Calcium homeostasis during pregnancy and lactation in primiparous and multiparous women with sub-adequate calcium intakes

Role of calcium during pregnancy: maternal and fetal needs

Although the demand for additional calcium during pregnancy is recognized, the dietary reference intake for calcium was lowered for pregnant women in 1997 to amounts recommended for nonpregnant women (1,000 mg/day), and recently (November 2010) the Institute of Medicine report upheld the 1997 recommendation. It has been frequently reported that women of childbearing age do not consume the dietary reference intake for calcium and that calcium intake in the United States varies among ethnic groups. Women who chronically consume suboptimal amounts of calcium (<500 mg/day) may be at risk for increased bone loss during pregnancy. Women who begin pregnancy with adequate intake may not need additional calcium, but women with suboptimal intakes (<500 mg) may need additional amounts to meet both maternal and fetal bone requirements. The objective of this review is to elucidate the changes in calcium metabolism that occur during pregnancy as well as the effect of maternal calcium intake on both maternal and fetal outcomes.

Increased bone turnover during the third trimester of pregnancy and decreased bone mineral density after parturition in adolescents as compared to age-matched control patients

To evaluate the impact of pregnancy on bone, we studied bone turnover at the first (T1) and third (T3) trimester of gestation in 58 adolescents and 28 healthy adolescents who had never been pregnant. Total body (TB) and lumbar spine (LS) bone mineral density (BMD) and body composition were evaluated by dual-energy X-ray absorptiometry in all control patients (C) and after parturition in 28 pregnant patients (G). Paired and unpaired t tests, Mann-Whitney and Pearson correlation tests were used. Bone turnover markers were above the reference range for adult women in more than 80% of the adolescents, with no difference between C and G patients at T1. Increase in urinary N-telopeptide crosslinks of type I collagen and serum bone-specific alkaline phosphatase, markers of bone turnover, was seen during pregnancy ( p < 0.0001). Body composition did not differ between groups, but LS BMD, percentage of expected LS BMD, LS Z-score, percentage of expected TB BMD and TB Z-score were lower in G than C patients ( p < 0.05). TB BMD was positively correlated with LS BMD (r2 = 0.52). The inverse correlations between bone markers and LS BMD suggest that the increased bone turnover during pregnancy probably explains the low bone density after parturition. The impact on future peak bone mass must be studied.

Lactation and maternal bone health

Women lose bone during lactation, and this is an important mechanism to provide calcium for human milk. Bone loss during lactation occurs even in women with high calcium intakes. Lactation-induced bone loss is transient because bone density increases rapidly after weaning. Bone loss during lactation and recovery after weaning are related to ovarian function and the length of postpartum amenorrhea. The recovery of bone after weaning can occur with shortly spaced pregnancies. Women who have breastfed several infants do not have reduced bone density after menopause. Overall, the transient bone loss during lactation does not seem to increase a woman's risk of osteoporotic fracture in her elder years. Further research is needed on special subgroups of women, such as adolescents, women who are vitamin D deficient or have extremely low calcium intakes, and women who have simultaneously breastfed multiple infants to determine whether these women are able to regain sufficient bone mass after lactation to preserve their bone health.

Avaliação da dieta de gestantes com sobrepeso

O objetivo deste estudo foi avaliar o consumo alimentar e verificar a adequação de calorias e de alguns nutrientes em gestantes com sobrepeso pré-gestacional. Estudou-se uma amostra de 110 gestantes que freqüentavam ambulatório de assistência pré-natal na cidade de São Paulo. A alimentação foi verificada pelo método de inquérito recordatório de 24 horas. A proporção dos macronutrientes foi de 55% de carboidratos, 16% de proteínas e 29% de lipídios. A média de energia da dieta foi de 1736 kcal. Entre os micronutrientes analisados, apresentaram consumo inadequado: o cálcio, com aproximadamente 50% de adequação; o ferro, com 33%; e o folato, com 43%. A dieta mostrou-se satisfatória em energia e insuficiente em relação ao cálcio, ao ferro e ao folato. Estes dados permitem supor a existência de deficiências nutricionais específicas no grupo estudado.

Pregnancy and lactation affect markers of calcium and bone metabolism differently in adolescent and adult women with low calcium intakes

Physiologic adaptation to the high calcium demand during pregnancy and lactation may be different in adolescents than in adults, particularly at low calcium intake. The aim of this cross-sectional study was to compare biochemical markers of calcium and bone metabolism between adolescent (14-19 y) and adult (21-35 y) women with calcium intake approximately 500 mg/d, in three different physiologic states, i.e., control (nonpregnant, nonlactating; NPNL), pregnant and lactating. Markers of calcium metabolism [serum Ca, P and intact parathyroid hormone (iPTH); urinary Ca and P] and of bone turnover [urinary deoxypyridinoline (D-Pyr) and plasma bone alkaline phosphatase (BAP)] were measured in NPNL (adolescents, n = 12 and adults, n = 25), pregnant (adolescents, n = 30 and adults, n = 36) and lactating (adolescents, n = 19 and adults, n = 26) women. In the NPNL women, iPTH, D-Pyr and BAP were higher (P < 0.001) and urinary Ca was lower (P < 0.001) in adolescents than in adults. Serum iPTH was higher (P < 0.001) and urinary Ca was lower (P < 0.01) in adolescents than in adults also in pregnancy and lactation. Compared with NPNL women, serum Ca decreased (P < 0.001) with pregnancy in adolescents but not in adults. The increase in D-Pyr with pregnancy and lactation was very pronounced in adults ( approximately 130%, P < 0.001) but less in adolescents (<25%, P < 0.01). BAP increased (P < 0.001) with pregnancy and lactation in adults ( approximately 60%) but decreased (P < 0.001) with pregnancy in adolescents ( approximately 13%). Pregnancy and lactation appear to affect bone turnover in adolescent and adult women with low calcium intake differently.

Calcium supplementation during lactation blunts erythrocyte lead levels and delta-aminolevulinic acid dehydratase zinc-reactivation in women non-exposed to lead and with marginal calcium intakes

The purpose of this study was to evaluate the effect of calcium supplementation during lactation on changes in blood lead indices from late pregnancy to early lactation in women with low calcium intakes and low lead-exposure. Forty-seven women, non-occupationally exposed to lead and with habitually low calcium intake ( approximately 600 mg/d), participated in the study from 29 to 38 weeks of pregnancy to 7-8 weeks post-partum, non-supplemented (n=25) and supplemented (n=22) with calcium (500 mg/d) during 6 weeks after delivery. Erythrocyte lead (PbRBC) and in vitro reactivation with zinc of blood delta-aminolevulinic acid dehydratase (Zn-delta-ALAD% reactivation) were used as lead indices. In the non-supplemented group, PbRBC and Zn-delta-ALAD% reactivation increased significantly (P<0.001) from pregnancy (0.202+/-0.049 microg Pb/g protein and 18.3+/-6.0%) to lactation (0.272+/-0.070 microg Pb/g protein and 22.7+/-6.2%). No significant changes of these indices were observed in the calcium-supplemented group from pregnancy (0.203+/-0.080 microg Pb/g protein and 15.8+/-4.5%) to lactation (0.214+/-0.066 microg Pb/g protein and 16.3+/-4.1%). PbRBC levels and Zn-delta-ALAD% reactivation at lactation were lower (P<0.05) and hematocrit levels were higher (P<0.05) in the calcium-supplemented compared to the non-supplemented women. Calcium supplementation during lactation appears to blunt the lactation-induced increase in maternal blood lead and its inhibitory effect on delta-ALAD and possibly on maternal erythropoiesis.

Ultrasonographic bone velocity in pregnancy: a longitudinal study

OBJECTIVE

Longitudinal changes in bone mass were evaluated with use of ultrasonography and bone remodeling markers in 40 normal pregnant women in relation to their calcium intake.

STUDY DESIGN

The study took place at the University of Alcalá Hospital in Madrid. Biochemical markers of bone remodeling and ultrasonographic bone propagation velocity in the proximal phalanxes of fingers 2 to 5 were measured in all three trimesters of pregnancy. Wilcoxon, unpaired and paired t tests, and analysis of variance were used.

RESULTS

Ultrasonographic bone propagation velocity (meters per second) was lower in the second and third trimesters of pregnancy (p < 0.0001) compared with the respective preceding trimesters and in the third trimester in the overall group of pregnant women. Tartrate-resistant acid phosphatase and alkaline phosphatase levels increased significantly (p < 0.0001) in parallel with the ultrasonographic bone propagation velocity decrease.

CONCLUSIONS

Gestation was accompanied by a reduction in ultrasonographic bone propagation velocity that was greater in women with low calcium intake.

The study of a physiological significance of prolactin in the regulation of calcium metabolism during pregnancy and lactation in rats

Since a pharmacological dose of prolactin has previously been reported to enhance calcium absorption and bone calcium turnover, the role of endogenous prolactin in the regulation of calcium metabolism was investigated in the balance studies of Wistar rats between days 17 and 20 of first (P1) and fourth (P4) pregnancy and between days 12 and 15 of lactation (L). Each group was divided into 3 subgroups: one subgroup was given 0.9% NaCl (control); one was given 0.3 mg bromocriptine/100 g body weight ip twice daily for 3 days (to suppress prolactin secretion); and one was given bromocriptine and 0.25 mg prolactin/100 g body weight sc daily for 3 days. All three groups received 1 mL/100 g body weight of 1.25 mM calcium gluconate containing 2 mCi (1 Ci = 37 GBq) 45Ca daily for 3 days. Compared with the two pregnant controls, the L group had higher food consumption and higher fecal calcium excretion and lower urinary calcium excretion (% intake). Bromocriptine administration increased total calcium excretion from 59% intake to 84 and 66% intake in P1 and P4, respectively, suggesting that endogenous prolactin decreased total calcium excretion. On the other hand, exogenous prolactin had no effect on the calcium balance of P1 but increased the total calcium excretion in P4 from 57 to 66% intake. In contrast, the calcium balance of lactating rats was not altered by suppression of endogenous prolactin secretion or exogenous prolactin. Considering bone 45Ca content as representing bone Ca turnover, a lower value of bone 45Ca content indicated an accelerated bone Ca turnover. It was found that bromocriptine had no effect in P1 but decreased bone Ca turnover rate in the P4 and L groups, indicating an accelerating effect of endogenous prolactin on bone Ca turnover in the P4 and L groups. Exogenous prolactin, on the other hand, decreased bone Ca turnover rate in every group. Muscle Ca turnover was affected by bromocriptine and exogenous prolactin in the same manner as bone 45Ca contents. Interestingly, the biphasic action of prolactin was demonstrated in both calcium absorption and bone calcium turnover. It could be concluded that during pregnancy and lactation, endogenous prolactin increases food consumption, fractional calcium absorption, and bone calcium turnover, apparently to increase calcium availability for fetal development and milk calcium secretion.Key words: bone turnover, bromocriptine, calcium absorption, calcium excretion, calcium retention, prolactin.