Gynecol, obstet. Invest.

15: 93-102 (1983)

Relative Fatty Acid Composition of Serum Lecithin in the

Normal Puerperium

Ulf Rosing, Per Johnson, Anders Ölund, Göran Samsioe

Department of Obstetrics and Gynecology, Huddinge University Hospital,
Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and
Gynecology, Sahlgrenska Hospital, Göteborg, Sweden

Key Words. Lipids • Phospholipids ■Fatty acids ■Unsaturated fatty acids ■

Puerperium

Abstract. 21 women who had been followed regularly during their normal pregnan­
cies were examined in the puerperium. The relative fatty acid composition of serum leci­
thin was analyzed by means of gas-liquid chromatography. Palmitic acid decreased and
stearic acid increased, which indicates a shift to more pathway II-synthesized lecithin in
the puerperal period. Linoleic acid increased and the longer polyunsaturated fatty acids
decreased. These changes were slow as compared to the changes in the saturated fatty acids.
No correlations were found between the saturated fatty acids and linoleic acid dominating
the polyunsaturated fatty acids. The results indicate different incorporational ways into the
lecithin molecule of these fatty acid groups. It is suggested that the deacylation-reacylation
cycle is responsible for the high content of longer polyunsaturated fatty acids still 1 week
after delivery'. 6 weeks after delivery normal values were recorded. Breast-feeding did not
seem to influence the fatty acid pattern of serum lecithin.

Introduction

It is a well-known fact that normal pregnancy induces changes in lipid

metabolism. The highest values of serum lipids are found during the third
trimester [18]. The major phospholipid in serum is lecithin (phosphatidyl­
choline), which comprises approximately 70% of all serum phospholipids
during pregnancy [3. 6] as well as in the nonpregnant state [19]. Except for
lysolecithin all other phospholipids increase during pregnancy [18]. This
pattern is reversed in the early puerperium [17], During pregnancy not only
© 1983 S. Karger AG, Basel
137.73.144.138 - 3/5/2018 6:16:22 AM

0378-7346/83/0152-0093S2.75/0
King's College London
Downloaded by:
 Rosing/Johnson/Olund/Samsioe 94

quantitative but also qualitative changes take place [3, 7, 15]. Towards
delivery the most marked changes in the fatty acid composition of serum
lecithin are encountered. Other studies have indicated that qualitative dif­
ferences are present also in complicated pregnancies as in cholestasis of
pregnancy [3], diabetic pregnancy [14] and preeclampsia [8].
Changes in lipid metabolism have been associated with the hormonal
environment. Estrogens and progestogens are markedly increased during
pregnancy and are abruptly reduced after delivery [16]. Studies of estrogen
supplementary therapy suggest a connection between estrogens and triglyc­
erides and phospholipids [13, 19] as well as the serum lecithin fatty acid
pattern [13]. Progestogens do not seem to interfere with these parameters to
the same extent as estrogens. A study with medroxyprogesterone acetate
which resembles the endogenously produced gestagens showed no effect on
lipid metabolism when 10 mg/d were used [12].
At the present time, little information is at hand as to the fatty acid
composition of lecithin in the puerperium. The aim of the present study,
which is part of a prospective investigation covering the second half of
pregnancy and the puerperal period, is to analyze the relative fatty acid
composition of serum lecithin during the normal puerperium.

Material and Methods

Clinical Series. 21 women who had fulfilled a normal pregnancy during which they
had been regularly checked with venous blood samples [7] were further examined in the
puerperium. During delivery no abnormal blood loss (> 6 0 0 ml) was recorded. One sam­
ple. however, was lost. All mothers were in good health at their departure from the hospital
as well as at the regular checkup 6 weeks after delivery. During the 1st week after delivery
all women started breast-feeding but 3 of them stopped shortly after returning home.

