Condition management

It is important to complete an individual risk assessment for your patient and to apply the principles of prescribing during pregnancy when looking at the available information and making treatment decisions. Check to see if a risk assessment has already been completed.

Vitamin D is a fat-soluble vitamin produced by the body when exposed to summer sunlight in the UK. It regulates calcium and phosphate in the body which is needed for healthy bones, teeth, and muscles.

During pregnancy, vitamin D supports the fetus’s normal growth and development. Deficiency can lead to abnormal bone growth, fractures, or rickets in newborns, and may increase the risk of adverse outcomes such as pre-eclampsia and low infant birthweight.

Guidelines

The management of vitamin D deficiency in pregnancy is based on specialist consensus opinion rather than specific guidance. You should check if there is local guidance for you to use in your area.

The American College of Obstetrics and Gynecologists (ACOG) committee opinion on vitamin D: screening and supplementation during pregnancy provides information on the vitamin D dose that is safe to use when vitamin D deficiency is identified during pregnancy.

The European Food Safety Authority (EFSA) and the UK Scientific Advisory Committee on Nutrition (SACN) also make recommendations on the safe dose of vitamin D in pregnancy.

Treatment options

Use oral vitamin D (either as colecalciferol or ergocalciferol) to treat vitamin D deficiency during pregnancy. Some products are licensed for use in pregnancy.

Seek specialist advice in complex cases such as a history of rickets in a previous pregnancy.

Do not prescribe vitamin D injections in pregnancy.

Dose

Consider a daily dose between 1000 units to 2000 units to manage vitamin D deficiency during pregnancy.

When selecting a dose within this range, consider factors such as:

• the extent of deficiency
• whether there are symptoms of deficiency
• advice of the specialist
• the amount of vitamin D in supplements being taken

It may be appropriate to consider a daily dose of up to 4000 units in some cases of severe vitamin D deficiency that is symptomatic.

Duration

There is no guidance on duration.

A cumulative dose of 300,000 units is sufficient to correct vitamin D deficiency in adults.

Using the dosing range above, it could take several months to correct deficiency.  For example, in a patient taking 2000 units daily, it may take five months to correct the deficiency.

After correction, provide advice on preventing recurrence of vitamin D deficiency.

Preventing recurrence

All pregnant women should take a 10 micrograms (400 units) vitamin D supplement daily from October to March. Women with dark skin or those who cover their skin may need supplements year-round.

Most pregnancy supplements contain 400 units of vitamin D.

Monitoring in pregnancy

Use of vitamin D at any stage in pregnancy is not regarded as grounds for additional fetal monitoring.

Vitamin D

There is no specific guidance for monitoring vitamin D levels during pregnancy. The monitoring requirements would be the same as for non-pregnant patients.

Routine monitoring of vitamin D levels is generally unnecessary but may be appropriate in patients with symptomatic deficiency, malabsorption or where poor compliance is suspected. Vitamin D levels can be checked around 3 to 6 months after starting treatment when steady state levels are likely to have been attained.

Calcium

Check adjusted plasma calcium levels 1 month after starting vitamin D in case primary hyperparathyroidism has been unmasked.

Neonatal monitoring

Neonatal calcium and vitamin D levels may be checked at delivery if there are concerns about these.

Pregnancy outcome information

UK Teratology Information Service (UKTIS) has safety and pregnancy outcome information on the use of Vitamin D in pregnancy.

Patient information

UKTIS has corresponding BUMPS patient information on the use of vitamin D in pregnancy.

The NHS provides advice to patients on vitamin D supplements and nutrition in pregnancy to help to prevent deficiency.

Further Information

SPS provides guidance on safety considerations when using Vitamin D.

Advice on safe exposure to sunlight may also help healthcare professionals to advise patients how to prevent deficiency.

The Royal Osteoporosis Society guidance on vitamin D and bone health provides practical guidance on management (including monitoring) of patients with vitamin D deficiency.

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