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The FETAL AND MATERNAL
HEALTHTeratogenicityPrenatal CareMaternal Adaptation to PregnancyPsychological/Emotional Adaptation to
Pregnancy
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TeratogensCommon things that can harm
fetal development.
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TERATOGENS substances that are toxic to some part of a developing
embryo or fetus
Word root: terato- = monster
-gen = to make
CATEGORY DESCRIPTION
A Well controlled studies in women fail to demonstrate a risk tothe fetus
B Animal studies do not demonstrate a risk, no studies in women
Animal studies uncovered some risk, but no adequate studies inwomen
C Animal studies indicates adverse risk to the fetus, and nocontrolled studies in women. Studies in women and animal arenot available
D Human experiences shows association of drugs with birthdefects, but the potential benefits of a drug may be accepted
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TERATOGENS
Recereational Drugs Narcotics Cocaine Crack
Teratogenicity of Alcohol
Congenital Deformities Metal Retardation FAS
Teratogenicity of Cigarette Environmental Teratogenes Radiation Hyperthermia/Hypothermia Teratogenicity of Maternal Stress
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Nicotine and Cocaine
Both nicotine andcocaine are known to beaddictive.
Developing fetusesbecome addicted too.
Both drugs constrictblood vessels.
This decreases oxygendelivery to the fetus.
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Results of Nicotine andCocaine Use
Low birth weight babies,because they didnt get
enough oxygen to grow. Newborns going through
withdrawal from drugs. Most cannot adjust their own
body temperatures.
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can also cause Neuraltube defects
A neural tubedefect is a problemwith the formationof the brain and/orspinal cord.
The most commonneural tube defectsare spina bifida andmyelomeningocoel.
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Alcohol
Alcohol is anaddictive and
LEGAL drug. Beer, wine and
liquor all affect thefetus the same.
Just as alcoholdamages adultbrains, it alsodamages fetal
brains.
Both brains are from 6 week oldnew borns.
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Some Potentially/Positively Teratogenic Drugs
Accutane Congenital anomalies Androgens Masculinization of the female fetus Antiepileptics Cleft lip and palate, Congenital heart
anomalies
Antineoplatics Anxiolytics Congenital malformation Iodide 131 Destroy the thyroid of the fetus Oral anticoagulant Bleeding Phenothiazines Retinopathy Vaccine Vitamin c
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Prescription drugs can also beharmful.
Even prescriptions thatyou took beforepregnancy should be
carefully considered. Anti-epileptic drugs, acne
treatments, sedatives
and antibiotics candamage developingfetuses.
Streptomycin anti TB &
or Quinine (anti malaria)
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Anticonvulsives
Common prescriptions
for controlling
epilepsy can have bad
effects.
Dilantin, Valproicacid and
Trimethadione can all
cause defects.
Always discuss
medications with your
prenatal physician.
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Diethylstilbestrol (DES)
This drug wasgiven to treat
menstrual crampsand preventmiscarriages.
It was found to
have toxic effectson the sex organsof the babies.
It affects both
male and female
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Thalidomide
This used to begiven to prevent
morning sickness. Many children
whose moms tookthalidomide were
horribly deformed. This drug is no
longer given topregnant women.
Th lid id ff t d th
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Thalidomide affected thedevelopment of arms andlegs.
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CARE?Goals of Prenatal Care: To ensure a healthy and uncomplicated pregnancy and
the delivery of a healthy infant To identify and treat high risk condition
To individualize patient care To assist the patient for her preparation for labor,
delivery and puerperium To screen and identify risk factors or disease that may
affect the mother or the infants health and life
To reinforce healthy habits to the woman and herfamily
Definition of Terms:
GravidaNulligravida
Primigravida
Multigravida
Para.Parity refers to the number of pregnancies that has reachedthe period of viability (possibility of survival outside the uterus,
after 24 weeks gestation, at least 20 cm length, or at least600g)regardless of the number of fetuses and whether it is dead
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Local Setting: Components of PrenatalCare at the BHS and RHU
1. History Taking (HBMR) is used when rendering prenatal care inpregnancy, childbirth and postpartum period identifying risk factors,danger signs, health education and referrals.
