Perubahan Selama Kehamilan Dan AKG Kehamilan
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Transcript of Perubahan Selama Kehamilan Dan AKG Kehamilan
NUTRITION DURINGPREGNANCY
PREGNANCY
FIRST,
THEN,
AND THEN
OBJECTIVESNutrition for Pregnancy
To produce, healthy, normal weight infants while minimizing health risks to the mother.
To determine appropriate weight gain during pregnancy for normal, under and overweight women.
To recognize the additional energy, vitamin and mineral requirements for women during pregnancy.
To understand changing nutritional needs during pregnancy
PERUBAHAN PADA TUBUH APA YANG TERJADI PADA SAAT HAMIL Nesting instinct Sulit konsentrasi Perubahan mood Ukuran BH meningkat Kulit mengalami perubahan Rambut dan kuku berubah tekstur Ukuran sepatu berubah Mobilitas persendian lebih longgarPeningkatan
hormon relaxin memang diperlukan oleh ibu hamil untuk elastisitas serviks.
Pembesaran pembuluh darah, ambeien dan konstipasi
Gusi berdarah
OVERVIEW
Masalah-masalah Kehamilan
INCREASED NUTRITIONAL RISK
Pregnant women who are:• Drug or alcohol abusers• Vegetarians• Smokers• Anorexic or bulimic, underweight, or obese
Pregnant women with:• Hyperemesis • Poor weight gain or weight loss • Dehydration, constipation• Pre-existing medical conditions
OBSTETRICAL HISTORY
Past medical history (wt gained in pregnancy)
Current dietary intake patterns and ETOH Vitamin, mineral and herbal intake PICA: dirt, starch, clay, ice, detergent Caffeine and other fluids Nausea, vomiting, and heartburn Constipation
OBSTETRICAL PHYSICAL EXAM
Low pre-pregnancy weight and low maternal weight gain are risk factors for: Intrauterine growth retardationLow birth weight baby Increased incidence of perinatal death
Need to asses:Pre-pregnancy weight (BMI)Current weight (BMI)Weight gain from previous visit
NAUSEA AND VOMITING Associated with increased levels of
HCG (Chronionic Gonadotropin)asal dari plasenta Peaks at 12 weeks gestation
Strategies for managing morning sickness: Eat small, low-fat meals and snacks Drink fluids between meals, avoid caffeine Reduce citrus, spearmint, peppermint Limit spicy and high-fat foods Avoid lying down after eating or drinking Take a walk after meals Wear loose-fitting clothes
CONSTIPATION Constipation during pregnancy is associated
with: increased progesterone levels and smooth-
muscle relaxation of the GI tract.
This results in GI discomfort, a bloated sensation, increased hemorrhoids, and decreased appetite.
Increase fluid and fiber intake to reduce constipation.
FAKTOR-FAKTOR YANG MEMPENGARUHI GIZI IBU HAMIL
Kebiasaan dan oandangan wanita terhadap makanan
Status ekonomi Pengetahuan zat gizi dalam makanan Status kesehatan Aktifitas Suhu lingkungan Berat badan Umur
GENERAL OVERVIEW OF NINE MONTHS OF PREGNANCYFrom Conception to Birth
THE FIRST TRIMESTER
Lasts from conception to the twelfth week of pregnancy
3 periods during the first trimester: The Germinal Period
Fertilized egg travels and implants in wall of uterus Implantation occurs 10-14 days after conception
The Period of the Embryo Lasts from third through eighth week of pregnancy Major organs and anatomical structures begin to form
The Period of the Fetus Lasts from ninth week of pregnancy until birth All major organs continue rapid growth and become
interconnected
THE SECOND TRIMESTER
Fetus assumes distinct human appearance The nails harden and skin thickens, as well as
the eye lashes, eye brows, and scalp hair appear during fifth and sixth months
Fetus’s visual and auditory senses are functional
THE THIRD TRIMESTER
All organ systems mature rapidly Fetus prepares for birth Fetus reaches ‘age of viability’, the
point at which the fetus can survive outside of the uterus
Fetus shows better-organized gross motor activity, and sleepiness/ waking activity
Towards end of ninth month, fetus is positioned head-down with limbs curled up in ‘fetal position’
TERATOGENS
External agents such as viruses, drugs, chemicals and radiation that can harm a developing embryo or fetus.
