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MALNUTRITION INDUCED COMPLICATIONS IN PREGNANT WOMEN

Diet and nutrition

A healthy and varied diet is important at all times in life, but particularly so during pregnancy. The maternal diet must provide sufficient energy and nutrients to meet the mother’s usual requirements as well as the needs of the growing fetus, and enable the mother to lay down the stores of nutrients required for fetal development as well as for lactation.

Diet and nutritional status, before and during pregnancy, plays role in the early processes of fetal development and outcome Nutrition interventions should be assessed over an entire reproductive cycle with its depletion,repletion phases, and pre pregnancy nutrition status Nutritional needs are higher when pregnant and these needs helps protect the long-term health of fetus and mother Maternal nutrition has a role in the regulation of placental-fetal development and productivity of offspring.

Protective effects of many nutrients for deficiency diseases had been shown, including thiamine (beriberi), niacin (pellagra), vitamin D (rickets), vitamin A (night blindness), iron (anemia), and iodine (goiter) Mothers who practiced good nutrition such as consuming foods were less likely to have low birth weight babies Requires very diverse nutrients, including essential amino acids, macro mineralscalcium, phosphorus, magnesium, etc.and micronutrients/vitamins and minerals

Table 1: Nutrients and their sources

 

        Nutrients

 

 

                                                       Sources

 

Riboflavin (B2)

 

Dairy products, eggs, yeast extract, wheat germ, almonds, soya beans, fortified foods including breakfast cereals and soya milk, mushrooms and seaweeds

Vitamin B12

 

Dairy products, eggs, fortified foods including yeast extract, soya milk, textured soya protein and breakfast cereals.
Vitamin D

 

Dairy products, eggs, fortified foods including margarine and other fat spreads, breakfast cereals, soya milk and other soya products.
 

Calcium

Milk and dairy products, green leafy vegetables, pulses, soybeans and fortified foods, e.g. bread and soya milk, tofu, nuts and dried fruit.
 

Iron

Pulses, dark green leafy vegetables, and fortified foods including breads and fortified breakfast cereals, dried fruit, nuts and seeds.
Iodine

 

Iodised salt, milk and seaweeds.

 

 

Table 2: Infections associated with foods


Consequences of infection in pregnancy
Causes Foods to avoid
ListeriosisCan cause miscarriage, stillbirth or severe illness in the newborn.unpasteurized milk and milk products.
SalmonellaIn severe cases may cause miscarriage or premature labour.Raw eggs or foods containing raw or partially cooked eggs, e.g. home-made mayonnaise.
CampylobacterMay cause premature birth, spontaneous abortion or stillbirth.Raw or undercooked poultry; unpasteurized milk and milk products.

 

Malnutrition

Malnutrition means an abnormal physiological condition caused by inadequate, unbalanced, or excessive consumption of macronutrients or micronutrients Half of the world’s malnourished children live in three countries that are Bangladesh, India, and Pakistan In Pakistan researchers concluded that dietary diversity is a good proxy indicator for nutritional status of pregnant women.

Malnutrition includes undernutrition and overnutrition as well as micronutrient deficienciesThe excessive consumption of some nutrients may also be harmful to the body and could lead to metabolic disorders or as in case of excessive consumption of fat as carbohydrate lead to obesity Overnutrition is a result of excessive food intake relative to dietary nutrient requirements Fetalundernutrition results in a wide range of consequences and there is growing evidence of causal links to chronic diseases much later in life Undernutrition is the outcome of undernourishment, poorabsorption, and poor biological use (bioavailability) of nutrients consumed as a result of repeated infectious/parasitic diseases, alone or in combination

 

Stunting is also known as linear growth retardation, and it is defined as low height for age, reflecting a past episode or episodes of chronic undernutrition Some causes of malnutrition to child bearing mothers, these involved cultural belief, socio cultural factors are important factors in considering the quantity of food Socio economic factor is one of the causes of consequences in pregnant mothers Malnutrition is often associated with under nutrition due to reduced access to food, unsanitary living conditions, overcrowding, and inadequate child care This is due to some people who are of low income class who find it difficult to meet their ends Overcrowded housing and poor sanitation favor the emergence of frequent infections and infectious disease outbreak such as Ebola.

Malnutrition is a worldwide problem especially in the developing countries where starchy tubers and cereals form the staple food This includes problems of food production or supply at the national, regional, or household level, as well as problems of families and communities in accessing sufficient amounts of safe and nutritious food for normal growth and development and an active and healthy life Socio cultural factors are important factors in considering the quantity of food Pica practice and out of home eating, which is associated with the consumption of non-hygienic, and junk foods especially in developing countries was also associated with increased risk of low birth weight. Also fasting during pregnancy could affect dietary intake as well as fetal growth as some of the women might have fasted in the month of Ramadan.

