IJCM  Vol.6 No.3 , March 2015
Vitamin D Efficiency in Pregnancy: An Updated Viewpoint in Indian Scenario
A decade ago identified as bone-building mineral improving calcium absorption, today new re-search opens potentials of Vitamin D in spectrum of diseases from diabetes, hypertension to cancer including special population like pregnancy & lactation. As calcium demands increase during pregnancy, Vitamin D status becomes crucial for optimal maternal & fetal outcomes. Adverse health outcomes such as preeclampsia, low birth weight, neonatal hypocalcemia, bone fragility & increased incidence of autoimmune diseases have been linked to low Vitamin D levels during pregnancy & infancy. Vitamin D deficiency is common during pregnancy & lactation despite widespread use of prenatal vitamins, because these are inadequate to maintain normal Vitamin D levels. The current IOM (US) as well as ICMR (India) recommendations for Vitamin D supplementation is not sufficient to maintain the optimal levels of serum 25(OH) D above 30 ng/ml required during pregnancy. It may therefore be judicious to include screening of all pregnant women for Vitamin D levels as a part of routine antenatal care and supplementation should be considered if deficiency persists. Till date interventional trials in special population suggest that administration of Vitamin D during pregnancy & lactation is safe & beneficial for optimal maternal & fetal outcomes. When Vitamin D deficiency is identified during pregnancy, most experts agree that up to 2000 IU/day of Vitamin D is safe. This review elaborates Vitamin D deficiency in Indian scenario and the need for Vitamin D supplementation, expounds and exercises the facts for implementation of Vitamin D supplementation to be advised when planning for pregnancy, current recommendations and implications of Vitamin D deficiency during pregnancy and lactation.

Cite this paper
Maladkar, M. , Sankar, S. and Kamat, K. (2015) Vitamin D Efficiency in Pregnancy: An Updated Viewpoint in Indian Scenario. International Journal of Clinical Medicine, 6, 204-216. doi: 10.4236/ijcm.2015.63026.
[1]   Van Schoor, N.M. and Lips, P. (2011) Worldwide Vitamin D Status. Best Practice & Research Clinical Endocrinology & Metabolism, 25, 671-680.

[2]   Mithal, A., Wahl, D.A., Bonjour, J.P., Burckhardt, P., Dawson-Hughes, B., Eisman, J.A., El-Hajj Fuleihan, G., Josse, R.G., Lips, P. and Morales-Torres, J., IOF Committee of Scientific Advisors (CSA) Nutrition Working Group (2009) Global Vitamin D Status and Determinants of Hypovitaminosis D. Osteoporosis International, 20, 1807-1820.

[3]   Van der Meer, I.M., Middelkoop, B.J., Boeke, A.J. and Lips, P. (2011) Prevalence of Vitamin D Deficiency among Turkish, Moroccan, Indian and Sub-Sahara African Populations in Europe and Their Countries of Origin: An Overview. Osteoporosis International, 22, 1009-1021.

[4]   Rathi, N. and Rathi, A. (2011) Vitamin D and Child Health in 21st Century. Indian Pediatrics, 48, 619-625.

[5]   Londhey, V. (2011) Vitamin D Deficiency: Indian Scenario. Journal of the Association of Physicians of India, 59, 695-696.

[6]   Seshadria, KG., Tamilselvana, B. and Rajendrana, A. (2011) Role of Vitamin D in Diabetes. Journal of Clinical Endocrinology & Metabolism, 1, 47-56.

[7]   Wang, T.J., Pencina, M.J., Booth, S.L., Jacques, P.F., Ingelsson, E., Lanier, K., Benjamin, E.J., D’Agostino, R.B., Wolf, M. and Vasan, R.S. (2008) Vitamin D Deficiency and Risk of Cardiovascular Disease. Circulation, 117, 503-511.

[8]   Holick, M.F. (2010) Vitamin D Physiology, Molecular Biology, and Clinical Applications. Nutrition and Health, Humana Press, XXVI, 1160.

[9]   Mulligan, M.L., Felton, S.K., Riek, A.E. and Bernal-Mizrachi, C. (2010) Implications of Vitamin D Deficiency in Pregnancy and Lactation. American Journal of Obstetrics & Gynecology, 202, 429, e1-e9.

[10]   Wagner, C.L., Taylor, S.N., Dawodu, A., Johnson, D.D. and Hollis, B.W. (2012) Vitamin D and Its Role during Pregnancy in Attaining Optimal Health of Mother and Fetus. Nutrients, 4, 208-230.

[11]   Lucas, R.M., Ponsonby, A.L., Pasco, J.A. and Morley, R. (2008) Future Health Implications of Prenatal and Early-Life Vitamin D Status. Nutrition Reviews, 66, 710-720.

[12]   Thorne-Lyman, A. and Fawzi, W.W. (2012) Vitamin D during Pregnancy and Maternal, Neonatal and Infant Health Outcomes: A Systematic Review and Meta-Analysis. Paediatric and Perinatal Epidemiology, 26, 75-90.

[13]   Goswami, R., Gupta, N., Goswami, D., Marwaha, R.K., Tandon, N. and Kochupillai, N. (2000) Prevalence and Significance of Low 25-Hydroxyvitamin D Concentrations in Healthy Subjects in Delhi. American Journal of Clinical Nutrition, 72, 472-475.

[14]   Balasubramanian, K., Rajeswari, J., Gulab, Govil, Y.C., Agarwal, A.K., Kumar, A. and Bhatia, V. (2003) Varying Role of Vitamin D Deficiency in the Etiology of Rickets in Young Children vs. Adolescents in Northern India. Journal of Tropical Pediatrics, 49, 201-206.

[15]   Clements, M.R., Johnson, L. and Fraser, D.R. (1987) A New Mechanism for Induced Vitamin D Deficiency in Calcium Deprivation. Nature, 325, 62-65.

[16]   Agarwal, K.S., Mughal, M.Z., Upadhyay, P., Berry, J.L., Mawer, E.B. and Puliyel, J.M. (2002) The Impact of Atmospheric Pollution on Vitamin D Status of Infants and Toddlers in Delhi, India. Archives of Disease in Childhood, 87, 111-113.

[17]   Sahu, M., Bhatia, V., Aggarwal, A., Rawat, V., Saxena, P., Pandey, A. and Das, V. (2009) Vitamin D Deficiency in Rural Girls and Pregnant Women Despite Abundant Sunshine in Northern India. Clinical Endocrinology, 70, 680-684.

[18]   Sachan, A., Gupta, R., Das, V., Agarwal, A., Awasthi, P.K. and Bhatia, V. (2005) High Prevalence of Vitamin D Deficiency among Pregnant Women and Their Newborns in Northern India. American Journal of Clinical Nutrition, 81, 1060-1064.

[19]   Bhalala, U., Desai, M., Parekh, P., Mokal, R. and Chheda, B. (2007) Subclinical Hypovitaminosis D among Exclusively Breastfed Young Infants. Indian Pediatrics, 44, 897-901.

[20]   Farrant, H.J., Krishnaveni, G.V., Hill, J.C., Boucher, B.J., Fisher, D.J., Noonan, K., Osmond, C., Veena, S.R. and Fall, C.H. (2009) Vitamin D Insufficiency Is Common in Indian Mothers but Is Not Associated with Gestational Diabetes or Variation in Newborn Size. European Journal of Clinical Nutrition, 63, 646-652.

[21]   Agarwal, N. and Arya, S.C. (2011) Vitamin D3 Levels in Pregnant Women and Newborns at a Private Tertiary Care Hospital in Delhi, India. International Journal of Gynecology & Obstetrics, 113, 240-241.

[22]   Krishnaveni, G.V., Veena, S.R., Winder, N.R., Hill, J.C., Noonan, K., Boucher, B.J., Karat, S.C. and Fall, C.H. (2011) Maternal Vitamin D Status during Pregnancy and Body Composition and Cardiovascular Risk Markers in Indian Children: The Mysore Parthenon Study. American Journal of Clinical Nutrition, 93, 628-635.

[23]   Marwaha, R.K., Tandon, N., Chopra, S., Agarwal, N., Garg, M.K., Sharma, B., Kanwar, R.S., Bhadra, K., Singh, S., Mani, K. and Puri, S. (2011) Vitamin D Status in Pregnant Indian Women across Trimesters and Different Seasons and Its Correlation with Neonatal Serum 25-hydroxyvitamin D Levels. British Journal of Nutrition, 106, 1383-1389.

[24]   Dasgupta, A., Saikia, U. and Sarma, D. (2012) Status of 25(OH)D Levels in Pregnancy: A Study from the North Eastern Part of India. Indian Journal of Endocrinology and Metabolism, 16, S405-S407.

[25]   Mave, V., Shere, D., Gupte, N., Suryavanshi, N., Kulkarni, V., Patil, S., Khandekar, M., Kinikar, A., Bharadwaj, R., Bhosale, R., Sambarey, P., Chandanwale, A., Bollinger, R. and Gupta, A., SWEN India and Byramjee-Jeejeebhoy Medical College Clinical Trials Unit Study Team (2012) Vitamin D Deficiency Is Common among HIV-Infected Breastfeeding Mothers in Pune, India, but Is Not Associated with Mother-to-Child HIV Transmission. HIV Clinical Trials, 13, 278-283.

[26]   Kalra, P., Das, V., Agarwal, A., Kumar, M., Ramesh, V., Bhatia, E., Gupta, S., Singh, S., Saxena, P. and Bhatia, V. (2012) Effect of Vitamin D Supplementation during Pregnancy on Neonatal Mineral Homeostasis and Anthropometry of the Newborn and Infant. British Journal of Nutrition, 108, 1052-1058.

[27]   Jani, R., Palekar, S., Munipally, T., Ghugre, P. and Udipi, S. (2014) Widespread 25-Hydroxyvitamin D Deficiency in Affluent and Nonaffluent Pregnant Indian Women. BioMed Research International, 2014, Article ID: 892162, 8 pages.

[28]   Seth, A., Marwaha, R.K., Singla, B., Aneja, S., Mehrotra, P., Sastry, A., Khurana, M.L., Mani, K., Sharma, B. and Tandon, N. (2009) Vitamin D Nutritional Status of Exclusively Breast Fed Infants and Their Mothers. Journal of Pediatric Endocrinology and Metabolism, 22, 241-246.

[29]   Mehrotra, P., Marwaha, R.K., Aneja, S., Seth, A., Singla, B.M., Ashraf, G., Sharma, B., Sastry, A. and Tandon, N. (2010) Hypovitaminosis D and Hypocalcemic Seizures in Infancy. Indian Pediatrics, 47, 581-586.

[30]   Agarwal, N., Faridi, M.M., Aggarwal, A. and Singh, O. (2010) Vitamin D Status of Term Exclusively Breastfed Infants and Their Mothers from India. Acta Paediatrica, 99, 1671-1674.

[31]   Jain, V., Gupta, N., Kalaivani, M., Jain, A., Sinha, A. and Agarwal, R. (2011) Vitamin D Deficiency in Healthy Breastfed Term Infants at 3 Months & Their Mothers in India, Seasonal Variation & Determinants. Indian Journal of Medical Research, 133, 267-273.

[32]   Holick, M.F., Binkley, N.C., Bischoff-Ferrari, H.A., Gordon, C.M., Hanley, D.A., Heaney, R.P., Murad, M.H. and Weaver, C.M., Endocrine Society (2011) Evaluation, Treatment, and Prevention of Vitamin D Deficiency: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism, 96, 1911-1930.

[33]   Barrett, H. and McElduff, A. (2010) Vitamin D and Pregnancy: An Old Problem Revisited. Best Practice & Research Clinical Endocrinology & Metabolism, 24, 527-539.

[34]   Bodnar, L.M., Catov, J.M., Simhan, H.N., Holick, M.F., Powers, R.W. and Roberts, J.M. (2007) Maternal Vitamin D Deficiency Increases the Risk of Preeclampsia. Journal of Clinical Endocrinology & Metabolism, 92, 3517-3522.

[35]   Arora, C.P. and Hobel, C.J. (2010) Vitamin D and IL-6 in Pregnancies with Subsequent Preterm Birth. Reproductive Sciences, 17, 179à-180à.

[36]   Chander, P.A. and Hobel, C.J. (2010) Vitamin D—A Novel Role in Pregnancy. Biopolymers and Cell, 26, 97-104.

[37]   Merewood, A., Mehta, S.D., Chen, T.C., Bauchner, H. and Holick, M.F. (2009) Association between Vitamin D Deficiency and Primary Cesarean Section. Journal of Clinical Endocrinology & Metabolism, 94, 940-945.

[38]   Javaid, M.K., Crozier, S.R., Harvey, N.C., Gale, C.R., Dennison, E.M., Boucher, B.J., Arden, N.K., Godfrey, K.M. and Cooper, C., Princess Anne Hospital Study Group (2006) Maternal Vitamin D Status during Pregnancy and Childhood Bone Mass at Age 9 Years: A Longitudinal Study. Lancet, 367, 36-43.

[39]   Morley, R., Carlin, J.B., Pasco, J.A. and Wark, J.D. (2006) Maternal 25-Hydroxyvitamin D and Parathyroid Hormone Concentrations and Offspring Birth Size. Journal of Clinical Endocrinology & Metabolism, 91, 906-912.

[40]   Scholl, T.O. and Chen, X. (2009) Vitamin D Intake during Pregnancy: Association with Maternal Characteristics and Infant Birth Weight. Early Human Development, 85, 231-234.

[41]   Leffelaar, E.R., Vrijkotte, T.G. and van Eijsden, M. (2010) Maternal Early Pregnancy Vitamin D Status in Relation to Fetal and Neonatal Growth: Results of the Multi-Ethnic Amsterdam Born Children and Their Development Cohort. British Journal of Nutrition, 104, 108-117.

[42]   Hillman, L.S. and Haddad, J.G. (1974) Human Perinatal Vitamin D Metabolism, I: 25-Hydroxyvitamin D in Maternal and Cord Blood. Journal of Pediatrics, 84, 742-749.

[43]   Ala-Houhala, M. (1985) 25-Hydroxyvitamin D Levels during Breast-Feeding with or without Maternal or Infantile Supplementation of Vitamin D. Journal of Pediatric Gastroenterology & Nutrition, 4, 220-226.

[44]   Hollis, B.W., Roos, B.A., Draper, H.H. and Lambert, P.W. (1981) Vitamin D and Its Metabolites in Human and Bovine Milk. Journal of Nutrition, 111, 1240-1248.

[45]   Hatun, S., Ozkan, B., Orbak, Z., Doneray, H., Cizmecioglu, F., Toprak, D. and Calikoglu, A.S. (2005) Vitamin D Deficiency in Early Infancy. Journal of Nutrition, 135, 279-282.

[46]   Muhe, L., Lulseged, S., Mason, K.E. and Simoes, E.A. (1997) Case-Control Study of the Role of Nutritional Rickets in the Risk of Developing Pneumonia in Ethiopian Children. Lancet, 349, 1801-1804.

[47]   Zittermann, A., Schleithoff, S.S. and Koerfer, R. (2005) Putting Cardiovascular Disease and Vitamin D Insufficiency into Perspective. British Journal of Nutrition, 94, 483-492.

[48]   Hollis, B.W. (2005) Circulating 25-Hydroxyvitamin D Levels Indicative of Vitamin D Sufficiency, Implications for Establishing a New Effective Dietary Intake Recommendation for Vitamin D. Journal of Nutrition, 135, 317-322.

[49]   Hollis, B.W. and Wagner, C.L. (2006) Vitamin D Deficiency during Pregnancy: An Ongoing Epidemic. American Journal of Clinical Nutrition, 84, 273.

[50]   Hollis, B.W., Johnson, D., Hulsey, T.C., Ebeling, M. and Wagner, C.L. (2011) Vitamin D Supplementation during Pregnancy, Double-Blind, Randomized Clinical Trial of Safety and Effectiveness. Journal of Bone and Mineral Research, 26, 2341-2357.

[51]   Wagner, C.L., McNeil, R., Hamilton, S.A., Winkler, J., Rodriguez Cook, C., Warner, G., Bivens, B., Davis, D.J., Smith, P.G., Murphy, M., Shary, J.R. and Hollis, B.W. (2013) A Randomized Trial of Vitamin D Supplementation in 2 Community Health Center Networks in South Carolina. American Journal of Obstetrics and Gynecology, 208, 137.e1-137.e13.

[52]   Baker, A.M., Haeri, S., Camargo Jr., C.A., Espinola, J.A. and Stuebe, A.M. (2010) A Nested Case-Control Study of Midgestation Vitamin D Deficiency and Risk of Severe Preeclampsia. Journal of Clinical Endocrinology & Metabolism, 95, 5105-5109.

[53]   Bodnar, L.M., Krohn, M.A. and Simhan, H.N. (2009) Maternal Vitamin D Deficiency Is Associated with Bacterial Vaginosis in the First Trimester of Pregnancy. Journal of Nutrition, 139, 1157-1161.

[54]   Boggess, K.A., Espinola, J.A., Moss, K., Beck, J., Offenbacher, S. and Camargo Jr., C.A. (2011) Vitamin D Status and Periodontal Disease among Pregnant Women. Journal of Periodontology, 82, 195-200.

[55]   Walker, V.P., Zhang, X., Rastegar, I., Liu, P.T., Hollis, B.W., Adams, J.S. and Modlin, R.L. (2011) Cord Blood Vitamin D Status Impacts Innate Immune Responses. Journal of Clinical Endocrinology & Metabolism, 96, 1835-1843.

[56]   Camargo Jr., C.A., Ingham, T., Wickens, K., Thadhani, R., Silvers, K.M., Epton, M.J., Town, G.I., Pattermore, P.K. and Espinola, J.A., New Zealand Asthma and Allergy Cohort Study Group (2011) Cord-Blood 25-Hydroxyvitamin D Levels and Risk of Respiratory Infection, Wheezing, and Asthma. Pediatrics, 127, e180-e187.

[57]   Jones, A.P., Palmer, D., Zhang, G. and Prescott, S.L. (2012) Cord Blood 25-Hydroxyvitamin D3 and Allergic Disease during Infancy. Pediatrics, 130, e1128-e1135.

[58]   Food and Nutrition Board, Standing Committee in the Scientific Evaluation of Dietary References Intakes (2010) Dietary Reference Intakes for Vitamin D and Calcium. National Academics Press, Washington DC, 291-340.

[59]   Hollis, B.W. and Wagner, C.L. (2013) Vitamin D and Pregnancy: Skeletal Effects, Nonskeletal Effects, and Birth Outcomes. Calcified Tissue International, 92, 128-139.

[60]   Institute of Medicine (US) Standing Committee on the Scientific Evaluation of Dietary Reference Intakes (1997) Dietary References Intakes for Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. National Academy Press, Washington DC, 250-287.

[61]   ACOG Committee on Obstetric Practice (2011) ACOG. Committee Opinion No. 495: Vitamin D: Screening and Supplementation during Pregnancy. Obstetrics & Gynecology, 118, 197-198.

[62]   Dawodu, A., Saadi, H.F., Bekdache, G., Javed, Y., Altaye, M. and Hollis, B.W. (2013) Randomized Controlled Trial (RCT) of Vitamin D Supplementation in Pregnancy in a Population with Endemic Vitamin D Deficiency. Journal of Clinical Endocrinology & Metabolism, 98, 2337-2346.

[63]   Grant, C.C., Stewart, A.W., Scragg, R., Milne, T., Rowden, J., Ekeroma, A., Wall, C., Mitchell, E., Crengle, S., Trenholme, A., Crane, J. and Camargo, C. (2014) Vitamin D during Pregnancy and Infancy and Infant Serum 25-Hydroxyvitamin D Concentration. Pediatrics, 133, e143-e153.

[64]   Godel, J.C. (2007) Vitamin D Supplementation: Recommendations for Canadian Mothers and Infants. Paediatrics and Child Health, 12, 583-589.

[65]   National Institute of Health and Care Excellence Guidelines (2008) Maternal and Child Nutrition. NICE Public Health Guidance 11, London, 1-105.

[66]   Hollis, B.W. and Wagner, C.L. (2004) Assessment of Dietary Vitamin D Requirements during Pregnancy and Lactation. American Journal of Clinical Nutrition, 79, 717-726.

[67]   Mannion, C., Gray-Donald, K. and Koski, K. (2006) Association of Low Intake of Milk and Vitamin D during Pregnancy with Decreased Birth Weight. Canadian Medical Association Journal, 174, 1273-1277.

[68]   Hypponen, E. (2005) Vitamin D for the Prevention of Preeclampsia? A Hypothesis. Nutrition Reviews, 63, 225-232.

[69]   Moncrieff, M. and Fadahunsi, T.O. (1974) Congenital Rickets Due to Maternal Vitamin D Deficiency. Archives of Disease in Childhood, 49, 810-811.

[70]   Hathcock, J.N., Shao, A., Vieth, R. and Heaney, R.P. (2007) Risk Assessment for Vitamin D. American Journal of Clinical Nutrition, 85, 6-18.

[71]   Holick, M.F. (2007) Vitamin D Deficiency. New England Journal of Medicine, 357, 266-281.

[72]   Vieth, R., Bischoff-Ferrari, H., Boucher, B.J., Dawson-Hughes, B., Garland, C.F., Heaney, R.P., Holick, B.W., Lamberg-Allardt, C., McGrath, J.J., Norman, A.W., Scragg, R., Whiting, S.J., Willett, W.C. and Zittermann, A. (2007) The Urgent Need to Recommend an Intake of Vitamin D that Is Effective. American Journal of Clinical Nutrition, 86, 649-650.

[73]   Hollis, B.W., Wagner, C.L., Kratz, A., Sluss, P.M. and Lewandrowski, K.B. (2005) Normal Serum Vitamin D Levels. New England Journal of Medicine, 352, 515-516.

