VITAMIN AND MINERAL SUPPLEMENTATION DURING PREGNANCY

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VITAMIN AND MINERAL SUPPLEMENTATION DURING
PREGNANCY Aboubakr Elnashar Benha University
Hospital, Egypt
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• Sources
• Institute of Obstetricians and Gynaecologists and
  
• Royal College of Physicians of Ireland, 2013
• AAP and ACOG, 2013
• Institute of Medicine, 2011
• RCOG, 2011
• Cochrane systematic Review, 2010

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• Recommended Dietary Allowances(RDA)
• Excessive supplements during pregnancy.
• Potentially toxic
• iron, zinc, selenium, and vit A, B6, C, and D.
• Teratogenic
• Excessive vit A10,000 IU/d
• Vit and mineral intake more than twice RDA should
  be avoided
• (American Academy of Pediatrics and ACOG, 2007)

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• Institute of Medicine, 2011
• RDA amount of nutrients /d needed for
  maintenance of good health and recommended by the
  Food and Nutrition Board of the National Research
  Council.
• The tolerable upper nutrient intake level (UL)
  maximum amount of a nutrient that will not cause
  an adverse effect on an individual's health

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• A. Vitamins
• 30 of pregnant women suffer from any vit
  deficiency
• without prophylaxis 75 of these would show a
  deficit of at least one vitamin.
• (Hovdenak , Haram, 2012)
• Developing countries routine multivit
  supplementation reduce LBW and IUGR, but did not
  alter PTL or PNMR
• (Fawzi, 2007).

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• Fat soluble vitamins
• 1. Vitamin A
• RDA
• 750 ug/d
• Toxicity
• gt 10,000 IU/d congenital malformations (RCOG,
  2011)
• similar to those produced by vit A derivative
  isotretinoin (Accutane)
• Most prenatal vit contain vit A in doses
  considerably below the teratogenic threshold.

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• Sources Beta-carotene precursor of vit A
• found in fruits and vegetables No vit A
  toxicity.
• (Azais-Braesco and Pascal, 2007).
• Deficiency increased risk
• Maternal anemia impairing Fe status and
  resistance to infections
• PTL.

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• In USA
• Dietary intake of vit A adequate
  supplementation is not routinely recommended.
• The recommended upper limit for
  retinol supplements is 3000 IU/d.
• Avoid
• 1. Supplements containing pre-formed vit A
• (RCOG, 2011)
• 2. Eating liver and liver products contain high
  levels of vit A. e.g. cod liver oil
• (NICE, 2008).
• 3. Overdosing
• (Hovdenak , Haram, 2012)

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• In developing world
• Vit A deficiency prevalent, an endemic
• 6 million pregnant women
• suffer from night blindness
• vit A deficiency
• (West, 2003).
• In India
• Overt deficiency night blindness 3 in 3rd T.
• (Radhika et al, 2002)
• Subclinical deficiency 27 serum retinol 20
  µg/dL.

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• 2. Vitamin D
• Sources
• Few foods flesh of fatty fish
• Some fish liver oils (however fish liver oil
  should be avoided in pregnancy)
• Foods fortified with vit D margarine, milk and
  cereals
• Also synthesized endogenously with exposure to
  sunlight.

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• Essential in
• Absorption of calcium
• Prevention of
• autoimmune diseases
• (Fronczak et al, 2003 Hypponen et al 2001).
• adverse pregnancy outcomes PET
• rickets and osteomalacia.
• Vit D deficiency
• Disordered skeletal homeostasis
• Congenital rickets
• fFactures in the newborn
• (ACOG, 2011).

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• Women at risk of vit D deficiency
• ethnic minorities with darker skin,
• South Asian, African, Caribbean or Middle Eastern
  family origin
• limited exposure to sunlight
• vegetarians
• women with pre-pregnancy obesity.
• (Bodnar, 2007)

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• Adequate provision of vit D
• reduction in the risk of many types of cancer
• CVDs
• Autoimmune diseases
• DM 1 and 2
• Neurological disorders
• Several bacterial and viral infections
• (FSAI, 2007).

