The role of vitamin C in prevention of preterm premature rupture of membranes

Vitamin C Levels in Pregnant Women and the Efficacy of Vitamin C Supplements in Preventing Premature Rupture of Membranes: A Systematic Review and Meta-Analysis

Background

Premature rupture of membranes (PROM) is defined as the leakage of amniotic fluid before the onset of labor and delivery contractions. Some studies found that women who experienced PROM had significantly lower vitamin C blood levels than those who did not, while others found no significant differences. Previous systematic reviews and meta-analyses on the efficacy of vitamin C in the prevention of PROM had conflicting results.

Aims

Conduct a systematic review and meta-analysis to determine if there was a significant difference in vitamin C blood levels in women who had PROM versus the control group who did not and to determine if vitamin C supplements could help prevent it.

Study Design

Systematic review and meta-analysis.

Methods

We registered our protocol with PROSPERO (CRD42022371644). We searched PubMed/MEDLINE, Web of Science, and Scopus through February 15, 2024. Additionally, backward and forward citation searches were conducted. Studies were selected based on predetermined inclusion and exclusion criteria. Meta-Essentials: Workbooks for Meta-Analysis (version 1.5) was used for analysis.

Results

Twenty-five studies (26 reports) met all eligibility criteria, with 18 studies (18 reports) assessing vitamin C levels and seven studies (eight reports) evaluating efficacy. Women with PROM, whether preterm or term, had significantly lower vitamin C levels [Hedges’ g, -1.48; 95% confidence interval (CI): -2.82, -0.14; p = 0.020; I2 = 94.08%) and specifically preterm PROM after removing the outlying study [Hedges’ g, -1.29; 95% CI: -1.85, -0.73; p < 0.001; I2 = 87.35%). Vitamin C supplementation significantly reduced the risk of preterm or term PROM [risk ratio (RR), 0.57; 95% CI: 0.39, 0.81; p < 0.001; I2 = 12.17%), particularly for preterm PROM (RR, 0.67; 95% CI: 0.45, 0.99; p = 0.001; I2 = 0.00%). There were no significant differences in vitamin C levels between women with term PROM and controls, and there were no differences in the risk of developing term PROM between women taking vitamin C supplements and controls. Results were not robust in all sensitivity analyses.

Conclusion

Women with PROM, particularly those who developed it preterm, appear to have significantly lower vitamin C levels, and vitamin C supplementation appears to be effective in reducing the risk of PROM, particularly preterm PROM. More high-quality studies with low risk of bias, more homogenous, and larger samples are needed to confirm these findings.

Role of Vitamin C Supplementation in the Prevention of Premature Rupture of Membranes (PROM) and Preterm PROM: A Systematic Review and Meta-Analysis

Vitamin C is a micronutrient assumed to have effects on the occurrence of "preterm premature rupture of membranes" (PPROM) and "premature rupture of membranes" (PROM). The objective of this review was to find the pooled incidence of PROM and/or PPROM between subgroups in relation to dose, mode of therapy (monotherapy vs. combination therapy) and history of PROM/PPROM in previous pregnancies. A search was conducted in the electronic databases (PubMed, Google Scholar, Scopus) from inception to November 2022, using the search terms "Vitamin C", "Ascorbic acid", "preterm premature rupture of membrane" and "premature rupture of membrane". The lists of references of all the selected eligible articles were also searched to find studies of interest. A total of nine randomized controlled trials (published in English) with 16,076 participants involving the supplementation of vitamin C during pregnancy were picked up for analysis. Data management was done using the Review Manager (RevMan 5.3). A statistical test for publication bias was done in jamovi, version 2.3.18. In comparison to placebo, vitamin C supplementation was not found to be significantly effective in preventing the occurrence of PPROM/PROM. However, a low dose of vitamin C and the monotherapy mode of administration significantly decreased the occurrence of PPROM/PROM. Vitamin C has significant beneficial effects in women with a history of PROM in a previous pregnancy. Hence, we conclude that vitamin C administered as monotherapy in low doses (preferably 100 mg/day) has definite benefits in preventing the occurrence of PROM/PPROM with greater advantages seen in those with a history of similar complications in a previous pregnancy.

