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Pregnancy
Pregnancy is a normal physiological process, “an
integrated maternal-cum-fetal system”
undergoing progressive change
In order that the growth of the product of
conception may be safeguarded even under
conditions of environment stress, change in
ordinary physiological functions is not merely
normal, but necessary
Critical periods that deverse special attention to
achieves & maintain optimum health
2
A person’s nutritional state can profoundly affect
ultimate height, age of sexual maturation, ability
to conceive & for a woman, the success of
childbearing, the length of time between
conceptions & the age of menopause
3
Perhatian khusus
Defisiensi gizi selama kehamilan dapat berefek
merugikan bagi ibu & janin
BB ibu sebelum hamil dan kenaikan selama
kehamilan sangat mempengaruhi hasil kehamilan
tsb
Studi eksperimental hewan (rat), diduga bahwa
inadekuat nutrisi maternal selama kehamilan
menyebabkan kelambatan pertumbuhan in utero &
mengganggu perkembangan otak fetal
4
Retardasi pertumbuhan intrauterin
mengiplikasikan beberapa faktor
membatasi pertumbuhan normal selama
fullterm pregnancy
5
Suplai nutrien pada pertumbuhan fetus
tergantung :
Kualitas & komposisi darah maternal sampai
plasenta
Integritas & kapabilitas plasenta untuk
memekatkan, sintesis & transpor nutrien
esensial dari maternal ke fetal
Variasi pertumbuhan intrauterin sebagai cermin
berat lahir terkait beberapa faktor termasuk
nutrisi maternal selama kelaparan akut, kelahiran
berulang (multiparitas), usia dan ukuran maternal
& perokok
6
Diet & pregnancy
If a woman remains healthy during pregnancy, give
birth to a healthy, fullterm baby, is capable of
satisfactory lactation and shows normal recovery, then
her diet, is nutritionally adequate
The effects of maternal malnutritional may be both
immediate & long term
In the most severe cases, maternal starvation or acute
under nutrition can cause a cessation of mentruation
(amenorrhea) & conception cannot occur
7
If severe malnutrition is imposed upon a previously
well-nourished woman, a reduction infant birth weigh
will result
8
Studi in animals
The nutrition deprivation (protein & calories) during
pregnancy, adversely effects cognitive, emotional &
neurologic development of the offspring
9
Nutritional Requirements During Pregnancy
Increase in weight (g) up to : (weeks)
10 20 30 40
Fetus 5 300 1500 3300
Placenta 20 170 430 650
Amnionic fluid 30 250 600 800
Uterus 135 585 810 900
Mammay glands 34 180 360 405
Maternal blood 100 600 1300 1250
No accounted 326 1915 3500 5195
for
Observed total 650 4000 8500 12500
gain
11
In early phase pregnancy, the weight increament of the
various component are minimal
At 20 weeks of gestation, most of the gain reflects
increases in maternal component
In the final phase, the predominant gain involves the
fetal compartment
At 40 weeks, approximately 1 kg of the unexplained
gain of about 5 kg may be water & the rest is assumed
to be fat. These extra fat deposits may serve to
subsidize lactation
12
If the pregnant woman is slighly overweigh (obese), weight
gain must be carefully monitored by adjusting both intake
& expenditure of energy
Underweight woman who become pregnant also
need careful nutritional guidance to achieve
satisfactory weight gain
13
It has been found :
The average weight of the baby born to a woman
who gains < 4,5 kg during pregnancy will weight
about 0,45 kg less than a baby born to a woman
gains 18,0 kg
Short women give birth to babies who are about 8%
lighter than those of all women
Underweight women give birth to babies who are
about 8% lighter than those of overweight women
Women who are both short & light give birth to
babies who are about 14% lighter than those of all &
heavy women
14
Nutritional Risk Factors
1. Before pregnancy
These factors can & do influence the course &
outcome of her pregancy as well as her ability to
handle the physical & emotional demands of
motherhood
Nutritional & health habits
15
– Kekurangan BB sbl hamil
• Cenderung melahirkan lebih cepat (prematur)
• BBLR (resiko tinggi kelangsungan hidup)
16
1.a. Adolescence/age
A pregnant woman 18 years of age or younger is
often termed a Juvenile gravida, she is at
nutritional risk by virtue of her age
Chronological age is not as important as her
reproductive biological age (chronological age
minus age of menarche)
Female with a reproductive age less than 3 years
at particular risk for reproductive problems
17
The risk of infant death is twice as high for
teenage mother as for those in their twenties
