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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 19
| Issue : 2 | Page : 65-69 |
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Prevalence of vitamin D deficiency in pregnant population at the first antenatal visit
Asfia Siddiquie1, Amera Afeen1, Jalal Mohiuddin Mohammed2, Mohammed Jaan Basha2, C Shamsunder2
1 Department of Orthopedics and Traumatology, Deccan College of Medical Sciences, Hyderabad, Telangana, India
2 Department of Orthopedics, Deccan College of Medical Sciences, Hyderabad, Telangana, India
| Date of Submission | 23-Sep-2022 |
| Date of Decision | 28-Sep-2022 |
| Date of Acceptance | 01-Oct-2022 |
| Date of Web Publication | 09-Feb-2023 |
Correspondence Address:
Jalal Mohiuddin Mohammed
Department of Orthopedics, Deccan College of Medical Sciences, Hyderabad, Telangana
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/joasis.joasis_30_22
Background: Vitamin D deficiency is a growing health concern and pregnant population is considered to be high risk group. The proposed regimen for the Vitamin D supplementation during pregnancy is 400 IU,1000 IU daily for routine and high risk group (dark skin, obese, inadequate sunlight exposure) respectively. 20,000 units weekly for 6-8 weeks followed by maintenance dose in population with Vitamin D deficiency. The effects of Vitamin D deficiency include pre-eclampsia, increased LSCS incidence, impaired glucose tolerance for mother and low birth weight, hypocalcaemia, poor skeletal growth and immunity for the foetus. Although food may provide small amounts of both vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol), exposure to sunlight is by far the major source of vitamin D to the body, the vitamin being synthesized from cholesterol derivatives. Materials and Method: A cross sectional study over 50 subjects was done after ethical clearance in the department of orthopedics of our medical college. The blood samples along with demographic and clinical data in a questionnaire collected. Results: The results revealed 92% of the study subjects to have either deficiency or insufficiency of vitamin D. The various other parameters contributing directly or indirectly were evaluated. Conclusion and Recommendation: There is need for taking a multidisciplinary approach to patient care and referral to Orthopedics department at the earliest red flags signs of vitamin D deficiency. Creating awareness in the target population can be achieved with counselling and using print media with the pregnancy kits.
Keywords: Pregnancy, sunlight, Vitamin D
How to cite this article:
Siddiquie A, Afeen A, Mohammed JM, Basha MJ, Shamsunder C. Prevalence of vitamin D deficiency in pregnant population at the first antenatal visit. J Orthop Assoc South Indian States 2022;19:65-9 |
How to cite this URL:
Siddiquie A, Afeen A, Mohammed JM, Basha MJ, Shamsunder C. Prevalence of vitamin D deficiency in pregnant population at the first antenatal visit. J Orthop Assoc South Indian States [serial online] 2022 [cited 2023 Mar 27];19:65-9. Available from: https://www.joasis.org/text.asp?2022/19/2/65/369404 |
| Introduction | |  |
Vitamin D deficiency is a public health problem. The population of pregnant women is considered high-risk group since 20%–40% of the pregnant population has Vitamin D deficiency.[1]
The proposed regimen for the Vitamin D supplementation during pregnancy is:[2]
- 400 IU daily for the routine pregnant population
- 1000 IU daily with calcium for the high-risk group (dark skin, obese, and inadequate sunlight exposure)
- 20,000 units weekly for 6–8 weeks, followed by maintenance dose in population with Vitamin D deficiency.
There are many upcoming studies regarding the musculoskeletal and nonmusculoskeletal effects of Vitamin D deficiency over the mother and the fetus.[3] These effects include pre-eclampsia, increased LSCS incidence, impaired glucose tolerance for the mother and low birth weight, hypocalcemia, poor skeletal growth, and immunity for the fetus.[4]
The main source of Vitamin D in humans is sunlight exposure. Therefore, the main cause of its deficiency is the decrease of its endogenous production. The UVB rays, which are available from 10 a.m. to 2 p.m.,[5] are the prime source of vitamin D production. The former belief that early morning sunlight exposure is the best has been proven to be false. However, it is a big hindrance to the population to sit in sunlight in the afternoon. This contributes to the intensity of the problem. Half an hour of sunlight exposure delivers 50,000 IU of Vitamin D to people with white-complexioned skin.[6] The amount of exposure needed is a little higher in darker-skinned populations, as melanin absorbs a considerable amount of UV radiation.
The endocrine society has graded Vitamin D levels in the serum as follows:[7]
- <20 ng/ml: Deficiency
- 21-29 ng/ml: Insufficiency
- >30 ng/ml: Sufficiency
- >150 ng/ml: Toxicity.
