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VITAMIN D
IN
PREGNANCY
Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MIOG, DICOG , FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, F...
INTRODUCTION
• Vitamin D is a Secosteriod (steroid with a
broken ring).
• The most important compounds in this group
are v...
INTRODUCTION
• Vitamin D3 is three times more effective
and has a longer half life than vitamin D2.*
• Calcifediol or 25(O...
Name Chemical Composition Structure
Vitamin D1
Mixture of molecular compounds
of ergocalciferol with lumisterol, 1:1
Vitam...
HISTORY
• In 1922, Elmer McCollum discovered and named
Vitamin D ( D as it was the 4th vitamin to be
discovered).
• In 192...
SOURCE OF VITAMNIN D
• Vitamin D subcutaneously
produced in humans from 7-
dehydrocholecalciferol upon
exposure to ultravi...
METABOLISM
• Vitamin D is absorbed with other dietary fats in
the small intestine.
• The main pathway of vitamin D uptake ...
PHYSIOLOGY
• Whether it is made in the skin or ingested,
cholecalciferol is hydroxylated in the liver at position
25 to fo...
PHYSIOLOGY
• Calcifediol is transported to the proximal tubules of
the kidneys, where it is hydroxylated at the 1-α
positi...
WHAT IS THE OPTIMUM VITAMIN D LEVEL?
• Institute of Medicine defined adequate vitamin D status
as having serum 25-hydroxyv...
FACTORS AFFECTING VITAMIN D STATUS
Vitamin D status is affected by factors that regulate its production in
the skin and by...
MAGNITUDE OF D3 DEFICIENCY DURING
PREGNANCY
• A recent review included 17 studies in pregnant and lactating women
found th...
VITAMIN D METABOLISM IN PREGNANCY
• By 12 weeks of gestation, 1,25(OH)2D levels are more than twice that of a
nonpregnant ...
VITAMIN D METABOLISM IN PREGNANCY
• This is dependent on available 25-
dihydroxyvitamin D levels but independent
on calciu...
VITAMIN D METABOLISM IN PREGNANCY
• The human endometrial decidua makes 1,25(OH)
2D and 24,25(OH) 2D and the placenta synt...
RECOMMENDED INTAKE
• The 2012 recommendation from UK Chief Medical
Officers and NICE guidelines state that all pregnant
an...
SCREENING OF VITAMIN D DEFICIENCY
DURING PREGNANCY
• Routine screening of Vitamin D levels are not
advisable.
• Even scree...
WHY VITAMIN D IS IMPORTANT
DURING PREGNANCY ?
• Vitamin D deficiency during pregnancy is associated with the non-
classical actions of this hormone.
• VDD is associated...
VITAMIN D & PRE ECLAMPSIA
In a meta analysis of 8 studies published in 2013, it was found that
Maternal vitamin D deficiency in pregnancy (25(OH)D <...
• In another metanalysis of 3357 papers published in 2013 in BMJ , it
was found that low levels of Vitamin D is significan...
PATHOPHYSIOLOGY
• There is an abnormal expression of 1α-hydroxylase
in preeclamptic pregnancies, revealing a potential
rol...
PATHOPHYSIOLOGY
• Vitamin D is a potent endocrine suppressor role in renin
biosynthesis for the regulation of the renin-an...
RECOMMENDATION
• Women at high risk of pre-eclampsia are
advised to take at least 800 units a day
combined with calcium.
V...
VITAMIN D & GDM
• In this case-control study, 54 women with diagnosed GDM and 39
women with IGT (1 abnormal oral glucose tolerance test) w...
• Farrant et al studied 559 pregnant women in India and found no
association between second trimester 25(OH)D levels and G...
PATHOPHYSIOLOGY
• Vitamin D has a direct effect on pancreatic beta cells and
increases transcription of insulin.
• It has ...
PATHOPHYSIOLOGY
• 1,25(OH)2D appears to stimulate the expression of insulin
receptors.
• It enhances insulin sensitivity b...
RECOMMENDATIONS
• Vitamin D supplementations are not recommended for either
treatment or prevention of GDM.
• Rudnicki and...
