VEGETARIAN DIETS AND PREGNANCY?

Vegan and vegetarian diets are plant-based diets. They are gaining popularity as people try to make better choices in terms of their health when it comes to food.  A vegetarian diet refers to diet that is devoid of animal (meat). It can be a total (vegan) or partial exclusion of animal derived food, allowing dairy products and eggs.

Plants, in general tend to be more nutrient-dense and associated with a number of health benefits, including lower body mass index, cardiovascular diseases, obesity, diabetes and cancer prevention. This diet also has a higher content of magnesium, folate, and fiber, compared to the meatier westernized diets.

Studies has demonstrated that partial vegan diet intake fulfilled the UK recommended nutritional intake (RNI) but the vegan had a lower vitamin B12, riboflavin, calcium and iodine.  These vegans were also had a lower iron, zinc and vitamin D due to exclusion of meat from their diet (Draper 1993, Philips 2005).

Effect of vegetarian diet in pregnancy

Draper (1993) finds that in non-pregnant vegetarians, the mean intakes of micronutrients met the UK recommended nutrient intake (RNI) among partial vegetarian but strict vegans have intakes of riboflavin, vitamin B12, calcium and iodine that were below the RNI.

Pregnancy is associated with an increased requirement for energy, protein and some micronutrients, including thiamin, riboflavin, folate and vitamins A, C and D. Although a vegetarian diet can meet the increased demand for energy and protein during pregnancy, but there may be difficult to achieve the recommended intake of some vitamins and minerals, especially for vegans, due to dietary restrictions. This group has difficulty meeting their requirements for riboflavin, vitamin B12, calcium, iron and zinc. The intake of these important nutrients during pregnancy need to be supplemented (Philips 2005).

Effect on pregnancy outcome

Studies comparing birth outcomes (e.g. birthweight, length of gestation) in vegetarian  mothers and omnivores, have so far not produced consistent results. One study found no difference in length of gestation, birthweight, birth length or head circumference between the babies of vegetarians, fish-eaters and meat-eaters (Drake 1998). Others found that white, vegan mothers had lower birthweight babies compared with women from the rest of the population (Sanders 1995, Reddy 1994).

 

Conclusions

The current evidence on vegan–vegetarian diets in pregnancy is mixed and limited. The type of dietary advice that is applicable to vegetarians and vegans during pregnancy depends, to a certain extent, on the type of vegetarian diet followed.  The vegetarian diet is associated with risk for low intakes of certain nutrients during pregnancy.

The vegetarian diets may be considered safe in pregnancy as most should be able to meet their nutrient requirements with careful dietary planning. However, those on very restricted diets may also need to consume fortified foods or supplements.

 

References

  1. Drake R et al., Vegetarian Nutrition: An International Journal 1995
  2. Draper A et al., British Journal of Nutrition 1993.
  3. Philips F. Nutrition Bulletin 2005
  4. Reddy S et al., European Journal of Clinical Nutrition 1994.
  5. Sanders TAB.  Pediatric Nutrition 1995

THE LATEST SCARE – ZIKA VIRUS AND PREGNANCY

For the last two months, the world is shocked by news of microcephalic babies born after suspected Zika virus infected mothers in South America. These babies have smaller than normal head circumference, with high probability of brain damage, blindness or even deafness. It affects more than 2000 pregnant mothers in South America and the government has advised women to postpone pregnancy for six to eight months in order to avoid potential infection.

Zika virus, is a member of the family Flaviviridae, together with dengue and chikungunya viruses. The main transmission is via mosquito bites, mainly the Aedes Aegypti and A. Albopictus. Majority of patient infected with Zika virus are asymptomatic while others presented with mild rash, fever, muscle pain and conjunctivitis. All these symptoms last for about one week. Only a few cases need hospitalization while Gullain- Barrre syndrome has been associated with this infection.

Testing of Zika virus infection in symptomatic pregnant mother can done using immunoglobulin M and neutralizing antibody. When congenital infection is suspected, an amniocentesis can be used to look for Zika virus RT-PCR.

Currently, there is no specific antiviral treatment available for Zika virus disease. The current treatment is generally supportive, including hydration, analgesia and anti-pyrexia.

 Recommendation for pregnant mothers

The CDC recommends that all pregnant mothers should consider avoiding areas where Zika virus transmission is ongoing. For those who have to travel to these endemic areas, a strict adherence to prevention from mosquito bite must be followed. This includes wearing long sleeved shirts and long pants, using insect repellent and staying in screened-in or air-conditioned rooms.