Disrupted Balance of the Oxidant-Antioxidant System in the Pathophysiology of Female Reproduction: Oxidative Stress and Adverse Pregnancy Outcomes

The significance of oxidative stress in the pathophysiology of male reproductive processes has been closely studied in the last two decades. Recently, it has become clear that oxidative stress can lead to numerous pathological conditions during female reproductive processes as well, contributing to the development of endometriosis, polycystic ovary syndrome and various forms of infertility. During pregnancy, physiological generation of reactive oxygen species (ROS) occurs in association with several developmental processes including oocyte maturation and implantation. An overproduction of ROS can lead to disturbances in fetal development and increases the risk for missed abortion, intrauterine growth restriction, pre-eclampsia, premature delivery and gestational diabetes. Our review focuses on the etiological role of the disrupted oxidant-antioxidant system during human gestation as it relates to adverse pregnancy outcomes.

The efficacy and safety of vitamin C administration to women with history of premature preterm rupture of membrane in prevention of such event in current pregnancy: Randomized controlled clinical trial

BACKGROUND

When rupture of membrane happens before onset of labor, the condition in obstetric practice is defined as "Prelabor rupture of membranes (PROM)" leading to leakage of amniotic fluid through ruptured chorioamniotic membranes and the conditions happens before 37 weeks of pregnancy the term "preterm PROM (PPROM)" is applied. Lack of vitamin C has been suggested as a predisposing factor and vitamin C supplementation has been suggested as a preventive measure.

AIM OF THE STUDY

This study was aimed to determine the efficacy and safety of administration of vitamin C women with history of premature preterm rupture of membrane in prevention of such event in current pregnancy.

PATIENTS AND METHODS

The present randomized controlled clinical trial was performed in Maternity and Children Teaching Hospital in Al-Diwaniyah province in Iraq. It included 100 women with previous history of premature preborn rupture of membrane who were randomly allocated into two groups. The first group, the study group included 55 women who received vitamin C supplementation orally staring from 14 weeks gestation and the second group, the reference group was the placebo group (n = 45). Data regarding age, previous abortion, body mass index, number of previous pregnancies and previous abortions were obtained and outcome variables included gestational age at which rupture of membrane happened, gestational age at which delivery happened and birth weight were collected.

RESULTS

Vitamin C was able to significantly increase the GA at rupture or membrane (p = 0.033), form 29.00 ± 2.92 weeks to 30.11 ± 2.21 weeks. Vitamin C was also able to significantly increase the GA at birth (p = 0.019), form 32.04 ± 2.88 weeks to 33.31 ± 2.43 weeks. In addition, Vitamin C was also able to significantly increase the birth weight (p = 0.019) from 1951.10 ± 869.72 gram to 2409.10 ± 613.44 gram.

CONCLUSION

Vitamin C Administration to women with previous history of Premature Preterm Rupture of Membrane is efficient and safe in prevention of such event in current pregnancy.

The Management of Pregnancy Complicated with the Previable Preterm and Preterm Premature Rupture of the Membranes: What about a Limit of Neonatal Viability?-A Review

Preterm premature rupture of the membranes (PPROM) at the limit of viability is associated with low neonatal survival rates and a high rate of neonatal complications in survivors. It carries a major risk of maternal morbidity and mortality. The limit of viability can be defined as the earliest stage of fetal maturity when a fetus has a reasonable chance, although not a high likelihood, for extra-uterine survival. The study reviews available data on preventing preterm delivery caused by the previable PPROM, pregnancy latency, therapeutic options including the use of antibiotics and steroids, neonatal outcomes, and future directions and opportunities.

Evidence based recommendations for an optimal prenatal supplement for women in the US: vitamins and related nutrients