Blood Sampling. Venous blood samples were drawn at the ward about 1 week (mean
6 days) after delivery and after at least 8 h of fasting. Fasting venous blood samples were
also collected at the regular examination 6 weeks after delivery. Samples were also drawn at
or immediately after delivery. During labor the women were allowed to drink water and
fruit juices. The samples were drawn from an antecubital vein and immediately centrifuged
at 2,000 rpm for 10 min. Serum was recovered at once, frozen and stored at -2 0 °C in glass
tubes with Teflon screw caps until assayed.

Laboratory Analyses. The relative fatty acid composition of serum lecithin was ana­
lyzed in a gas-liquid chromatograph. The method is described elsewhere [7], The fatty acid
values are given in mole percent of the fatty acid methyl esters. Fatty acids not exceeding
1% (minor fatty acids) have not been tabulated. S-Thyroxin, normalized s-thyroxin and
137.73.144.138 - 3/5/2018 6:16:22 AM
King's College London
Downloaded by:
 Scrum Lecithin Fatty Acids in Norma! Puerperium 95

the saturational level of s-thyroxin-binding proteins were determined according to the

standard procedures at the Department of Clinical Chemistry, Huddinge University Hos­
pital. They were analyzed 6 weeks after delivery to ensure a normal thyroidal metabo­
lism.

Statistical Methods. Student’s t test was employed for paired data. Correlation analy­
sis was used. Values of p < 0.05 were considered statistically significant.

Results

Clinical Series
Mean age was 27.1 years and mean parity was 1.7. Mean weight
increase during pregnancy was 14.9 kg and the women still exceeded their
weight before pregnancy with a mean of 4.6 kg 6 weeks after deliver)'. In 3
cases cesarean section was performed; the other women had normal deliv­
eries. All women gave birth to healthy infants of normal weight and length
and with Apgar scores of 9 or 10 after 5 min. Besides iron supplementary
therapy 9 mothers were prescribed methylergometrin (Methergin®, San-
doz). 25 mg three times a day for 5 days. 1 female was treated with pivam-
picillin (Pondocillin®, Lovens) because of endometritis. The thyroid gland
screening tests were all within normal ranges 6 weeks after delivery.

Serum Lecithin Fatty Acids

In table I the mean values of the major fatty acids of serum lecithin are
given. The mean values were recorded at delivery and at 1 week and 6
weeks thereafter. In figure 1 the values from table I are illustrated. Dotted
lines illustrate the distribution during pregnancy.
In table II mean fatty acid differences between different sampling times
are summarized. During the 1st week after delivery a decrease in palmitic
acid (p < 0.001) was found concomitant with an increase in stearic (p <
0.001) and oleic (p < 0.05) acids. In the following 5 weeks palmitic acid was
further reduced (p < 0.001). At the same time statistically highly significant
reductions were also found for palmitoleic, oleic, dihomo-y-linolenic and
22:6 acids and for the sum of the linolenic acid series. At the same time
there was a further increase in stearic acid (p < 0.001) while increased
values were noted for linoleic acid (p < 0.001) as well as for the sum of the
linoleic acid series (p < 0.001). The individual fatty acid development
between delivery and 6 weeks thereafter corresponded to the development
between 1 and 6 weeks after delivery.
137.73.144.138 - 3/5/2018 6:16:22 AM
King's College London
Downloaded by:
 Rosing/Johnson/Ôlund/Samsioe 96

Table I. Relative composition of major fatty acids in serum lecithin in the normal puerpé­
rium (mean ± SEM)

Fatty acid Delivery (n = 20) 1 week after 6 weeks after

delivery (n = 21) delivery (n = 21)

16:0 36.2 ±0.22 33.4±0.24 30.8 ±0.19

18:0 9.2 ± 0.16 10.4 ± 0.19 12.5 ± 0.17
16:1 (n-7) 1.50 ±0.08 1.54 ±0.04 1.26 ±0.06
18:1 (n-9) 12.3 ±0.24 13.1 ±0.27 11.5 ±0.22
18:2 (n-6) 22.8±0.52 22.0±0.54 27.2 ±0.49
20:3 (n-6) 3.7 ±0.13 3.9 ± 0.13 2.9 ±0.11
20:4 (n-6) 6.8 ±0.26 7.5±0.25 7.0 ±0.18
18-22 (n-6) 34.0 ±0.46 34.2 ±0.31 37.5±0.45
22:6 (n-3) 4.7 ±0.21 4.7 ±0.21 3.6±0.20
18-22 (n-3) 6.2 ±0.24 6.2 ±0.20 5.1 ±0.23

Common names of the fatty acids are given in table IV.

Table II. Mean differences (A) between different stages of the normal puerperium in indi­
vidual fatty acids and fatty acid groups

Fatty acid Delivery - 1 week after Delivery -

1 week after delivery - 6 weeks after
delivery 6 weeks after delivery
delivery
A A A

16:0 - 2.8*** - 2.6*** - 5.4***

18:0 + 1.2*** + 2.1*** + 3.3***
16:1 (n-7) + 0.04 - 0.28*** - 0.24*
18:1 (n-9) + 0.8* - 1.6*** -0 .8 *
18:2 (n-6) - 0 .8 + 5.2*** + 4.3***
20:3 (n-6) + 0.2 - 1.0*** -0.8***
20:4 (n-6) + 0.7 - 0 .5 + 0.2
18-22 (n-6) + 0.2 + 3.3*** + 3.4***
22:6 (n-3) 0 + 1.1*** - 1.2***
18-22 (n-3) + 0.1 - 1.1** - 1.1**

n = 20 at delivery, n = 21,1 and 6 weeks after delivery.

Statistical significance: * p = 0.05; ** p = 0.01; ***p = 0.001.
137.73.144.138 - 3/5/2018 6:16:22 AM
King's College London
Downloaded by:
 Serum Lecithin Fatty Acids in Normal Puerperium 97

In table III correlation coefficients between certain fatty acids are

reported. A negative correlation was found between palmitic and stearic
acids at delivery (p < 0.01), at 1 week thereafter (p < 0.001) and at 6 weeks
after delivery (p < 0.05). Linoleic acid had a strong positive relationship
with the sum of the linoleic acid series on all three occasions. Accordingly,
there were negative correlations between linoleic acid series at delivery (p <
0.05). at 1 week thereafter (p < 0.01) and at 6 weeks after delivery (p <
0.1). 1 week after delivery linoleic and arachidonic acid showed a negative
correlation (p < 0.05) simultaneously with a slight decrease in linoleic acid
and an increase in arachidonic acid. No relationship was noticed between
linoleic and dihomo-y-linolenic acids. The sum of the linoleic acid series
showed statistically significant negative correlations to palmitoleic acid at
delivery and to oleic acid on all three occasions. There was no relationship
between palmitic or stearic acid and linoleic acid on any occasion. Statisti­
cally highly significant correlations were recorded between 22:6 acid and
the sum of the linolenic acid series on all the three occasions. The results

Table III. Correlation coefficients between selected fatty acids of serum lecithin in the
normal puerperium

Correlation coefficients (r values) '

delivery 1 week after 6 weeks after

delivery delivery

16:0 versus 18:0 -0.57** -0.74*** -0 .5 2 *

18:2 (n-6) versus 18-22 (n-6) + 0.82*** + 0.64** + 0.87***
18:2 (n-6) versus rest of n-6 series - 0.48* -0.65** -0 .3 6
18:2 (n-6) versus 20:3 (n-6) - 0 .2 9 -0 .3 2 -0 .2 7
18:2 (n-6) versus 20:4 (n-6) -0 .2 8 -0 .4 4 * -0 .2 6
22:6 (n-3) versus 18-22 (n-3) + 0.99*** + 0.98*** + 0.97***
18:3 (n-3) versus 22:6 (n-3) -0 .0 6 -0 .3 5 + 0.24
18-22 (n-6) versus 18-22 (n-3) - 0.72*** - 0 .3 7 -0.63**
18-22 (n-6) versus 22:6 (n-3) -0.71*** - 0 .3 0 -0.61**
18-22 (n-6) versus 16:1 (n-7) -0.68*** -0 .3 6 -0 .1 9
18-22 (n-6) versus 18:1 (n-9) -0.56** - 0.60** -0.67***

n = 20 at delivery, n = 21, 1 and 6 weeks after delivery.

