1. The document discusses folic acid supplementation recommendations during pregnancy. It recommends that all women of reproductive age take a folic acid supplement before and during early pregnancy to help prevent neural tube defects and other congenital anomalies. 2. Women are classified as low, moderate, or high risk depending on their personal and family health histories. The recommendations include taking 0.4 mg, 1.0 mg, or 4.0 mg of folic acid daily based on risk level, beginning several months before conception through the first trimester and continuing through pregnancy. 3. Folic acid supplementation has been shown to reduce the risk of neural tube defects by up to half, as well as certain other birth defects, anemia

1. FOLIC ACID SUPPLEMENTATION
DURING PREGNANCY
SOGC Guidelines, 2015
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt

2. Recommended Dietary Allowances(RDA)
Amount of nutrients/d needed for maintenance of good
health
recommended by the Food and Nutrition Board of the
National Research Council.
Excessive supplements during pregnancy.
Potentially toxic :
Iron, zinc, selenium
vit A, B6, C, and D.
Teratogenic:
Excessive vit A≥10,000 IU/d
Vit and mineral intake more than twice RDA
should be avoided
(American Academy of Pediatrics and ACOG, 2007)
ABOUBAKR ELNASHAR

3.  Requirement for iron
2 to 3 fold increase
not only for Hb synthesis but for
certain enzymes and for the
fetus.
Requirements for folate
10 to 20 fold increase
Requirement for vit B12.
2 fold increase
ABOUBAKR ELNASHAR

4. Institute of Medicine,
2011
RDA:
ABOUBAKR ELNASHAR

5. ABOUBAKR ELNASHAR

6. Vitamins
30% of pregnant women:
suffer from vit deficiency
without prophylaxis:
75% of these would show a deficit
of at least one vit.
(Hovdenak , Haram, 2012)
Developing countries:
Routine multivit supplementation:
reduce LBW and IUGR
did not alter PTL or PNMR
(Fawzi, 2007).
ABOUBAKR ELNASHAR

7. FOLIC ACID
Sources:
1. Green leafy vegetables
2. Citrus fruit
3. Whole grains
4. Legumes
5. Foods fortified with folic acid:
breads and cereals.
 {nutritional sources alone are insufficient}
folic acid supplementation is recommended
(ACOG, 2013).
ABOUBAKR ELNASHAR

8. 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)
ABOUBAKR ELNASHAR

9. 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
ABOUBAKR ELNASHAR

10. Folic acid supplementation
Could modulate other adverse pregnancy outcomes
seizures in women known with epilepsy or seizure
disorders
Preeclampsia
Pregnancy-induced anemia
Autism
Fetal growth restriction
Preterm delivery
(SOGC, 2015)
ABOUBAKR ELNASHAR

11. Folic acid supplementation
An important part of the prenatal care of women with
epilepsy
{interference of antiepileptic drugs in folate metabolism}.
Play a role in reduction of the incidence of
gestational hypertension or preeclampsia.
{correct hyperhomocysteinemia: optimizing the homocysteine
pathway}
Reducing the risk of autism
 under study
Treat folate deficiency anemia in pregnancy
ABOUBAKR ELNASHAR

12. Riske and cautions
Generally safe
The potential side effects
difficulty in ruling out B12 deficiency
interaction with drugs that inhibit folate
metabolism
decreased zinc absorption
hypersensitivity reactions
association with malignancy
Neurotoxicity
epileptogenic effects
increased susceptibility to malaria.
(SOGC, 2015)
ABOUBAKR ELNASHAR

13. ABOUBAKR ELNASHAR
On fetus:
Folic acid dosing above the recommended supplementation
amountshas not been shown to have any added fetal/maternal
health or developmental benefits, although recent epigenetic/
methylation studies in animals and humans have indicated that
some caution and research is required.
The folic acid doses of 5 mg have not been reported
to have maternal or fetal risks, but long-term high-dose
5 mg folic acid use has not been well studied in a prenatal
population.
Recent summary conclusions from colorectal cancer
reviews of the topic are still cautionary.
Two studies show no association of folic acid with
colorectal adenoma or recurrence.

