Nutrition and Micronutrients in Pregnancy

1. Nutrition and Micronutrients in Pregnancy Prof. Surendra Nath Panda, M.S. Department of Obstetrics & Gynaecology M.K.C.G.Medical College Berhampur, ORISSA, INDIA

2. 2 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda

3. 3 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Nutritional Interventions in Pregnancy

4. 4 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Nutritional Interventions in Pregnancy The newborns in this study were small but healthy.The newborns in this study were small but healthy.

5. 5 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Maternal Malnutrition and Pregnancy Outcome Severe nutritional deprivation studies show: Periconception: decreased fertility, increased neural tube defect. 1st t trimester: increased stillbirths, preterm births, early newborn deaths. 2nd & 3rd trimester: low birth weight, small for gestational age, preterm birth. Birth weight significantly influenced by starvation Perinatal mortality rate not affected. No increase in incidence of malformation. In healthy women, state of near starvation is needed to affect pregnancy outcome. The newborns in this study were small but healthy.The newborns in this study were small but healthy.

6. 6 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Maternal Malnutrition and Pregnancy Outcome Dietary restriction trials in pregnant women: - Inconclusive results to demonstrate or exclude effect on fetal growth or any significant effect on other outcomes Nutritional supplementation trials: -Mixed result High protein: no evidence of benefit on fetal growth Balanced protein and energy: minimal increase in average birth weight (~30 g) and small decrease in incidence of small for gestational age newborns Conclusion: - Women manifesting nutritional deficits can benefit from a balanced energy/protein supplementation Calorie restriction will not restrict birth weight. High protein and energy has minimal effect on birth weight. Calorie restriction will not restrict birth weight. High protein and energy has minimal effect on birth weight.

7. 7 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Micronutrients and pregnancy outcome Micronutrient deficiencies associated with adverse pregnancy outcomes?. Folic Acid neural tube defects. Iron anaemia, haemorrhage. Iodine cretinism. Calcium hypertension, pre-eclampsia. Zinc anaemia, neural tube defects, low birth weight, anencephaly. Vitamin A Vertical transmission of HIV, Infant survival, Maternal anemia, Infection, Maternal mortality.

8. 8 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Micronutrients and pregnancy outcome

9. 9 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Folic Acid Strong evidence that folic acid prevents preconceptionally recurrent and first occurent neural tube defects Increasing evidence that folic acid reduces risk of some other birth defects Improves the hematologic indices in women receiving routine iron and folic acid USPHS/CDC recommends for US women 400 ?g/day: all women in childbearing age 1 mg/day: pregnant women 4 mg/day: women with history of neural tube defect deliveries take folic acid 1 month prior to conception and during first trimester Folic acid can be found in foods such as spinach, parsley, broccoli, lettuce, lima beans, turnip greens, asparagus and beef liver.Folic acid can be found in foods such as spinach, parsley, broccoli, lettuce, lima beans, turnip greens, asparagus and beef liver.

10. 10 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Nutritional Supplementation and Anemia WHO definition of severe anemia: hemoglobin < 7 g/dl Level of risk Moderate anemia (Hgb 7�11 g/dl): not increased Severe anemia: significant risk Severe anemia is associated with: Low birth weight newborns Premature newborns Increased perinatal mortality Increased maternal mortality and morbidity Classifications of anemia were taken from the World Health Organization (WHO). December 2000. Essential Care Practice Guide: Pregnancy, Childbirth and Newborn Care. Draft. Severe anemia is associated with a significantly increased risk of complications in pregnancy, specifically low birth weight newborns, premature birth, perinatal mortality, and increased maternal mortality and morbidity. This increase is due to low oxygen-carrying capacity for both fetus and mother.Classifications of anemia were taken from the World Health Organization (WHO). December 2000. Essential Care Practice Guide: Pregnancy, Childbirth and Newborn Care. Draft. Severe anemia is associated with a significantly increased risk of complications in pregnancy, specifically low birth weight newborns, premature birth, perinatal mortality, and increased maternal mortality and morbidity. This increase is due to low oxygen-carrying capacity for both fetus and mother.