The blood levels of most vitamins decrease during pregnancy if un-supplemented, including vitamins A, C, D, K, B1, B3, B5, B6, folate, biotin, and B12. Sub-optimal intake of vitamins from preconception through pregnancy increases the risk of many pregnancy complications and infant health problems. In the U.S., dietary intake of vitamins is often below recommended intakes, especially for vitamin D, choline and DHA. Many studies suggest that insufficient vitamin intake is associated with a wide range of pregnancy complications (anemia, Cesarean section, depression, gestational diabetes, hypertension, infertility, preeclampsia, and premature rupture of membranes) and infant health problems (asthma/wheeze, autism, low birth weight, congenital heart defects, intellectual development, intrauterine growth restriction, miscarriage, neural tube defects, orofacial defects, and preterm birth). The primary goal of this paper is to review the research literature and propose evidence-based recommendations for the optimal level of prenatal supplementation for each vitamin for most women in the United States. A secondary goal was to compare these new recommendations with the levels of vitamins in over 180 commercial prenatal supplements. The analysis found that prenatal supplements vary widely in content, often contained only a subset of essential vitamins, and the levels were often below our recommendations. This suggests that increasing prenatal vitamin supplementation to the levels recommended here may reduce the incidence of many pregnancy complications and infant health problems which currently occur.

Effects of Antioxidant Intake on Fetal Development and Maternal/Neonatal Health during Pregnancy

During pregnancy, cycles of hypoxia and oxidative stress play a key role in the proper development of the fetus. Hypoxia during the first weeks is crucial for placental development, while the increase in oxygen due to the influx of maternal blood stimulates endothelial growth and angiogenesis. However, an imbalance in the number of oxidative molecules due to endogenous or exogenous factors can overwhelm defense systems and lead to excessive production of reactive oxygen species (ROS). Many pregnancy complications, generated by systemic inflammation and placental vasoconstriction, such as preeclampsia (PE), fetal growth restriction (FGR) and preterm birth (PTB), are related to this increase of ROS. Antioxidants may be a promising tool in this population. However, clinical evidence on their use, especially those of natural origin, is scarce and controversial. Following PRISMA methodology, the current review addresses the use of natural antioxidants, such as epigallocatechin gallate (EGCG), melatonin and resveratrol (RESV), as well as other classical antioxidants (vitamin C and E) during the prenatal period as treatment of the above-mentioned complications. We review the effect of antioxidant supplementation on breast milk in lactating mothers.

First-Trimester Prediction of Preterm Prelabour Rupture of Membranes

BACKGROUND

Preterm prelabour rupture of membranes (PPRoM) is commonly associated with preterm delivery and affects up to 3% of all pregnancies. It is associated with high rates of morbidity and mortality for the mother and the newborn.

OBJECTIVES

To identify risk factors for PPRoM and develop a model for first-trimester prediction of risk of PPRoM.

METHODS

A retrospective analysis of a series of women who had first-trimester (11-13+6 weeks) screening for aneuploidy and pre-eclampsia and delivered in the same institution was performed. Univariate and multivariate logistic regression analyses were used to identify maternal and pregnancy factors and then develop a clinical prediction model for PPRoM.

RESULTS

10,280 women were screened between April 2010 and October 2016. 144 (1.4%) had PPRoM. Maternal factors predictive of PPRoM included nulliparity (parous women, OR 0.53; 95% CI 0.4-0.8), pre-existing diabetes mellitus (DM) (Type 1 DM, OR 6.7; 95% CI 2.3-19.4, Type 2 DM, OR 5.3; 95% CI 1.6-18.3), maternal age group (p = 0.004), and BMI category (p = 0.012). Uterine artery pulsatility index (UAPI) and biochemical parameters (PAPP-A, free βHCG) did not reach statistical significance. The predictive model had moderate efficacy with an area under the ROC curve of 0.67.

CONCLUSIONS

Several maternal characteristics collected during first-trimester screening predict PPRoM. Biomarkers currently measured during first-trimester screening (PAPP-A, βHCG, and UAPI) do not predict PPRoM. Whilst a predictive model can be generated with information currently collected at 11-13+6 weeks, this has only modest screening performance. First-trimester screening provides a structured framework where other predictors could improve model performance, and future studies should focus on the addition of other risk factors and biomarkers that may improve screening efficacy.

Incidence and risk factors of preterm premature rupture of membranes in singleton pregnancies at Siriraj Hospital

AIM

To obtain the incidence of preterm premature rupture of membranes (PPROM) at Siriraj Hospital during 2012-2016 and to identify its possible risk factors in singleton pregnancies.

METHODS

This study was a retrospective case-control study. The institutional ethical committee has approved the study. The medical records of eligible cases were reviewed. To assess the risk factors of PPROM, the data of the cases with PPROM in 2016 were compared with the data of pregnant women who did not have PPROM and delivered at term. Fifteen variables of interest were studied.