Mother age 15 & younger are twice as likely to
have LBW babies
During this time, the woman is still growing
herself & pregnancy imposes additional
nutritional demands
18
1.b. deviation in Pregravid Weight
The 2 best predictors of infant birth weight are the
maternal pregravid weight & the amount of weight
gained during gestation
Underweight (10% or more below ideal weight for
height) & overweight (20% or more above ideal
weight for height) women are at special risk during
pregnancy
Despite normal :
Weight gain, some degree of intrauterine growth
retardation is often seen in the infants of these women
19
For underweight woman, a large proportion of the
gained during gestation is diverted to correct her
own weight deficit
The obese woman requires a large provision of
calories just for her own metabolic maintenance
In both instances, less nutrients are available for
developing fetus, resulting in less than optimal
intrauterine growth
It is best to begin pregnancy within the normal
weight range
20
1.c. Obstetric & medical history
The total number of pregnancies is important,
since high parity (number of pregnancies)
carries the risk of depletion of maternal store,
especially with interconception intervals of less
than 1 year
The outcome of previous pregnancies &
complications in the infants are also important,
because many problems related to maternal
nutrition will manifest themselves in condition
of the infant
21
Withdrawal symptons may result from maternal drug
use, fetal alcohol syndrome from maternal alcoholism
Stillbirth or infants greater than 9 lb may be
related to undiagnosed or uncontrolled
maternal diabetes
Prematurity or intrauterine growth retardation
can result from poor maternal nutrition or
anemia
A history of such complications in previous
pregnancies indicates the need from preventive
measure during present pregnancy
22
The maternal course & complications may be
caused or influenced by inadequate meternal
nutrition
23
1.d. life style & habits
The excessive use alcohol, cigarettes & even
coffee (& other coffeine containing foods) has
been shown to have an adverse effect on the
growth & development of unborn child
24
2. during pregnancy
– Kenaikan BB tidak adekuat
• BB normal/kurang, kenaikan selama hamil
berhubungan langsung dengan BB bayi
• Kenaikan ≤ 1 kg/bl pada TM 2/3 BB normal &
≤ 0,5 kg obesitas perlu diselidiki
• Inadequate weight gain (<20-25 lb) & excessive
weight gain (>35 lb) have both been associated
with increased fetal & maternal complications &
taxemia with are hypertensive disease of
pregnancy
25
• Weight reduction should never be attempted
during pregnancy because of potential adverse
effects on fetal growth & development
• Morning sickness, excessive vomiting, usually
seen during early pregnancy but may continue
until delivery, is though to be related to rising
hormone level & may cause weight loss
• If the vomiting is severe enough to cause ketosis,
intravenous feedings may be necessary
26
- Kenaikan BB berlebihan
Kenaikan ≥3 kg/bulan akibat makan berlebih,
depot cairan & mungkin kehamilan menginduksi
hipertensi & kehamilan kembar
Tinggi badan (pendek < 157 cm) resiko
disproporsi fetopelvis, seksio sesar, trauma
kelahiran & kematian bayi.
Kelebihan lemak tubuh cenderung
menetap obesitas
27
RDA 1989, selama TM 2-3 konsumsi 300 kkal/hari lebih
dari sebelum hamil kenaikan BB adekuat
Protein
Total protein 60 g/hari pertumbuhan normal
janin, pembesaran uterus & payudara,
pembentukan sel darah & produksi cairan
amnion
Zat besi
Massa sel darah merah mengembang 15%
selama kehamilan perlu kenaikan substansi
Fe ibu & deposisi simpanan bayi
28
Seng
Absorpsi Zn dihambat dg masuknya Fe & asam folat
dlm jumlah besar perlu konsumsi makanan kaya Zn
(daging) setiap hari
Fitat & oksalat (buah/biji padi-an, sayur) menghambat
absorpsi Zn
Kalsium
Kebutuhan meningkat per hari pada kalsifikasi fetalis,
RDA wamil 1200 mg
Asam folat
RDA 180 ug tak hamil 400 ug pada kehamilan
produksi sel darah merah, sintesis DNA janin &
pertumbuhan plasenta
Defisiensi asam folat kelainan neural tube
29
Potensi toksin
Kafein
Efek terhadap janin tak diketahui pasti
Konsumsi berat kenaikan bayi mati, abortus
spontan & persalinan prematur
30
Alkohol
Peminum berat sindroma fetal alkohol
(mikrosefalus, kegagalan pertumbuhan sebelum
& sesudah persalinan, retardasi mental,
abnormalitas okular, celah palatum, kelainan
sendi tulang/jantung)
Peminum sedang beberapa sindroma fetal
alkohol
Tak diketahui batas aman asupan alkohol saat
hamil
31
Alkohol
Peminum berat sindroma fetal alkohol
