How important is Periconceptional nutrition?

How do maternal body weight and weight gain in pregnancy affect pregnancy out come?.

Are vitamin and mineral supplement necessary during pregnancy?.

Importance of exercise. Can pregnant lady travel?.

Periconceptional Periconceptional nutrition nutrition Folic acid periconcoption (0.4 mg) at least (1month) periconcoption until the end of first trimester- decrease the chance of neural tubal defect.

Diabetic patient should be counseled periconceptional regarding nature of her diet (four fold increase in incidence of major congenital malformation in poor control dunning emloryogenesis).

Women with phenyl ketonuria have increased risk of fetal malformation including cardiac defects and microcephaly .

This can be decreased significantly if phenyl alanine restricted diet is implemented (3months) before conception and low birth wt is reduced if phenylanin level normalized by (8weeks) of gestation.

Maternal body wt gain and its effect of pregnancy out

come Optimal amount of prenatal weight

gain is modified by woman’s

pregnancy weight for height (BMI).

0.5 kg/wk for under weight.

0.4 kg/wk for normal weight.

0.3 kg/wk for over weight.

Under weigh woman and women with low pregnancy gain are at higher risk for delivery of low birth wt (<2.500kg) and preterm delivery .

Over weight women and women with high pregnancy weight gain are at risk of macrosomia (>4.5kg) which at risk for shoulder dystocia- Erb’s palsy- cesarean section- Hypertension- diabetes- post- operative wound infection.

How vitamins and minerals supplement necessary during

pregnancy Animal studies have shown better fetal

outcome when foliate- vitamins and amino acids are supplemented (including greater fetal weight and decease subcutaneous bleeding, more ossification centers and fewer malformation.

Lead exposure toxicity can be minimized by supplementation of vit (C & E) (anti-oxidant).

HIV infection- supplemental selenium has been shown to inhibit reverse transcriptase activity in RNA of virus infected animal, selenium with antioxidant vit (C & E) speculated as measure to decrease the probability of placental transmission of HIV.

Hypertension may benefit from calcium supplementation.

Diet requirement in pregnancy

As the energy requirement in pregnancy are increased by approximately (17%) over the non pregnant state.

A woman of normal weight should consume an additional 300k cal/ day and these calories should be concentrated in foods of high nutrient density a value based on the percent protein – vitamins and minerals per (100 k calory).

Generally- thin and under nourished women require higher energy intake than other women.

Birth weight is affected- more significantly by number of calories not the form of calories.

Total caloric intake will based on BMI (women pre- pregnancy wt on height) but the average recommendation is 2500 h cal / day.

Protein

Should comprise (20%) of normal pregnancy diet. Recommended daily allowance for pregnant women is (60)grams mainly from animal sources as fish-egg-meat to provide appropriate amino acids .

Animal protein sources are high in fat these should used sparingly so as to avoid excessive weight gain.

Fat: Should Comprise (30%) of diet in pregnancy.

Carbohydrate: Comprise (30%).

Should the diet differ for multiple pregnancy?

• Yes. The recommendation of additional (300 kcal) and (10 grams) of protein per fetus beyond singleton are standard.

Iron- (300 mg) of iron is transferred to the fetus and (800 mg) is incorporated in to maternal Hb mass.

- 0.6 mg/ day requirement in second half of pregnancy very few women have sufficient iron stores and diet seldom contains enough iron to meet the demand and and ensure adequate intake and iron supplementation is recommended.

- Iron absorption was observed

to increase with gestational

age. (7% at 12wks, 36% at

24 wks and 66% by 36 wks).

Minerals

The sorts of food should be encouraged to increase iron in the diet:

- High sources: lean red meat especially liver.- In vegetarian: diets beans when consumed

with acidic beverage such orange. - Moderate sources : enriched grain products

and cereals. - Calcium and magnesium inhibit iron absorption

and iron whether dietary or supplement should not be consumed within one hour of calcium intake.

- Antacids taken for heart burn (which common complain in pregnancy interfere with iron absorption. Tea- caffie can decrease non heme iron to more than half.

Calcium

(30 g) Calcium (2.5% of total maternal calcium is needed for fetus.

Most maternal calcium is in bone and can easily mobilized to meet needs of the fetus.

Also absorption by intestine (es) during pregnancy and calcium supplement may recommended in certain types of patient as grand multipara.

Iodine: Increased fetal requirment and increased

maternal renal loss- use of iodized salt meet this requirment.

Copper: Pregnancy affects copper metabolism

because it increase serum ceruloplasmin and plasma copper. Howerver copper deficiency in pregnancy has not been documented.

Most other element not need supplementation in pregnancy inspite certain elements could be toxic in high doses as zinc ( which may suppress immune system).

What vitamins are important in pregnancy

Folic acid: - Maternal foliate requirement are

slightly increased during pregnancy.- Patient prone to foliate deficiency

which rarely leads to megaloblastic anemia (in certain patient as twins pregnancy and grand multiparty).

- ( 0.4mg) daily for all women of childbearing age to prevent neural tubal defect.

Vit B12 : Deficiency is usually seen only in strict

vegetarians. In breast fed infant of vegetarians B12

deficiency pronounced.

Vit C:- Requirement is (20%) higher in

pregnancy.- Vitamins (A- B6 – C and D ) are toxic in

high dose.

Fluid requirement during pregnancy

Pregnancy associated with increased fluid requirement.

An average of 9 L of fluid gained during gestation translates into (30ml/day) above the non pregnant state.

Maternal fluid status affect the regulation of amniotic fluid volume.

Acute changes in maternal osmolality affect fetal hydration.

Exercise during pregnancy

What changes in physiologic parameters are seen in exercising pregnant women compared to the non pregnant state?.

HR changes not grate. Strock volume and cardiac output are

increased. Interesting a (12%) incidence of ST

segment depression on ECG has been reported but is not felt to be related to ischemic and has no clinical sequalae.

Points to be taken in consideration regarding exercise

during pregnancy Because of increased ligamentous laxity pregnant women more subject to sprains and other ligament injury and the shift in center of gravity as pregnancy progresses makes balance more difficult (↑es chance of falling down so jumping- Horse back ride are discouraged).

Patient should not do exercise in supine position after (20) weeks because of supine hypotension affect ever if its asymptomatic.

The decrease in placental blood flow due to combination of :

1- Caval compression.2- Shunting of blood to working skeletal

muscles is believed to be potentially harmful to the fetus.

Generally encourging the pregnant ladies slowly begins a low-impact exercise program (as walking) unless the lady has a hypertensive disorder- Multiple pregnancy IUGR or heart disease.

Travel

No harm full effects on an other wise healthy women.

Seat belt should be worn properly with three-point restrains (lap belt should be placed under the abdomen and shoulder belt between breasts.

Air travel

International travel all right up to 32-35 weeks Advise patient to carry her own notes with EDD and appropriate insurance.

Aisle seat over a bulk head provides most space and a seat over the wing in the midplane region will give the smoothest ride.

Advise to walk every (30 minutes) and flex and extend ankles frequently ( to prvent the risk of deep vein thrombosis).

Low dose aspirin (75 mg/ may think about pre travelling ( started by ≈ 3 days) in patient at risk as obesity.

Safety belt to be fastened at pelvic level.

Fluids to be taken liberally because of dehydrating effects of low humidity in the air craft.

If Bp raised should not 90- should have Bp checked during the away.