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Journal of Mahatma Gandhi Institute of Medical Sciences Volume 19 Issue 2 September 2014 Pages 83-???

Mahatma Gandhi
Institute of Medical Sciences
Official Publication of Mahatma Gandhi Institute of Medical Sciences
September 2014 / Volume 19 / Issue 2
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 Review Article

Pregnancy and Vitamin D

Jitendra Ingole, Sonali Ingole1

Abstract
Vitamin D insufficiency is common in women across different races of childbearing age. It is being increasingly
discovered that vitamin D has many important bodily functions apart from skeletal actions pertaining to Calcium
homeostasis. Evidence suggests that the maternal risks due to vitamin D deficiency includes eclampsia, increased
risk of gestational diabetes mellitus, glucose intolerance; and fetal risks include risk of rickets, osteoporotic
fracture in late adulthood. It may be prudent to include screening of all pregnant women for vitamin D level as a
part of routine antenatal care and supplementation be given if found deficient.

Keywords: Maternal and fetal health, pregnancy, vitamin D

Introduction But what came as a surprise was high incidence of

The role of vitamin D during pregnancy and its effect
on maternal and fetal health is just beginning to be
understood. In the last 5 years, there has been an
explosion of published data concerning the immune
effects of vitamin D, yet little is known in this regard
about the specific immune effects of vitamin D during
the pregnancy period. What is clear, however, is that
vitamin D deficiency during pregnancy is rampant
throughout the world.[1-3]
Epidemiology
From early 1980s, when the laboratory test for serum
vitamin D level began available, there was surge in
diagnosis of vitamin D deficiency. It also became clear
in subsequent years to come, that persons having dark
skin pigmentation and having less exposure to Sun
were amongst majority in deficient group.[1]
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DOI:
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vitaminD deficiency, even in fair skinned people. The
prevalence of vitamin D deficiency is thus, widespread
equally in developing as well as developed countries.
Its presence in pregnant women, carries a special
importance due to possible chance of affecting fetus.
It may be worthwhile to note that a few years ago, a
14-year-boy lead campaign to Scottish parliament
for special importance of vitamin D awareness and
recommendation in antenatal care (ANC) program in
Scotland.[4]
Although, it is difficult to predict exact figures
of pregnant females with vitamin D deficiency in
developing countries due to lack of proper data;
but nonetheless the condition is also common
in India and needs urgent insight on broader
level.[5] Ifcertaindisorders can be prevented
by supplementing with an essential vitamin, it
definitely will go a long way toward promotion
of better health for expectant mothers and their
off springs. Canadian Pediatric Society, in 2007,
therefore recommended 2000 IU of vitamin D3
for pregnant and lactating mothers with periodic
blood tests to check levels of 25-hydroxy vitamin
D (25(OH)D) and calcium.[6,7]

Department of Internal Medicine, 1Department of Obst & Gynecology, Smt. Kashibai Navale Medical College,
Pune,Maharashtra, India

Address for correspondence:

Dr. Jitendra Ingole, Smt. Kashibai Navale Medical College, Pune, Maharashtra, India. E-mail: jitendra.ingole@gmail.com

