nutrition and micro nutrients

8/6/2019 Nutrition and Micro Nutrients

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A D VA N C E S I N M A T E R N A L A N DN E O N A T A L H E A L T H

Nutrition and Micronutrients

in Pregnancy

BY: Louella Ramos



Ev idence of Nutritional Inter v entionEffecti v eness

Nutrition and Micronutrients in Pregnancy

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y Maternal malnutrition

y Folate

y Iron

y Iodine

y Vitamin A y Zinc

y Calcium



Maternal Malnutrition and Pregnancy Outcome


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y Se v ere nutritional depri v ation (Netherlands 1944±45)

Birth weight significantly influenced by star v ation

Perinatal mortality rate not affected

No increase incidence of malformation In healthy women, state of near star v ation is needed to affect

pregnancy outcome

y Se v ere nutritional depri v ation (Netherlands 1944±46)

Periconception: Decreased fertility, increased neural tube defect

1st trimester: Increased stillbirths, preterm births, early newborn

deaths 3rd trimester: Low birth weight, small for gestational age,

preterm birth

Cunningham et al 1997; Susser and Stein 1994.



Nutritional Supplementationand Anemia


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y W HO definition of se v ere anemia: Hemoglobin < 7 g/dL

y Le v el of risk

Moderate anemia (Hgb 7±11 g/dL): Not increased

Se v ere anemia: Significant risk

ySe v ere anemia associated with: Low birth weight newborns

Premature newborns

Perinatal mortality

Increased maternal mortality and morbidity



Anemia and Obstetrical Hemorrhage


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y Anemia does not cause obstetrical hemorrhage (e v en se v ere anemia)

y Etiology of obstetric hemorrhage

Early pregnancy: Abortion complications

Mid/late pregnancy to deli v ery: Pre v ia, abruption, atony, retained placenta, birth canal laceration

y Primary factors affecting outcome: R apid inter v ention to pre v ent exsanguination

A v ailability of skilled pro v ider, drugs, blood and fluids

y There is no e v idence that high le v els of hemoglobin are beneficial in withstanding a hemorrhagic e v ent.

Enkin et al 2000; Mahomed 2000a.



Iron Supplementation


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y Iron requirements:

A v erage non-pregnant adult:

Ù 800 Qg iron lost/day

Ù + 500 Qg iron lost/day during menses

Pregnant woman: Increased needÙ Expanded blood v olume

Ù Fetal and placental requirements

Ù Blood loss during deli v ery

y R outine v s. selecti v e iron supplementation:

Pre v alence of nutritional anemia R outine iron and folate supplementation where nutritional

anemia is pre v alent

R ecommended dose: 60 mg elemental iron + 5 Qg folic acid

Mahomed 2000b; WHO 1994.



Iodine Supplementation


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y Iodine deficiency is a pre v entable cause of mental impairment

y Iodine supplementation and fortification programs ha v e been largely successful in decreasing iodine deficiency conditions

y Population with high le v els of mental retardation (e.g., some parts of

China): Supplementation may be effecti v e at preconception up to mid-

pregnancy period

Form of iodine supplementation (iodinating food or oral/injectableiodine) depend on:

Ù Se v erity of iodine deficiency

Ù

CostÙ A v ailability of different preparation

Enkin et al 2000; Mahomed and Gülmezoglu 2000.



Other Micronutrients: Calcium


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y Association between reduction in pregnancy induced hypertension (PIH) andcalcium supplementation

R eduction of incidence of PIH

R outine supplementation likely beneficial in women at high risk of

de v eloping PIH or ha v e low dietary calcium intake High calcium doses (2 g/day) not associated with ad v erse e v ents

Need adequately sized and designed trials in different settings to confirm beneficial effects

y R ecommend increase in calcium intake through diet in women at risk of hypertension or low calcium areas

Bucher et al 1996; Kulier et al 1998; Lopez-Jaramillo et al 1997.



