ASDs were diagnosed in 0.32% of the children. Questionnaires reported maternal folic acid supplementation varied from 33% using it before conception, 71% during weeks 9-12 of pregnancy and 46% during weeks 13 to 16. The most severe form of ASD, autistic disorder, was present in 0.10% of children who mothers used folic acid supplements from 4 weeks pre-pregnancy to week 8 of the pregnancy and in 0.21% of children whose mothers did not take folic acid. In the analysis, neither folic acid supplementation during week 22 nor periconceptional fish oil supplementation affected risk for autistic disorder and folic acid use was not significantly associated with Asperger syndrome or other autism spectrum disorders.

Commentary: Sadly, the incidence of autism spectrum disorders is rising and we have only little understanding of why, and how to prevent it. This observational study supports the notion that the benefits of folic acid before and during pregnancy may be helpful in prevention beyond neural tube defects. In women who took the folic acid for one month before and 8 weeks into the pregnancy, they gave birth to half as many children with ASD as those women who did not take any. Folic acid later in pregnancy or fish oil before and during pregnancy, appeared to have no impact for this issue. Given the incredible inexpensive costs of folic acid supplementation, this continues to be one of the most important periconception and pregnancy vitamin for women to take. This nutrient should be in all prenatal vitamins.

Currently, the average intake of folic acid from the diet of women of childbearing age is about 170mcg/day. A diet without folic acid fortified grains is typically 140 mcg/day. Clearly, too few women are achieving adequate serum folate levels through diet alone and do require supplementation. The RDA for folate in non-pregnant women is 400 mcg per day. The RDA for folate in pregnancy is 600 mcg per day although the latest US Preventive Services Task Force recommendation is 400mcg-800 mcg per day for women of childbearing age. The American College of Obstetricians and Gynecologists recommends that non pregnant women of childbearing aged consume 400 mcg/day. This variability reflects the uncertainty about the exact dose that is optimal for the prevention of neural tube defects. For women with a previous pregnancy resulting in a neural tube defect, 4,000 mcg is necessary to achieve these prevention benefits.

Women with a known genetic defect in folic acid absorption, should look for prenatal vitamins with the already converted form of folic acid, called methylfolate or L-methylfolate or MTHF.

Reference

Suren P, et al. Association between maternal use of folic acid supplements and risk of autism spectrum disorders in children. JAMA 2013. Feb 13;309:570

Sources: Chemical and Engineering News 2013;90(50)

www.goodcleanlove.com

Commentary: Personal lubricants have been seen as potential deliveries of microbicide components in the gel that could protect individuals from HIV. Unfortunately, the promise of nonoxynol-9 in vaginal gels actually failed to show protection of women from HIV and in 2002, it actually increased the risk of HIV infection. It turns out that nonoxynol-9 is not only an effective spermicide, it also damages the cells lining the vagina and rectum and this then alters the potential inherent protective aspect of the mucosal lining of the vagina. Nonoxynol-9 is still used on some condoms today. Safety issues regarding spermicides and personal lubricant ingredients led to the investigations of the scientists at Johns Hopkins and they then proceeded to investigate the osmolarity of lubricants and how that may be related to tissue injury. Previous studies have also investigated this. Hyperosmolar rectally applied personal lubricants was associated with greater epithelial denudation (cell injury) and mucosal permeability in a 2007 study. These changes are thought to be associated with increased risk of HIV transmission. Lubricant use was a strong predictor of BV in another study.

K-Y Warming Jelly has an osmolality more than 30 times the body’s own fluid and increased herpes transmission more than 9 times when compared to no lubricant administered in an animal study. In 2007, another Johns Hopkins researcher demonstrated in a human study that ID Glide, which is a hyperosmolar lubricant similar to Astroglide and K-Y Jelly, caused significant damage to the rectal tissue. But, recently researchers observed that while hyperosmolar lubricants did damage normal rectal and cervical cells, they did not increase HIV infection. There have been other studies that have reported no cell toxicity from hyperosmolar lubricants as well, including one using K-Y Warming Jelly, with the active microbicide, glycerol monolaurate.

