Primary Prevention of Birth Defects by

Periconceptional Folic-Acid Containing Multivitamin

Supplementation

Primary Prevention of Birth Defects by

Periconceptional Folic-Acid Containing Multivitamin

Supplementation

Prof. Andrew E. Czeizel, MD., C.Sc., D.Sc.(Scientific director of the Foundation for Community Control of

Hereditary Diseases,Budapest, Hungary)

Dr. Attila Vereczkey, M.D., M.A.

(Medical Director of the Versys Clinics, Human Reproduction

Institute, Budapest, Hungary)

Prof. Andrew E. Czeizel, MD., C.Sc., D.Sc.(Scientific director of the Foundation for Community Control of

Hereditary Diseases,Budapest, Hungary)

Dr. Attila Vereczkey, M.D., M.A.

(Medical Director of the Versys Clinics, Human Reproduction

Institute, Budapest, Hungary)

• The deficiency or overdosage of certain nutrients may have a role in the origin of birth defects.

• First in 1932 Fred Hale demonstrated that a vitamin A-free diet during early pregnancy of sows resulted in offspring without eyeballs, oral clefts, accessory ears, malposition of kidney and defects of hind legs.

• Joseph Warkany (1902-1992), known as „ father of teratology”, recognized the importance of purified diets and used these to test various vitamin deficiencies for their teratogenic effects.

• Warkany found that maternal dietary deficiency can induce structural birth defects, i.e., congenital abnormalities (CAs).

• In 1964 Hibbard reported a higher rate of CAs (3%) in the infants of folate-deficient mothers than in controls (1.6%)

• Hibbard and Smithells showed a relationship between human embryopathy and a deficiency of folate metabolism

• Smithells et al demonstrated the role of vitamin deficiencies in the origin of neural-tube defects (NTD).

• He was the first who hypothesized that among triggering environmental factors in the origin of NTDs, undernutrition could be the common and major denominator.

Richard W Smithells (1924 - 2002)MD, FRCPCH, FRCP, FRCPE, FRCOG, DCHProfessor of Paediatrics and Child Health, 1968-1988

NTD : Anencephalus

NTD: Encephalocele, occipital

3/a 3/b

NTD: spina bifida aperta NTD: spina bifida cystica

NTD: closed spina bifida

NTD: spinal dysraphism

Characteristics of NTDCharacteristics of NTD

1. Origin of isolated NTDs (92% of all cases) can be explained by gene-environmental

interaction.

2. Polygenic predisposition: fact that recurrence in first degree relatives is 10 times

higher than their occurrence

3. Environmental factors: very wide range (0.5-12 per 1000) of NTD incidences in

different populations, rapid secular changes and seasonal variation of births with

NTD’s were observed. Socio-economic status dependence (a low risk in the highest

class to an above-average risk in the lowest class) which was found in several

populations

4. Early critical period: between 15th and 28th postconceptional days, this explains

the use of "periconceptional supplementation".

5. Estimated annual number of cases affected with NTD throughout the world is about

400,000

1. Origin of isolated NTDs (92% of all cases) can be explained by gene-environmental

interaction.

2. Polygenic predisposition: fact that recurrence in first degree relatives is 10 times

higher than their occurrence

3. Environmental factors: very wide range (0.5-12 per 1000) of NTD incidences in

different populations, rapid secular changes and seasonal variation of births with

NTD’s were observed. Socio-economic status dependence (a low risk in the highest

class to an above-average risk in the lowest class) which was found in several

populations

4. Early critical period: between 15th and 28th postconceptional days, this explains

the use of "periconceptional supplementation".

5. Estimated annual number of cases affected with NTD throughout the world is about

400,000

conception Closure of neural tubes

21-26 days

menstruation

Periconceptional vitamin supplementation:• Commence 28 days prior to conception• Continue until the second missed MP

Hungarian Periconceptional Service (HPS)1984.

• The Hungarian Periconceptional Service (HPS) was launched in 1984 by A.E.Czeizel.

• It embraces all the ethods for the prevention of structural birth defects (i.e. congenital abnormalities) and pre-term birth known at that time.