RESULTS

During the 5-year period, there were 43 727 deliveries at Siriraj Hospital and 1280 (2.93%) cases had PPROM. In 2016, 252 pregnant women were diagnosed PPROM and data of 199 cases were compared with the data of 199 control cases. Mean latency period was 2 days and mean gestational age at birth was 34.7 weeks in PPROM group. Logistic regression analysis showed that diabetes mellitus, poor weight gain and history of previous preterm birth were the factors that significantly associated with PPROM, with adjusted odds ratio (OR) 3.22 (95% confidence interval [CI] 1.47-7.05), 2.58 (95% CI 1.63-4.07) and 8.81 (95% CI 2.81-28.69), respectively (P < 0.05), while multiparity decreased the risk of PPROM (adjusted OR = 0.36, 95% CI 0.23-0.57) (P < 0.001).

CONCLUSION

The incidence of PPROM during 5-year period was 2.93%. Diabetes mellitus, poor maternal weight gain and history of previous preterm birth significantly increased risk of PPROM while multigravida reduced the risk.

[Epidemiology, risk factors and child prognosis: CNGOF Preterm Premature Rupture of Membranes Guidelines]

OBJECTIVES

To synthetize the available evidence regarding the incidence and risk factors of preterm premature rupture of membranes (PPROM). To describe the evolution of pregnancy, neonatal outcomes and the prognosis of infants born in a context of PPROM, according to the existence of an associated intrauterine infection and to the latency duration.

METHOD

Consultation of the Medline database, from 1980 to February 2018.

RESULTS

PPROM before 37 and before 34 weeks' gestation occur in 2-3% and <1% of pregnancies, respectively (LE2). Although many risk factors are identified, few are modifiable, and the vast majority of patients have no risk factors (LE2). Consequently, individual prediction of the risk of PPROM and primary prevention measures have not been shown to be effective and are not recommended in clinical practice (Grade B). Most women give birth within the week following PPROM (LE2). The main complications of PPROM are prematurity, intrauterine infection and obstetric and maternal complications (LE2). Latency duration and the frequency of complications decrease with increasing gestational age at PPROM (LE2). Neonatal prognosis is largely conditioned by gestational age at birth, with no apparent over-risk of poor outcomes linked to PPROM compared to other causes of preterm birth (LE2). In contrast, intrauterine infection is associated with an increased risk of in utero fetal death (LE3), necrotizing enterocolitis (LE1) and early-onset sepsis (LE2). The association of intrauterine infection with neurological morbidity remains controversial. Prolongation of latency, from gestational age at PPROM, is beneficial for the child (LE2).

CONCLUSION

PPROM is a major cause of prematurity and short- and long-term mortality and morbidity. Antenatal care is an important issue for obstetric and pediatric teams, aiming to reduce complications and adverse consequences for both mother and child.

Prevention of Prematurity: Advances and Opportunities

Preterm birth (PTB) rate varies widely and has significant racial and ethnic disparities. Although causal mechanisms are ill understood, socioenvironment, phenotype, and genotype provide insight into pathways for preventing PTB. Data suggest varied response to current medical interventions is explicable Approved by underlying pharmacogenomics. Currently, prevention focuses on minimizing iatrogenic PTB and risk reduction especially in those with prior PTB using proven medical and public health strategies. In the future, preventive approaches will be based on better understanding of sociodemography, nutrition, lifestyles, and underlying individual genetic and epigenetic variation. Statistical approaches and "big-data" models are critical in future study.

Effect of vitamin C on collagen structure of cardinal and uterosacral ligaments during pregnancy

OBJECTIVE

This study aimed to investigate changes in collagen structure in the cardinal and uterosacral ligaments of rats that were administered vitamin C during pregnancy.

STUDY DESIGN

Eighteen female rats were divided into three groups: six pregnant rats administered 1.25mg/ml/day of vitamin C during pregnancy (Group A); six non-pregnant rats that were not administered vitamin C (Group B); and six pregnant rats that were not administered vitamin C during pregnancy (Group C). Fifteen days after delivery, the uteruses of all rats were removed. The intensity of staining (mild, moderate or severe) and the extent of positive staining areas (%) of type I and type III collagen H scores for types I and III collagen, and intensity of elastin fibres in the cardinal and uterosacral ligaments were investigated immunohistochemically. Differences between groups were analysed using Kruskal-Wallis and independent samples tests.

