Vitamin D deficiency in mothers, neonates and children

Vitamin D is produced in response to the exposure of skin to sunlight through UV-B synthesis. It can also be obtained from diet and dietary supplements. Vitamin D is essential for strong bones as it helps to absorb calcium from diet. Vitamin D deficiency mainly occurs if strict vegetarian diet is followed as mostly the source of vitamin D is animal based; therefore, exposure to sunlight is restricted or having dark skin color. Low vitamin D levels results in increased possibility of gestational diabetes among pregnant women, low birth weight and pre-eclampsia in infants, and mothers may suffer bone impairment, osteoporosis, hypocalcaemia, and hypertension. Vitamin D deficiency is directly linked with severe complication in mothers and neonates, causing rickets, poor fetal growth and infantile eczema in neonates. Higher prevalence rate of vitamin D deficiency has led professionals to emphasize on development of relevant precautionary measures.

Effect of Docosahexaenoic Acid on Apoptosis and Proliferation in the Placenta: Preliminary Report

INTRODUCTION

Observational studies confirm a higher incidence of preeclampsia in patients with low erythrocyte concentrations of omega-3 fatty acids. Observations point to an association of disorders of pregnancy, such as intrauterine growth restriction (IUGR) and preeclampsia, with excessive apoptosis. One potential mechanism of action of docosahexaenoic acid (DHA) promoting a reduction in the risk of pathological pregnancy may be by influencing these processes in the placenta.

MATERIALS AND METHODS

We investigated 28 pregnant women supplemented with a fish oil product containing 300 mg DHA starting from pregnancy week 20 until delivery (DHA group). The control group consisted of 50 women who did not receive such supplementation (control group). We determined the expression of Ki-67 and p21 as markers of proliferation and caspase 3 activity as a marker of apoptosis and DHA levels in umbilical cord blood.

RESULTS

Caspase 3 activity was significantly lower in the DHA group in comparison to the control group. Umbilical cord blood DHA concentration was higher in the DHA group. The expression of the proteins p21 and Ki-67 did not differ significantly between the groups.

CONCLUSIONS

We observed an association between DHA supplementation and inhibition of placental apoptosis. We did not find an association between DHA and proliferation process in the placenta.

Probiotics and pregnancy

Complications of pregnancy are associated with adverse outcomes for mother and baby in the short and long term. The gut microbiome has been identified as a key factor for maintaining health outside of pregnancy and could contribute to pregnancy complications. In addition, the vaginal and the recently revealed placental microbiome are altered in pregnancy and may play a role in pregnancy complications. Probiotic supplementation could help to regulate the unbalanced microflora composition observed in obesity and diabetes. Here, the impact of probiotic supplementation during pregnancy and infancy is reviewed. There are indications for a protective role in preeclampsia, gestational diabetes mellitus, vaginal infections, maternal and infant weight gain and allergic diseases. Large, well-designed randomised controlled clinical trials along with metagenomic analysis are needed to establish the role of probiotics in adverse pregnancy and infancy outcomes.

The role of calcium, magnesium, and zinc in pre-eclampsia

Pre-eclampsia is the most common medical complication of pregnancy associated with increased maternal and infant mortality and morbidity. Its exact etiology is not known, although several evidences indicate that various elements might play an important role in pre-eclampsia. This study was carried out to analyze and to compare the concentration of calcium, magnesium, and zinc in the serum of women with pre-eclampsia and in normal pregnant women. Fifty clinically diagnosed patients with pre-eclampsia (25 with mild and 25 with severe pre-eclampsia) and 50 normal pregnant controls were enrolled in this study. The serum calcium, magnesium, and zinc levels were estimated with an atomic absorption spectrophotometer. The mean serum levels of calcium, magnesium, and zinc in normal pregnant group were 2.45 +/- 0.18 mmol/L, 0.79 +/- 0.13 mmol/L, and 15.64 +/- 2.4 micromol/L, respectively, while in mild pre-eclamptic group, these were 2.12 +/- 0.15 mmol/L, 0.67 +/- 0.14 mmol/L, and 12.72 +/- 1.7 micromol/L, respectively. Serum levels in severe pre-eclamptic group were 1.94 +/- 0.09 mmol/L, 0.62 +/- 0.11 mmol/L, and 12.04 +/- 1.4 micromol/L, respectively. These results indicate that reduction in serum levels of calcium, magnesium, and zinc during pregnancy might be possible contributors in etiology of pre-eclampsia, and supplementation of these elements to diet may be of value to prevent pre-eclampsia.