Calcium Supplementation: Objecti v e and Design


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y Objecti v e: To assess effects of calcium in pre v ention of hypertensi v e disordersof pregnancy

y Methods: Meta analysis of randomized controlled trial

y Outcomes:

Mothers: H ypertension +/- proteinuria, maternal death or seriousmorbidity, abruption, cesarean section, length of stay

Newborns: Preterm deli v ery, low birth weight/small for gestational age,neonatal intensi v e care unit admission, length of stay, still birth/death,disability, hypertension

Atallah, Hofmeyr and Duley 2000.



Calcium Supplementation: R esults


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y Mothers:

H ypertension+/-proteinuria:

Ù Less hypertension: RR 0.81 (0.74±0.89)

Ù Less pre-eclampsia: RR 0.70 (0.58±0.83)

Ù Better if low calcium intake, high risk

y Newborns:

Low birth weight: RR 0.83 (0.71±0.98), best for women at highest risk

Chronic hypertension: RR 0.59 (0.39±0.91)

No difference in preterm deli v ery, neonatal intensi v e care unit admission,stillbirth, death




Calcium Supplementation: Conclusions


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y Calcium decreases risk of hypertension, pre-eclampsia, low birth weight, andchronic hypertension in children

y R ecommend for high risk women with low calcium intake, if pre-eclampsia isimportant in the population

y Calcium has other health benefits not related to pregnancy: Maintaining bone strength

Proper muscle contraction

Blood clotting

Cell membrane function

Healthy teeth




Summary of Nutritional R e v iew Findings


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y Ev idence of nutritional inter v ention effecti v eness

Iron supplementation

Periconceptional folic acid intake

Iodine use

Balanced energy/protein supplementation Calcium

y Confirmatory studies to examine effecti v eness

Vitamin A

Zinc



R eferences (continued)


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Enkin M et al. 2000. A Guide to Effective Care in Pregnancy and Childbirth, 3rd

ed. Oxford Uni v ersity Press: Oxford.

KulierR et al. 1998. Nutritional inter v entions for the pre v ention of maternal morbidity. Int J Gyn Obstet 63: 231±246.

Lopez-Jaramillo P et al. 1997. Calcium supplementation and the risk of preeclampsia inEcuadorian pregnant teenagers. Obstet Gynecol 90(2):162±167.

Mahomed K. 2000a. Iron supplementation in pregnancy (Cochrane R e v iew), in TheCochrane Library. Issue 4. Update Software: Oxford.

Mahomed K. 2000b. Iron and folate supplementation in pregnancy (Cochrane R e v iew),in The Cochrane Library.Issue 4. Update Software: Oxford.

Mahomed K and A Gülmezoglu. 2000. Maternal iodine supplements in areas of deficiency (Cochrane R e v iew), in The Cochrane Library. Issue 4. Update Software:Oxford.



R eferences (continued)


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Mahomed K et al. 1998. R isk factors for pre-eclampsia among Zimbabwean women:maternal arm circumference and other anthropometric measures of obesity. Paediatr Perinat Epidemiol 12: 253±262.

Medical R esearch Council Vitamin Study R esearch Group. 1991. Pre v ention of neuraltube defects: results of the Medical R esearch Council Vitamin Study. Lancet 338

(8760):131±137.R othman KJ et al. 1995. Teratogenicity of high v itamin A intake. N Engl J Med 333(21): 1369±1373.

Suharno D et al. 1993. Supplementation with v itamin A and iron for nutritionalanaemia in pregnant women in West Ja v a, Indonesia. Lancet 342: 1325±1328.

Susser M and Z Stein. 1994. Timing in prenatal nutrition: A reprise of the Dutchfamine study. Nutrition Reviews 52 (3): 84±94.

West Jr. KP et al. 1999. Double blind, cluster randomised trial of low dosesupplementation with v itamin A or beta carotene on mortality related to pregnancy inNepal. Br Med J 318: 570±575.

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