Effects Of Vitamin D Supplementation On Maternal And Neonatal Outcomes During Pregnancy

Methodology

Question:

Discuss about the Pregnancy and Gestational Diabetes Mellitus.

Yes. The researcher clearly stated in the objectives that the aim of the systematic review was to examine and determine whether Vitamin D oral supplements alone or in combination with other vitamins or calcium and minerals improve neonatal and maternal outcomes when administered to women during their pregnancy (De-Regil et al., 2016). Previous studies provided evidence for occurrence of adverse effects among pregnant women who were deficient in Vitamin D (Burris et al., 2012). The use of Vitamin D as a nutritional supplement management has been widely accepted. Thus, the systematic review addressed a focused question in investigating the effects of vitamin D on pregnant and infant outcomes.

Yes. The systematic review contacted the Trails Search Co-ordinator and searched for papers from the Cochrane Pregnancy and Childbirth Group’s Trials Register. The register contained trial records which were identified from weekly searches of Embase and MEDLINE (Ovid), monthly searches of CINAHL and CENTRAL (Cochrane Central Register of Controlled Trials) and proceedings from 30 journals that were hand searched (McGowan et al., 2016). All relevant research studies that illustrated the effects of Vitamin D supplementation on gestational and neonatal health were included in the review. Most of the studies were randomized controlled trials.

Yes. The study intended to include all quasi-randomised and randomized trials at cluster or individual levels. However, only randomized controlled trials were available. The review did not include any observational designs such as case-control studies or cohort. Nor did it focus on cross-over trials for carrying out this meta-analysis. Any discussion that contained relevant information on interventions that focused on Vitamin D during pregnancy in women, irrespective of the gestation time, chronological age, fetus number or number of births were included.

Yes. All the references that were included in the meta-analysis after rigorously searching the electronic database management were independently assessed by two authors of the research. Duplicate analysis was conducted for all the selected papers. Disagreements were resolved through discussion between the two authors. At times, consultation of a third author was asked for, as well to resolve differences that arose while including the papers. The authors of certain studies that had been published only in the form of abstracts were contacted to procure more information on the design and results of the study. Similar procedure was followed for those reports that had less information on the methodology. Thus, all potentially eligible studies were screened and included.

Results

The results and data analysis of most of the studies were combined based on the primary and secondary outcomes they reported. The data analysis of the studies was grouped according to the outcomes on which they showed the effect of vitamin D supplementation. The results were combined into the groups that showed the effect of vitamin D pre-eclampsia on women, gestational diabetes, gestational hypertension, preterm birth, infant underweight, neonatal death and many other parameters (Asemi et al., 2012). It was completely reasonable to combine the statistical results from the studies that were selected to give a broader understanding of the efficacy of Vitamin D intervention among pregnant women and infants.

This review evaluated the effects of vitamin D supplementation either alone or in combination with other vitamins, calcium and minerals during pregnancy. It included 15 small trials that involved 2833 women. 9 of those trials compared effect of vitamin D intervention alone versus placebo or no treatment and 6 trials compared its effects in combination with calcium in comparison with no intervention. The effects of vitamin D and calcium were not compared with calcium or other micronutrients among the target population in comparison with the group that received no intervention or a placebo (Asemi et al., 2012) (Brooke et al., 1980). Women, who received daily supplements of oral vitamin D during their pregnancy, reported significantly greater concentration of 25-hydroxyvitamin D at the end of their gestation period. However, their response to Vitamin D supplementation was heterogeneous. No statistically significant differences were observed for the risk of pre-eclampsia. However, two studies reported a low risk of pre-aclampsia mong women who were on Vitamin D intervention. Reduction in pre-eclampsia risks was statistically significant among women who received vitamin D supplementation along with calcium (Marya, Rathee & Manrow, 1987).

Moreover, the rates of preterm births and low birth weights showed a reduction in 3 trials and 4 trials respectively where women were on Vitamin D supplementation. In addition, the intervention demonstrated a longer birth length (4 trials) and greater head circumference among infants who were born to women, subjected to the intervention during their pregnancy (Marya, Rathee & Manrow, 1987) (Sablok et al., 2015). Birth weight differences were not seen between placebo and no intervention group with respect to supplemented groups. However, vitamin D supplementation in combination with calcium increased the risk of preterm birth significantly in 3 trials (Diogenes et al., 2013) (TAHERIAN, Taherian & Shirvani, 2002) (Asemi et al., 2012). Adverse effects were reported by only few trials. 1 trial demonstrated the incidence of nephritic syndrome in a woman who was not under intervention.

