Nutritional supplement recommendations for multiple pregnancies include: 1) Women with twin or triplet pregnancies should receive the same dietary, lifestyle, and supplement advice as women with singletons. 2) Women with multiples have a higher risk of anemia and should have their iron and folate levels checked at 20-24 weeks and 28 weeks. 3) A balanced diet with adequate calories is important, along with supplements of folic acid, iron, vitamin D, and DHA omega-3 fatty acids. 4) The optimal diet for multiples is uncertain due to lack of research evidence, but general guidelines are provided.

1. Nutritional supplement
in multiple pregnancy
2015.04.28
Fellow. You Jung, Shin

2. Nutrition and complications
associated with multiple gestation
• Pregnant women
• Pre-eclampsia
• IDA
• Preterm delivery
• Cesarean delivery
• Postpartum hemorrhage
• Fetus/Infants
• Prematurity
• Low birth weight
• Intrauterine growth restriction
• Neonatal morbidity
• High perinatal, and infant
mortality
Luke B. What is the influence of maternal weight gain on the fetal growth of twins?
Clin Obstet Gynecol. 1998;41:56–64.
Mares M, Casanueva E. Embarazo gemelar: determinantes
maternas del peso al nacer. Perinatol Reprod Hum. 2001;15:238–244.

3. Kosuke kawai et al. Bull World health organ 2011;89:402-411B

4. Summary of pooled estimates for the
effect of maternal micronutrient
supplementation on pregnancy outcomes
Kosuke kawai et al. Bull World health organ 2011;89:402-11B

5. Physiologic changes

6. Component of weight gain during pregnancy
Williamson, Nutrition in pregnancy, 2006 British nutrition foundation nutrition bulletin 2006;31:28-59

7. Weight gain

8. Chart for estimating BMI
• Williams figure 48-1
• P962
• Prenatal care
Williams 24/e

9. BMI-specific weight gain goals.
Underweight
(BMI<19.8)
Normal
(BMI 19.8-26)
Overweight
(BMI 26.1-29)
Obese
(BMI >29)
Luke et al, J repord Med 2003;48:217-24
Goodnight, Obstet Gynecol , 2009;149:1121-1134

10. Weight gain
in twin and singleton
Cambell, Nutrition During Pregnancy Part I: Weight Gain, Part II: Nutrient Supplements, 1986

11. Weight gain recommendation
Prepregnancy weight
category (BMI)
Weight gain range
(kg[Ib])
Weight gain in
2nd and 3rd
trimester
(kg/wks)
Singleton Underweight (<18.5) 12.5-18.0 [28-40] 0.6 (0.5-0.6)
Normal weight (18.5-24.9) 11.5-16.0 [25-35] 0.5 (0.4-0.5)
Overweight (25.0-29.9) 7.0-11.5 [15-25] 0.3 (0.2-0.3)
Obese (≥30.0) 5.0-9.1 [11-20] 0.2 (0.2-0.3)
Twin Underweight (<18.5)
Normal weight (18.5-24.9) 16.8-24.5 [37-54]
Overweight (25.0-29.9) 14.1-22.7 [31-50]
Obese (≥30.0) 11.3-19.1 [25-42]
2009 IOM guideline

12. Weight gain & Calories

13. Calories and weight gain
in multiple pregnancies
• In multiple pregnancy, as the metabolic rate of the mother is
greater than in singleton pregnancy, it has been suggested that at
high calorie diet may help maintain her nutritional state.
• A low rate of gain (<6kg) before 24 weeks is significantly associated
with poor fetal growth and higher morbidity
• twins were three times more likely to be born prematurity to
women of any weight who lost weight after 28 weeks gestation.
Konweinski et al. Acta Geneticae Medicae et Gemellologiae 1973;22(suppl.),44-47

14. Program dietary recommendations
and weight grain goals
Luke, Am J Obstet Gynecol, 2003;189,934-38

15. Williams 24/e
Recommendations measured adequate intake
from Institute of medicine,2006,2011

16. Nutrition During Pregnancy:
Part I: Weight Gain, Part II: Nutrient Supplements(1990)

17. Reported average nutrient intakes by
pregnant women in comparison with
1989 recommended dietary allowances

18. Twin Pregnancy Nutritional Recommendations
Goodnight, Obstet Gynecol , 2009;149:1121-1134

19. Iron

20. Risk of iron deficiency
• Pregnancy (second two trimesters)
• Menorrhagia (loss of more than 80 ml of blood per month)
• Diets low in both meat and ascorbic acid
• Multiple gestation
• Blood donation more than three times per year
• Chronic use of aspirin
Antenatal care, NICE public health guidance 62. 2014
Multiple pregnancy, NICE clinical guideline, 2014