Conventional, non organic lubricants contain a variety of ingredients including glycerin and chlorhexidine. Chlorhexidine is a broad spectrum microbicide (kills bacteria, including the dominant protective vaginal bacteria, lactobacilli species, which competitively inhibit infection causing bacteria), which may cause toxic effects to mucosal tissues. Glycerin is thought to increase osmolarity while its effects on the protective lactic acid producing lactobacilli species is not known. It seems wise to use personal lubricants that do not contain petrochemicals, parabens, glycerin or nonoxynol-9. While nonoxynol-9 (N-9) is the active ingredient used in all spermicides in the U.S. and contraceptive effectiveness with diaphragms and condoms and the FemCap is more effective with this spermicide, the CDC and the World Health Organization seem to agree on the following:

1) N-9 is a safe, effective contraceptive option for women at low risk of HIV/STIs who do not use the product more than once per day.

2) N-9 should not be used to prevent HIV/STIs

3) N-9 should not be used rectally

Comments: This study is concerning on many fronts– our waterways are polluted and women of reproductive age are being significantly affected by mercury, lead and PCBs; and… they are passing on these neurotoxins to their breastfed babies. As women age, there is an increasing level of body burden of at least these 3 neurotoxins, and likely continue to accumulate these neurotoxins beyond reproductive age. More than 20% of these women of child-bearing age had these three neurotoxins, mercury, lead and PCBs at or above the average. Another 33% had two neurotoxins at or above the average.

So….do we stop eating fish? I think it’s appropriate to keep the fish intake at once per week.  The problem is, this is an insufficient amount of omega-3 intake, especially for pregnant and breastfeeding women. Fortunately, there is a great solution— purified fish oils tested for contaminants such as lead, mercury and PCBs and removed if present to none or below harmful levels. Assure a pure and fresh fish oil source and certificates of analysis to prove it!

It’s more than distressing, that as a people occupying this beautiful earth, and supposed stewards of it, we have managed to harm it in oh so many ways, and I am afraid that this study only scratches the surface.

Reference

Thompson M, Boekelheide K. Multiple environmental chemical exposures to lead, mercury and polychlorinated biphenyls among childbearing-aged women. (NHANES 1999-2004): body burden and risk factors. Environ Res. 2012. Epub ahead of print.

Results: Compared to baseline pre-study, pycnogenol significantly improved all symptoms with the exception of itching sensation and abnormal perceptions. There was a significant overall placebo effect as well in the majority of the WHQ categories. But, pycnogenol was especially effective and significantly more effective than placebo for improving hot flashes and night sweats and insomnia/sleep problems. The total KI for the severity score of perimenopausal symptoms was decreased by 56% in the pycnogenol group and 39% in the placebo group, after 12 weeks, but it was already significantly better after 4 weeks of pycnogenol treatment.

Commentary: In a past study, pycnogenol was shown to improve perimenopause symptoms in all categories of the WHQ when compared to placebo. (Yang H, et al. Acta Obstet Gynecol Scand 2007;86:78-985) That study used a rather high dose of pycnogenol at 100 mg twice daily in perimenopausal Taiwanese women. Based on other research using pycnogenol at 60 mg/day for endometriosis and dysmenorrhea , the current authors theorized that a lower dose of pycnogenol could also help with menopausal symptoms, thus their choice of 60 mg/day versus duplicating the 200 mg/day dosing of the other study. However, the results of this current study do not duplicate the same level of efficacy as was seen in the Taiwanese study of 200 mg/day. Perhaps this could be explained by the lower dose. Another study was done in the past where 100 mg /day was used and showed benefit using a different questionnaire than the WHQ or the KI. In any case, the KI was statistically significant in the current study of 60 mg/day of pycnogenol. The mechanism of action of pycnogenol for this purpose remains unknown, but we do know from other research that pycnogenol helps to dilate the peripheral vascular system due to its effects on the endothelium of the vessels. Thermodysregulation is related to lowered estrogen levels at menopause- both in the blood and in the temperature regulating center of the hypothalamus, and estrogen treatment is very effective at eliminating hot flashes and night sweats. Perhaps the effect of pycnogenol on vasodilation helps the body to emit the excess heat; only a theory. In any case, pycnogenol should now be considered a reasonable option for hot flashes/night sweats, and given the increased risk of cardiovascular disease associated with postmenopause, and the improvement of pycnogenol on endothelial function, it becomes an option with more than one purpose and benefit.

