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Galassi FM, Lorkiewicz W, Filipiak J, Nikodem A, Żądzińska E. Age- and sex-related changes in vertebral trabecular bone architecture in Neolithic and Mediaeval populations from Poland. Sci Rep 2024; 14:9977. [PMID: 38693297 PMCID: PMC11063184 DOI: 10.1038/s41598-024-59946-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 04/17/2024] [Indexed: 05/03/2024] Open
Abstract
This paper investigates trabecular bone ontogenetic changes in two different Polish populations, one prehistoric and the other historical. The studied populations are from the Brześć Kujawski region in Kujawy (north-central Poland), one from the Neolithic Period (4500-4000 BC) and one from the Middle Ages (twelfth-sixteenth centuries AD), in total 62 vertebral specimens (32 males, 30 females). Eight morphometric parameters acquired from microCT scan images were analysed. Two-way ANOVA after Box-Cox transformation and multifactorial regression model were calculated. A significant decrease in percentage bone volume fraction (BV/TV; [%]) with age at death was observed in the studied sample; Tb.N (trabecular number) was also significantly decreased with age; trabecular separation (Tb.Sp) increased with advancing age; connectivity density (Conn.D) was negatively correlated with biological age and higher in the Neolithic population. These data are found to be compatible with data from the current biomedical literature, while no loss of horizontal trabeculae was recorded as would be expected based on modern osteoporosis.
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Affiliation(s)
- Francesco Maria Galassi
- Department of Anthropology, Faculty of Biology and Environmental Protection, University of Lodz, Lodz, Poland.
| | - Wiesław Lorkiewicz
- Department of Anthropology, Faculty of Biology and Environmental Protection, University of Lodz, Lodz, Poland
| | - Jarosław Filipiak
- Department of Mechanics, Materials and Biomedical Engineering, Faculty of Mechanical Engineering, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Anna Nikodem
- Department of Mechanics, Materials and Biomedical Engineering, Faculty of Mechanical Engineering, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Elżbieta Żądzińska
- Department of Anthropology, Faculty of Biology and Environmental Protection, University of Lodz, Lodz, Poland
- Biological Anthropology and Comparative Anatomy Research Unit, School of Medicine, University of Adelaide, Adelaide, SA, 5005, Australia
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2
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Athonvarangkul D, Wysolmerski JJ. Crosstalk within a brain-breast-bone axis regulates mineral and skeletal metabolism during lactation. Front Physiol 2023; 14:1121579. [PMID: 36875035 PMCID: PMC9979219 DOI: 10.3389/fphys.2023.1121579] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/27/2023] [Indexed: 02/18/2023] Open
Abstract
To support the increased calcium demands for milk production during lactation, a dramatic and reversible physiological response occurs to alter bone and mineral metabolism. This coordinated process involves a brain-breast-bone axis that integrates hormonal signals that allow for adequate calcium delivery to milk yet also protects the maternal skeletal from excessive bone loss or decreases in bone quality or function. Here, we review the current knowledge on the crosstalk between the hypothalamus, mammary gland, and skeleton during lactation. We discuss the rare entity of pregnancy and lactation associated osteoporosis and consider how the physiology of bone turnover in lactation may impact the pathophysiology of postmenopausal osteoporosis. Further understanding of the regulators of bone loss during lactation, particularly in humans, may provide insights into new therapies for osteoporosis and other diseases of excess bone loss.
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Affiliation(s)
- Diana Athonvarangkul
- Section of Endocrinology and Metabolism, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
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Elliott-Sale KJ, Bostock EL, Jackson T, Wardle SL, O'Leary TJ, Greeves JP, Sale C. Investigating the Efficacy of an 18-Week Postpartum Rehabilitation and Physical Development Intervention on Occupational Physical Performance and Musculoskeletal Health in UK Servicewomen: Protocol for an Independent Group Study Design. JMIR Res Protoc 2022; 11:e32315. [PMID: 35648463 PMCID: PMC9201705 DOI: 10.2196/32315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 03/08/2022] [Accepted: 03/18/2022] [Indexed: 11/20/2022] Open
Abstract
Background Postpartum women are at an increased risk of pelvic floor dysfunction, musculoskeletal injury, and poor psychological health and have reduced physical fitness compared to before pregnancy. There is no formal, evidence-based rehabilitation and physical development program for returning UK servicewomen to work following childbirth. Objective This study aims to examine the efficacy of a rehabilitation and physical development intervention for returning postpartum UK servicewomen to occupational fitness. Methods Eligible servicewomen will be assigned to a training or control group in a nonrandomized controlled trial 6 weeks after childbirth. Group allocation will be based on the location of standard pregnancy and postpartum care. The control group will receive standard care, with no prescribed intervention. The training group will start an 18-week core and pelvic health rehabilitation program 6 weeks post partum and a 12-week resistance and high-intensity interval training program 12 weeks post partum. All participants will attend 4 testing sessions at 6, 12, 18, and 24 weeks post partum for the assessment of occupational physical performance, pelvic health, psychological well-being, quality of life, and musculoskeletal health outcomes. Occupational physical performance tests will include vertical jump, mid-thigh pull, seated medicine ball throw, and a timed 2-km run. Pelvic health tests will include the Pelvic Organ Prolapse Quantification system, the PERFECT (power, endurance, repetitions, fast, every contraction timed) scheme for pelvic floor strength, musculoskeletal physiotherapy assessment, the Pelvic Floor Distress Inventory–20 questionnaire, and the International Consultation on Incontinence Questionnaire–Vaginal Symptoms. Psychological well-being and quality of life tests will include the World Health Organization Quality of Life questionnaire and the Edinburgh Postnatal Depression Scale. Musculoskeletal health outcomes will include body composition; whole-body areal bone mineral density; tibial volumetric bone mineral density, geometry, and microarchitecture; patella tendon properties; muscle architecture; muscle protein and collagen turnover; and muscle mass and muscle breakdown. Data will be analyzed using linear mixed-effects models, with participants included as random effects, and group and time as fixed effects to assess within- and between-group differences over time. Results This study received ethical approval in April 2019 and recruitment started in July 2019. The study was paused in March 2020 owing to the COVID-19 pandemic. Recruitment restarted in May 2021. The results are expected in September 2022. Conclusions This study will inform the best practice for the safe and optimal return of postpartum servicewomen to physically and mentally demanding jobs. Trial Registration ClinicalTrials.gov NCT04332757; https://clinicaltrials.gov/ct2/show/NCT04332757 International Registered Report Identifier (IRRID) DERR1-10.2196/32315
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Affiliation(s)
- Kirsty Jayne Elliott-Sale
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom.,Institute of Sport, Manchester Metropolitan University, Manchester, United Kingdom
| | - Emma Louise Bostock
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Thea Jackson
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Sophie Louise Wardle
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Thomas James O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | | | - Craig Sale
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom.,Institute of Sport, Manchester Metropolitan University, Manchester, United Kingdom
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Kyle EM, Miller HB, Schueler J, Clinton M, Alexander BM, Hart AM, Larson-Meyer DE. Changes in Bone Mineral Density and Serum Lipids across the First Postpartum Year: Effect of Aerobic Fitness and Physical Activity. Nutrients 2022; 14:nu14030703. [PMID: 35277062 PMCID: PMC8839917 DOI: 10.3390/nu14030703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 12/20/2022] Open
Abstract
This study evaluated the changes in bone mineral density (BMD) and serum lipids across the first postpartum year in lactating women compared to never-pregnant controls, and the influence of physical activity (PA). The study also explored whether N-telopeptides, pyridinoline, and deoxypyridinoline in urine serve as biomarkers of bone resorption. A cohort of 18 initially lactating postpartum women and 16 never pregnant controls were studied. BMD (dual energy X-ray absorptiometry), serum lipid profiles, and PA (Baecke PA Questionnaire) were assessed at baseline (4–6 weeks postpartum), 6 months, and 12 months. Postpartum women lost 5.2 ± 1.4 kg body weight and BMD decreased by 1.4% and 3.1% in the total body and dual-femur, respectively. Furthermore, BMDdid not show signs of rebound. Lipid profiles improved, with increases in high-density lipoprotein-cholesterol (HDL-C) and decreases in low-density lipoprotein cholesterol (LDL-C) and the cholesterol/HDL-C ratio at 12 months (vs. baseline). These changes were not influenced by lactation, but the fall the Cholesterol/HDL-C ratio was influenced by leisure-time (p = 0.051, time X group) and sport (p = 0.028, time effect) PA. The decrease in BMD from baseline to 12 months in total body and dual femur, however, was greater in those who continued to breastfeed for a full year compared to those who stopped at close to 6 months. Urinary markers of bone resorption, measured in a subset of participants, reflect BMD loss, particularly in the dual-femur, and may reflect changes bone resorption before observed changes in BMD. Results provide support that habitual postpartum PA may favorably influence changes in serum lipids but not necessarily BMD. The benefit of exercise and use of urinary biomarkers of bone deserves further exploration.