• prefer to use the term “periconceptional” rather than “preconceptional”

• The most sensitive and vulnerable early period of fetal development, is not covered by the standard medical health service, leaving embryos uncared for and in general unprotected

Prof. A.E. Czeizel

The three stages of the Hungarian Periconceptional Service, and activities

undertaken at each stage • 1) Reproductive Health check-up• a) Family history of prospective mother and father, and obstetric

history of females.• b) Case history and available medical records of females, e.g.,

epilepsy, diabetes, • c) Vaginal and cervical smear screening for sexually transmitted

infections/disorders.• d) Sperm analysis to detect subfertility and pyosperm (i.e. pus

cells in the semen as indicators of sexually transmitted infections)• e) Psychosexual assessment.• f) Blood screening of women to detect rubella seronegativity, or

lack of previous exposure to varicella (vaccination will be offered), or HIV positivity. In addition, carrier screening for cystic fibrosis, and, more recently, predictive genetic diagnostic tests are carried out at this stage.

The three stages of the Hungarian Periconceptional Service, and activities undertaken at each stage• 2) The 3-month preparation for conception period• a.) Protection of germ cells: avoidance of tobacco, alcohol or

narcotic consumption, and taking of unnecessary drugs.• b) Discontinuation of oral contraception, and removal of IUDs

(condoms are provided).• c) Occupational history of females • d) Menstrual history; measurement of basal body temperature for

detection of hormonal dysfunction (and commencement of further investigation and treatment, if necessary).

• e) Start of pre-conceptional multivitamin supplementation.• f) Recommendation that dental status be checked.• h) Guidelines for physical exercise.• i) Guidelines for healthy diet

The three stages of the Hungarian Periconceptional Service, and activities undertaken at each stage• 3) Better protection of early pregnancy

• a) Undertaking of all additional investigation/treatment necessitated by conditions and disorders detected at the pre-conception check-up.

• b) Appropriate investigation and treatment of women shown to suffer from hormonal dysfunction

• c) Optimal timing of conception in relation to ovulation.

• d) Early pregnancy confirmation using pregnancy tests and ultrasound scanning.

• e) Post-conceptional multivitamin supplementation.

• f) Avoidance of teratogenic and other risks.

• g) Referral of pregnant women to prenatal care clinics.

Data and Results of Previous Intervention Studies for

the Reduction of Recurrent NTDType Method Location Supplement Risk Reduction

Recurrence Non-randomized Yorkshire

Multivitamin(0.36 mg Folic Acid) 91%

Northern Ireland 83%

Randomized Multicenter MRCFolic Acid(4.0 mg) 71%

19. Smithells RW, Sheppard S, Schorah CJ, et al. Possible prevention of neural tube defects by periconceptional vitamin supplementation. Lancet 1980; 1: 339-340.20. Smithells RW, Sheppard S, Wild J, Schorah CJ. Prevention of neural tube defect recurrences in Yorkshire: final report. Lancet 1989; 2: 498-499.21. Nevin NC, Seller MJ. Prevention of neural tube defect recurrences. Lancet 1990; 1: 178-179.

Based upon the results of the MRC Vitamin Study, the Centers for Disease Control (CDC) in 1991 recommended daily supplementation of diet with 0,4 mg of folic acid under medical supervision in the periconception period for women at high risk (i.e. who had one or more previous offspring with NTD) for the reduction of NTD recurrence.

Goals of the Hungarian randomized double-blind controlled trial (RCT)

Goals of the Hungarian randomized double-blind controlled trial (RCT)

About 95% of women with NTD offspring have no previous NTDpregnancies.

- Thus the question is whether the periconceptional folic acid-containing multivitamin supplementation can reduce the firstoccurrence of NTD?

The pharmacological dose (> 1 mg, e.g., 4 mg) of folic acid cannot berecommended for the population at large or without medicalsupervision.

- Thus, the question is whether a physiological dose (< 1 mg) is effectiveor not?

Possible other beneficial or adverse effects of periconceptionalmultivitamin supplementation.