Statistical significance: * p = 0.05; ** p = 0.01; *** p = 0.001.
137.73.144.138 - 3/5/2018 6:16:22 AM
King's College London
Downloaded by:
 Rosing/Johnson/Olund/Samsioe 98

imply that these metabolites are exchangeable for each other. Thus both of
them showed a negative relationship to the sum of the linoleic acid series at
delivery (p < 0.001) and at 6 weeks after delivery (p < 0.01), but not at 1
week after delivery. Linolenic acid manifested no relationship to 22:6 acid.
Breast-feeding did not seem to interfere with the fatty acid composition of
maternal serum lecithin. 6 weeks after delivery there were no fatty acid
differences between the breast-feeding women and the small group of non-
lactating mothers.

Discussion

Serum lecithin is mainly synthesized in the liver along three endoge­

nous pathways: pathway I (cytidine diphosphate choline diglyceride path­
way), pathway II (cytidine diphosphate ethanolamine methylation path­
way) and Lands deacylation-reacylation cycle [2, 4], According to van
Deenen [ 1] the deacylation-reacylation cycle is a second step redistributing
fatty acid of de novo synthesized lecithin. In this way especially longer
polyunsaturated fatty acids seem to be incorporated in position 2 of lecithin
in exchange of shorter unsaturated fatty acids. Saturated fatty acids mainly
incorporated in position 1 seem to be less affected by redistributional activ­
ities. Pathway I is, compared to pathway II, the faster and quantitatively
more important biosynthetical route [9, 10]. The increase in the shorter
palmitic acid at the cost of the longer stearic acid suggests a stimulated
synthesis of pathway I. This shift was found during the normal pregnancy

Table IV. Common names of fatty acids given in tables I—III and in figure 1

16:0 palmitic acid

18:0 stearic acid
16:1 (n-7) palmitoleic acid
18:1 (n-9) oleic acid
18:2 (n-6) linoleic acid
18:3 (n-3) linolenic acid
20:3 (n-6) dihomo-y-linolenic acid
20:4 (n-6) arachidonic acid
22:6 (n-3) 22:6 acid (of the linolenic acid series)
18-22 (n-6) sum of linoleic acid series
18-22 (n-3) sum of linolenic acid series
137.73.144.138 - 3/5/2018 6:16:22 AM
King's College London
Downloaded by:
 Serum Lecithin Fatty Acids in Normal Puerperium 99