Risk factors that needs close monitoringand referrals:
Below 18 years old and above 35 years old
Below 4 feet or 145 cm
5th or more pregnancy
Previous CS
Previous postpartum hemorrhage
TB
Heart Diseases
Diabetes
Bronchial Asthma
Goiter
Three consecutive abortion
2. Physical Examination per visit
3. Treatment of Diseases
4. TT Immunization
5. Supplementation
6. Health Education
7. Laboratory Examination8. Oral Dental
l i f l
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Local Setting: Components of PrenatalCare at the BHS and RHU
9. Referral when necessary
10. Home Delivery Only normal cases are qualified for homedelivery
11. Postnatal services
Components of Prenatal Clinic Visit
First Clinic Visit is a time to obtain baseline data throughinterview, laboratory test and complete physicalexamination. Activities on initial clinic visit consistprimarily of:
History Taking
Complete PE
Lab test
Fetal Assessment Health Teaching
Subsequent Clinic Visits
A. Maternal Assessment Blood Pressure
Weight Nutrition
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Components of Prenatal Clinic Visit
B. Fetal assessment FHR
Quickening Fundal Ht.
Specific assessment
Abdominal palpation
Late in Pregnancy vaginal examination, pelvic measurement,dilatation and station and cervical effacement
C. Health Teaching Normal s/sx of pregnancy
Minor discomforts, prevention management
Danger signs of pregnancy
Nutrition and diet
Rest, exercise
Avoid drugs, alcohol, cigarettes and too much caffeine Clothing
Sexual relations
Employment
Travel
Preparation for babys birth, labor, delivery and puerperium
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Obstetrical History Taking
G.P and T.P.A.L.(Gravida.Parity.Term.Preterm.Abortion.Living)
Example:
A woman who has had two previous pregnancies, has
delivered two term children, and is again pregnant.What is the GP?
G3P2A woman who has had two abortions at 3 months and
is again pregnant. What is the GP?
G3POA patient who is pregnant for the second time, butmiscarried her first pregnancy would be ;
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Obstetrical History Taking
T.P.A.L.T the number of full term infant born at 37 weeksor after
P the number of preterm infant born before 37
weeksA the number of induced/spontaneous abortion
L the number of living children
Example:
A woman who has 2 living children born as preterm twins in herfirst pregnancy would be designated as. GTPAL?
G1 P 0-1-0-2A patient was pregnant twice, did not carry any to full-term, had one pre-term(pre-mature), had one abortion (or spontaneous abortion which is commonlyreferred to as miscarriage), and one (the twin to the one delivered pre-term) is
livingG2P 0-1-1-1
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NCLEX Question:
Mrs. Donna, pregnant for 16 weeksage of gestation (AOG), visits the healthcare facility for her prenatal check-upwith her only son, Mark. During
assessment the client told the nursethat previously she got pregnant twice.The first was with her only child, Mark,who was delivered at 35 weeks AOG and
the other pregnancy was terminated atabout 20 weeks AOG.
Based on the data obtained, Mrs.Donnas GTPAL score is:
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Leopold's Maneuver
In obstetrics, Leopold'sManeuvers are a common and systematic
way to determine the position of
a fetus inside the woman's uterus; they are
named after the gynecologist Christian
Gerhard Leopold. They are also used to
estimate term fetal weight.
The maneuvers consist of four
distinct actions, each helping to determine
the position of the fetus. The maneuvers
are important because they help determine
the position and presentation of the fetus,which in con unction with
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Leopold's Maneuver
Leopold's Maneuvers performed
by are difficult to perform
on obese women and women who
have polyhydramnios.
The palpation can sometimes
be uncomfortable for the woman
if care is not taken to ensure she
is relaxed and adequately
positioned.
To aid in this, the health care
provider should first ensure that
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Leopold's ManeuverFirst maneuver: Fundal Grip
While facing thewoman, palpate thewoman's upper abdomenwith both hands. Aprofessional can oftendetermine the size,consistency, shape, andmobility of the form that isfelt.
The fetal head is hard, firm,round, and movesindependently ofthe trunk whilethe buttocks feel softer,
are symmetric, and theshoulders and limbs have
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Leopold's ManeuverSecond maneuver: UmbilicalGrip After the upper abdomen has been
palpated and the form that is foundis identified, the individualperforming the maneuver attemptsto determine the location of the fetal
back. Still facing the woman, thehealth care provider palpates theabdomen with gentle but also deeppressure using the palm ofthe hands.
First the right hand remains steadyon one side of the abdomen whilethe left hand explores the right sideof the woman's uterus. This is thenrepeated using the opposite side andhands.
The fetal back will feel firm andsmooth while
fetal extremities (arms, legs, etc.)should feel like small irregularities
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Leopold's ManeuverThird maneuver: Pawlick'sGrip In the third maneuver the health
care provider attempts to determinewhat fetal part is lying above theinlet, or lower abdomen.Theindividual performing the maneuver
first grasps the lower portion of theabdomen just above the pubicsymphysis withthe thumb and fingers of the righthand.