The viremia period for Zika infection is about one week. This virus will have been removed from the body’s circulation after this short period. Any pregnancy after this interval is unlikely to be harmed by Zika virus.

PELVIC FLOOR INJURY – A PRICE TO PAY FOR VAGINAL BIRTH?

Pelvic floor (Levator ani) injury occurs in 3 of 10 vaginal deliveries and often results in pelvic floor dysfunction including pelvic organ prolapse and incontinence.

The pelvic floor muscles is consist of three main muscle groups: the puborectal, the pubococcygeal, and the iliococcygeal. The main function is to support the vagina and pelvic organs, and maintenance of urinary and fecal continence.

During vaginal childbirth, the opening of the genital hiatus distends substantially to allow the passage of the fetus. This stretches the pelvic floor muscle greater than 3 times their original length, thereby putting strain on the muscles and can result in damage.

In addition, during the second stage of labor as the fetal head descends, excess stretch and distention of the muscles result in stretch and distention of the nerve to the levator ani. Prolonged stretching of this motor nerve has the potential to permanently damage the nerve, leading to laxity or sagging of one or both sides of the Iliococcygeus muscle.

 The above two labor related mechanisms have the potential to cause significant injury to the pevic floor muscle attachments and nerve supply, leading to an increase risk of urinary and fecal incontinence and future development of pelvic organ prolapse (POP).

 The prevention for pelvic floor dysfunction may be reduced by pelvic floor education and exercises during and after pregnancy. In one study, women who received pelvic floor therapy from 20 weeks’ gestation were less likely to report urinary incontinence in late pregnancy, at 3 months and 6 months postpartum. It appears that routine pelvic floor education or referral to pelvic floor physical therapy during the intrapartum and postpartum period may be beneficial, especially in high-risk patients.

 

Reference

  1. Dietz HP. Pelvic Floor trauma in childbirth. Aust N Z J Obstet Gynaecol. 2013;53:220-230.
  2.  Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106:707–712.

RECURRENCE OF ENDOMETRIOSIS – HOW TO PREVENT IT

Endometriosis is a common, benign gynecological disorder and a leading cause of disability in women of reproductive age, responsible for dysmenorrhea, pelvic pain and subfertility.  It is a debilitating and costly disease. Surgery is the treatment of choice for its management since the efficacy of medical treatment alone is often inadequate or of limited efficacy.  Surgical excision of lesions (conservative surgery) has been shown to both improve pain and enhance fertility. This is preferred over radical surgery because most women with endometriosis are of reproductive age.

The recurrence rate

Recent reviews had estimated the recurrence rate of endometriosis to be 21.5% at 2 years and 40-50% at 5 years (Guo SW 2009), which is more frequent than previously believed.  It seems that the recurrence rate for pain or dysmenorrhea is higher than that for the clinical recurrence as defined by presence of ovarian endometrioma on pelvic ultrasound scan.  These recurrences, which lead to repeat surgeries can further reduce fertility, exacerbate pain and complications of operation, which in turn affects quality of life, and increases social costs.

How recurrences happen?

There are two main explanations leading to the recurrence of endometriosis, namely re-growth of residue lesion and de novo lesion formation.

Vignali et al. observed that during a repeat surgery, most endometriosis recurrence occurred at the same area.  Similar observation was found in cases of ovarian endometrioma, where majority (88.7%) of the recurrences was from the previously treated ovary (Guo SW 2009). Conservative surgery is sometimes insufficient to remove these lesions completely, allowing it to re-develop after operation.  The de novo endometriosis lesion occurs via the monthly retrograde menstrual blood flow into the abdominal cavity, allowing the endometrial tissue to implant.

Prevention of Recurrence

Pain symptoms

The pain symptoms of endometriosis include non-cyclical pelvic pain (chronic pelvic pain), painful menses and intercourse. The use of oral contraceptives (OC) for a period of six month or more is found to be effective in reducing endometriosis associated pain symptom recurrence.   The continuous OC regime has an advantage over the cyclical OCs, with lower recurrence and earlier benefits (Seracchioli 2010; Vlahos 2013).  Medication should be given for at least 18-24 months as the recurrence occur rapidly when medication is stopped.

 

Ovarian endometriosis (endometrioma)

Postoperative OC conveys a protective effect against recurrence.  Again, the continuous regime has an edge over the cyclical OC regime.  This benefit is conferred as long as the woman is on OC treatment but vanished rapidly upon discontinuation (Kaori K 2015).

Recommendations

All women with endometriosis, following a conservative surgery (for pain symptoms or endometrioma), should be on medication (continuous OC) as long as possible until she is ready to conceive (Dunselman GA 2014). This will effectively reduce endometriosis recurrence and need for repeat surgery, which carries its own complications.