[7], The same study also showed an increased incorporation of longer poly­
unsaturated fatty acids as well as of monoenoic nonessential (palmitoleic
and oleic) acids at the cost of linoleic acid. The increase in longer polyun­
saturated fatty acids was thought to be associated with the deacylation-
reacylation cycle.
In the present study the puerperal influence on the relative fatty acid
composition of serum lecithin is reported. There was a reduction of pal­
mitic acid concomitant with an increase in stearic acid. This finding would
emphasize a shift in pathways for the lecithin synthesis and cannot be
explained only by an increased removal rate. Also there was a negative
relationship between these saturated fatty acids, which implies that they are
metabolically associated with each other, i.e., one molecule of palmitic acid
is most often exchanged for one molecule of stearic acid or vice versa. This
observation further supports the assumption that these saturated fatty acids
share a common position in lecithin, i.e., position 1. It is well documented
that phosphoglycerides also are able to esterify monoenoic fatty acids in
position 1. In rodents, figures around 5% have been reported [1,2, 4] while
only trace amounts of polyunsaturated fatty acids have been found in this
position.
In the present report oleic acid increased in the first puerperal week,
which was the only unsaturated fatty acid change during this period. The
total increase in oleic and stearic acids together was of the same magnitude
as the decrease in palmitic acid at this opportunity. Therefore, it is not
unlikely, that this finding reflects an increased incorporation of monoenoic
acids in position 1 of lecithin in the puerperal period. If this assumption is
correct, pregnancy should be associated with a reduced content of mono­
enoic fatty acids in position 1. This suggestion is indirectly supported by the
high negative correlation coefficients between palmitic and stearic acids in
the second half of pregnancy as well as by the tendency towards a gradually
increased total content of saturated fatty acids [7],
In the present study linoleic acid, which was unchanged or somewhat
reduced 1 week after delivery, manifested a dramatical increase thereafter.
Mechanisms associated with this increased level are probably linked to the
withdrawal of the endogenous demands and/or an altered endogenous
metabolism suggested to be at hand during pregnancy [7],
In the present study all changes in the polyunsaturated fatty acid pat­
tern occurred more than 1 week after delivery. This behavior is interesting
as it differs from what was found in the saturated fatty acids, which showed
evident changes already 1 week after delivery.
137.73.144.138 - 3/5/2018 6:16:22 AM
King's College London
Downloaded by:
 Rosing/Johnson/Ôlund/Samsioe 100

Week

.
Fig. 1 The relative composition of major fatty acids in serum lecithin at different
stages of the normal puerperium. Dotted lines illustrate the distribution in normal preg­
nancy. D = Delivery'. Common names of the fatty acids are given in table IV.

In figure 1 the different fatty acids are illustrated from midpregnancy

until 6 weeks after delivery. There is a gradual change of palmitic, stearic
and linoleic acids during pregnancy. However, this was not the case with the
other polyunsaturated fatty acids. They showed only a slight increase in the
second half of pregnancy or no increase at all as in the 22:6 acid. Compared
to their values 6 weeks after delivery the major changes occurred during
early pregnancy. Furthermore, there was no relationship between either
stearic or palmitic acid with linoleic acid at any instance in the pregnancy or
in the puerperium. Therefore, there are doubtlessly different incorpora-
tional ways between saturated and polyunsaturated fatty acids during preg­
nancy as well as in the puerperal period. These findings support the above-
mentioned two-step synthesis of lecithin.
137.73.144.138 - 3/5/2018 6:16:22 AM
King's College London
Downloaded by:
 Serum Lecithin Fatty Acids in Normal Puerperium 101

Linoleic acid reduction during pregnancy is discussed elsewhere [7],

Fetal demands of essential fatty acids were suggested to be considerable.
However, the still unchanged level of linoleic acid 1 week after delivery
indicates that fetal demands are of less importance than would be expected
from the reduced level of this fatty acid. Dietary habits interfere with the
content of essential fatty acids in breast milk [5]. The present investigation
did not show any fatty acid differences in serum lecithin between breast­
feeding and nonlactating mothers. All fatty acid values 6 weeks after deliv­
ery are close to or equivalent with those of nonpregnant women earlier
reported [11].

Acknowledgments

We appreciate especially Mrs. Birgit Haggquist for her skilful performance of the
GLC analysis and blood sampling as well as the midwives at the delivery and ward depart­
ment for blood sampling. We also thank Mrs. Rose-Marie Hdkansson for typing the manu­
script.