14. ABOUBAKR ELNASHAR
On child:
High-dose (5 mg) was associated with an increased rate of
wheeze and respiratory infection
asthma medication among children
bronchiolitis diagnosis
{ methyl donors in the maternal diet during pregnancy may
influence respiratory health in children consistent with
epigenetic
Mechanisms}.
Now some caution in favour of using the lowest effective folic
acid supplementation dose is required.

15.  Risk groups: SOGC, 2015
1. Personal positive or family history of other folate-sensitive congenital
anomalies
cardiac, limb, cleft palate, urinary tract, congenital hydrocephaly
2. Family history of NTD in a first or second-degree relative.
3. Diabetes (type I or II)with secondary fetal teratogenic risk.
Measurement of red blood cell folate levels could be part of the
preconception evaluation to determine the multivitamin and folic acid
supplementation dose strategy (1.0 mg with RBC folate< 906 and 0.4 to
0.6 mg with RBC folate >906) with a multivitamin).
4. Medications
 Anticonvulsant medications:
carbamazepine, valproic acid, phenytoin,primidone, phenobarbital
 Metformin
 Methotrexate
 Sulfasalazine, triamterene, trimethoprim (as in cotrimoxazole),
 Cholestyramine.
5. GI malabsorption conditions
 Crohn’s
 Active Celiac disease
 Gastric bypass surgery
 Advanced liver disease
 kidney dialysis
 Alcohol overuse.
ABOUBAKR ELNASHAR

16. 1. LOW risk group:
 Women or their male partner
 with no personal or family history of health risks
for folic acid sensitive birth defects.
2. MODERATE risk group:
 Women with the following personal or co-morbidity
scenarios (1–5) or
 Male partner with a personal scenario (1 and 2).
3. HIGH risk group:
 Women or their male partners
 with a personal NTD history
ABOUBAKR ELNASHAR

17. The recurrence risk for a fetus with an NTD
is shared by both mother’s and father’s personal
reproductive history, but
only the mother is treated with the supplemental
dose of pre-conception/first trimester folic acid.
ABOUBAKR ELNASHAR

18. 1. Low risk group
0.4 mg/d
beginning 3 months before conception
continuing
throughout the pregnancy and for
4–6 w postpartum or as long as breastfeeding
continues
2. Moderate risk group
1.0 mg/d
beginning at least 3 months before conception
continuing until 12 w.
0.4–1.0 mg/d
From 12 w, continuing
throughout the pregnancy, and for
4-6 w postpartum or as long as breastfeeding
continues ABOUBAKR ELNASHAR

19. 3. High risk group
4.0 mg/day:
beginning at least 3 months before conception,
continuing until 12 w.
0.4–1.0
From 12 w, continuing
throughout the pregnancy, and for
4-6 w postpartum or as long as breast feeding
continues,
ABOUBAKR ELNASHAR

20. ABOUBAKR ELNASHAR
3rd T2nd T1st TPreconceptionOutcome/time
No benefitSig benefitNTD
BeneficialSig benefitBeneficialPET
BeneficialAnemia
BeneficialSig benefitIUGR
No benefitBeneficialAutism
Folic acid supplementation timing and pregnancy
outcome

21. ABOUBAKR ELNASHAR
Recommendations
1. Women should be advised to maintain a healthy
folate-rich diet; however, folic acid/multivitamin
supplementation is needed to achieve the red blood cell
folate levels associated with maximal protection against
NTD. (III-A)

22. ABOUBAKR ELNASHAR
2. All women in the reproductive age group (12–45 years
of age) who have preserved fertility (a pregnancy is
possible) should be advised about the benefits of folic
acid in a multivitamin supplementation during medical
wellness visits (birth control renewal, Pap testing, yearly
gynaecological examination) whether or not a pregnancy
is contemplated. Because so many pregnancies are
unplanned, this applies to all women who may
become pregnant. (III-A)

23. ABOUBAKR ELNASHAR
3. Folic acid supplementation is unlikely to mask vitamin
B12 deficiency (pernicious anemia). Investigations
(examination or laboratory) are not required prior to
initiating folic acid supplementation for women with a risk
for primary or recurrent neural tube or other folic acid-
sensitive congenital anomalies who are considering a
pregnancy. It is recommended that folic acid be taken in
a multivitamin including 2.6 ug/day of vitamin B12 to
mitigate even theoretical concerns. (II-2A)