NUTRITION IN PREGNANCY AND LACTATION

Lingegowda Krishna1

Nageshu Shailaja 2

Namrata Kulkarni3

1- Professor and Head, Department of Obstetrics and Gynaecology, PES Institute of Medical

Sciences and Research, Kuppam.

2-Associate Professor, Department of Obstetrics and Gynaecology, PES Institute of

Medical Sciences and Research, Kuppam.

3- Assistant Professor, Department of Obstetrics and Gynaecology, PES Institute of

Medical Sciences and Research, Kuppam.

*Corresponding Author: Address: Dr.L Krishna, Professor and Head of the Department,

Obsterics and Gynaecology, Medical Superintendent PESIMS&R, Kuppam-517425,

Chittoor(Dt), Andhra Pradesh, India.

Phone:+9391833730, E- mail: drlkrishnas@gmail.com

Introduction

A critical element of the health care system is the health of women in the

childbearing age and children under five. A child’s nutritional well-being begins with

the mother’s nutritional status during adolescence and pregnancy. Pregnancy is a

critical period during which good maternal nutrition is a key factor influencing the

health of both mother and child. The vast majority of them die from complications,

which could be reduced through better nutrition.

Consequences of Maternal Nutritional Deficiency

Inadequate intake of the micronutrients may have a profound impact on both

the mother and fetus during pregnancy.

Vitamin A deficiency is linked to maternal death.

Inadequate folate during preconceptional period and the first trimester of

pregnancy can cause birth defects like neural tube defects, such as spina

bifida and anencephaly.

Folate deficiency can also increase the risk of low birth weight (LBW) and

maternal mortality.

Iodine deficiency increases the risk of still birth and miscarriage and can

cause severe learning disabilities in children.

Zinc deficiency can result in prolonged labour, which increases the odds of

the mother dying and can impair fetal development.

LBW babies tend to have slower growth rate and stunting, unless there is an

early intervention.

Energy requirements during pregnancy and lactation

Pregnant and lactating women require additional dietary intake, as they have

to meet their own nutritional requirements and also supply nutrients to the growing

fetus and the infants. The Indian Council of Medical Research has recommended an

additional intake of 300kcals /day during the second and third trimester of

pregnancy. According to dietary guidelines women should consume a variety of

foods to meet the additional nutrient needs and achieve the recommended weight

gain.

Key nutrient &

RDA

Important functions Important source Comments

Calories

N-2200

P-2200(1st

trimester)

P-2500(2nd & 3rd

trimester)

L-2700

Provide energy for

tissue building &

increased metabolic

requirements

Carbohydrates ,fats

& proteins

Calorie

requirements vary

according to the

stage of pregnancy,

size of pregnant

woman, activity

level, pre pregnant

weight & how well

nourished they are

Water or liquids

N-8 glasses

P-10 glasses

L-12-14 glasses

Carries nutrients to

cells

Carries waste

products away.

Provides fluid for

increased blood,

tissue & amniotic fluid

volume.

Helps regulate body

temperature.

Aids digestion.

Water, juices &

milk

Liquid is often

neglected, but it is

an important

nutrient

Protein

N-50g

P-65g

L-75g

Builds & repairs

tissue.

Helps build blood,

amniotic fluid &

placenta.

Helps form antibodies.

Supplies energy

Meat, fish, poultry

eggs, milk, cheese,

dried beans & peas,

peanut butter,

nuts, whole grains

& cereals

Fetal increase by

1/3rd in late

pregnancy as the

baby grows

Minerals

Key nutrient & RDA

Important functions Important source Comments

CalciumN-400mgP-1000mgL-1000mg

Helps build bones & teeth.Important in blood clotting.Helps regulate use of other minerals in the body.

Milk, cheese, whole grains, vegetables, egg yolk, whole canned fish, ice cream

Fetal requirements increase in late pregnancy.Caffeine can decrease the amount of calcium available to fetus.

PhosphorousN-800mgP-1200mgL-1200mg

Helps build bones & teeth

Milk, cheese, lean meats

Calcium & phosphorous exist in a constant ratio in the blood,an excess limits the use of calcium

IronN-30mgP-38mgL-30mg

Combines with proteins to make hemoglobin.Provides iron for fetal storage.

