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Sun L, Li Y, Xie W, Xue X. Association between omega-3 fatty acid supplementation and lower risk of preterm delivery: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2020; 35:2294-2303. [PMID: 32942938 DOI: 10.1080/14767058.2020.1785423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To explore whether omega-3 fatty acid supplementation is associated with lower risk of preterm delivery. METHODS Searching the RCTs which were compared preterm birth between women with omega-3 fatty acid supplementation and without before December 2019 on Medline, EMBASE and Cochrane's Library, then performing a meta-analysis. RESULTS 26 trials were identified, included 20124 women. There was almost no association between omega-3 fatty acid supplementation and lower risk of preterm delivery (risk ratio 0.92, 95% confidence interval 0.85 to 1.01, I2 = 9%), gestational duration (0.30, -0.05 to 0.64, I2 = 48%). In subgroup analyses, preterm delivery lower rate occurred in groups with mixed DHA and EPA supplementation not only DHA supplementation groups (P for interaction = 0.02); The dose of equivalent greater than 1 g made a higher reduction in preterm birth significantly. CONCLUSIONS Omega-3 fatty acid supplementation was not associated with reduced risk of preterm delivery compared with placebo or no treatment during pregnancy. Relationship between Omega-3 fatty acid supplementation and other pregnant outcomes need more evidence and clinical studies.
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Affiliation(s)
- Lu Sun
- Department of Gynecology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China and China-Japan Friendship Hospital, Beijing, China
| | - Yuxin Li
- Department of Gynecology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China and China-Japan Friendship Hospital, Beijing, China
| | - Wei Xie
- Department of Gynecology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China and China-Japan Friendship Hospital, Beijing, China
| | - Xiaoou Xue
- Department of Gynecology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China and China-Japan Friendship Hospital, Beijing, China
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Chowdhury MH, Ghosh S, Kabir MR, Mamun MAA, Islam MS. Effect of supplementary omega-3 fatty acids on pregnant women with complications and pregnancy outcomes: review from literature. J Matern Fetal Neonatal Med 2020; 35:2564-2580. [PMID: 32643471 DOI: 10.1080/14767058.2020.1786522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Numerous benefits have been associated with omega-3 fatty acid consumption during pregnancy and the postpartum period, whether it is consumed in the diet with seafood or via supplements such as fish oil. This review primarily aimed to assess the current situation of the impact of omega-3 long-chain Poly Unsaturated Fatty Acid (PUFA) supplementation on the outcomes of pregnancy. The electronic search of Medline, PubMed, Public Library of Science (PLOS) and Google Scholar databases was carried out for papers from 01 February 1995 to 01 March 2017 using keywords such as "pregnancy," "supplement," "long-chain polyunsaturated fatty acids," "omega 3 fatty acids," and "clinical trials." Out of twenty-six studies, both observational and interventional, fourteen studies found the influence of omega 3 fatty acids during pregnancy or the early postpartum period on the duration of gestation and infant size at birth, preeclampsia, depression, and infant visual function and neurodevelopment have been reported. Omega 3 fatty acid intakes (both in terms of absolute amounts of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) and the ratio of these 2 fatty acids) varied widely in these studies, however, and no clear consensus exists regarding the effects of omega 3 fatty acids on any of these outcomes. Because of the potential importance of these fatty acids for pregnant or lactating women, fetus, and newborn infants and the limited data from clinical trials assessing the effect of these fatty acids on pregnancy and infant outcomes, additional research is required to better define optimal intakes of specific omega 3 fatty acids during these critical periods.
