Yeditepe University Kozyatağı Hospital Gynecology and Obstetrics Specialist explained the use of vitamin D in pregnant women.

• Why Did Vitamin D Gain So Much Importance with Covid-19?

Apart from its known functions in calcium metabolism, vitamin D has immunomodulatory, anti-inflammatory, and endocrine functions. Vitamin D deficiency is a serious health problem. Vitamin D supplementation programs do not seem to be sufficient. While it is estimated that approximately one billion people in the world have vitamin D deficiency, it is known that this deficiency, which is seen at a rate of 60-70% in Turkey, seriously affects health. Vitamin D supplementation has been shown to have protective effects against respiratory tract infections. For this reason, we would like the vitamin D level to be above 30 ng/ml during the pandemic period. Vitamin D supplementation does not prevent us from getting sick, but it makes us stronger while fighting the disease. We can assume that our vitamin D levels have decreased even more as we spend more time at home and are exposed to less sunlight during the pandemic period.

• Is There Vitamin D in Foods?

The most important source of vitamin D is UV rays. It is a cholesterol-derived steroid hormone. 95% of it is synthesized in the skin. Its dietary forms are D2 and D3. D2: herbal, ergocalciferol, D3: animal, cholecalciferol. D3 is 3 times more potent than D2. D2 is found in moss, and mushrooms, and D3 is found in fish, milk, eggs, and liver. In terms of fish, the most vitamin D is found in salmon and herring. Regular consumption of milk and dairy products and eggs is necessary. In addition, care should be taken to consume fish at least 2 times a week.

• Is Vitamin D Taken in Summer and Winter?

In case of sufficient sunbathing in the summer, it is not necessary to take it. Sunbathing should be done between 10:00 and 3:00 p.m. White-skinned people should sunbathe for 15 minutes, and dark-skinned and obese people should sunbathe for 30 minutes. There should be no cream on the skin. The most beautiful and natural form of sunbathing is done on the sea sand. Those who do this tell that they do not get sick in the winter that year. If there is no possibility of sunbathing or if the season is winter, 2 types of dose adjustments are made:

Skin color (the risk increases as the color gets darker), obesity, low-income groups, northern regions, a high altitude cold areas, winter and spring months, and working in indoor spaces are the factors effective in the high-risk group for Vitamin D deficiency. The reasons that decrease the synthesis of vitamin D are:

• Air pollution (it may reduce UV exposure)
• Avoiding sun exposure due to fear of skin cancer, using sunscreens with high protection factors.
• Working indoors
• Closed clothing style
• Increase in indoor activities such as TV, PC
• Restriction in outdoor activities due to pregnancy

The best vitamin D synthesis is achieved at noon and without sunscreen. 10 000-25 000 IU vit D is synthesized by sunbathing for 30 minutes at noon. It can go up to 50 000 IU in people with white skin.

• What Causes Vitamin D Deficiency in Pregnant Women?

Its main function is to provide calcium balance. In addition, it has many functions in the immune system, including cell proliferation, cellular differentiation, and endocrine. In pregnancy, it provides immune tolerance and prevents the expulsion of the fetus, and also shows antimicrobial activity. Bacterial vaginosis is commonly observed in vitamin D deficiency. With the effect of vitamin D during pregnancy, calcium absorption from the mother's intestine increases by 35%. A baby born to a mother with a low vitamin D level is prone to rickets. It has been shown in various studies that its deficiency causes preterm birth and low birth weight. it has been observed that, if there is a deficiency, the babies born have learning and memory problems in the future. Vit D is effective in regulating insulin secretion and reducing insulin resistance by stimulating pancreatic β cells. Vit D may play a role in the inflammation process in metabolic syndrome and DM with its anti-inflammatory activity. There is a significant relationship between vitamin D deficiency (<50 nmol/l) and gestational diabetes. Postpartum depression is more commonly observed in pregnant women with deficiency.

• What Conditions Does an Excess of Vitamin D Cause in Pregnant Women?

Vitamin D toxicity is extremely rare. No side effects were observed in non-pregnant volunteers at a dose of 10 000 IU/day. It is very difficult to reach toxic doses at daily therapeutic doses. It is reached in very high intakes. The upper limit of vitamin D in the blood is 120ng/ml. Hypercalcemia is a toxic effect, the blood level must exceed 150ng/ml for it to develop. With these given doses, the blood level is usually around 40-70 ng/ml.

• What are the Mistakes in Vitamin D Use in Pregnant Women?

During pregnancy, vitamin D supplementation should be started from the 12th week and, if necessary, continued throughout the entire pregnancy. In general, it is necessary to start after the first 3 months. It should not be taken on an empty stomach. It is preferably taken in the evening after eating greens and yogurt for dinner. After eating greens and yogurt, vitamin D is dripped onto bread and eaten. It can also be dripped directly on the tongue. Since it is oily, if it is dropped into the water or milk in the glass, it sticks to the rim of the glass and is not taken enough. It remains in the glass or mug and is taken incompletely.

There are so many vitamin D options on the market. How should choices be made? Can you list the criteria in items?

