February 2020 Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004-2020 Magellan Rx Management. All Rights Reserved.

Prenatal Vitamins Therapeutic Class Review (TCR)

February 10, 2020

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FDA-APPROVED INDICATIONS

Prenatal vitamins are approved for nutritional supplementation of females of childbearing potential during pre-conception, pregnancy, or lactation.1

Current products are listed in Appendix A.

OVERVIEW

Prenatal vitamins provide supplementation for both the mother and fetus. While prenatal supplements contain numerous vitamins and minerals, the folic acid, iron, and calcium content are particularly important.2

When folic acid stores are replenished before pregnancy, a 50% reduction in neural tube defects has been observed.3 The 2017 American College of Obstetricians and Gynecologists (ACOG) Neural Tube Defect Practice Bulletin recommends periconceptional folic acid supplementation as it has shown to reduce the occurrence and recurrence of neural tube defects.4 All women of child-bearing potential should take folic acid supplementation daily. For women at low-risk of neural tube defect, folic acid supplementation of 400 mcg per day is recommended. Supplementation should be initiated at least 1 month prior to pregnancy and continued through the first 12 weeks of pregnancy. For females at high-risk, defined as those who have had a prior neural tube defect pregnancy, who have a neural tube defect themselves, or who have a partner who has a neural tube defect or a child with a neural tube defect, folic acid supplementation of 4 mg/day is recommended. Supplementation in high-risk patients should be initiated ≥ 3 months prior to pregnancy and continued until 12 weeks of gestational age. Higher levels of folic acid supplementation (> 400 mcg/day) should be achieved by taking an additional folic acid supplement and not by taking excess multivitamins, since they may contain vitamin A, which is potentially teratogenic at high doses.

In 2017, the U.S. Preventive Services Task Force (USPSTF) reaffirmed its 2009 statement on folic acid for neural tube defect prevention.5 The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement 400 mcg to 800 mcg of folic acid (Grade A recommendation). This recommendation does not apply to women who have had a prior pregnancy affected by neural tube defects or women taking certain anti-epileptic medicines. Most organizations recommend that these women take higher doses of folic acid.6 The task force found that most women in the U.S. are not ingesting fortified foods at a level thought to provide optimal benefit. In a setting in which food is fortified with folic acid, the effective amount of additional folic acid supplementation is unclear.

The Centers for Disease Control (CDC) and March of Dimes actively recommend folic acid as one of the nutrients needed in prenatal vitamins.7,8 Iron is recommended to prevent maternal anemia, preterm labor, low birth weight, and aid in maternal/fetal muscle development. Calcium, along with vitamin D, is important for skeletal development, as well as preventing future maternal osteoporosis.9

For pregnant and lactating women ages 14 to 18 years old, the Institute of Medicine (IOM) recommended daily allowance (RDA) is 1,300 mg/day and 600 IU/day of calcium and vitamin D, respectively.10 For pregnant and lactating women ages 19 to 50 years old, the RDA is 1,000 mg and 600 IU daily calcium and vitamin D supplementation, respectively.

Some vitamins contain omega-3 fatty acids, such as docosahexaenoic acid (DHA), in their products to support neural and ophthalmic development. The March of Dimes actively recommends at least 200 mg of DHA/day for women.11

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According to the Academy of Nutrition and Dietetics (formerly the American Dietetic Association), daily vitamin supplementation is not a substitute for a healthy diet.12 Prenatal vitamins should be used along with balanced meals to ensure adequate levels of vitamins and minerals and ensure a healthy pregnancy outcome.

PHARMACOLOGY13

Calcium is used to maintain calcium balance. Adult pregnant and lactating females require 1,000 mg elemental calcium per day. Calcium supplementation decreases the risk of preeclampsia and hypertensive disease in pregnancy.

Folic acid is necessary for formation of a number of coenzymes in many metabolic systems, especially for purine and pyrimidine synthesis. Folic acid is essential for neural tube development occurring within 28 days of conception.

