Researchers in Mexico found that giving high risk pregnant women at risk for developing pre-eclampsia L-arginine and antioxidant vitamins helps prevent preeclampsia.
L-arginine is an amino acid needed in order for the body to make nitric oxide, a vasodilator, which helps relax smooth muscle and in turn lower blood pressure. People with low levels of L-arginine are at increased risk of developing high blood pressure and in pregnant women, the high blood pressure progressing to pre-eclampsia.
Felipe Vadillo-Ortega, from the Department of Experimental Medicine, School of Medicine, Universidad Nacional, Autonoma de Mexico, Ciudad Universitaria, Mexico, and colleagues found women at high risk for pre-eclampsia given supplement bars containing the amino acid L-arginine as well as antioxidant vitamins had a reduced risk of developing pre-eclampsia compared to women who took antioxidant supplements alone or no supplements whatsoever.
Of the 672 women studied, 228 received with food bars containing L-arginine plus antioxidant vitamins, 222 received antioxidant vitamins alone and 222 received placebo. Preeclampsia developed in 30.2% of the placebo group (Those who got no supplements) , 22.5% of the vitamin-only group, and 12.7% in the L-arginine plus vitamin group. There was also a non-statistically significant benefit for antioxidant vitamins alone vs placebo. It must be noted that L-arginine and antioxidants do not prevent pre-eclampsia from occuring. In simple terms, L-arginine and antioxidant vitamins can’t stop pre-eclampsia from developing, but in women at risk for this complicated and potentially deadly disorder, taking the supplement bars and vitamins seems to reduce their risk of developing pre-eclampsia.
This is potentially exciting news. Pre-eclampsia affects an estimated 2% to 6% in healthy, nulliparous (first time pregnant) American women. Among all cases of the preeclampsia, 10% occur in pregnancies of less than 34 weeks’ gestation. The global incidence of pre-eclampsia has been estimated at 5-14% of all pregnancies. While much more information is needed to be able to draw definitive conclusions and to then make recommendations for implementation, the very idea that there may be a way to reduce the incidence of pre-eclampsia amongst women at risk is exciting. What’s more, the treatment is simply eating supplement bars and taking vitamins. No invasive procedures, no hard core medications.
But it’s not all rosy. To date, there is no data that tells the effectiveness of L-arginine alone on pre-eclampsia. We know that antioxidant vitamins alone offer some benefit, but the benefit was not shown to be statistically significant. There is no data on the potential side effects of L-argninine. There hasn’t been a dosage established that produced optimum effect and no dosages that are ineffective or potentially harmful. Since this is the first (or one of few) studies to look at the effect of dietary supplements on pre-eclampsia, much more research needs to be done to determine if this was a “fluke”, if the data can be reproduced and if the study can be successfully carried out in other areas of the world.
So much to evaluate and determine, but for this moment, I am giddy at the fact that nutritional bars may hold a key to helping lower the incidence of pre-eclampsia.
This study abstract was published in the May 19, 2011 on line British Medical Journal. BMJ. 2011;342:d2777, d2901
A summary was presented on MedScape.
I assumed that pregnant women all take prenatal vitamins, but recently have found that this is an erroneous assumption. In the past month or so, I have had inquiries from pregnant or immediately post partum women who are not taking prenatal vitamins and what’s more, when they asked their obstetricians (Not a slam against OB’s, it just so happens that the women who have inquired about prenatal vitamins were all being cared for by OB’s) which vitamins they should be taking, they were told, “any of the prenatal vitamins from the store will do.”
I’m going on the record right now to say that I disagree.
First and foremost, I believe that EVERY pregnant woman, trying to conceive woman and nursing mother should be taking a good quality dietary supplement. In an ideal world, women would be able to receive all the nutrients that they need from the foods that they eat. Sadly, with the depletion of nutrients in our soil, the hormones and antibiotics injected into our meets, the wide array of processing of our foods and other environmental factors, our food supply is not as nutritionally dense as it once was. Couple that with the fact that most Americans get far fewer servings of recommended fruits, vegetables, whole grains and lean meats and it’s safe to say that most of us are “under nourished”.
