MUSC Department of Ob-Gyn, Maternal-Fetal Medicine Division
This is described at Grassroots Health
This hospital protocol minimizes the chance that doctors will be sued - they are just following the protocol.
A rapidly evolving body of literature, including sentinel studies done by Carol Wagner and colleagues here at MUSC, has documented both the perinatal and child health benefits of achieving therapeutic 25-0H Vitamin D levels (> 40 ng/ml) during pregnancy. Simultaneously, we are aware that almost 80% of our obstetrical population and virtually 100% of our African-American obstetrical population have 25-0H Vitamin D levels that fall below this therapeutic threshold.
Studies by Wagner as well as others have demonstrated significant reductions in the rate of preterm birth among pregnant women who achieve 25-0H Vitamin D levels greater than 40 ng/ml via prenatal supplementation. Vitamin D deficiency and appropriate supplementation may both explain and help improve the high rates of premature birth in our community and region. Other potential perinatal benefits include the possibility of reducing the incidences of Gestational Diabetes, pre-eclampsia, depression and postpartum depression.
Perinatal supplementation and achievement of therapeutic maternal 25-0H Vitamin D levels has also been associated with improved neonatal and childhood immune function. This improved immune function has translated into reduced risks of upper respiratory infection, bronchitis, ear infections and pneumonia. A soon to be published prospective randomized trial will demonstrate a significant reduction in childhood asthma among the children of women who achieve therapeutic Vitamin D levels during pregnancy.
Figure 1. illustrates the potential disease incidence prevention associated with increasing the 25-0H Vitamin D level to > 40 ng/ml. The recommended range for 25-0H Vitamin D is between 40-60 ng/ml.
- A 25-0H Vitamin D level will be obtained routinely as part of the New OB prenatal blood work.
- If the 25-0H Vitamin D level is < 40 ng/ml you can begin supplementation with 4000-5000 IU of Vitamin D per day.
- More specific supplementation dosing can be achieved with the use of Figure 2. which provides a recommended daily dose of 25-0H Vitamin D based on the initial starting level and anticipating a goal of > 40 ng/ml.
- Using the chart in Figure 2. to get 90% of the patients from an initial level of 20 ng/ml (many are even lower) to a level of 45 ng/ml, the likely required daily dose will be 5000 IU / day.
- GrassrootsHealth through the Protect Our Children NOW! project has provided free Vitamin D (5000 IU capsules) for your patients that they can obtain by taking their prescription to the Rutledge Tower Pharmacy to have it filled.
- The 25-0H Vitamin D level should be rechecked along with the routine Glucola screen at 24-28 weeks gestation. Vitamin D dosing adjustments can be made based on this mid-trimester measurement.
- The 25-0H Vitamin D level should be checked a third time at 34-36 weeks gestation along with the third trimester CBC and / or STD blood work. A further dosage adjustment can be made at that time if required.
- The 25-0H Vitamin D level is covered by insurance as part of the prenatal panel. Follow up testing is also covered if "Vitamin D Deficiency" is added to the problem list if the Vitamin D level is < 40 ng/ml.
Vitamin D toxicity is an uncertain entity and rarely encountered. Most labs will identify a 25-0H Vitamin D level of > 100-120 ng/ml as being potentially toxic. Toxicity is typically defined by elevations of the serum or urinary calcium levels and potentially kidney stones. We have not encountered any Vitamin D levels that high either before or after supplementation. Nor have we encountered any side effects attributed to Vitamin D supplementation. This experience includes several high dose Vitamin D supplementation trials by Dr. Wagner. Published literature shows no toxicity under 200 ng/ml and 30,000 IU/day. This greatly exceeds any dosing regimen we would have.
It is important to perform follow up Vitamin D testing as there can be significant individual variation in the response to Vitamin D supplementation.
Obviously not all patients show up in the first trimester for their initial prenatal visit. Additionally, at MUSC we see a number of women referred at later gestational ages due to high risk conditions. Many of these women will have already had their prenatal blood work performed.
If these women are seen later in pregnancy, please obtain a 25-0H Vitamin D level if not already performed. Based on results, initiate aggressive supplementation as soon as possible. With daily supplementation maternal Vitamin D levels can normalize as quickly as 2 months. Vitamin D is believed to prevent preterm birth through its anti-inflammatory and immune modulating properties. Therefore, supplementation even in just the third trimester is still beneficial.