11. 11 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Anemia and Obstetrical Hemorrhage Anemia (even severe anemia) does not cause obstetrical hemorrhage. Etiology of obstetric hemorrhage. Early pregnancy: abortion complications. Mid/late pregnancy to delivery: Previa, abruption, atony, retained placenta, birth canal laceration. Primary factors affecting outcome: Rapid intervention to prevent exsanguination. Availability of skilled provider, drugs, blood and fluids. There is no evidence that high levels of hemoglobin are beneficial in withstanding a hemorrhagic event.

12. 12 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Iron Supplementation Iron requirements: Average non-pregnant adult: 800 ?g iron lost/day + 500 ?g iron lost/day during menses Pregnant woman: increased need due to Expanded blood volume Fetal and placental requirements Blood loss during delivery Routine vs. Selective iron supplementation: Prevalence of nutritional anemia Routine iron and folate supplementation where nutritional anemia is prevalent Recommended dose: 60 mg elemental iron + 500 ?g folic acid Foods abundant in iron include: red meat (especially liver), poultry, fish, whole grains, dark green leafy vegetables, shellfish and dried fruit. Absorption is improved if taken with foods containing vitamin C. Adult females should get 30 mg/day, especially if they are pregnant. Foods abundant in iron include: red meat (especially liver), poultry, fish, whole grains, dark green leafy vegetables, shellfish and dried fruit. Absorption is improved if taken with foods containing vitamin C. Adult females should get 30 mg/day, especially if they are pregnant.

13. 13 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Iodine Supplementation Iodine deficiency is a preventable cause of mental impairment Iodine supplementation and fortification programs have been largely successful in decreasing iodine deficiency conditions Population with high levels of mental retardation (e.g.:- Some parts of china): Supplementation may be effective at preconception up to mid-pregnancy period Form of iodine supplementation (iodinating food or oral/injectable iodine) depend on: Severity of iodine deficiency Cost Availability of different preparation Some salts, bread and seafood have been supplemented with iodine. Iodine may be found in other locally available foods. The US recommended daily allowance is 150?g/day for adults, 175 ?g/day for pregnant women and 200 ?g/day for lactating women.Some salts, bread and seafood have been supplemented with iodine. Iodine may be found in other locally available foods. The US recommended daily allowance is 150?g/day for adults, 175 ?g/day for pregnant women and 200 ?g/day for lactating women.

14. 14 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Calcium Association between reduction in pregnancy induced hypertension (PIH) and calcium supplementation. Reduction of incidence of PIH. Routine supplementation likely to be beneficial in women at high risk of developing PIH or have low dietary calcium intake High calcium doses (2 g/day) not associated with adverse events. Need adequately sized and designed trials in different settings to confirm beneficial effects. Recommend increase in calcium intake through diet in women at risk of hypertension or low calcium areas.

15. 15 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Calcium Supplementation Meta analysis of randomized controlled trials regarding- Mothers: hypertension +/- proteinuria, maternal death or serious morbidity, abruptio placetae, caesarean section, length of stay Newborns: Preterm delivery, low birth weight/small for gestational age, neonatal intensive care unit admission, length of stay, still birth/death, disability, hypertension

16. 16 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Calcium Supplementation: Results Mothers: Hypertension+/-proteinuria: Less hypertension: RR 0.81 (0.74�0.89). Less pre-eclampsia: RR 0.70 (0.58�0.83). Better if low calcium intake, high risk. Newborns: Low birth weight: RR 0.83 (0.71�0.98), best for women at highest risk. Chronic hypertension: RR 0.59 (0.39�0.91). No difference in preterm delivery, neonatal intensive care unit admission, stillbirth, death.

17. 17 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Calcium Supplementation: Conclusions Calcium decreases risk of hypertension, pre-eclampsia, low birth weight, and chronic hypertension in children Recommend for high risk women with low calcium intake, if pre-eclampsia is important in the population Calcium has other health benefits not related to pregnancy: Maintaining bone strength Proper muscle contraction Blood clotting Cell membrane function Healthy teeth Foods abundant in calcium include: dairy products, dark green vegetables, nuts, grains and beans.Foods abundant in calcium include: dairy products, dark green vegetables, nuts, grains and beans.

18. 18 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Zinc and pregnancy outcome Zinc � involved in 300 enzymes, nucleoprotein, DNA and protein synthesis, cell division. Serum zinc levels in pregnant women - Normal range- 7-10 mol/l Fall (13 ) No change ( 6 ) Rise (one) Birth weight- Positive correlation in 4 studies Negative correlation in 1 study No correlation in 7 studies

19. 19 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Zinc and pregnancy outcome

20. 20 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Vitamin A Safe vitamin A dosage during pregnancy/Preventive-10 000IU daily or 25 000IU weekly Indications for vitamin A supplementation: Vertical transmission of HIV (ongoing) Infant survival Maternal anemia: positive interaction with iron in reducing anemia Infection Maternal mortality: Vitamin A vs. Placebo RR 0.60 (0.37�0.97) Beta-carotene vs. Placebo RR 0.51 (0.30�0.86) Potential adverse effects of vitamin A and related substances: Total daily dose > 10,000 IU before 7th week of gestation associated with birth defects: craniofacial, central nervous system, thymic cardiac Overall effectiveness and safety of vitamin A supplementation needs to be evaluated The maternal mortality study (West et al 1999) showed a reduction in maternal mortality related to pregnancy up to 12 weeks with vitamin A versus placebo and with beta-carotene versus placebo. Vitamin A, therefore, should be supplemented in areas where deficiency is endemic. Care must be taken not to give too much during pregnancy. In Nepal, Vitamin A supplementation of 23,300 IU on a weekly basis to nearly 45,000 women of reproductive age over a 3.5 year period, decreased maternal mortality by 40% (This dose delivers the equivalent of a liberal dietary allowance). Not clear yet, studies with conflicting results. Further Evaluation Needed: - Long term affect of supplementation unknown. Lower dose may be effective, but needs to be studied. Vitamin A can be found in foods such as carrots, eggs, fish oil, liver and broccoli. The recommended amount is 800 retinol equivalents/day for women age 17-50. If too much vitamin A is taken, toxicity can occur: fatty liver, nausea, vomiting, fatigue, headaches and birth defects.The maternal mortality study (West et al 1999) showed a reduction in maternal mortality related to pregnancy up to 12 weeks with vitamin A versus placebo and with beta-carotene versus placebo. Vitamin A, therefore, should be supplemented in areas where deficiency is endemic. Care must be taken not to give too much during pregnancy. In Nepal, Vitamin A supplementation of 23,300 IU on a weekly basis to nearly 45,000 women of reproductive age over a 3.5 year period, decreased maternal mortality by 40% (This dose delivers the equivalent of a liberal dietary allowance). Not clear yet, studies with conflicting results. Further Evaluation Needed: - Long term affect of supplementation unknown. Lower dose may be effective, but needs to be studied. Vitamin A can be found in foods such as carrots, eggs, fish oil, liver and broccoli. The recommended amount is 800 retinol equivalents/day for women age 17-50. If too much vitamin A is taken, toxicity can occur: fatty liver, nausea, vomiting, fatigue, headaches and birth defects.