Liver, red meatsEgg yolk, whole grains, leafy vegetables, nuts, legumes, dried fruits, prunes & apple juice

Fetal requirements increase 10 fold in the last 6 weeks of pregnancy.Supplement 30-60mg of iron daily is recommended by National Research Council.

ZincN-12 mgP-15mgL-19mg

Component of insulin. Important in growth of skeleton.

Meat, liver, eggs, sea food (especially oysters & nervous system)

Deficiency can cause malformations of fetal skeleton & nervous system

IodineN-150mcgP-175mcgL-200 mcg

Helps control the rate of body’s energy use. Important in thyroxine production.

Sea foods, iodised salt

Deficiency may cause goiter in infant

MagnesiumN-280mgP-320mgL-355g

Helps energy, protein & cell metabolism.Enzyme activator.Helps tissue growth & muscle action.

Nuts ,cocoa, green vegetables, whole grains & direct beans & peas

Most is stored in bones.Deficiency may cause dysfunction.

Fat soluble vitamins

Key nutrient & RDA Important functions

Important source Comments

Vitamin AN-600mcg REP-600mcg REL-950mcg RE

Helps bone & tissue growth & development.Essential in development of enamel-forming cells in gum tissue.Helps maintain health of skin & mucous membrane.

Butter, fortified margarine, green & yellow vegetables, liver

In excess amounts ,it is toxic to fetus.It loses its potency when exposed to light.

Vitamin DN-5mcgP-10mcgL-10mcg

Needed for absorption of calcium & phosphorous, & mineralization of bones & teeth

Fortified milk, fortified margarine, fish, liver, oil , sunlight on your skin

Toxic to fetus in excess amounts.

Vitamin EN-8mg TEαP-10mg TEαL-12mg TEα

Needed for tissue growth, cell wall integrity & red blood cell integrity.

Vegetable oils, cereals, meat, eggs, milk, nuts & seeds

Enhances absorption of vitamin A.

Vitamin KN-65mcgP-65mcgL-65mcg

Essential for synthesis of blood clotting factors.

-

Produced in the body by the intestinal flora.

Water soluble vitamins

Key nutrient & RDA

Important functions Important source

Comments

Folic acidN-180mcgP-1400mcgL-280mcg

Essential in hemoglobin synthesis.Involved in DNA & RNA synthesis.Needed for synthesis of amino acids.

Liver, green leafy vegetables & yeast

Deficiency leads to anemia, neural tube defects.Can be destroyed in cooking & storage.Supplement of 400 mcg/day is recommended by National Research Council.Oral contraceptives may reduce blood level of folic acid.

NiacinN-15mgP-17mgL-20mg

Needed for energy & protein metabolism.

Pork, organ meats, peanuts, beans, peas & enriched grains

Stable; only small amounts are lost in food preparation.

RiboflavinN-1.3mgP-1.6mgL-1.8mg

Essential for energy & protein metabolism.

Milk, lean meat, enriched grains, green leafy vegetables

Oral contraceptives may reduce serum concentration of riboflavin.

Thiamin (B1)N-1.1mgP-1.5mgL-1.6mg

Important for energy metabolism.

Pork, beef, liver, whole grains & legumes

Essential for conversion of carbohydrates into energy in the muscular & nervous systems.

Pyridoxine(B6)N-1.6mgP-2.2mgL-2.1mg

Important in aminoacid metabolism & protein synthesis required for fetal growth.

Unprocessed cereals, grains, wheat germ, nuts, seeds, legume & corn

Excessive amounts may reduce milk supply in lactating women.May help reduce nausea in early pregnancy.

Cobalamin (B12)N-2.0mcgP-2.2mcgL-2.6mcg

Essential in protein metabolism.Important in formation of red blood cells.

Milk, eggs, meat, liver, cheese

Deficiency leads to anemia & CNS damage.It is manufactured by microorganisms in the intestinal tract.Oral contraceptives may reduce serum concentration.

