U

Module 3.1 T3.1 – Supplements in Pregnancy (Quiz Debrief & Clinical Application)

Administrative / Logistical Context

  • Session framed around an interactive Kahoot® quiz in Module 3 → Topic 3.1 “Supplements in Pregnancy”.
  • Access path for online students:
    • Canvas → Module 3 → Topic 3.1 → below “Supplements in Pregnancy” PPT → Kahoot link.
  • Activity originally set as an “assignment” closing 26\,\text{Aug}; facilitator tries to switch to “live host” so class can play simultaneously.
  • Mixed delivery:
    • On-campus students already engaged; online cohort requested re-posting of URL.
    • Technical delays, asynchronous starts; agreement to finish individually then reconvene for de-brief.
  • Recording confirmed (“I’m recording this”). Plan: walk through every quiz item, clarify any ambiguous or multi-answer questions, correct errors, and embed clinical reasoning.

Over-Arching Principles on Prenatal Supplementation

  • “One-size-fits-all” does NOT apply.
    • Not every pregnant person automatically needs a prenatal multivitamin.
    • Key determinants: existing diet quality, past medical/obstetric history, current medications, cultural eating pattern, blood results.
  • Healthy diet remains foundational even when supplements are prescribed.
    • Supplements ≠ licence to eat poorly.
    • Micronutrient synergy: whole foods supply co-factors and fibre that tablets/gummies cannot replicate.
  • Risk of unnecessary megadoses:
    • Excess water-soluble vitamins are renally excreted → wasted money & pill burden.
    • Fat-soluble excess (e.g. vitamin A) can accumulate → teratogenic risk.
  • Initial antenatal conversation must cover:
    • Full dietary recall.
    • Over-the-counter products, herbal blends, functional foods.
    • Family history of neural-tube defects (NTDs), metabolic or renal disorders, malabsorption, haemoglobinopathies.

True/False Items & Explanations

  • Q1 “Everyone should take prenatal vitamins” → FALSE.
  • Q2 “You need not eat healthy if taking prenatals” → FALSE.
  • Q3 “You must start vitamins before pregnancy” → Context-dependent.
    • Official guidance: ideally commence ext{≥1 month} prior to conception (especially for folic acid & iodine).
    • Reality: some are already on a balanced diet or long-term multivitamin.

Formulation Considerations – Tablets vs Gummies

  • Gummies popular for swallow-avoidant clients but carry limitations:
    • Manufacturing: either surface-sprayed (risk of micronutrient loss) or fully incorporated (requires controlled temperature; risk of degradation/hardening).
    • Higher sugar load.
    • Less stable folic acid/potency variability.
  • Tablets/chewable tablets generally preferred for reliable dosing & stability.

Supplement-Specific Key Points

Folic Acid (Vitamin B9)

  • Standard pregnancy RDI: 800\,\mu g\,(0.8\,mg) daily.
  • High-dose 5\,mg indicated when ANY high-risk factor present:
    • Previous NTD or family history of NTD/anencephaly.
    • BMI ≥ 30\,kg\,m^{-2}.
    • Diabetes requiring insulin (type 1 or type 2).
    • Epilepsy treated with anticonvulsants.
    • Renal pathology or malabsorption disorders.
  • Stop at 12\,\text{weeks} gestation unless individualised plan states otherwise (little evidence of benefit beyond first trimester).

Iodine

  • Needed for foetal neurodevelopment & maternal thyroid homeostasis.
  • Routine 150\,\mu g daily recommended in NZ (can begin pre-conception and continue until cessation of breastfeeding).
  • Contra-indications / caution:
    • Pre-existing hypo- or hyper-thyroidism: prescribing decision should rest with GP/endocrinologist; midwife may collaborate but not initiate.
    • Kelp/seaweed supplements: unpredictable iodine content; risk of thyroid dysregulation.

Vitamin D (Cholecalciferol)

  • Essential for calcium absorption, bone mineralisation, immune modulation.
  • Standard daily supplement range: 400\text{–}800\,IU (10\text{–}20\,\mu g).
  • Moderate deficiency: 1000\text{–}2000\,IU (25\text{–}50\,\mu g) oral daily can be midwife-prescribed.
  • High-dose 50{,}000\,IU monthly oral capsules (12.5 mg) now re-classified as UNAPPROVED in NZ → midwives CANNOT prescribe.
  • Highest foetal demand in 3rd trimester → ensure adherence.
  • Populations at risk in NZ (warrant testing/empirical supplementation per BPAC 2025):
    • Living south of Nelson-Marlborough.
    • Dark skin pigmentation.
    • Cultural/religious clothing limiting sun exposure.
    • Winter months.
    • High BMI.
    • Renal/hepatic disease affecting activation.
  • New infant recommendation (BPAC 2025):
    • All babies receiving <500\,mL formula/day (partially or exclusively breast-fed) should get daily liquid colecalciferol drop from birth (or ≥4 weeks) until 12 months.