References

1 Deenen, L.L.M. van: Chemistry of phospholipids in relation to biological mem­

branes. Pure appl. Chem. 25: 25-56 (1971).
2 Gompertz, D.: Phospholipids and their metabolism. J. clin. Path. 26: suppl. 5,
pp. 11-16 (1973).
3 Johnson, P.; Olcg&rd, R.; Samsioe, G.; Gustavsson, A.: Studies in cholestasis of preg­
nancy. III. Fatty acid composition of serum phosphoglycerides. Acta obstet. gynec.
scand. 54: 241-246 (1975).
4 McMurray, W.C.; Magee, W.L.: Phospholipid metabolism. A. Rev. Biochem. 41:
129-160 (1972).
5 Potter, J.M.; Nestel, P.J.: The effects of dietary fatty acids and cholesterol on the milk
lipids of lactating women and the plasma cholesterol of breast-fed infants. Am. J.
clin. Nutr. 29: 54-60 (1976).
6 Renkonen, O.-V.: Serum lipids of labouring mothers and newborn babies. Annls
Med. exp. Biol. Fenn. 44: suppl., pp. 10-48 (1966).
7 Rosing, U.; Johnson, P.; Olund, A.; Samsioe, G.: The relative fatty acid composition
in the second half of normal pregnancy. Obstet. gynec. Invest, (in press).
8 Rosing, U.; Samsioe, G.: The relative fatty acid composition of serum lecithin in
pre-eclampsia. Acta obstet. gynec. scand., suppl. 93, p. 43 (1980).
9 Sakamoto, H.; Akino, T.: Interrelationship between bile lecithin and liver lecithin
newly synthesized through phosphatidic pathway. Tohoku J. Med. 106: 45-59
(1972).
137.73.144.138 - 3/5/2018 6:16:22 AM
King's College London
Downloaded by:
 Rosing/Johnson/Ölund/Samsioe 102

10 Sakamoto, H.; Akino, T.: Interrelationship between bile lecithin and liver lecithin
newly synthesized through methylation and direct acylation pathways. Tohoku J.
Med. 106: 61-74 (1972).
11 Samsioe, G.: Serum lipids and fatty acid composition of serum lecithin in the non­
pregnant state in patients with previous cholestasis of pregnancy. Acta obstet, gynec.
scand. 55: 1-6 (1976).
12 Silfverstolpe, G.; Gustavsson, A.; Samsioe, G.; Svanborg, G.: Lipid metabolic studies
in oophorectomized women. Effects of three different progestogens. Acta obstet,
gynec. scand., suppl. 88, pp. 89-95 (1979).
13 Silfverstolpe, G.; Johnson, P.; Samsioe, G.; Svanborg, A.; Gustavsson, A.: Lipid
metabolic studies in oophorectomized women. Effects induced by two different estro­
gens on serum individual phospholipids and serum lecithin fatty acid composition;
diss. University of Göteborg (1981).
14 Skryten, A.: Lipid metabolism in diabetic pregnancy; diss. University of Göteborg
(1977).
15 Skryten, A.; Johnson, P.; Gustavsson, A.: Studies in normal pregnancy. III. Fatty acid
composition of serum phosphoglycerides and cholesterol ester. Acta obstet, gynec.
scand. 59: 305-309 (1980).
16 Suginami, H.: Composite microassays of plasma progesterone, 17a-OH-progester-
one, estrone, 17ß-estradiol and estriol in normal adult women. II. Steroid patterns in
normal pregnancy, labor and the puerperium. Folia endocr. jap. 51: 924-937
(1975).
17 Svanborg, A.; Vikrot, O.: Plasma lipids during the first week after delivery. Acta med.
scand. 178: 631-636 (1965).
18 Svanborg, A.; Vikrot, O.: Plasma lipid fractions, including individual phospholipids,
at various stages of pregnancy. Acta med. scand. 178: 615-630 (1965).
19 Svanborg, A.; Vikrot, O.: The effect of estradiol and progesterone on plasma lipids in
oophorectomized women. Acta med. scand. 179: 615-622 (1966).

Received: November 20, 1981; accepted: February 5, 1982

Dr. Ulf Rosing. Department of Obstetrics and Gynecology.

Huddinge University Hospital, S—141 86 Huddinge (Sweden)
137.73.144.138 - 3/5/2018 6:16:22 AM
King's College London
Downloaded by: