Table of contents
- Covid-19 & Vitamin D : dangers in pregnancy - Dr. Grimes - May 2021
During the Covid-19 pandemic there has been a disproportionately high incidence of disease and death among black African and Asian minority ethnic (BAME) communities. For example, a publication as early as April 10th 2020 showed that of 3883 patients with confirmed Covid-19, 14% were of Asian ethnicity and 12% were of black African ethnicity, much higher than their proportion in the UK population (Intensive Care National Audit and Research Centre).
A little-discussed aspect of the Covid-19 pandemic has been its particularly damaging effect in pregnancy.
There has been an increased incidence of Covid-19 in pregnant women, and especially in ethnic black and Asian pregnant women who are far more likely to be admitted to hospital on account of Covid-19.
Compared to pregnant ethnic white women, pregnant ethnic black African women in the UK have been eight times more likely to be admitted to hospital on account of Covid-19, and ethnic Asian women four times more likely.
Of 427 pregnant women in the UK admitted to hospital on account of Covid-19, more than half (55%) were from black African and Asian ethnic groups. There was no mention of vitamin D deficiency being a possible important factor, with only psychological and social pressures being identified. (British Journal of Midwifery, October 2020).
Black African and Asian ethnic (BAME) women, whether pregnant or not, have a had particularly high death rate from Covid-19 when on Intensive Care Units (Knight et al 2020).
Before the Covid-19 pandemic, it had been recognised in the UK that ethnic black African women have a five-fold incidence of death during pregnancy, and women of Asian ethnicity a two-fold incidence (Nair et al, 2014).
Pakistani women living in the UK have been more likely to have a premature baby or neonatal death than had they been living in Pakistan.
Pregnant BAME women have been disproportionately destined to die from Covid-19.
Overall, the Covid-19 death rate of people of black African ethnicity has been 3.5 times greater than for ethnic white UK people, for black Caribbean ethnicity 1.7 times, and for those of Pakistani descent was 2.7 times higher (Kirby 2020).
The obvious disadvantage of these BAME women has been attributed to racial discrimination, that they have been treated less favourably by the maternity and other parts of the health service. However had they been discriminated against, they would not have had a much higher admission rate to hospital but might have languished at home.
Of 240 pregnant women with Covid-19, 10% required admission to hospital, a higher proportion than expected that indicates a particular susceptibility to severe Covid-19 when pregnant.
It has been suggested that unfamiliarity with accessing health services because of language difficulties, discrimination and immigration status impede the treatment of ethnic minority women. Although there might be truth in this, the very high admission rate of ethnic minority pregnant women with Covid-19 to hospital and intensive care suggests that there has been no impediment to necessary care.
For example in a study of 240 pregnant women in Washington, USA, the hospital admission rate for COVID-19 was 3.5-fold higher (10%) than non-pregnant women.
In this study 3 out of 240 pregnant women with COVID-19 died, which equates to a maternal mortality rate of 1,250 out of 100,000 pregnancies. COVID-19 mortality rate was therefore 13.6-fold higher than the rate in similarly aged non-pregnant women.
The papers providing the data presented above show a frightening disadvantage experienced by BAME women in pregnancy. However, apart from suggested neglect by health professionals, no explanation is proposed. As with other health disadvantages of BAME people, no answers but continuing disadvantage, including early death.
Vitamin D was not mentioned in any of the papers that I have read. We know that vitamin D deficiency is widespread, but particular so in people with ethnically determined melanin-rich dark skin. It is very likely that vitamin D deficiency is the crucial and immediately reversible factor that is responsible for these tragically high death rates in pregnancy.
How common is vitamin D deficiency in pregnancy? Is there ethnic variation?
