gestational diabetes

Mamas on Bedrest: The Votes are in-The Affordable Care Act Stands!

November 9th, 2012

With the Re-election of President Barack Obama, The Affordable Care Act (aka Obamacare) is pretty much solidified as part of American Culture. Here, Bedrest Coach Darline Turner reviews just what the Affordable Care Act provides for women, Mamas on Bedrest in particular.

Mamas on Bedrest: Medications in Pregnancy-Updates on the Latest Research

November 5th, 2012

Whether or not to use medications during pregnancy and which medications are safe to take during pregnancy are always difficult conversations. When a mama has a medical condition, health care providers are always faced with the question,

“Does the risk of using a particular medication outweigh the benefit that the medication will provide to both the mama and baby? Are there potential side effects that are harmful to mama, baby or both?”

These are difficult questions to answer given that there is little research done on the effects of medications during pregnancy due to fear of harm to mama, baby or both. Recently, there have been some published studies indicating that there are some beneficial and safe medications to use during pregnancy and some medications that we may really want to avoid. The FDA has also created a new department to assess risk of medications during pregnancy. All of this breaking news is summarized below.

Probiotics in Pregnancy Reduce Eczema in Pregnancy. In June 2010, research was published in the British Journal of Dermatology that suggests that mamas who take probiotics during the third trimesters and for the first 3 month post partum while breastfeeding showed reduced incidence of eczema in the newborns, but there was no effect on the subsequent development of allergic rhinitis, asthma or atopic dermatitis later on. Because taking probiotics is safe and relatively inexpensive, researchers believe that recommending that pregnant mamas take probiotics during this time period poses no health risk or threat and is most likely beneficial to mamas and infants.

New Recommendations for Tetanus, Diphtheria and Pertussis Vaccination During Pregnancy. Originally posted on October 26, 2012, this post reviews the current guidelines and recommendations for Tdap vaccination during pregnancy.

Link Found Between Vitamin D Levels and Gestational Diabetes. In this blog posted on October 19, 2012, we share the latest data presented at the European Association for the Study of Diabetes (EASD) 48th Annual Meeting suggesting that low Vitamin D levels early on in pregnancy put mamas at greater risk for developing gestational diabetes.

Fish Oil for the Treatment of Post Partum Depression. This Blog post highlights research presented by Dr. Kathleen Kendall-Tackett on La Leche League’s website discussing the role that chronic inflammation plays in post partum depression. She also states that supplementing with fish oil, rich in the Omega 3 Fatty Acids docosaheaenoic acid (DHA) and eicosapentaenoic acid (EPA), fhave been found to be more potent in reducing inflammation and in turn, depression.

Selective Serotonin Reuptake Inhibitors (SSRI’s) for treatment of Depression in Pregnancy. It is a well established fact that depression during pregnancy can lead to serious morbidity and mortality for both mamas and babies. Depression is also more common in women who are experiencing infertility and difficulty conceiving, and until now, SSRI’s were the first line medications prescribed. However, recent data published by Alice Domar, PhD, from Beth Israel Deaconess Medical Center and executive director of the Domar Center for Mind/Body Health at Boston IVF, in Massachusetts shows that treating depression in infertile women with SSRI can have serious deleterious effects for women trying to conceive as well as their babies when they become pregnant.

Publishing in Human Reproduction, Domar states the know evidence.

“SSRI use is associated with possible reduced infertility treatment efficacy as well as higher rates of pregnancy loss, preterm birth, pregnancy complications, neonatal issues and long-term neurobehavioral abnormalities in offspring.

As a result Domar recommends that clinicians consider alternative treatments for depression in women trying to conceive and women who become pregnant using Assisted Reproductive Technologies (ART), namely, Cognitive Behavioral Therapy (CBT).

The Establishment of the Medication Exposure in Pregnancy Risk Evaluation Program. In 2009, the U.S. Food and Drug Administration (FDA) announced the creation of the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). This pilot program is intended to provide a large, ethnically and geographically diverse population with which to address a variety of important and timely issues surrounding the safety of medication use during pregnancy. MEPREP is intended to provide the expertise and data resources to enable studying drug exposures for which there is a signal of potential fetal risk from animal studies, human case reports, or other published literature.

MEPREP is a collaborative effort between The FDA and researchers at the HMO Research Network (HMORN), Kaiser Permanente Northern and Southern California, and Vanderbilt University School of Medicine. It also encompasses the affliated organizations at Kaiser Permanente Northern California, Kaiser Permanente Southern California, Kaiser Permanente Georgia, Kaiser Permanente Northwest, Kaiser Permanente Colorado, Harvard Pilgrim Health Care Institute, Group Health Research Institute, HealthPartners Research Foundation, Lovelace Clinic Foundation, the Meyers Primary Care Institute/Fallon Community Health Plan, and Vanderbilt University School of Medicine.

Data generated comes from the electronic medical records at each institution as well as birth certificate data obtained from the state departments of public health. This extensive data base allows for diverse patient data across a wide demographic of age, racial and ethnicity and geographic area.

It is great to finally see research being done of medication use, efficacy and safety during pregnancy. It is highly likely that as a result of all of this attention and research new, more effective and safer treatments will become available for women with medical illnesses, lessening the risk of complications, poor outcomes and (thankfully) death before,  during and after pregnancy for mamas and babies.

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