Vitamin A supplemntain in pregancy : Should it be a routine prcedure??

How many of us routinely use Vitamin A supplementation in pregancy?? WHO remarks:-"-Although pregnant women are susceptible to vitamin A deficiency throughout gestation, deficiency is most common in the third trimester due to accelerated fetal development and the physiological increase in blood volume during this period . In a pregnant woman with moderate vitamin A deficiency, the fetus can still obtain sufficient vitamin A to develop appropriately, but at the expense of the maternal vitamin A stores .

Vitamin A deficiency may also occur during periods when infectious disease rates are high and/or during seasons when food sources rich in vitamin A are scarce . The prevalence of night blindness (a consequence of

vitamin A deficiency) is also more common in the third trimester of pregnancy, and populations with a prevalence >5% are considered to have a significant public health problem with regard to vitamin A deficiency

. It is currently estimated that 9.8 million pregnant women are affected by night blindness worldwide

There is some indication that low doses of vitamin A supplements given on a daily or weekly basis, starting in the second or third trimester, can reduce the severity of decline in maternal serum retinol levels during late pregnancy and the symptoms of night blindness . One study has suggested that 12 weeks of supplementation is needed to prevent decline in serum retinol levels .

Vitamin A is available in multiple vitamin formulations for prenatal care in some countries. When provided alone, the compounds most commonly used are retinyl palmitate and retinyl acetate in tablet form or oil-based solutions. Alternative forms of delivery include fish liver oils, p-carotene, and a combination of p-carotene and vitamin A. Recommended doses of vitamin A supplements are generally well tolerated by pregnant women; however, vitamin A may become toxic for the mother and her fetus when levels of intake exceed 10 000 IU daily or 25 000 IU weekly . p- carotene, a precursor of vitamin A, may be preferred over vitamin A supplements in pregnant women because excess of p-carotene is not known to cause birth defects .

📷The symptoms of acute vitamin A toxicity include dizziness, nausea, vomiting, headaches, blurred vision, vertigo, reduced muscle coordination, skin exfoliation, weight loss and fatigue . Toxicity generally results from excessive ingestion of vitamin A supplements but regular intake of large amounts of liver, although usually not a problem in vitamin A-deficient areas, may also result in toxicity due to its high content of vitamin A .

Two Cochrane systematic reviews assessing the effects and safety of vitamin A supplementation in pregnant women were updated for this guideline . The first review evaluated the effectiveness of vitamin A (or one of its derivatives) supplementation in pregnancy, alone or in combination with other vitamins and minerals, in relation to maternal and newborn outcomes . It showed that giving vitamin A supplements to women during pregnancy had no effect on the risk of maternal mortality (three trials: risk ratio (RR) 0.78; 95% confidence interval (CI) 0.55­1.10), perinatal mortality (one trial: RR 1.01; 95% CI 0.95-1.07), neonatal mortality (three trials: RR 0.97; 95% CI 0.90-1.05) or stillbirth (one trial: RR 1.06; 95% CI 0.98-

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1.14). In one trial, vitamin A supplementation reduced the risk of maternal night blindness (RR 0.70; 95% CI 0.60-0.82). All trials that investigated maternal and perinatal mortality used weekly supplementation with vitamin A. WHO performed an additional meta-analysis after excluding one study conducted only in HIV-positive pregnant women. The only critical outcome affected by the removal of this study was neonatal mortality, although the effect of vitamin A supplementation remained non­significant (two trials: RR 1.00; 95% CI 0.88-1.14) (Annex 1).