This maneuver should yield theopposite information and validatethe findings of the first maneuver. Ifthe woman enters labor, this is thepart which will most likely come firstin a vaginal birth.
If it is the head and is not activelyengaged in the birthing process, it
may be gently pushed back andforth. The Pawlick's Grip, although
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Leopold's ManeuverFourth maneuver: PelvicGrip
The last maneuver requires thatthe health care provider face thewoman's feet, as he or she will
attempt to locate thefetus' brow. The fingers of bothhands are moved gently downthe sides of the uterus towardthe pubis.
The side where there is
resistance to the descent of thefingers toward the pubis isgreatest is where the brow islocated. If the head of the fetusis well-flexed, it should be on theopposite side from the
fetal back. If the fetal head isextended thou h the occi ut is
Maternal Adaptation to
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Maternal Adaptation toPregnancy
Cardiovascular Changes The heart is displaced upwards There may be splitting of the heart sound, with common systolic
murmurs Cardiac Volume increases by 40 to 50% causing slight cardiac
hyperthrophy and increase in CO Physiologic Anemia Total circulating blood cells increases Leukocyes count is elevated during labor
Fibrinogen levels increased by 50% along with other clottingfactors
Endocrine Changes Placenta starts producing estrogen, progesterone, HCG, HPL
Elevated estrogen and progesterone level suppresses the LH,FSH Ox tocin
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Pathogenic Anemia iron deficiency anemia isthe most common hematological disorder. Itaffects toughly 20% of pregnant women.
Assessment reveals: Pallor, constipation Slowed capillary refill Concave fingernails (late sign of progressive
anemia) due to chronic physio-hypoxia
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Nursing Care:
Nutritional instruction kangkong, liver dueto ferridin content, green leafy vegetable-
alugbati,saluyot, malunggay, horseradish,
ampalaya Parenteral Iron ( Imferon) severe anemia,
give IM, Z tract- if improperly administered,
hematoma.
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Alert:
Iron from red meats is better absorbed than
form other sources
Iron is better absorbed when taken with foods
high in Vitamin C such as orange juice
Higher iron intake is recommended since
circulating blood volume is increased and
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Edema lower extremities due venous return is
constricted due to large belly, elevate legs abovehip level.
Varicosities pressure of uterus use support stockings, avoid wearing knee high socks use elastic bandage lower to upper
Vulbar varicosities- painful, pressure ongravid uterus to relieve- position side lying with pillow
under hips or modified knee chest position
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Thrombophlebitis presence of thrombus at inflamed blood vessel
o pregnant mom hyper-fibrinogenemiao increase fibrinogeno increase clotting factoro thrombus formation candidate
outstanding sign
(+) Homan's sign pain on cuff during
dorsiflexion
Managemento Bed resto Never massageo Assess + Homan sign once only might dislodgethrombus
Maternal Adaptation to
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Maternal Adaptation toPregnancy
Reproductive System Enlargement and thickening of the uterus most manifested in
the fundus Starting at 12 weeks gestation , the fundus can already be
palpated as it rises out of the pelvic cavity. Being muscular, the uterus undergoes irregular contractions
starting on the first trimester. Hegars Sign Color of the cervix change in color from pinkish to purplish Leukorrhea ---- mucus plug ---- SHOW Ovulation ceases throughout pregnancy Increased vascularity, hyperemia, and softening of the perineum
and vulva Vaginal secretion increases, decrease PH 3.5 to 6 Breast becomes tender and tingle in the early weeks of
pregnancy Increased in size ,larger nipples and more pigmented
Maternal Adaptation to
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Maternal Adaptation toPregnancy
Integumentary System Striae Gravidarum reddish, slightly depressed streaks in the
abdominal wall, breast and the thighs Linea Nigra line of dark pigment extending from the umbilicus
down the midline of the symphysis pubis. Chloasma are brownish patches of pigment on the face
Metabolic Changes Weight Gain is average 11 to 13 kgs (24-28 lbs) Fetus (3400gm), Placenta (450 gm), AF (900 gm), Breast Tissue
(1400gm), Blood Volume (1800gm), Maternal Store (1800-3600gm)
HPL, estrogen, progesterone and insulin produced by theplacenta during pregnancy oppose the action of insulin duringpregnancy.
