1
|
Cohen A. Bone Metabolism, Bone Mass, and Bone Structure During Pregnancy and Lactation: Normal Physiology and Pregnancy and Lactation-Associated Osteoporosis. Endocrinol Metab Clin North Am 2024; 53:453-470. [PMID: 39084819 DOI: 10.1016/j.ecl.2024.05.003] [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] [Indexed: 08/02/2024]
Abstract
This article reviews bone metabolism, bone mass, and bone structure changes expected during and after pregnancy and lactation, as well as the condition of pregnancy and lactation-associated osteoporosis (PLO)-a presentation with fragility fracture(s) in the context of these physiologic changes. Clinical implications of physiologic bone changes will be addressed, as will specific management considerations that apply to premenopausal women with PLO.
Collapse
Affiliation(s)
- Adi Cohen
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians & Surgeons, 180 Fort Washington Avenue, HP9-910, New York, NY 10032, USA.
| |
Collapse
|
2
|
Ali DS, Khan AA, Brandi ML. Effective strategies for pregnancy and lactation-associated osteoporosis: teriparatide use in focus. Endocrine 2024:10.1007/s12020-024-03946-6. [PMID: 39008200 DOI: 10.1007/s12020-024-03946-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Pregnancy and lactation-associated osteoporosis (PLO) is a rare condition characterized by fragility fractures occurring during late pregnancy or lactation, primarily affecting the spine and causing significant morbidity and back pain. PLO can lead to mobility impairment and work incapacity, with recovery taking up to several years. Due to the lack of clinical trials, treatment strategies remain poorly defined, historically focusing on calcium supplements, vitamin D, and weaning from breastfeeding. However, recent attention has turned to teriparatide (TPD) as an option due to its anabolic properties and potential suitability for women of childbearing age. METHODS This review evaluates TPD's use in PLO treatment, using published systematic reviews and case studies. Over 300 cases with PLO were identified through PubMed, Google Scholar, and Cochrane searches until August 2023. RESULTS We identified 175 cases with PLO treated with TPD alone or followed by antiresorptive therapy. Most women (85.7%) were primiparas. The mean ± SD duration of TPD use was 15 ± 6 months. Among the study patients, 91.4% used TPD alone, while 8.6% (15/175) utilized sequential therapy. Approximately 93% of our cohort exhibited potential risk factors for PLO. Despite the increased risk of recurrent fractures in PLO, only 14.7% (20/175) of those treated with TPD sustained new fractures during a 9-month to 9 years' follow-up period. The mean ± SD percent increase in BMD at the LS was 21.14% ± 7.4%, and at the FN it was 12.1% ± 9.3%. The baseline Z-scores at the LS ranged from -3.3 (-3.7 to -2.7), while the baseline Z-scores at the FN ranged from -2.0 (-2.7 to -1.5). CONCLUSION This review emphasizes PLO severity, advocating for increased awareness and timely interventions. TPD emerges as a promising therapeutic option in certain cases.
Collapse
Affiliation(s)
- Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada.
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Maria Luisa Brandi
- Fondazione FIRMO Onlus; Italian Foundation for the Research on Bone Diseases, Florence, Italy
- Donatello Bone Clinic, Villa Donatello Hospital, Sesto Fiorentino, Italy
| |
Collapse
|
3
|
Kasahara K, Tanaka-Mizuno S, Tsuji S, Ohashi M, Kasahara M, Kawasaki T, Murakami T. Pregnancy and lactation-associated osteoporosis as a major type of premenopausal osteoporosis: a retrospective cohort study based on real-world data. BMC Pregnancy Childbirth 2024; 24:301. [PMID: 38649869 PMCID: PMC11034016 DOI: 10.1186/s12884-024-06520-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Pregnancy and lactation-associated osteoporosis (PLO), as well as premenopausal osteoporosis, might be a predictor of future fracture. This study aimed to describe the clinical features of PLO as a subtype of premenopausal osteoporosis and to evaluate medical interventions for it. METHODS From an administrative claims database including 4,224,246 people in Japan, we classified women for whom the date of childbirth had been defined and who had suffered low-trauma fracture between the ages of 18-47 years as the premenopausal osteoporosis group. A fracture site for which the odds ratio for fractures occurring between 5 months before and 12 months after childbirth (around childbirth) was greater than 1 was considered the PLO site. We classified patients with a fracture at the PLO site around childbirth as the PLO group. The control group consisted of 500 women without fragility fractures. We investigated some drugs and diseases to explore fracture-causing factors, as well as medical interventions such as osteoporosis diagnosis, bone densitometry, anti-osteoporosis pharmacotherapy, and lactation inhibitors. RESULTS In total, 231 parous women were classified into the premenopausal osteoporosis group. The most common fracture was vertebral fracture and was likely to occur around childbirth, followed by distal radius and sacral fractures, which were rare around childbirth. Considering vertebral, pelvic, and proximal femoral fractures as PLO sites, 56 women with 57 PLO fractures were classified into the PLO group. The incidence of PLO was estimated at 460 per million deliveries. Ovulation disorder and high maternal age were associated with the development of PLO. Vertebral fracture was the most common PLO fracture. It was mainly diagnosed a few months, and possibly up to 1 year, postpartum. PLO patients with vertebral fractures underwent more medical interventions than did those with other fractures, but they were still inadequate. CONCLUSIONS PLO with vertebral fracture was one of the major types of premenopausal osteoporosis. The prevalence of PLO is considered to be higher than previously thought, indicating the presence of potentially overlooked patients. More timely interventions for PLO might lead to the improved management of latent patients with premenopausal osteoporosis and reduce future fracture risk.
