This document provides guidelines on vitamin and mineral supplementation during pregnancy. It recommends routine supplementation with folic acid, iron, and vitamin D for most pregnant women. Excessive supplementation above recommended daily allowances should be avoided, as some vitamins and minerals can be toxic or teratogenic in high amounts. The document reviews the roles, sources, deficiencies, and supplementation recommendations for numerous vitamins and minerals, including fat-soluble and water-soluble vitamins, as well as iron. It emphasizes tailoring supplementation to individual needs and avoiding overtreatment.

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