Fats are more completely absorbed during pregnancy, plasmalipid levels increase during the second half of pregnancy
Maternal Adaptation to
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Maternal Adaptation toPregnancy
Respiratory Changes Hyperventilation occurs Enlarging uterus elevates the diaphragm Thoracic cage expands by means of flaring of the ribs
Nasal Stuffiness
Urinary Tract Changes Ureters becomes dilated and oblongated GFR increase
Glocusuria Protein in the urine should be reported
Maternal Adaptation to
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Maternal Adaptation toPregnancy
Gastrointestinal Changesv Nausea and Vomiting on the first trimesterv Pika/Pica craving for nonfood stuff or unusual food stuffs is common in
some culturesv Hemorrhoids are commonv Effects ofPROGESTERONE
v Constipationv Pyrosis/Heartburn
v Generalized itching
v Effects ofESTROGENv Ptylaism
v Epulis
Skeletal Changesv Softening of the joints, ligamentsv Low backachev Lordosis
v Leg Cramps
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Leg Cramps
prolonged standing, fatigue, Ca & phosphorous imbalance(#1 cause while pregnant)
chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerveplexus
Management:
Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis, sardines withbones, brocolli, seafood-tahong (mussels), lobster, crab.
Vitamin D for increased Ca absorption
Dorsiflexion
h l i l/ i l d i
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Psychological/Emotional Adaptations to
Pregnancy
First Trimester Acceptance of PregnancySecond TrimesterAccepting the Baby
Third Trimester Preparing for Parenthood
First Trimester
Acceptance of the reality of pregnancy is the first psychological task that a woman isabout to become a mother faces. Aside from the signs and symptoms of pregnancyis experienced, the doctors conformation often helps the woman to accept the factthe she is pregnant. At this stage the unborn is incorporated as part of the woman'sbody image or as part of herself.
Second Trimester
Quickening by 20 weeks gestation can be very significant in helping the womanrealize that the fetus inside her womb is not just a part of her body but a real andseparate individual of care. She begin to fantasize about the sex and appearance.
The woman becomes introspective during this stage because she is preoccupied witthe fantasies about her unborn child.
h l i l/ i l d i
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Psychological/Emotional Adaptations to
Pregnancy
First Trimester Acceptance of PregnancySecond TrimesterAccepting the Baby
Third Trimester Preparing for Parenthood
Third Trimester
The woman begins to plan about the birth of the baby. She select babyslayette, choose name for her baby, makes plan on how the baby will befed, where the baby will sleep at home.
Emotional Reactions Experienced by a Newly Pregnant Woman Ambivalence Fear and Anxiety Introversion or Narcissism Uncertainty
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TYPES OF PELVIS
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TYPES OF PELVIS
Gynecoid Pelvis
This is the normal female pelvis. The inlet of this type of
pelvis is well rounded forward and backward, and the pubic
arch is wide. This type of pelvis ideal for childbirth.
Anthropoid Pelvis
This has a long,oval brim in which the antero-posterior
diameter is longer than the transverse.This does not
accommodate a fetal head. an ape like
Platypelloid Pelvis
This flat pelvis has a kidney-shaped brim in which the
anteposterior diameter is reduced and the transverse
increased. flattened one the inlet is oval smoothly curved.
A fetal head would not be able to rotate to matched the curve.Android pelvis
male pelvis the pubic arch of this type pelvis forms an
acute angle making the lower diameter of the pelvis extremely
narrow.
Internal Measurement of
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Internal Measurement ofPelvis
Internal Measurement of
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Internal Measurement ofPelvis
Diagonal Conjugate is thedistance between the sacralprominence and the anteriorsurface of the SP. This is themost useful measurement forestimation of the pelvic size. Ifthis measurement is more than12.5 cm the pelvic inlet isadequate.
True Conjugate or conjugatevera, is the measurementbetween the AP surface of the
sacral prominence and theposterior surface of the inferiormargin of the SP. 10.5 to 11 cm.
Ischial Tuberositydiameter isthe distance between the ischialtuberosities or the transverse
diameter of the outlet. A Williamsor Thomas pelvimeter is
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Diagonal Conjugate
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N t iti l N d D i
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Nutritional Needs DuringPregnancy
Components of Maternal Weight Gain
Fetal Part Pounds Kilograms
Fetus 7 3.4
Placenta 1.5 .6
Amniotic Fluid 1.76 .8
Uterus 2.1 .97
Breast .9 .4
Blood 3.2 1.45
Extra vascularFluid 3.2 1.48
Maternal Stores 7.3 3.3
Total 26.96 12.5
Nutritional Needs During
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Nutritional Needs DuringPregnancy
Nutritional Risk Factors Pregnant Adolescent Successive Pregnancies
Maternal Weight Low Income Pregnancy Complications and Existing
Medical Condition
Alcohol Consumption and CigaretteSmoking Bizarre Food Patterns Women on Vegetarian Diets
Nutritional Needs During
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Nutritional Needs DuringPregnancy
Abnormal weight gain:
1. Weight gain is less than 2 lb a month on
the 2nd and 3rd trimester2. Weight gain of more than 2 lb a week is asign of hypertension of pregnancy
3. Further evaluation is needed if weight gainis persistently slow or does not equal to 10 lbby mid pregnancy
Nutritional Needs During
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Nutritional Needs DuringPregnancy
What are the NUTRITIONALREQUIREMENTS:
Essential to supply energy for increased metabolic rate
Utilization of nutrients protein sparing so it can be used for growth of fetus
Development of structures required for pregnancy including placenta, amniotic fluid, and tissue growth.