(mikrosefalus, kegagalan pertumbuhan sebelum
& sesudah persalinan, retardasi mental,
abnormalitas okular, celah palatum, kelainan
sendi tulang/jantung)
Peminum sedang beberapa sindroma fetal
alkohol
Tak diketahui batas aman asupan alkohol saat
hamil
32
Merokok
BB Bayi lahir < non perokok
Resiko tinggi prematur, mortalitas perinatal &
kemungkinan abortus spontan
Meningkatkan kecepatan metabolisme &
kebutuhan kalori
Kenaikan BB/BB pra hamil < non perokok
Penurunan kadar zat gizi (vit c, asam folat, Zn &
Fe)
33
Penggunaan obat terlarang
Meningkatnya resiko retardasi pertumbuhan
intrauterin (IUGR) & persalinan preterm
(marihuana/ganja)
Resiko erupsio plasenta (kokain)
Abnormalitas pengetahuan & tingkah laku
menetap (crack cocaine)
34
Komplikasi kehamilan dengan implikasi
gizi
Mual muntah
Jarang berlangsung lama sering tak ganggu
status gizi
Hiperemesis gravidarum kehilangan cairan,
elektrolit & menghambat asupan seluruh gizi
lain
35
Konstipasi
Terjadi penurunan motilitas GI, karena
meningkatkan kadar progesteron
Meningkatnya tekanan pada saluran cerna, krn
membesarnya uterus & menurunnya aktivitas
fisik
36
Hipertensi yang diinduksi kehamilan
(preeklamsia/toksemia)
Ditandai hipertensi, albuminuria dan edema
yang berlebihan terutama TM-3
37
Diabetes
Wanita dengan diabetes/intoleran terhadap
glukosa atau diabetes gestasional, kebutuhan
insulin turun saat awal kehamilan, tapi naik
TM-2 & tetap tinggi sampai persalinan
Kontrol kadar gula darah yang buruk
meningkatkan jumlah malformasi kongenital &
kematian janin
Penting kontrol kadar gula sebelum hamil
cegah resiko preeklamsia & malformasi janin
38
Penatalaksanaan gizi kehamilan
1. Pendidikan & intervensi pasien
Tujuan :
Mengenal atau mengubah kebiasaan atau
temuan yang dapat mengganggu status gizi &
hasil kehamilan yang optimal
Menetapkan sasaran kenaikan BB dengan batas
yang dianjurkan & kenaikan BB sesuai harapan
Mempersiapkan mental terhadap perubahan
fisiologis yang dapat mengganggu masuknya
makanan bergizi
39
2. Memilih makanan seimbang
Wanita sehat, kebutuhan zat bergizi dipenuhi
dari makanan normal yang bervariasi (piramida
pedoman makanan), kecuali zat besi
40
A. Kilokalori
Diperlukan ekstra 300 kkal, dengan menambah
2 gelas susu setiap hari dan kenaikan jumlah
kecil makanan mengandung protein, buah atau
sayuran
Bila aktivitas turun, kebutuhan kalori turun
Wamil perlu rencana olah raga 3 -4 x seminggu,
tidak > 35 menit
Hindari denyut > 140/menit, kepanasan
41
B. Protein
Ekstra protein 1 gelas susu & 28,3 g daging per
hari
Masukan protein lebih dari dianjurkan tidak
manfaat
42
C. Mineral dan vitamin
Fe
Suplemen 30 mg(150 mg fero sulfat)/hari TM2-3
Zn
Kerang, daging merah, ayam, telur, ikan susu, keju,
polong-polongan & biji padian
Ca
Susu, buttermilk & keju
44
3. Hindari/batasi agen yang membahayakan janin
Batasi kafein (mak 300 mg/hari)
Pantang alkohol (sedikit dan sejarang mungkin)
Merokok & penggunaan obat terlarang sangat
merugikan janin
Aspartam meski tak ada efek merugikan tapi dihindari
wamil homozigot karena fenilketon urea
Sakarin tidak menunjukkan aman bagi wamil
45
Penggunaan pengukuran gizi untuk
mengatasi perasaan tak enak
1. Mual muntah
Porsi kecil & sering, lapar perburuk mual
Hindari cairan 1-2 jam sebelum/setelah makan
Makan makanan tak berlemak & terbuat dari tepung
mudah dicerna, tak iritatif
Hindari makanan berempah & pedas, makanan
berlemak (lemak menunda pengosongan lambung,
meningkatkan mual)
Kurangi kontak makanan berbau keras, merangsang
46
2. Hiperemesis gravidarum
Perlu rawat inap dengan cairan iv untuk rehidrasi
Gizi parenteral perifer (glukosa, asam amino, vitamin,
elektrolit) digunakan awal perawatan
Makanan oral dengan porsi kecil & rendah lemak,
tepung-tepungan yang mudah dicerna, ayam tanpa
kulit, daging tak berlemak
Bila parah perlu gizi parenteral secara total (Total
parenteral nutrition, TPN)
47
3. Konstipasi
Naikkan makanan berserat tinggi (bijian, polongan,
buah, sayuran segar)
Minimal 50 ml/kg/hari untuk membantu konstipasi
Olah raga teratur membantu fungsi pencernaan
48
Penggunaan pengukuran gizi untuk membantu
mengontrol hipertensi yang diinduksi oleh
kehamilan dan diabetes
Hipertensi yang diinduksi kehamilan
Batasi Natrium 2-3 g/hari
Diet rendah garam
Hindari garam & makanan asin (keripik, kue asin),
daging, ayam yang diasap/dikaleng , bumbu masak,
sayur kalengan
Buah segar, sayuran segar tanpa garam dan daging,
ikan, ayam belum diproses merupakan makanan
rendah garam
Diabetes
Pengontrolan gula darah ketat
49
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