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Affiliation(s)
- Erin M. Kyle
- Department of Family and Consumer Sciences, University of Wyoming, Laramie, WY 82071, USA; (E.M.K.); (J.S.); (M.C.)
| | - Hayley B. Miller
- Department of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA 24061, USA;
| | - Jessica Schueler
- Department of Family and Consumer Sciences, University of Wyoming, Laramie, WY 82071, USA; (E.M.K.); (J.S.); (M.C.)
| | - Michelle Clinton
- Department of Family and Consumer Sciences, University of Wyoming, Laramie, WY 82071, USA; (E.M.K.); (J.S.); (M.C.)
| | - Brenda M. Alexander
- Department of Animal Science, University of Wyoming, Laramie, WY 82071, USA;
| | - Ann Marie Hart
- School of Nursing, University of Wyoming, Laramie, WY 82071, USA;
| | - D. Enette Larson-Meyer
- Department of Family and Consumer Sciences, University of Wyoming, Laramie, WY 82071, USA; (E.M.K.); (J.S.); (M.C.)
- Department of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA 24061, USA;
- Correspondence: ; Tel.: +1-540-231-1025
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5
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Oboh I, Coleman C, Cremona A. The influence of lactation and its duration on bone mineral density in pregnancy and postpartum: A systematic review with meta-analysis. Clin Nutr ESPEN 2021; 46:121-132. [PMID: 34857185 DOI: 10.1016/j.clnesp.2021.08.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/19/2021] [Accepted: 08/22/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND There is a plethora of research on the association of parity and duration of lactation with bone mineral density (BMD) during and after pregnancy. However, there are no consensus conclusions on the impact of the duration of lactation on BMD. AIMS The aim of this study was to examine the effect of pregnancy, and the duration of lactation on BMD during pregnancy, postpartum phase and 12 months post-delivery. METHODS The search terms 'parity' 'lactation' 'BMD' were searched for using PubMed, CINAHL, SCOPUS and EMBASE databases in English language. Two independent reviewers assessed the quality of the included studies using Critical Appraisal Skills Program (CASP) appraisal tool and extracted data on BMD (g/cm2) in Excel. A meta-analysis was conducted with a random effect model using Cochrane Review Manager (Rev 5.4) to analyse the outcome. Heterogeneity was assessed with Chi Squared and I2 test. The duration of lactation was grouped into short lactation duration (SLD), ≤4 months and longer lactation duration (LLD) > 6 months. RESULTS Twenty-one studies were included in this review with four studies included in the meta-analysis. BMD reduced during pregnancy and lactation. Recovery and net gains in BMD followed weaning. However, at 12 months postpartum, women in the LLD group had significant losses at the lumbar spine while those in the SLD recovered BMD. Between the SLD and LLD groups, the change in BMD was not significant 0.48 g/cm2 (95% CI -0.14, 1.10, p = 0.13). BMD losses were greater in primiparous women than multiparous women. CONCLUSION Women who breastfed for >6 months had significantly reduced BMD. However, compared to women that breastfed for a ≤4 months there was no significant change in BMD. Further investigation is needed to clarify the association between lactation and BMD in a postpartum population in those women extending breastfeeding beyond one year.
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Affiliation(s)
- Isabella Oboh
- University Hospital Limerick (UHL), Limerick, Ireland
| | - Cynthia Coleman
- College of Medicine, Nursing and Health Science, School of Medicine, Regenerative Medicine Institute (REMEDI), National University of Ireland Galway (NUI Galway), Galway, Ireland
| | - Alexandra Cremona
- School of Allied Health, University of Limerick, Limerick, Ireland; Health Research Institute, University of Limerick, Limerick, Ireland; Irish Nutrition and Dietetics Institute, Dublin, Ireland.
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6
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Li Y, de Bakker CMJ, Lai X, Zhao H, Parajuli A, Tseng WJ, Pei S, Meng T, Chung R, Wang L, Liu XS. Maternal bone adaptation to mechanical loading during pregnancy, lactation, and post-weaning recovery. Bone 2021; 151:116031. [PMID: 34098162 PMCID: PMC8504362 DOI: 10.1016/j.bone.2021.116031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/25/2021] [Accepted: 06/01/2021] [Indexed: 12/16/2022]
Abstract
The maternal skeleton undergoes dramatic bone loss during pregnancy and lactation, and substantial bone recovery post-weaning. The structural adaptations of maternal bone during reproduction and lactation exert a better protection of the mechanical integrity at the critical load-bearing sites, suggesting the importance of physiological load-bearing in regulating reproduction-induced skeletal alterations. Although it is suggested that physical exercise during pregnancy and breastfeeding improves women's physical and psychological well-being, its effects on maternal bone health remain unclear. Therefore, the objective of this study was to investigate the maternal bone adaptations to external mechanical loading during pregnancy, lactation, and post-weaning recovery. By utilizing an in vivo dynamic tibial loading protocol in a rat model, we demonstrated improved maternal cortical bone structure in response to dynamic loading at tibial midshaft, regardless of reproductive status. Notably, despite the minimal loading responses detected in the trabecular bone in virgins, rat bone during lactation experienced enhanced mechano-responsiveness in both trabecular and cortical bone compartments when compared to rats at other reproductive stages or age-matched virgins. Furthermore, our study showed that the lactation-induced elevation in osteocyte peri-lacunar/canalicular remodeling (PLR) activities led to enlarged osteocyte lacunae. This may result in alterations in interstitial fluid flow-mediated mechanical stimulation on osteocytes and an elevation in solute transport through the lacunar-canalicular system (LCS) during high-frequency dynamic loading, thus enhancing mechano-responsiveness of maternal bone during lactation. Taken together, findings from this study provide important insights into the relationship between reproduction- and lactation-induced skeletal changes and external mechanical loading, emphasizing the importance of weight-bearing exercise on maternal bone health during reproduction and postpartum.
