Folate Metabolism
In response to an inquiry about cleft lip/palate [Issue 3:27]
While the entire question of folic acid supplementation has been shown to have
an association with reduced rates of cleft lip and palate (CLP) in some studies,
there is nowhere near the kind of solid evidence to connect reduced CLP and folic
acid supplementation as there is between folic acid and neural tube defects. Also,
there have not been any large-scale, properly conducted studies on CLP prevention
using folic acid supplementation of the size and validity of those that have been
done with neural tube defects and folic acid. There is also some question about
whether cleft lip with cleft palate is the same thing, genetically, as cleft lip
alone. It is possible CL, but not CLP, can be prevented by folic acid supplementation
or perhaps vice versa. So at this point, in assessing the literature, it is impossible
to conclude that any lack of folic acid had anything to do with your son's condition
or that you could have done anything to prevent it.
That being said, the kind of embryonic processes that produce a properly sealed
neural tube are very similar to those that produce a properly sealed lip and palate.
Therefore, it is logical to assume that since folic acid supplementation prevents
50-70% of the neural tube defects, it should also prevent some forms of CLP. You
should be taking folic acid before conception and in early pregnancy in order to prevent neural tube defects anyway so if you take it in an effort to also prevent
CLP, you are doing the right thing, whether or not the reason is necessarily 100%
correct.
Now as to what dose of folic acid is correct and if you should be on a higher
dose: There are many enzymes involved in folic metabolism and well-known variants
of these enzymes work less efficiently. One good example is the enzyme methylenetetrahydrofolate
reductase, the subject of my PhD thesis in progress. In the province of Manitoba,
Canada, 7% of the population (as assessed by analysis of 1000 anonymous consecutive
newborn screening blood spots) is homozygous (has two genes for) the inefficient
version of the enzyme. Such people need higher doses of folic acid to make up
for the inefficiency and for such a person the amount of folic acid in the standard
prenatal vitamin may not be enough.
I do not recommend going out and getting genetic screening for this particular
variant because it is only one of several variants that can be present. What we
do in the course of our research, if we discover that a person has the inefficient
version, is check the outcome of the entire system working as a whole by three
simple blood tests. If these are normal, we are not concerned about the homozygote
being at risk for poor folic acid metabolism beyond recommending that they get
these tests repeated at regular intervals by their own doctors. I personally think,
without proof, that some women must have a more efficient version of another one
of the enzymes because they appear to compensate for being homozygotes for the
variant MTHFR without any extra supplements.
You can check red blood cell folate, which reflects how well you used and stored
folate over the last three months in your blood. A result in the high normal range
should reassure you that you are getting enough folic acid. If your result is
low normal, you are likely not getting enough because the published normal ranges
for this test are based on healthy men and women and do not take into account
the extra needs of pregnancy.
You can also check your levels of serum homocysteine, an amino acid that is
used up as folic acid is metabolised. A low normal serum homocysteine (less than
10umol/L value) means you are getting enough folic acid. A high normal range likely
means you need more folic acid for the same reason as in the case of low normal
RBC value. There is some evidence to suggest this is the most sensitive way to
test your folic acid metabolism. (Homocysteine has also been rather strongly implicated
in vascular disease during later life and less strongly implicated in placental
malfunctions leading to complications of pregnancy. That is part of my thesis
so I can hopefully give you a definitive answer on homocysteine and placental
functioning in about three years time.) There are two excellent review articles
on the topic of homocysteine and vascular disease at
www.heartcenteronline.com
and the American Heart Association's professional advisory statements at
www.americanheart.org/Scientific/statements/1999/019901.html
These papers explain all about testing homocysteine levels, vitamin cofactors, and who should or should not be evaluated.
A third test you can use checks your serum folate level, which reflects the
free folate in your blood waiting to be used. Because at least one genetic variant
causes very little folic acid to get into the blood, a normal result would reassure
you about your own personal absorption of the vitamin.
Even doing these tests can be questionable, however. If you are pregnant, your
levels will be altered by the hormones of pregnancy, making it difficult to interpret
the results without expert guidance. They are also expensive tests to undergo
simply for the purpose of easing your mind about your vitamin pill. Also, there
does not appear to be any harm to taking up to 5 mg per day of folate (with one
exception I will outline below). Our clinical geneticists now routinely recommend
5 mg/day preconceptionally for all female relatives of people with neural tube
defects in their past pregnancy history. Excess folic acid is excreted in the
urine and there are no reports in the literature that I have been able to find
that show any ill effects on the children of women taking this dosage. Women with
a previous baby with a neural tube defect and their female relatives have been
taking this higher dosage for many years and delivering many normal healthy babies.