VITAMIN D & LOW BIRTH
WEIGHT
• Its was cross-sectional, descriptive analytical study, involving 112
neonates in Iraq – Tehran.
• Mean maternal vitamin ...
PATHOPHYSIOLOGY
• Adequate nutritional vitamin D status during
pregnancy is important for foetal skeletal development,
too...
VITAMIN D & PRETERM
DELIVERY
• Maternal circulating 25-OHD deficiency <50 nmol/L is associated with
preterm delivery.
• Vitamin D supplementation sugge...
PATHOPHYSIOLOGY
• Protective effect is due to immunomodulator effects
of 25-OHD.
• Vitamin D might protect against PTB by ...
VITAMIN D & NEONATAL
IMMUNITY
• Low cord blood 25(OH)D concentrations have been associated with
respiratory syncytial virus bronchiolitis and respirator...
PATHOPHYSIOLOGY
• Maternal vitamin D supplementation is
associated increased gene expression of
tolerogenic immunoglobulin...
OTHERS
• The risk was four-fold higher in women with serum 25(OH) D levels
below 37.5 nmol/L (15ng/mL) in women undergoing...
TREATMENT OF VDD IN PREGNANCY
• Treatment : either with cholecalciferol
20 000 IU a week or ergocalciferol 10 000 IU
twice...
DRUG SAFETY DURING PREGNANCY
• US FDA pregnancy category: C
• US Recommended DA during pregnancy and lactation is
400IU an...
CONCLUSION
• Vitamin D deficiency (VDD) during pregnancy is an unappreciated
global pandemic.
• There is an increased requ...
CONCLUSION
• Low vitamin D concentrations have been associated with a wide range
of adverse maternal and offspring health ...
REFERENCES
• Logan VF, Gray AR, Peddie MC, Harper MJ, Houghton LA. Long-term vitamin D3
supplementation is more effective ...
REFERENCES
• Wagner CL, Taylor SN, Johnson DD, Hollis BW. The role of vitamin D in pregnancy and lactation:
emerging conce...
REFERENCES
• Scholl TO, Chen X, Stein P. Maternal vitamin D status and delivery by
cesarean. Nutrients 2012;4(4):319-30.
•...
VITAMIN D IN PREGNANCY
VITAMIN D IN PREGNANCY
VITAMIN D IN PREGNANCY
VITAMIN D IN PREGNANCY
VITAMIN D IN PREGNANCY
VITAMIN D IN PREGNANCY
VITAMIN D IN PREGNANCY
VITAMIN D IN PREGNANCY
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Vitamin D deficiency (VDD) during pregnancy is an unappreciated global pandemic.

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VITAMIN D IN PREGNANCY

  1. 1. VITAMIN D IN PREGNANCY
  2. 2. Dr. Niranjan Chavan MD, FCPS, DGO, DFP, MIOG, DICOG , FICOG Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H Chairperson, FOGSI Oncology and TT Committee (2012-2014) Treasurer, MOGS (2017- 2018) Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016) Chief Editor, AFG Times (2015-2017) Editorial Board, European Journal of Gynecologic Oncology Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters Member, Managing Committee, IAGE (2013-2017) Member , Oncology Committee, AOFOG (2013 -2015) Recipient of 6 National & International Awards Author of 15 Research Papers and 19 Scientific Chapters Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH
  3. 3. INTRODUCTION • Vitamin D is a Secosteriod (steroid with a broken ring). • The most important compounds in this group are vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol). • Vitamin D2 and D3 are collectively called calciferol. • It is a pro hormone with its active form calcitriol.
  4. 4. INTRODUCTION • Vitamin D3 is three times more effective and has a longer half life than vitamin D2.* • Calcifediol or 25(OH)D serum levels are measured to determine Vitamin D status. * Logan VF, Gray AR, Peddie MC, Harper MJ, Houghton LA. Long-term vitamin D3 supplementation is more effective than vitamin D2 in maintaining serum 25-hydroxyvitamin D status over the winter months. Br J Nutr. 2013 Mar 28;109(6):1082-8. doi: 10.1017/S0007114512002851. Epub 2012 Jul 11.
