Maternal pdf - د. بتول

Maternal Nutrition during

Pregnancy and Lactation

Assistant Professor

Dr. Batool Ali Ghalib Yassin

Dept. of Community & family Medicine

College of Medicine – University of Baghdad

2015 - 2016

Objectives

By the end of this lecture you should be able to:

Understand the impact of maternal nutrition on

pregnancy outcome.

List the physiological changes on different systems

during pregnancy.

Numerate the possible outcomes of maternal

under nutrition.

Define low birth weight and prematurity.

List maternal and fetal factors leading to low birth

weight and prematurity

Identify the immediate and late causes of death

among low birth weight and premature infants

Maternal Nutrition during Pregnancy

and Lactation

Nutritional Status of the mother is

important for its impact on:

Mother’s health.

Fetal wellbeing

Lactation

Certain deficiencies cause dangerous

situations eg. Iodine deficiency

Physiological changes during pregnancy

General

metabolism

Anabolic

state

↑ BMR

Blood

volume

↑ plasma

volume

by 50%

and red

cell mass

by 20%

↓Hb concentration

in the peripheral

blood by 2 g/dl

Physiological

anemia

Water

metabolism

amount

of water

in the

maternal

body is

increased

by about

7 liters

Renal

function

GIT

↑ GFR

loss of

sugar

and

amino

acids

in the

urine

nausea,

vomiting,

constipati

on and

impaired

absorption

eg. iron

Maternal Nutrition during Pregnancy

and Lactation

Under

normal

conditions

the

mother’s weight increase by about 20 %
during pregnancy. In well nourished

mothers this correspond to an average

weight gain of 12.5 Kg (10-12 Kg)

throughout the pregnancy.

Possible Outcomes of Maternal

Under-nutrition:

1. Pre-eclampsia and Eclampsia:



A condition characterized by hypertension,

edema and protein urea



More common in lower socio-economic

groups and in developing countries.



They may be related to certain nutritional

deficiencies.

Possible Outcomes of Maternal Under-nutrition:

2. Anemia

Defined as a hemoglobin concentration of less than

11gm/dl

Physiological changes during pregnancy

→ relative

anaemia  of  pregnancy  and  is  not  always  accompanied  by
hypochromia  (as  indicated  by  normal  MCHC  values).
However, this is the picture in the peripheral blood.

In developing countries the iron stores are usually

depleted  due  to  successive  periods  and  pregnancy  and
lactation  and  diets  containing  low  iron,  mostly  of  low  bio-
availability.

Low MCHC means low Hb content of RBC & hypocromic and
microcytic RBCs will appear on blood film.

Possible Outcomes of Maternal Under-Nutrition; 2. Anaemia:

Degree of anaemia

Moderate (Hb 7 -10 gm/dl) - PCV (24 – 37 %)

Severe (Hb 4 -6.9 gm/dl) - PCV (13 – 23 %)

Very severe (Hb less than 4 gm/dl) - PCV (< 13 %)

The causes of anaemia during pregnancy are:

Increased iron requirements due to foetal & placental growth.

Impairment of iron metabolism during pregnancy.

Short spacing.

Dietary iron deficiency (low iron content and low bio-
availability).

Blood loss due to parasites (anchylostoma and plasmodia).

Anaemia may also be due to the deficiency of folic acid and/or
vitamin B

. This is manifested by very low HB values of <7g/dl.

In Iraq, low Hb levels not responding to iron supplements may
indicate thalassaemia or sickle cell anaemia.

Possible Outcomes of Maternal Under-Nutrition

3. Low Birth weight & Prematurity:



Both of these outcomes show a socio-economic gradient.



They are more common among lower social classes and

in developing countries.

4. Foetal and Neonatal Morbidity and Mortality:



There is also a socio-economic gradient in fetal and

neonatal morbidity and mortality.



The under-nourished fetus and neonate usually show a

general depression of vitality and have an increased
chance of death during the neonatal period.



Congenital malformations have been produced in

pregnant animals maintained on deficient diets.

Low Birth Weight (LBW) and Prematurity; Definitions

The birth weight of an infant is very important because it
determines his ability to adapt to the new environment and
develop normally.

Many factors causes variation in weight at birth but in

developing countries, the mother’s health , nutritional
status and diet during pregnancy are probably most
important.

Normal birth weight for infants of either sex (3.3-3.5Kg)

Environmental and hereditary factors affect the infant’s
birth weight.

Low Birth Weight (LBW) and Prematurity; Definitions

LBW infant:

A live born infant weighing less than 2500g at birth.

Pre-term infant:

An infant born before 37 completed weeks of gestation

calculated from the first day of the last menstrual period.
Full-term infant:

An infant born between 37-42 completed weeks of

gestation calculated from the first day of the last menstrual
period.
Post-term infant:

An infant born after 42 completed weeks of gestation

calculated from the first day of the last menstrual period.

Causes; I - Complications During Pregnancy:

1. Hypertension:
It can happen with or without proteinuria (pre-eclampsia or

essential hypertension). It can be associated with or lead to
placental abnormalities. These conditions may lead to both
IUGR & pre-term delivery.

2. Diabetes Mellitus:

Sometimes pregnancy is terminated before 37 completed weeks
of gestation, to protect the vitality of the infant. This will lead to
the birth of a pre-term infant. Sometimes, DM is associated with
placental insufficiency which in severe cases is associated with
the birth of a small-for –date infant, although DM is usually
associated with the birth of a large-for-date infant.

3. Heart Diseases:
associated with pre-term delivery, which is sometimes induced.
4. Anaemia:
associated with LBW and pre-term delivery.

