Bone Loss

Mamas on Bedrest: The End of Bed Rest?

June 21st, 2013

Mamas on Bedrest,

There is no medical or scientific evidence that the bed rest prescription prolongs pregnancy, prevents preterm labor or ameliorates any of the conditions for which it is prescribed. The fact that bed rest is prescribed in the face of these facts goes against the medical covenant into which health care providers enter when they swear to uphold the Hippocratic Oath as they receive their credentialing. As medical treatments and technologies evolve and improve, obstetricians and gynecologists themselves are beginning to question this commonly prescribed treatment that has the potential to do more harm than good.

In the June issue of Obstetricians and Gynecologists, McCall et. al and Joseph Biggio, MD review the practice of bed rest and conclude that bed rest is not an evidence based practice, has the potential to cause harm to mamas and babies and they recommend that the practice be discontinued-immediately.

This is a HUGE shift (okay, one that is taking place) in the position of the American Congress of Obstetricians and Gynecologists. To date, ACOG has held tenaciously to bed rest, citing the thousands of “successful” pregnancies and births as a result of the practice. However, obstetricians have ignored the negative consequences of bed rest; the potential for blood clot development and embolism, bone loss, muscle loss and depression. Additionally, the health care community has long ignored the impact that the bed rest prescription has on a woman’s family, her job/career, her finances and overall emotional well being. The focus has always been, “this is what is best for the baby-to ensure a full term outcome.” McCall et al show via an extensive review of the literature that bed rest does not ensure a positive birth outcome and noted that women who were put on bed rest are more likely to suffer the aforementioned complications and not necessarily deliver a full term infant.

Dr. Biggio accurately states in his editorial that we regard mamas and babies as separate entities; “bed rest will improve the birth outcomes for the baby”, yet we completely disregard the impact that bed rest has on mamas. Additionally, (and I believe that this is the brilliance in his statement!) mamas and their babies are most intimately connected. To regard the health and well being of one without considering the health and well being of the other is short sighted. And in view of the Hippocratic Oath, bed rest is actually “doing harm”.

Both publications accurately state that the advances in prenatal screening and treatments enable health care professionals to evaluate the status of mamas and babies and intervene as necessary. Hence, placing them on bed rest-often prophylactically-can be at the least irresponsible and at best unjust and a form of malpractice.

While it is not yet clear the direction American obstetricians and gynecologists will go with high risk pregnancies, change is definitely on the horizon. Rest assured, we here at Mamas on Bedrest & Beyond will keep our eyes and ears open and report any changes in obstetrical practices as soon as they are available.

In the meantime, know that Mamas on Bedrest & Beyond will continue to support Mamas on Bedrest and will evolve our practice and services to continue to meet the needs of high risk pregnant mamas.

What are your thoughts on this bed rest debate mamas? Share your thoughts in the comments section below!!

 

Mamas on Bedrest: Magnesium Sulfate and Your Baby’s Bones

May 31st, 2013

Magnesium Sulfate has long been used in obstetrics to prevent seizures associated with pre-eclampsia, eclampsia, pregnancy induced hypertension and preterm labor. On May 30, 2013, the United States Food and Drug Administration issued a drug safety alert stating that clinicians should not prescribe Magnesium Sulfate for seizure prevention during pregnancy for more than 5-7 days because of the risk of low calcium and bone abnormalities in the fetus.

Magnesium Sulfate has been used for decades “off label ” (not for its originally FDA approved indication) for the prevention of preterm labor and the prevention of seizures caused by markedly increased blood pressure as seen in pre-eclampsia and eclampsia. It was first prescribed in Germany in 1906 to prevent seizures associated with eclampsia and was injected into the intrathecal cavity (at the base of the spine). In 1926 it was prescribed intra-muscularly and in  1933, the IV form of “Mag Sulfate” became available.

As recently as February 2013, researchers published a study touting the benefits of Magnesium Sulfate and saying that there were no appreciable side effects. Upon close scrutiny of  the article, one clearly sees that this particular study only addressed potential side effects to the mother. This study, like many others, completely ignored the potential harm to the developing fetus, assuming that if  magnesium sulfate is in fact safe for mamas it is safe for babies. This simply isn’t the case.

In response to 18 adverse drug reports submitted to the Safety Information and Adverse Event Reporting system, the FDA conducted its own research to see why some mothers had problems and some did not.  Babies born to these 18 women all had osteopenia (low bone mass density) and were at greater risk of sustaining fractures. The average amount of time the mamas received Magnesium sulfate was over a 10 weeks.  The FDA found that the maximum time that a mamas should take Magnesium Sulfate is a mere 5-7 days and then the FDA recommends stopping the medication. The prolonged administration of Magnesium Sulfate led to the side effects, which seem to resolve once Magnesium Sulfate is stopped.