Vitamin CN-40mgP-40mgL-45mg

Helps tissue formation & integrity.It is “cement” substance in connective & vascular tissue.Increases iron absorption.

Citrus fruits, berries, melons, tomatoes, chilly, pepper, green vegetables & potatoes

Large supplementary doses in pregnancy may create a larger than normal need in infant.Benefits of large doses in preventing cold have not been confirmed

Note: N – Nonpregnant P – Pregnant L - Lactation

Protein requirement during pregnancy and lactation:

During pregnancy, the expansion of blood volume and the growth of

maternal tissues requires substantial amount of protein. Growth of the fetus and

placenta also places protein demand on the pregnant woman. Thus an additional

protein intake is essential for the maintenance of a successful pregnancy.

Factorial Estimate of Protein Components of Weight Gain in a

Normal Full-Term Pregnancy

Component Weight (in kg) Protein (in kg)

Fetus

Placenta

Amniotic fluid

Uterus

Blood

Extra cellular fluid

Total

3.4

0.7

0.9

0.9

1.5

1.5

8.9

0.44

0.1

0.003

0.166

0.081

0.135

0.925

The deposition of protein is not linear throughout pregnancy. Early during

pregnancy the protein requirement for fetal development is minimal, whereas the

requirement for maternal volume expansion and tissue growth may be substantial.

Late in pregnancy the fetus may account for a major increase in protein needs.

Safe Level of Additional Protein During Pregnancy

Trimester Additional Protein Required(g/day)

1 1.2

2 6.1

3 10.7

An extra 25 gram/day of protein with a chemical score of 70 is recommended

during lactation by FAO/WHO.

A safe level of extra protein intake during lactation is 16g/day during the

first 6 months of lactation, 12g/day during the second 6 months and 11g/day

thereafter.

The protein content of pulses is twice that of cereals (22-25%) and almost

equal to that of meat and poultry but the quality of protein is inferior to animal

protein.

Recommended Essential Fatty Acid Intake

Adequate intakes (AI) have been set for Linoleic acid(LA) and Alpha Linolenic

acid(ALA)

The AI for LA is 17 and 12g/d for men and women aged 19 – 50yrs,

respectively. The AI for ALA is 1.6 and 1.1g/d for men and women aged 19 to >

70yrs, respectively.

Recommendations Concerning Essential Fatty Acid Intakes:

The ratio of linoleic to alpha-linolenic acid in the diet should be between 5:1 and

10:1

Individuals with a ratio in excess of 10:1 should be encouraged to consume more

n-3 rich foods such as green vegetables, legumes, fish and other seafood.

Particular attention must be paid to promoting adequate maternal intakes of

essential fatty acids throughout pregnancy and lactation to meet the requirements

of fetal and infant development

Emerging role of Docosahexaenoic acid (DHA):

DHA is an omega 3 fatty acid, the predominant fatty acid in the brain and retina. Due

to low conversion rate of alpha linolenic acid (ALA) to DHA, it is important to directly

consume DHA, especially during pregnancy and lactation. The brain has its growth spurt in

the third trimester of pregnancy and during early childhood. Therefore, an appropriate

pre-and post-natal supply of these LCPs or their precursors is thought essential for normal

fetal and neonatal growth, neurologic development and function, learning and behavior.

DHA also has an important role in fetal retinal function and in prevention of maternal

postpartum depression.

Dietary sources of DHA: fish and fish oil, present in fatty fish and algae

Recommendations on DHA intake:

Organization DHA Recommendations

International society for the study

of Fats and Lipid (ISSFAL)

Adequate intake for adults to be at least 220mg per day

and 300mg per day for pregnant and lactating women

Committee On Medical Aspects Of

Food Policy (COMA)

1.5g EPA plus DHA per week(i.e 214mg mg per day)

British Nutrition Foundation(BNF) 8g EPA plus DHA per week for women(i.e 1145 mg per

day) 10g EPA plus DHA per week for men(i.e 1430 mg

per day)

Expert workshop of the European

Academy of Nutrition Sciences held

in 1997(EANS)

“ People who do not eat fish should consider consuming

marine n-3 PUFA equivalent to the amount obtained

from fatty fish, namely 200mg EPA plus DHA daily”.