Discussion

Effects of oral Vitamin D supplementation alone when compared to no intervention or placebo showed borderline statistical significance with respect to pre-eclampsia (average risk ratio (RR) 0.52; 8.9% versus 15.5%; 95% confidence interval (CI) 0.25-1.05), no clear difference in incidence of gestational diabetes (RR 0.43; 95% CI 0.05-3.45) and highly heterogeneous response to maternal 25-hydroxyvitamin D concentrations (I² = 99%, Tau² = 554.9 and Chi² test for heterogeneity P < 0.00001) (Sablok et al., 2015) (Grant, 2010). It ranged from 16.3 nmol/l (95% CI 13.6-19.0) to 152 nmol/l of 25- hydroxyvitamin D (95% CI 127-177) (Mallet 1986) (Brooke 1980). No statistically significant risks were found associated with the intervention and risk of nephritic syndrome among pregnant women (RR 0.17; 95% CI 0.01 to 4.06). A lower risk of preterm births (average RR 0.36; 3.3% versus 9.9%; 95% CI 0.14-0.93) and less frequent birth weight below 2500gm was recorded from the analysis (average RR 0.40; 9.2% versus 19.6%; 95% CI 0.24-0.67). Neonatal death did not show any clear difference (RR 0.27; 95% CI 0.04 to 1.67).

Supplementation of Vitamin D along with other minerals and calcium showed less occurrence of pre-eclampsia (5% versus 9%; average RR 0.51; 95% CI 0.32 to 0.80) (Marya, Rathee & Manrow, 1987). No clear evidence was found for the effects of the intervention on gestational diabetes (RR 0.33; 95%CI 0.01 to 7.84), 25- hydroxyvitamin D concentrations and low birth weight. Preterm births were showed more likelihood to occur before 37 weeks among women who received the intervention (RR 1.57; 95% CI 1.02 to 2.43; low quality) (Asemi  et al., 2012) (TAHERIAN, Taherian & Shirvani, 2002). No statistically significant differences were observed in gestational hypertension risks (RR 0.26; 95% CI 0.06 to 1.12). Therefore, it can be stated that the results were quite precise.

Can’t tell. The effects of Vitamin D supplementation, alone or in combination with calcium or other minerals have shown improvements in increase length, pre-eclampsia and circumference of the head at birth. However, before the interventions can be applied to all populations as a part of routine care procedure to improve infant and maternal health outcomes, there is a need to confirm the effects by a detailed analysis of many more randomized trials (Pludowski et al., 2013). Definite conclusions on the safety and usefulness of the intervention in all population cannot be drawn from the results.

No. The effects of an increase in serum 25-hydroxyvitamin D concentration on improved infant and maternal outcomes in different populations that have different degrees of skin pigmentation, body mass index and settings were not measured (Pludowski et al., 2013). Furthermore, the effects of vitamin D supplementation among women who were diagnosed with gestational diabetes or greater risk of pre-eclampsia were not assessed.

Conclusion

Overdose of vitamin D supplementation can lead to several harmful effects such as hypercalciuria, hypercalcemia, delayed ossification, growth restriction and craniofacial hypoplasia (Vanstone et al., 2012) (Schroth et al., 2014). Thus, adequate information on effective and safe usage of the supplement and the probable toxic effects should be considered before applying the intervention.

From the critically analyzed study, I developed the idea that maintaining maternal and infant health safety should be my utmost priority. I need to develop competence and clinical skills to create a sense of trust among pregnant women under my care. I need to make them realize that they are safe in my hands and I will adopt all possible methods to ensure safety of their child (Noseworthy et al., 2013). I will develop knowledge on the prevalence of Vitamin D insufficiency among women and the adverse effects it can create on maternal and infant health outcomes. I will try to develop my communication skills and gain knowledge from the patient on their Vitamin D consumption rates. I will make them aware of the necessity of the supplement for proper growth of the fetus. I will seek help of experienced midwives to learn the effective dosage and timing of vitamin D administration among pregnant women who have been admitted. A knowledgeable and competent midwife will help me identify the different approaches that I need to develop while dealing with women who show deficiency of Vitamin D in their diet. Showing empathy towards them would enhance in building a rapport with the women and their families (Doust, 2016). That would provide them support if any adverse incidents of stillborn child occur (Ayers, 2014). Thus, from the above reflections I conclude that I will display clinical excellence while caring for pregnant women and would administer Vitamin D supplements by considering the effectiveness of the drug dosage and timing to prevent occurrence of any untoward incident.