• Fat-soluble vitamins have toxicity. For this reason, loading doses (ampoules) are generally not recommended in pregnant women.
• The best ones are in the form of drops or sprays.
• If the drops or sprays are taken, the equivalent amount of vitamin D in each puff should be checked and it should be taken at the dose recommended by the physician.
• In addition, vitamin D combined with vitamin K2, which increases the positive effect on bone, can be preferred more.

What is the Appropriate Range for Pregnant Women?

The vitamin D support program for pregnant women was started by the Ministry of Health in May 2011. Vitamin D supplementation is recommended for mothers from the 12th week for a total of 12 months, six months during pregnancy, and six months after birth.

The dose of vitamin D to be administered to mothers in the prenatal and postnatal period should be 1200 IU (9 drops) to be taken as a single daily dose. Vitamin D deficiency can be detected by measuring blood values. Values below 30 ng/ml are considered insufficiency and values below 10 ng/ml are considered a deficiency. Vitamin D supplementation to be administered to the pregnant should start from the 12th week and, if necessary, continue throughout the entire pregnancy. The supplement to be administered should be 1200 iu daily (9 drops). 

• Empirical Treatment (in Children and Adults)

Blood level measurement and follow-up are not performed. Because the dosage is kept low. It is taken at the level of 1000 units per day (8 drops of vitamin D) in children and 2000 units (15 drops) in adults. Drops can be taken all at once or by division. It is preferably taken in the evening after eating greens and yogurt for dinner. Before starting this treatment, half ampoule of vitamin D in children and 1 ampoule of vitamin D in adults is consumed after eating greens and yogurt in the evening by dripping onto bread to fill the stores.

• Controlled Treatment of Vitamin D Level in Adults

First, the level of vitamin D is checked, if it is low, first the stores are filled, then daily treatment is started.

• If the blood level is below 20 ng/ml, 1 ampoule of vitamin D is broken, dripped onto bread, and eaten after eating greens and yogurt on the 1st, 15th, and 30th days. The stores are filled with a total of 3 ampoules. Then the daily treatment is started.
• If the blood level is between 20-30 ng/ml, 1 ampoule of vitamin D is broken, dripped onto bread, and eaten after eating greens and yogurt on the 1st and 15th days. The stores are filled with a total of 2 ampoules. Then the daily treatment is started.
• If the blood level is below 30-40 ng/ml, 1 ampoule of vitamin D is broken, dripped onto bread, and eaten after eating greens and yogurt. The stores are filled with 1 ampoule. Then the daily treatment is started.

Daily Treatment (Maintenance Treatment)

Some sources recommend taking vitamin D between 2000 units and 5000 units in an adult per day. The immune system uses vitamin D more depending on age, weight, skin color, and chronic disease (diabetes, cardiovascular disease, rheumatic, autoimmune, infection, cancer, etc.). So, the dosage varies between individuals. In addition, vitamin D receptor sensitivity differs between individuals. Therefore, vitamin D and blood calcium levels should be checked from time to time. The daily dose can be taken every day in drops or as a depot.

a- It is taken in the form of daily drops, with 8 drops per 1000 units/day. If this is too much and tiring, 1 ampoule of vitamin D is broken and added into a 1 vit D drop bottle, then it becomes fortified and 1 drop contains 1000 units.

b- The best form of maintenance treatment is daily drops. Thus, you feel more cheerful and stronger. But if you find it difficult, instead of daily drops, you can break the vitamin D ampoule, which is the depot method of maintenance treatment, and take it every 3 months. The ampoule or drop of vitamin D mentioned on this page is 25 HO D3 and is not an active vitamin. It is used in the body by activating it as needed by the tissues, especially the kidney. It is again 25 HO D3 when measured in blood.

How Should Pregnant Women Take It, and At What Times, with Meals or Between Meals?

Vitamin D deficiency can be detected by measuring blood levels. Values below 30 ng/ml are considered insufficiency and values below 10 ng/ml are considered a deficiency. Vitamin D supplementation to be administered to the pregnant should start from the 12th week and, if necessary, continue throughout the entire pregnancy. The supplement to be administered should be 1200 iu daily (9 drops). It is preferably taken after eating greens and yogurt at dinner. After eating greens and yogurt, vitamin D is dripped onto bread and eaten. Since it is oily, if it is dripped into a glass of water or milk, it sticks to the rim of the glass and is not taken enough. It stays in the cup or mug.

Connection Between Sunscreens and Vitamin D

• It prevents the entry of UVB into the skin, while it does not prevent the entry of UVA.
• Substances such as Paraben, Retinyl palmitate, Benzophenol, and Oxitrilene in sunscreens are associated with cancer.
• There is only a 3% difference in protection between SPF 20 and SPF 50 sunscreens. But there are more chemicals in SPF 50 sunscreen.
• Mineral sunscreens reflect all the rays of the sun like a mirror.
• After Vitamin D is synthesized on the surface of the skin, it resurfaces and is reabsorbed by the secretions of the sebaceous glands.
• Taking a shower by scrubbing with soap and shampoo immediately after sunbathing causes the loss of synthesized vitamin D.