EPA- Eicosapentaenoic acid

Importance of dietary fibre:

Dietary fibre consists of the remnants of edible plant cells, polysaccharides,

lignin and associated substances resistant to digestion. Modest increases in the

intake of fruits, vegetables, legumes and whole and high-fiber grain products, would

bring the majority of the Indian pregnant women close to the recommended range

of dietary fiber intake of 20 – 35 g/day.

An intake of food high in fiber is likely to be less calorically dense and is

lower in fat and added sugar.

Dietary fiber intake should be considered while counseling patients about

the management of gestational diabetes, constipation and other problems like

hemorrhoids, bowel distress and elevated blood pressure.

Food guide pyramid during pregnancy

Everyday use nine servings of cereals, four servings of vegetables, three

servings of fruit, milk and meat. Use fats sparingly. An increased amount of calcium

can be obtained from low fat milk, low fat cheese, yogurt, dark green vegetables or

fruit juices with calcium added.

Sample menu for a pregnant lady

BREAKFAST1cup milk (225ml), 2 dosas with green chutney (without coconut)

MID MORNING 1cup milk (150ml) + 1 sweet limeLUNCH 1 katori rice, 3 chapathis, 2 katori tur dal, palak fish(3 slices), French

beens bhaji, toasted saladMID AFTERNOON 1 glass buttermilk (made from skim milk)TEATIME 1cup tea with half cup skim milk (75ml), 1 katori poha with peasMID EVENING 1cup skim milk + 1 appleDINNER Mixed vegetable soup, khichidi 2 katoris, kadhi 1 ½ katori,potato

cauliflower bhaji 1 katori,pumpkin raithaBED TIME 1 cup milk(225ml) & papaya (2 slices)

Weight gain during pregnancy:

The pre-pregnancy weight, socioeconomic status, genetics, health condition,

parity, and nutritional factors affect maternal weight during pregnancy.

The components of weight gain can be divided into 2 parts – the products of

conception and maternal tissue accretion. The products of conception comprise of

the fetus, placenta and amniotic fluid. Cross-sectional data indicate that fetal growth

follows a sigmoid curve with growth slowing in the final week of gestation. The rate

of placental growth also declines towards the end of pregnancy. The expansion of

maternal tissue accounts for approximately two-thirds of the total gain. In addition

to increases in uterine and mammary tissue mass, there is also an expansion of

maternal blood volume, extracellular fluid, fat stores and possibly other tissues.

Components of weight gain Component In Kg

BabyPlacentaAmniotic fluidMother

Breasts Uterus Body fluids Blood Maternal stores of fat, protein

and other nutrients

3.40.70.9

0.90.91.51.53.1

Total 12.9

Weight – for – height and Recommended Weight gain

Weight – for – height category Recommended total gain, kg(lb)

Normal (BMI 19.1 – 24.9kg/m2) 11.5 – 16(25 – 35)

High (BMI > 25 – 29.9kg/m2) 7 – 11.5 (15 – 25 )

Obese (BMI > 30kg/m2) No more than 7

Twin Gestation(any BMI) 23

Medical conditions where consultation with registered dietician is advisable:

Multiple gestation

Frequent gestation (<3months interpregnancy interval)

Tobacco, alcohol of chronic medicinal or illicit drug use

Severe nausea and vomiting

Eating disorders

Inadequate weight gain during pregnancy

Adolescents

Restricted eating

Food allergies/intolerances

GDM/prior history of GDM

Prior history of LBW babies/other obstetrical complications

Social factors that may limit appropriate intake(Eg.religion,poverty)

Nutrition during labour

Withholding food and drink inappropriately from women in labour may

result in dehydration, ketosis, fatigue and can increase levels of stress which

in turn can affect the Neuro-hormonal balance that enables labour to

progress unhindered.

The prophylactic use of antacids or reduction of the volume of stomach

contents by restricted oral Intake has not been shown to be successful in

preventing Mendelson’s syndrome.

