VITAMIN AND MINERAL SUPPLEMENTATION DURING PREGNANCY

1. VITAMIN AND MINERAL
SUPPLEMENTATION DURING
PREGNANCY
Aboubakr Elnashar
Benha University Hospital, Egypt
ABOUBAKR ELNASHAR

2. 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
ABOUBAKR ELNASHAR

3. Recommended Dietary Allowances(RDA)
Excessive supplements during pregnancy.
Potentially toxic :
iron, zinc, selenium, and 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

4. 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
ABOUBAKR ELNASHAR

5. 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).
ABOUBAKR ELNASHAR

6. Fat soluble vitamins
1. Vitamin A
RDA:
750 ug/d
Toxicity:
> 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.
ABOUBAKR ELNASHAR

7. 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.
ABOUBAKR ELNASHAR

8. 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)
ABOUBAKR ELNASHAR

9. 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}.
ABOUBAKR ELNASHAR

10. 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.
ABOUBAKR ELNASHAR

11. 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).
ABOUBAKR ELNASHAR

12. 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)
ABOUBAKR ELNASHAR

13. 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).
ABOUBAKR ELNASHAR

14.  Vit D supplementation is needed by most
women during pregnancy
1. 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}.
2. Sun exposure may increase the risk of
melanoma: advising sun exposure is not an effective public
health strategy
3. 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)
ABOUBAKR ELNASHAR

15. 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
ABOUBAKR ELNASHAR

16. 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. ABOUBAKR ELNASHAR

17. 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).
ABOUBAKR ELNASHAR

18. 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

19. 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

20. Start
Before conception.
Up to
12 w {NT will have closed}
Throughout pregnancy.
{role in red blood cell manufacture and in cell replication}
ABOUBAKR ELNASHAR

21. Dose:
400mcg/d=0.4 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).
ABOUBAKR ELNASHAR

22. 2. Vitamin B12
In developing countries diets are generally low in
animal products and consequently in vitamin B12
content.
ABOUBAKR ELNASHAR

23. Maternal plasma levels decrease in normal pregnancy
1. Reduced plasma levels of their carrier proteins:
transcobalamins
2. Vit B12 occurs naturally only in foods of animal origin
3. 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
ABOUBAKR ELNASHAR

24. 3. Vit B6—Pyridoxine
Supplementation
Routine: No benefits
(Thaver, 2006, RCOG, 2011)
ABOUBAKR ELNASHAR

25.  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
ABOUBAKR ELNASHAR

26. 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)
ABOUBAKR ELNASHAR

27. 4. Vitamin C
Sources
Fruits and vegetables.
(RCOG, 2011)
Essential in:
1. collagen synthesis
2. wound healing
3. prevention of anaemia
4. As an antioxidant.
ABOUBAKR ELNASHAR

28. 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)}
ABOUBAKR ELNASHAR

29. B. Minerals
1. 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 mg:{Average increase in the total circulating erythrocyte
volume: 450 mL] {each 1 mL of erythrocytes contains 1.1 mg of iron}.
ABOUBAKR ELNASHAR

30. {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: ABOUBAKR ELNASHAR

31. 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.
ABOUBAKR ELNASHAR

32. 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
 iron–folic acid supplementation
improved birth weight.
ABOUBAKR ELNASHAR

33.  Dietary Advice
 Diet rich in iron
PoorMediumRich
milk and its
products, root
vegetables
meat, chicken,
fish, spinach,
banana, apple
liver, egg yolk, dry
beans, dry fruits,
wheat germ, yeast
ABOUBAKR ELNASHAR

34.  Avoid inhibitors of iron absorption
EnhanceInhibit
HemePhytates: cereals
Ascorbic acidTannins: tea –coffee
Ferrous iron(Fe2+)Calcium
ABOUBAKR ELNASHAR

35. 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
ABOUBAKR ELNASHAR

36. 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).
ABOUBAKR ELNASHAR

37. 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.
ABOUBAKR ELNASHAR

38. {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.
ABOUBAKR ELNASHAR

39. 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
ABOUBAKR ELNASHAR

40. 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.ABOUBAKR ELNASHAR

41. 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
ABOUBAKR ELNASHAR

42. 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 ABOUBAKR ELNASHAR

43. 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)
ABOUBAKR ELNASHAR

44. Calcium Supplementation
1.5–2.0 g elemental Ca daily for pregnant women
in areas with low dietary calcium.
(WHO 2011)
LDC: <1 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 8–12 w
tended to reduce miscarriage
ABOUBAKR ELNASHAR

45. 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.
ABOUBAKR ELNASHAR

46. 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
ABOUBAKR ELNASHAR

47. 5. Magnesium
Deficiency
In normal pregnancy has
not been recognized.
But during
1. prolonged illness
2. intestinal bypass surgery
:hematological and teratogenic damage
ABOUBAKR ELNASHAR

48. 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.
ABOUBAKR ELNASHAR

49. 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.
ABOUBAKR ELNASHAR

50. 7. Fluoride
Supplementation
Not beneficial
(Institute of Medicine, 1990).
{Fluoride metabolism is not altered during
pregnancy.}
(Maheshwari et al, 1983)
ABOUBAKR ELNASHAR

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

52. 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
ABOUBAKR ELNASHAR

53. 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.
ABOUBAKR ELNASHAR

54. 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.
ABOUBAKR ELNASHAR

55. Thank you
ABOUBAKR ELNASHAR