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• Vit D supplementation is needed by most women
  during pregnancy
• Vit D3 cannot be made in the skin from October to
  March UV light that is able to promote Vit D
  synthesis cannot penetrate the atmosphere during
  this time.
• Sun exposure may increase the risk of melanoma
  advising sun exposure is not an effective public
  health strategy
• In order to meet nutritional requirements for vit
  D women should take oily fish once or twice a
  week not widespread
• (FSAI, 2011).
• Supplementation in 3rd T in vitamin D deficient
  women beneficial. (Hovdenak , Haram, 2012)

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• RDA during pregnancy and lactation
• 15 µg/d(600 IU/d).
• (The Food and Nutrition Board of the Institute of
  Medicine, 2011)
• Higher dose
• history of rickets in a sibling or
• known maternal vit D deficiency

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• 3. Vitamin K
• Essential in
• blood coagulation.
• (RCOG, 2011)
• Supplementation
• risk of cerebral hge in preterm babies
• non-significant reduction in cerebral hge
• no improvement in neuro-development outcomes in
  childhood.

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• Water soluble vitamins
• 1. Folic Acid
• Folate a B vit which is referred to as folic
  acid in the synthetic form.
• Sources
• Green leafy vegetables
• Citrus fruit
• Whole grains
• Legumes
• Foods fortified with folic acid
• breads and cereals.
• nutritional sources alone are insufficient
  folic acid supplementation is recommended
• (ACOG, 2013).

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• Folate deficiency
• 25 of pregnant women in India
• congenital malformations (NTD, orofacial clefts,
  cardiac anomalies)
• Anaemia, spontaneous abortions
• PET, IUGR
• Abruptio placentae.
• (Hovdenak , Haram, 2012)

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• Folic acid supplementation
• strong protective effect against
• NTD half can be prevented
• Other congenital anomalies CV defects, limb
  defects
• Paediatric cancers leukaemia, paediatric brain
  tumours and neuroblastoma.

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• Start
• Before conception.
• Up to
• 12 w NT will have closed
• Throughout pregnancy.
• role in red blood cell manufacture and in cell
  replication

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• Dose
• 400mcg/d0.4 mg (CDC, 2004)
• 4000mcg/ 4 milligrams
• 1. Family history of NTDs
• 2. Pre-existing diabetes (HSE 2010).
• 3. Obese women (CMACE, 2010 Institute of
  Obstetricians and Gynaecologists, 2011)
• incidence of congenital malformations, including
  NTDs, are higher in obese (Rasmussen et al,
  2008).
• 4. Anti-seizure medication (FSAI, 2011).
• Care should be taken increased risk of
  colorectal adenomas with prolonged high dose
  intake (Cole BF et al, 2007 Fife J et al,
  2009).

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• 2. Vitamin B12
• In developing countries diets are generally low
  in animal products and consequently in vitamin
  B12 content.

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• Maternal plasma levels decrease in normal
  pregnancy
• Reduced plasma levels of their carrier proteins
  transcobalamins
• Vit B12 occurs naturally only in foods of animal
  origin
• Excessive ingestion of vit C functional
  deficiency of vit B12.
• low levels of vit B12 preconceptionally (similar
  to folate)
• increase the risk of NTD (Molloy, 2009
  Thompson, 2009).
• Reduce fetal growth.
• Vit B12 supplementation 
• in vegetarian

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• 3. Vit B6Pyridoxine
• Supplementation
• Routine No benefits
• (Thaver, 2006, RCOG, 2011)

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• Vitamin B6 deficiency
• High risk
• Substance abusers
• Adolescents
• Multifetal gestation
• PET, gestational carbohydrate intolerance,
• H gravidarum, neurologic disease of infants.
• 2-mg/d
• Benefits
• Reduces the severity of nausea but not vomiting
  (RCOG, 2011)
• when combined with the antihistamine doxylamine
  dec nausea and vomiting (Boskovic, 2003
  Staroselsky, 2007).
• Decrease dental decay

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• Vit B1, B2, B3, B5, B7, and B12
• minimal data on the benefits and harms of
  supplementation
• no strong evidence to support supplementation
  (RCOG, 2011)

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• 4. Vitamin C
• Sources
• Fruits and vegetables.
• (RCOG, 2011)
• Essential in
• collagen synthesis
• wound healing
• prevention of anaemia
• As an antioxidant.