21. Normal hemoglobin values during pregnancy.
Svanberg et al. (1976a), Sjöstedt et al. (1977), Puolakka et al. (1980b), and Taylor et al. (1982). The baseline values
(zero weeks) are based on LSRO (1984), and the 4- and 8-week values are extrapolated from all these data and from
Clapp et al. (1988). Unpublished figure from R. Yip, Centers for Disease Control, 1989.
Nutrition During Pregnancy:
Part I: Weight Gain, Part II: Nutrient Supplements(1990)

22. Changes in maternal iron status
in twin pregnancy
Luke et al, Seminars in perinatology, 2005;29:349-54

23. IDA
• a/w Preterm births, low birth weight, development of chronic disease.
• high placental/birth weight ratio <-development of a large placenta
: predictive of long-term programming of hypertension and
cardiovascular disease.
• 2.4-4 times IDA in multiple gestation
• Iron requirement :nearly two fold in twin
• Dietary sources of iron ( preferable, particularly heme-iron-rich sources )
: red meat, pork, poultry, fish, and eggs.
Luke et al, Seminars in perinatology, 2005;29:349-54
Bricker, Best practice & research clinical obstetrics and gynecology 2014;28:305-17

24. Folic acid

25. Folic acid
• Required for DNA synthesis and cell division, plays a
critical role in fetal development.
• Megaloblastic anemia d/t 2o folate def.
: 8 times higher in multiple pregnancies.
• Low folate status
• preterm delivery, low birth weight, fetal growth
restriction.
Berry, Clin obstet and gynecol 1995:38(3);455-62
Scholl & Johnson, AM J Clin Nutr 2000 May;71(5 Suppl):1295S-303S.

26. Folic acid
• Health professionals should:
• Use any appropriate opportunity to advise women who may become pregnant
that they can most easily reduce the risk of having a baby with a neural tube
defect (for example, anencephaly and spina bifida) by taking folic acid
supplements. Advise them to take 400 micrograms (μg) daily before pregnancy
and throughout the first 12 weeks, even if they are already eating foods
fortified with folic acid or rich in folate.
• Advise all women who may become pregnant about a suitable folic acid
supplement, such as the maternal Healthy Start vitamin supplements.
• Encourage women to take folic acid supplements and to eat foods rich in folic
acid (for example, fortified breakfast cereals and yeast extract) and to
consume foods and drinks rich in folate (for example, peas and beans and
orange juice). Maternal and child nutrition, NICE public health guidance 11. 2014

27. Folic acid
• Dietary source
: fortified grains, spinach, lentils, chick peas, asparagus, broccoli,
peas, Brussels sprouts, corn, and oranges.
• Recommended
• 0.4 mg/d (400mcg/d)
• 4 mg/d (to prevent recurrence of NTD)
• 600mcg/d, once pregnant
IOM, subcommittee on nutritional status and weight gain during pregnancy 1990

28. High dose folic acid
• GPs should prescribe 5 mg of folic acid a day
for women who are planning a pregnancy, or are
in the early stages of pregnancy, if they:
1. (or their partner) have a NTD
2. have had a previous baby with a NTD
3. (or their partner) have a family history of NTD
4. have diabetes.
Maternal and child nutrition, NICE public health guidance 11. 2014

29. Interactions:
Drugs and folic acid
J Obstet Gynaecol Can. 2007;29(12):1003-13

30. Micronutrients
• Vitamins
• Fat soluble :A,D,E,K
• Water soluble: B, C, Folate
• Minerals and trace elements
• Calcium
• Magnesium
• Zinc

31. Vitamin A
• Maximal recommended vitamin A supplement in pregnancy is 8,000
IUs/d.
• Excessive doses of vitamin A (at least more than 10,000 IUs/d
and probably more than 25,000 IUs) in pregnancy have been
associated with fetal anomalies, including anomalies of the
cardiovascular system, face and palate, ears, and genitourinary
tract.
• Excessive supplementation of most other vitamins can result in
GI disturbances but seem without teratogenic effect.
Goodnight, Obstet Gynecol , 2009;149:1121-1134