RESULTS

The intensity and extent of type I and type III collagen, the H scores for type I and type III collagen, and the ratio of type III collagen H score: type I collagen H score differed significantly between groups. Pregnant rats administered vitamin C (Group A) had significantly higher values compared with non-pregnant rats (Group B): intensity of type I collagen (p=0.001), extent of type I collagen (p≤0.001), H score for type I collagen (p≤0.001), intensity for type III collagen (p=0.002), extent of type IV collagen (p=0.007), H score for type III collagen (p=0.017), type III collagen H score: type I collagen H score (p=0.039) and intensity of elastin fibres (p=0.097). A significant difference in the ratio of type III collagen H score: type I collagen H score was found between pregnant rats administered vitamin C (Group A) and pregnant rats not administered vitamin C (Group C) (p=0.002).

CONCLUSIONS

The administration of vitamin C to rats during pregnancy had a favourable impact on collagen structure in the cardinal and uterosacral ligaments, suggesting that vitamin C supplementation during pregnancy may help to prevent pelvic organ prolapse and stress urinary incontinence.

Vitamin C supplementation in pregnancy

BACKGROUND

Vitamin C supplementation may help reduce the risk of pregnancy complications such as pre-eclampsia, intrauterine growth restriction and maternal anaemia. There is a need to evaluate the efficacy and safety of vitamin C supplementation in pregnancy.

OBJECTIVES

To evaluate the effects of vitamin C supplementation, alone or in combination with other separate supplements on pregnancy outcomes, adverse events, side effects and use of health resources.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials evaluating vitamin C supplementation in pregnant women. Interventions using a multivitamin supplement containing vitamin C or where the primary supplement was iron were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

Twenty-nine trials involving 24,300 women are included in this review. Overall, 11 trials were judged to be of low risk of bias, eight were high risk of bias and for 10 trials it was unclear. No clear differences were seen between women supplemented with vitamin C alone or in combination with other supplements compared with placebo or no control for the risk of stillbirth (risk ratio (RR) 1.15, 95% confidence intervals (CI) 0.89 to 1.49; 20,038 participants; 11 studies; I² = 0%; moderate quality evidence), neonatal death (RR 0.79, 95% CI 0.58 to 1.08; 19,575 participants; 11 studies; I² = 0%), perinatal death (average RR 1.07, 95% CI 0.77 to 1.49; 17,105 participants; seven studies; I² = 35%), birthweight (mean difference (MD) 26.88 g, 95% CI -18.81 to 72.58; 17,326 participants; 13 studies; I² = 69%), intrauterine growth restriction (RR 0.98, 95% CI 0.91 to 1.06; 20,361 participants; 12 studies; I² = 15%; high quality evidence), preterm birth (average RR 0.99, 95% CI 0.90 to 1.10; 22,250 participants; 16 studies; I² = 49%; high quality evidence), preterm PROM (prelabour rupture of membranes) (average RR 0.98, 95% CI 0.70 to 1.36; 16,825 participants; 10 studies; I² = 70%; low quality evidence), term PROM (average RR 1.26, 95% CI 0.62 to 2.56; 2674 participants; three studies; I² = 87%), and clinical pre-eclampsia (average RR 0.92, 95% CI 0.80 to 1.05; 21,956 participants; 16 studies; I² = 41%; high quality evidence).Women supplemented with vitamin C alone or in combination with other supplements compared with placebo or no control were at decreased risk of having a placental abruption (RR 0.64, 95% CI 0.44 to 0.92; 15,755 participants; eight studies; I² = 0%; high quality evidence) and had a small increase in gestational age at birth (MD 0.31, 95% CI 0.01 to 0.61; 14,062 participants; nine studies; I² = 65%), however they were also more likely to self-report abdominal pain (RR 1.66, 95% CI 1.16 to 2.37; 1877 participants; one study). In the subgroup analyses based on the type of supplement, vitamin C supplementation alone was associated with a reduced risk of preterm PROM (average RR 0.66, 95% CI 0.48 to 0.91; 1282 participants; five studies; I² = 0%) and term PROM (average RR 0.55, 95% CI 0.32 to 0.94; 170 participants; one study). Conversely, the risk of term PROM was increased when supplementation included vitamin C and vitamin E (average RR 1.73, 95% CI 1.34 to 2.23; 3060 participants; two studies; I² = 0%). There were no differences in the effects of vitamin C on other outcomes in the subgroup analyses examining the type of supplement. There were no differing patterns in other subgroups of women based on underlying risk of pregnancy complications, timing of commencement of supplementation or dietary intake of vitamin C prior to trial entry. The GRADE quality of the evidence was high for intrauterine growth restriction, preterm birth, and placental abruption, moderate for stillbirth and clinical pre-eclampsia, low for preterm PROM.