One thing is certain: the foetus takes whatever it needs from its mother, with possible disadvantage to its mother. We know that the foetus requires iron, and so iron deficiency anaemia is common in pregnant women, with iron supplement being standard care. We know that folic acid deficiency is common in pregnant women, as folic acid is necessary for a the high cell division rate in the foetus. Deficiency of folic acid becomes a great disadvantage to the foetus and to the mother. Folic acid is also a standard supplement in pregnancy.
Vitamin D is essential for the development of the foetus, and in particular for neurological maturation in the later stages of pregnancy. The foetus must obtain its vitamin D from its mother, who is therefore at risk of development of vitamin D deficiency during pregnancy, as with iron and folic acid.
If the mother is deficient of vitamin D at the onset of pregnancy, the deficiency will worsen when the foetus takes as much as it can. The vitamin D deficient expectant mother will have impaired immunity. As a specific result, during the past year she will be susceptible to critical or fatal Covid-19.
The result of vitamin D deficiency in the foetus will be an impairment of brain development in particular. The main result in the infant will be the development of the bone disease rickets, most obvious when walking commences. This has been seen in recent years in the children of ethnic black African and South Asian mothers in the UK and the USA.
Unfortunately I have not been able to locate any studies that show the effect of pregnancy on blood levels of vitamin D. However if low levels of vitamin D were identified during early pregnancy a supplement would be given, or at least I hope so. Medical ethics should determine that we will never know the effect of pregnancy on maternal blood levels of vitamin D.
In a study of 239 women in early pregnancy in Indonesia, 82% were deficient in vitamin D as judged by blood level less than 20ng/ml (50nmol/L). If we now consider from our experience of Covid-19 that a blood level of 40ng/m (100nmol/L) is ideal, then perhaps all were deficient.
Generally there has been very little research into the importance of vitamin D in pregnancy. What is theoretically necessary is recording the natural history by observation of the vitamin D status of pregnant women at first booking in the ante-natal clinic, and then following the pregnancy, birth, and the development of the baby. As mentioned this is unlikely to happen. We cannot observe the natural history of any condition when treatment is readily available and safe. This applies particularly to a hormone, vitamin, or essential nutrient deficiency. Furthermore, during the Covid-19 pandemic the value of careful observation has been constantly downplayed, despite it being the foundation of science since the time of Francis Bacon (c1620) and through the Age of Enlightenment.
Research into the human condition is constrained by ethical considerations and the Nuremberg Code. Research might therefore be inconclusive and doctors will need to use judgement on what is to be done in the best interests of their patients. Identification of a deficiency (for example iron or vitamin D) should be looked for as a routine when its probability is high, and correction should be undertaken as a medical duty.
This is an example of "Perfection must not become the enemy of the good", wisdom from my friend Linda Benskin. Medical practice must not stand still while awaiting the perfect research study: it must acknowledge and act on the results of good research.
As an aside, research into the importance of vitamin D and its deficiency during the Covid-19 pandemic has on some occasions led to blood being taken at the onset of illness but only afterwards analysing it for vitamin D, and so being able to associate blood level with outcome, the natural history. These studies could be regarded as cynical disregard of the Nuremberg Code: testing the blood at the time of it being taken and then correcting deficiency might have prevented many deaths. However the studies have the clear result of temporality, that vitamin D deficiency results in an increased risk of Covid-19 death.
The major complication of pregnancy is toxaemia, or pre-eclamptic toxaemia (PET), or pre-eclampsia (PE) which is the preferred term at present. It is characterised by high blood pressure, ankle swelling, kidney damage with protein in the urine, and if uncontrolled it leads to convulsions (eclampsia). It was first described by Hippocrates in the 5th century BCE, and term "eclampsia" comes from the Greek word for "lightning". There is a high risk of foetal death in pre-eclampsia, but these days medical control is usually successful, with emergency caesarian section delivery sometimes being necessary.