  5. 5. Name Chemical Composition Structure Vitamin D1 Mixture of molecular compounds of ergocalciferol with lumisterol, 1:1 Vitamin D2 Ergocalciferol (made from ergosterol) Vitamin D3 Cholecalciferol (made from 7- dehydrocholesterol in the skin). Vitamin D4 22-dihydroergocalciferol Vitamin D5 Sitocalciferol (made from 7-dehydrositosterol)
  6. 6. HISTORY • In 1922, Elmer McCollum discovered and named Vitamin D ( D as it was the 4th vitamin to be discovered). • In 1925, it was established that sunlight exposure produces D3 from 7-dehydrocholesterol. • Adolf Windaus, received the Nobel Prize in Chemistry in 1928 for his work on the constitution of sterols and their connection with vitamin D. Adolf Windaus
  7. 7. SOURCE OF VITAMNIN D • Vitamin D subcutaneously produced in humans from 7- dehydrocholecalciferol upon exposure to ultraviolet light B (UVB) radiation. • Fish-liver oils • Fatty fish • Mushrooms • Egg yolks • Liver
  8. 8. METABOLISM • Vitamin D is absorbed with other dietary fats in the small intestine. • The main pathway of vitamin D uptake is incorporation into chylomicrons that reach the systemic circulation via the lymphatics. • The products of vitamin D metabolism are excreted through the bile into the faeces, and very little is eliminated through the urine.
  9. 9. PHYSIOLOGY • Whether it is made in the skin or ingested, cholecalciferol is hydroxylated in the liver at position 25 to form 25-hydroxycholecalciferol (calcifediol or 25(OH)D). • This reaction is catalysed by vitamin D 25- hydroxylase, the product of the CYP2R1 human gene, and expressed by hepatocytes. • Calcifediol is released into the plasma, where it is bound to an α-globulin carrier protein named the vitamin D-binding protein.
  10. 10. PHYSIOLOGY • Calcifediol is transported to the proximal tubules of the kidneys, where it is hydroxylated at the 1-α position to form calcitriol (1,25- dihydroxycholecalciferol, 1,25(OH)2D). • It is catalysed by the enzyme 25-hydroxyvitamin D3 1-alpha-hydroxylase, which is the product of the CYP27B1 human gene. • The activity of CYP27B1 is increased by parathyroid hormone, and also by low calcium or phosphate.
  11. 11. WHAT IS THE OPTIMUM VITAMIN D LEVEL? • Institute of Medicine defined adequate vitamin D status as having serum 25-hydroxyvitamin D concentrations greater than 50 nmol/L (or 20 ng/mL) in both the general population and pregnant women.* • Some studies have proposed that concentrations around 80 nmol/L (32 ng/mL) are optimal since they suppress PTH levels and lead to the greatest calcium absorption.** *Food, Nutrition Board. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington DC: National Academy Press, 2010. **Dawson-Hughes B. Serum 25-hydroxyvitamin D and functional outcomes in the elderly. American Journal of Clinical Nutrition2008;88(2):527S-540S.
  12. 12. FACTORS AFFECTING VITAMIN D STATUS Vitamin D status is affected by factors that regulate its production in the skin and by factors affecting its absorption or metabolism. FACTORS REGULATING PRODUCTION • Skin pigmentation • Latitude • Dressing codes • Season • Aging • Sunscreen use • Air pollution FACTORS REGULATING ABSORPTION • Diet with less fatty acids • Bariatric surgery • Malabsorption syndromes • Celiac disease • Chronic pancreatitis • Cystic fibrosis • Reduced magnesium levels
  13. 13. MAGNITUDE OF D3 DEFICIENCY DURING PREGNANCY • A recent review included 17 studies in pregnant and lactating women found that Vitamin D deficiency is prevalent in • 33% US • 24% Canadian • 60% India • 35% UK • 45% Pakistan Palacios C, Gonzalez L. Is vitamin D deficiency a major global public health problem?. Journal of Steroid Biochemistry and Molecular Biology2014;144(Pt A):138-45.