AUTHORS' CONCLUSIONS

The data do not support routine vitamin C supplementation alone or in combination with other supplements for the prevention of fetal or neonatal death, poor fetal growth, preterm birth or pre-eclampsia. Further research is required to elucidate the possible role of vitamin C in the prevention of placental abruption and prelabour rupture of membranes. There was no convincing evidence that vitamin C supplementation alone or in combination with other supplements results in other important benefits or harms.

Fibronectin regulation by vitamin C treatment in kidneys of nicotinic mice offspring

Background:

Maternal cigarette smoking causes health risks and developmental defects in the offspring. So far, many studies have been conducted to suppress the effects of nicotine. However, the effects of coadministration of vitamin C and nicotine on extracellular matrix have not gained enough attention.

Objectives:

This study decided to investigate the effects of vitamin C on fibronectin expression in kidneys of mice offspring, treated with nicotine.

Materials and Methods:

Eighteen female pregnant BALB/c mice were selected; six mice in the experimental group 1 (exp 1) received nicotine (3 mg/kg/day), six mice in the experimental group 2 (exp 2) received 3 mg/kg/day nicotine and 9 mg/kg/day vitamin C simultaneously, and six were used as the control group and received 3 mL/kg/day normal saline via intraperitoneal (IP) injection parallel to other groups, since the 6th day of gestation to the end of prenatal period. In the first days of delivery, fibronectin content of neonatal kidneys was studied by immunohistochemistry (IHC) assay and gene expression was studied by the real-time PCR.

Results:

IHC results showed that fibronectin reaction significantly increased in proximal convoluted tubules of exp 1 compared with the control offspring; on the other hand, fibronectin reaction decreased in the mice offspring of exp 2. Gene expression results showed that fibronectin expression in the exp 1 offspring significantly increased compared with the control ones and fibronectin expression decreased in the mice offspring of exp 2.

Conclusions:

This study revealed that vitamin C could reduce the fibronectin accumulation effects of nicotine on kidney.

Uterine artery embolization for treatment of symptomatic fibroids: a review of the evidence

Fibroids are the most common benign tumors of the uterus during female reproductive age. Uterine artery embolization (UAE) using embolic particles (PVA, Gelfoam) to occlude the uterine arteries, have been reported as a relatively safe, effective, and durable nonsurgical alternative to hysterectomy in diminishing fibroid-related symptoms. To block the arterial blood supply to the fibroid completely, UAE is typically performed in both uterine arteries by an experienced interventional radiologist. Reduction in menorrhagia has been reported as 80-93 percent and the mean decrease in fibroid size varies from 50-78% in the literature. In our center improvement in menstrual bleeding after 6 months was 80.3%, and uterine fibroids underwent shrinkage of 63.7±33.7% after12 months. Complication rate including amenorrhea ranges from 1% - 7% in the literature. UAE may be followed by menopause in 1% of cases. Nevertheless, it is usually encountered in women in their late 40s. It seems that the future of UAE depends on optimal selection of patients according to volume-shrinkage prediction and fertility outcome. Although pregnancy is possible after embolization, however neither fertility preservation nor improvement can be guaranteed following UAE. Indeed, Women who desire to become pregnant should be cautioned about potential complications during pregnancy. The aim of this review is to discuss about the efficacy, safety, technique, and choice of embolic agent. Also we present the effects of this technique on fertility and pregnancy outcome and also methods for dose reduction during this procedure.