Pre-eclampsia is related to vitamin D deficiency and the association has been identified on many occasions. PE appears to be driven by inflammatory processes that originate in the placenta, and with Covid-19 pneumonia these inflammatory processes have come to be called a "cytokine storm". It is very damaging. It is known that vitamin D down-regulates these otherwise uncontrolled inflammatory processes by linking with VDR and down-regulating specific genes. What initiates the inflammatory processes originating within the placenta is unknown.
As with Covid-19 and vitamin D deficiency, the huge background of observational and basic scientific research has not led to an adequate exploration of the therapeutic potential of vitamin D in pre-eclampsia. The problems are a lack of the necessary medical knowledge within maternity care, and once again the ethical constraints on clinical research. But as we are dealing with serious deficiency of a known vitamin/hormone, correction of this is a clinical duty without the necessity of delays while awaiting further research.
If pregnant women were to be tested and found to be deficient of vitamin D in early pregnancy, could a random half of them give informed consent to be given a placebo rather than vitamin D? This marks the limitation of the randomised controlled trial. Is it ethical to withhold (with full informed consent) vitamin D at such an important time, knowing that the pregnant woman is deficient?
Also, if vitamin D is given it must be followed up to achieve a target blood level, and this should be 40ng/ml, 100nmol/L. It is of no help to give a sub-optimal dose of vitamin D and conclude that vitamin D is of no value. Giving two units of insulin will not help someone with diabetes, but this does not mean that insulin is of no value. Meeting pre-determined blood effects must be achieved.
A policy of correcting vitamin D deficiency in early pregnancy would be to help the foetus during gestation and following birth. But the initial benefit would be for the prevention of pre-eclampsia.
If the serious illness of pre-eclampsia were to occur and emergency treatment be required, then as with serious Covid-19 pneumonia, vitamin D treatment should be given in its natural activated form 25(OH)D, calcifediol. The reason for this is that, starting from deficiency, vitamin D itself will take about two weeks to reach a good blood level because it must be activated by the liver to 25(OH)D, and this is a slow process. However when 25(OH)D calcifediol itself is given a good level is achieved in two hours. This has been shown to be very effective in the treatment of serious Covid-19 pneumonia. Could it be of similar dramatic benefit in pre-eclampsia? Clinical observation of this treatment could show a dramatic benefit, far superior to any other treatment.
The Covid-19 pandemic has brought to attention the importance of vitamin D deficiency and the potential of its correction to help human health and reverse specific conditions associated with reduced immunity and uncontrolled inflammation. This must be taken very seriously and not simply ignored or discarded as has happened during the past year.
All items are automatically updated
- COVID-21 (COVID-19 with mutations) causing increased pregnancy problems in Brazil and India – May 2021
- COVID-19, dark skin, pregnancy - Dr. Grimes, etc. - May 2021
- Increased pregnancy problems with COVID-19 – meta-analysis and letter to editor – April 2021
- COVID-19 while pregnant increased many infant health problems by 1.5X – April 29, 2021
- COVID-19 while pregnant is not good (increased risk of dying by 22X) – April 2021
- Vaccine trials excluded pregnancies, but it is OK to be vaccinated while pregnant
- Vitamin D plus Inositol might help pregnancies during COVID-19 – April 2021
- COVID-19 resulted in 3.7X decrease in Irish Very Low Weight Births (Vitamin D) - June 2020