Time when organ system or body part is at highest risk of effects from teratogens is known as ‘sensitive period’.
Effects of teratogens on a body part or organ system are worst during the period when that structure is forming and growing most rapidly.
TERATOGENS The same defect can be caused by
different teratogens. A variety of defects can be caused by
a single teratogen. The longer the exposure or the higher
the ‘dose’ of the teratogen, the more likely it is that serious harm will be done.
The long-term effects of a teratogen often depend on the quality of the postnatal environment.
RECOMMENDED WEIGHT GAIN
>0,26.8Obese BMI > 30.0
0,36.8-11.4Overweight BMI 25-29.9
0,411.4-15.9Normal Weight BMI 19-24.9
0.512.7-18.2Underweight BMI < 18.5
Weight Gain 2nd&3rd trimester (kg/week)
Weight Gain (kg)BMI Weight (kg) Height (m2)
Institute of Medicine. Weight Gain During Pregnancy. National Academy Press. 1999.
Twin 15.9-20.4 0,7
RATE OF WEIGHT GAIN
Pattern of weight gain in pregnancy as important as total weight gain.
Deviations from expected patterns of weight gain are signals for intervention.
Pre-term birth doubles when 3rd trimester weight gain is low or inadequate.
Pregnancy is an anabolic state, resulting in increased energy (300 kcal/day) utk wanita umur 25-50
thn dgn kebutuhan energi 2000kkal/hari and nutrient needs.
PROPORSI PERTAMBAHAN BB KEHAMILAN
Janin 25-27% Plasenta 5% Cairan amnion 6% Ekspansi volume darah 10% Peningkatan lemak tubuh 25-27% Pertambahan uterus dan payudara 11%
NUTRITIONAL NEEDS DURING PREGNANCY Energy:
First Trimester - no change—indo +180 kkal/hari Second Trimester - increases 340 –indonesia +300
kcal/daypertambahan darah, perkembangan uterus, pertumbuhan jaringan mamae dan penimbunan lemak
Third Trimester - increases 450 –indo +300kcal/daypertumbuhan janin dan plasenta
Karbohidrat 40 g glukosa/hari≈60% dari total energi atau 1500 kal karbo
Protein dan asam amino: Total Increases 68% atau +17 gr/hari menjadi 60-76 gr
protein per hari
Total protein yg dibutuhkan fetal selama
masa gestasi: 350-450 g
Timester pertama sampai kedua: < 6g/hari
Pada usia 20 minggu fetus mulai menerima
asam amino esensial dari ibu, namun asam
amino non esensial (arginin dan kristin) tidak
dapat disintesis oleh fetus
Trimester akhir: 10 g/hari
KEBUTUHAN PROTEIN UNTUK FETUS
LEMAK
Tidak lebih dari 25% dari seluruh kalori yang
dikonsumsi sehari menjaga BB ideal agar
tidak menyulitkan persalinan
Lemak yang dikonsumsi sebaiknya
mengandung asam lemak esensial (Omega
3/asam lemak linolenat dan Omega 6/asam
lemak linoleat)
Omega 6 otak janin dan jaringan lain.
Sumber: biji2an
Rasio omega 6:omega 3= 4:1
OMEGA-3 FATTY ACIDS
Reduces the incidence of heart disease and heart related death of the infant
Recommended 300 milligrams per day Turunan omega 3: EPA dan DHA Important for
brain development and preventing preterm birth and Essential for visual development
Select the orange to proceed.
GOOD SOURCES OF OMEGA-3 FATTY ACIDS
Fish oil capsules Certain fish such as salmon, trout, mackerel,
sardines, and fresh tuna Vegetable oils such as sunflower, rapeseed,
flaxseed, and walnut oils
Select the orange to proceed.
VITAMIN AND MINERALREQUIREMENTS IN PREGNANCY
• Pregnant women are at increased risk for folic acid, iron, and calcium deficiencies.