For those women for whom a general anaesthetic is not anticipated a light,

low residue, low fat diet may be recommended in latent phase. Allow oral

fluids to maintain hydration in the active phase

For those women for whom a general anaesthetic is anticipated allow only

clear liquids.

The administration of opioids delays stomach emptying. So, allow only liquid

diet.

Suggested drinks for women in labour:

Low fat yoghurt drinks

Fresh fruit juices(avoid apple, pineapple, mango and lemon as they

tend to be more acidic)

Coffee/Tea with skimmed milk

Soups (cream of tomato or vegetable etc)

Squash drinks – not too concentrated

Water and ice

Naturally carbonated mineral water

Suggested foods for women in labour:

Idli

Toast with low fat spread, jam/honey

Cereals with skimmed milk/ganji

Plain sweet biscuits

Smooth soup

Low fat, smooth yoghurt

Guidelines for diet in gestational diabetes mellitus

Energy (Calories):

Carbohydrates: 55-60% of total calories. Encourage complex carbohydrates i,e

grains, cereals, pulses, beans, vegetables and salads. Avoid simple and refined

carbohydrates like sugar , honey, maida and jaggery.

Foods with low glycemic index is advised. Breakfast is 10-15%, Lunch and

dinner 25-30% and 4 snacks of 5-10% of total calories required per day.

Proteins: 1gm/kg body weight + 14 grams. Avoid red meat and egg yolk.

Fats: 22-15% of total calories. Saturated fat should be 6-7% of total calories.

Fruits: Consume one fresh fruit per day. Avoid juices. Ideal fruits are citrus fruits,

guava, apple, papaya and watermelon

Dietary fibres: 30-40 gram/day. Indian diet is rich in fibre. Avoid the loss of fibre

by refining and processing the food.

Condiments and spices: Include in diet plan. Provide antioxidants, trace elements,

minerals and omega 3 fatty acids.

Artificial sweeteners: Use of aspartame and artificial sweeteners is prohibited in

pregnancy and lactation.

Role of nutrition in IUGR:

Nutrition is the major intrauterine environmental factor that alters

expression of the fetal genome and may have life long consequences (Barker

hypothesis).Protein energy supplementation decreases the risk of IUGR by 30% in

those with inadequate nutritional intake. Mothers with decreased serum zinc

concentration benefit from zinc supplementation. Zinc is recognized as an important

factor for normal fetal growth and development.

Nutritive needs in Pregnancy induced hypertension:

Nutritional interventions such as calcium supplementation, antioxidants like

Vitamin C & E and fish oil have shown promise in the prevention and reduction of

PIH , especially in high risk groups, teenage pregnancies and in women with diets

low in calcium.

Maternal nutrition – tips to give your patient

Pregnancy is very special moment in someone’s life, it includes the joys and

challenges of motherhood and requires that your patient is given adequate

information with the best possible care, essential for a healthy pregnancy. It is

undoubtedly a very exciting time, but is also a period of great psychological stress

for a woman as she nurtures a growing fetus in her body. Fetal development is

accompanied by many physiological, biochemical and hormonal changes which

occur in the maternal body and influence the need for nutrients and the efficiency

with which the body uses them.

Nutrition is not only important for the unborn baby but is also essential for

the mother’s current and future state of health. The diet during pregnancy and

lactation is designed to promote optimal nutrition for the woman and fetus in

pregnancy and for the mother and infant during lactation.

1. A pregnant woman is always advised to eat what she wants, in amounts she

desires and food should be salted to her taste. Mothers who are in negative

energy in terms of both food storage and heavy workload deliver low birth

weight babies. Pregnant women from low socio economic group should make

efforts to ensure a healthy diet.

2. Proteins are needed for repair of the mother’s tissue as well as for added

demands of growth, increased blood volume and repair of placenta, uterus

and breast. They can be supplied from either meat, milk, eggs, pulses ,

legumes, cheese, poultry or fish. Generally if a pregnant woman consumes

enough calories in her food, her protein needs are taken care of.

3. Her weight should be checked serially with the intention of gaining about 10 –

12 kg during the whole period of 40 weeks.