So what does that mean for a pregnant, trying to conceive or nursing mother? It means that she may not have adequate energy and nutrient supplies within her body to adequately nourish herself and her growing baby. How does this manifest? In women trying to conceive, it may manifest as difficulty conceiving or early miscarriages. In pregnant mamas it may manifest as deficiencies in mama’s body such as anemia, bone loss or stress fractures, cavities or other anomalies. Post partum, it may manifest as low milk production or even birth defects such as spina bifida in the baby. So yes, I firmly believe that any woman trying to conceive, who is pregnant or breastfeeding needs to be on a high quality vitamin or supplement that will provide her with the extra nutrients that she needs to not only produce a healthy baby and generous, nutrient dense breast milk, but will also supply her body with what it needs to sustain her health as well.
What types of Vitamins are Best?
The Vitamin and supplement industry is not regulated. The US Food and Drug Administration (FDA) classifies dietary supplements as a category of foods and not as drugs. While pharmaceutical companies are required to obtain FDA approval which involves assessing the risks and benefits of drugs prior to their entry into the market, dietary supplements do not need to be pre-approved by FDA before they can enter the market. Consequently, any manufacturer can produce a dietary supplement, claim that it contains certain vitamins, mineral or dietary enhancements and there really is no one to hold that manufacturer to his word. For this reason, many physicians don’t advocate taking vitamins or supplements unless a patient wants “expensive urine” meaning that most of the ingredients in many supplements merely wash through the body.
But are all supplements bad? Are they unnecessary? Of course not. Just like anything else, there are “good” brands of vitamins and supplements and “not so good” brands of vitamins and supplements. What I have learned is that it is best to take vitamins or supplements that are manufactured according to GMP* or Good Manufacturing Processes. These regulations, which have the force of law, require that manufacturers, processors, and packagers of drugs, medical devices, some food, and blood take proactive steps to ensure that their products are safe, pure, and effective. What this means is that products manufactured by companies that make the effort to ensure that their products meet these stringent guidelines will contain the ingredients that they say they contain and at the strengths stated. In this way, consumers can be sure that the potency and efficacy is as stated.
For women trying to conceive, who are pregnant or nursing, I usually suggest that they do some research on prenatal vitamins and look for one that is manufactured using GMP. This information can be obtained from various guides to nutritional supplements as well as some online websites (see the resources below).
So What Should My Prenatal Vitamin Contain?
According to the Mayo Clinic, prenatal vitamins should contain Folic Acid, Calcium, Iron, Omega 3 Fatty Acids and Vitamin D. While this is a good start, how much? The Cleveland Clinic gives the following recommendations:
- 4,000 and 5,000 IU (international units) of vitamin A
- 800 and 1,000 mcg (1 mg) of folic acid
- 400 IU of vitamin D
- 200 to 300 mg of calcium
- 70 mg of vitamin C
- 1.5 mg of thiamine
- 1.6 mg of riboflavin
- 2.6 mg of pyridoxine
- 17 mg of niacinamide
- 2.2 to 12 mcg of vitamin B-12
- 10 mg of vitamin E
- 15 mg of zinc
- 30 mg of iron
These are good starting points. So as you are researching prenatal vitamins, look for brands that contain at least the amounts indicated above (The Cleveland Clinic is a highly reputable institution and I feel VERY comfortable echoing their recommendations) and look for companies that use GMP to produce their products.
The Bottom Line
Prenatal Vitamins can help reduce the incidences of birth defects such as spina bifida as well as the risk of developing a low birth weight baby. Studies have shown that even in women who eat a “healthy and nutrient dense” diet, the bodily demands of pregnancy and lactation are often more than their bodies can meet on their normal diets alone. Hence, even though many obstetricians and midwives won’t give a specific recommendation, they all generally agree that most women need some sort of vitamin supplementation during pregnancy.
If you are confused or overwhelmed with what your body needs in terms of vitamins and supplements during pregnancy, Let’s talk about it. Sign up for a Complimentary 30 Minute Bedrest Breakthrough Session and we can go over your nutritional needs and your supplement options. To schedule your complimentary session, send an e-mail to email@example.com.
ISPE - ISPE, the International Society for Pharmaceutical Engineering, is the world’s largest not-for-profit association dedicated to educating and advancing pharmaceutical manufacturing professionals and their industry.
How to find out which companies manufacture according to GMP
Nutritsearch Comparative Guide to Nutritional Supplements by Lyle MacWilliam, MSc. FP. Copyright 2007, NutriSearch Corporation.
NSF International – The Public Health and Safety Company™, a not-for-profit, non-governmental organization, is the world leader in standards development, product certification, education, and risk-management for public health and safety.