300 calories/day above the pre-pregnancy daily requirement to maintain ideal body weight and meetenergy requirement to activity level
Begin increase in second trimester
Use weight gain pattern as an indication of adequacy of calorie intake.
Failure to meet caloric requirements can lead to ketosis as fat and protein are used for energy; ketosis hasbeen associated with fetal damage.
Caloric increase should reflect :
Foods of high nutrient value such as protein, complex carbohydrates (whole grains, vegetables, fruits)
Variety of foods representing foods sources for the nutrients requiring during pregnancy
No more than 30% fat
Protein
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Protein
Essential for: Fetal tissue growth
Maternal tissue growth including uterus and breasts
Development of essential pregnancy structures
Formation of red blood cells and plasma proteins
* Inadequate protein intake has been associated with onset of pregnancy induceshypertension (PIH)
60 mg/day or an increase of 10% above daily requirements for age group
Adolescents have a higher protein requirement than mature women since adolescentsmust supply protein for their own growth as well as protein t meet the pregnancyrequirement
Protein increase should reflect:
Lean meat, poultry, fish Eggs, cheese, milk
Dried beans, lentils, nuts
Whole grains
* vegetarians must take note of the amino acid content of CHON foods consumed to ensureingestion of sufficient quantities of all amino acids
Calcium Phosphorous
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Calcium-Phosphorous
Essential for:
Growth and development of fetal skeleton and tooth buds Maintenance of mineralization of maternal bones and teeth Current research is : Demonstrating an association between adequate calcium intake and the
prevention of pregnancy induce hypertension
Calcium increases of : 1200 mg/day representing an increase of 50% above prepregnancy daily
requirement. 1600 mg/day is recommended for the adolescent. 10 mcg/day of vitamin D is
required since it enhances absorption of both calcium and phosphorous
Calcium increases should reflect:
dairy products : milk, yogurt, ice cream, cheese, egg yolk whole grains, tofu green leafy vegetables canned salmon & sardines w/ bones
Ca fortified foods such as orange juice Vitamin D sources: fortified milk, margarine, egg yolk, butter, liver, seafood
Iron
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Iron
Essential for:
Expansion of blood volume and red blood cells formation
Establishment of fetal iron stores for first few months of life
30 mg/day representing a doubling of the pregnant daily requirement
Begin supplementation at 30- mg/day in second trimester, since diet alone is unable tomeet pregnancy requirement
60 120 mg/day along with copper and zinc supplementation for women who have low
hemoglobin values prior to pregnancy or who have iron deficiency anemia. 70 mg/day of vitamin C which enhances iron absorption
inadequate iron intake results in maternal effects anemia depletion of iron stores,decreased energy and appetite, cardiac stress especially labor and birth
fetal effects decreased availability of oxygen thereby affecting fetal growth
* iron deficiency anemia is the most common nutritional disorder of pregnancy.
Iron increases should reflect:
liver, red meat, fish, poultry, eggs
enriched, whole grain cereals and breads
dark green leafy vegetables, legumes
nuts, dried fruits
vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, broccoli or cabbage,
potatoes iron from food sources is more readil absorbed when served with foods hi h in vitamin C
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, ,Folate
Zinc is Essential for:
* the formation of enzymes
* maybe important in the prevention of congenital malformation of the fetus.
15mcg/day representing an increase of 3 mg/day over pre-pregnant daily requirements.
Zinc increases should reflect
q liver, meats
q shell fish
q eggs, milk, cheese
q whole grains, legumes, nuts
Folate/Folacin/Folate is Essential for:
q formation of red blood cells and prevention of anemia
q DNA synthesis and cell formation; may play a role in the prevention of neutral tube
defects (spina bifida), abortion, abruption placentaq 400 mcg/day representing an increase of more then 2 times the daily prepregnant
requirement. 300mcg/day supplement for women with low folate levels or dietarydeficiency
q 4 servings of grains/day
Increases should reflect:
q liver kidney lean beef veal
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