5. Infections:
Infections during pregnancy are associated with fever, immunological

reactions, obliterative vasculitis, release of toxic substances. The damage caused
is related

to the infectious agent

, the

timing of the infection

and

the organs or

tissues involved

. These infections may be:

A. Viral

Rubella, Cytomegalovirus, and Herpes

Bacterial

: can either be

Amniotic

fluid infections (ascending antenatal bacterial infections, which are the

most common, are associated with protein energy malnutrition and heavy
physical work and lead to preterm delivery).

Trans-placental infections

(TB or syphilis which cause placental insufficiency

and preterm delivery).

Urinary tract infections

(UTIs which are associated with preterm delivery).

C. Parasitic:

Plasmodia

(congenital malaria is very rare as the fetus is protected by trans-

placental transmitted anti malarial antibodies, and the LBW and preterm delivery
are caused by the associated fever and severe anemia) .

Toxoplasma

(which is associated with pre-term delivery and congenital

malformations rather than LBW).

Causes; I - Complications During Pregnancy:

6. Cervical incompetence: may be also associated with

infections and lead to preterm delivery.

7. Uterine abnormalities: congenital malformations of the

uterus and fibromyomas can lead to preterm delivery.

8. Polyhydramnios: is associated with preterm delivery.

9. Premature rupture of the membranes: is associated

with preterm delivery.

10. Antepartum haemorrhage: is associated with fetal

growth retardation and preterm delivery.

Causes; I - Complications During Pregnancy:

11.Placental factors: the small placenta and the

diseased placenta (abruptio placentae and

placental infarcts) are both associated with IUGR.

12.Amniocentesis: is associated with infections

and preterm delivery.

13.Maternal surgery: abdominal surgery may lead

to preterm delivery.

14.Trauma: may lead to preterm delivery.

15.Iatrogenic:

incorrect

estimation

the

gestational age may lead to preterm induction of

labour.

Causes; I - Complications During Pregnancy:

II- Multiple Pregnancy

–

In humans, intrauterine growth begins to falter between

26-30 weeks of gestation depending on the number of

fetuses.

– BW and GA decrease with increasing number of fetuses,

leading to a higher incidence of LBW and preterm delivery

in a multiple pregnancy. There is also a high incidence of

placental abnormalities in multiple pregnancies.

III-Congenital

malformations

More LBW and preterm deliveries are found in

newborns with congenital malformations.

This is especially true in chromosomal abnormalities

and serious congenital malformations (cardiac and

cephalic).

IV- Sex of the Infant

LBW

is higher in

female infants

, while

preterm

deliveries

are higher in the

male infant

V- Biological Factors

1.Maternal age: more LBW and preterm births happen before 20

years and after 35 years of age.

2.Maternal height: more LBW in shorter mothers.

3.Maternal weight: low pre-pregnancy weight, low weight gain

during pregnancy and low quality diets are associated with LBW.

4.Parity: increased chance of LBW in first and after the 4th birth.

5.Short spacing: increased chance of LBW and preterm delivery.

6.Drugs and alcohol:
a) Medicinal drugs:

Some are teratogenic and may lead to IUGR

b) Narcotics:

Decrease food intake leading to maternal under-

nutrition and IUGR.

c) Alcohol:

Is teratogenic leading to LBW and fetal alcohol

syndrome.

Poor antenatal care

: increased chance of LBW and preterm

delivery.

Previous LBW

: increased chance of LBW and preterm delivery.

Residence

: Increased LBW in rural areas and in higher altitudes.

V) Biological Factors

10.Occupation and physical activity

: hard

physical work are associated with a higher

chance of LBW and preterm deliveries especially

in developing countries.

11.Psychological stress

: is associated with

preterm labour.

12.Genetic factors

: about 40% of the variation in

birth weight is attributed to genetic factors

(ethnic and familial).

VI) Socioeconomic Factors:



Low social status,



Low family income,



low educational level and some husband’s

occupations

May lead to poor maternal nutrition which is

associated with LBW

VII) Cigarette Smoking:



Smoking depresses appetite leading to under-

nutrition,



it has a direct toxic effect of the fetus, it

decreases placental perfusion (vaso-constrictive

effect of nicotine)



and causes hypoxia due to the accumulation of

CO in the maternal blood.



This will lead to LBW, the degree of which is dose

related.



One should not forget the role of passive

smoking on pregnant women and their fetuses

Effects of LBW and Prematurity

on the Fetus



Of all those prematurely born fetuses,

and those born with a low weight,

    - 50% will die during the first 24 hours,
    -15% will die during the second day.
    -Fatality increases with decreasing

gestational age at birth.

- many of them will live with

complications ( thin, stunted growth)

Causes of Morbidity and Mortality;

Immediate:

Respiratory: asphyxia, apnoea and RDS.

Neurological: intra-cranial haemorrhage.

Cardiovascular: bradycardia and

hypotension.

Haematological: anaemia and bleeding

tendency.

Nutritional and gastro-intestinal:

feeding problems.

Causes of Morbidity and Mortality;

Immediate:

Metabolic: hypocalcaemia and

hyperbilirubinaemia.

Renal: Lower GFR.

Temperature regulation: hypo and

hyperthermia.

Immunity: increased risk of infections.

10.

Ophthalmic: retrolental fibroplasia and

blindness.



CNS dysfunction.



Chronic lung diseases.



Poor growth.

In Iraq LBW decreased from up to 22%

during the nineties to 10.2%, 6.06%

& 5.9% during 2010, 2011 & 2012

respectively

Causes of Morbidity and Mortality;

Long Term: