The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20

Evaluating the effects of copper supplement

during pregnancy on premature rupture of
membranes and pregnancy outcome.
Maryam Kashanian MD, Hasti Hadizadeh, Masoomeh Faghankhani M.D,
Mitra Nazemi MSc & Narges Sheikhansari MSc
To cite this article: Maryam Kashanian MD, Hasti Hadizadeh, Masoomeh Faghankhani
M.D, Mitra Nazemi MSc & Narges Sheikhansari MSc (2016): Evaluating the effects of copper
supplement during pregnancy on premature rupture of membranes and pregnancy outcome.,
The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2016.1274299
To link to this article: http://dx.doi.org/10.1080/14767058.2016.1274299

Accepted author version posted online: 21

Dec 2016.

Submit your article to this journal

Article views: 6

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ijmf20
Download by: [University of Western Ontario]

Date: 03 January 2017, At: 01:36

Evaluating the effects of copper supplement during pregnancy on premature

rupture of membranes and pregnancy outcome.

Maryam Kashanian, MD: Professor of Iran University of Medical Sciences,

Department of Obstetrics & Gynecology, Akbarabadi Teaching Hospital, Tehran,
Iran.
Hasti Hadizadeh, Medical Student Research Committee (MSRC), Iran University

of Medical Sciences, Faculty of Medicine , Tehran, Iran

TE

Masoomeh Faghankhani, M.D: Research Associate. Tehran University of Medical

EP

Sciences, Tehran, Iran.

Iran.

Student of Public Health, Faculty of Medicine,

AC

Narges Sheikhansari, MSc:

Mitra Nazemi, MSc: Social Security Organization, 12 Bahban Hospital, Tehran,

ST

University of Southampton, Southampton, UK.

JU

IRCT ID: IRCT201008112624N7

Running Head: copper supplement during pregnancy.

Abstract:
Objective:
To evaluate the effects of copper supplementation during pregnancy on the rupture
of membranes and pregnancy outcomes.
Method:
Study was conducted as a triple blind randomized clinical trial. In one group copper
in a dose of 1000 milligram per day and in the other group, placebo was prescribed

TE

orally from 16th week of pregnancy.

Results:

EP

The women of the 2 groups did not have significant difference according to age,
gestational age at recruitment, BMI, and socioeconomic conditions. There was no
statistically significant difference between case and control group regarding the
incidence of PPROM, PROM, preterm labor, vaginal bleeding during pregnancy,
pre-eclampsia and the incidence of placenta abruption.

ST

AC

There was a 75% and 90% decrease in depressive symptoms in 2nd trimester and
3rd trimester in supplemented group respectively. Also, there was a 45% and 80%
decrease in anxiety symptoms in 2nd trimester and 3rd trimester in the
supplemented group respectively.
The rate of infection during pregnancy was significantly higher in control group (P:
0.046).

JU

There was no difference between the 2 groups according to neonatal outcomes.

Conclusion:

Copper supplementation during pregnancy could not influence positively on ROM,

however, could improve some mood status of the women.
Key words:
Pregnancy, copper supplementation, rupture of membrane, pregnancy outcome.

Introduction:
During late pregnancy, a condition called premature rupture of membranes (PROM)
-rupture of amniotic sac, before the onset of regular uterine contraction- affects both
the fetus and mother. The condition may occur at term (37 weeks of gestation) or
preterm (<37 weeks of gestation). Maternal and fetal infection are the most
common complications of PROM; in the case of latter, PROM increases the
morbidity up to ten times compared to normal delivery. (13) The exact cause of
PROM is still unknown. Yet, some risk factors are associated with higher incidence
of PROM including: infection, cigarette smoking, low socioeconomic status and the
most insidious and subtle one; nutritional deficits. (4)

EP

TE

Minerals -form only 5% of typical human diet- play an important role in passing a
healthy pregnancy. Diet with inadequate micronutrient including zinc, magnesium,
Iron, and copper increases the risk of adverse pregnancy outcomes, specifically
PROM. (58) Copper (Cu) is a vital trace element for function of several
cuproenzymes including: Zinc-copper superoxide dismutase (antioxidant defense),
dopamine mono-oxygenase (neurotransmitter synthesis), Lysyl oxidase (collagen
cross-linking, bone formation), Ceruloplasmin (copper transporter and ferroxidase),
Cytochrome c oxidase (electron transport), Factor V (thrombosis), Tyrosinase
(melatonin production).(810)

JU

ST

AC

Since Copper is a component of Lysyl oxidase -an enzyme involved in collagen

cross-linking, its deficiency can weaken collagen and elastin fibers in amniotic
membranes and result in PROM. (8) Lower serum copper level in pregnant women
and fetuses has been associated with PROM and low birth weight. (1113)
Furthermore, Copper as a part of dopamine mono-oxygenase; an enzyme involved
in neuro transmitter synthesis, can play an important role in catecholaminergic
pathways in brain which is involved in pathophysiology of depression. (14) In
support, several studies also reported that changes in serum copper level is
associated with depression during pregnancy, postpartum, and major depression.
(1519)
Lower micronutrient density diet is more prevalent among pregnant women in
developing countries and in low socioeconomic area. (20) There is yet no study on
Copper intake in Iranian general population diet (21); However, low levels of serum
copper had been detected in Iranian pregnant women especially those who live in
poor socioeconomic areas and have hemoglobin more than 13.2 gr/dl. (2224)
Based on the probable relationship of serum copper level and the incidence of

PROM and also the relation between serum copper level and frequency of
depression, in this study we evaluated the effect of copper supplement on: (1) the
incidence of PROM and some pregnancy outcomes, (2) self-reported depressive and
anxiety symptoms during pregnancy, (3) outcomes related to neonates.
Method and Material:
Participants and setting:

EP

TE

We conducted a triple-blinded, randomized, controlled clinical trial study on nulli

para pregnant women referring to prenatal care facility in Akbarabadi Teaching
Hospital, Tehran, Iran, from April 2010 to April 2013. Inclusion criteria were
healthy nullipara pregnant women; 18<age<35 y; gestational age>12 weeks;
singleton pregnancy; no medical history of acute or chronic diseases including
cardiovascular, respiratory, renal, hepatic disorders, diabetes, hypertension, Wilson
disease, hemochromatosis, iron deficiency anemia, and hemoglobinuria , no
consumption of any medications (including antacis, nifedipine, zidovudine, Dpenicillamine, and ethambutol) except iron and folic acid. We excluded participants
with poor dental hygiene. We recruited women with convenience sampling method.

Randomization:

AC

The review board of ethics institution approved the study protocol which was also
registered in Iran Registry of Clinical Trial (IRCT ID: IRCT201008112624N7). We
explained the purpose and design of the study to all women and a written informed
consent were obtained from every one before entering the study.

JU

Blinding:

ST

Selected participants were randomly allocated with Random Allocation Software

version 1.0.0 using simple block randomization with one-block method to one of
two groups: (A) Copper supplement group, (B) placebo group.

Two trained data collectors received serially numbered, opaque, sealed envelopes
containing a treatment group from an independent third party. In addition, check
lists were numbered and headers were separated. Therefore, the participants, care
providers, data collectors, outcome assessors, and research analyzer were blinded in
this study.

Intervention:
Group A received copper supplement 1000 milligram per day, single dose, orally
since early 17 weeks of gestational age till delivery and group B received placebo
in the way as group A did. Both copper supplements and placebo were produced
by Aburaihan Pharmaceutical Company and were identical in package, figure,
color, taste, smell, size, dosage, and route of administration. Data collectors
followed the participants monthly in their prenatal care visits and weekly by
telephone and asked them to bring their supplements to assess mothers compliance
to the treatment.
Outcomes:

AC

EP

TE

Primary outcome measures were the rate of preterm rupture of membrane and
premature preterm rupture of membrane. The secondary outcome measures fell into
two categories: mother related outcomes including the prevalence of self-reported
depressive and anxiety symptoms in each trimester; urogenital infection, placental
abruption, pre-eclampsia, and vaginal bleeding during pregnancy; weight at
delivery and weight gain during pregnancy; caesarian delivery rate; and compliance
to the treatment using a 5- point Likert sale and neonate related outcomes including
fifth-minute Apgar score; birth weight; gestational age at labor; the rate of adverse
drug events, neonatal anomaly, and neonatal adverse outcomes.

JU

ST

Data collectors collected primary and secondary outcomes using prenatal care and
labor documents. Self-reported depressive symptoms were assessed in each
trimester asking mothers about the presence of depressed mood most of the day,
nearly every day or markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day. Self-reported anxiety symptoms in
each trimester were assessed asking mothers about the presence of 2 items of
following: Worrying too much about different things, Not being able to stop or
control worrying, Becoming easily annoyed or irritable, Trouble relaxing ,
Being so restless that it is hard to sit still, Feeling nervous, anxious or on edge,
and Feeling afraid as if something awful might happen.
Demographic characteristics included: age; gestational age at the time of entry;
marital status; familys economic situation; job; height; weight before pregnancy;
perceived emotional stress and fatigue resulted from job based on mothers
perception, emotional support received from family based on mothers opinion
using a 5-point Likert scale; smoking; alcohol consumption; opium abuse; past

medical history of depressive and anxiety disorders; polyhydramonios; placenta

previa; and anemia.
Statistical method:

Results:
Baseline characteristics:

AC

EP

TE

Statistical analyses were conducted using SPSS 21 (IBM; Chicago, IL, USA). A
two sided P value0.05 was considered statistically significant. We performed an
intention to treat analysis. Categorical variables were assessed using the Chi2 test or
the Fisher exact test. Normally distributed continuous variables were assessed using
independent samples T test while non-normally distributed variables were assessed
using Mann-Whitney test. To estimate the effect of copper supplement on PROM
and depression adjusted for confounders, we created a binary logistic regression
model including potential confounders which either unevenly distributed between
two groups or have previously shown to have a clinical correlation, and then we
calculated odds ratio. To assess the incidence of depressive symptoms in 2nd
trimester, in the analysis we excluded patients who had a history of depression
before pregnancy or had depressive symptoms in 1 st trimester. Then the relative risk
was calculated. Similarly, to assess the incidence of depressive symptoms in the
third trimester, in the analysis we excluded patients who had a history of depression
before pregnancy or had depressive symptoms in 1 st or 2nd trimester. We performed
the same analysis to assess the incidence of anxiety symptoms.

JU

ST

A total of 238 pregnant women enrolled the trial. Figure 1 shows patients progress
through the study. Baseline demographic and clinical characteristics were
comparable between two groups and are listed in table 1. The median age was 24
(IQR: 6) years and the mean gestational age was 16 weeks (SD: 1 day). The
distribution of Emotional stress & fatigue caused by job based on mothers
perception and Compliance to the supplement/placebo were significantly
different in two groups.
Primary outcomes:
The overall incidence of PROM was 7.6%. The risk of PROM was 3% higher (RR:
1.03 95% CI 0.96-1.11) in the placebo group (6.7%) compared to supplemented
group (9.9%) (P: 0.469). The difference between groups was not significantly
different even after adjustment for confounders (P: 0.316). The overall incidence of
PPROM was 1.3%. The risk of PPROM was 1% higher (RR: 1.01 95% CI 0.98-

1.04) in the placebo group (0.7%) compared to supplemented group (1.8%) (P:
0.600)
Secondary outcomes:
Outcomes related to mothers:

TE

There was a 6.7-fold increase in the risk of self-reported depressive symptoms (95%
CI 2.46-18.59) and a 2-fold increase in the risk of self reported anxiety symptoms in
the first trimester in supplemented group; while there was a 75% decrease (95% CI
0.11-0.63) in depressive symptoms in 2nd trimester and 90% decrease (95% CI
0.03-0.31) in depressive symptoms in 3rd trimester in supplemented group. Also,
there was a 45% decrease (95% CI 0.37-0.83) in anxiety symptoms in 2nd trimester
and 80% (95% CI 0.10-0.35) decrease in anxiety symptoms in 3 rd trimester in the
supplemented group. (Table 2) The odds of depressive and anxiety symptom in 2 nd
trimester were 32 times and 7 times higher in the placebo group; respectively,
which was significant after adjustment for confounders.

EP

The incidence of depression in the 1st (r: 0.130, P: 0.045), 2nd (r: 0.164, P: 0.011),
and 3rd trimester (r: 0.147, P: 0.023), were significantly correlated with the history
of depression before pregnancy.

ST

AC

The rate of infection during pregnancy was significantly higher in control group
4(3.7%) compared to no one in case group (P: 0.046). Pregnant women who
received copper supplement gained weight 12.3 kg (SD= 4.3) compared to 11.1 kg
(SD=4.7) in placebo group (P=0.04). However, there was no statistically
significant difference between case and control group regarding mothers weight at
delivery (73.910.1 vs.758.7, respectively).

JU

There was also 67% higher risk (RR: 1.67, 95% CI 1.13-2.46) of caesarian section
in case group (40.9%) compared to control group (24.5%) (P= 0.009). In a binary
logistic regression model, adjusting for possible confounders, copper supplement
increased the odds of caesarian section up to 112%. (OR: 2.13, 95% CI 1.22-4.16)
(P: 0.009) We also found that by each 100 grams increase in fetus weight, the odds
of cesarean section increases 13%. (OR: 1.13, 95% CI 1.03-1.24) (P: 0.006)
There was no statistically significant difference between case and control group
regarding the incidence of pre-eclampsia (2 (1.6%) vs. 0, respectively, P: 0.500),
and the incidence of placenta abruption (1 (0.7%) vs. 0 (0%) respectively; P: 1.000).

The rate of vaginal bleeding during pregnancy was not statistically significantly
different among supplemented and placebo groups (4 (3.2%) vs. 7 (6.7%),
respectively, P: 0.335).
Outcomes related to neonates:

TE

There was no statistically significant difference in the distribution of neonatal

Apgar score between two groups (In both group: median: 10, IQR: 0; P: 0.898).
Also, the mean of neonatal birth weight of 3277 grams (SD=353) in case group
compared to mean neonatal birth weight of 3250 grams (SD=319) in control group
was not significantly different. Besides, there was 5 small for gestational age and 8
large for gestational age neonates in control group compared to 1 small for
gestational age and 12 large for gestational age neonates in case group. Similarly
gestational age at delivery was not significantly different between case (mean= 39
weeks + 3 days, SD= 21 days) and control group (39 weeks + 2 days, SD= 26
days).

EP

Drug adverse effect:

AC

Two of pregnant women who received copper supplement reported nausea (2

mothers) and vomiting (1 mother); while, nine pregnant women who received
placebo reported nausea (6 mothers), fatigue and weakness (3 mothers), and vertigo
(1 mother). There was significantly higher rate of adverse effect report in placebo
group compared to case group (P=0.01)
Neonatal anomaly and other neonatal adverse outcomes:

JU

Discussion:

ST

We didnt find any neonatal anomaly; however, we had one intrauterine fetal death
in 22nd week of pregnancy in the placebo group.

The present study shows that the odds of incidence of PROM were not significantly
lower in the supplemented group; even after adjustment for possible confounders.
Existence of a possible link between level of blood copper and PROM is not widely
acknowledged. Several studies have associated hypocupremia (low levels of copper
in blood) with cervical insufficiency. They claimed that hypocupremia decreases
synthesis and storage of many cuproenzymes such as Lysyl oxidase which is
involved in collagen cross-linking; leading in synthesis of weak collagen and elastin
fibers in amniotic membranes. (8,25,26) Vukeli et al (27) found that serum copper

level were significantly lower in women with pathological pregnancies including

PROM than women with healthy pregnancies.

Rahmanian et al (28) found that copper concentration in blood, is not significantly

different in women with and without PROM. Zhang et al (29) indicated that after 28
weeks of pregnancy, lower serum copper level is associated with higher rates of
PROM. They also found that Serum copper level was positively correlated with
amniotic copper in both groups of women with and without PROM; and it was not
significantly different among groups. But, Lysyl oxidase (LOX) and collagen III
were significantly decreased in PROM group for 37-42 weeks pregnant women.
However, all of the above studies were performed in a cross sectional setting; yet,
they are unable to provide cause-and-effect relationships.

AC

EP

TE

In our study, the prevalence of depressive symptoms in the first trimester before
starting the trial- was almost 6 times higher in supplemented group. After excluding
the women who had prior depressive symptoms (women with depressive symptoms
both before pregnancy and in the first trimester) from analysis, the risk of having
depressive symptoms in placebo group was 16 times higher. It first struck our
minds that this extreme result is due to potential confounders. We therefore built a
logistic regression model to adjust for confounders; resulting in a significant odds
ratio near 32 again a striking difference. Another unexpected result was that 27
women who had depressive symptoms in 1st trimester were free of the symptoms in
2nd trimester. There is no rational basis for this result, as we cannot consider
therapeutic value more than the best available antidepressants for copper
supplement.

JU

ST

There is some possible explanation as included: data collection was not performed
by same persons; there was a possibility for the interviewer to affect pregnant
womens result; the fact that data collectors were not physicians, but obstetricians;
and also the measure to assess depression with, was a 3-item self report, which is
not a precise method for evaluation of depression.
After excluding women (from both groups) with depressive symptoms in 2 nd
trimester, the risk of having depressive symptoms in 3rd trimester was 8.5 times
higher in placebo group. We couldnt adjust the result for confounders, though (as
we had limited outcome positives).
If we refer to this result, there are two possibilities:

1) The potential prophylactic effect of copper supplement peaks early after adding it
to the diet of pregnant women, and reaches a plateau after that.
2) Based on possible physiologic reasons, the effectiveness of copper as a
prophylactic agent for depression may be higher in 2nd trimester than 3rd trimester.
Previous studies indicated that shifts in estrogen/progesterone ratio during
pregnancy result in decreased biliary copper excretion which subsequently increases
serum copper level. (27,30) Since fluctuations in these two hormones are more
frequent in late pregnancy, we could set up a hypothesis that the sooner a pregnant
woman get copper supplement, the more it helps as a prophylactic agent.

TE

While our data suggest a positive role for copper, it have been previously
hypothesized that Cu is a potential inhibitor of responses evoked by GABA
especially in Purkinje cells, and high level of Cu might modulate GABA -which
worsen symptoms- and as long as Cu levels remain high, symptoms exist. (31)

EP

Studying other outcomes related to mothers, we found no incidence of infection in

supplemented group, but 4 in placebo group, which was significantly different. We
can explain our result by the correlation between copper deficiency and immune
defects, including lymphopenia and reduced IL-2 response, by reduced antioxidant
function. (3234)

ST

AC

Our result shows that copper supplement increased the odds of caesarian section up
to 115%. The possible mechanism should be investigated. We also found that by
each 100 grams increase of the fetus weight, the odds of caesarian section increases
14%. Although the incidence of pre-eclampsia, placenta abruption, and vaginal
bleeding during pregnancy was not statistically significantly different among
supplemented and placebo groups.

JU

There was no significant difference in outcomes related to neonates in two groups;

there was no neonatal anomaly in either group. Previous studies have shown that
copper deficiency can result in fetal biochemical and structural abnormalities, but
the extent of copper deficiency needed to impact placental development has not yet
been indicated. (35,36)
Limitations:
We did not evaluate the rate of unplanned pregnancy in patients which is associated
with higher risk of antenatal depression. (37) Also, we didnt evaluate other
psychiatric co-morbid diagnosis like dysthymia or other factors affecting
psychological well-being during pregnancy. We evaluated depression and anxiety

only by self reported symptoms which is not a powerful tool to measure depression
and anxiety and is affected by other factors like personality features. Women were
not randomized in the trial based on the presence of depressive symptom in the first
trimester and women who had depressive symptoms in the first trimester or before
pregnancy was also included (although we excluded such cases from our analysis).
In the analysis of some variables, we could not include all possible confounders in
the logistic regression model because of limited outcome positives.
Study Strengths:

TE

To the authors knowledge, our study is the first to assess three main variables
(incidence of PROM, anxiety and depression during pregnancy) which have been
shown to be correlated but in separate comparisons. We omitted possible
confounders effect by precise inclusion criteria.
Big picture:

ST

AC

EP

Maintaining and improving mothers and their infants has always been a priority for
medical community and health strategy decision makers. Its no secret that
psychiatric disorders like depression and anxiety can be as disabling as other
medical disease for mothers. Considering the major difficulties maternal/infantile
diseases can impose on society, introducing a supplement with prophylactic effects
on depressive and anxiety symptoms in pregnant mothers must be considered
worthy. We showed adding copper supplement to mothers diets during pregnancy
has significantly prevented incidence of depression and anxiety in pregnant
mothers. Maybe its time to consider copper a precious metal; for mothers sake.

JU

Conflict of interest: None

References:
1.

Bahasadri S, Kashanian M, Khalili S. Evaluation of vaginal fluid -human

chorionic gonadotrophin for the diagnosis of preterm premature rupture of

membranes. J Obstet Gynaecol Res. 2013 Apr ; 39(4):777-82
2.

Goya M, Bernabeu A, Garca N, Plata J, Gonzalez F, Merced C, et al.

Premature rupture of membranes before 34 weeks managed expectantly:
maternal and perinatal outcomes in singletons. J Matern Fetal Neonatal Med.

Wang H, Liddell CA, Coates MM, Mooney MD, Levitz CE, Schumacher AE,

TE

3.

2013 Mar;26(3):2903.

et al. Global, regional, and national levels of neonatal, infant, and under-5

EP

mortality during 1990-2013: a systematic analysis for the Global Burden of

Disease Study 2013. Lancet. 2014 Sep 13;384(9947):95779.
Cunningham FG, ,Leveno KJ ,Bloom sl, Sponge CY, Dashe JS,

4.

AC

Haffman BL, Casey BM, Sheffield JS; Williams obstetrics, New York ,

Scott JHEFFTWA. The Influence of Prenatal Diet on the Mother and Child.
1942 Jan 1;20(1):3546.

6.

Primrose T, Higgins A. A study in human antepartum nutrition. J Reprod

Med. 1971 Dec;7(6):25764.

7.
8.

ST

5.

JU

24th edition:MCGraw-Hill,2014 : 1799.

Czeizel AE. Nutritional supplementation and prevention of congenital

abnormalities. Curr Opin Obstet Gynecol. 1995 Apr;7(2):8894.
Olivares M, Uauy R. Copper as an essential nutrient. Am J Clin Nutr.
1996;63(5):791S 6S.

9.

Prasad AS. Essential and toxic trace elements in human health and disease.
Alan R. Liss Inc., New York, NY; 1988;

10.

Danks DM. Copper Deficiency in Humans. Annual Reviews 4139 El Camino

Way, P.O. Box 10139, Palo Alto, CA 94303-0139, USA; 2003 Nov 28;

Artal R, Burgeson R, Fernandez FJ, Hobel CJ. Fetal and maternal copper
levels in patients at term with and without premature rupture of membranes.
Obstet Gynecol. 1979 May;53(5):60810.

12.

Kiilholma P, Grnroos M, Erkkola R, Pakarinen P, Nnt V. The role of

calcium, copper, iron and zinc in preterm delivery and premature rupture of
fetal membranes. Gynecol Obstet Invest. 1984 Jan;17(4):194201.

13.

Fu YH. [Serum copper levels and pathologic changes in the fetal membranes
in cases of premature rupture of the membranes]. Zhonghua Fu Chan Ke Za
Zhi. 1989 Sep;24(5):2768, 317.

14.

Heninger GR, Delgado PL, Charney DS. The revised monoamine theory of
depression: a modulatory role for monoamines, based on new findings from
monoamine depletion experiments in humans. Pharmacopsychiatry. 1996
Jan;29(1):211.

15.

Hansen CR, Malecha M, Mackenzie TB, Kroll J. Copper and zinc deficiencies
in association with depression and neurological findings.

16.

Crayton JW, Walsh WJ. Elevated serum copper levels in women with a
history of post-partum depression. J Trace Elem Med Biol. 2007;21(1):1721.

17.

Etebary S, Nikseresht S, Sadeghipour HR, Zarrindast MR. Postpartum

depression and role of serum trace elements. Iran J Psychiatry. 2010
Jan;5(2):406.

18.

Zieba A, Kata R, Dudek D, Schlegel-Zawadzka M, Nowak G. Serum trace

elements in animal models and human depression: Part III. Magnesium.
Relationship with copper. Hum Psychopharmacol. 2000 Dec;15(8):6315.

19.