About 95% of women with NTD offspring have no previous NTDpregnancies.

- Thus the question is whether the periconceptional folic acid-containing multivitamin supplementation can reduce the firstoccurrence of NTD?

The pharmacological dose (> 1 mg, e.g., 4 mg) of folic acid cannot berecommended for the population at large or without medicalsupervision.

- Thus, the question is whether a physiological dose (< 1 mg) is effectiveor not?

Possible other beneficial or adverse effects of periconceptionalmultivitamin supplementation.

Composition of Supplements

"Multivitamin(Elevit Pronatal)"

"Placebo-likeTrace Elements"

VitaminsA 4000 IUB1 1.6 mgB2 1.8 mgNicotinamid 19.0 mgB6 2.6 mgCalcium Panthothenate 10.0 mgBiotin 0.2 mgB12 4.0 mcgC 100.0 mg 7.5 mgD 500.0 IUE 15.0 mgFolic Acid 0.8 mgMineralsCalcium 125.0 mgPhosphorus 125.0 mgMagnesium 100.0 mgIron 60.0 mgTrace ElementsCopper 1.0 mg 1.0 mgManganese 1.0 mg 1.0 mgZinc 7.5 mg 7.5 mg

Result of the Hungarian RCT: Reduction of the First Occurrence of NTD

Study groups Number of informative offspring

Observed NTD No. per 1000

Expected NTD No. per 1000

Multivitamin 2,471 0 0.00 6.9 2.78

Placebo-like trace element

2,391 6* 2.51 6.6 2.78

Relative risk (with 95% confidence interval) = 0.06 (0.00, 0.63) Fisher test P2= 0.01

* anencephaly 2, spina bifida aperta 2, anencephaly + spina bifida 2

Based upon the Hungarian RCT and some observational studies, the CDC in September 1992 recommended that "all women of childbearing age who are capable of becoming pregnant should consume 0.4 mg of folic acid per day for the purpose of reducing their risk of having a pregnancy affected with spina bifida or other NTD” and this recommendation was subsequently followed by several countries.

• CDC. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR 1992; 41: 1233-1238.

Number and rate (per 1000) of different CA-groups in multivitamin and no multivitamin supplemented group

Categories of CAsGroup of CAs

Multivitamin(N=2,471)

No multivitamin(N=2,391)

RR (with 95% CI)No. Rate No. Rate

Isolated CAsNTDOrofacial cleftsCardiovascular

CAsCAs of urinary

tractLimb

deficienciesCong. pyloric

stenosisOthers

04

10212

22

0.01.624.050.810.400.818.90

65

20958

32

2.512.098.363.762.093.34

13.38

0.07 (0.04, 0.13)0.77 (0.22, 2.69)0.42 (0.19, 0.98)0.21 (0.05, 0.95)0.19 (0.03, 1.18)0.24 (0.05, 1.14)0.68 (0.37, 1.10)

Multiple CAs 10 4.05 12 5.02 0.81 (0.36, 1,26)

Total 51 20.64 97 40.57 0.53 (0.35, 0.70)

OTHER EXPERIENCES OF THE HUNGARIAN RANDOMIZED CONTROLLED TRIAL

• Female cycle become more regular• No difference between sexual activity• 7% higher rate of conceptions • Time to become pregnant was slightly but significantly shorter• Significantly lower rate of severe morning sickness, neusea vomiting in

pregnancy (3,0 vs 6,6%)• No difference in maternal weight gain• Constipation (1,8 vs 0,8%) diarrhoea (1,4 vs 0,4%) more often• Multiple birth was 40% higher in multivitamin group• No significant difference in fetal deaths ( biochemical PR, ectopic PR,

miscarriages, stillbirths), somewhat higher in multivitamin group ( no terathanasia- multiple PR)

• Sex ratio showed slightly girl excess vs 51% boy predominance• No difference in gestational age at birth, and birth weight• No difference in postnatal somatic and mental development until 6 yrs

