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Am I on right treatment during pregnancy?

Q: I am a 39 years old female in to my 26th week of pregnancy. This is my first pregnancy at the age of 39 years. My doctor has prescribed me to take these medicines - Livozen.z containing ferrous fumarate (152 mg), folic acid (750 mcg), and zinc sulphate monohydrate (61.8 mg). Is one tablet sufficient for a day? At what time of the day it should be taken? Shelcal has also been prescribed to be taken as 1 BD. I am taking one Shelcal (500 mg) tablet after breakfast and one after dinner. Can Livozen.z or any iron capsule be taken before lunch?

A:You have written that you are taking iron and calcium preparations and you are 26 weeks pregnant. I am not sure you have a medical reason for taking these ‘supplements’ or just taking it as a matter of ‘routine’. Actually diet supplements should really be called substitutes. While they are essential for those who are not able to eat proper healthy balanced diet, either because they cannot afford it, or because they have medical conditions like mal-absorption, or just what we increasingly see ‘food fads’. In case you do not have any such problem and have 3 square meals a day, i wonder why you need ‘supplements’ or ‘sustitutes’. In case you diet is inadequate, you need to improve your diet and not take more tablets as they will never substitute for proper nutrition, which is all about healthy balanced diet, and not about more tablets and injections. I can understand people prescribing Iron to all pregnant women in public clinics and govt hospitals where unfortunately 2/3rd of all women are iron deficient as they cannot afford proper balanced healthy diet. Checking each women in these clinics, with limited resources, for anemia and then finding the cause, systematically exclude all other causes of anemia, and identify the group which needs iron tablets would be logistically nearly impossible. That is why perhaps a national policy supported by the WHO of giving iron to all pregnant women is justifiable. But if you have a normal nutrition and having your first baby at the age of 39, i wonder why you would need it. Let me tell you the background of the policy of iron supplementation during pregnancy. Unfortunately, like all well meaning interventions designed to improve pregnancy outcomes in the last fifty years or so, has boomeranged and proven to be counterproductive. In the fifties it was noted that most pregnant women had less Hb than non-pregnant women in similar age and social class matched groups. This lead to widespread assumption that pregnancy causes anemia and Iron prevents or treats it. In the sixties WHO prescribed universal ‘supplementation’ of iron during pregnancy. In our country WHO still maintains this is essential. The only problem is that sometimes in the seventies, it was found that women who take iron throughout pregnancy actually have lighter babies than those who do not, by up to 300 G. Further studies showed that iron intake not only causes unpleasant symptoms like acidity, constipation etc., it possibly prevents absorption of many essential elements like trace metals and micro nutrients now considered essential for a healthy fetal growth, by blocking the absorption site which are overwhelmed by IRON tablets (similar block is not significantly seen if iron is given in diet as iron rich foods). There is also considerable debate on what should be the ideal Hb level, especially in mid pregnancy, for optimal fetal growth and for the health of the mother. Most authorities investigating this now believe it should be between 9.5 and 10.5 G%, a level which would be considered anemia 10 years ago. Any artificial increase in Hb levels at this stage causes problems in fetal growth. We now believe that dilution of blood which appears as lowered Hb levels in mid pregnancy because the body holds a lot of water, is essential as the thin blood is able to traverse thinnest of placental vessels and deliver the oxygen where it is really required for fetal growth. Alternately a higher Hb will make the Blood viscous and though we may be happy that we have ‘treated or prevented the anemia of pregnancy’, it may actually be counter-productive, Thick viscous blood will not go where it is most required, and this is now considered the most likely explanation for lower birth weight seen in the women who take Iron despite having normal level of Hb . This is in no way to suggest that anemia of pregnancy should not be treated. If a woman is anemic during pregnancy which should mean a Hb level of less than 9.5 G% in mid pregnancy, the cause of anemia should be sought. All women, especially those with low Hb levels, should have an HPLC a test to rule out thalassemia and Sickle cell disease and other similar disorders which cause anemia. And if the anemia is due to iron deficiency, proven by a low Serum Iron level and a high serum total IRON binding capacity (TIBC). This can also be suggested by looking at the peripheral blood smear which shows typical cellular pattern. Once iron deficiency is identified, these women should be given ORAL IRON . It is in these women alone we need to discuss the type of oral iron and the dose. In most market preparation have Folic acid as well as some anemia may be because of the folic acid deficiency and some are marketed with zinc and yet others with other ‘micro nutrients’. There is little