Collapse
Affiliation(s)
- Kyoko Kasahara
- The Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Shiga, Japan.
| | - Sachiko Tanaka-Mizuno
- The Laboratory of Epidemiology and Prevention, Kobe Pharmaceutical University, Kobe, Japan
| | - Shunichiro Tsuji
- The Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Mizuki Ohashi
- The Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Makiko Kasahara
- The Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Taku Kawasaki
- The Department of Orthopedic Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Takashi Murakami
- The Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Shiga, Japan
| |
Collapse
|
4
|
Formosa MM, Christou MA, Mäkitie O. Bone fragility and osteoporosis in children and young adults. J Endocrinol Invest 2024; 47:285-298. [PMID: 37668887 PMCID: PMC10859323 DOI: 10.1007/s40618-023-02179-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/16/2023] [Indexed: 09/06/2023]
Abstract
Osteoporosis is a metabolic bone disorder which increases fragility fracture risk. Elderly individuals, especially postmenopausal women, are particularly susceptible to osteoporosis. Although rare, osteoporosis in children and young adults is becoming increasingly evident, highlighting the need for timely diagnosis, management and follow-up. Early-onset osteoporosis is defined as the presence of a low BMD (Z-score of ≤ -2.0 in individuals aged < 20 years; T-score of ≤ -2.5 in those aged between 20 to 50 years) accompanied by a clinically significant fracture history, or the presence of low-energy vertebral compression fractures even in the absence of osteoporosis. Affected children and young adults should undergo a thorough diagnostic workup, including collection of clinical history, radiography, biochemical investigation and possibly bone biopsy. Once secondary factors and comorbidities are excluded, genetic testing should be considered to determine the possibility of an underlying monogenic cause. Defects in genes related to type I collagen biosynthesis are the commonest contributors of primary osteoporosis, followed by loss-of-function variants in genes encoding key regulatory proteins of canonical WNT signalling (specifically LRP5 and WNT1), the actin-binding plastin-3 protein (encoded by PLS3) resulting in X-linked osteoporosis, and the more recent sphingomyelin synthase 2 (encoded by SGMS2) which is critical for signal transduction affecting sphingomyelin metabolism. Despite these discoveries, genetic causes and underlying mechanisms in early-onset osteoporosis remain largely unknown, and if no causal gene is identified, early-onset osteoporosis is deemed idiopathic. This calls for further research to unravel the molecular mechanisms driving early-onset osteoporosis that consequently will aid in patient management and individualised targeted therapy.
Collapse
Affiliation(s)
- M M Formosa
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta
- Center for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M A Christou
- Department of Endocrinology, School of Medicine, University of Ioannina, Ioannina, Greece
- Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - O Mäkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
- Folkhälsan Research Centre, Folkhälsan Institute of Genetics, Helsinki, Finland.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden.
| |
Collapse
|
5
|
Brent MB. Pharmaceutical treatment of bone loss: From animal models and drug development to future treatment strategies. Pharmacol Ther 2023; 244:108383. [PMID: 36933702 DOI: 10.1016/j.pharmthera.2023.108383] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/18/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023]
Abstract
Animal models are fundamental to advance our knowledge of the underlying pathophysiology of bone loss and to study pharmaceutical countermeasures against it. The animal model of post-menopausal osteoporosis from ovariectomy is the most widely used preclinical approach to study skeletal deterioration. However, several other animal models exist, each with unique characteristics such as bone loss from disuse, lactation, glucocorticoid excess, or exposure to hypobaric hypoxia. The present review aimed to provide a comprehensive overview of these animal models to emphasize the importance and significance of investigating bone loss and pharmaceutical countermeasures from perspectives other than post-menopausal osteoporosis only. Hence, the pathophysiology and underlying cellular mechanisms involved in the various types of bone loss are different, and this might influence which prevention and treatment strategies are the most effective. In addition, the review sought to map the current landscape of pharmaceutical countermeasures against osteoporosis with an emphasis on how drug development has changed from being driven by clinical observations and enhancement or repurposing of existing drugs to today's use of targeted anti-bodies that are the result of advanced insights into the underlying molecular mechanisms of bone formation and resorption. Moreover, new treatment combinations or repurposing opportunities of already approved drugs with a focus on dabigatran, parathyroid hormone and abaloparatide, growth hormone, inhibitors of the activin signaling pathway, acetazolamide, zoledronate, and romosozumab are discussed. Despite the considerable progress in drug development, there is still a clear need to improve treatment strategies and develop new pharmaceuticals against various types of osteoporosis. The review also highlights that new treatment indications should be explored using multiple animal models of bone loss in order to ensure a broad representation of different types of skeletal deterioration instead of mainly focusing on primary osteoporosis from post-menopausal estrogen deficiency.
Collapse
Affiliation(s)
- Mikkel Bo Brent
- Department of Biomedicine, Aarhus University, Denmark, Wilhelm Meyers Allé 3, 8000 Aarhus C, Denmark.
| |
Collapse
|
6
|
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.
Collapse
Affiliation(s)
- Diana Athonvarangkul
- Section of Endocrinology and Metabolism, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
| | | |
Collapse
|
7
|
Ryan BA, McGregor NE, Kirby BJ, Al-Tilissi A, Poulton IJ, Sims NA, Kovacs CS. Calcitriol-Dependent and -Independent Regulation of Intestinal Calcium Absorption, Osteoblast Function, and Skeletal Mineralization during Lactation and Recovery in Mice. J Bone Miner Res 2022; 37:2483-2497. [PMID: 36128890 DOI: 10.1002/jbmr.4712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 08/19/2022] [Accepted: 09/17/2022] [Indexed: 11/06/2022]
Abstract
Recovery from lactation-induced bone loss appears to be calcitriol-independent, since mice lacking 1-alpha-hydroxylase or vitamin D receptor (VDR) exhibit full skeletal recovery. However, in those studies mice consumed a calcium-, phosphorus-, and lactose-enriched "rescue" diet. Here we assessed whether postweaning skeletal recovery of Vdr null mice required that rescue diet. Wild type (WT) and Vdr null mice were raised on the rescue diet and switched to a normal (1% calcium) diet at Day 21 of lactation until 28 days after weaning. Unmated mice received the same regimen. In WT mice, cortical thickness was significantly reduced by 25% at 21 days of lactation and was completely restored by 28 days after weaning. Three-point bending tests similarly showed a significant reduction during lactation and full recovery of ultimate load and energy absorbed. Although Vdr null mice exhibited a similar lactational reduction in cortical thickness and mechanical strength, neither was even partially restored after weaning. Unmated mice showed no significant changes. In micro-computed tomography scans, diaphyses of Vdr null femora at 28 days after weaning were highly porous and exhibited abundant low-density bone extending into the marrow space from the endocortical surface. To quantify, we segregated bone into low-, mid-, and high-density components. In WT diaphyses, high-density bone was lost during lactation and restored after weaning. Vdr null mice also lost high-density bone during lactation but did not replace it; instead, they demonstrated a threefold increase in low-density bone mass. Histology revealed that intracortical and endocortical surfaces of Vdr null bones after weaning contained very thick (up to 20 micron) osteoid seams, covered with multiple layers of osteoblasts and precursors. We conclude that during the postweaning period, osteoblasts are potently stimulated to produce osteoid despite lacking VDRs, and that either calcitriol or a calcium-enriched diet are needed for this immature bone to become mineralized. © 2022 American Society for Bone and Mineral Research (ASBMR).