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Affiliation(s)
- Mohammad Hasan Chowdhury
- Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Noakhali, Bangladesh
| | - Susmita Ghosh
- Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Noakhali, Bangladesh
| | - Md Ruhul Kabir
- Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Noakhali, Bangladesh
| | - Md Abdullah Al Mamun
- Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Noakhali, Bangladesh
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Lazzarin N, Vaquero E, Exacoustos C, Bertonotti E, Romanini ME, Arduini D. Low-dose aspirin and omega-3 fatty acids improve uterine artery blood flow velocity in women with recurrent miscarriage due to impaired uterine perfusion. Fertil Steril 2009; 92:296-300. [DOI: 10.1016/j.fertnstert.2008.05.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 04/28/2008] [Accepted: 05/15/2008] [Indexed: 10/21/2022]
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Qiu C, Sanchez SE, Larrabure G, David R, Bralley JA, Williams MA. Erythrocyte omega-3 and omega-6 polyunsaturated fatty acids and preeclampsia risk in Peruvian women. Arch Gynecol Obstet 2006; 274:97-103. [PMID: 16520922 DOI: 10.1007/s00404-006-0140-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Accepted: 02/14/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This case-control study was conducted in Lima, Peru, from June 1997 through January 1998 to assess whether alteration in maternal erythrocyte omega-3 (n-3) and omega-6 (n-6) fatty acids was associated with increased risk of preeclampsia. METHODS A total of 99 preeclampsia and 100 normotensive pregnant women were included. Maternal erythrocyte n-3 and n-6 fatty acids were determined using capillary gas chromatography/mass spectrometry and expressed as micromolar (mM) concentrations. We employed logistic regression procedures to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULT n-3 fatty acids were consistently lower in preeclampsia cases than controls. After adjusting for confounders, the corresponding ORs for preeclampsia across decreasing quartiles of sum of long-chain n-3 fatty acids were 1.0, 3.3, 2.4, and 3.3, respectively (P=0.07 for trend). A similar pattern was observed for eicosapentenoic acid (20:5n-3, EPA) and docosahexenoic acid (22:6n-3, DHA). There was no clear evidence of an association between arachidonic acid (20:4n-6, AA) and preeclampsia risk, the ORs in successively lower quartiles were 1.0, 1.1, 1.0, and 1.5 (P=0.48 for trend). A similar pattern was seen for the sum of long-chain n-6 fatty acids. CONCLUSION In Peruvian women, low erythrocyte n-3 fatty acids appeared to be associated with an increased risk of preeclampsia.
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Affiliation(s)
- Chunfang Qiu
- Center for Perinatal Studies, Swedish Medical Center, 747 Broadway (Suite 4 North), Seattle, WA 98122, USA.
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Velzing-Aarts FV, van der Klis FR, van der Dijs FP, van Beusekom CM, Landman H, Capello JJ, Muskiet FA. Effect of three low-dose fish oil supplements, administered during pregnancy, on neonatal long-chain polyunsaturated fatty acid status at birth. Prostaglandins Leukot Essent Fatty Acids 2001; 65:51-7. [PMID: 11487309 DOI: 10.1054/plef.2001.0288] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Adequate long-chain polyunsaturated fatty acid (LCP) status during pregnancy is important. We studied the effect of three low-dose fish oil supplements, administered during uncomplicated pregnancy, on neonatal LCP status at term delivery. Supplements were administered from the second trimester to delivery, either as fish oil capsules ("fish-1": 336 mg LCPomega3, n=15; and "fish-3": 1,008 mg LCPomega3, n=20) or milk-based supplement ("Mum": 528 mg LCPomega3, n=24). Fifty-seven untreated women served as controls. Fatty acids of umbilical veins (UV) and arteries (UA) were measured. The fish-1 group showed no differences, compared to controls. The Mum group had higher 20:5omega3, 22:5omega3, 22:6omega3, LCPomega3 and 22:6omega3/22:5omega6 in UV and UA. The fish-3 group had higher 22:5omega3 and 22:6omega3 (UA), LCPomega3 and 22:6omega3/22:5omega6 (UV and UA) and 20:3omega6 (UV). A 500-1000 mg daily LCPomega3 supplement, taken either as a milk-based supplement or fish oil capsules, effectively increases fetal LCPomega3 status, without affecting LCPomega6 status.