Another inevitable issue is when and how to initiate supplementation. Selecting a dose based on measured Vitamin D levels is ideal, but misses the opportunity to discuss and initiate treatment at that first prenatal visit. That missed opportunity becomes more problematic when it is remembered that 80% of all our patients and 100% of our African- American patients are Vitamin D deficient (<40 ng/ml).
What I do is inform my patients of the above reality and prescribe 2000 IU of 25-0H Vitamin D capsules. I recommend that my patient take 2 / day (4000 IU) until their Vitamin D level is available. If worse than anticipated I can increase my advisory to 3 / day and if better than anticipated I can decrease to 1/day. If the level is > 40 ng/ml, I advise that she take one supplement every other day. If the patient decides to get the free supplements from Rutledge Tower Pharmacy (5000 IU/capsule) I advise them to take 1/day until her Vitamin D level is available. At that point supplementation can be doubled if severely deficient or cut down to once every 2 or 3 days if levels are better than expected.
In a collaboration between MUSC and GrassrootsHealth we will use electronic medical records and perinatal outcome summary data to assess the uptake and impact of the Vitamin D testing and supplementation program on Obstetrical outcomes at MUSC.
As a greater number of obstetrical patients are tested for Vitamin D deficiency and appropriately supplemented to achieve levels > 40 ng/ml we expect to see measurable reductions in our institution's preterm delivery rate as well as potentially other perinatal measures.
(signed) Dr. Rodger Newman, Professor and Maas Endowed Chair of Reproductive Sciences
Download the Protocol PDF from VitaminDWiki
This is a great first protocol
- Get Vitamin D levels high as soon as possible (loading dose: 1 week, vs 8+ weeks)
With daily dosing an 8 week delay is too long
- Cofactors (Magnesium, Omega-3, etc.)
To balance the increased vitamin D
To improve health during and after pregnancy
- Other forms/types of vitamin D are needed if:
Dislike/unable to take capsules
Have a gut problem
Have a liver or kidney problem
Unlikely to take the supplement daily (poor compliance)
- Start with more vitamin D if person is likely to be deficient
Indoors a lot
Wear concealing clothing
One or more Vitamin D diseases in person or in family
which is a indication of poor vitamin D genes
- Season - if at high latitude
- Start earlier in pregnancy - before conception is great
- Encourage vitamin D after pregnancy- for both mom and infant
Healthy pregnancies need lots of vitamin D has the following summary
|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
|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
One pill every two weeks gives you all the vitamin D most adults need
Vitamin D is being used to prevent premature births – Baggerly interview – Dec 2015
Ensure a healthy pregnancy and infant with as little as $20 of Vitamin D
Near the end of pregnancy 50,000 IU vitamin D weekly was great – RCT April 2013
Many groups of pregnant women are at high risk of being vitamin D deficient – Jan 2013
Overview Vitamin D Dose-Response
Reasons for low response to vitamin D
Healthy in Seven Days- Success through vitamin D treatment – book 2014
Restocking vitamin D quickly gets you to a good level during pregnancy (from the book: Healthy in Seven Days)
The articles in Pregnancy AND Intervention are here:
- Massive improvement in vaginal microbiome during pregnancy with Vitamin D – March 2019
- Autism risk reduced 2X by prenatal vitamins (Vitamin D or Folic) – Feb 2019
- Fetal bones helped a bit by 1,000 IU of vitamin D – RCT Feb 2019
- Adding 1,000 IU vitamin D while pregnant did not help much (no surprise) – RCT Jan 2019
- Pregnancies helped a lot by Vitamin D (injection then 50,000 IU monthly) – RCT May 2018
- 430 genes changed when 3,800 IU Vitamin D added in late second trimester – RCT May 2018
