Lesson 1: Nutrition During Pregnancy

The module presents the roles of nutrition in fostering proper fetal growth,
development and long-term health; it discusses the physiology of the
different stages of pregnancy and the nutrient requirements at each stage.
The discussion covers common problems during pregnancy with nutritional
measures to address them.
Learning objectives:
1. Describe the physiological changes/adjustments during pregnancy
2. Discuss the nutritional requirements during pregnancy as basis for
meal planning.
3. Discuss the nutritional concerns/problems during pregnancy and
measures to address them.
Topics
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Physiology of pregnancy
Characteristics of Pregnant woman
Recommended Energy and Nutrient Requirement
Food Guide Pyramid
Monitoring weight
Nutritional Concerns
Myths and Facts

Definition of Terms
1. edema - the build-up of excess fluid in extracellular spaces
2. hemodilution - "physiological anemia of pregnancy" resulting from
increased blood volume
3. heartburn - a pain emanating from the esophagus as a result of
stomach acid backward flow into the esophagus causing irritation of
the esophageal lining
4. glomerular filtration rate - measure of the amount of blood filtered
by the cup-like glomerulus at the head of each kidney nephron, per
unit of time.
5. insulin resistance - a condition in which cells "resist" the action of
insulin in facilitating the passage of glucose into cells.
6. basal metabolic rate - the rate at which the body uses energy to
support all the involuntary activities that are necessary to sustain life
like circulation, respiration, etc. Basal metabolism is the largest
component of the average person's daily energy expenditure.

7. tidal volume - amount of gases, oxygen, and carbon dioxide passing

into and out of the lungs in each respiratory cycle.
8. hyperemesis gravidarium - excessive vomiting
9. gestation - the time of fetal growth from conception to birth
10. vasodilation - Widening of blood vessels resulting from relaxation of
the muscular wall of the vessels
11. peristalsis - a wave-like progression of alternate contraction and
relaxation of the muscle fibers of the gastrointestinal tract.

Introduction
Pregnancy is the period during which the fertilized ovum implants itself in
the uterus, undergoes differentiation, and grows until it can support extrauterine life. It lasts for 266-280 days or 37-40 weeks. The three stages of
pregnancy are:
. Implantation- the first two weeks of gestation when the fertilized ovum
becomes imbedded in the wall of the uterus and the placenta develops
. Organogenesis- the next six weeks of pregnancy where vital organs
develop or undergoes differentiation.
. Growth- the remaining 7 months of pregnancy, characterized by rapid cell
division and development
Characteristics
Pregnancy is accompanied by anatomic and physiologic changes that affect
almost every function of the body. Most of these changes occur in the early
weeks of pregnancy.
1. Blood volume and composition
Plasma volume increase to about 50% greater than it was at conception by
34 weeks of gestation. Red cell production is stimulated and thereby
increases during pregnancy. Since the increase in red cell volume is
proportionately less than the increase in plasma volume, the concentration
of red cells in the blood as well as the hemoglobin declines. This is referred
to as "hemodilution" or "physiological anemia of pregnancy".
2. Changes in the Cardiovascular system
During the first half of pregnancy, there is a decrease in both systolic and
diastolic pressure by 5-10 mm Hg. The decrease is probably the result of
peripheral vasodilation brought about by hormonal changes during
pregnancy.

3. Respiratory changes
Maternal oxygen requirements increase in response to the acceleration in
metabolic rate and the need to add to the tissue mass in the uterus and
breast. The pregnant woman breathes deeper (greater tidal volume) but
increases the respiratory rate only slightly.
4. Gastrointestinal function
There are changes in the functioning of the gastrointestinal tract which result
to an increase in appetite, occurrence of nausea and vomiting, diminished
gastro-intestinal motility, reduced intestinal secretion, altered sense of taste
and enhanced absorption of nutrients.
Increased progesterone production causes decreased tone and motility of
the stomach muscles. This leads to esophageal regurgitation, decreased
emptying of the stomach, and reverse peristalsis. As a result, the pregnant
woman may experience heartburn. The decreased smooth muscle tone also
results in an increase in water absorption from the colon and constipation
may result.
5. Hormonal Changes
Progesterone and estrogen are two hormones that have major effects on
maternal physiology during pregnancy. The chief action of progesterone is to
cause a relaxation of the smooth muscles of the uterus, so it can expand as
the fetus grows. The secretion of estrogen is slower than that of
progesterone during the early months of pregnancy. Its role is to promote
the growth and control the function of the uterus. Because of estrogen,
many pregnant women complain of excess fluid retention in the skin, or
edema.
6. Metabolic adjustments
The metabolic rate usually rises by the fourth month of gestation, although
small increments may occur before that time. The elevation in BMR reflects
increased oxygen demands of the uterine-placental fetal unit as well as
oxygen consumption from increased maternal cardiac work.