The second review evaluated the effectiveness and safety of vitamin supplementation with regard to the risk of spontaneous miscarriage, maternal adverse outcomes and fetal and infant adverse outcomes (21). The review found no difference in total fetal loss (including miscarriages or combined miscarriages and stillbirths) in women given vitamin A compared with placebo (one trial: RR 1.04; 95% CI 0.92-1.17), p-carotene compared with placebo (one trial: RR 1.03; 95% CI 0.91­1.16), vitamin A with or without multivitamins compared with multivitamins (excluding vitamin A) or placebo (one trial: RR 0.80; 95% CI 0.53-1.21), or vitamin A plus iron and folic acid compared with iron and folic acid (three trials: RR 1.01; 95% CI 0.61-1.66). Similarly, there was no difference in the rates of stillbirth and neonatal deaths between women given any type of vitamin A, alone or in combination with p- carotene, multivitamins or iron and folic acid, compared with controls.

📷The overall quality of the available evidence for maternal mortality was high, whereas for all other critical outcomes it was moderate .

• Vitamin A supplementation is not recommended during pregnancy as part of routine antenatal care for the prevention of maternal and infant morbidity and mortality (strong recommendation[1]).

• In areas where there is a severe public health problem related to vitamin A deficiency vitamin A supplementation during pregnancy is recommended for the prevention of night blindness (strong recommendation1).

A strong recommendation is one for which the guideline development group is confident that the desirable effects of adherence outweigh the undesirable effects. The recommendation can be either in favour of or against an intervention. Implications of a strong recommendation for patients are that most people in their situation would desire the recommended course of action and only a small proportion would not. For clinicians the implications are that most patients should receive the recommended course of action, and that adherence to this recommendation is a reasonable measure of good-quality care. With regard to policy-makers, a strong recommendation means that it can be adapted as a policy in most situations.

[2] Determination of vitamin A deficiency as a public health problem involves estimating the prevalence of deficiency in a population by using specific biochemical and clinical indicators of vitamin A status. Classification of countries based on the most recent estimates is available in reference.Source : WHO

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  WHO:--.
  • Vitamin A supplementation is not recommended during pregnancy as part of routine antenatal care for the prevention of maternal and infant morbidity and mortality (strong recommendation ).
  • In areas where there is a severe public health problem related to vitamin A deficiency , vitamin A supplementation during pregnancy is recommended for the prevention of night blindness (strong recommendation1).

  •  Two decades back , Worldwide, approximately 1000 women die every day from complications related to pregnancy or childbirth . Almost all of these deaths occur in developing countries and most could be averted by preventing complications such as severe bleeding (haemorrhage), infections, high blood pressure, obstructed labour, unsafe abortion and diseases such as malaria, anaemia and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) during pregnancy . Although between 1997 and 2007 there was a decrease in the number of infant deaths from 60 to 40 per 1000 live births, infant mortality rates has still remain high in World Health Organization (WHO) regions such as Africa, Eastern Mediterranean and South-East Asia
• . Neonatal deaths account for 36% of deaths among children under 5 years of age .These deaths are mainly due to prematurity and low birth weight (31%), neonatal infections (26%), birth asphyxia (lack of oxygen at birth) and birth trauma (23%). A non-negligible proportion of neonates die because of congenital anomalies (6.8%), other non-infectious perinatal causes (5.7%), tetanus (5%) and diarrheal diseases (2.6%).
  Vitamin A deficiency also remains a public health problem among women, affecting an estimated 19 million pregnant women with the highest burden found in the WHO regions of Africa and South-East Asia. During pregnancy, vitamin A is essential for the health of the mother as well as for the health and development of the fetus. This is because vitamin A is important for cell division, fetal organ and skeletal growth and maturation, maintenance of the immune system to strengthen defences against infection, and development of vision in the fetus as well as maintenance of maternal eye health and night vision .Thus, there is an increased need for vitamin A during pregnancy, although the additional amount required is small and the increased requirement is limited to the third trimester. The recommended
  nutrient intake (RNI) of vitamin A for women during pregnancy is 800 pg retinol equivalents (RE)/day , which may be difficult to achieve through the diet alone in vitamin A-deficient areas. Dietary sources of provitamin A include vegetables such as carrot, pumpkin, papaya and red palm oil; animal foods rich in preformed vitamin A include dairy products (whole milk, yogurt, cheese), liver, fish oils and human milk
  -Source: WHO

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