Effects of prolonged oral supplementation with l-arginine on blood pressure and nitric oxide synthesis in preeclampsia

BACKGROUND

Several lines of evidence point to the dysfunction of the endothelial l-arginine-NO system in preeclampsia. We investigated the influence of dietary supplementation with l-arginine on blood pressure and biochemical measures of NO production in women with preeclampsia in prospective, randomized, placebo-controlled study.

DESIGN

The 61 preeclamptic women on a standardized low nitrate diet received orally 3 g of l-arginine (n = 30) or placebo (n = 31) daily for 3 weeks as a supplement to standard therapy. The differences between the two groups in systolic (SBP), diastolic (DBP) and mean arterial blood pressures (MAP) as well as in plasma levels of selected aminoacids, plasma concentrations of nitrates/nitrites (NOx) and in 24-h urine NOx excretion were determined.

RESULTS

After 3 weeks of treatment, values of SBP, DPB and MAP were significantly lower in the group taking l-arginine as compared with the placebo group (SBP: 134.2 +/- 2.9 vs. 143.1 +/- 2.8; DBP: 81.6 +/- 1.7 vs. 86.5 +/- 0.9; MAP: 101.8 +/- 1.5 vs. 108.0 +/- 1.2 mmHg, P < 0.01). Importantly, treatment with exogenous l-arginine significantly elevated 24-h urinary excretion of NOx and mean plasma levels of l-citrulline. Exogenous l-arginine did not influence plasma concentrations of l-arginine, l-ornithine and methylated arginines (ADMA, SDMA, L-NMMA).

CONCLUSIONS

We conclude that in women with preeclampsia, prolonged dietary supplementation with l-arginine significantly decreased blood pressure through increased endothelial synthesis and/or bioavailability of NO. It is tempting to speculate that the supplementary treatment with l-arginine may represent a new, safe and efficient strategy to improve the function of the endothelium in preeclampsia.

Influence of preeclampsia or maternal intake of omega-3 fatty acids on the vasoactive effect of prostaglandin F-two-alpha in human umbilical arteries

The vasoactive effect of prostaglandin F(2alpha) (PGF(2alpha)) was studied in in vitro perfused human umbilical arteries following maternal dietary supplementation with omega-3 fatty acids or in pregnancies complicated by a moderate degree of preeclampsia. In most preparations PGF(2alpha) induced a biphasic pressure response with a transient dilatation followed by a constrictory response. The pressure increase was significant in both groups, but no significant differences in the constrictory response or in the proportions of preparations displaying dilatatory responses were observed when compared to appropriate control groups. In conclusion, neither preeclampsia nor dietary supplementation with cod-liver oil had any significant effect on the vasoactive response to PGF(2alpha) in umbilical cord arteries.

Supplementary calcium in prevention of pre-eclampsia

OBJECTIVE

To study the effect of calcium supplementation on reduction of pre-eclampsia in Iranian women at high risk of pre-eclampsia.

METHODS

Thirty pregnant women at high risk of developing pre-eclampsia were randomized to 2 g of daily calcium and placebo. Subjects and investigators were blinded to treatment allocation. The inclusion criteria were positive rollover test, having at least one risk factor for pre-eclampsia, between 28 and 32 weeks of pregnancy, and blood pressure less than 140/90 (mm Hg). Exclusion criteria were having any chronic condition. Pre-eclampsia was defined as systolic/diastolic blood pressure over 140/90 plus proteinuria. All the subjects were followed up to delivery.

