Planning for a Healthy Pregnancy

Ann Lovick, ND

When patients come into my office to discuss fertility, the first thing I tell them is to start acting like they are pregnant. This means that they need to be conscious of everything they put in their mouth and decide whether it is good for baby. The mom-to-be needs to cease smoking, stop drinking alcohol, and begin taking prenatal vitamins. Starting good nutritional habits before baby is born accomplishes the following: First, it helps establish healthy eating habits that carry into pregnancy. Second, it increases the overall health of the mother, enhances fertility, and minimizes complications during pregnancy. Third, it improves the overall health and development of the baby.

Importance of Folic Acid

Let us look at the nutrients that are commonly associated with birth defects. Folic acid is usually the first that comes to mind, possibly along with conditions such as spina bifida and anencephaly. Numerous studies have proven the importance of folic acid in the development of the neural tube during embryonic growth. However, other studies^1,2 have shown the importance of folic acid in cardiovascular health.

I confess that I do not remember this from embryology class, but a review of the literature shows that ventrally emigrating neural tube cells contribute to the development of the cardiovascular system.³ When you consider that congenital heart defects are the most common birth defect and that structural heart abnormalities are responsible for most sudden cardiac deaths in young athletes, perhaps we should look at whether moms are getting enough folic acid.

The March of Dimes (http://www.marchofdimes.com) recommends 400 µg/d of folic acid before pregnancy and 600 µg/d during pregnancy for the prevention of neural tube defects. They also recommend taking folic acid for at least 1 year before getting pregnant to reduce the risk of premature birth. Unfortunately, I do not meet a lot of women who start planning their pregnancy 12 months out. A Canadian study⁴ showed that up to 5 mg/d for at least 2 months before conception through the first trimester was needed to restore folate levels in high-risk women. Two months is a more reasonable wait time for most women, although I recommend 3 to 4 months of nutritional fortification. Because folic acid is important during the first 4 weeks of fetal development, before most women know they are pregnant, this is a crucial nutrient for preconception nutrition. I ask moms to take 800 to 1200 µg/d of folate.

B Vitamins and Nutrition in Pregnancy

A 2009 study⁵ showed that up to 90% of pregnant women experience the joys of morning sickness in the first trimester, with some intensifying to hyperemesis gravidarum. During this time, mom may become nutritionally depleted because she is unable to hold down food. Vitamin B₆ is a common treatment for pregnancy-associated nausea. Remember that birth control pills deplete the body of vitamin B₆. I am seeing more and more women who have been put on oral contraceptives starting around menarche to regulate their cycles, decrease symptoms of premenstrual syndrome, and clear up acne. So, by the time they are ready to stop the pill and get pregnant, they are low in vitamin B₆. Restoring their vitamin B₆ levels may help ward off morning sickness during pregnancy.

Be careful with vitamin B₆ dosing. Although vitamin B₆ is a water-soluble vitamin, too much can be toxic. I recommend higher doses of 100 mg/d of vitamin B₆ during preconception planning, but I decrease that to about 20 mg/d of vitamin B₆ during pregnancy.

Folic acid, vitamin B₆, and vitamin B₁₂ are needed for DNA synthesis, cell growth, and homocysteine metabolism. A buildup of homocysteine can increase a woman’s chance of developing preeclampsia and may adversely affect placental development. High levels of homocysteine and reduced levels of folate are linked to restricted fetal growth.⁶

Vitamin B₁₂ is another vitamin that is ideal for preconception fortification. It is required for red blood cell formation. It also gives mom energy, and a deficiency can cause nausea and loss of appetite. Vitamin B₁₂ is important for neurological function, whereas a deficiency can cause numbness and tingling in the hands and feet. Be aware, though, that numbness and tingling in the extremities are also a sign of vitamin B₆ toxic effects. Always ensure you are doing appropriate monitoring and testing to make sure mom has the proper levels of the nutrients that she and baby need.

Iron is most needed during the second and third trimesters, when the maternal blood supply can increase up to 50%. Iron is crucial to make hemoglobin for the increased blood supply. However, it is not uncommon for menstruating women to be anemic, so many women start out their pregnancy low in iron. One of the symptoms of anemia can be nausea, and iron supplements are known to be hard on the stomach. Low levels of folate and vitamin B₁₂ can also cause anemia. Preconception nutrition should include blood work to verify the future mom’s nutritional status to see if she needs more than the recommended daily dose. In 2011, a study⁷ in The Journal of Nutrition called for investigations of the neuropsychological consequences of iron deficiency on mothers and their offspring.

Minerals and Hormones for Strong Mothers and Babies

Calcium is important for the baby’s skeletal growth and for cardiovascular health. If mom does not get enough calcium in her diet, baby usually takes it straight from the mother’s bones. I recommend 1000 mg/d of calcium, along with 500 mg/d of magnesium, in divided doses taken away from the prenatal vitamin. Prenatal vitamins typically contain iron, and there is some controversy as to whether calcium can block the absorption of iron. Just to be on the safe side, I recommend separating the doses from iron-containing supplements.

Vitamin D is certainly a popular vitamin these days. It improves calcium absorption and use for fetal skeletal development.⁸ Vitamin D has also been shown to reduce the incidence of asthma and atopy in children.⁹ One study showed that a deficiency in this vitamin “may be an environmental trigger”^10(p1541) for autism. Vitamin D dosing depends on the deficiency status of the mom and is typically anywhere from 1000 to 5000 IU/d.