References

Asemi, Z., Tabassi, Z., Heidarzadeh, Z., Khorammian, H., Sabihi, S. S., & Samimi, M. (2012). Effect of calcium-vitamin D supplementation on metabolic profiles in pregnant women at risk for pre-eclampsia: a randomized placebo-controlled trial. Pakistan journal of biological sciences: PJBS, 15(7), 316-324.

Ayers, S. (2014). Fear of childbirth, postnatal post-traumatic stress disorder and midwifery care. Midwifery, 30(2), 145-148.

Brooke, O. G., Brown, I. R., Bone, C. D., Carter, N. D., Cleeve, H. J., Maxwell, J. D., … & Winder, S. M. (1980). Vitamin D supplements in pregnant Asian women: effects on calcium status and fetal growth. Br Med J, 280(6216), 751-754.

Burris, H. H., Rifas-Shiman, S. L., Kleinman, K., Litonjua, A. A., Huh, S. Y., Rich-Edwards, J. W., … & Gillman, M. W. (2012). Vitamin D deficiency in pregnancy and gestational diabetes mellitus. American journal of obstetrics and gynecology, 207(3), 182-e1.

De-Regil, L. M., Palacios, C., Lombardo, L. K., & Peña-Rosas, J. P. (2016). Vitamin D supplementation for women during pregnancy. Sao Paulo Medical Journal, 134(3), 274-275.

Diogenes, M. E. L., Bezerra, F. F., Rezende, E. P., Taveira, M. F., Pinhal, I., & Donangelo, C. M. (2013). Effect of calcium plus vitamin D supplementation during pregnancy in Brazilian adolescent mothers: a randomized, placebo-controlled trial. The American journal of clinical nutrition, 98(1), 82-91.

Doust, J. (2016). Young women midwifery care: A community engagement. Australian Midwifery News, 16(1), 26.

Grant C. (2010) Randomised placebo controlled study of vitamin D during pregnancy and infancy. Australian New Zealand Clinical Trials Register [www.anzctr.org.au] (accessed 17 August 2010).

Mallet, E., Gügi, B., Brunelle, P., Henocq, A., Basuyau, J. P., & Lemeur, H. (1986). Vitamin D supplementation in pregnancy: a controlled trial of two methods. Obstetrics & Gynecology, 68(3), 300-304.

Marya, R. K., Rathee, S., & Manrow, M. (1987). Effect of calcium and vitamin D supplementation on toxaemia of pregnancy. Gynecologic and obstetric investigation, 24(1), 38-42.

McGowan, J., Sampson, M., Salzwedel, D. M., Cogo, E., Foerster, V., & Lefebvre, C. (2016). PRESS peer review of electronic search strategies: 2015 guideline statement. Journal of clinical epidemiology, 75, 40-46.

Noseworthy, D. A., Phibbs, S. R., & Benn, C. A. (2013). Towards a relational model of decision-making management in midwifery care. Midwifery, 29(7), e42-e48.

Pludowski, P., Holick, M. F., Pilz, S., Wagner, C. L., Hollis, B. W., Grant, W. B., … & Soni, M. (2013). Vitamin D effects on musculoskeletal health, immunity, autoimmunity, cardiovascular disease, cancer, fertility, pregnancy, dementia and mortality—a review of recent evidence. Autoimmunity reviews, 12(10), 976-989.

P?udowski, P., Karczmarewicz, E., Bayer, M., Carter, G., Chlebna-Sokó?, D., Czech-Kowalska, J., … & G?uszko, P. (2013). Practical guidelines for the supplementation of vitamin D and the treatment of deficits in Central Europe—recommended vitamin D intakes in the general population and groups at risk of vitamin D deficiency. Endokrynologia Polska, 64(4), 319-327.

Sablok, A., Batra, A., Thariani, K., Batra, A., Bharti, R., Aggarwal, A. R., … & Chellani, H. (2015). Supplementation of vitamin D in pregnancy and its correlation with feto?maternal outcome. Clinical endocrinology, 83(4), 536-541.

Schroth, R. J., Lavelle, C., Tate, R., Bruce, S., Billings, R. J., & Moffatt, M. E. (2014). Prenatal vitamin D and dental caries in infants. Pediatrics, 133(5), e1277-e1284.

TAHERIAN, A. A., Taherian, A., & Shirvani, A. (2002). Prevention of preeclampsia with low-dose aspirin or calcium supplementation.

Vanstone, M. B., Oberfield, S. E., Shader, L., Ardeshirpour, L., & Carpenter, T. O. (2012). Hypercalcemia in children receiving pharmacologic doses of vitamin D. Pediatrics, 129(4), e1060-e1063.