Iron replaces iron found in hemoglobin, myoglobin, and enzymes. Iron allows for the transportation of oxygen via hemoglobin. Iron stores are vital for maternal safety. Maternal iron stores at conception are a strong indicator of maternal iron status and risk of iron deficiency and anemia in later pregnancy. The recommendation for pregnant females within the first trimester is 15 mg of elemental iron per day; and 27 mg of elemental iron per day during the second and third trimesters. Lactating females require 9 mg to 10 mg of elemental iron per day.

PHARMACOKINETICS14

Prenatal supplements are available as over-the-counter (OTC) and prescription. They differ in their consistency, quality level, and relative bioavailability for fat-soluble and water-soluble vitamins and important minerals. Most OTC supplements now contain higher levels of folic acid.

CONTRAINDICATIONS/WARNINGS15

Hypersensitivity to any component of the formulation and pre-existing hypervitaminosis are considered contraindications. Iron toxicity is a boxed warning. Severe iron toxicity may occur in overdose, particularly if ingested by children. It should be stored out of reach of children and in child resistant bottles. Iron supplementation should be avoided in patients with hemochromatosis and hemosiderosis. Prenatal vitamin formulations containing omega-3 fatty acids, such as ALA (alpha-linolenic acid, EPA (eicosapentaenoic acid), and DHA (docosahexaenoic acid), from fish oils may potentially have antithrombotic activities; thereby, increased bleeding times may be noticed. The administration of DHA should be avoided in patients with inherited or acquired bleeding diatheses, including patients taking anticoagulants. Prenatal vitamins should be used with caution in patients with severe hepatic and renal impairment. Use caution in patients with kidney stones due to the calcium content.

DRUG INTERACTIONS16

The absorption of iron can be inhibited by eggs and milk. Some products may contain phenylalanine. Pyridoxine supplements should not be taken with levodopa alone. The actions of levodopa may be antagonized with concomitant use.

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ADVERSE EFFECTS17

Common reactions to prenatal supplements are gastrointestinal including abdominal pain, constipation, dark stools, diarrhea, nausea, and vomiting. Allergic reactions can occur.

SPECIAL POPULATIONS18

Pediatrics

Prenatal vitamins are approved in adolescents and adult females.

Pregnancy

All products are generally recognized as safe (Pregnancy Category A).

Hepatic Impairment

Prenatal vitamins should be used in caution in patients with severe hepatic impairment.

Renal Impairment

Prenatal vitamins should be used with caution in patients with severe renal impairment. Use caution in patients with kidney stones due to the calcium content.

DOSAGES19

Prenatal vitamins are available as oral dosage forms, including tablet, caplets, capsules, softgel capsules, chewable tablets, liquid, powder, and bars. They should be taken once daily with food, unless otherwise specified. If patients cannot tolerate prenatal vitamins, time of dosing can be changed; taking the vitamin prior to sleep or changing the dosage form may help.

CLINICAL TRIALS

Search Strategy

Articles were identified through searches performed on PubMed, and review of information sent by manufacturers. Search strategy included the agents in this class. Randomized, controlled, comparative trials are considered the most relevant in this category. Studies included for analysis in the review were published in English, performed with human participants, and randomly allocated participants to comparison groups. In addition, studies must contain clearly stated, predetermined outcome measure(s) of known or probable clinical importance, use data analysis techniques consistent with the study question, and include follow-up (endpoint assessment) of at least 80% of participants entering the investigation. Despite some inherent bias found in all studies, including those sponsored and/or funded by pharmaceutical manufacturers, the studies in this therapeutic class review were determined to have results or conclusions that do not suggest systematic error in their experimental study design. While the potential influence of manufacturer sponsorship and/or funding must be considered, the studies in this review have also been evaluated for validity and importance.

A randomized, double-blind, multicenter prevention trial with a factorial design tried to determine whether supplementation with folic acid or a combination of seven other vitamins (A, D, B1, B2 , B6, C, and nicotinamide) around the time of conception can prevent neural tube defects, particularly

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anencephaly, spina bifida, and encephalocele.20 A total of 1,817 women at high risk of having a pregnancy with a neural tube defect, due to a prior affected pregnancy, were randomized to 1 of 4 groups (folic acid, other vitamins, both, or neither). A total of 1,195 had a completed pregnancy where the fetus or infant was known to have or not have a neural tube defect; 27 had a known neural tube defect, 6 in the folic acid groups, and 21 in the 2 other groups, a 72% protective effect (relative risk [RR], 0.28; 95% confidence interval [CI], 0.12 to 0.71). The other vitamins showed no significant protective effect (RR, 0.8; 95% Cl, 0.32 to 1.72). No adverse events for folic acid were seen.