RESULT

A sevenfold reduction in the occurrence of pre-eclamsia were seen among the calcium group compared with the placebo group (7 out of 15 developed pre-eclampsia in control group vs. 1 out of 15 in calcium group, P=0.014). No major effect on pregnancy induced hypertension was seen (66% in placebo and 76% in calcium group developed hypertension) but the onset of hypertension was delayed 3 weeks in the calcium group. A longer duration of pregnancy was seen in calcium than placebo (mean+/-S.D.=37+/-2 for calcium and 34+/-2 for placebo, P<0.05). Infants born to the calcium group, on average, were 552 g heavier than infants born to the placebo group, P<0.05.

CONCLUSION

Calcium supplementation is beneficial for preventing pre-eclampsia among Iranian women at high risk of developing pre-eclampsia.

Eclampsia despite strict dietary sodium restriction

The classic indication for prescribing dietary sodium restriction in pregnancy has been the prevention of eclampsia. We describe a case of intrapartum eclampsia in a 24-year-old nulliparous woman. A strongly sodium restricted diet was prescribed because of pre-eclampsia. Compliance to the diet was checked with 24-hour urinary sodium excretion. This report, describing the first case of eclampsia despite neglectable urinary sodium excretion, adds to the view that sodium restriction in pregnancy is obsolete.

Same nutrient, different hypotheses: disparities in trials of calcium supplementation during pregnancy

Calcium supplementation during pregnancy has been provided either to increase the intake in those with a deficiency or to obtain a pharmacologic, perhaps nonnutritional, effect in individuals with an adequate calcium intake. A systematic review, including only randomized, double-blind, controlled trials of calcium supplementation during pregnancy was prepared independently for the Cochrane Library and updated by us for this paper. In view of the heterogeneity of results included in the meta-analysis, a stratified analysis by baseline dietary calcium intake (mean calcium intake in the population < or >/=900 mg/d) was conducted. On the basis of the results of the 5 randomized, controlled trials available, the risk of high blood pressure was lower in women with low baseline dietary calcium [typical relative risk (TRR): 0.49; 95% CI: 0.38, 0.62]. Of the 4 trials in which subjects had adequate dietary calcium, the TRR of high blood pressure was 0.90 (95% CI: 0.81, 0.99). The risk of preeclampsia was considerably reduced in the 6 trials conducted in populations with low-calcium diets (TRR: 0.32; 95% CI: 0.21, 0.49) but was not reduced as much in women enrolled in the 4 trials with adequate-calcium diets (TRR: 0.86; 95% CI: 0.71, 1.05). On the basis of these results, it seems clear that calcium supplementation during pregnancy for women with deficient calcium intake is a promising preventive strategy for preeclampsia. Calcium supplementation in pregnancy should be evaluated definitively in an adequately sized trial conducted in a population with a low calcium intake because this is the most likely population to benefit from such a nutritional intervention. Long-term health benefits for the offspring are also an attractive possibility.

[Sodium concentration and pre-eclampsia: is salt restriction of value?]

The significance of sodium metabolism with respect to preeclampsia is discussed in the literature with a wide range of diverging opinions. The presented work analyses the influence of a low salt diet on the symptoms of preeclampsia and the consequences for the newborn.

MATERIAL AND METHODS

160 patients with preeclampsia between 1989 and 1993 were retrospectively studied. Serum sodium values (at hospital admission, lowest prepartal level, immediate and 3-8 days postpartum) were compared with the corresponding gestosis symptoms.

RESULTS

The mean sodium serum concentration at admission was 135.6 mmol/l (lower norm: 136 mmol/l). This was significantly different from the mean lowest prepartal value of 134.9 mmol/l (p < 0.0001). Postpartum the mean fell again significantly to 134.0 mmol/l (p < 0.0001). None of the parameters for gestosis symptoms, which were investigated (diastolic blood pressure, edema, proteinuria, serum protein levels and hyperreflexia) showed any statistically significant association with the serum sodium concentration. Five patients had very low serum natrium values, 130 mmol/l, either at admission or during hospitalisation. Three of the five infants of these patients had hyponatremia; two needed sodium supplementation.

