SUPERStudy: Folate Supplementation in Pregnancy

By usmlevideoss

SUPERStudy: Folate Supplementation in Pregnancy

Introduction: Folate (vitamin B9) is an essential nutrient during pregnancy, playing a crucial role in DNA synthesis, cell division, and the formation of the neural tube in the developing fetus. Folate supplementation is critical for preventing neural tube defects (NTDs) such as spina bifida and anencephaly.

Pathophysiology: During pregnancy, folate requirements increase 5- to 10-fold because of transfer of folate to the growing fetus, which draws down maternal folate stores. Folate (vitamin B9) is essential for DNA synthesis, repair, and cell division, processes critical for rapidly dividing cells in early fetal development. A deficiency in folate disrupts these processes, leading to incomplete neural tube closure. This results in structural abnormalities of the brain, spine, or spinal cord. Folate is particularly important in the first trimester, often before a pregnancy is confirmed. Without adequate maternal folate stores, the risk of NTDs increases significantly.

Types of Neural Tube Defects

1.Spina Bifida:

  • Incomplete closure of the spinal column.
  • Severity ranges from mild (occulta) to severe (myelomeningocele), where the spinal cord and meninges protrude through the opening.
  • Can lead to paralysis, incontinence, and developmental delays.

2.Anencephaly:

  • Failure of the cranial portion of the neural tube to close.
  • Results in absence of major portions of the brain and skull.
  • Incompatible with life, often leading to stillbirth or neonatal death.

3.Encephalocele:

  • Herniation of brain tissue and meninges through a skull defect.
  • Severity depends on the location and size of the defect.

Risk Factors for NTDs

1.Folate Deficiency:

  • Primary preventable cause of NTDs.
  • Inadequate intake or absorption of folate during the periconceptional period.

2.Genetic Factors:

  • Family history of NTDs increases risk.

3.Maternal Conditions:

  • Diabetes and obesity.

4.Medications:

  • Antiepileptic drugs (e.g., valproate) can interfere with folate metabolism.
  • Folic acid deficiency may arise in chronic exfoliative dermatitis, in which folate losses of 5–20 mcg/day may occur. Patients with psoriasis who are treated with methotrexate have an added reason for developing signs of folate deficiency. Pretreating such patients with folate may prevent these signs without impairing the therapeutic effect of methotrexate.

Recommendations for Folate Supplementation:

1.Preconception:

  • Women planning pregnancy are advised to take folic acid supplements at least one month before conception to ensure adequate folate levels during early fetal development.
  • Recommended dose: 400–800 mcg of folic acid daily.

2.During Pregnancy:

  • Supplementation should continue throughout pregnancy, especially during the first trimester when the neural tube closes.
  • Women at higher risk (e.g., previous pregnancy with NTD, certain genetic conditions, or taking anti-seizure medications) may require higher doses (4 mg/day). 

Dietary Sources of Folate:

In addition to supplements, pregnant women should consume folate-rich foods, including:

  • Leafy green vegetables (spinach, kale)
  • Legumes (lentils, beans)
  • Citrus fruits (oranges)
  • Fortified cereals and bread
  • Nuts and seeds

Benefits of Folate Supplementation:

1.Prevention of Neural Tube Defects:

  • Reduces the risk of spina bifida and anencephaly by up to 70%.

2.Support for Fetal Growth:

  • Necessary for proper cell growth and tissue development.

3.Reduced Risk of Other Complications:

  • May lower the risk of congenital heart defects, cleft lip/palate, and preeclampsia.

SUPERPoint: Folate supplementation before and during pregnancy is essential for preventing neural tube defects and supporting healthy fetal development, with a recommended dose of 400–800 mcg/day for most women and higher doses for high-risk cases.

SUPERFormula: Folate Supplementation in Pregnancy

It is essential for DNA synthesis and cell division + it prevents neural tube defects (spina bifida, anencephaly) + Recommended dose is 400–800 mcg/day starting one month before conception + Higher doses (4 mg/day) for high-risk pregnancies + Continue throughout pregnancy, especially in the first trimester + Found in leafy greens, legumes, citrus fruits, and fortified cereals + Reduces risks of congenital defects, preeclampsia, and anemia = Folate supplementation 

References: 

Williams Hematology, 10e

Kenneth Kaushansky, Josef T. Prchal, Linda J. Burns, Marshall A. Lichtman, Marcel Levi, David C. Linch

Williams Obstetrics, 26e

Gary Cunningham, Kenneth J. Leveno, Jodi S. Dashe, Barbara L. Hoffman, Catherine Y. Spong, Brian M. Casey