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• RDA
• 80 mg/d
• 20 more than when nonpregnant
• A low dose
• 20 mg is commonly included in many multivitamin
  pregnancy preparations.
• Routine supplementation of higher dose vitamin C
  and E Not recommended.
• No effect on prevention of
• PET (Conde-Agudelo, 2011)
• PTL (Swaney et al, 2014)
• PROM
• IUGR
• Miscarriage or SB (Cochrane SR, 2005)

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• B. Minerals
• Iron
• Increased iron Requirements
• 1000 mg required for normal pregnancy
• 300 mg actively transferred to the fetus and
  placenta
• 200 mg lost through normal excretion routes,
  primarily GIT.
• 500 mgAverage increase in the total circulating
  erythrocyte volume 450 mL each 1 mL of
  erythrocytes contains 1.1 mg of iron.

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• most iron is used during the latter half of
  pregnancy iron requirement becomes large after
  midpregnancy and averages 7 mg/day (Pritchard,
  1970).
• Few women have sufficient iron stores or dietary
  iron intake to supply this amount

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• Maternal iron deficiency
• Direct impact on neonatal Fe stores
• Birth weight
• may cause cognitive and behavioural problems in
  childhood.
• Fe supplementation
• low-income pregnant women
• pregnant women in developing countries
• documented deficiency
• overtreatment should be avoided.

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• Universal supplementation
• From booking
• (WHO, 2001) or
• From 2nd T
• (INACG)
• (Stolzfus et al, 1998).
• Cochrane review (2009)
• Iron supplementation improved
• birth length
• Apgar scores
• infant ferritin at 3 months
• reduces postpartum maternal transfusion
• ironfolic acid supplementation
• improved birth weight.

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• Dietary Advice
• Diet rich in iron

Poor Medium Rich
milk and its products, root vegetables meat, chicken, fish, spinach, banana, apple liver, egg yolk, dry beans, dry fruits, wheat germ, yeast
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• Avoid inhibitors of iron absorption

Enhance Inhibit
Heme Phytates cereals
Ascorbic acid Tannins tea coffee
Ferrous iron(Fe2) Calcium
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• Oral Iron
• Patil et al, 2012 I J Med Pharmaceutical Sci
• I. Conventional iron preparations
• Fe sulfate, Fe fumarate.
• Cheap.
• Should not be given with food
• salts bind the iron impair absorption
• Side effects
• 40
• Nausea, vomiting, heart burn, metallic taste,
  constipation, abdominal cramps, diarrhea.
• 10 Discontinue

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• Extended (slow) release capsules or enteric
  coated capsules
• Less side effect
• slow/decreased iron absorption, absorbed lower
  parts of the GI
• Iron absorption occurs at the duodenum and
  proximal jejunum
• Not very effective
• Should be avoided
• majority of the iron is carried past the
  duodenum limiting absorption
• (Tapiero, 2001).

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• II. New iron preparations
• Multi Amino Acid Chelated iron, Carbonyl iron,
  Iron polymaltose, others.
• Multi Amino Acid Chelated iron Vs iron salt
• (Pineda et al, 1994 Sofia et al, 2001)
• Low GIT intolerance
• Increase Hbg level faster with significant low
  doses
• High bioavailability and regulation
• Better improve iron stores
• Higher cost.

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• Higher stability of amino acid chelate
• prevents the molecule from being destroyed in the
  gut less GI irritation
• Atomic structure and chemistry
• protects the ferrous iron from undesirable
  chemical reactions in the stomach and intestine
  that limit iron absorption.
• Absorption
• not reduced in presence of phytates.

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• 2. Iodine
• Dietary sources
• Seaweed
• iodized salt
• dairy products and
• fish.
• Iodine requirements
• increase by 50
• (Stagnaro-Green et al 2011)
• RDA
• 220 µg (American Thyroid Association,
  Stagnaro-Green et al 2011)
• 500 µg (WHO)
• 600µg/day (EFSA , 2009)
• Prenatal vits contain various amounts

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• Iodine deficiency
• maternal thyriod gland cannot meet the demand
  for increasing production of thyroid hormones
  (Obican et al 2012).
• Endemic cretinism multiple severe neurological
  defects.
• Hypothyroinaemia and elevated TSH in infants
  cognitive and psychomotor deficits