Hungarian Cohort-Controlled Trial ( CCT ) of Periconceptional Multivitamin SupplementationSupplemented cohort:

• Participants of the Hungarian Periconceptional Service (HPS) with the same multivitamin use(0.8mg folic acid), until 14th week of gestation

• No. of participants:

• 3056

Unsupplemented cohort:

• Participants of regional Antenatal care, matched to age socioeconomic status and region, without folic acid /multivitamin supplementation use after 14th week of gestation

• 3056

Reduction of NTD by periconceptional folic acid-containing multivitamin supplementation in two

Hungarian intervention studiesIntervention studies Supplemente

dUnsupplemente

d

Randomized controlled trialNo. of informative offspringNo. of NTD offspringRR (95% CI)

2,4710

2,3916

Cohort controlled trialNo. of informative offspringNo. of NTD offspringOR (95% CI)

3,0561

3,0569

TogetherNo. of informative offspringNo. of NTD offspringOR (95% CI)

5,5271

5,44715

0.06 (0.04,0.13)

0.11 (0.01,0.91)

0.08 (0.01,0.47)

Number of informative offspring with cardiovascular CAs in multivitamin (MV) and no multivitamin (No-MV) groups

Cardiovascular CAs

RCT CCT Pooled data

MV(N=2,471)

No.

No-MV(N=2,391)

No.

MV(N=3,056)

No.

No-MV(N=3,056)

No.

MV(N=5,527)

No.

No-MV(N=5,447)

No.

ConotruncalVentricular

septal defectOthersSubtotal

213

82

10

538

191

20

7411

273

30

Others 7 10 23 30 30 40

Total 10 20 31 50 41 70

OR (with 95% CI) 0.42 (0.19, 0.98) 0.60 (0.38, 0.96) 0.57 (0.39, 0.85)

Number of informative offspring with urinary tract’s CAs in multivitamin (MV) and no multivitamin (No-MV) groups

CAs of urinary tract

RCT CCT Pooled data

MV(N=2,471)

No.

No-MV(N=2,391)

No.

MV(N=3,056)

No.

No-MV(N=3,056)

No.

MV(N=5,527)

No.

No-MV(N=5,447)

No.

Renal a/dysgenesis

Cystic kidney

Obstructive CAsPelvicuretericOthersSubtotal

0

1

011

3

1

415

2

2

28

10

0

0

136

19

2

3

2911

3

1

177

24

Total 2 9 14 19 16 28

OR (with 95% CI) 0.21 (0.05, 0.95) 0.71 (0.33, 1.50) 0.50 (0.30, 1.04)

Number of informative offspring with other „candidate” CAs in multivitamin (MV) and no multivitamin (No-MV) groups

Other„candidate” CAs

RCT CCT Pooled data

MV(N=2,471)

No.

No-MV(N=2,391)

No.

MV(N=3,056)

No.

No-MV(N=3,056)

No.

MV(N=5,527)

No.

No-MV(N=5,447)

No.

Orofacial clefts

Cleft lip ± palate 4 3 3 2 7 5Posterior cleft

palate 0 2 1 1 1 3

Total 4 5 4 3 8 8OR (with 95%

CI) 0.77 (0.22, 2.69) 1.63 (0.31, 28.8) 0.99 (0.37, 2.63)

Limb deficiencies 1 5 1 3 2 8 OR (with 95%

CI) 0.19 (0.03, 1.18) 0.33 (0.01, 3.71) 0.25 (0.05, 1.16)

Cong. pyloric stenosis 2 8 0 2 2 10 OR (with 95%

CI) 0.24 (0.05, 1.14) 0.00 (0.00, 26.8) 0.20 (0.04, 0.90)

Other observational studiesregarding periconceptional (folic acid containing) multivitamin supplementation

“Other” CAs Association confirmed refused

Cardiovascular CAs 5 1CAs of urinary tract 3 0Congenital limb deficiencies 3 0Congenital pyloric stenosis 0 1

Metabolism of Homocysteine and the Effect of Folate-Folic Acid (Vitamin B11), Vitamin B2, Vitamin B6

and Vitamin B12

MTHFR-gene

Vitamin B

Folate(polyglutamate)