32. Vitamin B
• Dietary source
:우유, 우유생성물, 시리얼, 고기, 고기 생성물, 초록색 잎이 많은 야채,
효모균 추출물, 간 등 (B2)
• Vitamin B1 (Thiamin): 0.1-0.9mg/day in 3rd trimester
• Vitamin B2 (Riboflavin): 0.3-1.4mg/day
Goodnight, Obstet Gynecol , 2009;149:1121-1134

33. Vitamin C
• 2 compounds- ascorbic acid, dehydroascorbic acid
• Electron donor in the metabolism of tyrosine, folate, histamine, and
some drugs and is involved in the synthesis of carnitine and bile
acids, release of corticosteroids, and incorporation of iron into
ferritin.
• Vitamin C deficiency : scurvy ( impairs the synthesis of collagen)
• Recommendation: 85mg/day
Goodnight, Obstet Gynecol , 2009;149:1121-1134

34. Vitamin D
• Essential for absorption of Calcium
• Vitamin D deficiency a/w
• SGA (x2.4) / HTN, Pre-eclampsia (x5, <50 nmol/l) / primary
C/S (x4, <37.5nmol/l).
• Rickets / hypocalcemic seizure
• Dietary source of vitamin D
: 계란, 고기 , 기름이 많은 생선 등
Goodnight, Obstet Gynecol , 2009;149:1121-1134

35. Vitamin D
• At-risk groups having a low vitamin D status include:
• All pregnant and breastfeeding women, particularly teenagers and young women
• Infants and children under 5 years
• People over 65
• People who have low or no exposure to the sun. For example, those who cover their
skin for cultural reasons, who are housebound or confined indoors for long periods
• People who have darker skin, for example, people of African, African–Caribbean
and South Asian origin.
• Recommendation
• 10 micrograms/day (400 IU)
Vitamin D: increasing supplement use among at-risk groups, NICE public
health guidance 56, 2014

36. Calcium
• Dietary sources
: milk, diary products with some calcium in green leafy
vegetables such as kale, and turnip greens, with
approximately one third of ingested calcium being absorbed.
• Recommendation of IOM:
• 1300mg (<18 years)
• 1000mg (19-50 years)
Goodnight, Obstet Gynecol , 2009;149:1121-1134

37. Essential fatty acid (EFA)
• vital components of the brain and retina cells and play a potentially
important role in the development of mental and visual function.
• Dietary source of EFA
• fresh or canned oil-rich fish such as salmon, tuna, sardines, mackerel
and herrings.
• walnuts, spinach and canola oil or canola margarine.
Rice et al. professional care of mother and child 1996:6(6);171-73
Roem, Twin research 2003:6(6);514-19

38. Essential fatty acid (EFA)
• Omega-6 FA
• linoleic acid
• Cereals, grains, processed foods, meat, milk, eggs, and oils,
including corn, sunflower, safflower, and sesame.
• Omega-3 FA:
• α-linoleic acid, EPA&DHA: 300-500mg/d (WHO)
• Fish oils, Sunflower, safflower, corn, and soybean oil, as well as egg
yolk, meat, and spinach
• Plant sources may not contain the necessary decosahexaenoic acid
(DHA) component of Omega-3 FA
Goodnight, Obstet Gynecol , 2009;149:1121-1134

39. Other micronutrients
• In a RCT in 2004,
• micronutrient supplementation (vitamin C 60 mg, B-carotene
4.8 mg, vitamin E 10 mg, thiamin 1.4 mg, riboflavin 1.6 mg,
niacin 15 mg, pantothenic acid 6 mg, folic acid 200 microgram,
cobalamin 1 microgram, zinc 15 mg, magnesium 87.5 mg, and
calcium carbonate 100 mg) in pregnancy resulted in a 10%
improvement in birth weight and a reduction in birth weight
below 2,700 g among singleton pregnancies.
Hininger et al, Eur J Clin Nutr 2004;58:52–9.