Collapse
Affiliation(s)
- Brittany A Ryan
- Faculty of Medicine-Endocrinology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Narelle E McGregor
- St. Vincent's Institute of Medical Research, Fitzroy, Victoria, Australia
| | - Beth J Kirby
- Faculty of Medicine-Endocrinology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Abdelkhayoum Al-Tilissi
- Faculty of Medicine-Endocrinology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Ingrid J Poulton
- St. Vincent's Institute of Medical Research, Fitzroy, Victoria, Australia
| | - Natalie A Sims
- St. Vincent's Institute of Medical Research, Fitzroy, Victoria, Australia.,Department of Medicine at St. Vincent's Hospital, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Christopher S Kovacs
- Faculty of Medicine-Endocrinology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| |
Collapse
|
8
|
García Martín A, Alhambra Expósito MR, Cortés Berdonces M, Jódar Gimeno E, Huguet I, Rozas Moreno P, Varsavsky M, Ávila Rubio V, Muñoz Garach A, Muñoz Torres M. Guía de manejo de las alteraciones del metabolismo mineral y óseo en la gestación y la lactancia. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
9
|
García Martín A, Alhambra Expósito MR, Cortés Berdonces M, Jódar Gimeno E, Huguet I, Rozas Moreno P, Varsavsky M, Ávila Rubio V, Muñoz Garach A, Muñoz Torres M. Guide of management of alterations in mineral and bone metabolism during gestation and lactation. ENDOCRINOL DIAB NUTR 2022; 69:530-539. [PMID: 36028449 DOI: 10.1016/j.endien.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 10/24/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To provide practical recommendations for the management of mineral and bone metabolism alterations in pregnancy and lactation. PARTICIPANTS Members of the Working Group on Osteoporosis and Mineral Metabolism of the Spanish Society of Endocrinology and Nutrition. METHODS Recommendations were formulated according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. A systematic search was carried out in Medline of the available evidence for each pathology. Papers in English with publication date until 29 February 2020 were included. A methodologist resolved the differences that arose during the process of reviewing the literature and formulating recommendations. The recommendations were discussed and approved by all members of the Working Group. CONCLUSIONS The document establishes practical recommendations based on evidence about the management of mineral and bone metabolism disorders in pregnancy and lactation.
Collapse
Affiliation(s)
- Antonia García Martín
- Servicio de Endocrinología y Nutrición, Hospital Universitario Clínico San Cecilio, Granada, Spain; Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), Granada, Spain.
| | - María Rosa Alhambra Expósito
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - María Cortés Berdonces
- Departamento de Endocrinología y Nutrición Clínica, Hospital Quirón Salud Madrid y Complejo Hospitalario Ruber Juan Bravo, Quirón Salud, Madrid, Spain; Departamento de Formación Médica, Universidad Europea de Madrid, Madrid, Spain
| | - Esteban Jódar Gimeno
- Departamento de Endocrinología y Nutrición Clínica, Hospital Quirón Salud Madrid y Complejo Hospitalario Ruber Juan Bravo, Quirón Salud, Madrid, Spain; Departamento de Formación Médica, Universidad Europea de Madrid, Madrid, Spain
| | - Isabel Huguet
- Servicio de Endocrinología y Nutrición, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Pedro Rozas Moreno
- Sección de Endocrinología y Nutrición, Hospital General Universitario, Ciudad Real, Spain
| | - Mariela Varsavsky
- Servicio de Endocrinología, Metabolismo y Medicina Nuclear, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Verónica Ávila Rubio
- Servicio de Endocrinología y Nutrición, Hospital Universitario Clínico San Cecilio, Granada, Spain; Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), Granada, Spain
| | - Araceli Muñoz Garach
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Manuel Muñoz Torres
- Servicio de Endocrinología y Nutrición, Hospital Universitario Clínico San Cecilio, Granada, Spain; Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), Granada, Spain; Departamento de Medicina, Universidad de Granada, Granada, Spain
| |
Collapse
|
10
|
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
Collapse
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
| |
Collapse
|
11
|
Abstract
PURPOSE Osteoporosis in pregnancy is an uncommon disease and there is little information regarding its pathogenesis and its effects on the skeleton. This review aims to describe changes in mineral metabolism during pregnancy and lactation as well as their clinical impact. METHODS We performed a narrative review of the literature using the PubMed and Google Scholar databases for articles published from 1955 to 2021. RESULTS Mineral metabolism in the mother must adapt to the demand created by the fetus and the placenta, which together absorb calcium and other minerals from the mother to mineralize the developing fetal skeleton; analyses of iliac bone biopsies at the beginning and end of pregnancy have shown that pregnancy significantly modifies maternal bone status. The greatest demand for calcium for the maternal skeleton occurs during lactation; women who breastfeed have an even greater loss of calcium to produce milk. However, it is controversial whether breastfeeding can increase the risk of osteoporotic fractures, and the possible mechanism is considerably complicated. Osteoporosis in pregnancy is an uncommon disease characterized by the occurrence of fragility fractures, most commonly in the vertebral column, in the third trimester of pregnancy, or early postpartum. The pathogenesis of PLO remains unclear owing to its rarity; DXA provides a sensitive and specific method for diagnosing osteoporosis by measuring BMD, one of the parameters that allow a better understanding of fracture risk. One limitation is the controversy in using radiation in pregnant women and the risk to the embryo/fetus; a safe alternative can be MRI. CONCLUSION Pregnancy and lactation alter the maternal bone status; without a balance in metabolism, this may cause an increased risk of fracture due to changes in BMD. There is little information on BMD during pregnancy; more clinical studies are required to elucidate if this represents a risk factor for osteoporosis.
