Mineral and Vitamin Deficiency in Pregnancy

Pregnancy and lactation most commonly unmask a deficiency in key vitamins and minerals. This is due to increased bodily demand during these times. In particular, vitamin B12, folate and copper deficiencies are often only detected once pregnant. As these three nutrients are all vital for proper red blood cell production, anaemia is often the first sign of deficiency.

There are a number of reasons why your intake of these nutrients may be inadequate. Dietary restrictions such as being vegetarian, vegan, or having a wheat free diet, or conditions that affect your nutrition intake such as anorexia nervosa or alcoholism will require you to take extra supplements during pregnancy. Improper absorption of these nutrients may also occur due to:

  • Use of antacids or pancreatic insufficiency
  • Previous surgery that removed any part of your gastrointestinal system
  • Bacterial overgrowth (or sprue) in your gut

Vitamin B12, folate and copper are available from a wide variety of nutritional sources.

Copper deficiency is a rarer cause for nutritional anaemia, despite this element being vital to production of new red blood cells, in part because only a small amount is required to maintain sufficiency in your body. Shellfish and nuts are the richest sources, followed by grains and legumes. Dietary insufficiency is seldom the cause of anaemia, as most diets exceed the recommended daily intake of 1.3mg, but we would consider this in patients with anaemia with unknown cause as part of a secondary screen.

Bariatric (gastric bypass) surgery with proximal bowel resection is a well-known cause of copper deficiency, as this procedure removes the primary site of copper absorption in your gut. As most people have a surfeit of dietary copper, this usually compensates for malabsorption. However given the additional nutritional demands of pregnancy in someone with already depleted copper stores, copper levels should be checked in patients with overt anaemia as their pregnancy progresses.

Correction of nutritional deficits generally results in a rapid improvement in symptoms. As treatment is readily available, well-tolerated, affordable and effective, the role of your doctor is vital in the timely detection of these deficiencies, done by screening those who are in any of these high-risk groups and/or investigating abnormal clinical or blood test findings.

Sometimes taking an extra supplement or a once-off iron infusion is all it takes to get you feeling back to normal. For more information, see this handy factsheet from Mothersafe: https://www.seslhd.health.nsw.gov.au/sites/default/files/groups/Royal_Hospital_for_Women/Mothersafe/documents/VitaminsmineralspandbupdateSept19.pdf


Keeping Current with COVID-19

Especially at this time of global turmoil, it’s understandable that pregnant women will feel a great sense of anxiety about their own health and that of their unborn or newborn baby. While it’s good to keep yourself informed with updated information from trusted sources, please be assured that the latest research indicates that the risk to you and your baby from Coronavirus is extremely small. Here are some statements from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) as of March 16th, 2020:

“[In contrast to greater risk from influenza infection during pregnancy] at this time, pregnant women do not appear to be more severely unwell if they develop COVID-19 infection than the general population. It is expected the large majority of pregnant women will experience only mild or moderate cold/flu like symptoms.”

“Furthermore, there is also no evidence that the virus can pass to your developing baby while you are pregnant (this is called vertical transmission). There is also no evidence that the virus will cause abnormalities in your baby.”

“Newborn babies and infants do not appear to be at increased risk of complications from the infection.”

As RANZCOG is monitoring the COVID-19 situation carefully both here and overseas, you might like to read their updates at: https://ranzcog.edu.au/statements-guidelines/covid-19-statement

We affirm that we are committed to maintaining a high-quality obstetric service in the setting of the unprecedented COVID-19 pandemic. So please do take these words to heart:

“Take the opportunity to rest, eat well and maintain your interests and hobbies, where possible. Your baby has the best protection it will ever have i.e. you, so caring for yourself, your emotional and physical health, is what is most important.”


Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a common endocrine disorder associated with insulin resistance and hyperandrogenism. PCOS affects 12-20% of Australian women of reproductive age, and is a leading cause of infertility. The condition also leads to an increased lifetime risk of gestational diabetes, type 2 diabetes and endometrial cancer.

How is PCOS diagnosed?

The first evidence-based international guideline on PCOS was published in June 2018, with more than 3000 international health professionals and patients involved in determining the topics needing to be addressed. This initiative represents the first time a full set of guidelines has been developed and published encompassing all aspects of the condition, including mental health aspects.

In short, a diagnosis of PCOS should meet any two of the following three criteria: visible ovarian cysts on ultrasound, unusually short or long menstrual cycles, and hyperandrogenism. Further, a PCOS specific tool, called the PCOSQ, has been developed and validated across ethnic groups with the condition, which includes 26 items that relate to a number of specific PCOS symptoms, such as emotions, hirsutism, weight, infertility and menstrual dysfunction.

How is PCOS treated?

According to the 2018 International Evidence-Based guideline for the Assessment and Management of PCOS, lifestyle management is the first-line therapy for ALL women diagnosed with PCOS, irrespective of insulin resistance, weight status or fertility concerns. 

“Lifestyle management” is essentially about weight loss and exercise, but it is important to follow research-based advice in both diet and physical activity. Avoiding restrictive or fad diets if you have PCOS is crucial. This includes the keto diet and diets that cut out dairy, soy, or gluten without medical reason. Dieticians recommend that women with PCOS learn how to optimise their glycaemic load across the day, that is, learn what and when to eat in order to manage blood glucose variation. Research also shows that increasing dietary fibre, particularly from eating legumes, may reduce free testosterone and manage cholesterol levels. More recently, it has been suggested that a “Mediterranean style” dietary approach, which increases omega-3 consumption, may improve insulin responses and your lipid profile. A doctor may also recommend certain supplements and a personalised strategy to target hormonal differences.