If there was a danger, it should have become apparent by now. So if it will reassure
you to take the higher dose without first doing blood tests, it is most likely
a completely safe choice.
I found one report on much higher equivalent doses (the human equivalent of
23mg/day) in rat mothers causing rat pups to be born slightly below the median
birthweight, but these baby rats quickly overcame the slightly low birthweights
and reached normal rat pup values within a few weeks. This report does not really
apply to humans, in my opinion, because rat embryos have a different enzyme complement
for some of the enzymes involved in folic acid metabolism compared to humans.
(If someone can find anything else I would love to hear about it for my thesis.)
I did mention one potential bad effect of taking folic acid. If a person is
deficient in vitamin B12 either because of diet (as in vegans) or because of a
genetic inability to absorb and use B12, taking folic acid can potentially mask
the symptoms of B12 anemia until serious and permanent neurological damage is
done. If you had the genetic version of inability to absorb B12 you would likely
already know for other reasons. Even so, it does make sense to add a B12 supplement
to your folic acid supplement if there isn't any in your prenatal supplement,
especially if you are a vegan.
B6 is another vitamin involved in the whole system as an essential cofactor
so adding B6 or having a supplement vitamin with B6 in it is probably a good idea
as well. In my own work with women who had a baby with a neural tube defect and
women who had normal outcomes after an elevated maternal serum screen, we found
low dietary intake of B6 was very common. (See Bjorklund NK, Evans JA, Greenberg
CR, "Folic acid supplementation: more work is needed," 2000; CMAJ, 163:1129)
- Natalie K Bjorklund
PhD Student, University of Manitoba
Biochemistry and Medical Genetics
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Midwifery Today's Online Forum
The midwife asked me what I was doing at home to try to bring on my labor. I
told her nothing except taking evening primrose oil 3 times a day for the last
2 weeks (but that's mostly because my cervix tore last birth and I want to help
the scar). I told her I felt that the baby was ready to come when it was ready
to come. She said "ok".
I'm wondering in your opinions under the circumstances of the BPP and non stress
tests looming over me, would I be wise to start the nipple stimulation, evening
primrose oil as cervical suppository etc to try to "naturally" bring
on labor? My only negative thought is that if the baby truly isn't ready, how
much different are these measures than Pitocin?
- Dianne
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Question of the Week
Editor's Note: Because E-News readers held forth so generously about
herpes, we will dedicate next week's issue to that subject and include the answers
we've received to last week's question about the condition. If you have information
about herpes and pregnancy/birth you would like to share, please write to mtensubmit@midwiferytoday.com
Thank you!
Question of the Week Responses
Q: What is the cause of swollen legs postdelivery?
One would think, were they swollen beforehand? Could it be: preeclampsia, too
much intravenous fluids, inactivity? This problem seems to be more common in the
ladies who have cesareans, forceps or ventouse, but I have seen it in normal births.
A: I have been massaging postpartum mothers at NY Presbyterian Hospital
since 1990 and clearly there is significantly more swelling after cesarean birth.
Gentle, therapeutic massage is a wonderful remedy for relief.
- Rochelle Aruti
Riverdale NY
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~*~*~*~*
International Connections
I am an apprentice midwife and do a lot of traveling internationally. I am finding
it hard to have adequate resources on hand simply because of the bulk weight of
my books. Does anyone know where I might find the classic textbooks and references
on CD-Rom? All suggestions welcome. Email me: mjfoxy7@yahoo.com
~*~*~*~*
On fibroids: I work at the A.R.E. (Edgar Cayce Foundation). One treatment we
offer is castor oil packs. I have heard numerous accounts of women healing themselves
of fibroids using castor oil externally, along with herbs and diet.
www.edgarcayce.org
- Angelica
Rainblurb@hotmail.com
I am 15 years old and have been seriously thinking about going to college to
become a midwife after I graduate from high school. Although that is a couple
years away I would like to learn more about midwifery. Are there many websites
where you can actually learn more about the field of midwifery and what the jobs
are of midwives? Is there any advice that you would have for an aspiring midwife?
- Anon.
[Ed note: We will forward your comments to this young woman when you write to
mtensubmit@midwiferytoday.com]
====
More on government regulation of homebirth [Issue 3:27 & 28]:
I am thinking about Yvonne Cryns, Nan Koehler, Abby Odam, the granny midwives,
and every other traditional birth attendant in this country who has been crucified
by the AMA or another source. We live in a society that values regulations. Without
these government regulations every birth attendant practicing in the home setting
is potentially an outlaw in the AMA's eyes. Wonderful, loving, competent midwives
have been jailed, lost their homes, spent thousands of dollars defending themselves,
or were placed under house arrest while serving families competently. The AMA
has a track record of prosecuting midwives in almost every state!
