Pregnancy and lactation final.ppt

Nutrition in Pregnancy and Lactation

Astiti Dwi Arumbakti

Eleonora Mitaning Christy

Patricia Amanda

Kurnia Sitompul

Adventia Natali

Physiology of Pregnancy

• Pregnancy averages 38 weeks, or 266 days, in length

• Commonly, pregnancy duration is given as 40 weeks (280 days) because it is measured from the date of the first day of the last menstrual period (LMP)

Normal PhysiologicalChanges During Pregnancy

• First half : “maternal anabolic” deliver relatively large quantities of blood, oxygen 10% of fetal growth in the first half of pregnancy

• Second half : “maternal catabolic”, which energy and nutrient stores, deliver stored energy and nutrients to the fetus, fetal growth90% occurs in the second half

1. Body Water Changes

• A woman’s body water ↑↑ during pregnancy = increased volumes of plasma and extracellular fluid, as well as amniotic fluid

Two-thirds of the expansion is intracellular (blood and body tissues)

One-third is extracellular

(fluid in spaces between cells)

Total body water increases in pregnancy from 7 to 10 liters

(2-2,5 gallons)

Body water (2)

• Plasma volume begins to increase after conception and reaches a maximum at ± 34 weeks

• Plasma-volume increases : primary reason that pregnant woman feel tired and become exhausted easily, make pregnant woman fatigue in second and third trimester

Body water (3)

• Birth weight strongly related to plasma volume generally, the greater the expansion, the greater the newborn size

• The increased volume of water in the blood is responsible for the “dilution effect” of pregnancy decreased levels of hemoglobin, serum albumin, other serum protein and water soluble vitamin

2. Cardiovascular and Pulmonary Function

• Increased cardiac output and cardiac size • Pressure of the expanding uterus on the inferior

vena cava Mild lower extremity edema • Blood return to the heart decrease cardiac

output ↓, fall in blood pressure , and lower-extremity edema

• Maternal oxygen requirements increase

3. Gastrointestinal function• First trimester : Nausea and Vomiting• Increased Progesterone level

• Relaxed lower esophageal sphincter and pressure on the stomach from the growing uterus---regurgitation and gastric reflux

• Gall bladder emptying becomes less efficient

Increased Progesterone concentration

Relax the uterine muscle

Decreasing GI motility with increased

reabsorption of water

Constipation

Allow for fetal growth

4. Renal Function

• The Glomerular Filtration Rate increases by 50%

• Renal tubular resorption is less efficient than in the nonpregnant state

• Glucosuria (+) – increase the risk for urinary tract infections

5. Hormonal Changes

• The placenta serves many roles, but a key one is the production of steroid hormones such as progesterone and estrogen.

• The placenta : main supplier of hormones needed to support the physiological changes of pregnancy

Hormonal Changes (2)

6. Maternal Nutrient Metabolism

Carbohydrate Metabolism

•Glucose is the fetus’s preferred fuel

•Carbohydrate metabolism in the first half of pregnancy is characterized by estrogen- and progesterone-stimulated increases in insulin production and conversion of glucose to glycogen and fat.

Carbohydrate Metabolism

•In the second half, rising levels of hCS and prolactin from the mother’s pituitary gland inhibit the conversion of glucose to glycogen and fat

•At the same time, insulin resistance builds in the mother, increasing her reliance on fats for energy

Protein Metabolism

•Nitrogen and protein needed >> for synthesis of new maternal and fetal tissues

•To some extent the increased need for protein is met through reduced levels of nitrogen excretion and the conservation of amino acids for protein tissue synthesis

Fat Metabolism

•Plasma triglyceride = three times non pregnant levels

•Cholesterol containing lipoprotein, phospolipid, and fatty acid also increase, but lesser than triglycerides

•Cholesterol supply used by placenta for steroid hormone synthesis and by the fetal for nerve and cell membrane formation

Mineral Metabolism

•Calcium metabolism characterized by increased rate of bone turnover and reformation

•↑↑ levels of body water and tissue synthesis -- increased requirements for sodium

•Sodium metabolism delicately balance by changes in the kidneys that increase aldosterone secretion and the retention of sodium

7. The Placenta

• Placenta derived from Latin word for cake.