SUMMARY

A prenatal vitamin with folic acid, iron, calcium, and vitamin D satisfies the requirements of most pregnant women.

REFERENCES

1 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 2 Rakel. Preconception counseling. Textbook of Family Medicine. 2007. 7th ed. Chapter 29. 3 Milunsky A, Jick H, Jick SS, et al: Multivitamin/folic acid supplementation in early pregnancy reduces the prevalence of neural tube defects. JAMA. 1988; 262:2847-2852. 4 ACOG Practice Bulletin No. 187: Neural Tube Defects. Obstet Gynecol. 2017; 130(6): e279-e290. DOI: 10.1097/AOG.0000000000002412. 5 U.S. Preventive Services Task Force. Folic acid for the prevention of neural tube defects: U.S. Preventive Services Task Force recommendation statement. JAMA, 2017; 317(92):183- DOI:10.1001/jama.2016.1943. Available at: http://jamanetwork.com/journals/jama/fullarticle/2596300. Accessed February 10, 2020. 6 Folic Acid. CDC. Available at: https://www.cdc.gov/ncbddd/folicacid/recommendations.html. Accessed February 10, 2020. 7 Centers for Disease Control. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR 1992; 41(No. RR-14). Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00019479.htm. Accessed February 10, 2020. 8 March of Dimes: Vitamins and minerals during pregnancy. Last updated February 2018. Available at: http://www.marchofdimes.org/pregnancy/vitamins-and-other-nutrients-during-pregnancy.aspx. Accessed February 10, 2020. 9 Salari P, Abdollahi M. The influence of pregnancy and lactation on maternal bone health: a systematic review. J Fam Reprod Health. 2014; 8(4): 135-148. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4266784/. Accessed February 10, 2020. 10 Dietary reference intakes for calcium and vitamin D. Institute of Medicine of National Academies. November 2010. Available at: http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/calciumvitd_lg.jpg?la=en. Accessed February 10, 2020. 11 March of Dimes: Vitamins and minerals during pregnancy. Last updated February 2018. Available at: http://www.marchofdimes.org/pregnancy/vitamins-and-other-nutrients-during-pregnancy.aspx. Accessed February 10, 2020. 12 Kaiser L, Allen LH. American Dietetic Association. Position of the American Dietetic Association: nutrition and lifestyle for a healthy pregnancy outcome. J Am Diet Assoc. 2008; 108(3):553-561. 13 Lowensohn RI, Stadler DD, Naze C. Current Concepts of Maternal Nutrition. Obstetrical & Gynecological Survey. 2016; 71(7): 413-426. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949006/. Accessed February 10, 2020. 14 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 15 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 16 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 17 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 18 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 19 Available at: http://www.clinicalpharmacology.com. Accessed February 10, 2020. 20 Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. Lancet. 1991; 338: 131.

PRENATAL VITAMINS, Appendix A; Current Product Listing

LABEL NAME MANUFACTURER DRUG TYPE PROVIDER SYNERGIES BRAND NAME ROUTE PROVIDER SYNERGIES MARKET BASKETCITRANATAL 90 DHA COMBO PACK MISSION PHARM. SSB CITRANATAL 90 DHA (ORAL) PRENATAL VITAMINSCITRANATAL ASSURE COMBO PACK MISSION PHARM. SSB CITRANATAL ASSURE (ORAL) PRENATAL VITAMINSCITRANATAL B-CALM COMBO PACK MISSION PHARM. SSB CITRANATAL B-CALM (ORAL) PRENATAL VITAMINS

CITRANATAL DHA PACK MISSION PHARM. SSB CITRANATAL DHA (ORAL) PRENATAL VITAMINSCITRANATAL HARMONY CAPSULE MISSION PHARM. SSB CITRANATAL HARMONY (ORAL) PRENATAL VITAMINS

