Presented by Nikki Warren, BHSc, N.D., M.H., M.NHAA., Chairperson of ARONAH Supplementing with the right nutrients according to each trimester
Overview • Why there is a need for a separate prenatal supplement for trimester one • Ways to reduce morning sickness • The benefits of supplementation for mum and baby • Brief discussion on methylation • Haemodilution • Pre-eclampsia • Gestational diabetes
Birth defects & infant deaths Between 1997-2010, the three leading • causes of infant death have remained unchanged – perinatal conditions, birth defects and symptoms, signs & abnormal findings (two thirds of these were due to SIDS). Birth defects accounted for 26% of all • infant deaths of which there are 5 in every 1000. Around 6.2% of babies are of low • birthweight. Babies born to younger and older mothers (aged less than 20 or 40 and over) were more likely to be of low birthweight – 8.6% and 7.6% respectively. Health risks associated with low birthweight include significant disabilities, type 2 diabetes, hypertension, metabolic and cardiovascular diseases and even obesity in later life. Ref: Australian Institute of Health and Welfare 2012. A picture of Australia’s children 2012. Cat. no. PHE 167. Canberra: AIHW
Preterm birth Reference: Li Z, Zeki R, Hilder L & Sullivan EA 2013. Australia’s • In 2011, 8.3% of babies were born mothers and babies 2011. Perinatal statistics series no. 28.Cat. no. preterm, a slight increase since PER 59.Canberra: AIHW National Perinatal Epidemiology and Statistics Unit 2004 when it was 8.2%. • Worldwide, preterm birth complicates approximately 5-10% of all births and is the major cause of perinatal mortality and long-term physical and neurological morbidity both in Western and developing countries. • Complications include acute respiratory, gastrointestinal, immunologic, central nervous system, hearing and vision problems, as well as longer-term motor, cognitive, visual, hearing, behavioural, social-emotional health and growth problems.
Preventative prenatal care Outcomes we wish to avoid in pregnancy include: Miscarriage • Hyperemesis gravidarum • Preterm birth • Low birth weight • Pre-eclampsia • Gestational diabetes • Birth defects • • In addition we aim to maximise a child’s potential: - Intellectually - Emotionally - Physically
Safety of CAM treatments during pregnancy • Even though herbal medicine and nutritional supplementation are considered safer than pharmaceuticals, we need to be wary of safety. • The body undergoes enormous stress during pregnancy and this affects the way the body metabolises food, medications and herbs. Motility of the digestive tract declines and this can lead to an increase in the absorption of nutrients and herbs. • However, correctly chosen CAM treatments which are deemed to be safe to use during pregnancy can greatly benefit the mother which in turn benefits the baby. If there is an absence of evidence then use risk versus benefit. • Remember - absence of evidence does not mean it is not safe or effective.
Morning sickness Up to 85% of women suffer from morning sickness which varies from mild nausea to severe nausea and vomiting several times a day (otherwise known as hyperemesis gravidarum). It usually starts around 6 weeks gestation and resolves by week 14-16 of pregnancy. Morning sickness is debilitating, affects a woman’s ability to work and as a result creates a significant public health issue that has a psychological, emotional and social impact on women and their families and an economic impact on society. Women need to be educated on what aggravates morning sickness and they need a solution that is not pharmaceutical. Currently women who see their doctor for morning sickness will often be prescribed Zofran (ondansetron) which may be harmful to the foetus.