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Affiliation(s)
- F V Velzing-Aarts
- Pathology and Laboratory Medicine, Groningen University Hospital, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
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Olsen SF, Secher NJ, Tabor A, Weber T, Walker JJ, Gluud C. Randomised clinical trials of fish oil supplementation in high risk pregnancies. Fish Oil Trials In Pregnancy (FOTIP) Team. BJOG 2000; 107:382-95. [PMID: 10740336 DOI: 10.1111/j.1471-0528.2000.tb13235.x] [Citation(s) in RCA: 199] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To test the postulated preventive effects of dietary n-3 fatty acids on pre-term delivery, intrauterine growth retardation, and pregnancy induced hypertension. DESIGN In six multicentre trials, women with high risk pregnancies were randomly assigned to receive fish oil (Pikasol) or olive oil in identically-looking capsules from around 20 weeks (prophylactic trials) or 33 weeks (therapeutic trials) until delivery. SETTING Nineteen hospitals in Europe. SAMPLES Four prophylactic trials enrolled 232, 280, and 386 women who had experienced previous pre-term delivery, intrauterine growth retardation, or pregnancy induced hypertension respectively, and 579 with twin pregnancies. Two therapeutic trials enrolled 79 women with threatening pre-eclampsia and 63 with suspected intrauterine growth retardation. INTERVENTIONS The fish oil provided 2.7 g and 6.1 g n-3 fatty acids/day in the prophylactic and therapeutic trials, respectively. MAIN OUTCOME MEASURES Preterm delivery, intrauterine growth retardation, pregnancy induced hypertension. RESULTS Fish oil reduced recurrence risk of pre-term delivery from 33% to 21% (odds ratio 0.54 (95% CI 0.30 to 0.98)) but did not affect recurrence risks for the other outcomes (OR 1.26; 0.74 to 2.12 and 0.98; 0.63 to 1.53, respectively). In twin pregnancies, the risks for all three outcomes were similar in the two intervention arms (95% CI for the three odds ratios were 0.73 to 1.40, 0.90 to 1.52, and 0.83 to 2.32, respectively). The therapeutic trials detected no significant effects on pre-defined outcomes. In the combined trials, fish oil delayed spontaneous delivery (proportional hazards ratio 1.22; 1.07 to 1.39, P = 0.002). CONCLUSIONS Fish oil supplementation reduced the recurrence risk of pre-term delivery, but had no effect on pre-term delivery in twin pregnancies. Fish oil had no effect on intrauterine growth retardation and pregnancy induced hypertension, affecting neither recurrence risk nor risk in twin pregnancies.
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Affiliation(s)
- S F Olsen
- Maternal Nutrition Group, Danish Epidemiology Science Centre, Statens Serum Institut, Copenhagen.
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Cervar M, Nelson DM, Kainer F, Desoye G. Drug actions in preeclampsia: aspirin, but not magnesium chloride or dihydralazine, differentially inhibits cultured human trophoblast release of thromboxane and prostacyclin without affecting angiotensin II, endothelin-1, or leukotriene B4 secretion. Am J Obstet Gynecol 1997; 176:66-72. [PMID: 9024091 DOI: 10.1016/s0002-9378(97)80013-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We hypothesized that aspirin Mg++, and dihydralazine affect the release of vasoactive agents from cultured human placental trophoblast. STUDY DESIGN Cytotrophoblasts isolated from placentas of preterm or term deliveries of 14 healthy control women and 15 preeclamptic women were cultured in Dulbecco's modified Eagle's medium for 5 days in the presence or absence of either 0.1 mmol/L aspirin, 3 mmol/L magnesium chloride, or 136 ng/ ml dihydralazine. Vasoactive substances were quantitated by radioimmunoassay with mean +/- SEM percentage of untreated cells (= 100%) compared by the Mann-Whitney U test and analysis of variance. RESULTS Aspirin inhibited (p < 0.01) both thromboxane and prostacyclin on days 1 and 2 in culture but not on days 3 to 5 unless the Dulbecco's modified Eagle's medium was supplemented with arachidonic acid. Aspirin inhibition was greater (p < 0.01) for thromboxane in cells cultured 24 hours after preeclamptic pregnancy (preterm 29.9% +/- 6.8%, term 20.1% +/- 5.9%) compared with normal controls (preterm 66.3% +/- 10.6%, term 68.9% +/- 11.6%). Aspirin reduced (p < 0.01) the ratio of thromboxane to prostacyclin in media of cells from preeclampsia (untreated 27.8 +/- 7.2, aspirin 13.3 +/- 4.4), but aspirin had no effect on this ratio in cultures from control normal pregnancies (untreated 6.8 +/- 2.9, aspirin 4.8 +/- 1.1). Neither magnesium chloride nor dihydralazine affected trophoblast prostanoid production, and no drug altered the media levels of angiotensin II, endothelin-1, or leukotriene B4. CONCLUSION Aspirin selectively inhibits trophoblast prostanoid production. This inhibition depends on the availability of arachidonic acid and the presence or absence of preeclampsia. Magnesium and dihydralazine effects in pregnancy are not related to altered release of trophoblast vasoactive compounds.
