1. Maternal Nutrition during Pregnancy and Lactation
Assistant Professor
Dr. Batool Ali Ghalib Yassin
Dept. of Community & family Medicine
College of Medicine – University of Baghdad

2. 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

3. 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

4. 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, constipation and impaired absorption eg. iron

5. 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.

6. 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.

7. 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.

8. Possible Outcomes of Maternal Under-Nutrition; 2. Anaemia:
Degree of anaemia
Moderate (Hb gm/dl) - PCV (24 – 37 %)
Severe (Hb 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 B12. 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.

9. 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.

10. 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 ( Kg)
Environmental and hereditary factors affect the infant’s birth weight.

11. 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 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.

12. Causes; I - Complications During Pregnancy:
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.
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.
Heart Diseases:
associated with pre-term delivery, which is sometimes induced.
Anaemia:
associated with LBW and pre-term delivery.

13. Causes; I - Complications During Pregnancy:
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:
Viral: Rubella, Cytomegalovirus, and Herpes.
B. 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).

14. Causes; I - Complications During Pregnancy:
Cervical incompetence: may be also associated with infections and lead to preterm delivery.
Uterine abnormalities: congenital malformations of the uterus and fibromyomas can lead to preterm delivery.
Polyhydramnios: is associated with preterm delivery.
Premature rupture of the membranes: is associated with preterm delivery.
Antepartum haemorrhage: is associated with fetal growth retardation and preterm delivery.

15. Causes; I - Complications During Pregnancy:
Placental factors: the small placenta and the diseased placenta (abruptio placentae and placental infarcts) are both associated with IUGR.
Amniocentesis: is associated with infections and preterm delivery.
Maternal surgery: abdominal surgery may lead to preterm delivery.
Trauma: may lead to preterm delivery.
Iatrogenic: incorrect estimation of the gestational age may lead to preterm induction of labour.

16. II- Multiple Pregnancy
In humans, intrauterine growth begins to falter between 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.

17. V- Biological Factors
Maternal age: more LBW and preterm births happen before 20 years and after 35 years of age.
Maternal height: more LBW in shorter mothers.
Maternal weight: low pre-pregnancy weight, low weight gain during pregnancy and low quality diets are associated with LBW.
Parity: increased chance of LBW in first and after the 4th birth.
Short spacing: increased chance of LBW and preterm delivery.
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.

18. V) Biological Factors VI) Socioeconomic Factors:
Occupation and physical activity: hard physical work are associated with a higher chance of LBW and preterm deliveries especially in developing countries.
Psychological stress: is associated with preterm labour.
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

19. 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.

20. 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)

21. 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.

22. Causes of Morbidity and Mortality; Immediate:
Metabolic: hypocalcaemia and hyperbilirubinaemia.
Renal: Lower GFR.
Temperature regulation: hypo and hyperthermia.
Immunity: increased risk of infections.
Ophthalmic: retrolental fibroplasia and blindness.

23. Causes of Morbidity and Mortality; Long Term:
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