4. Iron is the only nutrient for which requirements cannot be met by diet alone.

Iron deficiency anemia is a significant cause of increased maternal mortality

and has an adverse effect on the health and development of the newborn.

Tablets of simple iron salts that provide 30 – 60mg of iron/day should be

taken. Iron supplementation is not necessary in the first trimester and it also

aggravates nausea and vomiting. Recheck the hemoglobin concentration at 28

– 32wks to detect any significant decrease.

5. The increased requirements of all vitamins can be generally supplied by the

usual diet, except for folic acid, which is required more in pregnancies, that

are complicated by protracted vomiting, hemolytic anemia, multiple fetuses

and those on antiepileptic drugs. Folic acid tab of 5mg/day should be taken

not only during pregnancy but also three months before you are planning to

start a family, especially in cases with a genetic or family history of neural

tube defects.

6. Strict vegetarians may have low vitamin B12, so supplementation of vitamin

B12 may be required in such cases. Studies show that multi vitamin

supplementation for women who do not consume an adequate diet are not

really helpful.

7. Calcium is deposited in the fetus during later pregnancy. This amount

represents about 2.5% of maternal calcium, most of which is present in the

bone and can be readily used for fetal growth. So it is only in developing

countries where there is deficiency of vitamin D and calcium that

supplementation is required. One cup of cow’s milk provides approximately

1gm of calcium.

8. Iodised salt should always be used. So as you can see, pregnancy does not

require too much of extra nutrition. Rather a good balanced diet with all the

specific nutrients is required for the benefit of the mother and the growing

fetus.

Nutritional guidelines for a pregnant mother

o Drink plenty of fluids in the form of water and juices, which help increase the

volume of breast milk.

o The maximum amount of energy should be derived from whole grain cereals

rather than from fats and sugars.

o The source of carbohydrates should be mainly from the consumption of

whole grain cereals rather than from sugars and refined products.

o Non-vegetarians can get protein from meat, poultry and eggs. Vegetarians

can derive quality proteins from a combination of cereals, legumes, pulses

and nuts. Intake of sprouted pulses is desirable.

o Mineral and vitamin requirements should be met by consuming a variety of

fruits(including seasonal) and vegetables, especially those rich in vitamin C

such as orange and green leafy vegetables.

o Vegetarians should drink milk can serve as a source of calcium and vitamin

B12 and D.

o A combination of PUFA (Poly unsaturated fatty acids) and MUFA (Mono

unsaturated fatty acids) oils as a source of energy and is preferable to

saturated fats.

o Eat foods rich in vitamin C, such as citrus fruits, amla, guava, sprouts etc with

meals in order to improve the absorption of iron from the food.

o Milk and curd are the best sources of biologically available calcium.

o Foods that are not nutritious, like those that are fried or barbecued, should

be avoided, including those that can cause allergic reactions in the pregnant

woman.

o A pregnant mother may also require calcium, iron and vitamin B-12

supplements.

o Choose at least five daily servings of fruits and vegetables. Also try whole

grain foods such as ragi, dal, brown bread, whole grain pulses and lentils.

o Whenever possible eat fruits with the peel and remember that eating a fruit

is more beneficial than drinking fruit juice.

o Drink at least 12 glasses of fluid per day.

o Only take chemical laxatives prescribed by an obstetrician.

If weight gain is too rapid during any part of the pregnancy, the following guidelines

should be used to manage weight:

Avoid high-calorie, low-nutrient foods such as sweets, cakes, pastries,

desserts and fried snacks like chips, vadas, bondas etc.

Use low-fat dairy products-skimmed milk and yogurt/curd made with

skimmed milk.

Use only lean meats, poultry and fish.

Bake, broil, grill, or stir-fry instead of frying foods.

Increase physical activity.

Do not crash diet!!!

References:

1) Williams obstetrics 23rd edition

2) D.K.James - High risk pregnancy management options 4rd edition

3) Steven G Gabbe -Obstetrics 5th edition

4) Maternal nutrition: A Quintessential Guide- Kamini Rao, Vindhya Subbiah