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Calik-Ksepka A, Stradczuk M, Czarnecka K, Grymowicz M, Smolarczyk R. Lactational Amenorrhea: Neuroendocrine Pathways Controlling Fertility and Bone Turnover. Int J Mol Sci 2022; 23:ijms23031633. [PMID: 35163554 PMCID: PMC8835773 DOI: 10.3390/ijms23031633] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 02/06/2023] Open
Abstract
Lactation is a physiological state of hyperprolactinemia and associated amenorrhea. Despite the fact that exact mechanisms standing behind the hypothalamus-pituitary-ovarian axis during lactation are still not clear, a general overview of events leading to amenorrhea may be suggested. Suckling remains the most important stimulus maintaining suppressive effect on ovaries after pregnancy. Breastfeeding is accompanied by high levels of prolactin, which remain higher than normal until the frequency and duration of daily suckling decreases and allows normal menstrual function resumption. Hyperprolactinemia induces the suppression of hypothalamic Kiss1 neurons that directly control the pulsatile release of GnRH. Disruption in the pulsatile manner of GnRH secretion results in a strongly decreased frequency of corresponding LH pulses. Inadequate LH secretion and lack of pre-ovulatory surge inhibit the progression of the follicular phase of a menstrual cycle and result in anovulation and amenorrhea. The main consequences of lactational amenorrhea are connected with fertility issues and increased bone turnover. Provided the fulfillment of all the established conditions of its use, the lactational amenorrhea method (LAM) efficiently protects against pregnancy. Because of its accessibility and lack of additional associated costs, LAM might be especially beneficial in low-income, developing countries, where modern contraception is hard to obtain. Breastfeeding alone is not equal to the LAM method, and therefore, it is not enough to successfully protect against conception. That is why LAM promotion should primarily focus on conditions under which its use is safe and effective. More studies on larger study groups should be conducted to determine and confirm the impact of behavioral factors, like suckling parameters, on the LAM efficacy. Lactational bone loss is a physiologic mechanism that enables providing a sufficient amount of calcium to the newborn. Despite the decline in bone mass during breastfeeding, it rebuilds after weaning and is not associated with a postmenopausal decrease in BMD and osteoporosis risk. Therefore, it should be a matter of concern only for lactating women with additional risk factors or with low BMD before pregnancy. The review summarizes the effect that breastfeeding exerts on the hypothalamus-pituitary axis as well as fertility and bone turnover aspects of lactational amenorrhea. We discuss the possibility of the use of lactation as contraception, along with this method's prevalence, efficacy, and influencing factors. We also review the literature on the topic of lactational bone loss: its mechanism, severity, and persistence throughout life.
Collapse
Affiliation(s)
- Anna Calik-Ksepka
- Department of Gynaecological Endocrinology, Medical University of Warsaw, Karowa 2, 00-315 Warsaw, Poland; (M.G.); (R.S.)
- Correspondence:
| | - Monika Stradczuk
- Student’s Academic Association, Department of Gynecological Endocrinology, Faculty of Medicine, Medical University of Warsaw, Żwirki i Wigury 61, 02-091 Warsaw, Poland; (M.S.); (K.C.)
| | - Karolina Czarnecka
- Student’s Academic Association, Department of Gynecological Endocrinology, Faculty of Medicine, Medical University of Warsaw, Żwirki i Wigury 61, 02-091 Warsaw, Poland; (M.S.); (K.C.)
| | - Monika Grymowicz
- Department of Gynaecological Endocrinology, Medical University of Warsaw, Karowa 2, 00-315 Warsaw, Poland; (M.G.); (R.S.)
| | - Roman Smolarczyk
- Department of Gynaecological Endocrinology, Medical University of Warsaw, Karowa 2, 00-315 Warsaw, Poland; (M.G.); (R.S.)
| |
Collapse
|
14
|
O'Brien EC, Geraghty AA, Kilbane MT, McKenna MJ, McAuliffe FM. Bone resorption and dietary calcium in pregnancy-a window to future maternal bone health. Osteoporos Int 2021; 32:1803-1814. [PMID: 33659997 DOI: 10.1007/s00198-021-05891-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pregnancy is characterized by increased bone turnover and reversible loss of bone mineral density (BMD) to meet fetal calcium demands. The long-term effect of bone turnover and maternal diet in pregnancy on maternal bone is not well established. OBJECTIVE We aimed to determine if an association exists between [1] bone resorption, [2] dietary calcium, and [3] serum 25-hydroxyvitamin D in pregnancy with maternal BMD 5-year postpartum. DESIGN This is a prospective, longitudinal study of 107 women recruited to the ROLO low glycemic index dietary intervention trial in pregnancy and followed-up at 13, 28, and 34 weeks' gestation and 5 years' postpartum. At 13 and 28 weeks' gestation, a biomarker of bone resorption, urine cross-linked N-telopeptide of type I collagen (uNTX), was measured. At the 5-year follow-up BMD was measured using dual-energy X-ray absorptiometry. Anthropometry, dietary intakes, and serum 25-hydroxyvitamin D were measured in pregnancy and at 5 years. Multiple linear regression, controlling for confounders, was used for analysis. RESULTS Mean BMD at 5 years was 1.208 g/cm2. In pregnancy, 24-34% reported dietary calcium intakes <800 mg/day. Vitamin D deficiency (< 30 nmol/L) was observed in 38-41% of women in pregnancy and in 29% of women at the 5-year follow-up. At 13 and 28 weeks' gestation, uNTX levels greater than the median were associated with 0.060 and 0.050 g/cm2 lower BMD 5 years later, respectively. Dietary calcium <800 mg/day in trimester 3 was associated with 0.072 g/cm2 lower BMD 5 years later. Vitamin D deficiency at 5 years, but not in pregnancy, was associated with lower BMD. CONCLUSION Higher bone resorption and low dietary calcium in pregnancy were associated with lower BMD 5 years later. These findings could enable the identification of women at risk of declining of BMD in later life, but further research is needed. Adequate dietary calcium should be advised in the antenatal setting to promote lifelong maternal bone health.
Collapse
Affiliation(s)
- E C O'Brien
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - A A Geraghty
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - M T Kilbane
- Department of Clinical Chemistry, St Vincent's University Hospital, Dublin, Ireland
| | - M J McKenna
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
- Department of Endocrinology, St Vincent's University Hospital, Dublin, Ireland
| | - F M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland.
| |
Collapse
|
15
|
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: 12] [Impact Index Per Article: 4.0] [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.