- 300,000 IU of Vitamin D is not enough during pregnancy – RCT May 2018
- Preeclampsia risk reduced 7X by 4,000 IU of Vitamin D daily – RCT March 2018
- Risk of infant Asthma cut in half if mother supplemented Vitamin D to get more than 30 ng – RCT Oct 2017
- Gestational diabetes 30 percent less likely if consumed more than 400 IU of vitamin D daily – Oct 2017
- Monthly 120,000 IU Vitamin D plus daily Calcium was great during pregnancies – RCT Sept 2017
- Preterm birth rate reduced by vitamin D – 78 percent if non-white, 39 percent if white – July 2017
- 1,000 IU of Vitamin D while pregnant helped a little bit (4,000 IU helps a lot) – RCT Dec 2016
- Preeclampsia recurrence reduced 2 X by 50,000 IU of vitamin D every two weeks – RCT July 2017
- Only a select group of women will get a modest benefit from 800 IU of vitamin D – Jan 2017
- Reduction of infant asthma may require good vitamin D when lung development starts (4 weeks) – March 2017
- Gestational diabetes treated by Vitamin D plus Omega-3 – RCT Feb 2017
- 3,800 IU Vitamin D during pregnancy did not help much – RCT Jan 2017
- 50,000 IU of vitamin D for 8 weeks of pregnancy raised most above 30 nanograms - RCT Jan 2017
- Gestational Diabetes reduce 3 times by 5,000 IU of Vitamin D – RCT Jan 2016
- Preeclampsia risk reduced by higher levels of vitamin D (VDAART 4,400 IU) - RCT Nov 2016
- Gestational Diabetes treated with 50,000 IU every two weeks – RCT Sept 2016
- Perinatal depression decreased 40 percent with just a few weeks of 2,000 IU of vitamin D – RCT Aug 2016
- Pregnancy – adding 35,000 IU Vitamin D weekly was nice, but not enough – RCT April 2016
- Vitamin D once during pregnancy reduced infant health care costs (300 times ROI) – RCT Dec 2015
- Autism rate in siblings reduced 4X by vitamin D: 5,000 IU during pregnancy, 1,000 IU to infants – Feb 2016
- Preterm birth rate reduced 57 percent by Vitamin D – Nov 2015
- Pregnancy supplemented with 2,000 IU vitamin D got most infants to more than 12 nanograms – Aug 2015
- Preeclampsia reduced by Vitamin D (50,000 IU bi-weekly) and Calcium – Oct 2015
- Clinical trials for pregnancy with Vitamin D intervention – 51 as of Sept 2015
- No multiple sclerosis relapses during pregnancy if 50,000 IU of Vitamin D weekly – RCT April 2015
- Wheezing reduced 35 percent if vitamin D added during pregnancy – April 2015
- 4,000 IU raised vitamin D levels during pregnancy – July 2014
- Pregnant mothers in Quatar needed more than weekly 50,000 IU Vitamin D – Nov 2013
- Gestational diabetes – Vitamin D and Calcium provided huge benefits – RCT March 2015
- Pregnancy helped by single dose of 60,000 IU of Vitamin D – RCT March 2015
- Gestational diabetes reduced by just two 50,000 IU doses of vitamin D – RCT Nov 2014
- Improved births with 2,000 IU vitamin D during pregnancy in India - RCT Feb 2015
- Vitamin D intervention (amount not stated in abstract) helped pregnancy – RCT Feb 2015
- Infant much healthier if Gestational Diabetic mother got 2 doses of vitamin D – RCT Nov 2014
- 2000 IU vitamin D during pregnancy and 800 IU to infant resulted in less use of antibiotics – RCT April 2014
- Gestational Diabetes reduced with 50,000 IU of vitamin D every 3 weeks and daily Calcium – RCT June 2014
- Gestational Diabetes reduced 40 percent by 5,000 IU of vitamin D – RCT April 2014
- 5,000 IU Vitamin D was not enough to reduce preeclampsia but did help future infant – RCT April 2014
- Breast milk resulted in 20 ng of vitamin D for infant if mother had taken 5,000 IU daily – RCT Dec 2013
- Vitamin D intervention for 8 weeks of pregnancy: infants taller, heavier and bigger heads – RCT Oct 2013
- Prenatal Vitamin D (35,000 weekly, 3rd trimester) resulted in 1 cm taller infants at age 1 year – RCT Aug 2013
- Insulin resistance during pregnancy improved with 50,000 IU of vitamin D every 2 weeks – RCT April 2013
- Bones better after pregnancy with just 200 IU of vitamin D plus 600 Calcium – RCT July 2013
- Near the end of pregnancy 50,000 IU vitamin D weekly was great – RCT April 2013