Chronic psychological stress may probably also contribute significantly to the problem of preterm delivery and low birth-weight or modify the effect of nutrition interventions Poor dietary practices during pregnancy such as pica, out of home eating, skipping breakfastwere found to be associated with increase odds for low birth weight Other important factors for are her basic dietary intake during this period, the energy and nutrient composition of the supplement, the timing and total duration of supplementation, the replacement level of the supplement, her level of physical activity, and her general health, especially the presence of infectious diseases.

 

Table 3: Risk factors for low birthweight (LBW) and links with low socio-economic status (SES)

Risk factorLink with low SES
Nutritional statusShort stature, low pre-pregnancy BMI, low gestational weight gain more common in low SES women
Micronutrient intakeLow dietary intake more common in low SES women
SmokingHigher prevalence and heavier smoking among low SES women
Psychosocial factorsMore stressful life events, more chronic stressors, more common depression and low levels of social support in low-SES groups

 

 

Malnutrition among pregnant women

Pregnancyis one of the logical target periods for nutrition interventions,potentially providing combined opportunities to treat or prevent maternal depletion and under-nutrition of the fetus Maternal malnutrition is common in the developing world and has detrimental effects on both the mother and infant.

Evidence available also shows that women who consumed minimal amounts over the first eight-week period had a higher mortality or disorder rate concerning their offspring than women who ate regularly If there is poor feeding or nutrition on pregnant mother then there will be general weakness, tiredness during some activities like walking long distance, weight loss of appetite, anemia and reduced immunity, mental and physical weakness A lot of babies are malnourished before birth Interventions that improve maternal nutrition before and or during pregnancy can reduce the risk of poor health outcomes in mothers and their children.

Elements associated with adverse pregnancy outcomes include copper, zinc, calcium, magnesium, iron and iodine Abortion and premature delivery is as a result of malnutrition, offspring with low birth weight and high risk of pre natal mortality and morbidity, less immunity which facilitates the entry and multiplication of infection can also result in decrease volume of breast milk The main causes of maternal morbidity and mortality are pregnancy induced hypertension hemorrhage, severe anemia, obstructed labor, infections, unsafe abortions and their subsequent complications.

The imbalance of the trace elements may be closely related to complications during pregnancy, including miscarriage, preterm delivery, stillbirth, intrauterine growth restriction, fetal malformations, premature rupture of membranes and other adverse pregnancy outcomes Neural tube defects remain an important cause of prenatal mortality and infantile paralysis worldwide Brain growth retardation occurs as a result of malnutrition Maternal nutritional status may be involved in the etiology of fetal neural tube defects.
 

Table 4: Body mass index and recommended weight gain

Pre-pregnancy BMI (kg/m)Recommended weight gain
<19.812.5–18 kg
19.8–2611.5–16 kg
>26–297–11.5 kg
>29≥6 kg

 

Nutritional components and deficiencies

Women of reproductive age, especially pregnant women, in low and middle income countries are at risk of several micronutrient deficiencies, such as iron, folic acid, iodine, zinc, vitamins A and D, riboflavin, B6 and B12, which could adversely affect the mother and pregnancy outcome Trace elements is closely associated with fetal growth and development during pregnancy. Deficiency can lead to adverse pregnancy outcomes.

 

Vitamin A deficiency most frequently occurs in young children. A child who lacks this vitamin is more susceptible to the negative effects of infections. Deficient intakes increase the risk of blindness. It also leads to alterations in the skin, mouth, stomach, and the respiratory system While The main causes of deficiency of vitamin D are low sunshine exposure and little dietary vitamin D intake Vitamin D has many functions in the body; it helps maintain bone integrity and calcium homeostasis Vitamin D deficiency seems to be common in pregnant women and would be associated with an increased risk of maternal and fetal poor outcomes vitamin D concentrations can affect the function of other tissues, leading to a greater risk of multiple sclerosis, cancer, insulin-dependent diabetes mellitus,and schizophrenia later in life.

 

Iron deficiency can lead to cause anemia in pregnant women Whereas Copper deficiency can cause problems in the maintenance of normal hematopoietic function and maintenance of the central nervous system, which promotes bone, blood vessels and skin health.

Calcium is the main component of the teeth and skeleton and it plays role in the activation of muscle-keeping, nervous excitement and enzyme activation. Calcium deficiency can cause gestational hypertension and aggravate postpartum hemorrhage whereas Iodine deficiency during fetal development and early childhood is associated with cognitive impairment Iodine-deficient diets can result in various diseases, including endemic goiter and cretinism. Iodine is an essential component for the synthesis of thyroid hormones, which have an important role in the regulation of metabolism, sustaining normal growth and intellectual development.