CITRANATAL RX TABLET MISSION PHARM. SSB CITRANATAL RX (ORAL) PRENATAL VITAMINSCOMPLETENATE TABLET CHEW TRIGEN LABORATO SSB COMPLETENATE CHEW TABLET (ORAL) PRENATAL VITAMINS

ENBRACE HR SOFTGEL JAYMAC PHARMA SSB ENBRACE HR (ORAL) PRENATAL VITAMINSEXPECTA PRENATAL COMBO PACK MJ NUTRITIONAL SSB EXPECTA PRENATAL OTC (ORAL) PRENATAL VITAMINS

ELITE-OB CAPLET TRIGEN LABORATO GEN FE C/FA (ORAL) PRENATAL VITAMINSIRON 100 PLUS TABLET CYPRESS PHARM. GEN FE C/VIT C/VIT B12/FA OTC (ORAL) PRENATAL VITAMINSMARNATAL-F CAPSULE MARNEL/ALLEGIS SSB MARNATAL-F (ORAL) PRENATAL VITAMINS

NESTABS ABC PRENATAL COMBO PK WOMEN'S CHOICE SSB NESTABS ABC (ORAL) PRENATAL VITAMINSNESTABS ONE SOFTGEL WOMEN'S CHOICE SSB NESTABS ONE (ORAL) PRENATAL VITAMINS

OB COMPLETE ONE SOFTGEL VERTICAL PHARM SSB OB COMPLETE ONE (ORAL) PRENATAL VITAMINSOB COMPLETE PETITE SOFTGEL VERTICAL PHARM SSB OB COMPLETE PETITE (ORAL) PRENATAL VITAMINSOB COMPLETE PREMIER TABLET VERTICAL PHARM SSB OB COMPLETE PREMIER (ORAL) PRENATAL VITAMINS

OB COMPLETE WITH DHA SOFTGEL VERTICAL PHARM SSB OB COMPLETE WITH DHA (ORAL) PRENATAL VITAMINSO-CAL FA TABLET PHARMICS SSB O-CAL FA (ORAL) PRENATAL VITAMINS

C-NATE DHA SOFTGEL CENTURION LABS GEN PNV 11-IRON FUM-FOLIC ACID-OM3 (ORAL) PRENATAL VITAMINSVIRT-NATE DHA SOFTGEL VIRTUS PHARMACE GEN PNV 11-IRON FUM-FOLIC ACID-OM3 (ORAL) PRENATAL VITAMINS

PNV-DHA SOFTGEL ACELLA PHARMACE GEN PNV COMBO#47/IRON/FA #1/DHA (ORAL) PRENATAL VITAMINSVIRT-PN DHA SOFTGEL VIRTUS PHARMACE GEN PNV COMBO#47/IRON/FA #1/DHA (ORAL) PRENATAL VITAMINS

ZATEAN-PN DHA CAPSULE TRIGEN LABORATO GEN PNV COMBO#47/IRON/FA #1/DHA (ORAL) PRENATAL VITAMINSSE-NATAL 19 CHEWABLE TABLET SETON PHARMACEU GEN PNV NO.118/IRON FUMARATE/FA CHEW TABLET (ORAL) PRENATAL VITAMINS

FOLIVANE-OB CAPSULE TRIGEN LABORATO GEN PNV NO.15/IRON FUM & PS CMP/FA (ORAL) PRENATAL VITAMINSPNV-SELECT TABLET ACELLA PHARMACE GEN PNV W-CA NO.40/IRON FUM/FA CMB NO.1 (ORAL) PRENATAL VITAMINS

PNV-OMEGA SOFTGEL ACELLA PHARMACE GEN PNV WITH CA NO.68/IRON/FA NO.1/DHA (ORAL) PRENATAL VITAMINSVIRT-PN PLUS SOFTGEL VIRTUS PHARMACE GEN PNV WITH CA NO.68/IRON/FA NO.1/DHA (ORAL) PRENATAL VITAMINS

ZATEAN-PN PLUS SOFTGEL TRIGEN LABORATO GEN PNV WITH CA NO.68/IRON/FA NO.1/DHA (ORAL) PRENATAL VITAMINSM-NATAL PLUS TABLET METHOD PHARMACE GEN PNV WITH CA,NO.72/IRON/FA (ORAL) PRENATAL VITAMINS