September 2014 | Vol 19 | Issue 2 Journal of Mahatma Gandhi Institute of Medical Sciences
90
Risk Factors for Vitamin D Deficiency
The following are postulated as risk factors for
causation of vitamin D deficiency in pregnancy: Lack
of sunlight exposure, fat malabsorption, vegetarian
diet, drug therapy (steroids, anti-epileptic drugs),
deeply pigmented skin and obesity.[8,9]
Why vitamin D deficiency is important
inrelation to pregnancy?
Vitamin D deficiency can be linked to maternal and
fetal effects. Maternal effect postulated to be due to the
deficiency are: Eclampsia,[10] insulin resistance[11] and
increased risk of gestational diabetes mellitus.[12]
Fetal effects of vitamin D deficiency are plenty some being
short term and others may become apparent in later life.
The skeletal role of vitamin D deficiency (in causation of
rickets) is well-documented. With severe maternal vitamin
D deficiency, the fetus rarely may develop rickets in utero
with manifestation at birth.[13] Throughout gestation, if a
woman is vitamin D deficient, it appears to impact fetal
bone health more than maternal.[14] Vitamin D status
during pregnancy also does play a role to certain extent
in fetal skeletal development, tooth enamel formation and
general fetal growth and development.[15]
Further, cardiovascular risk factors may have origin in
fetal vitamin D deficiency.[16] It has also been shown
conclusively that cord blood vitamin D level have strong
correlation with innate immune response of fetus.[17]
How common is vitamin D deficiency
inpregnant women
One recent study highlights the need of vitamin D in
pregnancy. Hamilton et al.[18] presented findings in a
study conducted on 559 pregnant women in year 2010.
Serum sample for vitamin D level (25(OH) vitamin D3)
was collected during routine ANC visits by pregnant
women. The study revealed widespread vitamin D
deficiency across different races African American
(48%), hispanic (38%), caucasian/other (14%).[18]
Another study by Javaid et al.[10] concluded that
maternal vitamin D insufficiency is common during
pregnancy and is associated with reduced bone-mineral
accrual in the offspring during childhood.
Diagnosis
Vitamin D deficiency should be suspected in a pregnant
woman having low exposure to Sunlight, vegetarian
Journal of Mahatma Gandhi Institute of Medical Sciences September 2014 | Vol 19 | Issue 2
Ingole and Ingole: Pregnancy and Vitamin D
dietary habits. Other clinical symptoms such as joint
pain(s) may be non-specific. Thus, estimation of
vitamin D level by laboratory remains the accurate way
of assessing the deficiency and its severity.[13]
The correct test to order for is serum 25(OH) vitamin
D test. It may be noted, that another test vitamin D,
1,25 dihydroxy does not reflect true status of vitamin D
deficiency. Studies have shown that the vitamin D, 1,25
dihydroxy level does not significantly change until
25(OH) vitamin D, drops to levels that are considered
severe vitamin D deficiency.[19]
There seems to be a lot of conflicting reports about
adequate level of vitamin D.[20] However many
experts accept a range 75 nmol/L (30 ng/mL) as
optimal. Further, controversy also exists regarding the
optimum concentration of vitamin D in pregnancy.
Most experts, though, agree that serum vitamin
D levels below 50 nmol/L (20 ng/mL) represent
deficiency.[13,22] However, this current practice is
based on the skeletal actions of the vitamin and it is
yet not clear whether the same values of vitamin D
Level are for applicable for pregnancy or not.
Therapy
Currently, women of reproductive age are assumed to
be able to obtain the recommended intake for vitamins
and no national organization recommends routine
vitamin D supplementation during the pregnancy
period. The US Preventive Services Task Force does
not comment for or against routine screening for
vitamin D deficiency in pregnant women.[19] Further,
there is a lot of information and misinformation about
vitamin D and suggestions about timing, dose, route of
vitamin D supplementation.
But now, given the fact that vitamin D deficiency
is much more common[10,18] than thought of,
pharmacotherapy remains the practical and feasible
option for correcting vitamin D levels. There are
wide differences of thoughts over what should be
the recommended dose for vitamin D. An important
point to note here is that vitamin D deficient patients
do require higher doses than recommended for
prophylaxis against vitamin D deficiency. Recently,
Institute of Medicine (USA) suggested that adequate
dose for vitamin D needs to be 2000 to maximum
4000 IU/day. Whilst this may appear as very large
dose, but there are no known teratogenic effects until
date found to be due to vitamin D supplementation.
Ingole and Ingole: Pregnancy and Vitamin D
In yet another study, wherein supplementation of
oral cholecalciferol in a 10 day course of 50,000 IU
(Total dose 5 Lac IU), did not cause toxicity such as
hypercalcemia.[21] suggesting that concern of vitamin
D toxicity is probably much feared than actually found
in clinical practice.
A recent randomized controlled trial with 350 women
of diverse racial and ethnic backgrounds showed that
4000 IU vitamin D/day is most effective in improving
the vitamin D status of pregnant women, attaining
circulating levels of at least 40 ng/mL (100 nmol/L) for
25(OH)D.[22]
Vitamin D supplementation during lactation
Human milk contains little vitamin D (approximately
20 IU/L) and women who are vitamin D-deficient
provide even less to their breastfed infants,[18] Lactating
women given 4000 IU of vitamin D3/day not only had
an increase in the level of 25(OH)D to more than 30
ng/mL but were also able to transfer enough vitamin
D3 into their milk to satisfy an infants requirement.
The vitamin is available as ergocalciferol (also called
vitamin D2); and cholecalciferol (vitamin D3 activated
form). Cholecalciferol (vitamin D3) is preferred over
ergocalciferol for replenishment.
Cholecalciferol is available in oral form sachet
containing 60,000 international units (IU); Tablets
containing 1000 IU; or Injection form (aqueous
solution vitamin D3 of strength 6 Lac IU). For
routine supplementation for pregnant women, sachet
containing 60,000 IU of vitamin D3 may be used
with added advantage of being non-invasive route of
administration.
Should vitamin D be incorporated in national
level maternal and child health care program
Serum level of vitamin D may be measured as routine
before planning for pregnancy/during antenatal visit
check-up. And if found deficient vitamin D may be
given as short course supplementation (Sachets form)
during routine follow-up visits of pregnant woman. As
the vitamin is fat soluble, short course supplementation
may also suffice purpose and also improving patient
compliance.
Areas of Uncertainty
Whilst majority of trials carried until recently were
highlighting importance of vitamin D in bone and
September 2014 | Vol 19 | Issue 2 Journal of Mahatma Gandhi Institute of Medical Sciences
91
mineral metabolism, the non-skeletal effects such as
effect on pregnancy, fetus are getting discovered. Thus,
effects of supplementation for skeletal benefit versus
non skeletal benefit also remains an area of research.[11,12]
Whether it is vitamin D alone which is responsible for
important functions during pregnancy or whether it is
complex interplay between genetics, epigenetics and
some other factors? Would supplementation of vitamin
D carry equal benefits amongst all given pregnant
women? What if vitamin D deficiency is detected late
in pregnancy Would supplementation will still be of
any value in such case? These questions still remain
elusive until date.
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Ingole and Ingole: Pregnancy and Vitamin D
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How to cite this article: Ingole J, Ingole S. Pregnancy and
Vitamin D. J Mahatma Gandhi Inst Med Sci 2014;19:89-92.
Source of Support: Nil, Conflict of Interest: None declared.