Supplements To Be Taken During Pregnancy

Both pre-pregnancy and pregnancy nutrition are important.

Prenatal nutrition

Prenatal vitamins are important to cover the nutritional gap in maternal nutrition.

Hardly anyone cares about the prenatal nutrition and as most of the pregnancies are unplanned, the first visit to the health care system is mostly scheduled in the first trimester.

Vitamins are organic compounds which are essential for normal cell function, growth and development. There are 13 essential vitamins: A, C, D, E, K and the B series, including B1 (thiamine), B2 (riboflavin), B3 (niacin), B5 (pantothenic acid), B6 (pyridoxine), B7 (biotin), B9 (folic acid) and B12 (cobalamin), sufficient levels of which are vital during pregnancy. In the pregnant state there is an increased demand for vitamins, such as folic acid, yet intake among women of reproductive age is reported to be low.

Of particular significance among the prenatal vitamins is folic acid.

Folic Acid

Folic acid prevents neural tube defects (NTD), affecting the brain and spinal cord. Its deficiency is also associated with low birth weight and preterm delivery. Neural tube develops during the first 28 days of conception, before many women know they are pregnant. Hence any women desiring to get pregnant is recommended to take 400 micro grams of Folic acid daily, starting at least 4 weeks prior to pregnancy and continuing it till 12th week of pregnancy.

In addition to preventing neural tube defects, recent studies also show a decrease among other congenital anomalies like cardiovascular defects, limb defects and some paediatric cancers including leukaemia, paediatric brain tumours and neuroblastoma.

A higher dose of 5 mg per day is recommended in:

• Pregnant female herself or partner with NTD
• History of previous babies with NTD
• Family history of NTD
• Having diabetes
• Taking anticonvulsant medicines
• Pregnant women with BMI > 35 KG/mt2
• Pregnant teenagers who have energy dense, micro nutrient poor diet.

RDA (Recommended Daily Allowance): Current guidelines recommend that every pregnant lady gets at least 600 microgms of folic acid daily. It is hard to get this amount from food alone .Hence a dose of 400 micro gms per day during first trimester and 680 micro gms per day later is recommended in supplements. Most of the supplements contain 500 to 1500 micro gms of folic acid with some containing 5 mg.

Folic acid rich substances include spinach, broccoli, green vegetables, nuts, beans, citrus fruits, etc. Some countries use bread, pasta, cereals fortification with folic acid.

So if you haven’t taken folic acid, start it now.

Iron

Iron in the red blood cells carries oxygen to your tissues and baby. An extra amount of iron is required during pregnancy.

Adequate pre-pregnancy iron is important to decrease the risk of iron deficiency anaemia in female and decrease the incidence of low birth weight, premature delivery and infant mortality.

Post-partum iron deficiency is co-related to depression, emotional instability and stress.

Once pregnant, it is difficult to replenish sub-optimal iron levels.

Iron requirement substantially increases from 1st trimester to 3rd trimester. The recommended daily allowance for iron during entire pregnancy is 27mg/day .This dose builds the iron stores for entire pregnancy. Diet alone cannot suffice as it provides around 11-14 mg of iron per day.

RDA: With low iron stores: 30 mg ferrous iron/day between meals or at bed time.

With iron deficiency (with or without anaemia): 100mg/day in 2nd and 3rd trimester.

Rich sources: lean meat, leafy vegetables, dried fruits, nuts, poultry, fish etc.

The upper intake for iron from all sources is 45mg per day, and most supplements have less than this. At higher levels, there is a risk of gastrointestinal upset and constipation, though this can be minimized by taking the pill with food and drinking plenty of water throughout the day. In cases of iron deficiency anemia, it’s essential to have a doctor supervise the intake of iron, as too much iron can lead to an excessive increase in red blood cells (called haemoconcentration), which thickens blood and slows its flow, causing, paradoxically, the same problems in fetuses as too little iron: premature birth and low birth weight. Iron supplements are also hazardous for the 1 in 300 people with Haemochromatosis, a condition that may not be diagnosed in women during their child-bearing years.

Calcium

A developing foetus needs calcium for healthy bones, teeth, muscles, nerves, and their heart.

Most of the calcium needs can be met through diet. Extra supplements of calcium are needed among:

• Pregnant teenagers
• People who avoid dairy products
• Women having vitamin D deficiency
• Vegans

Calcium supplements are important as it helps prevent women loose her own bone density as baby uses her calcium to build their bones and teeth.

RDA: Each woman should get 1000 to 1300mgs of calcium per day.

Good sources of calcium include dairy products like milk, yoghurt, cheese and non-dairy products like broccoli, fortified orange juice, and anchovies with the bones, soya with added calcium, green leafy vegetables, fish with bones, sardines and pilchards or a calcium supplement.

Vitamin D

Vitamin D increases the absorption of calcium and phosphorous from the intestine. Its deficiency adversely affects foetal bones, teeth and muscles as well as Vitamin D stores. It is also a key element for good skin and eye sight. 25 OH Vit D in plasma below 25 nmol/l indicated Vitamin D deficiency. While we can get our vitamin D from sun, its deficiency is emerging mainly due to having dark skin and covering up for religious and cultural reasons. Obesity is another risk factor. Thus, all pregnant and breastfeeding females should take a supplement with 10 micrograms of Vitamin D.