  14. 14. VITAMIN D METABOLISM IN PREGNANCY • By 12 weeks of gestation, 1,25(OH)2D levels are more than twice that of a nonpregnant adult and continue to rise two- to threefold from the nonpregnant baseline rising to over 700 pmol/l . • There is an increase in Vitamin D Binding Protein (VDBP) and Free 1,25(OH)2D levels. • Calcitonin rises during pregnancy and stimulates renal 1-α-hydroxylase gene expression independent of calcium levels & also protects by opposing hypercalcemia Møller UK, Streym S, Mosekilde L, Heickendorff L, Flyvbjerg A. Frystyk J, et al. Changes in calcitropic hormones, bone markers and insulin-like growth factor I (IGF-I) during pregnancy and postpartum: a controlled cohort study. Osteoporosis International 2013;24(4):1307-20.
  15. 15. VITAMIN D METABOLISM IN PREGNANCY • This is dependent on available 25- dihydroxyvitamin D levels but independent on calcium metabolism, which is a unique feature of pregnancy that allows such high levels of 1,25-dihydroxy vitamin D. • So an increased dietary intake is required to maintain the increase serum levels. • Calcium metabolism uncoupled from 1,25(OH)2D Wagner CL, Taylor SN, Johnson DD, Hollis BW. The role of vitamin D in pregnancy and lactation: emerging concepts. Women’s health (London, England). 2012;8(3):323-340. doi:10.2217/whe.12.17.
  16. 16. VITAMIN D METABOLISM IN PREGNANCY • The human endometrial decidua makes 1,25(OH) 2D and 24,25(OH) 2D and the placenta synthesizes only 24,25(OH) 2D. • 1,25(OH) 2D aids implantation and maintains normal pregnancy, supports foetal growth and limits production of proinflammatory cytokines. • 24,25(OH) 2D accumulates in bone and may be involved in ossification of the foetal skeleton. Shin JS, Choi MY, Longtine MS, Nelson DM. Vitamin D effects on pregnancy and the placenta. Placenta. 2010;31:1027–34
  17. 17. RECOMMENDED INTAKE • The 2012 recommendation from UK Chief Medical Officers and NICE guidelines state that all pregnant and breastfeeding women should take 10 micrograms of vitamin D supplements daily. • 1 micrograms is 40 IU. • Three categories of vitamin D supplementation are recommended are : General, High risk (subtypes high risk for pre eclampsia & high rick for VDD) and Deficient Chief Medical Officers for the United Kingdom. Vitamin D - advice on supplements for at risk groups. Cardiff, Belfast, Edinburgh, London: Welsh Government, Department of Health, Social Services and Public Safety, The Scottish Government, Department of Health; 2012
  18. 18. SCREENING OF VITAMIN D DEFICIENCY DURING PREGNANCY • Routine screening of Vitamin D levels are not advisable. • Even screening in all high risks (like on the basis of skin colour or coverage, obesity, risk of pre- eclampsia, or gastroenterological conditions limiting fat absorption) is not cost effective. • Measurement of vitamin D levels is recommended only in a hypocalcaemic or symptomatic woman. Vitamin D in pregnancy, scientific impact paper no. 43, July 2014, Royal college of obstetricians and gynaecologists
  19. 19. WHY VITAMIN D IS IMPORTANT DURING PREGNANCY ?
  20. 20. • Vitamin D deficiency during pregnancy is associated with the non- classical actions of this hormone. • VDD is associated with Preeclampsia Insulin resistance & gestational diabetes mellitus Immune modulation Preterm delivery LBW An increased risk for caesarean section delivery  Impaired neonatal immunity
  21. 21. VITAMIN D & PRE ECLAMPSIA
  22. 22. In a meta analysis of 8 studies published in 2013, it was found that Maternal vitamin D deficiency in pregnancy (25(OH)D < 50 nmol/L (20 ng/mL)) has been associated with an increased risk of pre-eclampsia.
  23. 23. • In another metanalysis of 3357 papers published in 2013 in BMJ , it was found that low levels of Vitamin D is significantly associated with new onset hypertension and proteinuria in pregnancy.