• Functions of the placenta include:

● Hormone and enzyme production,

● Nutrient and gas exchange between the mother and fetus

● Removal of waste products from the fetus

Placenta cont..

LACTATION PHYSIOLOGY

Mammary Gland•The functional units : alveoli•Each alveolus is composed of a cluster of cells (secretory cells) with a duct in the center•Each smaller duct leading to six to ten larger collecting ducts. •Myoepithelial cells surround the secretory cells can contract under the influence of oxytocin and cause milk to be ejected into the ducts.

• During puberty, the cyclic release of estrogen and progesteron governs pubertal breast development and usually complete within 12 to 18 months after menarche.

• Estrogen : stimulates development of the glands

• Progesterone : elongate tubules and duplicate the cells that line the tubules (epithelial cells)

Lactogenesis

• Lactogenesis I, begins during the last trimester of pregnancy untill first day postpartum, milk begins to form, lactose and protein content of milk increase

• Lactogenesis II : 2–5 days postpartum, increased blood flow to the mammary gland

• Lactogenesis III. This stage of breast milk production begins about 10 days after birth, the milk composition becomes stable.

Hormonal Control of Lactation

• Prolactin and oxytocin are necessary for establishing and maintaining a milk supply.

• Prolactin : stimulates milk production, stimulates by suckling, stress, sleep, and sexual intercourse

• In the last 3 months of pregnancy, prolactin activity is suppressed by a prolactin-inhibiting factor that is released by the hypothalamus

Hormonal control lactation cont..

• Oxytocin : main role is in letdown, or the ejection of milk from the milk gland (acinus) into the milk ducts.

• Stimulated by suckling or nipple stimulation

• Oxytocin also acts on the uterus, causing it to contract, seal blood vessels, and shrink its size.

The Letdown Reflex

• The letdown reflex : stimulates milk release from the breast

• The stimuli -- through nerves to the hypothalamus -- promoting oxytocin release – oxytocin : contraction of the myoepithelial cells -- milk is released through the ducts

• Other stimuli : hearing a baby cry, sexual arousal, and thinking about nursing, can also cause letdown

Indicator of Nutrional Status in Pregnancy

• Several Indicator of Nutional Status in Pregnancy : Upper arm muscle circumference, weight for height and eating patterns (weight gain), Hemoglobin.

Weight Gain During Pregnancy

Weight Gain

Upper Arm Circumference

Nutrional Assesment for Breastfeeding Women

Nutrition Requirement

• Factors affecting nutrient requirements during pregnancy:- prepregnancy nutrient stores- body size and composition- physical activity levels- stage of pregnancy- health status.

The need for energy

Energy requirements increase during pregnancy, mainly due to increased maternal body mass and fetal growth.

The increased need for energy in pregnancy averages 300 kcal a day.

The increased calorie need in pregnancy:1/3 increased work of the heart1/3 increased energy needs for respiration and accretion of breast tissue, uterine muscles, and the placenta 1/3 the fetus

The need for carbohydrate

Approximately 50–60% of total caloric intake during pregnancy should come from carbohydrates.

Women should consume a minimum of 175 grams carbohydrates to meet the fetal brain’s need for glucose.

The need for protein

The recommended protein intake for pregnancy is +25 grams per day. Less protein is used for energy and more is used for protein synthesis.

Approximately 925 grams of protein (2 pounds) accumulated in protein tissues during pregnancy- 440 grams are taken up by the fetus- 216 grams are used for increases in maternal blood and extracellular fluid volume- 166 grams are consumed by the uterus- 100 grams are accumulated by the placenta.

The need for fat

It is estimated that pregnant women consume 33% of total calories from fat.

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.

The need for water On average, women consume about 9 cups offluid daily during pregnancy (+300 mL a day).

Women who engage in physical activity in hotand humid climates should drink enough to keepurine light-colored and normal in volume.

Water, diluted fruit juice, iced tea, and other unsweetened beverages are good choices forstaying hydrated.