• Recommendations are: Iron – indonesia 30-60 mg/hari Folate – indo 400 mg/hari Calcium -indo 1200mg/hari Magnesium - —indo 320 Vitamin C – indo 70 mg/day Iodine—indonesia 175mg/hari
CALCIUM AND VITAMIN D Calcium and
vitamin D are needed for strong bones and teeth
Vitamin D is needed for the formation of the fetal bones
Recommended 10 micrograms of Vitamin D per day
Select the orange to proceed.
GOOD SOURCES OF CALCIUM AND VITAMIN D
Milk and other dairy products Eggs Meat Certain fish such as salmon, trout, mackerel,
sardines, and fresh tuna
Select the orange to proceed.
CALCIUM REQUIREMENTS
DRI Calcium Recommendations 9 - 18 y/o: 1300 mg/day 19 - 50 y/o: 1000 mg/day (adults, pregnant and lactating) >51 y/o: 1200 mg/day Increased requirements during the third trimester Supplementation shown to reduce hypertension during
pregnancy
Dietary sources Milk, yogurt (8 oz), cheese (1 oz) ~ 300 mg calcium Orange juice- fortified (1 cup = 300 mg) Broccoli, kale (1 cup cooked = 90 mg) Bok choy, mustard green (1 cup cooked =180 mg) Tofu (made with calcium citrate- (½ cup =260 mg) Canned salmon (3 oz = 180 mg)
NEURAL TUBE DEFECTS (NTD) PREVENTION: ROLE OF FOLATE Folate deficiency is the most common deficiency during
pregnancy
Functions: Serves as a co-factor in one-carbon transfers, (nucleic acids
and amino acids) and therefore required during periods of rapid growth.
Increased maternal erythropoesis causes increased folate needs during second and third trimesters.
Role in Prevention: NTD are thought to result from a dietary deficiency of folate
and/or a genetic defect affecting folate metabolism.
During pregnancy, the neural tube is formed from the 18th to the
26th DAY of gestation.
NEURAL TUBE DEFECTS
Select the orange to proceed.
FOLATE REQUIREMENTS IN PREGNANCY
Adequate folate is critical before and during the first 4 weeks of pregnancy.
Since 50% of pregnancies are unplanned and most women do not seek prenatal care until 8 weeks gestation, folate supplements prior to conception are critical to prevent NTD.
Folate Antagonists (taken during 2nd or 3rd trimester doubles fetal CV defects): Phenobarbiotic Phenytoin Primidone Carbamazepine Trimethoprin Triamterene
KNOWLEDGE THAT FOLATE PREVENTS BIRTH DEFECTS: STILL LOW
0%
10%
20%
30%
40%
50%
1995 1997 1998 2000 2001 2004
Source: March of Dimes Survey 1995-2004: Based on 2000 Non-pregnant Women Age 18 to 45.
WOMEN TAKING A DAILY MULITVITAMIN CONTAINING FOLATE
0%
10%
20%
30%
40%
50%
1995 1997 1998 2000 2001 2002 2003 2004
Source: March of Dimes Survey 1995-2004: Based on 2000 Non-pregnant Women Age 18 to 45.
FOLATE REQUIREMENTS IN PREGNANCY
DRI=600 g pregnancy or 500 g lactating female, 400 g for non-pregnant woman.
Beans, peas, orange juice, green leafy
vegetables, fortified cereals are good sources.
Prenatal vitamins contain 1000 g folate.
FOLATE INTAKE IN NON-PREGNANT WOMEN (16-39 Y/O): US 1988-1994
234 238
202
261
0
50
100
150
200
250
300
Total population White non-Hispanic
Black non-Hispanic
MexicanAmerican
(ug/
day)
Adapted from The Department of Health and Human Services Center of Disease Control and Prevention, July 2002.
FOLIC ACID KNOWLEDGE AND BEHAVIOR 1995 - 2004
40
12
24
77
33
10
20
80
28
2
4
52
0 20 40 60 80 100
Take folic acid daily
Knew folic acidshould be taken
before pregnancy
Knew folic acid canprevent birth
defects
Aware of folic acid
1995
2002
2004
PercentSource: March of Dimes Survey 1995-2004: Based on 2000 Non-pregnant Women Age 18 to 45.