40. Recommendation

41. Cochrane review
• Cochrane review found no RCTs to advise whether
specific dietary advice for women with multiple
pregnancy does more good than harm.
• The optimal diet for women with multiple pregnancies is
uncertain.
Nutritional advice for improving outcomes in multiple pregnancies
Cochrane Database Syst Rev. 2011;15(6):CD008867

42. 2014 NICE

43. NICE clinical guideline
(multiple pregnancy)
1.2.2 Diet, lifestyle and nutritional supplements
1.2.2.1 Give women with twin and triplet pregnancies the same advice about
diet, lifestyle and nutritional supplements as in routine antenatal care.
1.2.2.2 Be aware of the higher incidence of anemia in women with twin and
triplet pregnancies compared with women with singleton pregnancies.
1.2.2.3 Perform a full blood count at 20–24 weeks to identify women with
twin and triplet pregnancies who need early supplementation with iron or
folic acid, and repeat at 28 weeks as in routine antenatal care.
Multiple pregnancy, NICE clinical guideline 129. 2014

44. NICE public health guideline
(Antenatal care)
1.3.2 Nutritional supplements
1.3.2.1 Pregnant women (and those intending to become pregnant) should
be informed that dietary supplementation with folic acid, before
conception and throughout the first 12 weeks, reduces the risk of
having a baby with a neural tube defect (for example, anencephaly or
spina bifida). The recommended dose is 400 mcg per day.
1.3.2.2 Iron supplementation should not be offered routinely to all
pregnant women. It does not benefit the mother's or the baby's health
and may have unpleasant maternal side effects.
Antenatal care, NICE public health guidance 62. 2014

45. NICE public health guideline
(Antenatal care)
1.3.2.3 Pregnant women should be informed that vitamin A
supplementation (intake above 700 micrograms) might be
teratogenic and should therefore be avoided.
Pregnant women should be informed that liver and liver products
may also contain high levels of vitamin A, and therefore
consumption of these products should also be avoided.
Antenatal care, NICE public health guidance 62. 2014

46. NICE public health guideline
(Antenatal care)
1.3.2.4 New All women should be informed at the booking appointment about the
importance for their own and their baby's health of maintaining adequate vitamin D
stores during pregnancy and whilst breastfeeding. In order to achieve this, women
should be advised to take a vitamin D supplement (10 micrograms of vitamin D per day),
as found in the Healthy Start multivitamin supplement. Women who are not eligible for
the Healthy Start benefit should be advised where they can buy the supplement.
Particular care should be taken to enquire as to whether women at greatest risk are
following advice to take this daily supplement. women with darker skin (such as those of
African, African–Caribbean or South Asian family origin women who have limited
exposure to sunlight, such as women who are housebound or confined indoors for long
periods, or who cover their skin for cultural reasons.
Antenatal care, NICE public health guidance 62. 2014

47. JOINT SOGC-MOTHERISK
CLINICAL PRACTICE GUIDELINE
Recommendations 2007

48. JOINT SOGC-
MOTHERISK CLINICAL
PRACTICE GUIDELINE
J Obstet Gynaecol Can. 2007;29(12):1003-13

49. J Obstet Gynaecol Can. 2007;29(12):1003-13

50. JOINT SOGC-MOTHERISK
CLINICAL PRACTICE GUIDELINE
Recommendations
1. Women in the reproductive age group should be advised about the benefits of
folic acid in addition to a multivitamin supplement during wellness visits (birth
control renewal, Pap testing, yearly examination) especially if pregnancy is
contemplated. (III-A)
2. Women should be advised to maintain a healthy diet, as recommended in
Eating Well With Canada’s Food Guide (Health Canada). Foods containing
excellent to good sources of folic acid are fortified grains, spinach, lentils, chick
peas, asparagus, broccoli, peas, Brussels sprouts, corn, and oranges. However, it
is unlikely that diet alone can provide levels similar to folate-multivitamin
supplementation. (III-A)
J Obstet Gynaecol Can. 2007;29(12):1003-13

51. JOINT SOGC-MOTHERISK
CLINICAL PRACTICE GUIDELINE
Recommendations
3. Women taking a multivitamin containing folic acid should be advised not to
take more than one daily dose of vitamin supplement, as indicated on the
product label. (II-2-A)
4. Folic acid and multivitamin supplements should be widely available without
financial or other barriers for women planning pregnancy to ensure the extra
level of supplementation. (III-B)
5. Folic acid 5 mg supplementation will not mask vitamin B12 deficiency
(pernicious anemia), and investigations (examination or laboratory) are not
required prior to initiating supplementation. (II-2-A)
J Obstet Gynaecol Can. 2007;29(12):1003-13