  24. 24. PATHOPHYSIOLOGY • There is an abnormal expression of 1α-hydroxylase in preeclamptic pregnancies, revealing a potential role for 1,25(OH) 2D3 as a regulator of placentation. • There is decreased levels of IGF-I in pre eclampsia. • In vitro, IGF-1 increases 1,25(OH) 2D production by primary human syncytiotrophoblasts from placentas from normal pregnancies but not from preeclamptic pregnancies. • Thus, VDD CAUSES ABNORMAL
  25. 25. PATHOPHYSIOLOGY • Vitamin D is a potent endocrine suppressor role in renin biosynthesis for the regulation of the renin-angiotensin system (RAS) • VDD has been suggested to cause excess activity in Th-1 type cytokines and to decrease immunological tolerance for implantation and to trigger preeclampsia. • Vitamin D has angiogenetic properties . Thus, VDD is associated with narrowing of spiral arteries leading to pre eclampsia. Bakacak M, Serin S, Ercan O, et al. Comparison of Vitamin D levels in cases with preeclampsia, eclampsia and healthy pregnant women. International Journal of Clinical and Experimental Medicine. 2015;8(9):16280-16286.
  26. 26. RECOMMENDATION • Women at high risk of pre-eclampsia are advised to take at least 800 units a day combined with calcium. Vitamin D in pregnancy, scientific impact paper no. 43, July 2014, Royal college of obstetricians and gynaecologists
  27. 27. VITAMIN D & GDM
  28. 28. • In this case-control study, 54 women with diagnosed GDM and 39 women with IGT (1 abnormal oral glucose tolerance test) were compared with 111 non-GDM control women in whom GDM were excluded by glucose challenge test. • Maternal serum 25-hydroxy vitamin D(3) concentration in GDM and IGT groups at 24-28 weeks of gestation were significantly lower than non-GDM controls.
  29. 29. • Farrant et al studied 559 pregnant women in India and found no association between second trimester 25(OH)D levels and GDM.
  30. 30. PATHOPHYSIOLOGY • Vitamin D has a direct effect on pancreatic beta cells and increases transcription of insulin. • It has regulation of extracellular calcium concentration and flux through the beta cell, thus increasing insulin secretion. • It also regulates the function of calbindin, and acts as a modulator of depolarization-stimulated insulin release via regulation of intracellular calcium. Shahgheibi S, Farhadifar F, Pouya B. The effect of vitamin D supplementation on gestational diabetes in high-risk women: Results from a randomized placebo-controlled trial. Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences. 2016;21:2. doi:10.4103/1735-1995.175148.
  31. 31. PATHOPHYSIOLOGY • 1,25(OH)2D appears to stimulate the expression of insulin receptors. • It enhances insulin sensitivity by activating peroxisome proliferator-activated receptor delta (PPAR-δ). • It increases intracellular Ca concentration, which is required for insulin mediated functions. • VDD also leads to an increase in the levels of parathyroid hormone (PTH), which has been associated with insulin resistance. MITRI J, PITTAS AG. Vitamin D and diabetes. Endocrinology and metabolism clinics of North America. 2014;43(1):205-232. doi:10.1016/j.ecl.2013.09.010.
  32. 32. RECOMMENDATIONS • Vitamin D supplementations are not recommended for either treatment or prevention of GDM. • Rudnicki and Mølsted-Pedersen studied Vitamin D supplementation and glucose levels in 1997, they found that only IV (not oral) vitamin D administration lowered serum glucose levels compared to baseline, from 5.6 to 4.8 mmol/L (P<0.01). • Ongoing RCTs of vitamin D supplementation in pregnancy all are targeted at treatment of GDM and none is testing prevention of GDM. Rudnicki PM, Mølsted-Pedersen L. Effect of 1,25-dihydroxycholecalciferol on glucose metabolism in gestational diabetes mellitus. Diabetologia. 1997 Jan;40(1):40-4.
  33. 33. VITAMIN D & LOW BIRTH WEIGHT
  34. 34. • Its was cross-sectional, descriptive analytical study, involving 112 neonates in Iraq – Tehran. • Mean maternal vitamin D (vit D) level was 31.46 nmol/L in the study. • Vitamin D levels were significantly lower in mothers of LBW.