Collapse
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
| |
Collapse
|
16
|
Ó Breasail M, Ward KA, Schoenbuchner SM, Ceesay M, Mendy M, Jarjou LM, Moore SE, Prentice A. Pregnancy-Related Change in pQCT and Bone Biochemistry in a Population With a Habitually Low Calcium Intake. J Bone Miner Res 2021; 36:1269-1280. [PMID: 33784438 DOI: 10.1002/jbmr.4295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/07/2022]
Abstract
In pregnancy, changes in maternal calcium (Ca) economy occur to satisfy fetal Ca demand. It is unclear whether maternal mineral reserves facilitate these requirements and no data exist from sub-Saharan Africa. The aim was to determine skeletal changes with peripheral quantitative computed tomography (pQCT) and bone biochemistry between early second and third trimesters. Pregnant rural Gambians aged 18 to 45 years (n = 467) participating in a trial of antenatal nutritional supplements (ISRCTN49285450) had pQCT scans and blood collections at mean (SD) 14 (3) and 31 (1) weeks' gestation. Outcomes were pQCT: radius/tibia 4% total volumetric bone mineral density (vBMD), trabecular vBMD, total cross-sectional area (CSA), 33%/38% radius/tibia cortical vBMD, bone mineral content (BMC), total CSA; biochemistry: collagen type 1 cross-linked β-C-telopeptide (β-CTX), type 1 procollagen N-terminal (P1NP), parathyroid hormone (PTH), and 1,25(OH)2 D. Independent t tests tested whether pooled or within-group changes differed from 0. Multiple regression was performed adjusting for age. Data for change are expressed as mean (confidence interval [CI] 2.5, 97.5%). Radius trabecular vBMD, cortical vBMD, and BMC increased by 1.15 (0.55, 1.75)%, 0.41 (0.24, 0.58)%, and 0.47 (0.25, 0.69)%. Tibia total and trabecular vBMD increased by 0.34 (0.15, 0.54)% and 0.46 (0.17, 0.74)%, while tibia cortical vBMD, BMC, and cortical CSA increased by 0.35 (0.26, 0.44)%, 0.55 (0.41, 0.68)% and 0.20 (0.09, 0.31)%, respectively. CTX, PTH, and 1,25(OH)2 D increased by 23.0 (15.09, 29.29)%, 13.2 (8.44, 19.34)%, and 21.0 (17.67, 24.29)%, while P1NP decreased by 32.4 (-37.19, -28.17)%. No evidence of mobilization was observed in the peripheral skeleton. Resorption, although higher in late versus early gestation, was lower throughout pregnancy compared with non-pregnant non-lactating (NPNL) in the same community. Formation was lower in late pregnancy than in early, and below NPNL levels. This suggests a shift in the ratio of resorption to formation. Despite some evidence of change in bone metabolism, in this population, with habitually low Ca intakes, the peripheral skeleton was not mobilized as a Ca source for the fetus. © 2021 crown copyright . Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). The article published with the permission of the Controller of HMSO and the Queen's Printer of Scotland..
Collapse
Affiliation(s)
- Mícheál Ó Breasail
- MRC Nutrition and Bone Health Research Group, University of Cambridge, Cambridge, UK
| | - Kate A Ward
- MRC Nutrition and Bone Health Research Group, University of Cambridge, Cambridge, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK.,MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Simon M Schoenbuchner
- MRC Biostatistics Unit, University of Cambridge, Cambridge Institute of Public Health, Cambridge, UK
| | - Mustapha Ceesay
- MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Michael Mendy
- MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Landing M Jarjou
- MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Sophie E Moore
- MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia.,Department of Women and Children's Health, King's College London, London, UK
| | - Ann Prentice
- MRC Nutrition and Bone Health Research Group, University of Cambridge, Cambridge, UK.,MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| |
Collapse
|
17
|
Capozzi A, Scambia G, Lello S. Bone metabolism in pregnancy and lactation. Minerva Obstet Gynecol 2021; 73:697-703. [PMID: 34180616 DOI: 10.23736/s2724-606x.21.04905-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Different hormonal mechanisms regulate bone metabolism during pregnancy and lactation. In both those periods of life, a fine modulation of calcium metabolism is necessary to meet the needs of foetus and newborn. METHODS We review scientific literature on the topic "osteoporosis", "pregnancy" and "lactation", evaluating the most relevant data from original articles, reviews and meta-analyses. EVIDENCE SYNTHESIS Pregnancy- and lactation-associated bone loss and related fractures rarely occur and, generally, clinicians have to manage it case to case, since there is not a unique guideline. Fortunately, bone mineral density (BMD) usually tends to recover within 12 months after weaning, thus, it could be reasonable waiting of assessing the effective magnitude of bone mass regain before starting any pharmacological treatment. CONCLUSIONS Osteoporosis and/or fragility fractures remain uncommon events associated with gestation and/or breastfeeding. The management of bone loss and/or fractures during those periods is generally conservative and a tailored approach is advisable in the absence of any specific recommendation in this field.
Collapse
Affiliation(s)
- Anna Capozzi
- Department of Women and Child Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy -
| | - Giovanni Scambia
- Department of Women and Child Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Lello
- Department of Women and Child Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| |
Collapse
|
18
|
Evidence-Based Recommendations for an Optimal Prenatal Supplement for Women in the U.S., Part Two: Minerals. Nutrients 2021; 13:nu13061849. [PMID: 34071548 PMCID: PMC8229801 DOI: 10.3390/nu13061849] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 02/08/2023] Open
Abstract
The levels of many essential minerals decrease during pregnancy if un-supplemented, including calcium, iron, magnesium, selenium, zinc, and possibly chromium and iodine. Sub-optimal intake of minerals from preconception through pregnancy increases the risk of many pregnancy complications and infant health problems. In the U.S., dietary intake of minerals is often below the Recommended Dietary Allowance (RDA), especially for iodine and magnesium, and 28% of women develop iron deficiency anemia during their third trimester. The goal of this paper is to propose evidence-based recommendations for the optimal level of prenatal supplementation for each mineral for most women in the United States. Overall, the evidence suggests that optimal mineral supplementation can significantly reduce a wide range of pregnancy complications (including anemia, gestational hypertension, gestational diabetes, hyperthyroidism, miscarriage, and pre-eclampsia) and infant health problems (including anemia, asthma/wheeze, autism, cerebral palsy, hypothyroidism, intellectual disability, low birth weight, neural tube defects, preterm birth, rickets, and wheeze). An evaluation of 180 commercial prenatal supplements found that they varied widely in mineral content, often contained only a subset of essential minerals, and the levels were often below our recommendations. Therefore, there is a need to establish recommendations on the optimal level of mineral supplementation during pregnancy.
Collapse
|
19
|
Kishimoto K, Kodera C, Saito F, Ohba T, Katabuchi H. Progressive idiopathic juvenile osteoporosis in pregnancy: A case report of two successive pregnancies in the same woman. Case Rep Womens Health 2021; 31:e00325. [PMID: 34040998 PMCID: PMC8144659 DOI: 10.1016/j.crwh.2021.e00325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 11/25/2022] Open
Abstract
A 33-year-old primiparous woman with progressive idiopathic juvenile osteoporosis (IJO) who had had multiple vertebral compressions and bilateral femoral neck fractures since the age of 15 years presented for perinatal management at 11 weeks of gestation. Her vertebral bone mass was 0.634 g/cm2 before pregnancy. The target calcium intake was set at 800 mg/day. Cephalopelvic disproportion led to the patient having an elective cesarean section at 39 weeks 3 days of gestation and she delivered a female infant weighing 2785 g. After the delivery, her vertebral bone mass had increased to 0.700 g/cm2. At 34 years of age, she conceived her second child. With similar perinatal management, she delivered a female infant weighing 2580 g at 38 weeks of gestation by elective cesarean section. Her vertebral bone mass had increased again after the second pregnancy. Few cases of pregnancy complicated by progressive IJO have been reported. However, an uneventful pregnancy course can be expected with proper management, and pregnancy can be a good opportunity to increase bone mass. We managed two pregnancies with progressive idiopathic juvenile osteoporosis. These patients could drive increases in bone volume during pregnancy. Proper nutritional management can provide a favorable perinatal prognosis.
Collapse
Affiliation(s)
- Kaori Kishimoto
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan
| | - Chisato Kodera
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan
| | - Fumitaka Saito
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan
| | - Takashi Ohba
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan
| | - Hidetaka Katabuchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan
| |
Collapse
|
20
|
Scioscia MF, Vidal M, Sarli M, Guelman R, Danilowicz K, Mana D, Longobardi V, Zanchetta MB. Severe Bone Microarchitecture Impairment in Women With Pregnancy and Lactation-Associated Osteoporosis. J Endocr Soc 2021; 5:bvab031. [PMID: 33860131 PMCID: PMC8035983 DOI: 10.1210/jendso/bvab031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Indexed: 11/19/2022] Open
Abstract
Context Pregnancy- and lactation-associated osteoporosis (PLO) is a rare condition characterized by fragility fractures, mostly vertebral, during the third trimester of pregnancy or the early postpartum period. Objective The aim of this study was to evaluate bone microarchitecture in women with PLO to better understand the pathophysiology of this disease. Methods In this retrospective study, we included women with PLO referred to our bone center between November 2007 and July 2012. We assessed bone mineral density (BMD) by dual-energy x-ray absorptiometry, bone turnover markers, and bone microarchitecture by high-resolution peripheral quantitative computed tomography. Results were compared with a control group of healthy lactating women. Results Of the 7 primiparous patients with PLO, 6 suffered vertebral fractures and 1 developed a hip fracture during the seventh month of gestation. Fractures occurred within the eighth month of pregnancy and the fourth month post partum; vertebral fractures were multiple in 85.7%. Major or minor risk factors for osteoporosis were present in 86% of our patients. Trabecular density, number, and thickness were 34%, 20% and 22% lower than controls (P < .01, P = .01, and P = .01, respectively). Cortical parameters were also deteriorated but to a lesser extent. Conclusion In comparison with healthy lactating women, patients with PLO presented severe deterioration of bone trabecular and cortical microarchitecture. This significant compromise may explain the occurrence of multiple fractures in these otherwise healthy young women. Further prospective studies are needed to determine whether bone microarchitecture might be able to be restored in the future.
Collapse
Affiliation(s)
- Maria Florencia Scioscia
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, ZC 1012 Buenos Aires, Argentina
| | - Maritza Vidal
- Centro de Diagnóstico de Osteoporosis y Enfermedades Reumáticas (CEDOR), San Isidro 15047, Lima, Peru
| | - Marcelo Sarli
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, ZC 1012 Buenos Aires, Argentina
| | - Rodolfo Guelman
- Servicio de Endocrinología del Hospital Italiano de Buenos Aires, Sector Osteopatías Metabólicas, 1199 Buenos Aires, Argentina
| | - Karina Danilowicz
- División de Endocrinología, Hospital de Clínicas, Universidad de Buenos Aires, 1120 Buenos Aires, Argentina
| | - Daniela Mana
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, ZC 1012 Buenos Aires, Argentina
| | - Vanesa Longobardi
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, ZC 1012 Buenos Aires, Argentina
| | - María Belén Zanchetta
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, ZC 1012 Buenos Aires, Argentina
| |
Collapse
|
21
|
β-Hydroxy-β-Methylbutyrate (HMB) Supplementation Prevents Bone Loss during Pregnancy-Novel Evidence from a Spiny Mouse ( Acomys cahirinus) Model. Int J Mol Sci 2021; 22:ijms22063047. [PMID: 33802646 PMCID: PMC8002460 DOI: 10.3390/ijms22063047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 12/23/2022] Open
Abstract
The aim of this study was to determine the effects of ß-hydroxy-ß-methylbutyrate (HMB) supplementation during pregnancy on postpartum bone tissue quality by assessing changes in trabecular and compact bone as well as in hyaline and epiphyseal cartilage. The experiment was carried out on adult 6-month-old female spiny mice (Acomys cahirinus) divided into three groups: pregnant control (PregCont), pregnant HMB-treated (supplemented with 0.02 g/kg b.w of HMB during the second trimester of pregnancy, PregHMB), and non-pregnant females (NonPreg). Cross-sectional area and cortical index of the femoral mid-shaft, stiffness, and Young modulus were significantly greater in the PregHMB group. Whole-bone mineral density was similar in all groups, and HMB supplementation increased trabecular number. Growth plate cartilage was the thinnest, while the articular cartilage was the thickest in the PregHMB group. HMB supplementation increased the content of proteoglycans in the articular cartilage and the percentage of immature collagen content in metaphyseal trabeculae and compact bone. In summary, dietary HMB supplementation during the second trimester of pregnancy intensifies bone metabolic processes and prevents bone loss during pregnancy.
Collapse
|
22
|
Barr C, Sharafieh R, Schwarz G, Wu R, Klueh U, Kreutzer D. Noninflammatory Stress-Induced Remodeling of Mandibular Bone: Impact of Age and Pregnancy. J Oral Maxillofac Surg 2020; 79:1147-1155. [PMID: 33412113 DOI: 10.1016/j.joms.2020.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE The impact of noninflammatory stress, such as aging and pregnancy, on human long bone remodeling is well-established, but little is known about the impact of these stressors on oral bones, including the mandibular bone. To begin to fill this gap in our knowledge, we utilized a mouse mandibular model to evaluate the impact of noninflammatory simple stressors, ie, aging and pregnancy, on bone mandibular architecture and bone density in the mandible using micro-CT. MATERIALS AND METHODS For the present study, mandibles were obtained from both aged and pregnant C57BL/6 mice and analyzed using micro-CT technology. Micro-CT metrics included bone volume fraction (BVF), total volume (TV), tissue density, and apparent density in the mandible on the mandibular area of compact and trabecular bone, in which the teeth are embedded. All bone-related metrics data from aged and pregnant mice were analyzed using ANOVA analysis and visualized in boxplots. RESULTS Age-dependent bone remodeling occurred over 4 to 18 weeks of age, ie, increases in BVF, TV, BV/TV, as well as tissue and bone density. Evaluation of bone remodeling in breeder mice (repeated pregnancy model) and virgin mice (age-matched controls) at 37 weeks of age demonstrated that breeder mice had a dramatic decline in all bone metrics measured. CONCLUSIONS This study underscores the need for more research on noninflammatory stress-related mandibular bone remodeling (eg, age and pregnancy), which compromises bone strength and tooth anchoring. The data also underscores loss of alveolar bone height, as in periodontitis, is an important metric for a more complete assessment of bone loss. This report on mice provides essential data that can be applied for oral-maxillofacial surgeons and periodontists when planning for dental implants in patients with such stressors. Periodontitis related bone loss occurs independent of skeletal homeostasis, although osteoporosis may adversely affect alveolar bone height in humans.
Collapse
Affiliation(s)
- Charles Barr
- Former Professor, Department of Oral Health and Diagnostic Sciences. School of Dental Medicine, University of Connecticut, Farmington, CT
| | - Roshanak Sharafieh
- Assistant Professor, Department of Surgery, School of Medicine, University of Connecticut, Farmington, CT
| | - Gregory Schwarz
- Graduate Student, Department of Surgery, School of Medicine, University of Connecticut, Farmington, CT
| | - Rong Wu
- Research Associate II and Statistician, Connecticut Institute for Clinical and Translational Science, University of Connecticut, Farmington, CT
| | - Ulrike Klueh
- Associate Professor, Department of Biomedical Engineering, School of Engineering, Wayne State University, Detroit, MI
| | - Don Kreutzer
- Professor, Former Chair and Head of Immunology, Department of Surgery, School of Medicine, University of Connecticut, Farmington, CT.
| |
Collapse
|
23
|
Cai G, Tian J, Winzenberg T, Wu F. Calcium supplementation for improving bone density in lactating women: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr 2020; 112:48-56. [PMID: 32401318 DOI: 10.1093/ajcn/nqaa103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 04/17/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Clinical trials evaluating the effect of calcium supplementation on bone loss in lactating women have been small, with inconsistent results. OBJECTIVES We aimed to determine the effect of calcium supplementation on bone mineral density (BMD) in lactating women. METHODS An electronic search of databases was conducted from inception to January 2020. Two authors screened studies, extracted data, and assessed the risk of bias of eligible studies. Percentage change in BMD was pooled using random-effects models and reported as weighted mean differences (WMDs) with 95% CIs. Risk of bias was assessed using the Cochrane risk of bias tool. RESULTS Five randomized controlled trials including 567 lactating women were included. All had a high risk of bias. Mean baseline calcium intake ranged from 562 to 1333 mg/d. Compared with control groups (placebo/no intervention), calcium supplementation (600/1000 mg/d) had no significant effect on BMD at the lumbar spine (WMD: 0.74%; 95% CI: -0.10%, 1.59%; I2 = 47%; 95% CI: 0%, 81%; n = 527 from 5 trials) or the forearm (WMD: 0.53%; 95% CI: -0.35%, 1.42%; I2 = 55%; 95% CI: 0%, 85%; n = 415 from 4 trials). BMD at other sites was assessed in single trials: calcium supplementation had a small to moderate effect on total-hip BMD (WMD: 3.3%; 95% CI: 1.5%, 5.1%) but no effect on total body or femoral neck BMD. CONCLUSIONS Overall, the meta-analysis indicates that calcium supplementation does not provide clinically important benefits for BMD in lactating women. However, there was adequate dietary intake before supplementation in some studies, and others did not measure baseline calcium intake. Advising lactating women to meet the current recommended calcium intakes (with supplementation if dietary intake is low) is warranted unless new high-certainty evidence to the contrary from robust clinical trials becomes available. More research needs to be done in larger samples of women from diverse ethnic and racial groups.This systematic review was registered at www.crd.york.ac.uk/prospero as CRD42015022092.
Collapse
Affiliation(s)
- Guoqi Cai
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Jing Tian
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Tania Winzenberg
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Feitong Wu
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| |
Collapse
|
24
|
Grizzo FMF, Alarcão ACJ, Dell' Agnolo CM, Pedroso RB, Santos TS, Vissoci JRN, Pinheiro MM, Carvalho MDB, Pelloso SM. How does women's bone health recover after lactation? A systematic review and meta-analysis. Osteoporos Int 2020; 31:413-427. [PMID: 31897544 DOI: 10.1007/s00198-019-05236-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/14/2019] [Indexed: 01/11/2023]
Abstract
This is a systematic review aiming to evaluate the recovery of bone mass after lactation-related loss. Bone loss is transitory with recovery depending on the return of menstruation and weaning, and several compensatory homeostatic mechanisms are involved to minimize any significant damage to the maternal skeleton. Lactation has been associated with significant temporary bone loss, especially during the exclusive breastfeeding period. In the bone recovery phase, there is wide methodological heterogeneity among clinical trials, including follow-up timing, methods and sites of bone measurements, and body composition changes. The purpose of this study is to perform a systematic review and meta-analysis aiming to evaluate the recovery rate of bone mass after lactation-related loss, including the PubMed, Web of Science, and Scopus databases, with no publication date restrictions. The following MeSH terms were used: "bone diseases," "bone resorption," "bone density," "osteoporosis," "calcium," "postpartum period," "weaning," "breast feeding," and "lactation." The inclusion criteria were as follows: prospective human studies in women of reproductive age and bone measurements with two assessments in the postpartum period at least: the first one within the first weeks of lactation and another one 12 months after delivery, 3 months following the return of menses or 3 months postweaning. This research was recorded on the Prospero database (CRD42018096586Bone). A total of 9455 studies were found and 32 papers met the inclusion criteria. The follow-up period ranged from one to 3.6 years postpartum. Lactation was associated with transient bone loss, with a strong tendency to recover in all the sites studied, depending on the return of menstruation and weaning. Small deficits in the microarchitecture of the peripheral skeleton may be present, especially in women with prolonged breastfeeding, but with no deficit regarding the hip geometry was found. Women with a successive gestation after prolonged lactation and women who had breastfed when adolescents had no significant bone loss. Bone loss related to lactation is transitory, and several compensatory homeostatic mechanisms are involved to minimize any significant damage to the maternal skeleton.