Iron

  • Purpose: prevent & treat iron-deficiency anaemia, support expanding maternal RBC mass & foetal growth.
  • Do NOT give empirically in thalassaemia major/minor; risk of iron overload & crisis.
    • Management in haemoglobinopathies usually via haematologist ± transfusion.

Calcium

  • Least commonly prescribed routine supplement.
    • Exceptions: women at risk of pre-eclampsia, significant dietary insufficiency, malabsorption, or familial rickets.
    • Requires concurrent vitamin D for optimal uptake.

Vitamin A

  • Teratogenic in excess.
    • Avoid high-dose retinoid supplements unless specifically medically indicated.
    • Dietary caution for frequent liver/pâté consumption.

Vitamin B12 (Methyl/ Hydroxocobalamin)

  • Midwives may prescribe in dietary deficiency (e.g.
    • Strict vegan diet).
  • Must NOT prescribe when deficiency is secondary to gastrointestinal pathology (e.g.
    • Crohn’s disease, pernicious anaemia) → GP/specialist domain.

Prescribing Scope & Regulatory Framework (NZ-specific)

  • Governed by Primary Maternity Services Notice + NZ Formulary + Midwifery Council scope.
  • Midwives may only prescribe once woman is formally registered (usually >4 weeks gestation).
    • Cannot issue pre-conception scripts.
  • 3-Month maximum supply rule:
    • Applies to iodine, iron, vitamin D.
    • Folic acid generally NOT scripted for a full three months because therapy ideally ends at 12\,\text{weeks}.
  • Unapproved medicines (e.g.
    • 50{,}000\,IU cholecalciferol) outside midwifery prescribing rights.
  • Collaborative practice expected for co-morbidities: thyroid disease, haemoglobinopathies, renal disease, malabsorption, epilepsy.
  • If GP instructs midwife to prescribe (e.g.
    • iodine in mild hypothyroidism), midwife shares accountability; document clearly.

Practical / Ethical Considerations

  • Individualised Care:
    • Avoid blanket supplementation; tailor to biochemical results, dietary intake, cultural context.
  • Cost & Access:
    • Some supplements subsidised when GP-prescribed; others are OTC & self-funded → discuss affordability.
  • Informed Decision-Making:
    • Explain benefits, possible harms, alternative food sources.
  • Safe Storage & Stability:
    • Counsel on heat/light degradation (especially gummies), expiry dates, child safety caps.

Integrated Clinical Scenarios Mentioned

  • Woman with pre-existing thyroid disorder → GP to manage iodine; midwife discusses existing tablets.
  • Client requesting kelp tablets → advise against due to variable high iodine content.
  • Pregnant person with high BMI & family hx of NTD → qualifies for 5\,mg folic acid.
  • Anaemic woman of SE Asian ancestry; RBC microcytosis on FBC → consider thalassaemia screen before iron.
  • Breast-fed infant (<500\,mL formula) in Southland winter → needs daily colecalciferol drop.

Connections to Earlier / Future Lectures

  • This session sets groundwork for forthcoming detailed lecture on “Iron Supplementation & Anaemias”.
  • Builds on prior nutrition lecture covering macronutrient requirements.
  • Future pharmacology block will revisit “Unapproved Medicines” framework & collaborative prescribing.

Numerical / Dosage Summary (LaTeX)

  • Standard folic acid: 800\,\mu g\;\text{daily}.
  • High-risk folic acid: 5\,mg\;\text{daily}.
  • Iodine: 150\,\mu g\;\text{daily}.
  • Vitamin D maintenance: 400\text{–}800\,IU (10\text{–}20\,\mu g) daily.
  • Vitamin D moderate deficiency: 1000\text{–}2000\,IU (25\text{–}50\,\mu g) daily.
  • Infant colecalciferol: 400\,IU drop daily up to 12\,\text{months}.
  • Iron therapeutic dose varies (discussed in future session).

Outstanding Queries / Action Points for Students

  • Review 2025 BPAC statement on vitamin D (linked in Course Resources).
  • Familiarise with NZ Formulary prescribing status for common pregnancy supplements.
  • Practise dietary history-taking, focusing on micronutrient sources.
  • Read Primary Maternity Services Notice regarding medication supply limits.