CONCLUSION

There seems to be no reason supporting a low salt diet as therapy for preeclampsia, since it does not affect the symptoms and might lead to hyponatremia in the newborn.

Possible dietary measures in the prevention of pre-eclampsia and eclampsia

The recurring theme when considering the various dietary manipulations that have been advocated in the prevention of pre-eclampsia is of dietary deficiencies and excesses that appear to be associated with the disease. However, whether these deficiencies and excesses cause, or arise as a consequence of, pre-eclampsia has frequently not been established. Advocates of dietary theories of the aetiology of the disease have tended to base their claims upon uncontrolled clinical trails and inadequate research investigations. With very few exceptions, the better-designed studies have failed to show any effect of dietary supplementation or restriction on the incidence of pre-eclampsia. While certain manipulations, for example calcium and n-3 fatty acid supplementation seem intriguing and merit further study, potentially harmful effects of other manipulations, namely weight restriction (Campbell Brown, 1983), salt restriction (Robinson, 1958) and magnesium supplementation (Lamm et al, 1988), have been demonstrated. The persistent tendency for the medical profession to provide dogmatic and often conflicting advice, and to advocate rigorous intervention, is thus culpable. Until the appropriate research is performed in a less haphazard fashion, with all interventions performed in the context of controlled trials, no dietary intervention can be advocated.

Benefits and risks of modifying maternal fat intake in pregnancy and lactation

The National Cholesterol Education Program recommends that healthy Americans aged > 2 y reduce energy intake to maintain ideal body weight, saturated fat to 10% of energy, fat intake to 30% of energy, and cholesterol consumption to < 300 mg/d. Although these guidelines exclude pregnant or lactating women, nursing infants, and very young children, women with gestational diabetes, preeclampsia, and familial hyperlipidemias may benefit from them. In a normal pregnancy, serum cholesterol and triglycerides rise 25-40% and 200-400%, respectively. Multiparous middle-aged women may have an increased incidence of angina and cholesterol gallstones from the hypercholesterolemia of pregnancy. Few studies support the safety of maternal low-fat diets for the developing fetus or demonstrate benefits to the mother. Polyunsaturated fatty acids lower serum lipids, and n-3 fatty acids may improve some obstetric complications. Arachidonic acid (20:4) and docosahexaenoic acid (22:6) may benefit the psychomotor and visual development of children.

Dietary supplementation with primrose oil or fish oil does not change urinary excretion of prostacyclin and thromboxane metabolites in pre-eclamptic women

To study whether balance between antiaggregatory, vasodilatory prostacyclin (PGI2) and proaggregatory, vasoconstrictory thromboxane A2 (TXA2) could be affected by dietary manipulation, 18 pre-eclamptic women were treated in randomized order between 31 and 36 weeks of gestation either with primrose oil (n = 7), with fish oil (n = 5), or with placebo (n = 6). Urinary excretions of the degradation products of PGI2 (6-keto-PGF1 alpha, 2,3-dinor-6-keto-PGF1 alpha) and TXA2 (TXB2, 2,3-dinor-TXB2) were measured in 24 h urines before and serially during the supplementation. Fatty acid supplementation did not affect urinary prostanoid excretions or clinical signs of pre-eclampsia.

Interrelationship of magnesium and estrogen in cardiovascular and bone disorders, eclampsia, migraine and premenstrual syndrome

The anticonvulsive and antihypertensive values of magnesium (Mg) in eclampsia, and its antiarrhythmic applications in a variety of cardiac diseases, have caused Mg to be considered only for parenteral administration by many physicians. In contrast, nutritionists have long recognized Mg as an essential nutrient, because severe deficiencies elicit neuromuscular manifestations similar to those justifying its use in eclampsia. More recently, this element has been used to favorably influence latent tetany with and without thrombotic complications, to delay preterm birth, to influence premenstrual syndrome, and to ameliorate migraine headaches. Most of these disorders exclusively or largely afflict women. The lesions of arteries and heart caused by experimental Mg deficiency have been well documented and may contribute to human cardiovascular disease. Estrogen's enhancement of Mg utilization and uptake by soft tissues and bone may explain resistance of young women to heart disease and osteoporosis, as well as increased prevalence of these diseases when estrogen secretion ceases. However, estrogen-induced shifts of Mg can be deleterious when estrogen levels are high and Mg intake is suboptimal. The resultant lowering of blood Mg can increase the Ca/Mg ratio, thus favoring coagulation. With Ca supplementation in the face of commonly low Mg intake, risk of thrombosis increases.