The lack of other nutrients such as folate (or folic acid), protein, and vitamin B can also contribute to the onset of anemia. Ascorbic acid (vitamin C), vitamin E, copper, and pyridoxine (vitamin B) are also necessary for the production of red blood cells.Many studies have shown that there exist a link between pica and maternal anemia.Suboptimal maternal nutrition yields low birth weight, with substantial effect on the short-term morbidity of the newborn.

There is much evidence supporting the link between inadequate maternal nutritional status and adverse pregnancy outcomes, poor infant survival, risk of chronic diseases and impaired mental development in later life Fetal nutrition has permanent effects on growth, structure and metabolism (programming). This is supported by studies in animals showing that maternal under- and overnutrition during pregnancy can produce similar abnormalities in the adult offspring .

 

Table 5: Deficiencies and their consequences

Life cycle stageNutrition disorderMain consequences

 

Embryo/fetusIodine deficiency disordersLow birth weight
 Lack of folatePrematurity
 Stillbirth
Neonate (newborn)Iodine deficiency disordersAnemia
 Lack of folateLow birth weight
 Deafness
Pregnant and breast feeding womenIodine deficiency disordersIron deficiency anemia
 Protein energy malnutritionInadequate prenatal weight gain
 Vitamin A deficiencyIncreased risk of infection
Folate deficiencyNight blindness
Calcium deficiencyfetal mortality

 

Table 6: Extra requirement for pregnancy

Non pregnant women   Extra requirement for    Trimester

 

pregnancy

Energy (kcal)1940+200Last trimester
Protein (g)45+6
Thiamin (B1) (mg)0.8+0.1Last trimester
Riboflavin (B2) (mg)1.1+0.3
Folate* (µg)200+100
Vitamin C (mg)40+10Last trimester
Vitamin A (µg)600+100
Vitamin D (µg)

 

 

No RNI

 

.

 

Pregnant women are also advised to take a 400 µg/day supplement of folic acid prior to until the 12th week of pregnancy(more if there is a history of NTDs).

 

NTDs, neural tube defects; RNI, Reference Nutrient Intake

 

  1. Management of malnutrition

A diet consisting largely of plant source foods, such as staples, vegetables and fruits and animal-source foods, such as milk products, fish, meat and eggs are required for growth, health and development Ready-to-use therapeutic foods have been successfully used to manage severe acute malnutrition in the community Mandatory fortification of flour with folic acid has proved to be one of the most successful public health interventions in reducing the prevalence of Neural tube defects affected pregnancies Water supply, sanitation, and hygiene are important for the prevention of malnutrition because of their direct impact on infectious disease.

Citrus fruit could prevent scurvy in sailors, leading to the identification of vitamin C as essential for health Vitamin A supplementation decreases the incidence of diarrhea and measles Possible anthropometric measurements used to detect and monitor maternal malnutrition include pre-pregnancy BMI, weight gain, and mid upper arm circumference.
Food sources of iron are principally of animal origin (known as heme iron), such as liver, red meat, fish, and meat products. The plant sources of iron (called nonheme iron) are found in legumes, dark-green leafy vegetables, nuts, and seeds, but the body has greater difficulty in assimilating this type of iron Vitamin D is produced by the human body from exposure to sunlight and can also be consumed from foods such as fish-liver oils,fatty fish, mushrooms, egg yolks, and liver Folic acid available from ready-to-eat cereals and supplements.

 

  1. Discussion

 

Pregnant women should always attend the prenatal care clinics to learn more about what to eat. Government should establish more primary health centres especially in the rural areas so that pregnant women could attend Internationally, there is no agreement on the method of diagnosis or treatment of moderate or severe malnutrition during pregnancy The government should encourage agriculture by giving more loans to farmers so that their production will be on a large scale and the masses can feed well.

A global effort is required that should entail unified and compelling advocacy among governments, lead organizations, and institutions Nutrition programmes have to be made to break the cycle of malnutrition through food and micronutrient supplementation (and related activities) to pregnant women and infants Government should also sensitize pregnant women through the radio, television about the importance of attending ante natal clinics. Public health policies should target the awareness for optimal and safe sun exposure and adequate vitamin D dietary intake Vitamin D supplementation during pregnancy has been suggested as an intervention to protect against adverse gestational outcomes Tolerable vitamin D supplementation should be prescribed.

 

By: Mahum Zulqarnain, Doctor Of Pharmacy University Of Central Punjab Pakistan

 

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