to choose between one and the other . If indeed you need iron tablets the one which gives you least side effects is the one you should take. One tablet daily is more than what you need and you should take it after meals to reduce side effects. You should never take it simultaneously with calcium as it gets chelated and neither get absorbed. After which meal you take the iron tablet depends on your lifestyle and eating habits, as it should be taken with a substantial meal, breakfast or lunch. Generally people do not take it after dinner as it causes more side effects. For a woman like you, having your first child at 39 should rethink on taking iron. If your nutritional status is OK. I doubt if iron would do you any good. On the other hand if you are anemic you must find the cause and treat accordingly including iron if indeed you have iron deficiency. In case you are not anemic and you are being given iron ‘as a routine’ or to ‘prevent’ iron deficiency, or to ‘build stores’, other reasons often given to prescribe iron, i suggest you take more dietary iron rather than tablets. Iron is present in red meat and organ meat, very little in white meat and almost none in eggs and milk. Unfortunately there is very little iron in vegetarian diets. Spinach and other green vegetables are actually a poor source, contrary to popular belief. It has little iron and all of it in ferric form which is not absorbed. The vegetarian sources include whole grains and nuts (the iron is in the outer peels, the ‘chilka’, so if you remove it you lose it), fruits including pomegranate bananas and coconut water. The most important vegetable sources are Dates and figs. Figs have an added advantage of being an excellent remedy for constipation (common during pregnancy). I therefore suggest that you take a healthy balanced diet with adequate iron rather than tablets if your Hb right now is OK. Since it is not only useless it is possible harmful for a woman with normal iron to take iron. This is what the current guidelines of the royal college of UK and National institute of Clinical Excellence in the UK (NICE of the NHS) guidelines say. Similarly if you take enough fruits, vegetable and dairy products(food rich in calcium), you do not need calcium in a tablet form. Calcium tablets taken as ‘supplements’ even when you have no deficiency it itself not harmful, certainly not proven to be harmful so far, though there are suggestions that it may, in our weather, lead to a higher risk of urinary problems especially if the water intake is inadequate. Some recent studies suggest that calcium supplementation reduces your chance of getting high blood pressure later in pregnancy. You are more prone to getting hypertension in later pregnancy, as this is your first pregnancy and you are 39 years old. This itself may be a justification for taking calcium during pregnancy for you. Calcium supplementation in your case therefore may have some merit, and it is relatively harmless. The only problem here is seashell source calcium that you are taking(SHELCAL). Calcium carbonate is best absorbed with meals, so you can take it after any meal. Any preparation of calcium carbonate is fine, and i wonder why it needs to be from sea-shells. This is a result of another passing fad in medicine which went wrong. In 60s and 70s seashell source calcium was touted by the drug companies to be better since it was ‘natural’. In the eighties unacceptable levels of impurities like aluminium and many more heavy metals were detected in seashell source calcium in the market, with some damaging reports in scientific journals and lay press in the USA and elsewhere. Consequently it fell into disrepute in 1990s in the US and inevitably found a new market in India. As we know many a drug which has outlived its marketability in the west is dumped in India. It is very aggressively marketed here now, is a lot more expensive and touted to be ‘better’ than other calcium carbonates. This however is not true. The current FDA (Food and Drug administration of the USA) website states that it has no benefit to justify extra cost, its use and may have impurities harmful to human beings. Of course the drug companies claim that all impurities are removed, i would be very sceptical in prescribing it especially during pregnancy where relatively small amounts of impurities may affect the growing fetus. I suggest you take a simple preparation of calcium carbonate if indeed you do take calcium tablets, and not the seashell source. all calcium in the market are sold with some vitamin D3, a vitamin now considered more important during pregnancy than calcium. you need only 10 microgram everyday and most tablets have much more. so any preparation which gives ordinary calcium carbonate with 10 mcg of vitamin D 3 is ok (there are more than 300 such preparations in the market ) I have given a long answer of what you may consider a simple query, but i thought i give scientific reason for each line i wrote, and also what the world authorities on the subject like NICE AND FDA prescribe in their guidelines and their own website. I would like to clarify that all this is not my ‘personal opinion’ but the current consensus opinion. Needless to say diet supplements are not a substitute for a healthy balanced diet which you must take if you want to ensure proper fetal growth and remain healthy yourself.

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