Nutrition Problem in Pregnancy

• Obesity and Pregnancy• Hypertensive Disorders of Pregnancy• Diabetes in Pregnancy• Multiple Pregnancies

Nutrition Problem in Pregnancy (Indonesia)• Chronic Energy Impairment 38,5%

(LLA<23,5cm)• Anemia (37,1%) Hb<11• Eclampsia 24%• Malaria (1,9%) tend to increase risks of:

anemia, haemorrhage, LBW

Source: Riskesdas, 2013

Obesity and Pregnancy

• Associated with : gestational diabetes & hypertensive disorders

• Increase risks of: stillbirth, large-for-gestational newborns developing type 2 DM, Cesarean-section delivery

Comparative Prevalence of Obesity Prior to Pregnancy and Outcomes Related to Pregnancy

Source: Brown JD., Nutrition Through The Life Cycle. 4th Ed. Belmont : Wadsworth.2011.10 :135

Nutritional Recommendations andInterventions for Obesity During Pregnancy

• Meeting nutrient needs + variety of basic foods

• Changes in calorie intake and physical activity weight gain (same as those for women of other sizes)

• Monitoring and evaluation

Hypertensive Disorders of Pregnancy


Hypertensive Disorders of Pregnancy

• Related to chronic inflammation (oxidative stress, and damage to the endothelium)

• Affect 6 to 10% stillbirths, fetal and newborn deaths

Nutritional Recommendationsand Interventions for Pre-eclampsia• Adequate Calcium (recommendation: 1000-2000 mg

daily 3x500 mg daily) and Vitamin-D (RDA intake for pregnant women)

• Intake of anti-oxidants (ex: Vit.E,vit.C)• Five or more servings of colorful vegetables and fruits

daily• Consumption of the assortment of other basic food• Moderate exercise (walking, swimming, noncompetitive

tennis, or dancing for 30 minutes) daily unless medically contraindicated

• Weight gain

Diabetes in Pregnancy

• 7.5% of pregnant women, increasing along with obesity

• Gestational diabetes accounts for 88% of all cases of diabetes in pregnancy

Diets developed for women with gestational diabetes• Whole-grain breads and cereals,

vegetables, fruits, and high-fiber foods• Limited intake of simple sugars and foods

and beverages that contain them• Low-GI foods, or high fiber carbohydrate

foods that do not greatly raise glucose levels

• Unsaturated fats • Three regular meals and snacks daily

Estimating Levels of Caloric Need in Women with Gestational Diabetes


Multiple Pregnancy


Recommendation of NutritionDuring Multiple Pregnancy


Anemia in pregnancy

• Hb concentration <11 g/dL

-Increased maternal morbidity & mortality

-Increased fetal morbidity & mortality

-Increased risk of low birth weight• Therapy :

– Adequate intake of daily nutrition (heme-iron)– Iron supplement 3x/daily (ferrous sulphate

@300 mg metal element tablet @65 mg ), 2-3 months (+/- 90 tablets)

Nutrition Problem in Breastfeeding Women• Weight Loss During Breastfeeding

• Common Breastfeeding Conditions (ex: Hyperlactation, Plugged Duct, Mastitis, Engorgement)

• Low Vitamin and Mineral Intakes clinical manifestation based on those vitamin & mineral deficiency

Weight Loss During Breastfeeding

• Current DRIs assuming a weight loss of 0.8 kg/month

• Postpartum weight changes are smaller in developing countries (–0.1 kg/mo) than in industrialized nations (–0.8 kg/mo)

• Requirement of Energy, Vitamin, and Mineral based on RDA / AKG for Lactation Women

Common Breastfeeding Conditions

• Sore Nipples: proper positioning of the baby on the breast (nipple in junction of the hard and soft palate)

• Flat or Inverted Nipples• Plugged Duct : pain• Mastitis : inflamation

Low Vitamin and Minerals Intake

Intervention :

•Optimal diet

•Calcium, phosphate, folate, thiamin, vitamin A, vitamin D–rich foods such as: dairy products, fruit, vegetables, and whole-grain

•Requirement Vitamin and Mineral based on RDA / AKG

CASE

Energy Protein Fat Carbs Water

AKG (Usia 25 thn)