Reference

Kohama T, Negami M. Effects of low-dose French maritime pine bark extract on climacteric syndrome in 170 perimenopausal women. J Reprod Med 2013;58:39-46

The purpose of the current study was to determine the effect of aromatherapy massage on menopausal symptoms. This study was a randomized placebo-controlled clinical trial conducted at a menopause clinic in Iran. A total of 90 women were randomly assigned to an aromatherapy massage group, a placebo massage group, or a control group with no massage. Each massage group received a 30 minute massage twice a week for 4 weeks. Group one received a 30 minute massage twice weekly with a mixed aroma oil blend of lavender, rose geranium, rose and rosemary in a 4:2:1:1 ratio, diluted in almond oil (90%) and evening primrose oil (10%) at a final concentration of 3%. Group 2 received a 30 minute massage twice weekly with an odorless liquid soft paraffin. Group 3 received no treatment.

Results: Of the 90 women who qualified and consented to the study, 3 of them failed to attend more than 2 sessions and dropped out during the study, leaving a total of 87 women. There were 28 women in the aromatherapy massage group, 29 in the placebo group and 30 in the control group. After 8 sessions of intervention, the Menopause Rating Scale (MRS) score differed significantly among the three groups. Menopause symptoms decreased from 21.86 to 13.11 after aromatherapy massage and from 21.72 to 19.7 after placebo massage. A statistically significant difference was found between the pre and post MRS scores for aromatherapy massage and placebo massage but did not differ significantly in the control group. When comparing the aromatherapy massage and the placebo massage groups, the menopausal score after aromatherapy massage was significantly lower than that of the placebo massage group.

In summary, both aromatherapy massage and regular massage were effective in reducing menopause symptoms but the aromatherapy massage was more effective than massage alone.

Commentary: This study included women who reported a serious level of menopause symptoms, using the 11 items of the MRS including depressive mood, irritability, anxiety, hot flushes, heart discomfort, sleeping problems, muscle and joint problems, sexual problems, bladder problems and vaginal dryness. Each symptom is scored from 0 (no complaints) to 4 (severe symptoms). The total MRS score is the sum of the scores obtained for each symptom. Women who received the aromatherapy massage twice per week for 4 weeks had the greatest reduction in menopause symptoms, although there was a reduction in the massage only group but none in the control group. These results are similar to an earlier study of aromatherapy massage on menopause symptoms. (Hur M, et al. Evid Based Complement Altern Med 2008; 5:325-328). Another trial, although done with no control group, also demonstrated improvement of menopausal symptoms through aromatherapy massage. (Murakami S, et al. J Altern Complement Med 2005;11:491-494). The mechanism of aromatherapy massage and massage alone to improve menopause symptoms is not clear. It is possible that there is a hormonal change after massage therapy, but why the essential oils add additional benefit needs additional research if we want to know. We can certainly look to small studies on lavender aromatherapy and its ability to reduce anxiety as a possible mechanism of action. But when it comes to the benefits of nice smelling oils being applied with care through warm/gentle touch… do we really need further research to explain a mechanism of action? If nothing else, it feels good and 30 minutes twice weekly out of our usual activities and work and stressors sounds pretty good to me, menopause symptoms or not.

Reference

Darsareh F, Taavoni S, Joolaee S, Haghani H. Effect of aromatherapy massage on menopausal symptoms: a randomized placebo-controlled clinical trial. Menopause 2012;19(9):995-999

Well-woman visits: This would include an annual well-woman preventive care visit for adult women to obtain the recommended preventive services, and additional visits if women and their health care providers determine they are necessary.

Gestational diabetes screening: This screening is for women 24 to 28 weeks pregnant, and those at high risk of developing gestational diabetes.

HPV DNA testing: Women who are 30 or older will have access to high-risk human papilloma virus (HPV) DNA testing every three years, regardless of Pap smear results.

STI counseling: Sexually-active women will have access to annual counseling on sexually transmitted infections (STIs).

HIV screening and counseling: Sexually-active women will have access to annual counseling on HIV.

Contraception and contraceptive counseling: Women will have access to all Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling. These recommendations do not include abortifacient drugs.

