تناولها‬ ‫تقلٌل‬(‫الن‬ ‫نتبعه‬ ‫الذي‬ ‫و‬ ‫للصواب‬ ‫االقرب‬ ‫و‬ ‫السائد‬ ‫الرأي‬ ‫هو‬ ‫و‬
‫مطلقا‬ ‫الخطوره‬ ‫معاٌٌر‬ ‫تتجاوز‬ ‫لن‬ ‫منها‬ ‫اكلت‬ ‫مهما‬ ‫السٌده‬)
ABOUBAKR ELNASHAR

28. 4. Vitamin B6
 Fish, beef liver, potatoes,
other starchy vegetables, fruit
 No clear evidence of effects for supplementation in
US population
ABOUBAKR ELNASHAR

29. 5. Vitamin B12
 Fish, meat, poultry, eggs, milk, and dairy products;
vegetarians and vegans need supplements
 No clear evidence of effects for supplementation in
US population
ABOUBAKR ELNASHAR

30. 6. Vitamin C
 Citrus fruit, cantaloupe, kiwi fruit,
 mango, papaya, pineapple, strawberries,
blueberries
 500 mg/d prevents wheezing/asthma in children of
smokers
ABOUBAKR ELNASHAR

31. 7. Vitamin E
 Sunflower seeds, almonds, wheat germ oil,
sunflower oil
 No clear evidence of effects for supplementation in
US population
 Multivitamin supplements
Folate 0.8–1.0 mg/d. Iodine 200 μg/d
ABOUBAKR ELNASHAR

32. MINERALS
With the exception of iron and iodine, practically all diets
that supply sufficient calories for appropriate weight gain
will contain enough minerals to prevent deficiency
1. Iron
 cookware, clams, sunflower seeds,
nuts, whole grains,
dark leafy greens, tofu
 Supplementation 30–60 mg/d
 RDA 27 mg/day
PoorMediumRich
milk and its
products, root
vegetables
meat, chicken,
fish, spinach,
banana, apple
liver, egg yolk, dry
beans, dry fruits,
wheat germ, yeast ABOUBAKR ELNASHAR

33.  The pregnant woman may benefit from 60 to 100 mg
of elemental iron per day if
 she is large
 multifetal gestation
 begins supplementation late in pregnancy,
 takes iron irregularly, or
 has a somewhat depressed hemoglobin level.
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34. 2. Iodine
 Iodized salt, seafood, seaweed, kelp,
dairy products
(1/2 tsp salt = ~74 μg iodine)
 RDA 220 ug/d
250 μg/d (WHO)
 Supplementation
 100–150 ug/d
 200 ug/d
 Unlike most essential dietary nutrients, is not linked so
much to socio-economic development but more to
geography. In parts of China and Africa where this
condition is common, iodide supplementation very early
in pregnancy prevents some cretinism cases
 (Cao, 1994) .
 None additional supplementationABOUBAKR ELNASHAR

35. 3. Calcium
 Milk, yogurt, cheese, fortified juices,
tofu, cereals, Chinese cabbage,
broccoli, fish with bones
 RDA 1.0–1.3 g/d
 Supplementation 1.5–2 g/d in risk population (low
calcium intake)
 1–2 g/d lowers risk of preeclampsia and
hypertensive disease
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36. 4. Zinc
 RDA: 12 mg.
 Vegetarians have lower
zinc intakes
(Foster, 2015) .
 supplementation
 zinc-deficient women
in poor-resource
countries
(Nossier, 2015 ; Ota, 2015)
 women with poor GIT
function
.
ABOUBAKR ELNASHAR

37. 5. HABITS
1. Caffeine
 heavy intake
 5 cups or 500 mg/d of cafeine
 slightly raises the miscarriage risk.
 moderate" intake-
 less than 200 mg daily
 did not find a higher risk.
 no association between moderate cafeine consumption of less
than 500 mg/d and low birth weight, fetalgrowth restriction, or
preterm delivery.
(Clausson et al, 2002)
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38.  3 cups of cofee per day to cafeinated vs decafeinated
cofee.
 no diference in birth weight or gestational age at
delivery between groups.
(Bech et al, 2007)
 > 200 mg/d compared with those who consumed <
100 mg/d.
 l.4-fold risk for fetal-growth restriction
(The CARE Study Group, 2008)
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39.  Moderate consumption of caffeine- less than 200
mg/d
 does not appear to be associated with miscarriage
or preterm birth, but that the relationship between
cafeine consumption and fetal-growth restriction
remains unsettled.
(ACOG, 2016)
ABOUBAKR ELNASHAR

40. 2. Pica
 The craving of pregnant women for strange foods
 Prevalence: 30%
(Fawcett, 2016) .
 Nonfoods
 ice-pagophagia,
 starch-amylophagia, or
 clay-geophagia .
 ±triggered by severe iron deficiency.
ABOUBAKR ELNASHAR

41.  3000 women during the second trimester.
 The prevalence of pica was 4%
 The most common nonfood items ingested were
starch in 64%, dirt in 14%, sourdough in 9%, and
ice in 5%.
 The prevalence of anemia:15% compared with 6
percent in those without it.
 preterm birth was twice as high
(Patel et al, 2004)
ABOUBAKR ELNASHAR

42. 3. Ptyalism
 profuse salivation
 usually unexplained,
 sometimes appears to follow salivary gland
stimulation by the ingestion of starch.
ABOUBAKR ELNASHAR

43. ABOUBAKR ELNASHAR
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