PRENATAL VITAMIN PLUS LOW IRON generic GEN PNV WITH CA,NO.72/IRON/FA (ORAL) PRENATAL VITAMINSPREPLUS CA-FE 27 MG-FA 1 MG TB VIRTUS PHARMACE GEN PNV WITH CA,NO.72/IRON/FA (ORAL) PRENATAL VITAMINS

NIVA-PLUS TABLET NIVAGEN PHARMAC GEN PNV WITH CA,NO.74/IRON/FA OTC (ORAL) PRENATAL VITAMINSTARON-C DHA CAPSULE TRIGEN LABORATO GEN PNV#16/IRON FUM & PS/FA/OM-3 (ORAL) PRENATAL VITAMINS

VIRT-C DHA SOFTGEL VIRTUS PHARMACE GEN PNV#16/IRON FUM & PS/FA/OM-3 (ORAL) PRENATAL VITAMINSSE-NATAL-19 TABLET SETON PHARMACEU GEN PNV119/IRON FUMARATE/FA/DSS TABLET (ORAL) PRENATAL VITAMINSTHRIVITE 19 TABLET METHOD PHARMACE GEN PNV119/IRON FUMARATE/FA/DSS TABLET (ORAL) PRENATAL VITAMINS

COMPLETE NATAL DHA TRIGEN LABORATO GEN PNV2/IRON B-G SUC-P/FA/OMEGA-3 (ORAL) PRENATAL VITAMINSTRUST NATAL DHA VERTICAL PHARM GEN PNV2/IRON B-G SUC-P/FA/OMEGA-3 (ORAL) PRENATAL VITAMINS

TRIVEEN-DUO DHA COMBO PACK TRIGEN LABORATO GEN PNV53/IRON B-G HCL-P/FA/OMEGA3 (ORAL) PRENATAL VITAMINSPNV-DHA + DOCUSATE SOFTGEL ACELLA PHARMACE GEN PNV66/IRON FUMARATE/FA/DSS/DHA (ORAL) PRENATAL VITAMINSPRENAISSANCE PLUS SOFTGEL ACELLA PHARMACE GEN PNV69/IRON,CARBONYL/FA/DSS/DHA (ORAL) PRENATAL VITAMINS

PRENAISSANCE CAPSULE ACELLA PHARMACE GEN PNV80/IRON FUMARATE/FA/DSS/DHA (ORAL) PRENATAL VITAMINSVINACAL B PRENATAL COMBO PACK BRECKENRIDGE GEN PRENATAL #48/IRON CB&GLU/FA/B6 OTC (ORAL) PRENATAL VITAMINS

PNV 29-1 TABLET VIRTUS PHARMACE GEN PRENATAL VIT #76/IRON,CARB/FA (ORAL) PRENATAL VITAMINSTHRIVITE RX TABLET METHOD PHARMACE GEN PRENATAL VIT #76/IRON,CARB/FA (ORAL) PRENATAL VITAMINS

PRETAB 29 MG-1 MG TABLET VIRTUS PHARMACE GEN PRENATAL VIT NO.78/IRON/FA (ORAL) PRENATAL VITAMINSCLASSIC PRENATAL TABLET RUGBY GEN PRENATAL VIT/FE FUMARATE/FA OTC (ORAL) PRENATAL VITAMINSPRENATAL VITAMIN TABLET generic GEN PRENATAL VIT/FE FUMARATE/FA OTC (ORAL) PRENATAL VITAMINS

PRENATAL VITAMINS TABLET generic GEN PRENATAL VIT/FE FUMARATE/FA OTC (ORAL) PRENATAL VITAMINSPRENATE AM TABLET AVION PHARMACEU SSB PRENATE AM (ORAL) PRENATAL VITAMINS

PRENATE CHEWABLE TABLET AVION PHARMACEU SSB PRENATE CHEWABLE TABLET (ORAL) PRENATAL VITAMINSPRENATE DHA SOFTGEL AVION PHARMACEU SSB PRENATE DHA (ORAL) PRENATAL VITAMINSPRENATE ELITE TABLET AVION PHARMACEU SSB PRENATE ELITE (ORAL) PRENATAL VITAMINS