References

  1. Dunselman GA et al., Hum Reprod 2014
  2. Guo SW. Hum Reprod Update 2009
  3. Kaori K et al., Fert Steril 2015
  4. Seracchioli R et al., Fert Steril 2010
  5. Vlahos N et al., Fert Steril 2013
  6. Vignali M et al., J Minimal Invasive Gynecol 2005

CERVICAL MUCUS MONITORING- A SIMPLE WAY TO ENHANCE PREGNANCY CHANCE

The fertile window period is defined as the 6-day period ending on the day of ovulation (Brosens 2006). Intercourse is mostly likely to result in pregnancy when it occurs within this period.  The peak fecundability was observed when intercourse occured within 2 days prior to ovulation (Wilcox 1995).  It is desirable to predict the fertile window period and ovulation, to optimize conception rate but can be challenging with the available methods.  Amongst the methods available, include calendar method, basal body temperature (BBT), urinary LH detection, cervical mucus monitor, urinary estrogen metabolites and transvaginal ultrasound scan for follicle tracking.

Cervical mucus monitoring (CMM) is a prospective and inexpensive method to detect fertile window.  It was found to be as good as or better than BBT or urinary LH monitoring to predict the day-specific probabilities of conception (Bigelow 2004).  The cervical mucus is observed at the vulvar for its appearance and sensation.  Type 1 and 2 are typically present at the beginning of menstrual cycle.  They are associated with a dry (type 1) or damp (type 2) sensations at the vulva.  Type 3 is typically thick, creamy and whitish or yellowish mucus with damp sensation.  The type 4 cervical mucus is transparent, stretchy or elastic (raw egg white) with wet or slippery sensation.  Intercourse at this period is associated with a high conception rate.

Hoeker et al., observed that CMM when applied consistently resulted in increased fecundability. It is more effective for timing of intercourse than the calendar method, as it allows identification of onset and duration of fertile window to be determined prospectively.  It reduces the overall time to pregnancy.

CMM is a free, self-directed method used to detect fertile window prospectively.  When applied consistently, it reduces the interval to conception and enhances fecundity.

Note:

Fecundity : Ability to conceive or to produce offspring

Reference:

  1. Bigelow JL et al., Human Reprod 2004
  2. Brosens I et al., Sex Reprod Menopause 2006
  3. Evans-Hoeker E et al., Fert Steril 2013
  4. Wilcox AJ BMJ 1995

PRENATAL VITAMINS: A REVIEW OF THE LITERATURE ON BENEFITS AND RISKS OF VARIOUS NUTRIENT SUPPLEMENTS

Most pregnant women take a daily prenatal vitamin, but advising the patient can be difficult because so many different formulations are available.
Prenatal vitamins generally contain a variety of vitamins and minerals and may be similar to multivitamins used outside of pregnancy, with some notable differences. Some of these vitamins have been studied directly (eg, folic acid), and their recommended allowance comes from sound evidence. But for most vitamins, data are limited, and for multivitamins (also referred to as multimicronutrient supplements), study results can be biased by confounding variables.

“INCREASED RISK OF NEURAL TUBE DEFECT” – WHAT DOES IT MEAN?

Is there something wrong with my baby?

The above blood result does not necessarily indicate that there is something wrong with your baby.  The screening test, which is designed to assess if there is a greater than expected chance (an increased risk) of the fetus having a neural tube defect.  A positive result serves as a guide that there is a small chance (1 in 30) the fetus might have a neural tube defect. It does not mean that your baby definitely has a neural tube defect.

At this stage, the only answer is that one should consider further testing.  In 9 out of every 10 pregnancies reported as being at increased risk of neural tube defect, continue to deliver a normal healthy baby without a neural tube defect

 What is a neural tube defect?

Neural tube defects (NDT) are rare but serious abnormalities, which occur in the early development of the fetus.  It is not known what causes them. The two most common types are anencephaly (not compatible with live) and spina bifida.

 Further assessment to confirm the diagnosis

A detailed ultrasound scan to assess the fetal head and spine enable the diagnosis of NTD.  This is a safe procedure with no residue effect on the fetus.  It examines the physical features (structures) of the fetus.  If the fetal head and spine look normal on ultrasound scan, the chances of a NTD is very low. The ultrasound scan can detect fetus with NTD most of the time (sensitivity over 90%).

 Must I have further testing?

The option of further testing (detail ultrasound scan) following the result of increases risk for NTD is by choice.  It is helpful to discuss with the doctor looking after the pregnancy before making an informed decision.