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Affiliation(s)
- M Cervar
- Department of Obstetrics and Gynecology, University of Graz, Austria
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Adair CD, Sanchez-Ramos L, Briones DL, Ogburn P. The effect of high dietary n-3 fatty acid supplementation on angiotensin II pressor response in human pregnancy. Am J Obstet Gynecol 1996; 175:688-91. [PMID: 8828435 DOI: 10.1053/ob.1996.v175.a74248] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Our purpose was to evaluate the effects of n-3 fatty acid supplementation on vascular reactivity as measured by the angiotensin II sensitivity test. STUDY DESIGN Ten subjects with uneventful pregnancies, who were free of any chronic medical illnesses, between 24 and 34 weeks' gestation participated. Each subject was provided with OMEGA-3 700 softgel capsules and instructed to take three tablets three times daily (approximately 3.6 gm of eicosapentaenoic acid). The angiotensin II sensitivity test was performed before and 28 days after supplementation. Compliance was assessed by analysis of computerized pill bottles. Statistical analyses of the data were performed with a paired t test for evenly distributed continuous data. A sample size of eight patients was required to detect a difference in effective pressor dose of > or = 10 ng/kg/min between the presupplement and postsupplement results, assuming an alpha of 0.05 and a beta of 0.20 (80% power). RESULTS The effective pressor dose before treatment (13.6 +/- 6.3 ng/kg/min) (mean +/- SD) was significantly less (p = 0.001) than after supplementation (35.8 +/- 15.9 ng/kg/min). CONCLUSIONS High-dose n-3 fatty acid supplementation resulted in an enhancement of the pregnancy-acquired refractoriness to angiotensin II.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville, USA
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Dekker GA, van Geijn HP. Endothelial dysfunction in preeclampsia. Part II: Reducing the adverse consequences of endothelial cell dysfunction in preeclampsia; therapeutic perspectives. J Perinat Med 1996; 24:119-39. [PMID: 8773939 DOI: 10.1515/jpme.1996.24.2.119] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Next to low-dose Aspirin there appear to be several new and promising pharmacologie approaches for reducing the adverse consequences of endothelial cell dysfunction in preeclampsia. Among these are selective thromboxane-A2 synthetase and/or thromboxane-A2 receptor antagonists, stable prostacyclin analogues, selective S(erotonin)2-receptor blockers, nitrovasodilators, glycoprotein IIb/IIIa antagonists, hirudin, and ticlopidine. Early-onset preeclampsia appears to be associated with certain disorders that are likely to provoke an arterial thrombotic process by impairing the normal endothelial cell-platelet interactions. Especially heterozygous hyperhomocysteinemia, protein S deficiency and anticardiolipin antibodies appear to be fairly common. The management of these 3 separate disease entities will be discussed.
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Affiliation(s)
- G A Dekker
- Department of Obstetrics and Gynecology, Free University Hospital, Amsterdam, The Netherlands
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Abstract
The sexual behaviour and beliefs of 440 pregnant women from South-eastern Nigeria were investigated. The mean frequency of sexual intercourse during pregnancy (1.5 times per week) was less than that before pregnancy (2.3 times per week). The husband was the main initiator of sexual activity (41.6%), while the wife only rarely did so (2.7%). 44.3% of the respondents believed that sexual intercourse during pregnancy widens the vagina and facilitates labour; 34.8% that it improves fetal well-being; 30.2% that it caused abortion in early pregnancy while 21.1% had no knowledge of any repercussions of sexual intercourse in pregnancy. Coitus during pregnancy was always painful in 22.7% of the respondents; was always gratifying in 46.1%; was functional in 49.3% and helped to keep the husband around, also in 49.3% of the respondents. The majority of the respondents (83.4%) considered that coitus should not be stopped during pregnancy. Whereas 19.3% of the respondents believed that sexual frequency should be increased during pregnancy, 73.9% considered otherwise, and 63.6% actually felt it should be reduced. Findings from this study suggest a 'mixed-feeling' effect with a tilt towards a positive attitude to sexuality in pregnancy. Restriction should not be imposed on sexual activity during a normal pregnancy to enhance marital harmony.
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Affiliation(s)
- J I Adinma
- Department of Obstetrics and Gynaecology, College of Health Sciences, Nnamdi Azikiwe University, Nigeria
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Al MD, van Houwelingen AC, Badart-Smook A, Hasaart TH, Roumen FJ, Hornstra G. The essential fatty acid status of mother and child in pregnancy-induced hypertension: a prospective longitudinal study. Am J Obstet Gynecol 1995; 172:1605-14. [PMID: 7755079 DOI: 10.1016/0002-9378(95)90505-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Our purpose was to investigate, in a prospective way, whether the altered essential fatty acid status observed in pregnancy-induced hypertension is a consequence of the disease or may contribute to its cause. STUDY DESIGN Pregnant women healthy at the start of the study were asked to give a blood sample before 16 weeks, at 22 weeks, and at 32 weeks of gestation. After delivery a blood sample from the umbilical vein, a piece of the umbilical cord, and a maternal blood sample were collected. Fatty acid compositions were determined of the phospholipids isolated from plasma and umbilical arterial and venous vessel walls. The nutrient intake of the pregnant women was assessed by use of the dietary history method and food frequency questionnaires. The results of each woman with pregnancy-induced hypertension were compared with the results of three matched healthy controls. RESULTS During pregnancy (16 to 32 weeks) no significant differences were observed in nutrient intake and maternal plasma fatty acid composition between the group with pregnancy-induced hypertension (n = 52) and the control group (n = 156). After delivery the relative amounts of 18:2(n-6) and 18:3(n-3) in maternal plasma were significantly lower in pregnancy-induced hypertension than in normal pregnancy. This was associated with significantly higher levels of (n-6) long-chain polyenes and cervonic acid (22:6[n-3]). In comparison with the situation at 32 weeks, the postpartum cervonic acid status increased in pregnancy-induced hypertension, whereas it decreased in normal pregnancy. The cervonic acid levels in umbilical plasma phospholipids were significantly higher after pregnancy-induced hypertension than after normal pregnancy. No significant differences were observed for the fatty acid content in umbilical vessel walls. CONCLUSION The results indicate that the altered essential fatty acid status in pregnancy-induced hypertension is a late phenomenon and is therefore unlikely to have contributed to the pathogenesis of pregnancy-induced hypertension. Moreover, the neonatal essential fatty acid status is not negatively affected by pregnancy-induced hypertension.
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Affiliation(s)
- M D Al
- Department of Human Biology, University of Limburg, Maastricht, The Netherlands
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Graham J, Franks S, Bonney RC. In vivo and in vitro effects of gamma-linolenic acid and eicosapentaenoic acid on prostaglandin production and arachidonic acid uptake by human endometrium. Prostaglandins Leukot Essent Fatty Acids 1994; 50:321-9. [PMID: 7938084 DOI: 10.1016/0952-3278(94)90241-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This study examines the effect of a 6 month dietary supplement of either gamma-linolenic acid (GLA) or eicosapentaenoic acid (EPA) on the synthesis of prostaglandins E2 and F2 alpha by the endometrium of women with regular menstrual cycles. Samples of endometrium, obtained pre- and post-treatment, were incubated in vitro for 2 h and the prostaglandins E2 and F2 alpha released into the medium measured by radioimmunoassay. The ability of the tissue to take up 14C-arachidonic acid before and after treatment was also examined. Both GLA and EPA caused a marked decrease in the synthesis of prostaglandins E2 and F2 alpha (P < 0.001) but under the experimental conditions used, there was no consistent effect on arachidonic acid uptake. Body mass index, serum testosterone, fasting insulin and serum sex hormone-binding globulin (SHBG) concentrations did not change during the 6 month treatment period. An effect of GLA and EPA on arachidonic acid uptake into endometrial tissue explants was demonstrated in vitro. In the presence of both GLA and EPA, uptake into phospholipids (particularly phosphatidylcholine) decreased while uptake into triglycerides increased. Free 14C-arachidonic acid levels (that which could not be removed from the tissue by washing) also increased. Suppression of endometrial prostaglandin E2 and F2 alpha synthesis following GLA or EPA supplementation can be explained as direct competition between these fatty acids and arachidonic acid (the precursor of 2-series prostaglandins) for incorporation into membrane phospholipids. The amount of arachidonic acid available for 2-series prostaglandin synthesis will therefore be reduced. However, other mechanisms may exist which need to be investigated.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J Graham
- Unit of Metabolic Medicine, St Mary's Hospital Medical School, London, UK
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