Table 1. Recommended energy and nutrient intake of pregnant

women.
NUTRIENT
Energy (kcal)
Protein (g)
Vit A (ug RE)
Vit C (mg)
Thiamin (mg)
Riboflavin (mg)
Niacin (mg NE)
Folate (ug)
Calcium (mg)
Iron (mg)
Iodine (mg)

NON-PREGNANT 1ST TRI MESTER

1860
58
66
500
800
70
80
1.1
1.4
1.1
1.7
14
18
400
600
750
800
27
27
150
200

2ND 3RD
+300 +300
66 66
800 800
80 80
1.4 1.4
1.7 1.7
18 18
600 600
800 800
34 38
200 200

During pregnancy, additional 300 calories is required at the beginning of the

second trimester to support increased basal metabolism. Nutrients like
protein, Vitamin A, Vitamin C, niacin, folate, iron and iodine are increased.
Requirements for other nutrients do not change very much.
Knowing the nutrient requirements during pregnancy is important to prevent
deficiencies. According to the 6th National Nutrition Survey (2003), 28 in
every 100 pregnant women are considered nutritionally-at-risk. Between
2003 and 2005, there was 1.8 points increase in the proportion of
nutritionally at-risk pregnant women from 26.6 to 28.4.
The prevalence of anemia among pregnant women is 43.9% or four out of
10, while the prevalence of vitamin A deficiency (VAD) is 17.5% which
remains a significant public health problem. The median urinary iodine
excretion (UIE) among pregnant women is 142 ug/L indicating adequate
iodine intake and an optimal iodine nutrition.
Recommended Food Allowances for pregnant women
Food Groups
Recommended amount and food item *
Rice and Equivalents 5 -6 cups, cooked
1 cup rice cooked = 4 pieces Pandesal (about 17 g each); or
=4 slices loaf bread; or
=1 pack or 30 g instant noodles; or
=1 cup cooked macaroni or spaghetti; or
=1 small size root crop(e.g. kamote); 180 g
or 1 cup cooked, diced at least 3x/week

Meat and Alternatives Fish/meat/poultry/dried beans/nuts at least 3 servings:

1 serving cooked meat= 30 g or about 3cm cube;
=Fish- 2 pcs, med size (55-60 g each), about 16 cm long; or
=1 cup cooked dried beans/nuts preferably taken 3x/week;
or
=Egg, 1 pc, (taken 3-4x per week); or
=Milk 1 glass whole (240 mL)
Vegetables
Green, leafy and yellow cup cooked;
Other vegetables, 1 cup cooked
Fruits
Vit-C rich- 1 medium size fruit or 1 slice big fruit
Fats and Oils
7 teaspoons
Sugar
6 teaspoons
Water and Beverages 6-8 glasses (240 mL)
*The above allowances are based on a 2,160 kcalorie requirement of pregnant women during the
second and third trimester

Pregnancy weight gain

Weight gain during pregnancy is an important consideration because the
newborn's weight and health status tend to increase as the mother's weight
increases. The recommended weight gains for women throughout the entire
pregnancy can be monitored using a reference table for pregnant women.
The total weight gain of a normal pregnant woman should be between 11-12
kilos. The components of maternal weight gain are as follows:
Tissue
Fetus
Placenta
Amniotic Fluid
Uterus
Breast tissue
Increase in blood volume
Extracellular fluids
Fat
TOTAL

Weight (kg)
3.0-3.3
.65
.8
.9
.4
1.2
.9-1.4
.5-2.5
11-12 kg

(insert reference table for pregnant women)

"If a woman is malnourished during pregnancy, the child's physical and
mental growth and development may be slowed. This cannot be made up
when the child is older - it will affect the child for the rest of his or her life."
- Facts for Life 2002