Schlegel-Zawadzka M, Zieba A, Dudek D, Zak-Knapik J, Nowak G. Is serum

copper a trait marker of unipolar depression? A preliminary clinical study.
Pol J Pharmacol. 1999 Jan 12;51(6):5358.

EP

AC

ST

JU

20.

TE

11.

Raman L, Shatrugna V. Nutrition in pregnancy and lactation. Textb Hum Nutr

3/E. Oxford and IBH Publishing; 2009;233.

21.

-Mood MB, Zilaee M, -Mobarhan MG, Sheikh-Andalibi MS, MohadesArdabili H, Dehghani H, et al. Comparison of Dietary Macro and Micro
Nutrient Intake between Iranian Patients with Long-term Complications of
Sulphur Mustard Poisoning and Healthy Subjects. Malays J Med Sci.
Jan;21(6):1926.

22.

Shidfar F, Ameri A. Effect of iron supplements on serum copper status in

pregnant women in Islamshahr. Iran J Endocrinol Metab. 2003;5(4):299305.

Jafari syead M, Mohammadi M, Baghaei H, Movahed A, Akbarzadeh S,
Kowsarifard M, et al. Serum level of Zinc and Copper among pregnant
women of Jam area referred to Towhid Hospital,southern part of Bushehr.
ISMJ. ISMJ; 2015 May 15;18(2):34452.

24.

Janghorban R, Ziaei S, Faghihzade S. Evaluation of serum copper level in

pregnant women with high hemoglobin. Iran J Med Sci. 2006;31(3):1702.

25.

Ilhan N, Ilhan N, Simsek M. The changes of trace elements, malondialdehyde

levels and superoxide dismutase activities in pregnancy with or without
preeclampsia. Clin Biochem. 2002 Jul;35(5):3937.

26.

Vigeh M, Yokoyama K, Ramezanzadeh F, Dahaghin M, Sakai T, Morita Y, et

al. Lead and other trace metals in preeclampsia: a case-control study in
Tehran, Iran. Environ Res. 2006 Feb;100(2):26875.

27.

Vukeli J, Kapamadzija A, Petrovi D, Gruji Z, Novakov-Miki A,

Kopitovi V, et al. Variations of serum copper values in pregnancy. Srp Arh
Celok Lek. Jan;140(1-2):426.

28.

Rahmanian M, Jahed FS, Yousefi B, Ghorbani R. Maternal serum copper and

zinc levels and premature rupture of the foetal membranes. J Pak Med Assoc.
2014 Jul;64(7):7704.

29.

Zhang H, Chen H, Shan L. [Study on the relationship between copper, lysyl

oxidase and premature rupture of membranes]. Zhonghua Fu Chan Ke Za Zhi.
2006 Jan;41(1):711.

30.

Veena R, Narang AP, Banday AW, Bhan VK. Copper and zinc levels in
maternal and fetal cord blood. Int J Gynaecol Obstet. 1991 May;35(1):479.

31.

Russo AJ. Analysis of plasma zinc and copper concentration, and perceived
symptoms, in individuals with depression, post zinc and anti-oxidant therapy.
Nutr Metab Insights. 2011 Jan;4:1927.

ST

JU

32.

AC

EP

TE

23.

Cunningham-Rundles S, McNeeley DF, Moon A. Mechanisms of nutrient

modulation of the immune response. J Allergy Clin Immunol. Elsevier; 2005
Jun 6;115(6):111928; quiz 1129.

33.

Thakur S, Gupta N, Kakkar P. Serum copper and zinc concentrations and their
relation to superoxide dismutase in severe malnutrition. Eur J Pediatr. 2004
Dec;163(12):7424.

34.

Percival SS. Copper and immunity. Am J Clin Nutr. 1998 May;67(5

Suppl):1064S 1068S.
Morton MS, Elwood PC, Abernethy M. Trace elements in water and
congenital malformations of the central nervous system in South Wales. Br J
Prev Soc Med. 1976 Mar;30(1):369.

36.

Pathak P, Kapil U. Role of trace elements zinc, copper and magnesium during
pregnancy and its outcome. Indian J Pediatr. 2004 Nov;71(11):10035.

37.