Regarding exercise, for modest weight loss and prevention of weight regain, a minimum of 250 minutes of moderate intensity or 150 minutes of vigorous intensity physical activity per week, or an equivalent combination of both, is recommended. Physical activity may include leisure time activity, transportation such as walking or cycling, occupational work, household chores, games, sports or planned exercise in the context of daily, family and community activities.

If you suspect that you have PCOS, ask your GP for a referral to a gynaecologist and a dietitian.

Sources:

“A GP Guide to Polycystic Ovary Syndrome,” October 2019, found at http://www.ausdoc.com.au


Sunscreen and Safety during Pregnancy

As we all know, sun safety is very important particularly in high UV countries like Australia where about 14 000 cases of melanoma are diagnosed annually. Further, it’s important to make sure you have adequate vitamin D levels generally from spending a short amount of time outside each day. Recent reports in the media have cautioned that some sunscreens may contain chemicals that are absorbed in small amounts into the bloodstream. However it is currently unknown if this absorption has any effect on a mother or her unborn child, and the studies thus far have only tested excessive rather than normal sunscreen usage.

If concerned, women in pregnancy may choose to use sunscreens that work with a physical UV block rather than with UV absorption chemicals. Chemical sunscreens are typically less thick and more transparent, while physical sunscreens are generally white and heavier, and will list the natural minerals zinc oxide and/or titanium dioxide in the ingredients.

Zinc oxide (ZnO) and titanium dioxide (TiO2) are inorganic metal oxides, which are small particles that act as a physical blocker, absorbing and dissipating both UVA and UVB radiation. Usually recommended for people with sensitive skin, these sunscreens have been found to be less likely to cause irritation than chemical sunscreens. These days improved technology means that the minerals can be used in sunscreen in nanoparticle form, appearing on the label as ‘micronised,’ which enables the sunscreen to be more transparent.

Often physical blockers are used alongside chemical filters in a synergistic way to create very high-SPF, non-irritating sunscreens in light, breathable formulations, so please check the label. As always, sunscreen should be used in combination with hat, sunglasses, and other protective clothing for full sun safety.

For more information, see the Mothersafe fact-sheet on skin care, which can be found at: https://www.seslhd.health.nsw.gov.au/royal-hospital-for-women/services-clinics/directory/mothersafe/factsheets


Colposcopy

Why has my doctor sent me for a colposcopy?
If you have had an abnormal cervical screening test (CST) or symptoms of abnormal bleeding or discharge your doctor may send you for a Colposcopy.
A colposcopy is a test that allows your Doctor to look at your cervix using magnification. Biopsies or removing small tissue at the time of the colposcopy for examination in a laboratory small samples may also be done at the time of the colposcopy.
The colposcope magnifies the appearance of the cervix.

Acetic acid or vinegar is placed on the cervix and vagina to stain the cells and to allow the Doctor to better see where the abnormal cells are located and the size of any abnormal areas.

When monitored and treated early, pre-cancerous areas usually do not develop into cervical cancer.

 

 

 

PREPARING FOR COLPOSCOPY — Before your colposcopy appointment, you should not put anything in the vagina (eg, creams).

Colposcopy can be done at any time during your menstrual cycle, but if you have heavy vaginal bleeding on the day of your appointment, call your healthcare provider to ask if you should reschedule.

If you take any medication to prevent blood clots (aspirin, warfarin, heparin, clopidogrel), notify your healthcare provider in advance. These medications can increase bleeding if you have a biopsy during the colposcopy.

If you know or think you could be pregnant, let your healthcare provider know. Colposcopy is safe during pregnancy, although healthcare providers usually do not perform biopsies of the cervix when you are pregnant.

AFTER COLPOSCOPY — If you have a biopsy of your cervix, you may have some vaginal bleeding after the colposcopy. If your provider used the liquid bandage solution, you may have brown or black vaginal discharge that looks like coffee grounds. This should resolve within a few days.

Most women are able to return to work or school immediately after having a colposcopy. Some women have mild pain or cramping, but this usually goes away within one to two hours, this can be helped with NSAID’s like Ibuprofen tablets.

Do not put anything in the vagina (creams, douches, tampons) and do not have sex for 48 hours after having a biopsy.

If you have a biopsy, ask your Doctorwhen your results will be available (usually within 7 to 14 days). In most cases, further testing and treatment will depend on the results of the biopsy.

 

 

 

 

 


Menopause

Natural menopause is defined as the permanent cessation of menstrual periods and is determined retrospectively after a woman has experienced amenorrhea for 12 months. It is important that any other physiological cause or pathology is excluded as a cause.

The average age of occurrence is 51 to 52 years in normal women, and reflects the complete, or near complete, ovarian follicular depletion (no more eggs), with resulting decline in oestrogen and the associated symptoms.

Peri-menopause or the menopausal transition begins on average 2-4 years before the final menstrual period. During this time also there are a number of physiologic changes that may affect a woman’s quality of life. Some of the symptoms include an irregular menstrual cycles, hormonal fluctuations, hot flashes, sleep disturbances, mood changes, and vaginal atrophy that can present as dryness or dyspareunia (painful intercourse).

A lot of research has been done into menopause and whilst some treatments for menopause are hormonal there are many non-hormonal treatments now available.