Choline supplementation during pregnancy - what is the evidence?

Association between lower maternal choline levels and adverse pregnancy outcomes

Observational data indicates that higher maternal choline levels are associated with reduced risk of adverse pregnancy outcomes, including neural tube defects, but causality is not fully established and further research is needed.

However maternal choline level can only be measured under research settings, and not at the clinics.

Based on such findings, major nutrition guidelines from the United States Department of Agriculture, Food and Drug Administration, and the International Federation of Gynecology and Obstetrics emphasize the importance of adequate choline intake in pregnancy. Most advise an intake of 450 mg of choline per day.

Strategies to improve dietary choline intake during pregnancy

Effective strategies to increase dietary choline intake to recommended levels for pregnant women include prioritizing foods naturally rich in choline. The most choline-dense food is eggs, particularly the yolk, which consistently emerges as the single largest contributor to choline intake in multiple populations; regular egg consumption is strongly associated with meeting choline recommendations in pregnancy. If you take 2 eggs a day, you would have 250-300 mg of choline a day. Other key sources are red meat, dairy products, poultry, fish, and certain nuts and legumes.

For women following vegetarian or vegan diets, choline intake is typically much lower, and plant-based sources (such as soybeans, kidney beans, quinoa, and cruciferous vegetables) should be emphasized, though these are less concentrated in choline than animal-derived foods. Given the high prevalence of inadequate intake—less than 12% of pregnant women meet the recommended daily intake of 450 mg (United States Department of Agriculture, Food and Drug Administration, International Federation of Gynecology and Obstetrics) —choline-containing prenatal supplements may be recommended when dietary sources are insufficient, especially for those with dietary restrictions or low intake.

Is there good evidence that choline supplementation in pregnancy improve pregnancy outcomes?

Whilst there is observational data during pregnancy that low maternal choline levels are associated with poorer maternal outcomes, the gold standard for medical advice is to have studies that show that choline supplementation during pregnancy indeed improves pregnancy outcomes.

Unfortunately, there is very little evidence to prove that. In a recent systematic review in February 2025, the conclusion of that study was that current evidence is insufficient to support or refute the hypothesis that increasing choline intake in pregnancy improves the neurodevelopmental outcomes of the child.

There was a small randomized controlled trial in only 20 participants on each arm that showed that higher maternal choline intake during the third trimester (930 mg/day vs. 480 mg/day) leads to improved sustained attention at age 7 years and faster infant information processing speed, suggesting benefits for offspring cognitive function.

As there is a lack of good data to show that routine choline supplementation during pregnancy improves pregnancy outcomes, the international colleges of obstetrics and gynaecology have not yet adopted the recommendation that all pregnant women should be given routine choline supplementation.

Any side effects of maternal choline supplementation?

The potential side effects of choline supplementation during pregnancy are generally mild and infrequent at recommended dosages (typically 450–930 mg/day). Randomized controlled trials and systematic reviews indicate that choline is well tolerated, with no serious adverse effects reported at these intake levels in pregnant women. The most commonly reported side effects are gastrointestinal symptoms, such as mild nausea, diarrhea, or abdominal discomfort, which are dose-dependent and more likely at higher supplemental intakes.

As I am a vegan / vegetarian / don't take eggs, should I take choline supplementation then?

There is no widely accepted guideline on this issue yet. One has to balance the risks of side effects with the current theoretical benefits of choline supplementation during pregnancy. Discuss with us if you feel that you want choline supplementation.