Rich-Edwards JW, Kleinman K, Abrams A, Harlow BL, McLaughlin TJ,

Joffe H, et al. Sociodemographic predictors of antenatal and postpartum
depressive symptoms among women in a medical group practice. J Epidemiol
Community Health. 2006 Mar;60(3):2217.

JU

ST

AC

EP

TE

35.

Table 1: Descriptive characteristics of the participants

Supplemented
group
N
124
Mean SD
Height (cm)
1606
Gestational age (week day)
161
Weight before pregnancy (kg)
6210
2
BMI before pregnancy (kg/cm )
244
Family income per month (10 cubed IRR) 6,0005,000
Median (IQR)
Age (yrs)
24 (6)
Emotional stress/fatigue caused by job
3 (0)
based on mothers perception
Tolerable
Emotional support from family
4 (0)
based on mothers opinion
Good
2 (1)
Compliance to the supplement/placebo
Good
Frequency (%)
st
Depressive symptoms in 1 trimester
31(24.4%)
st
Anxiety symptoms in 1 trimester
72(56.6%)
Smoker
1 (0.8 %)
Alcohol consumption
0 (0 %)
Opium consumption
0 (0%)
History of anxiety disorders
5 (3.9%)
Polyhydramnios
0 (0 %)
Placenta Previa
1 (0.8%)
3 (2.4%)
Anemia

Placebo group
107
1606
161
638
253
5,5002,000
24 (7)
3 (0)*
Tolerable
4 (1)
Good
2 (1) *
Good

ST

AC

EP

TE

Parameters

JU

*P<.05, Mann-Witney U or Chi2

4(3.7%)*
30(27%)*
0 (0 %)
0 (0 %)
0 (0%)
3 (2.7%)
1 (0.9%)
1 (0.9%)
3 (2.7%)

Table2: primary and secondary outcomes related to mother in two groups

Placebo
group

Relative
Odds
PRisk
Ratio
value
(95%
(95%
CI)
CI)
8(6.7%)
10(9.9%)
1.03
1.57(1)
0.359
PROM
(0.96(0.601.11)
4.17)
1(0.79%)
2(1.80%)
1.01
PPROM
(0.981.04)
52(40.94%) 27(24.54%)
0.60(2)
0.47(3)
Cesarean
0.009
(0.41(0.24section
0.88)
0.82)
1(1.05%)
18(16.98%) 16.129
32.36(4) 0.004
Depression
(2.19(2.97(2nd)
125.03)
352.10)
(5)
rd
1(1.06%)
8(9.09%)
8.547
Depression (3 )
(1.0966.70)
nd
2(3.63%)
22
7.575
7.032(6) 0.015
Anxiety (2 )
(27.50%)
(1.85(1.4631.25)
33.90)
rd
0(0%)
10(17.24%)
Anxiety (3 )
* 1: adjusted for presence of intrauterine infection and depressive symptoms during
pregnancy (n=236)

ST

AC

EP

Self-reported symptoms
(trimester)

TE

Supplemented
group

* 2: P: 0.009 using Pearson Chi-Square

JU

* 3: adjusted for weight of neonate at delivery, state of polyhydramniosis, vaginal

bleeding, placenta previa, intra-uterine infection, pre-eclampsia, PROM, placenta
abruption. (n=233)
* 4: adjusted for state of job pressure, and age. (n=190)
* 5: P: 0.016 using Fishers Exact Test
* 6: adjusted for state of job pressure, depression in 2st trimester; and age. (n=128)

Figure1: Participants flow diagram

Assessed for eligibility (n= 2854)

Excluded (n=2616)
Not meeting inclusion criteria (n=2543)
Declined to participate (n=57)
Other reasons (n=16) due to poor dental
hygiene.

EP

TE

Randomization (n=238)

Allocated to copper supplement

(n=127)

Received placebo (n=111)

Did not received placebo (n=0)

Received copper suppl. (n=127)

Did not received copper suppl.
(n=0)

Lost to follow up (n=0)

ST

AC

Allocated to placebo (n=111)

JU

Discontinued copper suppl. (n=0)

Lost to follow up (n=0)

Discontinued placebo (n=2) due to
nausea.

Analyzed (n=127)

Analyzed (n=111)

Excluded from analysis (n=0)

Excluded from analysis (n=0)