WHY WOMEN MIGHT BE ENCOURAGED TO TAKE A DAILY MULTIVITAMIN
3
3
3
4
4
4
11
34
0 10 20 30 40
If pregnant
Someone to remind me
More info about benefits
Remembered to take
Needed vitamins
Feeling run down
Change in health
Advised by a health care provider
PercentSource: March of Dimes Survey 2002
IRON IN PREGNANCY
Iron is an essential element in all cells of the body.
During pregnancy, maternal blood volume increases 20-30%.
Iron needs increase from 18 to 27 g/day during pregnancy.
Deficiency increases risk of maternal and infant death, preterm delivery, and low birth weight babies.
DIAGNOSIS OF IRON DEFICIENCY ANEMIA
The CDC reference criteria for anemia during pregnancy:
First trimester Hgb <11.0 g/dl or Hct <33%
Second trimester Hgb < 10.4 g/dl or Hct <32%
Third trimester Hgb <11.0 g/dl or Hct <33%
IRON DEFICIENCY ANEMIA Susceptible Populations:
Pregnant women who have not been taking iron supplements
Infants and childrenMenstruating femalesTeensLow income women
Etiology: Poor iron intake - only 25% of females 12 - 49 meet
needs Diet with low bioavailable iron
IRON DEFICIENCY ANEMIA
Weakness, fatigue, poor work performance, and changes in behavior.
Physical signs include pallor, fatigue, coldness and paresthesia of the extremities, greater susceptibility to infections.
Infants and young children with iron deficiency may have low IQ levels, poor cognitive and motor development, learning, and behavioral problems.
IRON TREATMENT RECOMMENDATIONS
Iron-rich foods: Meat, fish, poultry, eggs Organ meats Peas and beans Dried fruit Whole grain and enriched cereal
Therapeutic dose/supplements 30 mg TID but can be constipating IV iron, but may cause a reaction
PREVALENCE OF ANEMIA BY TRIMESTER OF PREGNANCY, 1989-1996 PNSS
0
5
10
15
20
25
30
35
1989 1990 1991 1992 1993 1994 1995 1996
1st trimester 2nd trimester 3rd trimester
Adapted from Pregnancy Nutrition Surveillance, 1996 full report
VITAMIN A AND IODINE Vitamin A is needed in small(indo +300 mg/hari)
amounts to protect the fetus from immune system problems, blindness, infections, and death Can cause birth defects in high doses
Lack of iodine could contribute to stillbirth, birth defects, and decreased brain development
Iodine is important for brain development
Select the orange to proceed.
NO ALCOHOL AND LIMITED CAFFEINE
Protect the infant from fetal alcohol syndrome and other birth defects Avoid alcohol, including all wines, beers, hard liquor,
and wine coolers High caffeine intake linked to low birth weight and
spontaneous fetal death Avoid food and beverages such as teas, coffee, colas,
energy drinks, and chocolate
Select the orange to proceed.
FOOD BORNE ILLNESS
Raw and highly carnivorous fish should be avoided. Including: fresh tuna, shark, tilefish, swordfish, king mackerel
All dairy foods and juices should be pasteurized.
Food contaminated with heavy metals can have neurotoxic effects for the fetus. (Mercury) Minamata disaster
Listeria monocytogenes contamination in pregnancy develop into a serious blood borne, transplacental infection. Wash vegetables and fruits Cook meats Avoid processed, precooked meats (cold cuts) Avoid soft cheeses (brie, blue cheese, etc.)
EXERCISE DURING PREGNANCY
Benefits of exercise during pregnancy: Helps reduce backaches, constipation, bloating, and swelling May help prevent or treat gestational diabetes Increases energy, improves mood and sleep Improves your posture, promotes muscle tone, strength, and
endurance
Acceptable activities: Walking, dancing, biking Swimming, Yoga
Exercises to avoid: Downhill Skiing, Scuba Diving, Trampoline Contact Sports (Ice Hockey, Basketball, Amusement Slides) Hot tubs
Warning Signs to stop exercise: Vaginal bleeding, uterine contractions, decreased fetal movement,
fluid leaking from the vagina Dizziness or feeling faint, increased shortness of breath Chest pain, headache, muscle weakness, calf pain or swelling