RDA – 600 IU/day or 15 micrograms/day.

Most supplements contain 400IU equals to 10 micrograms of Vitamin D.

Main source: Skin synthesis

Other sources: Oily fish (salmon, mackerel, herring & sardines), eggs, red meat, fortified milk and cereal.

Iodine

Iodine requirement increases in pregnancy due to altered thyroid function. Deficiency affects both maternal and foetus. Iodine is important for the cognitive development. Deficiency of iodine causes stunned physical growth, severe mental disability and deafness.

Food provides around 60-70 microgms/day.

RDA: 220 microgms/day; (270 microgram per day for breastfeeding women)

Use iodized salt in cooking and on table, low milk fat, eggs etc.

It is recommended to take 150 microgms of potassium iodide daily or 150 microgram iodine in supplements as RDA recommendation of 220micrograms per day is not met by food alone.

Vitamin C

Vitamin C protects cells and keeps them healthy. It is needed for collagen synthesis, wound healing, works as an anti-oxidant and prevents anaemia by enhancing the absorption of non haem iron.

RDA: 50 mg per day (SP during last trimester)

A healthy diet can provide all the Vitamin C you need.

Good sources: Citrus fruits, peppers, strawberry, black current, broccoli, Brussel sprouts, potatoes etc.

Thiamine OR Vit B1

Requirements for thiamine parallel the requirements for energy and are subsequently higher for the last trimester of pregnancy.

RDA: An increase of 0.1 mg to a total of 0.9 mg per day during the last trimester

Riboflavin Vitamin B2

A significant proportion of women of childbearing age have intakes of riboflavin below the recommended level. Pregnant women should therefore be encouraged to consume plenty of riboflavin-containing foods.

RDA: The increment for average riboflavin intake is 0.3 mg per day to a total of 1.4 mg per day throughout pregnancy.

Pregnant women should therefore be encouraged to consume plenty of riboflavin-containing foods.

Good sources: Milk and milk products, cereals and cereal products (mainly fortified breakfast cereals), and meat and meat products, green leafy vegetables, yeast extract and liver; however, liver and liver products should be avoided during pregnancy.

Vitamin B6

It is important for the formation of red blood cells and helps the body use proteins, fat and carbohydrates. It is involved in myelin synthesis, neurotransmitter formation and haem formation. It may help relieve nausea of morning sickness. It also decreases homocysteine levels. Many supplements contain 50mgs. Safe maximum is 100mgs per day. Excess intake causes birth defects involving baby’s arm, legs and neuro development.

RDA: 1.9 mg/ day

Rich sources: Liver, pork, ham, whole grain, cereals, banana.

Vitamin B12

It is important for the formation of blood cells and neuro development.

RDA: 2.6micrograms/day

Good sources are meat, fish, poultry, milk (found only in animal products and a few algae)

Vegetarians should take supplements (250-500 micro grams ) as the main source of B12 is non-vegetarian food.

Vitamin A

Vit A is important for good eye sight and a healthy skin. It also helps bone growth.

RDA – 750 to 770 micro grams per day

Rich sources include carrots, green leafy vegetables and sweet potatoes.

Avoid excessive intake of Vitamin A. An intake more than 10,000 IU/Day must be avoided. High Vitamin A particularly affects cranial neural crest cells. Embryo-path is mostly found associated with 13 cis retinoic acid used to treat acne. Vitamin A is available as retinol and from the conversion of beta carotene. Avoid retinol- full fat dairy products, margarine, liver, and pate.

Vitamin K

Vitamin K is involved in blood coagulation. The risk of periventricular haemorrhage, in babies born before 34 weeks of gestation, and routine administration at delivery, have led researchers to investigate the role of vitamin K supplementation in pregnancy. Studies have demonstrated that antenatal vitamin K was associated with a non-significant reduction in all grades of periventricular haemorrhage with no improvement in neurodevelopmental outcomes in childhood. In few countries , it is recommend that oral vitamin K1 (phytomenadione) 10 mg daily should be given in the last month of pregnancy, only in those with risk factors for hemorrhagic disease of the newborn (maternal liver disease, anticipated premature delivery).

Omega 3 fatty acids

There is currently a lot of research interest in fish oil supplements and their potential benefits during pregnancy. There is some evidence that increasing the intake of long-chain n-3 PUFAs during pregnancy (e.g. from fish oils) may have beneficial effects on birth weight and the duration of pregnancy; however, not all studies have produced consistent results. The best dietary source of long-chain n-3 PUFAs is oil-rich fish, and regular consumption of oil-rich fish is recommended during pregnancy (up to two portions per week). However, taking cod liver oil supplements is not advised during pregnancy as they can contain high levels of vitamin A.

Hence to achieve a good pregnancy outcome, it is important to achieve a healthy body before pregnancy, have adequate weight gain during pregnancy and take a nutritional supplement with proper iron & folic acid.

Look for a prenatal supplement that includes:

• 400 microgms folic acid
• 400Iu Vit D
• 200 to 300 mg calcium
• 70mg vitamin C
• 3mg thiamine
• 2mg riboflavin
• 20 mg niacin
• 6 micro gram vitamin B12
• 10mg vitamin E
• 15mg zinc
• 17mg iron
• 150 microgms of iodine