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Affiliation(s)
- Yihan Li
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Chantal M J de Bakker
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Radiology, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - Xiaohan Lai
- Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Hongbo Zhao
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Ashutosh Parajuli
- Center for Biomechanical Research, Department of Mechanical Engineering, University of Delaware, Newark, DE, USA
| | - Wei-Ju Tseng
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Shaopeng Pei
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Biomechanical Research, Department of Mechanical Engineering, University of Delaware, Newark, DE, USA
| | - Tan Meng
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Rebecca Chung
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Liyun Wang
- Center for Biomechanical Research, Department of Mechanical Engineering, University of Delaware, Newark, DE, USA
| | - X Sherry Liu
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
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7
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Watts NB, Binkley N, Owens CD, Al-Hendy A, Puscheck EE, Shebley M, Schlaff WD, Simon JA. Bone Mineral Density Changes Associated With Pregnancy, Lactation, and Medical Treatments in Premenopausal Women and Effects Later in Life. J Womens Health (Larchmt) 2021; 30:1416-1430. [PMID: 34435897 DOI: 10.1089/jwh.2020.8989] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Bone mineral density (BMD) changes during the life span, increasing rapidly during adolescence, plateauing in the third decade of life, and subsequently entering a phase of age-related decline. In women, menopause leads to accelerated bone loss and an increase in fracture risk. Between peak bone mass attainment and menopause, BMD is generally stable and the risk of fracture is typically low. This time period is marked by life events such as pregnancy and lactation, which transiently decrease BMD, yet their long-term effects on fracture risk are less certain. BMD may also be altered by exposure to medications that affect bone metabolism (e.g., contraceptives, glucocorticoids, antidiabetic medications, antiepileptic drugs). Although oral contraceptives are often believed to be neutral with regard to bone health, depot medroxyprogesterone acetate (DMPA) and gonadotropin-releasing hormone (GnRH) agonists have been associated with decreases in BMD. Development of newer medical therapies, principally GnRH antagonists (e.g., ASP1707, elagolix, linzagolix, relugolix), for treatment of endometriosis-associated pelvic pain and heavy menstrual bleeding due to uterine fibroids has renewed interest in the short- and long-term impacts of changes in BMD experienced by premenopausal women. It is important to understand how these drugs influence BMD and put the findings into context with regard to measurement variability and naturally occurring factors that influence bone health. This review summarizes what is known about the effects on bone health pregnancy, lactation, and use of DMPA, GnRH agonists, and GnRH antagonists in premenopausal women and potential consequences later in life. ClinicalTrials.gov identifier: NCT03213457.
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Affiliation(s)
- Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, Ohio, USA
| | - Neil Binkley
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, The University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Elizabeth E Puscheck
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA.,InVia Fertility, Hoffman Estates, Illinois, USA
| | | | - William D Schlaff
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James A Simon
- IntimMedicine Specialists, Washington, District of Columbia, USA
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8
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Kurabayashi T, Nagai K, Morikawa K, Kamimura N, Yanase T, Hayashi K. Prevalence of osteoporosis and osteopenia assessed by densitometry in Japanese puerperal women. J Obstet Gynaecol Res 2021; 47:1388-1396. [PMID: 33559219 DOI: 10.1111/jog.14694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/23/2021] [Indexed: 01/13/2023]
Abstract
AIM The aim is to examine the prevalence of low bone mineral density (BMD) (osteoporosis and osteopenia) of lumbar and femoral bones in puerperal women for the prenatal and postnatal care to ensure their optimal bone health. METHODS We analyzed the first scan data of 1079 Japanese puerperal women without bone fracture (mean age 33.5 ± 4.5 years) who had undergone deliveries at Niigata City General Hospital for 10 years. We measured BMDs of the lumbar spine [LS], femoral neck [FN], and total hip [TH] with dual-energy X-ray absorptiometry (DXA) within 30 days after delivery. RESULTS The rates of osteoporosis of LS, FN, TH, and comprehensive diagnosis (CD) were 0.6%, 4.8%, 1.5%, and 5.4%, respectively, and osteopenia were 20.2%, 39.5%, 29.3%, and 44.3%, respectively. The multivariable-adjusted odds ratio (OR) for body mass index (BMI) before pregnancy reflected significant decreases in risk for low BMD with an OR of 0.78 (95% CI: 0.74-0.82) with the 1 kg/m2 increases. In lean women (BMI < 18.5), 71% of them had low BMD. CONCLUSIONS Approximately 50% of puerperal women had low BMD without bone fracture. BMD measurements at puerperium, especially for lean women, may be very useful for identifying at risk of osteoporosis in future.
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Affiliation(s)
- Takumi Kurabayashi
- Department of Obstetrics & Gynecology, Niigata City General Hospital, Niigata, Japan
| | - Kazue Nagai
- Unit of Community Health Sciences, School of Health Sciences, Gunma University, Gunma, Japan
| | - Kyoko Morikawa
- Department of Obstetrics & Gynecology, Niigata City General Hospital, Niigata, Japan
| | - Naomi Kamimura
- Department of Obstetrics & Gynecology, Niigata City General Hospital, Niigata, Japan
| | - Toru Yanase
- Department of Obstetrics & Gynecology, Niigata City General Hospital, Niigata, Japan
| | - Kunihiko Hayashi
- Unit of Community Health Sciences, School of Health Sciences, Gunma University, Gunma, Japan
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9
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Yoshikata H, Tsugawa N, Watanabe Y, Tsuburai T, Chaki O, Hirahara F, Miyagi E, Sakakibara H, Uenishi K, Okano T. 25-Hydroxyvitamin D profiles and maternal bone mass during pregnancy and lactation in Japanese women. J Bone Miner Metab 2020; 38:99-108. [PMID: 31432265 DOI: 10.1007/s00774-019-01032-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 07/13/2019] [Indexed: 01/28/2023]
Abstract
Vitamin D deficiency is observed worldwide and represents a health hazard for mothers, infants and elderly persons. We know that many young Japanese women experience vitamin D insufficiency; however, there is a lack of knowledge regarding the serum 25-hydroxyvitamin D [25(OH)D] profile of pregnant Japanese women and of the association between maternal 25(OH)D level and maternal bone mass during pregnancy and lactation. In this longitudinal study, 160 pregnant Japanese women were enrolled; of them, 68 have been followed-up from the first trimester through at least 1 year of breast-feeding. We estimated serum 25(OH)D levels, intact PTH levels, calcaneus quantitative ultrasound (QUS: T score) scores, bone mineral density at the distal one-third of the radius, dietary intakes according to the Food Frequency Questionnaire, and sunlight exposure times. We found that Vitamin D deficiency is prevalent in Japanese women, irrespective of pregnancy or lactation, and our analysis suggested that 25(OH)D levels and BMI in the first trimester were related to the lactating women's bone mass from after delivery to 1 year after delivery.
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Affiliation(s)
- Hiromi Yoshikata
- Yoshikata Obstetrics and Gynecology Clinic, 2430 Kozukue-cho, Kohoku-ku, Yokohama, Kanagawa, 222-0036, Japan.