In the Netherlands, midwives enjoy a place of honor alongside the physician
community. I envision homebirth as the norm for a percentage of our population
in the United States. I envision midwives enjoying the status they once held and
the freedom to practice as they once practiced prior to the AMA slander campaign
of the early 1900s and the current atmosphere of prosecuting midwives when one
bad outcome occurs. Bad outcomes unfortunately happen in the hospital quite frequently
and it is legally permissible. It is not permissible at all at home, yet who can
predict an amniotic fluid embolus?
I do not like regulations myself. I believe midwives deserve the status of independent
practitioner and should "refer" medically unstable pregnancies. A doctor
should not be dictating who can deliver at home and who cannot. Take the physician
out as middleman!
In one sense, homebirth can never really be regulated. However, it can be made
legal. It can be made available. When it is made legal it becomes even safer than
it is because it takes out the fear of transferring to hospital in the "illegal"
states. It becomes available to more women as "legality" opens the door
for more midwives; then women who want a midwife have access. Laurie [Issue 3:28],
you will find that you will strive for safety too when you become a midwife. One
can walk the wondrous road of birth and allow it to unfold unhampered, watch the
process and bless women and still be safe and be part of the "system"
legally. There can also be those midwives who choose to stay out of the "system".
I do not envision "rules and regulations" that contradict the heart
and science of homebirth. I see homebirth as being allowed to flourish in the
same manner as we currently practice. In Texas, we have been allowed to write
our own protocols (just like each hospital).
No midwife deserves prison any more than a physician or nurse does. I see the
midwife as part of the "birthing" team. I can choose to write my protocols
as best fits my midwifery style. I can choose to offer VBAC at home or Breech
if I am so qualified and have experience.
- Sandra Stine, CNM
More on Hyperemesis gravidarum:
Thank you so much for including hyperemesis gravidarum in your newsletter. I
am a birth teacher and labor assistant (and former apprentice) who has experienced
this nasty condition through three of my four pregnancies (the last three). I
know a study of one is hardly significant, but the psychological stigma that hung
over me during each "episode" was practically unbearable! The inferences
that I was not wanting the babies, that I had a bad relationship with my husband,
and worst of all that I was not even really experiencing the vomiting for any
other reason than I wanted it to happen were all incredible to me and simply added
to my stress. Pregnant women do not desire vomiting themselves to death! Even
though I know my own circumstances, I felt quite exonerated by reading your included
study!
What I would like to see addressed is treatment for the emotional/psychological
problems that stem from this condition. Frankly, the few students and clients
I have had who've experienced this and I lay in bed or on a couch for weeks and/or
months (when we weren't hanging over the toilet bowl) crying and wishing it would
end. By the time we had physically recovered, we were emotionally spent. Are there
herbal remedies that might work specifically on this (creams, aromatherapy)? Also,
has anyone ever looked at low pre-pregnancy weight or hormone levels as factors?
- Lori Stillwagon
As a past sufferer of severe and long-lasting morning sickness, I believe that
if any real statistical connection were to be found between psychological problems
such as "hysteria," "maternal overdependence," "pregnancy
rejection" and HG, it is probably more sensible to assume that the HG is
causing the psychological problems and not the other way around! Debilitating
HG brings out depression, dependence, and ambivalent feelings about pregnancy
in even the most sane of women. I would not be surprised if this psychological
connection theory is nothing more than a case of chicken-and-egg reasoning.
- Anon.
Did anyone see the latest study in the New England Journal of Medicine on the
safety of VBAC? I didn't get a chance to see the whole thing when it was reported
in the newspaper or write the reference down. It didn't look good. It seemed to
indicate that VBAC is too dangerous due to a high risk of uterine rupture. I also
got the feeling that induction was the contributing factor but that the researchers
weren't properly acknowledging that. Anyone have the reference or a conclusion
or analysis?
- Amy V. Haas, BCCE
Fairport, NY
I have had some very helpful responses to my question about the use of wild
yam and progesterone creams in pregnancy. Thank you to each of you who helped
me!
- Elaine
In response to the question regarding retained placenta piece [Issue 3:28}:
How about *not* trying to sue somebody? That response is contributing to the
ruin of healthcare in this country. And no, the placenta doesn't get weighed.
Every woman's placenta is different sized (even from one birth to the next) so
there would be no purpose to doing that. Practitioners check the placenta to see
that it looks "complete" (not as easy as it sounds), but even the most
careful of us will occasionally not see that a small piece is missing. Most women
will expel it within a couple of days. And no, your placenta did not "poison your blood."
- Anon.
EDITOR'S NOTE: Only letters sent to the E-News official email address, mtensubmit@midwiferytoday.com,
will be considered for inclusion. Letters sent to ANY OTHER email addresses will not be considered.
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