1. Common Health Problems during Pregnancy

Common ailments during pregnancy are better prevented than treated and
often can be relieved through dietary measures.
a. Nausea and vomiting are experienced during the first trimester and
suddenly disappear as pregnancy progresses. These are usually experienced
in the morning, thus, the term "morning sickness". The conditions are so
common that these are considered a normal part of pregnancy. The cause of
nausea and vomiting is not yet clear, but these are thought to be related to
increased levels of gonadotropin, progesterone, estrogen or other hormones
during the early part of pregnancy.
Management:
- small frequent feedings
- low fat foods
- liquids in between meals
b. Hyperemesis Gravidarum is characterized by severe nausea and
vomiting that last throughout pregnancy. In addition to the mother feeling
very sick, frequent vomiting can lead to weight loss, electrolyte imbalances
and dehydration.
Management:
- small frequent feedings
- low fat foods
- liquids in between meals
- may require rehydration therapy to restore fluids and electrolyte balance.
c. Heartburn
Pregnancy is accompanied by relaxation of gastrointestinal tract muscles.
This effect is attributed primarily to progesterone. Relaxation of the muscular
valve known as the cardiac or lower esophageal sphincter at the top of the
stomach is thought to be the principal reason for the incidence of heartburn
in women. The relaxed upper valve may allow stomach contents to be
pushed back into the esophagus
Management:
-small frequent feedings
-do not go to bed with full stomach
d. Constipation
Relaxed gastrointestinal muscle tone is thought to be responsible for the
increased incidence of constipation and hemorrhoids in pregnancy.

Management:
-high fiber foods
-drink plenty of water
e. Rapid weight gain or loss
Weight gain of 3 kg or more per month. This may be brought about by the
belief that a pregnant women is eating for two. On the other hand, failure to
gain weight of 1 kg every month during the first trimester is also a "risk
factor". The ideal total weight gain for the three trimesters is 24 lbs
Management:
-moderate calorie restriction for overweight
-increase consumption of nutrient-dense foods
f. Toxemia
Pregnancy-induced hypertension. It maybe a cause of maternal death, prenatal death and low birth weight infants
Symptoms:
-Rapid weight gain
-edema
-high blood pressure
-excretion of albumin in the urine
Management
-optimum nutrition
-protein foods of high biologic value
-adequate iron, calcium intake
g. Anemia
Lack of iron-rich foods; impairment in absorption and utilization of Fe as well
as vitamin B12 and folic acid
Management:
-increase intake of iron-rich foods like liver, green vegetables
-iron and folic acid supplementation
h. Gestational diabetes
An elevation of blood sugar (glucose) levels that occur during pregnancy but
returns to normal after delivery. The cause of gestational diabetes is not
known. But the condition is linked to the hormones from the placenta that
help the baby develop. These hormones also block the action of the mother's
insulin in her body. Glucose builds up in the blood to high levels. This
condition can be managed by eating a balanced diet, i.e. selecting foods that
do not elevate blood sugar levels very much.

i. Iodine deficiency disorder - results when there is lack of iodine intake

of the pregnant mother. It brings about devastating effects on the baby's
developing brain and also on physical growth. In the worst cases of severe
iodine deficiency, a child may be born with cretinism, a condition
characterized by severe mental retardation, growth stunting, apathy, and
impaired movement, speech or hearing.
Pregnant women are advised to use iodized salt in their diet and eat iodinerich foods like seafood and seaweeds.
Beliefs during Pregnancy
There are women who change their diets during pregnancy because of
certain cultural or folk beliefs. Some women avoid animal foods in order to
avoid excessive weight gain. Others believed that a mother can mark her
child before birth by eating specific foods. For instance, if a mother wants
her child to be white skinned, she will eat foods that are white in color and
avoid dark colored foods.
Others believes that unsatiated cravings could result to birthmarks that look
like the shape of the desired food. Caution should be exercised in assessing
the implication of these practices. The over-all picture of the mother's diet
should be considered also.
Pica during Pregnancy
Pica is the compulsion for persistent ingestion of unsuitable substances
having little or no nutritional value. Pica during pregnancy often involves
consumption of dirt or clay or starch.
The medical implications of pica are not well understood, although several
speculations have been made. The displacement effect of pica substances
could result in reduced intake of nutritious foods, leading to inadequate
dietary intakes of essential nutrients. Some, pica substances may contain
toxic compounds or quantities of nutrients not tolerated in disease states.
Some pica interfere with the absorption of certain mineral elements, such as
iron.
Conclusion
Maternal nutrition influences fetal growth. Likewise, physiologic changes
during pregnancy impact on the maternal diet and nutritional needs. Among
the factors affecting fetal growth and development, nutritional status stands
out.

Key Words
Implantation Organogenesis Growth Hormonal changes Pica