Dietary sodium restriction during pregnancy; a historical review

This article reviews the major milestones in obstetric research in the past 90 years, which have lead to the wide-spread use of salt restriction during pregnancy. Possibly the most ardent advocate of the view that salt plays a crucial role in eclampsia was De Snoo (1877-1949), a Dutch obstetrician. However, despite many enthusiastic clinical reports, no convincing evidence has ever been produced that salt restriction helps in the prevention of hypertension during pregnancy.

Preeclampsia: a hyperdynamic disease model

Preeclampsia is a common disease and as such is a significant contributor to maternal and neonatal morbidity and mortality. Despite the ubiquity of the disease and its public health impact, no comprehensive mechanism has been established. Therapy has been limited to bed rest and premature delivery. The purpose of this article is to examine preeclampsia from a hemodynamic point of view and to advance a hypothesis of disease mechanism.

Hypertension in pregnant women

Although hypertension is the most common and significant risk factor in pregnancy, the risks can be minimized with careful supervision and therapy. The mere presence of hypertension, even of severe hypertension, is neither a contraindication to pregnancy nor an indication for the termination of pregnancy, provided that appropriate management principles are applied. For optimum management, the skills of the obstetrician, the physician and, later in pregnancy, of the neonatologist should all be employed to the full. The ability to monitor the fetus closely, and to offer intensive care to the premature newborn, is critical in making decisions about the timing and mode of delivery. These women, as all other women with high-risk pregnancies, should be receiving treatment in centres which can offer adequate care both to the mother and to the baby.

Maternal and infant nutrition recommendations: a review

New knowledge of maternal and infant nutrition has resulted in several changes within the past decade. Major changes in recommendations for maternal and infant nutrition have been highlighted. These recommendations are important to update dietitians, extension nutritionists, home economists, nurses, and other health professionals and paraprofessionals on the current maternal and infant nutrition recommendations.

[Present day status in therapy of toxemia of pregnancy (author's transl)]

Since the causes of toxemia of pregnancy are unknown, therapy is still symptomatic and is now determined by the most recent knowledge of the pathophysiology of the disease. Rest, a balanced, predominantly protein-rich diet and avoidance of stress are recommended as prophylactic treatment of toxemia of pregnancy in patients with a predisposition of the condition. Early recognition of the symptoms of toxemia of pregnancy is of great importance. Treatment of mild cases consists of bed rest, possibly supplemented by sedatives and a preponderantly proteinrich diet. Administration of diuretics is obsolete and sodium restriction is no longer recommended. Antihypertensives are seldom indicated. Overweight women are no longer maintained on specially low calorie diets. Severe cases of toxemia of pregnancy must be trated as inpatients under intensive care. Principles of treatment are: 1. Prevention of seizures (by sedation). 2. Improvement of the general condition of the women (especially circulation and renal function). 3. Delivery at an opportune time for mother and child. Treatment of eclampsia follows largely the same principles. In these cases, immediate delivery is required regardless of the condition of the fetus.

The effect of a low calorie diet or a thiazide diuretic on the incidence of pre-eclampsia and on birth weight

A 1200 calorie diet or cyclopenthiazide with potassium was given to two groups of 51 high weight gain primigravidae and baby weight and the incidence of pre-eclampsia were compared with those in a matched control group. There was no difference in the development of pre-eclampsia, but the weight of babies in the control group was higher than in the treated groups. The body fat was reduced in the diet group and the total body water in the diuretic group.