[74]   Hamilton, B.E., Minino, A.M., Martin, J.A., Kochanek, K.D., Strobino, D.M. and Guyer, B. (2007) Annual Summary of Vital Statistics. Pediatrics, 119, 345-360.

[75]   Lacroix, M., Battista, M.C., Doyon, M., Houde, G., Ménard, J., Ardilouze, J.L., Hivert, M.F. and Perron, P. (2014) Lower Vitamin D Levels at First Trimester Are Associated with Higher Risk of Developing Gestational Diabetes Mellitus. Acta Diabetologica, 51, 609-616.

[76]   Karlsson, T., Andersson, L., Hussain, A., Bosaeus, M., Jansson, N., Osmancevic, A., Hulthén, L., Holmang, A. and Larsson, I. (2014) Lower Vitamin D Status in Obese Compared with Normal-Weight Women Despite Higher Vitamin D Intake in Early Pregnancy. Clinical Nutrition, xxx, 1-7.

[77]   Powe, C.E., Seely, E.W., Rana, S., Bhan, I., Ecker, J., Karumanchi, S.A. and Thadhani, R. (2010) First Trimester Vitamin D, Vitamin D Binding Protein, and Subsequent Preeclampsia. Hypertension, 56, 758-763.

[78]   Al Emadi, S. and Hammoudeh, M. (2013) Vitamin D Study in Pregnant Women & Their Babies. Qatar Medical Journal, 1, 32-37.

[79]   Taheri, M., Baheiraei, A., Rahimi Foroushani, A. and Modarres, M. (2014) Resolving Vitamin D Deficiency in the Preconception Period among High-Risk Reproductive Women: A Randomized Controlled Trial. Iranian Red Crescent Medical Journal, 16, e11175.

[80]   Vieth, R., Chan, P.C. and MacFarlane, G.D. (2001) Efficacy and Safety of Vitamin D3 Intake Exceeding the Lowest Observed Adverse Effect Level. American Journal of Clinical Nutrition, 73, 288-294.

[81]   Heaney, R.P., Davies, K.M., Chen, T.C., Holick, M.F. and Barger-Lux, M.J. (2003) Human Serum 25-Hydroxycholecalciferol Response to Extended Oral Dosing with Cholecalciferol. American Journal of Clinical Nutrition, 77, 204-210.

[82]   Zerofsky, M., Jacoby, B. and Stephensen, C. (2014) A Randomized Controlled Trial of Vitamin D Supplementation in Pregnancy, Effects on Vitamin D Status and Clinical Outcomes. The Journal of the Federation of American Societies of Experimental Biology, 28, Supplement 1041.5.

[83]   Saadi, H.F., Dawodu, A., Afandi, B.O., Zayed, R., Benedict, S. and Nagelkerke, N. (2007) Efficacy of Daily and Monthly High-Dose Calciferol in Vitamin D-Deficient Nulliparous and Lactating Women. American Journal of Clinical Nutrition, 85, 1565-1571.

[84]   Hollis, B.W. and Wagner, C.L. (2004) Vitamin D Requirements during Lactation: High-Dose Maternal Supplementation as Therapy to Prevent Hypovitaminosis D for both the Mother and the Nursing Infant. American Journal of Clinical Nutrition, 80, 1752S-1758S.

[85]   Marya, R.K., Rathee, S. and Manrow, M. (1987) Effect of Calcium and Vitamin D Supplementation on Toxaemia of Pregnancy. Gynecologic and Obstetric Investigation, 24, 38-42.

[86]   Marya, R.K., Rathee, S., Lata, V. and Mudgil, S. (1981) Effects of Vitamin D Supplementation in Pregnancy. Gynecologic and Obstetric Investigation, 12, 155-161.

[87]   Kaur, J., Marya, R.K., Rathee, S., Lal, H. and Singh, G.P. (1991) Effect of Pharmacological Doses of Vitamin D during Pregnancy on Placental Protein Status and Birth Weight. Nutrition Research, 11, 1077-1081.

[88]   Sahu, M., Das, V., Aggarwal, A., Rawat, V., Saxena, P. and Bhatia, V. (2009) Vitamin D Replacement in Pregnant Women in Rural North India: A Pilot Study. European Journal of Clinical Nutrition, 63, 1157-1159.

[89]   Singla, P., Parkash, A.A., Lal, H. and Nanda, S. (2012) Benefits of Vitamin D Supplementation in Pregnancy for Prevention of Preeclampsia. International Journal of Pharmacy & Biological Sciences, 2, 144-150.