Considering the above scenario, the present study is planned not only to recognize the problem but is also an attempt to solve it organically, by motivating patients to use sunlight as a natural source of Vitamin D.
| Review of literature | | |
Vitamin D deficiency is common in pregnant women (20%–40%) and in breastfed infants (10%–56%), despite the widespread use of prenatal vitamins, because these are inadequate to maintain normal Vitamin D levels (≥30 ng/mL). Newborn Vitamin D levels are largely dependent on maternal Vitamin D status. Consequently, infants of mothers with or at high risk of Vitamin D deficiency are also at risk of Vitamin D deficiency.[1],[8]
Although food may provide small amounts of both Vitamin D3 (cholecalciferol) and Vitamin D2 (ergocalciferol), exposure to sunlight is by far the major source of Vitamin D to the body, the vitamin being synthesized from cholesterol derivatives. Vitamin D is carried up to the liver and hydroxylated to 25(OH) D or calcidiol. The circulating 25(OH) D concentration is often used as an indicator of Vitamin D status, due to its high concentration and larger half-life compared to the active form; however, this inactive form of Vitamin D requires further hydroxylation into the kidneys to 1,25-dihydroxyvitamin D (1,25[(OH] 2D) or calcitriol, which is the active form of Vitamin D.[9]
The placenta is a key organ that mediates not only nutrient transfer, but it is also essential for immunotolerance adaptation during pregnancy. It is important to note here that 1, 25(OH) 2D does not practically cross the placenta tissue, while its inactive precursor 25(OH) D readily crosses the tissue to the fetal compartment.[4],[5] Besides the kidneys, the placenta can potentially activate 25(OH) D since it contains the enzyme 1-α-hydroxylase producing 1,25(OH) 2D.[4],[5] Moreover, the placenta has a paracrine control of vitamin D metabolism, and it may also inactivate 25(OH) D by 24-hydroxylation to 24,25(OH) 2D. This makes it possible for a local regulation of Vitamin D levels within the placental tissue that may modulate anti-inflammatory effects and affect pregnancy development and/or perinatal outcomes.[10]
The supplementation of Vitamin D needs to be more similar to physiological synthesis in the body, which is the administration of daily low doses rather than monthly or weekly loading doses. This need to be done under supervision as hypervitaminosis D and hypercalcemia have an adverse effect. In vivo studies demonstrated that acceptable supplementation is 4000 units/day, as more than that may cause teratogenic effects and subvalvular aortic stenosis.[11]
The IOM (Institute of Medicine) recommends an intake of 600 UL of Vitamin D to pregnant women with the goal to achieve in serum more than 20 ng/mL 25(OH) D. However, the US Endocrine Society suggests that at least 1500–2000 IU/of Vitamin D may be needed to maintain blood levels of 25(OH) D above 30 mg/dL. Nevertheless, both societies agree to consider the upper limit of intake as 4000 IU/day.[7]
The photoconversion of 7-DHC to previtamin D3 and its photoproducts is maximal between 11 a. m. to 2 p. m. throughout the year. Exposure of an adult in a bathing suit to an amount of sunlight that causes a slight pinkness to the skin (1 MED, known as a minimal erythemal dose) is equivalent to ingesting approximately 20,000 IU of vitamin D. Thus, exposure of arms (18% of the body surface) to sunlight between 11 a. m. and 2 p. m. for an amount of time to cause an MED would be equivalent to ingesting about 3600 IU vitamin D.[12]
Maternal Vitamin D deficiency in pregnancy is associated with:
- Low serum calcium in the newborn, with or without convulsions
- Rickets
- Defective tooth enamel.
- Lower birth weights and a higher risk of being small for gestational age
- Lower neonatal bone mineral accrual to be lower in the Vitamin D deficient groups, although bone mineral density differences were not statistically significant.
- Greater femoral metaphyseal cross-sectional area and a higher femoral splaying index at 19 and 34 weeks of pregnancy, suggesting that maternal Vitamin D deficiency can influence fetal femoral development as early as 19 weeks of pregnancy.[13]
Aims and objectives
Aims
- To evaluate the levels of Vitamin D and incidence of its deficiency at the first antenatal visit.
Objectives
- To correlate the Vitamin D levels with the order of pregnancy.
- To study the environmental factors affecting the Vitamin D levels.
- To find out the symptoms of Vitamin D deficiency in pregnancy.
| Materials and Methods | | |
The study was conducted after obtaining approval from the Institutional Review Board and informed written consent from the participants.
Place of study
The study was conducted in the Department of orthopedics of our medical college with support from the department of obstetrics.
Study duration
The duration of the study was 2 months.
Type of study
Cross-sectional study sample size: 50
Inclusion criteria
- All pregnant women at the first antenatal visit
- Any trimester any gravida.
Exclusion criteria
- Patients on medications which can affect Vitamin D levels (antiepileptics, oral contraceptives, etc.)
- Patients who received Vitamin D at a local clinic in the past 6 months.