Morning sickness – PUQE score In the last 12 hours, how many hours have you felt Total score is sum of replies to each of the three nauseated or sick to your stomach? questions. > 6 hrs (5 pts.) Nausea Score: 4-6 hrs (4 pts) 2-3 hrs (3 pts) Mild NVP = 6 ≤ 1 hr (2 pts) Moderate NVP = 7-12 – monitor closely Not at all (1 pt) Severe NVP = 13 – refer to doctor or midwife In the last 12 hours, how many times have you vomited? 7 or more (5 pts) 5-6 (4 pts) 3-4 (3 pts) 1-2 (2 pts) None (1 pt) In the last 12 hours, how many times have you had retching or dry heaves without bringing anything up? 7 or more (5 pts) 5-6 (4 pts) 3-4 (3 pts) 1-2 (2 pts) None (1 pt)
Morning sickness Factors that are avoidable: References: Iron and Zinc supplements can cause nausea and • vomiting. This is well documented in the BALLABIO, M., POSHYACHINDA, M. & EKINS, R.P. 1991. Pregnancy-induced literature, especially in the case of iron during changes in thyroid function: Role of Human chorionic gonadotropin as early pregnancy (Gill, 2009). putative regulator of maternal thyroid Journal of Clinical Endocrinology & Metabolism, 73 , 824-831. GILL, S. K., MALTEPE, C. & KOREN, G. 2009. The effectiveness of Hcg stimulates the thyroid. Avoid high doses of discontinuing iron-containing prenatal multivitamins on reducing the • severity of nausea and vomiting of pregnancy. Journal of obstetrics and iodine (Luetic, 2010, BALLABIO, 1991). gynaecology, 29 , 13-16. LUETIC, A. T. M., B. 2010. Is hyperthyroidism underestimated in pregnancy and misdiagnosed as hyperemesis gravidarum? Medical Hypotheses, 75 , High doses of vitamins B1, B2 and B3 can cause • 383-386. nausea in some women. NAMKIN, K., ZARDAST, M. & BASIRINEJAD, F. 2016. Saccharomyces Boulardii in Helicobacter Pylori Eradication in Children: A Randomized Trial From Iran. Iran J Pediatr, 26 , e3768. Hyperemesis gravidarum has been associated • SANDVEN, I. 2009. Helicobacter pylori infection and hyperemesis with helicobacter pylori in this systematic review gravidarum: a systematic review and meta-analysis of case–control studies. Acta obstetricia et gynecologica Scandinavica, 88 , 1190 -1200 and meta-analysis (Sandven, 2009) (Namkin et al., 2016). This needs to be diagnosed and treated prior to conception. Possible role of high dose choline • supplementation aggravating morning sickness. One of the reasons ginger works as an anti-emetic is that it is anticholinergic.
Morning sickness There are a few factors that can help ease References nausea and vomiting during pregnancy: BABAEI, A. H. F., M. H. 2014. A randomized comparison of 75mg of vitamin B6 has been shown in several studies vitamin B6 and dimenhydrinate in the treatment of nausea • published in peer-reviewed journal articles to reduce and vomiting in early pregnancy. Iranian Journal of Nursing the frequency and severity of nausea and vomiting in and Midwifery Research 19 , 199. pregnancy and is equivalent to ginger in efficacy*. In ENSIYEH, J. S., M-A. C. 2009. Comparing ginger and vitamin most studies, capsules were taken 2-3 times daily. B6 for the treatment of nausea and vomiting in pregnancy: a randomised controlled trial. Midwifery, 25 , 649-653. Stabilising blood sugar helps, therefore the nutrients HAJI SEID JAVADI, E., SALEHI, F. & MASHRABI, O. 2013. • chromium, biotin and alpha lipoic acid in particular Comparing the effectiveness of vitamin b6 and ginger in may help ease morning sickness. Other nutrients play treatment of pregnancy-induced nausea and vomiting. a role in carbohydrate metabolism including Obstetrics & Gynecology International, 2013. nicotinamide, pantothenic acid, riboflavin-5- SAHAKIAN, V., ROUSE, D., SIPES, S., ROSE, N. & NIEBYL, J. phosphate, thiamine hydrochloride, pyridoxal-5- 1992. Vitamin B6 is effective therapy for nausea and phosphate, hydroxocobalamin, magnesium, vomiting of pregnancy: A randomized, double-blind placebo- manganese and zinc. controlled study. International Journal of Gynecology and Obstetrics, 38 , 151. Ginger is a traditional remedy for morning sickness and SMITH, C., CROWTHER, C., WILLSON, K., HOTHAM, N. & • has been shown repeatedly in studies published in MCMILLIAN, V. 2004. A randomized controlled trial of ginger peer-reviewed studies to be effective. However the to treat nausea and vomiting in pregnancy. Obstetrics & longest study was only 3 weeks, therefore safety Gynecology, 103 , 639-645. hasn’t been established for the entire first trimester VUTYAVANICH, T., WONGTRA-NGAN, S. & RUANGSRI, R-A. although it should be noted that in the 3 week study, 1995. Pyridoxine for nausea and vomiting of pregnancy: A effectiveness increased over time. Most women will randomized, double-blind, placebo-controlled trial. American start taking ginger around 6 weeks and keep taking for Journal of Obstetrics and Gynecology, 173 , 881-884. at least 6-8 weeks. I find advising them to drink ginger tea and chew on crystallised ginger as needed is helpful.
Morning sickness – dietary guidelines Eat frequently – at least every 2 hours • Crystallised ginger when feeling nauseous • Ginger tea – grate 1 tsp ginger and steep in hot water • Carry some Quick Eze in handbag – neutralising the stomach acids can help reduce nausea • Snack on almonds and other nuts to stabilise blood sugar • Snack on apples, raisins, nuts and cheese – high in chromium • Eat protein last thing at night – yoghurt or nuts • Dry crackers or ginger biscuits on rising may help • If TSH is less than 1 tell her to drink lemon balm tea • Address constipation – x2 kiwifruit at night usually helps • Drink chamomile and peppermint tea – x1 bag of each in a cup •
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