- Department of Gynecology, Yokohama City University Medical Center Hospital, Yokohama, Japan.
| | | | - Yuna Watanabe
- Niigata University of Health and Welfare, Niigata, Japan
| | - Taku Tsuburai
- Department of Gynecology, Yokohama City University Medical Center Hospital, Yokohama, Japan
| | - Osamu Chaki
- Department of Gynecology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Fumiki Hirahara
- Department of Obstetrics and Gynecology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Etsuko Miyagi
- Department of Obstetrics and Gynecology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Hideya Sakakibara
- Department of Gynecology, Yokohama City University Medical Center Hospital, Yokohama, Japan
| | - Kazuhiro Uenishi
- Laboratory of Physiological Nutrition, Kagawa Nutrition University, Sakado, Japan
| | - Toshio Okano
- Department of Hygienic Sciences, Kobe Pharmaceutical University, Kobe, Japan
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10
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Liu XS, Wang L, de Bakker CMJ, Lai X. Mechanical Regulation of the Maternal Skeleton during Reproduction and Lactation. Curr Osteoporos Rep 2019; 17:375-386. [PMID: 31755029 PMCID: PMC7373497 DOI: 10.1007/s11914-019-00555-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This review summarizes recently published data on the effects of pregnancy and lactation on bone structure, mechanical properties, and mechano-responsiveness in an effort to elucidate how the balance between the structural and metabolic functions of the skeleton is achieved during these physiological processes. RECENT FINDINGS While pregnancy and lactation induce significant changes in bone density and structure to provide calcium for fetal/infant growth, the maternal physiology also comprises several innate compensatory mechanisms that allow for the maintenance of skeletal mechanical integrity. Both clinical and animal studies suggest that pregnancy and lactation lead to adaptations in cortical bone structure to allow for rapid calcium release from the trabecular compartment while maintaining whole bone stiffness and strength. Moreover, extents of lactation-induced bone loss and weaning-induced recovery are highly dependent on a given bone's load-bearing function, resulting in better protection of the mechanical integrity at critical load-bearing sites. The recent discovery of lactation-induced osteocytic perilacunar/canalicular remodeling (PLR) indicates a new means for osteocytes to modulate mineral homeostasis and tissue-level mechanical properties of the maternal skeleton. Furthermore, lactation-induced PLR may also play an important role in maintaining the maternal skeleton's load-bearing capacity by altering osteocyte's microenvironment and modulating the transmission of anabolic mechanical signals to osteocytes. Both clinical and animal studies show that parity and lactation have no adverse, or a positive effect on bone strength later in life. The skeletal effects during pregnancy and lactation reflect an optimized balance between the mechanical and metabolic functions of the skeleton.
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Affiliation(s)
- X Sherry Liu
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 332A Stemmler Hall, 36th Street and Hamilton Walk, Philadelphia, PA, USA.
| | - Liyun Wang
- Center for Biomechanical Research, Department of Mechanical Engineering, University of Delaware, Newark, DE, USA
| | - Chantal M J de Bakker
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - Xiaohan Lai
- School of Life Sciences, University of Science and Technology of China, Hefei, China
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Miyamoto T, Miyakoshi K, Sato Y, Kasuga Y, Ikenoue S, Miyamoto K, Nishiwaki Y, Tanaka M, Nakamura M, Matsumoto M. Changes in bone metabolic profile associated with pregnancy or lactation. Sci Rep 2019; 9:6787. [PMID: 31086225 PMCID: PMC6513862 DOI: 10.1038/s41598-019-43049-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 04/15/2019] [Indexed: 12/14/2022] Open
Abstract
Calcium and nutrients are transferred from mothers to fetuses or infants during pregnancy or lactation, respectively, promoting metabolic changes in the mother, many uncharacterized. To evaluate these changes, we undertook two parallel studies. In one we analyzed fourteen clinical cases of vertebral fragility fractures, at or before three months after partum, in mothers who breastfed their infants. In the other, we enrolled 79 additional pregnant subjects, some who chose to breastfeed and others who did not, and analyzed changes in bone metabolic status starting between 34 and 36 weeks of gestation and ending one month after partum. In the larger group, bone-resorbing and bone-forming parameters such as serum TRACP5b and osteocalcin, respectively, significantly increased after partum. Among parameters that changed after partum, serum PTH and the bone-resorbing markers serum TRACP5b and urine NTX were significantly higher in mothers who only breastfed infants compared to mothers who fed infants formula or a mix of both. However, bone-forming parameters were comparable between breastfeeding and non-breast-feeding groups after partum, suggesting that elevated bone-resorption occurs only in the breastfeeding group. Radiographic analysis after partum demonstrated that no subject among the 79 analyzed showed vertebral fractures, even those who breastfed exclusively. Among fracture cases analyzed, subjects exhibited significantly lower bone mineral density than did non-fracture cases in breastfeeding-only subjects. We conclude that bone metabolic status significantly changes over the period between pregnancy and post-partum lactation, and that low bone mineral density seen in a small subset of breastfeeding-only cases likely causes post-partum vertebral fragility fractures.
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Affiliation(s)
- Takeshi Miyamoto
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan. .,Department of Advanced Therapy for Musculoskeletal Disorders, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan. .,Department of Orthopaedic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan.
| | - Kei Miyakoshi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yuiko Sato
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Department of Advanced Therapy for Musculoskeletal Disorders, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yoshifumi Kasuga
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Satoru Ikenoue
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kana Miyamoto
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Department of Environmental and Occupational Health, School of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.,Department of Orthopaedic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuji Nishiwaki
- Department of Environmental and Occupational Health, School of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Mamoru Tanaka
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
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12
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de Bakker CM, Li Y, Zhao H, Leavitt L, Tseng WJ, Lin T, Tong W, Qin L, Liu XS. Structural Adaptations in the Rat Tibia Bone Induced by Pregnancy and Lactation Confer Protective Effects Against Future Estrogen Deficiency. J Bone Miner Res 2018; 33:2165-2176. [PMID: 30040148 PMCID: PMC6464108 DOI: 10.1002/jbmr.3559] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 06/08/2018] [Accepted: 07/14/2018] [Indexed: 12/31/2022]
Abstract
The female skeleton undergoes substantial structural changes during the course of reproduction. Although bone mineral density recovers postweaning, reproduction may induce permanent alterations in maternal bone microarchitecture. However, epidemiological studies suggest that a history of pregnancy and/or lactation does not increase the risk of postmenopausal osteoporosis or fracture and may even have a protective effect. Our study aimed to explain this paradox by using a rat model, combined with in vivo micro-computed tomography (μCT) imaging and bone histomorphometry, to track the changes in bone structure and cellular activities in response to estrogen deficiency following ovariectomy (OVX) in rats with and without a reproductive history. Our results demonstrated that a history of reproduction results in an altered skeletal response to estrogen-deficiency-induced bone loss later in life. Prior to OVX, rats with a reproductive history had lower trabecular bone mass, altered trabecular microarchitecture, and more robust cortical structure at the proximal tibia when compared to virgins. After OVX, these rats underwent a lower rate of trabecular bone loss than virgins, with minimal structural deterioration. As a result, by 12 weeks post-OVX, rats with a reproductive history had similar trabecular bone mass, elevated trabecular thickness, and increased robustness of cortical bone when compared to virgins, resulting in greater bone stiffness. Further evaluation suggested that reproductive-history-induced differences in post-OVX trabecular bone loss were likely due to differences in baseline trabecular microarchitecture, particularly trabecular thickness. Rats with a reproductive history had a larger population of thick trabeculae, which may be protective against post-OVX trabecular connectivity deterioration and bone loss. Taken together, these findings indicate that reproduction-associated changes in bone microarchitecture appear to reduce the rate of bone loss induced by estrogen deficiency later in life, and thereby exert a long-term protective effect on bone strength. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Chantal Mj de Bakker
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yihan Li
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hongbo Zhao
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Key Laboratory of Biorheological Science and Technology, Ministry of Education and Bioengineering College, Chongqing University, Chongqing, China
| | - Laurel Leavitt
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wei-Ju Tseng
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tiao Lin
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Musculoskeletal Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Tong
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ling Qin
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - X Sherry Liu
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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13
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Kovacs CS. Maternal Mineral and Bone Metabolism During Pregnancy, Lactation, and Post-Weaning Recovery. Physiol Rev 2016; 96:449-547. [PMID: 26887676 DOI: 10.1152/physrev.00027.2015] [Citation(s) in RCA: 251] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
During pregnancy and lactation, female physiology adapts to meet the added nutritional demands of fetuses and neonates. An average full-term fetus contains ∼30 g calcium, 20 g phosphorus, and 0.8 g magnesium. About 80% of mineral is accreted during the third trimester; calcium transfers at 300-350 mg/day during the final 6 wk. The neonate requires 200 mg calcium daily from milk during the first 6 mo, and 120 mg calcium from milk during the second 6 mo (additional calcium comes from solid foods). Calcium transfers can be more than double and triple these values, respectively, in women who nurse twins and triplets. About 25% of dietary calcium is normally absorbed in healthy adults. Average maternal calcium intakes in American and Canadian women are insufficient to meet the fetal and neonatal calcium requirements if normal efficiency of intestinal calcium absorption is relied upon. However, several adaptations are invoked to meet the fetal and neonatal demands for mineral without requiring increased intakes by the mother. During pregnancy the efficiency of intestinal calcium absorption doubles, whereas during lactation the maternal skeleton is resorbed to provide calcium for milk. This review addresses our current knowledge regarding maternal adaptations in mineral and skeletal homeostasis that occur during pregnancy, lactation, and post-weaning recovery. Also considered are the impacts that these adaptations have on biochemical and hormonal parameters of mineral homeostasis, the consequences for long-term skeletal health, and the presentation and management of disorders of mineral and bone metabolism.
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Affiliation(s)
- Christopher S Kovacs
- Faculty of Medicine-Endocrinology, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
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14
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Whisner CM, Young BE, Witter FR, Harris ZL, Queenan RA, Cooper EM, O'Brien KO. Reductions in heel bone quality across gestation are attenuated in pregnant adolescents with higher prepregnancy weight and greater increases in PTH across gestation. J Bone Miner Res 2014; 29:2109-17. [PMID: 24676885 DOI: 10.1002/jbmr.2233] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 03/07/2014] [Accepted: 03/17/2014] [Indexed: 11/11/2022]
Abstract
Few studies have examined the effect of maternal calcium intake and vitamin D status on bone health across gestation in pregnant adolescents. This study aimed to characterize maternal bone quality and determinants of bone-quality change across gestation in pregnant adolescents. Healthy pregnant adolescents (n = 156; aged 13 to 18 years) with singleton pregnancies and at 12 to 30 weeks gestation at enrollment were recruited from two urban maternity clinics in Baltimore, MD, and Rochester, NY, for this prospective longitudinal study. Maternal serum was collected at midgestation and at delivery for assessment of bone biomarkers and calcitropic hormones. Maternal bone quality (assessed by heel ultrasound) and sonographic fetal biometry were measured up to three times across pregnancy. Racially diverse teens (64.7% African American, 35.3% white) were followed from 21.0 (interquartile range [IQR] 17.3, 27.0) weeks of gestation until delivery at 40.0 (IQR 39.0, 40.7) weeks. Significant decreases in calcaneal speed of sound (SOS), broadband ultrasound attenuation (BUA), and quantitative ultrasound index (QUI) (-9.2 ± 16.1 m/s, -3.2 (-8.0, 2.1) dB/MHz and -5.3 ± 8.8, respectively) were evident across pregnancy. Multivariate analysis controlling for baseline measures and measurement intervals was used to identify independent predictors of normalized (per week) calcaneal bone loss. Weekly decreases in bone quality were not significantly associated with maternal calcium intake or 25(OH)D concentration. Greater weekly reductions in calcaneal bone quality were evident in teens with lower prepregnancy weight (BUA, p = 0.006 and QUI, p = 0.012) and among those with lower weekly increase in PTH (SOS, p = 0.046). Overall, significant decreases in calcaneal bone quality occurred across pregnancy in adolescents, but the magnitude of this loss was attenuated in those with greater prepregnancy weight and weekly increases in PTH. Further studies are needed to understand the role of elevated PTH and greater prepregnancy weight in preserving adolescent bone during pregnancy.
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Affiliation(s)
- Corrie M Whisner
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
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15
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Canal-Macias ML, Roncero-Martin R, Moran JM, Lavado-Garcia JM, Costa-Fernandez MDC, Pedrera-Zamorano JD. Increased bone mineral density is associated with breastfeeding history in premenopausal Spanish women. Arch Med Sci 2013; 9:703-8. [PMID: 24049532 PMCID: PMC3776181 DOI: 10.5114/aoms.2013.36903] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 09/19/2012] [Accepted: 11/29/2012] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION During lactation abundant calcium is lost from the mother as a result of the amount of breast milk produced. Lactation leads to transient fragility, with some women experiencing even fragility fractures, but nearly all of these women subsequently undergo a large increase in bone mineral density (BMD), confirming that the BMD must have declined during lactation but it increases after weaning. We have retrospectively examined the relationship between the duration of breastfeeding and bone properties in Spanish premenopausal healthy women, to identify the site-specific changes in BMD. MATERIAL AND METHODS Four hundred and thirty-three premenopausal healthy women, 295 with a mean of 7.82 ±6.68 months of exclusive breastfeeding and 138 control women, were studied. We examined total, trabecular and cortical volumetric BMD (mg/mm(3)) at the distal radius using peripheral quantitative computed tomography. Areal BMD (g/cm(2)) was measured using dual energy X-ray absorptiometry at the femoral neck, lumbar spine, trochanter and Ward's triangle. Phalangeal bone ultrasound was measured by amplitude-dependent speed of sound. RESULTS Areal BMD analysis at L2-L4 revealed significant intergroup differences (p < 0.05). There were significant intergroup differences in the volumetric BMD in both total and cortical bone (p < 0.05). The observed BMD of breast-feeders was higher than the BMD in non-breast-feeding women. Additionally, the lactation subgroup analysis revealed significant differences in the areal BMD at trochanter and L2-L4 (p < 0.05) and in the cortical volumetric BMD (p < 0.05). CONCLUSIONS This study adds to the growing evidence that breastfeeding has no deleterious effects and may confer an additional advantage for BMD in premenopausal women.
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Affiliation(s)
- Maria Luz Canal-Macias
- Metabolic Bone Diseases Research Group (GIEMO), University of Extremadura, School of Nursing and Occupational Therapy, Cáceres, Spain
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16
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Mourad WF, Packianathan S, Shourbaji RA, Jennelle R, Yang CC, Mobit P, Zhang Z, Khan MA, Graves M, Russell G, Vijayakumar S. The influence of pregnancy on heterotopic ossification post-displaced acetabular fractures surgical repair. J Orthop Res 2013; 31:944-8. [PMID: 23335247 DOI: 10.1002/jor.22309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 12/12/2012] [Indexed: 02/04/2023]
Abstract
Pregnancy is associated with maternal bone mineral density loss and modulation of calcium metabolism. We hypothesized that pregnancy may decrease the risk of heterotopic ossification (HO) after trauma. This is a single-institution, University of Mississippi Medical Center, retrospective study investigating the effect of pregnancy on the incidence HO after surgical repair (SR) of displaced acetabular fractures. Between January 1998 and 2010, 257 non-pregnant women (Group A) and 16 pregnant women (Group B) were identified. All the non-pregnant women received radiation therapy (RT) ± indomethacin. None of the pregnant women in group B received any prophylaxis. After a median follow-up of 6.6 years the incidence of HO in all patients was 27% (75/273). In Group A, non-pregnant, women who received RT ± indomethacin, 29% developed HO; HO risk was 0.4. In Group B, 16 pregnant patients, only one developed HO (6%); HO risk was 0.06. Thus, the risk of HO appears to be nearly six-fold higher in non-pregnant women despite prophylactic RT ± indomethacin. Our data suggest that pregnancy may be associated with a reduced risk of HO after SR of displaced acetabular fractures. Further analysis with a larger pregnant patient sample is necessary to confirm this finding.
