Nutritional supplement on multiple pregnancy

Nutritional supplement in multiple pregnancy

2015.04.28

Fellow. You Jung, Shin

Nutrition and complicationsassociated 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: determinantesmaternas del peso al nacer. Perinatol Reprod Hum. 2001;15:238–244.

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

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

Physiologic changes

Component of weight gain during pregnancy

Williamson, Nutrition in pregnancy, 2006 British nutrition foundation nutrition bulletin 2006;31:28-59

Weight gain

Chart for estimating BMI

• Williams figure 48-1

• P962

• Prenatal care

Williams 24/e

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;48:217-24Goodnight, Obstet Gynecol , 2009;149:1121-1134

Weight gain in twin and singleton

Cambell, Nutrition During Pregnancy Part I: Weight Gain, Part II: Nutrient Supplements, 1986

Weight gain recommendation

Prepregnancy weight category (BMI)

Weight gain range (kg[Ib])

Weight gain in 2nd and 3rdtrimester(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

Weight gain & Calories

Calories and weight gainin 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

Program dietary recommendations and weight grain goals

Luke, Am J Obstet Gynecol, 2003;189,934-38

Williams 24/eRecommendations measured adequate intake

from Institute of medicine,2006,2011

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

Reported average nutrient intakes by pregnant women in comparison with1989 recommended dietary allowances

Twin Pregnancy Nutritional Recommendations

Goodnight, Obstet Gynecol , 2009;149:1121-1134

Iron

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. 2014Multiple pregnancy, NICE clinical guideline, 2014

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)

Changes in maternal iron status in twin pregnancy

Luke et al, Seminars in perinatology, 2005;29:349-54

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;29:349-54Bricker, Best practice & research clinical obstetrics and gynecology 2014;28:305-17

Folic acid

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.

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

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

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

Interactions: Drugs and folic acid

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

Micronutrients

• Vitamins

• Fat soluble :A,D,E,K

• Water soluble: B, C, Folate

• Minerals and trace elements

• Calcium

• Magnesium

• Zinc

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.


Vitamin B

• Dietary source

:우유, 우유생성물, 시리얼, 고기, 고기생성물, 초록색잎이많은야채,

효모균추출물, 간등 (B2)

• Vitamin B1 (Thiamin): 0.1-0.9mg/day in 3rd trimester

• Vitamin B2 (Riboflavin): 0.3-1.4mg/day


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


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 , 기름이많은생선등


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

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)


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

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


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.

Recommendation

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 pregnanciesCochrane Database Syst Rev. 2011;15(6):CD008867

2014 NICE

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

NICE public health guideline(Antenatal care)

1.3.2 Nutritional supplements1.3.2.1 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

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.


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.


JOINT SOGC-MOTHERISK CLINICAL PRACTICE GUIDELINE

Recommendations 2007

JOINT SOGC-MOTHERISK CLINICAL PRACTICE GUIDELINE



JOINT SOGC-MOTHERISK CLINICAL PRACTICE GUIDELINERecommendations

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)


JOINT SOGC-MOTHERISK CLINICAL PRACTICE GUIDELINERecommendations3. 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)


JOINT SOGC-MOTHERISK CLINICAL PRACTICE GUIDELINERecommendations

• 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

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

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)


JOINT SOGC-MOTHERISK CLINICAL PRACTICE GUIDELINE RecommendationsOption 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)


JOINT SOGC-MOTHERISK CLINICAL PRACTICE GUIDELINE Recommendations8.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.


Thank you

for your attention

Health & Medicine

Nutritional supplement on multiple pregnancy