Nutrition and Micronutrients

in Pregnancy

ADVANCES IN MATERNAL AND NEONATAL

HEALTH

BY: Louella Ramos

 Evidence of Nutritional Intervention
Effectiveness
2

 Maternal malnutrition
 Folate
 Iron
 Iodine
 Vitamin A
 Zinc
 Calcium

Nutrition and Micronutrients in Pregnancy

 Maternal Malnutrition and Pregnancy Outcome
3

 Severe nutritional deprivation (Netherlands 1944–45)

Birth weight significantly influenced by starvation

 Perinatal mortality rate not affected
 No increase incidence of malformation
 In healthy women, state of near starvation is needed to affect
pregnancy outcome
 Severe nutritional deprivation (Netherlands 1944–46)
 Periconception: Decreased fertility, increased neural tube defect
 1st trimester: Increased stillbirths, preterm births, early newborn
deaths
 3rd trimester: Low birth weight, small for gestational age,
preterm birth

Cunningham et al 1997; Susser and Stein 1994.

Nutrition and Micronutrients in Pregnancy
 Maternal Malnutrition and Pregnancy Outcome
(continued)
4
 Dietary restriction trials in pregnant women
High weight for height or high weight gain

 Inconclusive results to demonstrate or exclude effect on fetal growth or any
significant effect on other outcomes
 Mixed result with nutritional supplementation trials
 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
 Women manifesting nutritional deficits can benefit from a balanced
energy/protein supplementation

Enkin et al 2000; de Onis, Villar and Gülmezoglu 1998.

Nutrition and Micronutrients in Pregnancy

 Folic Acid
5

 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

Czeizel 1993; Czeizel and Dudas 1992; Mahomed et al 1998; MRC Vitamin Study
Research Group 1991.
Nutrition and Micronutrients in Pregnancy
 Nutritional Supplementation
and Anemia
6

 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 associated with:

 Low birth weight newborns

 Premature newborns

 Perinatal mortality

 Increased maternal mortality and morbidity

Nutrition and Micronutrients in Pregnancy

 Anemia and Obstetrical Hemorrhage
7
 Anemia does not cause obstetrical hemorrhage (even severe anemia)
 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.

Enkin et al 2000; Mahomed 2000a.

Nutrition and Micronutrients in Pregnancy

 Iron Supplementation
8

 Iron requirements:
Average non-pregnant adult:

 800 g iron lost/day
 + 500 g iron lost/day during menses

 Pregnant woman: Increased need

 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 + 5 g folic acid

Mahomed 2000b; WHO 1994.

Nutrition and Micronutrients in Pregnancy
 Iodine Supplementation
9

 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

Enkin et al 2000; Mahomed and Gülmezoglu 2000.

Nutrition and Micronutrients in Pregnancy
 Vitamin A
10

 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

Rothman et al 1995; Suharno et al 1993;

West et al 1999.
Nutrition and Micronutrients in Pregnancy
 Other Micronutrients: Calcium
11

 Association between reduction in pregnancy induced hypertension (PIH) and

calcium supplementation
 Reduction of incidence of PIH

 Routine supplementation likely 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

Bucher et al 1996; Kulier et al 1998; Lopez-Jaramillo et al 1997.

Nutrition and Micronutrients in Pregnancy

 Calcium Supplementation: Objective and Design
12

 Objective: To assess effects of calcium in prevention of hypertensive disorders

of pregnancy
 Methods: Meta analysis of randomized controlled trial
 Outcomes:
 Mothers: Hypertension +/- proteinuria, maternal death or serious
morbidity, abruption, cesarean 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

Atallah, Hofmeyr and Duley 2000.

Nutrition and Micronutrients in Pregnancy
 Calcium Supplementation: Results
13

 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

Atallah, Hofmeyr and Duley 2000.

Nutrition and Micronutrients in Pregnancy
 Calcium Supplementation: Conclusions
14

 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

Atallah, Hofmeyr and Duley 2000.

Nutrition and Micronutrients in Pregnancy
 Summary of Nutritional Review Findings
15

 Evidence of nutritional intervention effectiveness

Iron supplementation

 Periconceptional folic acid intake
 Iodine use
 Balanced energy/protein supplementation
 Calcium
 Confirmatory studies to examine effectiveness
 Vitamin A
 Zinc

Nutrition and Micronutrients in Pregnancy

 References
16

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 Gülmezoglu. 1998. Nutritional intervention to prevent
intrauterine growth retardation: Evidence from randomized controlled trials. Eur J
Clin Nutr 52(Suppl 1): S83–S93.

Nutrition and Micronutrients in Pregnancy

 References (continued)
17

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.
Mahomed K. 2000a. Iron supplementation in pregnancy (Cochrane Review), in The
Cochrane Library. Issue 4. Update Software: Oxford.
Mahomed K. 2000b. Iron and folate supplementation in pregnancy (Cochrane Review),
in The Cochrane Library.Issue 4. Update Software: Oxford.
Mahomed K and A Gülmezoglu. 2000. Maternal iodine supplements in areas of
deficiency (Cochrane Review), in The Cochrane Library. Issue 4. Update Software:
Oxford.

Nutrition and Micronutrients in Pregnancy

 References (continued)
18

Mahomed K et al. 1998. Risk factors for pre-eclampsia among Zimbabwean women:
maternal arm circumference and other anthropometric measures of obesity. Paediatr
Perinat Epidemiol 12: 253–262.
Medical Research Council Vitamin Study Research Group. 1991. Prevention of neural
tube defects: results of the Medical Research Council Vitamin Study. Lancet 338
(8760):131–137.
Rothman KJ et al. 1995. Teratogenicity of high vitamin A intake. N Engl J Med 333
(21): 1369–1373.
Suharno D et al. 1993. Supplementation with vitamin A and iron for nutritional
anaemia in pregnant women in West Java, Indonesia. Lancet 342: 1325–1328.
Susser M and Z Stein. 1994. Timing in prenatal nutrition: A reprise of the Dutch
famine study. Nutrition Reviews 52 (3): 84–94.
West Jr. KP et al. 1999. Double blind, cluster randomised trial of low dose
supplementation with vitamin A or beta carotene on mortality related to pregnancy in
Nepal. Br Med J 318: 570–575.

Nutrition and Micronutrients in Pregnancy