PRENATE ENHANCE SOFTGEL AVION PHARMACEU SSB PRENATE ENHANCE (ORAL) PRENATAL VITAMINSPRENATE ESSENTIAL SOFTGEL AVION PHARMACEU SSB PRENATE ESSENTIAL (ORAL) PRENATAL VITAMINS

PRENATE MINI SOFTGEL AVION PHARMACEU SSB PRENATE MINI (ORAL) PRENATAL VITAMINSPRENATE PIXIE SOFTGEL AVION PHARMACEU SSB PRENATE PIXIE (ORAL) PRENATAL VITAMINS

PRENATE RESTORE SOFTGEL AVION PHARMACEU SSB PRENATE RESTORE (ORAL) PRENATAL VITAMINSPRENATE STAR TABLET AVION PHARMACEU SSB PRENATE STAR (ORAL) PRENATAL VITAMINSPRIMACARE SOFTGEL AVION PHARMACEU SSB PRIMACARE (ORAL) PRENATAL VITAMINSPROVIDA OB CAPSULE US PHARMACEUTIC SSB PROVIDA OB (ORAL) PRENATAL VITAMINS

PUREFE OB PLUS CAPSULE PURETEK CORPORA SSB PUREFE OB PLUS (ORAL) PRENATAL VITAMINSPUREFE PLUS CAPSULE PURETEK CORPORA SSB PUREFE PLUS (ORAL) PRENATAL VITAMINSSELECT-OB + DHA PACK EXELTIS USA, IN SSB SELECT-OB + DHA (ORAL) PRENATAL VITAMINS

SELECT-OB CHEWABLE CAPLET EXELTIS USA, IN SSB SELECT-OB TAB CHEW (ORAL) PRENATAL VITAMINSSTUART ONE CAPSULE EXELTIS USA, IN SSB STUART ONE OTC (ORAL) PRENATAL VITAMINS

TARON-PREX PRENATAL DHA CAP TRIGEN LABORATO SSB TARON-PREX PRENATAL (ORAL) PRENATAL VITAMINSTENDERA-OB SOFTGEL BONGEO PHARMACE SSB TENDERA-OB OTC (ORAL) PRENATAL VITAMINS

TRICARE PRENATAL TABLET MEDECOR PHARMA SSB TRICARE (ORAL) PRENATAL VITAMINSTRINATAL RX 1 TABLET TRIGEN LABORATO SSB TRINATAL RX 1 (ORAL) PRENATAL VITAMINS

TRISTART DHA SOFTGEL CARWIN ASSOCIAT SSB TRISTART DHA (ORAL) PRENATAL VITAMINSVINATE DHA RF GELCAP BRECKENRIDGE SSB VINATE DHA RF (ORAL) PRENATAL VITAMINS

VITAFOL FE PLUS SOFTGEL EXELTIS USA, IN SSB VITAFOL FE+ (ORAL) PRENATAL VITAMINSVITAFOL FE+ DOCUSATE COMBO PCK EXELTIS USA, IN SSB VITAFOL FE+ (ORAL) PRENATAL VITAMINS

VITAFOL NANO TABLET EXELTIS USA, IN SSB VITAFOL NANO (ORAL) PRENATAL VITAMINSVITAFOL GUMMIES EXELTIS USA, IN SSB VITAFOL TAB CHEW (ORAL) PRENATAL VITAMINS

VITAFOL ULTRA SOFTGEL EXELTIS USA, IN SSB VITAFOL ULTRA (ORAL) PRENATAL VITAMINSVITAFOL-OB CAPLET EXELTIS USA, IN SSB VITAFOL-OB (ORAL) PRENATAL VITAMINS

VITAFOL-OB+DHA COMBO PACK EXELTIS USA, IN SSB VITAFOL-OB+DHA (ORAL) PRENATAL VITAMINSVITAFOL-ONE CAPSULE EXELTIS USA, IN SSB VITAFOL-ONE (ORAL) PRENATAL VITAMINS

VP-CH-PNV PRENATAL SOFTGEL VIRTUS PHARMACE GEN VP-CH-PNV (ORAL) PRENATAL VITAMINS

1