Breastfeeding support, supplies, and counseling: Pregnant and postpartum women will have access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment.

Interpersonal and domestic violence screening and counseling: Screening and counseling for interpersonal and domestic violence should be provided for all adolescent and adult women.

Other tests and screening and services that are now mandated to be covered:

Anemia: screening on a routine basis for pregnant women

Bacteriuria: urinary tract or other infection screening for pregnant women

BRCA (breast cancer gene): counseling about genetic testing for women at higher risk

Breast Cancer Mammography: screenings every 1 to 2 years for women over 40

Breast Cancer Chemoprevention: counseling for women at higher risk

Chlamydia Infection: screening for younger women and other women at higher risk

Folic Acid: supplements for women who may become pregnant

Gonorrhea: screening for all women at higher risk

Hepatitis B: screening for pregnant women at their first prenatal visit

Syphilis: screening for all pregnant women or other women at increased risk

Osteoporosis: screening for women over age 60 depending on risk factors

Rh Incompatibility: screening for all pregnant women and follow-up testing for women at higher risk

Tobacco Use: screening and interventions for all women, and expanded counseling for pregnant tobacco users

Biomarkers of cardiovascular disease such as systolic and diastolic blood pressure, lipid profiles, fasting glucose, insulin, triglycerides, hemoglobin A1c (HbA1c), C-reactive protein (CRP) and flow-mediated dilation (FMD) were included.

FMD improved within 2 hours after ingestion of chocolate/cocoa in 11 studies and improved after chronic intake in 11 studies. There was also a reduction in fasting insulin and serum insulin after a glucose challenge in 2 trials after chocolate or cocoa use interventions. There appeared to be no effect on fasting glucose, HbA1c and triglycerides.

Reductions of diastolic blood pressure occurred in 22 trials after chronic intake. There was only a small effect on lowering LDL (-0.07 mmol/L) and HDL (0.03 mmol/L) in 21 studies. No significant effects were seen on CRP, total cholesterol or systolic BP after acute or chronic intake. There was insufficient information or too few trials to determine effect on body weight, body mass index and waist circumference.

Commentary: It’s always comforting news when a beloved food shows health benefits. This appears to be true for chocolate, cocoa, black tea and yes, even coffee, at least up to a point. There are obviously many studies on cocoa and chocolate and individual cardiovascular parameters but this is the first systematic review and meta-analysis assessing randomized clinical trials on cocoa and chocolate in terms of vital cardiovascular risk factors. In terms of lowering insulin resistance and reduction in insulin secretion, both cocoa and chocolate show benefit. The impact on FMD appears to be clinically significant. The effect on diastolic blood pressure and marginal effects on LDL and HDL have some small potential for clinical utility. Other than caloric impact of a specific chocolate/cocoa product, this systematic review confirms the value of the judicious use of these dietary and supplemental food items. Hooray!!!

Reference

Hooper L, Kay C, Abdelhamid A, et al. Effects of chocolate, cocoa, and flavan-3-ols on cardiovascular health: a systematic review and meta-analysis of randomized trials. Am J Clin Nutr. 2012; 95(3):740-751.

Ginger capsules were given in one of two methods: 1) 500 mg ginger capsules or placebo 3x/daily starting 2 days before the beginning of menses and continued through day 3 of menses; 2) 500 mg ginger capsules or placebo 3x/daily on days 1, 2 and 3 of menses. The severity and duration of the pain were assessed on the first 3 days of menses. The severity of pain was significantly reduced in the ginger group compared to the placebo group for both dosing methods with a lower p value (better results) in the first dosing method. It is important to note that these results in both dosing regimens were better than the baseline cramp severity before the study began and again, more meaningful for the first dosing method where the ginger is started 2 days prior to the onset of menses. A 1.4 to 2.0 point reduction in severity was seen with ginger and with the first dosing method ginger significantly reduced the duration of pain compared with placebo. There was a 4.6 ± 10.6 hour decrease in the duration of pain versus a 2.3 ± 18.2 hour increase in duration in the placebo group. The second ginger dosing method was not significant in pain duration between ginger and placebo. Ginger can cause heartburn, and 3% of women in the study experienced this.