This MedScape News Report has a couple of really good take home messages. First and foremost, clinicians must closely monitor Magnesium Sulfate administration and ensure that mamas understand that the drug is being used off label, has the potential to affect their unborn babies’ bones and that they have the right to say “no”. Second, we health care researchers have to be careful when reading studies lest we draw false conclusions and inform the public that there is no harm when there is or there is harm when there is not.

References

MedScape Newshttp://www.medscape.com/viewarticle/805009

Jeffrey Michael Smith, Richard F Lowe, Judith Fullerton, Sheena M Currie, Laura Harris and Erica Felker-Kantor

An integrative review of the side effects related to the use of magnesium sulfate for pre-eclampsia and eclampsia management.  BMC Pregnancy Childbirth, May 2013

The US Food and Drug Administration-Safety Alerts for Human Medical Products.

Mamas on Bedrest: Link Found Between Vitamin D and Gestational Diabetes

October 19th, 2012

Mamas, do you know your vitamin D level? Recent research suggests that if you are deficient in vitamin D early on in pregnancy, you are at risk for developing gestational diabetes.

At the the European Association for the Study of Diabetes (EASD) 48th Annual Meeting in Berlin Germany, Marilyn Lacroix, a master’s degree candidate from the Faculty of Medicine and Health Sciences at the University of Sherbrooke in Quebec, Canada reported that women with lower serum levels of vitamin D during the first trimester of pregnancy are at greater risk for developing gestational diabetes mellitus (GDM) later in pregnancy.

Study Design

According to Lacroix’s research, the association between vitamin D level and GDM risk was independent of age, season of blood sampling, vitamin D supplementation, and adiposity (fatness) of the mother. Women aged 18 years or older (n = 655) who were in their sixth to 13th week of pregnancy and in good health were recruited from the Sherbrooke area in Canada, which lies at about 45 degrees north latitude and therefore gets relatively less sun exposure than more southerly locations. The researchers made anthropometric (fat determination) measurements and determined 25OHD (Vitamin D) levels at the time of recruitment. Between the 24th and 28th weeks of pregnancy, they performed a 75-g fasting oral glucose tolerance test (OGTT) to determine normal glucose tolerance or GDM according to criteria of the International Association of the Diabetes and Pregnancy Study Groups (fasting glucose ≥ 5.1 mmol/L; 1 hour post-OGTT glucose ≥ 10.0 mmol/L; 2-h post-OGTT glucose ≥ 8.5 mmol/L)

Results

54 women, 8.2% of the study population developed GDM. These women were on average older and had larger waist circumferences  than their cohorts. According to Lacroix,

“The mean total 25OHD levels in our cohort was about 63 nmol/L, and participants with gestational diabetes mellitus had lower levels of 25OHD compared to [women with] normal glucose tolerance,” Lacroix reported. “The overall prevalence of vitamin D deficiency in our cohort was about 27%.”

Lower levels of Vitamin D were associated with an increased risk of incident GDM. When the data was adjusted for age, season of blood sampling, vitamin D supplementation, and waist circumference, the risk for GDM increased by 40% for each standard deviation (SD) decrease in Vitamin D level. Translation, for each decrease in Vitamin D by 18.8nmol/L, the risk for developing GDM increased 40%.  This result was consistent regardless of the measurement of adiposity used (waist circumference, body mass index, or percentage body fat). At these second trimester measurements, women with GDM also had lower insulin sensitivity. Lacroix also noted that women with lower levels of Vitamin D, higher waist circumference and lower insulin sensitivity also had lower B cell compensation. B cells are the insulin producing cells in the pancreas. However, B cell compensation was found to be independent of Vitamin D level.

Overall,  Lacroix and her colleagues concluded that lower vitamin D levels in the first trimester are associated with increased risk of developing GDM, independent of age, season of blood sampling, vitamin D supplementation, and adiposity measurements. Lower vitamin D levels are associated with insulin resistance but not with insulin secretion or β cell compensation after adjustment for confounders.

Discussion at the meeting

Anne Dornhorst, BM, BCh, from the Department of Diabetes and Endocrinology at Imperial College Healthcare NHS Trust in London, United Kingdom, commented,

“If you take women from sub-Saharan Africa and Muslim women who are not only dark skinned but covered, you can say to yourself, is there any point measuring it? Just give them vitamin D.