2250 kkal 56 gr 75 gr 309 gr 2300 ml

Ibu Menyusui

2580 kkal 76gr x 4 = 304 kkal

86gr x 9 = 774 kkal

354gr x 4 = 1416 kkal

3100 ml

Breakfast 20 % : Energy = 20% x 2580 kkal = 516 kkalWater = 20% x 3100 ml = 620 ml

Carbohydrate = 20% x 354 gr = 70, 8 gr Protein = 20% x 76 gr = 15,2 gr Fat = 20% x 86 gr = 17,2 gr

Snack 10 % :Energy = 10% x 2580 kkal = 258 kkalWater = 10% x 3100 ml = 310 ml

Carbohydrate = 10% x 354 gr = 35,4 gr Protein = 10% x 76 gr = 7,6 gr Fat = 10% x 86 gr = 8,6 gr

Lunch 30 % :Energy = 30% x 2580 kkal = 774 kkal Water = 30% x 3100 ml = 930 ml


Snack 10 % :Energy = 10% x 2580 kkal = 258 kkalWater = 10% x 3100 ml = 310 ml


Dinner 20% : Energy = 20% x 2580 kkal = 516 kkalWater = 20% x 3100 ml = 620 ml

Carbohydrate = 20% x 354 gr = 70, 8 gr Protein = 20% x 76 gr = 15,2 gr Fat = 20% x 86 gr = 17,2 gr

Snack 10 % :Energy = 10% x 2580 kkal = 258 kkalWater = 10% x 3100 ml = 310


Schedule Nutrient Percentage Variety of food

Breakfast Energy 516 kkal

Carbohydrate 106,2 grProtein 22,8 grFat 25,8 grWater 930 ml

Nasi putih 100 grTelur ayam rebus 1btr 55grTempe goreng 1 ptg grSayur sop 100 grPepaya 2 ptg bsr

180 kkal95,7 kkal87,5 kkal27 kkal100 kkal

Total : 490,2 kkal

Snack Energy 285 kkal


Lapis legit 50 grSusu skim cair 1 gls

194,5 kkal75 kkalTotal : 269,5 kkal

Lunch Energy 774 kkal


Nasi 150 grAyam goreng kalasan paha 40 grGado-gado 50 grKerupuk udang goreng 20 grSemangka 3 ptg bsr

270 kkal 110 kkal68.5 kkal95,4 kkal150 kkalTotal : 693,9 kkal

Schedule Nutrient Percentage Variety of food

SnackEnergy 258 kkal


Roti putih 2 ptg Keju 1 ptg 35 gr Madu 1 sdm

117 kkal125 kkal50 kkalTotal: 292 kkal

Dinner Energy 516 kkal


Nasi 100 grTahu goreng 1 ptg bsrTumis bayam bersantan 100 grYogurt non fat 2/3 glsPear 1 bh

180 kkal115 kkal48 kkal75 kkal100 kkalTotal: 518 kkal

Snack Energy 258 kkal


Pastel 80 gr 245,6 kkal

TOTAL : 2509,2 kkal

Human Milk Composition

• colostrum, first milk, thick, often yellow fluid produced

• Infants may drink only 2 to 10 mL (1.5–2 tsp) of colostrum per feeding in the first 2–3 days.

• Colostrum higher in immunoglobulin A and lactoferrin (the primary proteins present in colostrum), mononuclear cell, sodium, potassium, and chloride than more mature milk.

References

• Padilha PC, Accioly E, Libera BD, Chagas C, Saunders C. Anthropometric assessment of nutritional status in Brazilian pregnant women. Rev Panam Salud Publica. 2009;25(2):171–8

• Brown,E.Judith. Nutrition During Pregnancy (chapter4).In: Nutrition Through The Life Cycle (4th edition). USA: Wadsword, CA. 2011. Pg: 87-130

• Mahan, L. Kathleen., Escottt-Stump, Sylvia. 2008. The Nutrients and Their Metabolism. In: Krause’s Food and Nutrition Therapy, International edition 12nd. Missouri : Saunders El Savier.

Pregnancy and lactation final.ppt

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