Methodology
The demographic details and clinical data of the participants were recorded with the help of a questionnaire.
The participants were scrutinized, and 5–10 ml of venous blood was collected from those qualifying the inclusion criteria. These blood samples were then sent to the laboratory to be tested for the Vitamin D levels in the serum.
The method used by the laboratory is chemiluminescence immunoassay. Results were then analyzed.
| Results | | |
The total sample size was 50, ranging between ages 19 years and 32 years with a mean age of 23.56 years (standard deviation 2.61).
Considering the educational status of the population, 7/50 participants (13%) were illiterate, 30/50 participants (58%) had secondary school qualifications, 6/50 participants (11%) had studied till 12th, and 7/50 (13%) are graduates.
Occupational status of 48/50 participants (96%) is home making, and 2/50 participants (4%) are working.
Obstetric status of the patients was primigravida in 43% (22/50), gravida 2 in 39% (20/50), and more than gravida 2 in 15% (8/50).
Distance of the present gestation with previous pregnancy ranged between 7 months and 8 years with the mean duration of 27.16 months.
Gestational age at the first antenatal visit was <3 months (first trimester) in six participants (11%), 4–6 months (second trimester) in 34 participants (66%), and 7–9 months (third trimester) in 10 participants (19%).
Evaluation of the daily sunlight exposure revealed 16 participants (31%) had no sunlight exposure, 23 participants (45%) had <30 min, and 11 participants (21%) had more than 30 min of sunlight exposure.
Symptoms such as back pain, muscle spasms (tetany), and cramps were reported by 14 participants (27%), whereas 36 participants (73%) reported no specific symptoms.
Body mass index [Table 1] in 23 women (46%) was normal, 16 women (32%) were underweight, and 11 women (22%) were overweight.
Vitamin D levels [Table 2] in 4/50 women (8%) is normal and the remaining 46/50 (92%) had either deficiency or insufficiency.
The difference between the mean vitamin D levels [Table 3] in participants over 23 years (14.4) and those below 23 years (14.6) was not significant.
Based on obstetric status, the mean levels of vitamin D [Table 4] were slightly higher in primi participants (15.7) compared to gravida 2 and above (13.58); however, the difference was not significant.
Based on literacy status, the mean levels of vitamin D [Table 5] were nonsignificantly higher in illiterate participants (mean 20.43) than in literate participants (mean 13.55).
Based on sunlight exposure, the mean levels of Vitamin D [Table 6] are comparable in participants with no exposure to sunlight (mean Vitamin D 15.1) and some exposure to sunlight (mean Vitamin D 14.2)
The duration of exposure to sunlight [Table 7] did not reveal a significant difference in Vitamin D levels.
| Discussion | | |
- Median age at pregnancy in the Indian population is 20.3 years, which corresponds closely with that of our study sample (median age 23 years)[14]
- Gestational age at the first antenatal visit in our study group is predominantly the second trimester, as only 11% attended the antenatal clinic in the first trimester. However, it varies from 21% to 52% in the Indian population, depending on various factors[15]
- Sunlight exposure daily was not significant in the pregnant population as they require a higher amount of Vitamin D. This correlates with our study where the Vitamin D levels remained low even though there is a claim of significant sunlight exposure[16]
- Sharma et al.[17] found prevalence of Vitamin D deficiency in 93.5% in their study, which resembles our finding strongly as we have 92% of the population with vitamin D deficiency
- Addo[18] 4.4% women were underweight; whereas in our study, the population underweight is 32%. 47.4% fell in the normal weight bracket, which closely resembles with 46% normal weight participants of our study.
| Conclusion | | |
- In this digital era with restricted outdoor activity, sunlight exposure is deficient, especially in high-risk groups like the pregnant population
- The levels of Vitamin D are dangerously low, which can have a negative impact on fetomaternal life immediately and in the distant future
- There is no significant effect of literacy status, gestational age, age of mother, and gravid status on the maternal Vitamin D levels. Participants from varying sides of these parameters appear to have the risk of Vitamin D deficiency
- There is a constant delay by the pregnant population in seeking the first antenatal visit, as many of them visit in the late second trimester to establish care. This can negatively affect the fetomaternal care.
Recommendation
- Create awareness regarding the importance of Vitamin D in pregnancy and provide information on its sources by distributing flyers, pamphlets, and handouts at the first antenatal visit
- Easy understandable literature can be attached to every pregnancy kit, so that information can be reached to the high-risk group
- Women need to be started on prophylaxis of Vitamin D at the earliest
- Obstetricians need to be trained and educated regarding the red flag signs and refer patients to the orthopedics at the earliest, to cultivate multidisciplinary care and prevent adverse outcomes.
Ethical statement
The study was approved by the institutional Ethics Committee of Deccan college of Medical sciences (IRB no: 2020/31/005).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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