A six-week-old male presents with lethargy and
hypotonia. On physical exam he is jaundiced and
has a large protruding tongue. 
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• Iodine supplementation
• decrease the risk of cognitive and psychomotor
  developmental delay (Trumpff et al 2013).
• In parts of China and Africa where this condition
  is common
• very early in pregnancy (Cao, 1994).
• Recommendations
• use of iodized salt and bread products
• increase foods containing iodine

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• 3. Calcium
• The pregnant woman retains approximately 30 g of
  calcium.
• Most of this is deposited in the fetus late in
  pregnancy (Pitkin, 1985).
• This amount of calcium represents only 2.5 of
  total maternal calcium

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• Essential in
• development of healthy bones and teeth
• extra-cellular fluid, muscle, and other tissues.
• vascular contractions and vasodilation, muscle
  contractions
• neural transmission
• glandular secretion.
• Adequate dietary intake should be encouraged.
• 3 portions of dairy or calcium-fortified
  alternatives daily (FSAI, 2011).
• Calcium deficiency
• PET, IUGR. 
• Supplementation may reduce both the risk of LBW
  and the severity of PET (Hovdenak , Haram, 2012)

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• Calcium Supplementation
• 1.52.0 g elemental Ca daily for pregnant women
  in areas with low dietary calcium.
• (WHO 2011)
• LDC lt1 g/d, with or without other supplements.
  (linoleic acid, vit D) (Hofmeyr et al, 2014)
• PET was reduced consistently (nine trials, 2234
  women)
• LDC plus antioxidants commencing at 812 w tended
  to reduce miscarriage

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• 4. Zinc
• Severe deficiency
• poor appetite
• suboptimal growth
• impaired wound healing
• Impaired absorption
• Intake of cereal-based diets rich in phytate
• high intakes of supplemental Fe
• GITdisease
• RDA 12 mg.

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• Zn supplementation
• Small (14) but significant reduction in PTL
• (Cochrane systematic review, 2012)
• primarily in low income women
• No reduction in LBW
• No sig differences between  Zn and no Zn groups
  for any of the other maternal or neonatal
  outcomes
• Reduced acute diarrhea, dysentery, and impetigo.
  (Osendarp et al, 2001)
• Supplemental Zn
• women with poor GIT function
• Zn deficient women

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• 5. Magnesium
• Deficiency
• In normal pregnancy has
• not been recognized.
• But during
• prolonged illness
• intestinal bypass surgery
• hematological and teratogenic damage

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• Mg supplementation
• 365-mg from 13 to 24 w
• not improve any measures of pregnancy outcome
• (Sibai et al, 1989)
• A Cochrane review significant LBW risk
  reduction in Mg supplemented individuals.

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• 6. Potassium
• Concentration in
• maternal plasma
• decreases by 0.5 mEq/L
• by midpregnancy
• (Brown, 1986).
• Deficiency
• develops in the same
• circumstances as
• in nonpregnant individuals.

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• 7. Fluoride
• Supplementation
• Not beneficial
• (Institute of Medicine, 1990).
• Fluoride metabolism is not altered during
  pregnancy.
• (Maheshwari et al, 1983)

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• 8. Trace Metals
• Copper, selenium, chromium, and manganese
• important roles in certain enzyme functions.
• Most are provided by an average diet.

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• Selenium (Se)
• Antioxidant supporting humoral and cell-mediated
  immunity.
• Se deficiency
• identified in a large area of China
• fatal cardiomyopathy, recurrent abortion, PET,
  IUGR
• Se toxicity
• over supplementation has been observed.
• No need to supplement selenium in American women.
•  Se supplementation
• Although beneficial effects are suggested there
  is no evidence-based recommendation

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• Recommendations
• Vit and mineral supplements cannot replace a
  healthy diet
• Multivit supplements are recommended for pregnant
  women who cannot meet the RDAs through food
  intake
• At-risk populations include
• Adolescents
• women carrying multiple gestations
• those with a substance abuse history
• those with eating disorders
• those taking certain medications that can alter
  absorption
• strict vegetarians or vegans.

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• Pregnant women should stay below the upper limits
  of supplementation guidelines
• Pregnant women should be encouraged to take a
  multivit (vit C, vit D, folic ac) and iron
• Provide iodine supplementation in areas of known
  dietary insufficiency.

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Thank you