Folic acid(monoglutamate)

11

Reductase

5-methyl-THF

5,10-methylene-THF

Vitamin C

Tetrahydrofolate =THF

ReductaseDihydrofolate

Monoglutamate

Zinc

Conjugase

Methylene-THF-reductase=MTHFR

B2

Proteins

Methionine

S-adenosylmethionine

Homocysteine

Homocysteine

Homocystinuria

Cystathione

Cysteine

Sulphate

B 6

Cystathione-betasynthase

Serin

B 6

Cystathionase

B12

Methionine-synthase

CH+

3

CH3

MTHFR gene

• Gene location: Chromosome 1, short arm 36.3

• Mutation: 677 C T• Frequency of

• mutant homozygosity (TT): 5-15 % (11%)

• heterozygosity (CT): 25-65% (45%)

Optimal Dosage ?

Good400 microgram of folic acid

Better800 microgram of folic acid

BestMultivitamin containing 800 microgram folic acid

Comparison of different preventive approaches of NTD

Comparison of different preventive approaches of NTD

Prevention Method Efficacy(%)

Cost(US $)

Consequence

PrimaryPericonceptional multivitamin or folic acid supplementation

9070

505

True prevention

"Secondary"Prenatal screening of MS-AFP + ultrasound scannings of fetus

85 500*Termination of pregnancy

"Tertiary" In utero surgery ? Very high Correction (?)

* incl. termination of pregnancy* incl. termination of pregnancy

Conclusion I:Periconceptional multivitamin

(containing 0.8 mg folic acid) supplementation

• 1. Very effective (about 90%) for the prevention of NTD

• 2. Effective for the reduction of cardiovascular CAs (ventricular septal defect), CAs of urinary tract (stenosis/atresia of pelvicureteric junction) and congenital limb deficiencies (terminal transverse type)

• 3. No effective for the prevention of orofacial cleft (dose-dependent effect of folic acid alone?)

• 4. Effective for the reduction of total (birth+fetal) prevalence of major CAs at least by one-third

Conclusion II:• Neural-tube defects are preventable by periconceptional folic acid

or multivitamin supplementation.• The incidence of some other structural birth defects can also be

reduced by folic acid-containing multivitamin use during the periconception period.

• All women of childbearing age who are capable of becoming pregnant should consume folic and/or folic acid containing multivitamin during the periconception period.

• The primary prevention of birth defects by periconceptional folic acid/multivitamin supplementation is much better than the so-called secondary prevention, i.e. the termination of pregnancy due to severe fetal defects.

• Periconceptional care – beyond other benefits – is optimal for the introduction of periconceptional folic acid/multivitamin supplementation.

• Proper preparation for conception is the earliest and most effective method for the prevention of birth defects.

Thus G. P. Oakley is right: “Inertia on folic acid fortification equals public health malpractice”.

Oakley GP. Inertia on folic acid fortification: Public health malpractice. Teratology 2002; 66: 44-54.

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Preventive efficacy ofPreventive efficacy of

NTD

Other CAs

Other argumentsin hyperhomocysteinemia related NTD

Cost

NTD

Other CAs

Other argumentsin hyperhomocysteinemia related NTD

Cost

folic acid alone

70%

?

Key factor

Low

folic acid alone

70%

?

Key factor

Low

multivitamin

90%

At least three other CA-groups

Vitamin B12, B2 and B6 are independent factors

Moderate (reimbursement)

multivitamin

90%

At least three other CA-groups

Vitamin B12, B2 and B6 are independent factors

Moderate (reimbursement)

Cardiovacular defects: Government of Western Australia, WA Register of Developmental Anomaliessource: Department of Health, AU

Chromosomal defects: Government of Western Australia, WA Register of Developmental Anomaliessource: Department of Health, AU

NTD trends: Government of Western Australia, WA Register of Developmental Anomaliessource: Department of Health, AU

NTD trends: Government of Western Australia, WA Register of Developmental Anomaliessource: Department of Health, AU