- Flu vaccinations during pregnancy should NOT be the standard of care until tests show it is OK – Nov 2019
- see also
- Overview Pregnancy and vitamin D
- Number of articles in both categories of Pregnancy and:
25 ; Depression 19 ; Diabetes 40 ; Obesity 12 ; Hypertension 35 ; Breathing 30 ; Omega-3 33 ; Vitamin D Receptor 20
- All items in category Infant/Child
- breastfed OR breastfeeding 1920 items as of Dec 2020
- Preeclampsia 825 items as of Jan 2018
- Pre-term 368 items (not in PDF) as of Nov 2020
- "polycystic ovary syndrome" OR PCOS 303 items as of Jan 2018
- Gestational Diabetes
- c-section OR "caesarean section" (various spellings) 937 items as of Aug 2020
- postpartum depression 208 items as of Aug 2018
- Search VitaminDiiki for MISCARRIAGE OR "Spontaneous abortion" 794 as of Feb 2020
- Search VitaminDWiki for "Assisted reproduction" 33 items as of Feb 2017
- Fertility and Sperm category listing has
110 items along with related searches
- (Stunting OR “low birth weight” OR LBW) 1180 items as of June 2020
- Healthy pregnancies need lots of vitamin D
- Ensure a healthy pregnancy and baby - take Vitamin D before conception
Reduces Evidence 0. Chance of not conceiving 3.4 times Observe 1. Miscarriage 2.5 times Observe 2. Pre-eclampsia 3.6 times RCT 3. Gestational Diabetes 3 times RCT 4. Good 2nd trimester sleep quality 3.5 times Observe 5. Premature birth 2 times RCT 6. C-section - unplanned 1.6 times Observe Stillbirth - OMEGA-3 4 times RCT - Omega-3 7. Depression AFTER pregnancy 1.4 times RCT 8. Small for Gestational Age 1.6 times meta-analysis 9. Infant height, weight, head size
within normal limits
RCT 10. Childhood Wheezing 1.3 times RCT 11. Additional child is Autistic 4 times Intervention 12.Young adult Multiple Sclerosis 1.9 times Observe 13. Preeclampsia in young adult 3.5 times RCT 14. Good motor skills @ age 3 1.4 times Observe 15. Childhood Mite allergy 5 times RCT 16. Childhood Respiratory Tract visits 2.5 times RCT
RCT = Randomized Controlled Trial
- As of June 18, the page had: 34 trials, 5 trial results, 17 meta-analyses and reviews, 59 observations, 34 recommendations, 53 associations, 88 speculations, 45 videos see related: Governments, HealthProblems, Hospitals, Dark Skins, 26 risk factors are ALL associated with low Vit D, Recent Virus pages Fight COVID-19 with 50K Vit D weekly Vaccine problems
- COVID-19 was the third-leading cause of death in the US, especially in those with dark skins - April 1, 2021
- Prefer 40 – 60 ng of Vitamin D to minimize COVID-19 – March 17, 2021
- 26 health factors increase the risk of COVID-19 – all are associated with low vitamin D
- Those with recent cancer diagnosis had 7X increased risk of COVID-19 (more if A-A )- Dec 2020
- Healthcare workers at higher risk of COVID-19 if low vitamin D, especially if dark skin – Dec 2020
- Shift workers 2X more likely to get COVID-19 (low Vitamin D) - Dec 2020
- COVID-19 was killing dark-skinned doctors, then they got a Vitamin D recommendation
- COVID-19 antibodies 2.6 X more likely if had symptoms and low vitamin D (UK hospital staff)– Oct 5 2020
- Vitamin D could knock out COVID-19 in 3 months – Dr. Matthews interview Oct 2020
- Rate of COVID-19 test positive is 40 pcnt lower if high vitamin D (192,000 people) - Holick Sept 2020
- COVID-19 increased: 3.5 if Ultra-Orthodox, 2.6X if dark skin (52,000 Israelis) - Sept, 2020
- COVID-19 is harder for those with dark skins - perhaps due to low vitamin D – April 24, 2020
- COVID-19 more frequent and deadly for those with dark skins (high risk of low vitamin D)
- Indications of increase COVID-19 problems if dark skin in the UK- April 3 2020
- Association of Maternal SARS-CoV-2 Infection in Pregnancy With Neonatal Outcomes April 29, 2021, FREE PDF, JAMA. 2021;325(20):2076-2086. doi:10.1001/jama.2021.5775
- 2.5X more likely for child to die after birth - no data on still births, misconceptions, long-term problems
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- All items in category Infant/Child