ConsumerLab.com – ConsumerLab.com examines the research literature to understand the chemical makeup of products that have been shown useful in clinical (i.e., human) research studies—and establishes standards of quality for that product.
US Pharmacopeia – The USP Dietary Supplement Verification Program is a voluntary testing and auditing program that helps dietary supplement manufactures ensure the production of quality products for consumers.
I am a blog contributor on Lamaze International’s blog, Science and Sensibility. On April 12th, I wrote a commentary on the new guidelines and warnings issued by the FDA regarding the use of Terbutaline for the prevention of preterm labor. It created quite a stir.
In a nutshell, obstetricians were irritated (pun intended!) with my tone in that I feel that the use of Terbutaline should be severely limited if not completely banned. They challenged my authority to question their medical judgement and to demand full disclosure be given to patients regarding the off label use, the potential risks and complications as well as potential long term side effects. They all swore that most obstetricians follow ACOG guidelines for the use of Terbutaline for the prevention of preterm labor and that Terbutaline is always used responsibly and not for more then 48-72 hrs, just long enough to stabilize their patients.
However, the stories recounted by women who were on Terbutaline or who had been given Terbutaline to halt their preterm labor symptoms revealed an entirely different story. Women recounted being placed on continuous drips, daily injections and for being on the medication for weeks to months. Additionally, most of the women stated that they had not been fully informed about Terbutaline, knew nothing about it being used off label and had no idea of the potential risks and side effects. They were basically given the medication without any say whatsoever and were told it was what was needed to maintain their pregnancies.
Although that particular debate has waned, the controversy regarding the use of Terbutaline continues and underscores the pressing need for additional treatment options for high risk pregnancy and preterm labor.
Chavi Karkowsky, a second year Maternal Fetal Medicine Fellow at Albert Einstein College of Medicine/Montefiore Medical Center in New York City, wrote a blog post/case study on Medscape asking readers to indicate how they would manage a young pregnant woman with symptoms of preterm labor.
Karkowsky provided 5 possible treatment options. Readers were also able to write in their treatment plans. The results were very interesting. Most all of the readers wanted to give the patient something-even though it wasn’t clear that the patient was experiencing preterm labor (the Fetal Fibronectin test, a test that can definitively predict preterm labor, was unavailable). Interestingly, many of the responders felt that the patient was not in preterm labor, but wanted to give her something based on her presentation, social situation and her potential for complications. Here is how the treatment options ranked among clinician response.
a) She’s not in labor with that cervix. Send her home, with strict cautions. 15% (17)
b) She’s not in labor with that cervix, but she’s a little nervous-making, right? Let’s give her a dose of terb. I think she’ll eventually go home. I don’t want to give her steroids, since I think she won’t deliver within 7 days, but we’ll follow her closely as an outpatient. 9% (10)c) She’s not in labor, but terbutaline is bad, bad stuff. Didn’t you read the recent updates? Let’s give her a dose of nifedipine or indomethacin. I think I will send her home if her contractions abate, with close follow-up. 18% (21)
d) Let’s admit her- come on! She has a terrible social situation, and who knows where she’ll end up. I know her cervix is closed and long, but I want to tocolyse her properly and give her steroids. I will likely give her magnesium, given the recent data on neuroprotection. 21% (24)
e) Same as (d), but can we use a tocolytic that actually tocolyses? I’m voting for nifedipine to get her steroids on board.
Other Answers 6% (7)
As Karkowsky’s poll shows, there is little agreement among clinicians about the treatment of preterm labor and at times, it seems to be a bit of a crap shoot.
What I found interesting and what was advocated by a handful of practitioners was conservative observation at home, with home health nursing follow up. Novel approach? Not so much and one that is used with frequent regularity in countries with universal healthcare. Home care with professional follow up can provide a level of surveillence similar to that of being a hospital in patient in a more comfortable environment for the patient and at a fraction of the cost of a hospital admission. But in our health care climate of “managed care”, reimbursement and litigation, this is not going to be a first line option and one that many patients would in fact prefer.
Management of high risk pregnancy and the use of Terbutaline for the prevention of preterm labor in particular will continue to be a hot bed issue. As long as we have so few treatment options for the prevention of preterm labor, until we as a culture honor pregnancy and childbearing and provide women with modified work schedules and/or paid maternity leave, and until there is an incentive within our current health care system for less intervention and more preventive health care this debate will continue.