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Affiliation(s)
- Waleed F Mourad
- Department of Radiation Oncology, University of Mississippi Medical Center, Jackson, Mississippi, USA.
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17
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Abstract
Pregnancy and lactation are times of additional demand for Ca. Ca is transferred across the placenta for fetal skeletal mineralisation, and supplied to the mammary gland for secretion into breast milk. In theory, these additional maternal requirements could be met through mobilisation of Ca from the skeleton, increased intestinal Ca absorption efficiency, enhanced renal Ca retention or greater dietary Ca intake. The extent to which any or all of these apply, the underpinning biological mechanisms and the possible consequences for maternal and infant bone health in the short and long term are the focus of the present review. The complexities in the methodological aspects of interpreting the literature in this area are highlighted and the inter-individual variation in the response to pregnancy and lactation is reviewed. In summary, human pregnancy and lactation are associated with changes in Ca and bone metabolism that support the transfer of Ca between mother and child. The changes generally appear to be independent of maternal Ca supply in populations where Ca intakes are close to current recommendations. Evidence suggests that the processes are physiological in humans and that they provide sufficient Ca for fetal growth and breast-milk production, without relying on an increase in dietary Ca intake or compromising long-term maternal bone health. Further research is needed to determine the limitations of the maternal response to the Ca demands of pregnancy and lactation, especially among mothers with marginal and low dietary Ca intake, and to define vitamin D adequacy for reproductive women.
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Abstract
Combination hormonal contraception and progestin-only contraception (including depot medroxyprogesterone acetate [DMPA]) are effective and convenient forms of reversible contraception that millions of women use worldwide. In recent years, observations of reduced bone mineral density in current users of these methods have led to concerns that this hormone-induced bone loss might translate into long-term increased fracture risk. Special focus has been placed on adolescent users who have not yet attained their peak bone mass as well as perimenopausal users. In 2004, the FDA added a black box warning to DMPA package labeling warning of the risk of significant bone loss and cautioning against long-term use (> 2 years). This article reviews evidence on the use of hormonal contraception and its effect on bone density in adolescent, premenopausal, and perimenopausal populations. Recommendations from reproductive healthcare organizations are reviewed and clinical recommendations are provided.
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MESH Headings
- Adolescent
- Adult
- Bone Density/drug effects
- Contraceptive Agents, Female/administration & dosage
- Contraceptive Agents, Female/adverse effects
- Contraceptive Agents, Female/therapeutic use
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Combined/therapeutic use
- Contraceptives, Oral, Hormonal/adverse effects
- Contraceptives, Oral, Hormonal/therapeutic use
- Female
- Fractures, Bone/chemically induced
- Fractures, Bone/epidemiology
- Humans
- Lactation
- Perimenopause
- Practice Guidelines as Topic
- Risk Factors
- Young Adult
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Affiliation(s)
- Michelle M Isley
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, USA.
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Guilbert ER, Brown JP, Kaunitz AM, Wagner MS, Bérubé J, Charbonneau L, Francoeur D, Gilbert A, Gilbert F, Roy G, Senikas V, Jacob R, Morin R. The use of depot-medroxyprogesterone acetate in contraception and its potential impact on skeletal health. Contraception 2009; 79:167-77. [PMID: 19185668 DOI: 10.1016/j.contraception.2008.10.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Revised: 10/08/2008] [Accepted: 10/09/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND In the fall of 2007, the controversy about the contraceptive use of depot-medroxyprogesterone acetate (DMPA) and its potential impact on skeletal health reached the media in the province of Quebec, Canada, thereby becoming a matter of concern for the lay public and physicians. In order to discuss this subject openly, the National Institute of Public Health of Quebec (INSPQ) organized a scientific meeting on February 15, 2008, with targeted physicians delegated by their medical associations in the fields of general practice, obstetrics and gynaecology, rheumatology, orthopaedic surgery, physiatry and endocrinology. STUDY DESIGN Participants reviewed the scientific literature using the study classification method according to the level of evidence, reviewed published guidelines of medical societies and organizations on the subject and reached a consensus position. This manuscript presents a review of the literature and describes the consensus position of the targeted medical associations. RESULTS The consensus position adopted by all the targeted medical associations determined that DMPA was a cost-effective contraceptive option that must be considered in the light of the clinical situation and preference of each woman. Candidates for injectable contraception should be informed that the use of DMPA is associated with a slight decrease in bone mineral density (BMD), which is largely, if not completely, reversible. There should not be an absolute limit to the length of time that the DMPA contraceptive is used, regardless of the woman's age. Monitoring BMD is not recommended among users of DMPA for contraceptive purposes. Finally, the consensus statement declared that, although supplements of calcium and vitamin D are beneficial for skeletal health for women in general, such supplementation should not be recommended solely based on a woman's use of DMPA. CONCLUSION Given the scientific evidences, DMPA use remains a valid contraceptive option for women. Its potential impact on BMD must be balanced against the significant individual, familial and social consequences of unintended pregnancy.
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Kurabayashi T, Nagata H, Takeyama N, Matsushita H, Tanaka K. Bone mineral density measurement in puerperal women as a predictor of persistent osteopenia. J Bone Miner Metab 2009; 27:205-12. [PMID: 19172224 DOI: 10.1007/s00774-008-0028-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2007] [Accepted: 06/22/2008] [Indexed: 10/21/2022]
Abstract
The clinical value of bone mineral density (BMD) measurement in puerperal women is uncertain. Our aim was to examine the effectiveness of BMD measurement in puerperal women for identification of persistent osteopenia and osteoporosis. We addressed cross-sectional and longitudinal changes in BMD, assessed using dual-energy X-ray absorptiometry (DXA), in a postpartum female cohort from a single center in Japan. We measured BMD of the lumbar spine (L2-L4) with DXA in 2,436 puerperal women within 7 days of delivery (study 1). For 210 of the women, the BMD was measured again after 5-10 years (study 2). In study 1, 8 (0.3%) of the women were osteoporotic, 37 (17.0%) were osteopenic, and 2,013 (82.6%) were normal. In study 2, 27 (71.1%) of the 38 osteoporotic or osteopenic women identified in the puerperal scan were still osteopenic at the scan after 5-10 years. Over the same period, only 7 (4.1%) of 172 initially normal women became osteopenic. The mean of the BMD change per year was 0.15 +/- 0.82%/year. Osteopenia was associated with a significantly lower body weight and body mass index at puerperium and after 5-10 years compared to normal women. The multiple regression analysis showed that BMD at the first scan negatively contributed and body weight changes between the scans positively significantly contributed to the BMD changes per year. Puerperal BMD remained static over the subsequent 5-10 years. If the women have a low BMD at this stage of their reproductive life, it tends not to improve over this time. Perhaps identification of this at-risk group may lead to effective interventions to reduce fracture risk in later life.
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Affiliation(s)
- Takumi Kurabayashi
- Department of Obstetrics and Gynecology, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, Niigata 950-1197, Japan.
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Kaunitz AM, Arias R, McClung M. Bone density recovery after depot medroxyprogesterone acetate injectable contraception use. Contraception 2008; 77:67-76. [PMID: 18226668 DOI: 10.1016/j.contraception.2007.10.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Revised: 10/15/2007] [Accepted: 10/16/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND While depot medroxyprogesterone acetate (DMPA) is a highly effective contraceptive used by millions of women, its use is associated with bone mineral density (BMD) loss, raising concerns about long-term risk of osteoporosis and/or fractures. STUDY DESIGN We conducted a systematic review of studies published in PubMed from 1996 to 2006, evaluating changes in BMD after discontinuation of DMPA. Ten primary clinical or observational studies were identified addressing this issue. RESULTS BMD consistently returned toward or to baseline values following DMPA discontinuation in women of all ages. This recovery in BMD was seen as early as 24 weeks after stopping therapy and persisted for as long as women were followed up; BMD in past DMPA users was similar to that in nonusers. CONCLUSIONS Bone loss occurring with DMPA use is reversible and is not likely to be an important risk factor for low bone density and fractures in older women, although data on fracture risk in DMPA users are lacking.
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Affiliation(s)
- Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL 32209, USA.
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23
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Abstract
PURPOSE OF REVIEW To help clinicians guide adolescent patients to sound choices regarding long-acting contraceptives. The safety, side effects and non-contraceptive benefits of injectable, implantable and intrauterine contraception are detailed. RECENT FINDINGS The use of depot medroxyprogesterone acetate contraceptive injections has been associated with declines in teenage pregnancies in the United States. Although the US Food and Drug Administration has placed a black box warning concerning skeletal health and depot medroxyprogesterone acetate, data in adolescents confirm that declines in bone mineral density with depot medroxyprogesterone acetate are fully reversible. Concerns regarding skeletal health should not restrict the initiation or continuation of depot medroxyprogesterone acetate in adolescents. A highly effective, convenient, and easy to insert/remove single rod progestin-only contraceptive implant (Implanon) is now available in the United States. Although not widely used in adolescents, intrauterine devices offer selected adolescents convenient, highly effective, safe birth control. Use of the progestin-releasing intrauterine device (Mirena) is also associated with important non-contraceptive benefits. SUMMARY The efficacy and convenience associated with long-acting contraceptives make them indispensable for adolescent patients. This review will help clinicians guide teenage patients towards sound contraceptive choices and the successful long-term use of injectable, implantable and intrauterine methods of birth control.
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Affiliation(s)
- Lama L Tolaymat
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, Florida 32207, USA.
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Miglioli L, Costa-Paiva L, de Lourenço LS, Morais SS, Lopes de Lima MC, Pinto-Neto AM. The association of pregnancy history with areal and volumetric bone mineral density in adolescence. Osteoporos Int 2007; 18:101-8. [PMID: 16937071 DOI: 10.1007/s00198-006-0203-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2005] [Accepted: 07/05/2006] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Studies demonstrate that pregnancy may interfere with bone mineral density. Adolescence is a crucial time of life for bone mass acquisition and there are some questions as to the influence of pregnancy on bone mass at this age. OBJECTIVE To evaluate the association between pregnancy history and areal (BMD) and volumetric (vBMD) bone mineral density in adolescence. SUBJECTS AND METHODS A cross-sectional study of 119 adolescents ranging from 12-20 years of age was conducted; 30 of these girls had a history of full-term pregnancy. The adolescents were selected during a routine visit to the Adolescent Gynecology Outpatient Facility, completed a questionnaire, and had a physical examination to evaluate weight, height and Tanner stage. Bone mineral densitometry of the lumbar spine (L(1)-L(4)) and total body (TB) was performed to measure bone mineral density and body composition. RESULTS The mean measurements of the area, bone mineral content (BMC), BMD and vBMD of L(1)-L(4) and the area, BMC and BMD of TB were not significantly different between adolescents with and without a pregnancy history, stratified by chronologic and gynecologic age. The percentage of adolescents with altered Z-scores was similar in both groups, and the prevalence ratio showed no association between pregnancy history and low bone mass (PR=0.52; CI 0.04-6.07). Upon multiple regression analysis, body mass index (BMI) and lean body mass (LBM) were the main factors associated with lumbar spine and total body measurements. Pregnancy history was inversely associated with areal BMD of L(1)-L(4) (R (2)=0.04) and vBMD of L(1)-L(4) (R (2)=0.04), accounting for only 4% variation in the lumbar spine. CONCLUSION These data suggest that adolescent pregnancy seems to exert no significant influence on the acquisition of bone mass and does not appear to represent a risk factor for osteoporosis in the future.
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Affiliation(s)
- L Miglioli
- Department of Obstetrics and Gynecology, School of Medicine (FCM), Universidade Estadual de Campinas (Unicamp), Campinas, Sao Paulo, Brazil
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Kaunitz AM, Miller PD, Rice VM, Ross D, McClung MR. Bone mineral density in women aged 25–35 years receiving depot medroxyprogesterone acetate: recovery following discontinuation. Contraception 2006; 74:90-9. [PMID: 16860045 DOI: 10.1016/j.contraception.2006.03.010] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2005] [Revised: 03/09/2006] [Accepted: 03/10/2006] [Indexed: 11/25/2022]
Abstract
INTRODUCTION This 7-year, prospective, matched-cohort, clinical study evaluated the effects of intramuscular depot medroxyprogesterone acetate (DMPA) (150 mg/mL) on bone mineral density (BMD) in women aged 25-35 years. METHODS Bone mineral density changes in new DMPA-IM users (n=248) were compared with those in women using nonhormonal contraception (n=360) for up to 240 weeks of treatment and 96 weeks of posttreatment follow-up (in subjects receiving >or=1 dose). RESULTS At week 240 of treatment, mean percentage changes from baseline in DMPA-IM vs. nonhormonal subjects were: -5.16% (n=21) vs. +0.19% (n=65), total hip (p<.001); -5.38% (n=33) vs. +0.43% (n=105), lumbar spine (p<.001). At week 96 posttreatment, these values were: -0.20% (n=25) vs. +0.84% (n=43), total hip (p=.047); -1.19% (n=41) vs. +0.47% (n=66), lumbar spine (p=.017). CONCLUSIONS These results show BMD declines during DMPA-IM use; following discontinuation, significant increases in BMD occur through 96 weeks posttreatment.
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Affiliation(s)
- Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville, FL 32209, USA.
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Kolle E, Torstveit MK, Sundgot-Borgen J. Bone mineral density in Norwegian premenopausal women. Osteoporos Int 2005; 16:914-20. [PMID: 15502958 DOI: 10.1007/s00198-004-1783-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2004] [Accepted: 09/22/2004] [Indexed: 10/26/2022]
Abstract
The aims of this study were: 1) to determine bone mineral density (BMD) in different age groups, 2) to determine the prevalence of low BMD, and 3) to determine the possible association between BMD and a number of risk factors in Norwegian premenopausal women. BMD of the lumbar spine (L(2)-L(4)), total body, and the hip (total femur, femur neck, and trochanter) were measured using dual-energy X-ray absorptiometry (Prodigy, Lunar) in 145 randomly selected women aged 13-39 years. Information on other factors thought to influence BMD was obtained through questionnaire and a clinical interview. The group aged 25-29 years had the highest mean BMD in the total body, lumbar spine, and total femur while the group aged 13-19 years had the highest mean BMD in the femur neck and the trochanter. The mean BMD values of Norwegian premenopausal women were 3.4-5.1% higher than US/European reference data (P<0.05). Five percent of the study sample aged 20-39 years were defined with low BMD (Z-score <-2) using the standard values from this study. Weight-bearing physical activity, body weight, body height, and age were positively associated with BMD, whilst menstrual dysfunction and previous pregnancy were associated with lower BMD in some of the measurement sites. The results show that the factors associated with BMD are extensive, and the strategies to prevent low BMD have to be multifactorial. A follow-up study should be conducted on the study sample to investigate actual mean BMD values and BMD changes through time.
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Affiliation(s)
- Elin Kolle
- The Norwegian University of Sports and Physical Education, Ullevål Stadion, PO Box 4014, 0806 Oslo, Norway.
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Abstract
During pregnancy and lactation, changes occur in a variety of factors which have great potential to influence bone mineral density (BMD). Smoking habits, the level of alcohol consumption, the level of physical activity, body weight, soft tissue composition and hormone levels are all factors that change during the course of these conditions. Some of these factors are capable of increasing BMD, and some can reduce it. Due to these various changes, it is virtually impossible to predict the development in BMD that will occur during a pregnancy and lactation. However, longitudinal studies have suggested that both pregnancy and lactation are associated with a BMD loss of up to 5%, albeit that the BMD recovers after weaning. Cross-sectional studies have indicated that women with many children and a long total period of lactation have similar or higher BMD and similar or lower fracture risk than their peers who have not given birth. As the studies showing this trend have been observational and cross sectional case-control studies, the conclusions can only be regarded as being suggestive, and no causality can be proven.
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Affiliation(s)
- Magnus K Karlsson
- Department of Orthopedics, Lund University, Malmö University Hospital, SE-205 02, Malmö, Sweden.
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Gulson BL, Mizon KJ, Palmer JM, Korsch MJ, Taylor AJ, Mahaffey KR. Blood lead changes during pregnancy and postpartum with calcium supplementation. ENVIRONMENTAL HEALTH PERSPECTIVES 2004; 112:1499-507. [PMID: 15531434 PMCID: PMC1247613 DOI: 10.1289/ehp.6548] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2003] [Accepted: 07/27/2004] [Indexed: 05/20/2023]
Abstract
Pregnancy and lactation are times of physiologic stress during which bone turnover is accelerated. Previous studies have demonstrated that there is increased mobilization of lead from the maternal skeleton at this time and that calcium supplementation may have a protective effect. Ten immigrants to Australia were provided with either calcium carbonate or a complex calcium supplement (approximately 1 g/day) during pregnancy and for 6 months postpartum. Two immigrant subjects who did not conceive acted as controls. Sampling involved monthly venous blood samples throughout pregnancy and every 2 months postpartum, and quarterly environmental samples and 6-day duplicate diets. The geometric mean blood lead at the time of first sampling was 2.4 microg/dL (range, 1.4-6.5). Increases in blood lead during the third trimester, corrected for hematocrit, compared with the minimum value observed, varied from 10 to 50%, with a geometric mean of 25%. The increases generally occurred at 6-8 months gestation, in contrast with that found for a previous cohort, characterized by very low calcium intakes, where the increases occurred at 3-6 months. Large increases in blood lead concentration were found during the postpartum period compared with those during pregnancy; blood lead concentrations increased by between 30 and 95% (geometric mean 65%; n = 8) from the minimum value observed during late pregnancy. From late pregnancy through postpartum, there were significant increases in the lead isotopic ratios from the minimum value observed during late pregnancy for 3 of 8 subjects (p < 0.01). The observed changes are considered to reflect increases in mobilization of lead from the skeleton despite calcium supplementation. The identical isotopic ratios in maternal and cord blood provide further confirmation of placental transfer of lead. The extra flux released from bone during late pregnancy and postpartum varies from 50 to 380 microg lead (geometric mean, 145 microg lead) compared with 330 microg lead in the previous cohort. For subjects replete in calcium, the delay in increase in blood lead and halving of the extra flux released from bone during late pregnancy and postpartum may provide less lead exposure to the developing fetus and newly born infant. Nevertheless, as shown in several other studies on calcium relationships with bone turnover, calcium supplementation appears to provide limited benefit for lead toxicity during lactation.
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Affiliation(s)
- Brian L Gulson
- Graduate School of the Environment, Macquarie University, Sydney, New South Wales, Australia.
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Promislow JHE, Hertz-Picciotto I, Schramm M, Watt-Morse M, Anderson JJB. Bed rest and other determinants of bone loss during pregnancy. Am J Obstet Gynecol 2004; 191:1077-83. [PMID: 15507924 DOI: 10.1016/j.ajog.2004.05.058] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate patterns of bone loss during pregnancy and potential influences. STUDY DESIGN This was a prospective study of 181 women receiving prenatal care at Magee-Womens Hospital or its auxiliary clinics in Pittsburgh, Pennsylvania, between 1992 and 1995. Bone mineral density was measured at approximately 16 and 36 weeks' gestation. RESULTS Trabecular, but not cortical, bone loss occurred during pregnancy. Mean ultra-distal bone mineral density loss was 1.9% (95% CI 1.2-2.5) during the 20-week period. Women prescribed bed rest had an adjusted mean loss of 4.6% compared with 1.5% for women not prescribed bed rest ( P = .001) and 6-fold higher odds ( P = .001) of bone loss > or =5% during the 20-week period. Nulliparity, calcium intake < 2 000 mg/day, low weight gain, and maternal age < 21 or >30 years were more modestly associated with greater bone loss. CONCLUSION Substantial trabecular bone loss may occur during pregnancy, particularly in women prescribed bed rest. Study of postpartum bone recovery in such women is needed.
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Affiliation(s)
- Joanne H E Promislow
- Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, NC, USA.
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Abstract
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.
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Affiliation(s)
- Heidi J Kalkwarf
- Division of General and Community Pediatrics, Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Abstract
Despite numerous studies and case reports of changes in bone mineral density (BMD) during pregnancy, the postpartum, and lactation, controversy exists regarding the time course of BMD changes and recovery to baseline levels. The degree to which pregnancy affects BMD long-term remains unclear. Several influencing factors, including breast-feeding, length of amenorrhea after pregnancy, and parity, have been studied with respect to changes in BMD in healthy women. We conducted the first systematic review of its kind on this topic and evaluated the 23 identified citations according to the U.S. Preventive Services Task Force rating scale. Six studies qualified as Level II-2, 12 were Level II-3, and 5 were Level III. There seems to be good evidence that calcium is mobilized from the maternal skeleton to that of the developing fetus during pregnancy. However, the eventual return of BMD to prepregnancy values suggests that maternal bone loss may not be permanent. Results from the studies that specifically evaluated the effect of lactation on BMD were varied, ranging from a decrease in BMD to no change. Of the studies that evaluated the effect of parity on BMD, none found an association linking a greater number of pregnancies to greater decreases in BMD. Pregnancy-associated osteoporosis seems to be uncommon, based on the limited published reports. Overall, no long-term adverse clinical effects have been noted in healthy women who had at least one ongoing pregnancy, despite the good evidence that some bone loss does occur soon after delivery. Additional longitudinal studies need to be undertaken to provide more definitive information on the effects of pregnancy on BMD and risk of osteoporosis later in life.
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Affiliation(s)
- Mary H H Ensom
- Faculty of Pharmaceutical Sciences, University of British Columbia, Canada
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Bone Loss in Adolescent and Adult Pregnant Women. Obstet Gynecol 2000. [DOI: 10.1097/00006250-200008000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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