Commentary:

The cause of menstrual cramps is thought to be due to an increased production of prostaglandins in the endometrium (lining of the uterus). Menstrual blood of women with primary dysmenorrhea has greater amounts of the prospasmodic and proinflammatory prostaglandins, PGE₂ and PGF₂ alpha. It is thought that the anti-inflammatory properties of ginger are due to the gingerols, which can lead to a reduction in prostaglandins as well as some inflammatory substances. It would have been preferred if this study utilized a standardized ginger extract with the gingerol and shogaol content analyzed and reported. While it is not always possible to know the precise two days prior to the onset of menses, this technique of starting pain relief treatment with anti-inflammatories, whether herbal or pharmaceutical, a few days prior to the onset of menstrual pain is a very productive strategy that I recommend to my patients. Consider using ginger root either alone, or in combination with other important natural ingredients in the relief of menstrual cramps such as cramp bark, niacin, vitamin B6, valerian, wild yam and more.

Reference

Rahnama P, Montazeri A, Fallah Huseini H, Kianbakht S, Naseri M. Effect of Zingiber officinale R. rhizomes (ginger) on pain relief in primary dysmenorrhea: a placebo randomized trial. BMC Complement Altern Med. July 10, 2012;12(1):92

The individuals in the echinacea group had 149 colds that lasted a combined total of 672 days and those in the placebo group had a total of 188 colds with a length of 850 days. There were significantly fewer number of days with colds in the echinacea group than in the placebo group and there were fewer recurring colds in the echinacea group as well (65 vs. 100). Another interesting result was that for those with colds in the placebo group, more medications such as aspirin, acetaminophen and ibuprofen were used compared with the echinacea group (88 vs. 58). In the nasal swabs that were collected, fewer samples with viral infections that contained influenza, parainfluenza and other viruses were detected in the echinacea group compared with the placebo group, (24 vs. 47). When the researchers looked at those individuals in the study who were 100 % compliant with the treatment protocol, there was a combined total of 36 colds for a duration of 155 days in the echinacea group and 58 colds and a duration of 268 days in the placebo group.

Summary

This study reports that echinacea over a period of 4 months, provided good prevention with fewer episodes of colds, fewer days with colds, and fewer colds that required additional medications. Now is the season; a perfect time of year to start your 4 months of echinacea and/or echinacea containing products.

Reference

Jawad M, Schoop R, Suter A, et al. Safety and efficacy profile of Echinacea purpurea to prevent common cold episodes: a randomized, double blind, placebo-controlled trial. Evid Based Complement Alternat Med. 12012;841315. Epub 2012 Sept 16

Nearly all women can benefit from nutritional and multivitamin supplementation four to twelve months before and all during pregnancy, and throughout labor, delivery, and breast-feeding.

Numerous nutrients are associated with one or more facets of an optimal pregnancy whether it be reducing miscarriage, preventing birth defects, enhancing normal fetal development, preventing premature and low-birth weight infants, or preventing preeclampsia. While the list of important nutrients is long, three key nutrients stand out.

Essential fatty acids

Essential fatty acids (EFAs) have a unique role during pregnancy because of the rapid development of new cell growth, new tissues, and new organ systems in a developing fetus. Fetal development is associated with a high EFA requirement, and this supply is dependent on the amount and availability of EFAs from the mother.

Maternal levels of omega-3 fatty acids, especially DHA, decrease during pregnancy.[1] EFAs are components of breast milk and maternal levels may be reduced further in nursing women. For the fetus, a deficiency of EFAs, particularly EPA and DHA, may lead to a poorly developed central nervous system. EFA deficiency may also lead to intrauterine growth retardation leading to a lower whole body weight and slower growth of the brain.

Trials on omega-3 fatty acids conducted in pregnant women have shown a significant reduction in the incidence of premature delivery.[2] In one such study, fish oil was investigated for its effects on pregnancy duration, birth weight, intrauterine growth restriction, and pregnancy-induced hypertension.[3] Omega-3 fatty acid supplementation of 2.7 grams per day was compared to olive oil and/or no supplement. The fish oil-supplemented pregnancies lasted four days longer and birth weight was 107 gm greater. In another study, infants born of mothers who had been given cold liver oil had higher levels of DHA in their umbilical cord, and a longer gestation.[4] Fish oil also appeared to be related to a reduction in the risk of preterm delivery in those women who had had a previous preterm delivery. [5] In a study of pregnant women in Iceland those consuming liquid cod liver oil in the first 15 weeks of pregnancy had babies with higher birth weight.[6]

Prostaglandins, as determined by EFA status, are also involved in the development and clinical expression of preeclampsia. These prostaglandins are modulators of vascular smooth muscle tone and platelet aggregation (blood platelets sticking together). Preeclampsia is characterized by increased vasoconstriction, frequently associated with increased platelet aggregation, reduced uteroplacental blood flow, and premature delivery. In a placebo-controlled clinical trial, a group of pregnant women receiving a combination of evening primrose oil (EPO) and fish oil had a significantly lower incidence of edema. [7]

There is some evidence that EPO, taken both orally and vaginally can be used to promote cervical ripening. Clinically, EPO supplementation during pregnancy has been found by practitioners of natural childbirth to be an efficacious method to stimulate cervical ripening during labor, and PGE1 is known to stimulate cervical ripening and hasten the progression of labor.[8] Although practitioners using this supplement report no adverse effects, a retrospective trial comparing the oil to no supplement did not note a difference between groups and there was a suggestion that there was an increased incidence of premature rupture of membranes, labor augmentation, and assisted vaginal delivery in the evening primrose group.[9]

There are cautions about increased fish intake due to the mercury content. The Food and Drug Administration advises no more than 12 oz of fish / week, due to concerns about mercury content in fish and potential for adverse effects on the infant. Numerous nutrition groups point out that if women focus on the low mercury fish, that women should in fact eat a minimum of 12 oz of fish per week, in order to assure an adequate amount of essential fatty acids.

Supplementation with a daily complex of essential fatty acids and fish oils during pregnancy provides vital nutrients that supply the necessary EFAs for the increased nutritional and metabolic demand throughout the nine months of gestation.

Folic acid

Folic acid is the only vitamin whose requirement doubles during pregnancy. Deficiencies of folic acid have been linked to low birth weight infants and neural tube defects. According to one controlled study, women at high risk (having previously given birth to babies with neural tube defects) who were given folate supplementation showed a 72 percent protective effect compared to the placebo group. [10] In another study, a group of pregnant women given folate supplementation gave birth to infants with increased birth weight and Apgar scores and had a decreased incidence of fetal growth retardation and maternal infections. [11]

In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended that all women planning a pregnancy or possibly being able to become pregnant take a multivitamin supplement that contains folic acid, for the prevention of neural tube defects. The USPSTF has recently issued a new updated statement in the May 5, 2009 issue of Annals of Internal Medicine.[12] This statement is an update of the 1996 USPSTF recommendation. Based on the observational evidence and randomized controlled trials published since 1996, the USPSTF found convincing evidence that supplements containing 0.4 to 0.8 mg of folic acid during the preconception period lowers the risk for neural tube defects. They also concluded that adequate evidence suggests that folic acid from supplementation at usual doses is not associated with serious harm. Including no evidence found for the masking of vitamin B₁₂ deficiency in women of childbearing age. For women who are planning or are capable of pregnancy, the USPSTF concludes that there is a high certainty that the overall benefit of folic acid supplementation during pregnancy is substantial.

Zinc

Zinc is required for proper fetal growth and immunity. Plasma zinc levels decline about 30 % during pregnancy, ^[13] and low zinc intake is associated with spontaneous abortion and premature delivery, ^[14] as well as complications and labor abnormalities. ^[15] Low zinc was also associated with the specific complication of fetal distress,[16] and may be associated with CNS abnormalities in infants, including neural tube defects, [17]^,[18] as well as low birth weight infants [19]^,[20],[21] and toxemia of pregnancy.[22] Supplementation, especially if zinc levels are low, is recommended to reduce the risk of fetal and maternal complications.[23] In one study, labor complications (vaginal bleeding, fetal acidosis, uterine inertia) were improved.[24] Another study showed a lower incidence of pregnancy-induced hypertension (which is associated with preeclampsia and preterm labor).[25] Some food sources of zinc are oysters, beets, broccoli, wheat germ, wheat bran, fish, and lentils; and watercress (not in the first trimester).

References

[1] Hornstra G, Al MD, Van Houselingen AC, et al. Essential fatty acids in pregnancy and early human development. Eur J Obstet Gynecol Reprod Biol. 1995;61:57-62.

[2] Allen K, Harris M. The role of n-3 fatty acids in gestation and parturition. Exp Biol Med 2001;226(6): 498-506

[3] Olsen S, Sorensen J, Secher N, et al. Randomised controlled trial of effect of fish-oil supplementation on pregnancy duration. Lancet 1992;339:1003-1007.

[4] Helland I, Saugstad O, Smith L, et al. Similar effects on infants of n-3 and n-6 fatty acids supplementation in pregnant and lactating women. Pediatrics 2001;108(5):E82

[5] Olsen S, Secher N, Tabor A, et al. Randomized clinical trials of fish oil supplementation in high risk pregnancies. Fish oil trials in pregnancy team. Br J Obstet Gynaecol 2000;107:382-95

[6] Olafsdottir A, Magnusardiottir A, Thorgeirsdottir H, et al. Relationship between dietary intake of cod liver oil in early pregnancy and birth weight. BJOG 2005;111:424-429.

[7] D’Almeida A, Carter J, Anatol A, Prost C. Women and Health, 1992;19(2/3):117-131.

[8] McFarlin BL, Gibson MH, O’Rear J, Harman P. A national survey of herbal preparation use by nurse-midwives for labor stimulation. Review of the literature and recommendations for practice. J nurse-Midwifery 44(3):2095. 1999.

[9] Dove D, Johnson P. Oral evening primrose oil: its effect on length of pregnancy and selected intrapartum outcomes in low-risk Nulliparous women. J Nurse Midwifery.1994;44:320-324.

[10] MRC Vitamin Study Research Group. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. Lancet 1991;338:131-137.

[11] Tamura T, Goldenberg R, Freeberg L, et al. Maternal serum folate and zinc concentrations and their relationships to pregnancy outcome. Am J Clin Nutr 1992;56:365-370.

[12] Woffe T, Takacs-Witkop C, Miller T, Syed S. Folic acid supplementation for the prevention of neural tube defects: An update of the evidence for the U.S. Preventive Services Task Force. May 2009.150; (9): 632-639

[13] Argemi J, et al. Serum zinc binding capacity in pregnant women. Ann Nutr Metab 1988;32:121-126.

[14] Apgar J, Evertt G. Low zinc intake affects maintenance of pregnancy in guinea pigs. J Nutr 1991;121:192-2000.

[15] Lazebnik N, et al. Zinc status, pregnancy complications and labor abnormalities. Am J Obstet Gynecol 1988;158(1): 161-166.

[16] Mukherjee M, et al. Maternal zinc, iron, folic acid, and protein nutriture and outcome of human pregnancy. Am J Clin Nutr 1984;40(3):496-507.

[17] Buamah P, et al. Maternal zinc tatus: a determinant of central nervous system malformation. Br J Obstet Gynaecol 1984;91:788-90.

[18] Bergmann K, et al. Abnormalities of hair zinc concentration in mothers of newborn infants with spina bifida. Am J Clin Nutr 1980;33:2145.

[19] Malhotra A, et al. Placental zinc in normal and intrauterine growth-retarded pregnancies. Br J Nutr 1990;63:613-621.

[20] Higashi A, et al. A prospective survey of serial serum zinc levels and pregnancy outcome. J Ped Gastroenterol 1988;7:430-433.

[21] Singh P, et al. Maternal hypozincemia and low-birthweight infants. Clin Chem 1987;33:1950.

[22] Cherry F, et al. Plasma zinc in hypertension/toxemia and other reproductive variables in adolescent pregnancy. Am J Clin Nutr 1981;34(11): 2367-2375.

[23] Cherry F, et al. Adolescent pregnancy: associations among body weight, zinc nutriture, and pregnancy outcome. Am J Clin Nutr 1989;50:945-954.

[24] Kynast G, Saling E. Effect of oral zinc application during pregnancy. Gynecol Obstet Invest 1986;21(3):117-122.

[25] Hunt I, et al. Zinc supplementation during pregnancy: effects on selected blood constituents and on progress and outcome of pregnancy in low-income women of Mexican descent. Am J Clin Nutr 1984;40(3):508-521.