52. JOINT SOGC-MOTHERISK
CLINICAL PRACTICE GUIDELINE
Recommendations
• 6. The recommended strategy to prevent recurrence of a congenital anomaly
(anencephaly, myelomeningocele, meningocele, oral facial cleft, structural heart
disease, limb defect, urinary tract anomaly, hydrocephalus) that has been
reported to have a decreased incidence following preconception / first
trimester folic acid +/- multivitamin oral supplementation is planned pregnancy
+/- supplementation compliance. A folate-supplemented diet with additional
daily supplementation of multivitamins with 5 mg folic acid should begin at least
three months before conception and continue until 10 to 12 weeks post
conception. From 12 weeks post-conception and continuing throughout
pregnancy and the postpartum period (4–6 weeks or as long as breastfeeding
continues), supplementation should consist of a multivitamin with folic acid
(0.4–1.0 mg). (I-A) J Obstet Gynaecol Can. 2007;29(12):1003-13

53. JOINT SOGC-MOTHERISK
CLINICAL PRACTICE GUIDELINE
Recommendations
• 7. The recommended strategy(ies) for primary prevention or to decrease
the incidence of fetal congenital anomalies will include a number of options
or treatment approaches depending on patient age, ethnicity, compliance,
and genetic congenital anomaly risk status.
• Option A: Patients with no personal health risks, planned pregnancy, and
good compliance require a good diet of folate-rich foods and daily
supplementation with a multivitamin with folic acid (0.4–1.0 mg) for at least
two to three months before conception and throughout pregnancy and the
postpartum period (4–6 weeks and as long as breastfeeding continues). (II-
2-A)
J Obstet Gynaecol Can. 2007;29(12):1003-13

54. JOINT SOGC-MOTHERISK
CLINICAL PRACTICE GUIDELINE
Recommendations
• Option B: Patients with health risks, including epilepsy, insulin
dependent diabetes, obesity with BMI >35 kg/m2, family history of
neural tube defect, belonging to a high-risk ethnic group (e.g., Sikh)
require increased dietary intake of folate-rich foods and daily
supplementation, with multivitamins with 5 mg folic acid, beginning at
least three months before conception and continuing until 10 to 12
weeks post conception. From 12 weeks post-conception and continuing
throughout pregnancy and the postpartum period (4–6 weeks or as
long as breastfeeding continues), supplementation should consist of a
multivitamin with folic acid (0.4–1.0 mg). (II-2-A)
J Obstet Gynaecol Can. 2007;29(12):1003-13

55. JOINT SOGC-MOTHERISK
CLINICAL PRACTICE GUIDELINE
Recommendations
Option C: Patients who have a history of poor compliance with medications and
additional lifestyle issues of variable diet, no consistent birth control, and possible
teratogenic substance use (alcohol, tobacco, recreational non-prescription drugs)
require counselling about the prevention of birth defects and health problems with
folic acid and multivitamin supplementation. The higher dose folic acid strategy (5 mg)
with multivitamin should be used, as it may obtain a more adequate serum red blood cell
folate level with irregular vitamin / folic acid intake but with a minimal additional
health risk. (III-B)
J Obstet Gynaecol Can. 2007;29(12):1003-13

56. JOINT SOGC-MOTHERISK
CLINICAL PRACTICE GUIDELINE
Recommendations
8.The Canadian Federal Government could consider an evaluation process for the
benefit/risk of increasing the level of national folic acid flour fortification to 300 mg/100
g (present level 140 mg/100 g). (III-B)
9.The Canadian Federal Government could consider an evaluation process for the
benefit/risk of additional flour fortification with multivitamins other than folic acid. (III-
B)
10.The Society of Obstetricians and Gynaecologists of Canada will explore the possibility of
a Canadian Consensus conference on the use of folic acid and multivitamins for the primary
prevention of specific congenital anomalies.
The conference would include Health Canada/Congenital Anomalies Surveillance, Canadian
College of Medical Geneticists, Canadian Paediatric Society, Motherisk, and pharmaceutical
industry representatives.
J Obstet Gynaecol Can. 2007;29(12):1003-13

57. Thank you
for your attention