Docosahexaenoic acid (DHA) is crucial for central nervous system development and for healthy breast milk production. Supplementation of DHA is most important “during the fetal brain growth spurt in the last trimester of pregnancy.”^11(p123) It also benefits mom; one study¹² showed that decreased levels of maternal DHA are positively correlated with “depression-associated neurobiological changes.” High-dose DHA not only improves the cognitive function of infants but also reduces the risk and severity of postpartum depression in mothers. Moms who experience depression often cannot give their infants the care that they need; therefore, including adequate DHA prenatal supplementation improves baby’s life in many ways.¹³ With DHA dosing, more is better, and I recommend at least 1500 mg/d. If mom has a history of depression or mood disorders, I would double that dose.

Benefits of Preconception Nutrition

I love the idea of preconception nutrition. The stronger and healthier mom is, the stronger and healthier baby will be. I always tell moms that baby gets everything first and to get used to it now because that will happen for the rest of her life. I know that pregnancies are not always planned, so women of childbearing age should take steps to maximize their nutrition. For those women who may be struggling with fertility issues, I tell them that they are going to work very hard to conceive their baby. Therefore, they should work hard to fortify themselves for the wonderful adventure of motherhood. Good nutritional habits now will benefit the whole family for a lifetime.

Ann Lovick, ND is a naturopathic physician specializing in women’s healthcare. She graduated from Southwest College of Naturopathic Medicine, Tempe, Arizona, in 2007, and completed a 2-year family practice residency in Phoenix, Arizona. Born and raised in Texas, Dr Lovick originally received a BBA in finance and an MBA in information management from the University of Texas at Austin. Yet, extensive travel as a business consultant for Fortune 500 companies and life on the road took their toll on her health. After years of living with pain under the care of allopathic physicians, Dr Lovick sought out naturopathic medical care and found relief. In one visit, she decided she wanted to learn more and aimed to share what she has learned with others. Dr Lovick also served as president of the board of directors of the Arizona Naturopathic Medical Association and was named their 2009 Naturopathic Physician of the Year.

References

1. Wilson RD, Johnson JA, Wyatt P, et al. Pre-conceptional vitamin/folic acid supplementation 2007: the use of folic acid in combination with a multivitamin supplement for the prevention of neural tube defects and other congenital anomalies. J Obstet Gynaecol Can. 2007;29(12):1003-1026.
2. Czeizel AE. Periconceptional folic acid–containing multivitamin supplementation for the prevention of neural tube defects and cardiovascular malformations. Ann Nutr Metab. 2011;59(1):38-40.
3. Ali MM, Frooqui FA, Sohal GS. Ventrally emigrating neural tube cells contribute to the normal development of heart and great vessels. Vascul Pharmacol. 2003;40(2):133-140.
4. Kennedy D, Koren G. Identifying women who might benefit from higher doses of folic acid in pregnancy. Can Fam Physician. 2012;58(4):394-397.
5. Lacasse A, Rey E, Ferreira E, Morin C, Bérard A. Epidemiology of nausea and vomiting of pregnancy: prevalence, severity, determinants, and the importance of race/ethnicity. BMC Pregnancy Childbirth. 2009;9:26. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2713199/?tool=pubmed. Accessed June 14, 2012.
6. Furness D, Fenech M, Dekker G, Khong TY, Roberts C, Hague W. Folate, vitamin B₁₂, vitamin B₆ and homocysteine: impact on pregnancy outcome [published online October 24, 2011]. Matern Child Nutr. doi:10.1111/j.1740-8709.2011.00364.x. Medline:22023381
7. Murray-Kolb LE. Iron status and neuropsychological consequences in women of reproductive age: what do we know and where are we headed? J Nutr. 2011;141(4):747S-755S.
8. Young BE, McNanley TJ, Cooper EM, et al. Maternal vitamin D status and calcium intake interact to affect fetal skeletal growth in utero in pregnant adolescents. Am J Clin Nutr. 2012;95(5):1103-1112.
9. Hollams EM. Vitamin D and atopy and asthma phenotypes in children. Curr Opin Allergy Clin Immunol. 2012;12(3):228-234.
10. Kočovská E, Ferrell E, Billstedt E, Minnis H, Gillberg C. Vitamin D and autism: clinical review. Res Dev Disabil. 2012;33(5):1541-1550.
11. Makrides M, Smithers LG, Gibson RA. Role of long-chain polyunsaturated fatty acids in neurodevelopment and growth. Nestle Nutr Workshop Ser Pediar Program. 2010;65:123-136.
12. Levant B. N-3 (omega-3) fatty acids in postpartum depression: implications for prevention and treatment. Depress Res Treat. 2011;2011:467349. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989696/?tool=pubmed. Accessed June 14, 2012.

13. Prado EL, Ullman MT, Muadz H, Alcock KJ, Shankar AH; SUMMIT Study Group. The effect of maternal multiple micronutrient supplementation on cognition and mood during pregnancy and postpartum in Indonesia: a randomized trial. PLoS One. 2012;7(3)e32519. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299672/?tool=pubmed. Accessed June 14, 2012.