21. 21 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Vitamin D and Vitamin K Vitamin D. Function- for calcium absorption, Neonatal hypocalcaemia. No study. Routinely Administered. Vitamin K. Deficiency associated with haemorrhage? No study The maternal mortality study (West et al 1999) showed a reduction in maternal mortality related to pregnancy up to 12 weeks with vitamin A versus placebo and with beta-carotene versus placebo. Vitamin A, therefore, should be supplemented in areas where deficiency is endemic. Care must be taken not to give too much during pregnancy. In Nepal, Vitamin A supplementation of 23,300 IU on a weekly basis to nearly 45,000 women of reproductive age over a 3.5 year period, decreased maternal mortality by 40% (This dose delivers the equivalent of a liberal dietary allowance). Not clear yet, studies with conflicting results. Further Evaluation Needed: - Long term affect of supplementation unknown. Lower dose may be effective, but needs to be studied. Vitamin A can be found in foods such as carrots, eggs, fish oil, liver and broccoli. The recommended amount is 800 retinol equivalents/day for women age 17-50. If too much vitamin A is taken, toxicity can occur: fatty liver, nausea, vomiting, fatigue, headaches and birth defects.The maternal mortality study (West et al 1999) showed a reduction in maternal mortality related to pregnancy up to 12 weeks with vitamin A versus placebo and with beta-carotene versus placebo. Vitamin A, therefore, should be supplemented in areas where deficiency is endemic. Care must be taken not to give too much during pregnancy. In Nepal, Vitamin A supplementation of 23,300 IU on a weekly basis to nearly 45,000 women of reproductive age over a 3.5 year period, decreased maternal mortality by 40% (This dose delivers the equivalent of a liberal dietary allowance). Not clear yet, studies with conflicting results. Further Evaluation Needed: - Long term affect of supplementation unknown. Lower dose may be effective, but needs to be studied. Vitamin A can be found in foods such as carrots, eggs, fish oil, liver and broccoli. The recommended amount is 800 retinol equivalents/day for women age 17-50. If too much vitamin A is taken, toxicity can occur: fatty liver, nausea, vomiting, fatigue, headaches and birth defects.

22. 22 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Copper and pregnancy outcome Functions - Cu-proenzymes, Cytochrome-c - oxidase, angiogenesis, connective tissue synthesis. Normal range varies - 110 to 210 micro gm/dl. Peak value- 220-300 micro gm/dl. Pattern of rise- First/Second trimester. Postpartum levels- 2 / 4 / 8-12 weeks. Rise in serum copper during pregnancy in all studies. No correlation between maternal and foetal copper levels. No correlation with abortion, weight, preterm delivery or other adverse pregnancy outcomes. Inverse relationship with birth weight.

23. 23 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Selenium and pregnancy outcome Functions - antioxidant, co-factor for enzyme glutathione peroxidase, prevents free radical formation, DNA changes. Results of four prospective studies: - Fall in serum selenium during pregnancy Levels in pregnancy - 35-70 ng/ml Neural tube defects in one study First trimester miscarriage in one study Preterm delivery in one study

24. 24 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Magnesium and pregnancy outcome Functions: - anticonvulsant. Deficiency: - increased blood coagulability, toxaemia, preterm birth? Results of three prospective studies �. Levels in pregnant women - 1.55-4.92mg/dl . Inverse correlation with birth weight in one study. Intra uterine growth retardation in one study.

25. 25 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Micronutrients and pregnancy outcome Pregnancy outcomes- Not clearly defined. Fetus - intra uterine growth retardation, small for gestational age, low birth weight, preterm birth. Maternal - preterm delivery, ineffective labour, atonic uterine bleeding. Physiology of micronutrients-discrepancies across studies regarding normal range / peak values / pattern of rise/fall.

26. 26 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Micronutrients and pregnancy outcome

27. 27 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Summary of Nutritional Review Findings Evidence of nutritional intervention effectiveness exists for: - Balanced energy / protein supplementation. Iron supplementation. Periconceptional folic acid intake. Iodine use. Calcium. Confirmatory studies to examine effectiveness of other micronutrients are required.