She said also that blacks are at high risk for type 2 diabetes and gestational diabetes. Indians, too, have a very high level of vitamin D deficiency along with a high level of type 2 and gestational diabetes.

As of publication of the Abstract at the (EASD) 48th Annual Meeting October 3, 2012, there currently isn’t a recommended amount of Vitamin D for supplementation.

Other Research

Dr. Edward Giovannucci, nutrition researcher at the Harvard School of Public Health has studied Vitamin D extensively. He states,

“Throughout most of human evolution,” Dr. Giovannucci wrote, “when the vitamin D system was developing, the ‘natural’ level of 25-hydroxyvitamin D was probably around 50 nanograms per milliliter or higher. In modern societies, few people attain such high levels.”

People in colder regions form their year’s supply of natural vitamin D in summer, when ultraviolet-B rays are most direct. But the less sun exposure, the darker a person’s skin and the more sunscreen used, the less pre-vitamin D is formed and the lower the serum levels of the vitamin. People who are sun-phobic, babies who are exclusively breast-fed, the elderly and those living in nursing homes are particularly at risk of a serious vitamin D deficiency. The main dietary sources are wild-caught oily fish (salmon, mackerel, bluefish, and canned tuna) and fortified milk and baby formula, cereal and orange juice, yet experts say it is rarely possible to consume adequate amounts through foods.

Dr. Michael Holick of Boston University, a leading expert on vitamin D and author of “The Vitamin D Solution” (Hudson Street Press, 2010), said in an interview,

“We want everyone to be above 30 nanograms per milliliter, but currently in the United States, Caucasians average 18 to 22 nanograms and African-Americans average 13 to 15 nanograms.” African-American women are 10 times as likely to have levels at or below 15 nanograms as white women, the third National Health and Nutrition Examination Survey found.”

Recommendations

The current recommended intake of vitamin D, established by the Institute of Medicine, is 200 I.U. a day from birth to age 50 (including pregnant women); 400 for adults aged 50 to 70; and 600 for those older than 70. Dr. Holick, among others, recommends a daily supplement of 1,000 to 2,000 units for all sun-deprived individuals, pregnant and lactating women, and adults older than 50. The American Academy of Pediatrics recommends that breast-fed infants receive a daily supplement of 400 units until they are weaned and consuming a quart or more each day of fortified milk or formula.

But both Dr. Giovannucci and Dr. Holick say it is very hard to reach such toxic levels. Healthy adults have taken 10,000 I.U. a day for six months or longer with no adverse effects. People with a serious vitamin D deficiency are often prescribed weekly doses of 50,000 units until the problem is corrected. To minimize the risk of any long-term toxicity, these experts recommend that adults take a daily supplement of 1,000 to 2,000 units.

Implications for Mamas on Bedrest

I don’t know about any of you, but my Vitamin D levels were not measured either time that I was pregnant. In fact, they were only measured recently when I was seeing a gynecologists for hormonal imbalances related to perimenopause. Given the significance of vitamin D deficiency and its link to GDM, I hope that OB’s will begin screening for this very important vitamin and replacing it accordingly.

However, Vitamin D deficiency can have even farther reaching, more deleterious effects for mamas on bed rest. Vitamin D is important in calcium metabolism and bone formation. Judy Maloni, PhD has done extensive research on the effects of bed rest. She notes that in as little as 2 weeks, women on bed rest begin losing bone mass. So if women on bed rest are already at risk for bone loss, coupling that with low levels of Vitamin D only makes them at greater risk. While Bedrest is often a necessity, we can at least fight back against GDM and bone loss by providing adequate vitamin D supplementation. As Drs. Giovannucci and Holick have both stated, our diets and many of our supplements (speaking about prenatal vitamins here!) don’t provide adequate vitamin D supplementation.

Speak with your healthcare provider about the importance of Vitamin D and whether or not you need supplementation. If you have questions about how to go about finding a good Vitamin D supplement, e-mail us at info@mamasonbedrest.com.

References

MedScape News: OB/GYN & Women’s Health. “Low First-Trimester Vitamin D Predicts Gestational Diabetes” Marilyn Lacroix, Master’s Degree candidate from the Faculty of Medicine and Health Sciences at the University of Sherbrooke in Quebec, Canada. Presented at European Association for the Study of Diabetes (EASD) 48th Annual Meeting. Abstract 82. Presented October 3, 2012.

What Do You Lack? Probably Vitamin D-The New York Times

Astronauts and Pregnancy Bed Rest: What NASA is teaching us about inactivity Judith A Maloni, PhD, FAAN

Antepartum Bed Rest For Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth-Judith A Maloni, PhD, FAAN