  35. 35. PATHOPHYSIOLOGY • Adequate nutritional vitamin D status during pregnancy is important for foetal skeletal development, tooth enamel formation and perhaps general foetal growth and development. • Approximately 25-30 g of calcium are transferred to the foetal skeleton by the end of pregnancy, this requires high levels of D3. • Mannion et al., in 2006 found that with every additional 40 IU of maternal vitamin D intake, there was an associated 11-g increase in birth weight . Mannion C, Gray-Donald K, Koski K. Milk restriction and low maternal vitamin D intake during pregnancy are associated with decreased birth weight. CMAJ. 2006;174(9):1273–1277.
  36. 36. VITAMIN D & PRETERM DELIVERY
  37. 37. • Maternal circulating 25-OHD deficiency <50 nmol/L is associated with preterm delivery. • Vitamin D supplementation suggested that 25-OHD serum concentration > 100 nmol/L (vs <50 nmol/L) could significantly reduce the risk of PTB. Zhou SS, Tao YH, Huang K, Zhu BB, Tao FB. Vitamin D and risk of preterm birth: Up-to-date meta-analysis of randomized controlled trials and observational studies. J Obstet Gynaecol Res. 2017 Feb;43(2):247-256. doi: 10.1111/jog.13239. Review. Erratum in: J Obstet Gynaecol Res. 2017 Apr;43(4):783.
  38. 38. PATHOPHYSIOLOGY • Protective effect is due to immunomodulator effects of 25-OHD. • Vitamin D might protect against PTB by reducing infection and inflammation. • Inhibits inflammatory factors, such as tumour necrosis factor-α and interleukin & promotes anti- inflammatory cytokine and cathelicidin. • Improves placental function, and reduces oxidative stress. Chesney RW. Vitamin D and The Magic Mountain: The anti-infectious role of the vitamin. J Pediatr 2010; 56: 698– 703.
  39. 39. VITAMIN D & NEONATAL IMMUNITY
  40. 40. • Low cord blood 25(OH)D concentrations have been associated with respiratory syncytial virus bronchiolitis and respiratory infections. • Low levels of neonatal vitamin D have been linked to childhood asthma. • Cord blood samples deficient in vitamin D had less effect on adult monocyte cathelicidin gene expression compared with vitamin D replete cord blood (>75 nmol/l).
  41. 41. PATHOPHYSIOLOGY • Maternal vitamin D supplementation is associated increased gene expression of tolerogenic immunoglobulin such as immunoglobulin-like transcripts 3 and 4 (ILT3 and ILT4). • Cord blood 25(OH)D is correlated with mononuclear cell release of IFN-γ and hence Th1 cell development. • Vit. D Up-regulates the production of the antimicrobial peptides by macrophages and endothelial cells. Chi A, Wildfire J, McLoughlin R, Wood RA, Bloomberg GR, Kattan M, et al. Umbilical cord plasma 25- hydroxyvitamin D concentration and immune function at birth: the Urban Environment and Childhood Asthma study. Clin Exp Allergy 2011;41:842–50.
  42. 42. OTHERS • The risk was four-fold higher in women with serum 25(OH) D levels below 37.5 nmol/L (15ng/mL) in women undergoing LSCS.* • Vitamin D deficiency results in proximal muscle weakness and decreased lower extremity muscle function perhaps contributing to the risk for caesarean section. • Vitamin D deficiency is also associated with bacterial vaginosis in pregnant women.** *Aghajafari F, Nagulesapillai T, Ronksley PE, Tough SC, O’Beirne M, Rabi DM. Association between maternal serum 25-hydroxyvitamin D level and pregnancy and neonatal outcomes: systematic review and meta-analysis of observational studies. BMJ 2013;346:f1169. **Hensel KJ, Randis TM, Gelber SE, Ratner AJ. Pregnancy-specific association of vitamin D deficiency and bacterial vaginosis. Am J Obstet Gynecol 2011;204:41.e1–9.
  43. 43. TREATMENT OF VDD IN PREGNANCY • Treatment : either with cholecalciferol 20 000 IU a week or ergocalciferol 10 000 IU twice a week. • Duration : 4 – 6 weeks • Maintenance dose:1000 IU daily throughout the pregnancy. Vitamin D: screening and supplementation during pregnancy, committee opinion number 495, july 2011 (reaffirmed 2017), The American College of Obstetrician and Gynaecologists. National Institute for Health and Clinical Excellence. Antenatal care. NICE clinical guideline 62. Manchester: NICE; 2008.