28. 28 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda RDA and safety level in adults (WHO)

29. 29 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda RDA and safety level in adults (WHO)

30. 30 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda CONCLUSION Insufficient evidence exists to support micronutrient deficiency during pregnancy. Insufficient evidence exists to associate micronutrient deficiency with adverse pregnancy outcomes. There is insufficient research on the physiology of micronutrients and adverse pregnancy outcomes. Need for rigorous scientific research to assess maternal micronutrient status and it�s correlation with pregnancy outcomes. Need to identify the normal range of micronutrients during pregnancy. Need for standardised tests to assess maternal micronutrient status. References Atallah AN, GJ Hofmeyr and L Duley. 2000. Calcium supplements during pregnancy for prevention of hypertensive disorders and related problems (Cochrane review), in the Cochrane library, issue 3. Bucher HC et al. 1996. Effect of calcium supplementation on pregnancy-induced hypertension and preeclampsia: a meta-analysis of randomized controlled trials. JAMA 275(4): 1113�1117. Cunningham FG et al. 1997. Williams obstetrics, 20th ed. Appleton & Lange: Stamford, Connecticut. Czeizel AE. 1993. Controlled studies of multivitamin supplementation on pregnancy outcomes. Ann N Y Acad Sci 678: 266�275. Czeizel AE and I Dudas. 1992. Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation. N Engl J med 327 (26): 1832�35. De Onis M, J Villar and M G�lmezoglu. 1998. Nutritional intervention to prevent intrauterine growth retardation: evidence from randomized controlled trials. Eur J Clin Nutr 52(Suppl 1): S83�S93. Enkin M et al. 2000. A guide to effective care in pregnancy and childbirth, 3rd ed. Oxford university press: oxford. Kulier R et al. 1998. Nutritional interventions for the prevention of maternal morbidity. Int J Gyn Obstet 63: 231�246. Lopez-Jaramillo P et al. 1997. Calcium supplementation and the risk of preeclampsia in Ecuadorian pregnant teenagers. Obstet Gynecol 90(2):162�167.References Atallah AN, GJ Hofmeyr and L Duley. 2000. Calcium supplements during pregnancy for prevention of hypertensive disorders and related problems (Cochrane review), in the Cochrane library, issue 3. Bucher HC et al. 1996. Effect of calcium supplementation on pregnancy-induced hypertension and preeclampsia: a meta-analysis of randomized controlled trials. JAMA 275(4): 1113�1117. Cunningham FG et al. 1997. Williams obstetrics, 20th ed. Appleton & Lange: Stamford, Connecticut. Czeizel AE. 1993. Controlled studies of multivitamin supplementation on pregnancy outcomes. Ann N Y Acad Sci 678: 266�275. Czeizel AE and I Dudas. 1992. Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation. N Engl J med 327 (26): 1832�35. De Onis M, J Villar and M G�lmezoglu. 1998. Nutritional intervention to prevent intrauterine growth retardation: evidence from randomized controlled trials. Eur J Clin Nutr 52(Suppl 1): S83�S93. Enkin M et al. 2000. A guide to effective care in pregnancy and childbirth, 3rd ed. Oxford university press: oxford. Kulier R et al. 1998. Nutritional interventions for the prevention of maternal morbidity. Int J Gyn Obstet 63: 231�246. Lopez-Jaramillo P et al. 1997. Calcium supplementation and the risk of preeclampsia in Ecuadorian pregnant teenagers. Obstet Gynecol 90(2):162�167.

31. 31 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda CONCLUSION

32. 32 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda Acknowledgement I am thankful to these authors, whose excellent reviews of nutritional studies have helped me in preparing this presentation. -Dr.S.N.Panda Atallah, Hofmeyr and Duley Bucher et al Enkin et al Kulier et al Lopez-Jaramillo et al Mahomed and G�lmezoglu Rita Kabra & Gulmezoglu Rothman et al Suharno et al West et al

33. 33 11:51 AM Nutrition and Micronutrients in Pregnancy - Prof.S.N.Panda FOR A HEALTHY MOTHER AND A HEALTHY BABY