  44. 44. DRUG SAFETY DURING PREGNANCY • US FDA pregnancy category: C • US Recommended DA during pregnancy and lactation is 400IU and 600IU respectively. • The daily upper safe limit for vitamin D has been set at 4000 IU by IOM and 10,000 IU by the Endocrine Society. • Animal studies have shown foetal abnormalities associated with hypervitaminosis D, similar to supravalvular aortic stenosis syndrome. National Institute for Health and Clinical Excellence. Antenatal care. NICE clinical guideline 62. Manchester: NICE; 2008
  45. 45. CONCLUSION • Vitamin D deficiency (VDD) during pregnancy is an unappreciated global pandemic. • There is an increased requirement of vitamin D during pregnancy. • Routine screening for general and even in all high risk pregnancies is not recommended. • Both RCOG and ACOG advocate routine 400 IU daily supplementation of Vitamin D during pregnancy and lactation.
  46. 46. CONCLUSION • Low vitamin D concentrations have been associated with a wide range of adverse maternal and offspring health outcomes in observational epidemiological studies. • Further research should focus on the potential benefits and optimal dosing of vitamin D use in pregnancy.
  47. 47. REFERENCES • Logan VF, Gray AR, Peddie MC, Harper MJ, Houghton LA. Long-term vitamin D3 supplementation is more effective than vitamin D2 in maintaining serum 25-hydroxyvitamin D status over the winter months. Br J Nutr. 2013 Mar 28;109(6):1082-8. doi: 10.1017/S0007114512002851. Epub 2012 Jul 11. • Food, Nutrition Board. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington DC: National Academy Press, 2010. • Dawson-Hughes B. Serum 25-hydroxyvitamin D and functional outcomes in the elderly. American Journal of Clinical Nutrition2008;88(2):527S-540S. • Palacios C, Gonzalez L. Is vitamin D deficiency a major global public health problem?. Journal of Steroid Biochemistry and Molecular Biology2014;144(Pt A):138-45. • Møller UK, Streym S, Mosekilde L, Heickendorff L, Flyvbjerg A. Frystyk J, et al. Changes in calcitropic hormones, bone markers and insulin-like growth factor I (IGF-I) during pregnancy and postpartum: a controlled cohort study. Osteoporosis International 2013;24(4):1307-20. • Shin JS, Choi MY, Longtine MS, Nelson DM. Vitamin D effects on pregnancy and the placenta. Placenta. 2010;31:1027–34
  48. 48. REFERENCES • Wagner CL, Taylor SN, Johnson DD, Hollis BW. The role of vitamin D in pregnancy and lactation: emerging concepts. Women’s health (London, England). 2012;8(3):323-340. doi:10.2217/whe.12.17. • Chief Medical Officers for the United Kingdom. Vitamin D - advice on supplements for at risk groups. Cardiff, Belfast, Edinburgh, London: Welsh Government, Department of Health, Social Services and Public Safety, The Scottish Government, Department of Health; 2012 • Vitamin D in pregnancy, scientific impact paper no. 43, July 2014, Royal college of obstetricians and gynaecologists • Vitamin D: screening and supplementation during pregnancy, committee opinion number 495, July 2011 (reaffirmed 2017), The American College of Obstetrician and Gynaecologists. • National Institute for Health and Clinical Excellence. Antenatal care. NICE clinical guideline 62. Manchester: NICE; 2008. • Mithal A, Kalra S. Vitamin D supplementation in pregnancy. Indian Journal of Endocrinology and Metabolism. 2014;18(5):593-596. doi:10.4103/2230-8210.139204.
  49. 49. REFERENCES • Scholl TO, Chen X, Stein P. Maternal vitamin D status and delivery by cesarean. Nutrients 2012;4(4):319-30. • Tabesh M, Salehi-Abargouei A, Tabesh M, Esmaillzadeh A. Maternal vitamin D status and risk of pre-eclampsia: a systematic review and meta-analysis. Journal of Clinical Endocrinology and Metabolism2013;98(8):3165-73.

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