Collapse
Affiliation(s)
- F M F Grizzo
- Post Graduate Program in Health Sciences, Maringá State University, Avenida Colombo, 5790, Maringá, Paraná, 87020-900, Brazil.
| | - A C J Alarcão
- Post Graduate Program in Health Sciences, Maringá State University, Avenida Colombo, 5790, Maringá, Paraná, 87020-900, Brazil
| | | | - R B Pedroso
- Post Graduate Program in Health Sciences, Maringá State University, Avenida Colombo, 5790, Maringá, Paraná, 87020-900, Brazil
| | - T S Santos
- Post Graduate Program in Biosciences and Physiopathology, Maringa State University, Maringá, Paraná, Brazil
| | - J R N Vissoci
- Global Neurosurgery and Neuroscience Division, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - M M Pinheiro
- Rheumatology Division, Bone and Mineral Section and Spondyloarthritis Section, Federal University of São Paulo (Unifesp/EPM), São Paulo, Brazil
| | - M D B Carvalho
- Department of Health Sciences, State University of Maringá, Maringá, Paraná, Brazil
| | - S M Pelloso
- Department of Health Sciences, State University of Maringá, Maringá, Paraná, Brazil
| |
Collapse
|
25
|
Leere JS, Vestergaard P. Calcium Metabolic Disorders in Pregnancy: Primary Hyperparathyroidism, Pregnancy-Induced Osteoporosis, and Vitamin D Deficiency in Pregnancy. Endocrinol Metab Clin North Am 2019; 48:643-655. [PMID: 31345528 DOI: 10.1016/j.ecl.2019.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Physiologic changes during pregnancy include calcium, phosphate, and calciotropic hormone status. Calcium metabolic disorders are rare in pregnancy and management with close calcium and vitamin D control and supplementation. Primary hyperparathyroidism is mostly asymptomatic and does not affect conception or pregnancy. It requires control of plasma calcium levels. Surgical intervention may be indicated. Data on severe cases are missing. Osteoporosis in or before pregnancy is rare but usually diagnosed from fractures. Medical treatment other than supplementation is contraindicated. Vitamin D deficiency is common and may affect conception and increase complications. Current evidence does not prove vitamin D supplements effective in improving outcomes.
Collapse
Affiliation(s)
- Julius Simoni Leere
- Department of Clinical Medicine and Endocrinology, Aalborg University, Aalborg University Hospital, Aalborg, Denmark; Department of Endocrinology, Aalborg University Hospital, Mølleparkvej 4, Aalborg 9000, Denmark.
| | - Peter Vestergaard
- Department of Endocrinology, Aalborg University Hospital, Mølleparkvej 4, Aalborg 9000, Denmark; Steno Diabetes Center North Jutland, Aalborg, Denmark
| |
Collapse
|
26
|
Cohen A, Kamanda-Kosseh M, Dempster DW, Zhou H, Müller R, Goff E, Colon I, Bucovsky M, Stubby J, Nickolas TL, Stein EM, Recker RR, Lappe JM, Shane E. Women With Pregnancy and Lactation-Associated Osteoporosis (PLO) Have Low Bone Remodeling Rates at the Tissue Level. J Bone Miner Res 2019; 34:1552-1561. [PMID: 31348548 PMCID: PMC6744311 DOI: 10.1002/jbmr.3750] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/19/2019] [Accepted: 04/21/2019] [Indexed: 01/19/2023]
Abstract
Pregnancy and lactation-associated osteoporosis (PLO) is a rare, severe, early form of osteoporosis in which young women present with fractures, usually multiple vertebral fractures, during late pregnancy or lactation. In studies of idiopathic osteoporosis (IOP) in premenopausal women, we enrolled 78 women with low-trauma fractures and 40 healthy controls, all with normal menses and no secondary cause of bone loss. In 15 of the affected women, the PLO subgroup, fractures had occurred during late pregnancy or lactation. We hypothesized that clinical, bone structural, and metabolic characteristics would differ between women with PLO and those with (non-PLO) IOP and controls. All were evaluated > 12 months postpartum, when structural and remodeling characteristics would be expected to reflect baseline premenopausal status rather than transient postpartum changes. As previously reported, affected subjects (PLO and IOP) had BMD and microarchitectural deficiencies compared to controls. Women with PLO did not differ from those with IOP in terms of age, BMI, body fat, menarcheal age, parity, or age at first pregnancy. However, women with PLO had a more severe clinical presentation than those with IOP: more fractures (5.5 ± 3.3 versus 2.6 ± 2.1; p = 0.005); more vertebral fractures (80% versus 17%; p < 0.001); and higher prevalence of multiple fractures. BMD deficits were more profound and cortical width tended to be lower in PLO. PLO subjects also had significantly lower tissue-level mineral apposition rate and bone formation rates (0.005 ± 0.005 versus 0.011 ± 0.010 mm2 /mm/year; p = 0.006), as well as lower serum P1NP (33 ± 12 versus 44 ± 18 µg/L; p = 0.02) and CTX (257 ± 102 versus 355 ± 193 pg/mL; p = 0.01) than IOP. The finding that women with PLO have a low bone remodeling state assessed more than a year postpartum increases our understanding of the pathogenic mechanism of PLO. We conclude that women with PLO may have underlying osteoblast functional deficits which could affect their therapeutic response to osteoanabolic medications. © 2019 American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Adi Cohen
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mafo Kamanda-Kosseh
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - David W Dempster
- Department of Clinical Pathology and Cell Biology, Columbia University, New York, NY, USA.,Regional Bone Center, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - Hua Zhou
- Regional Bone Center, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - Ralph Müller
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Elliott Goff
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Ivelisse Colon
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mariana Bucovsky
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - Julie Stubby
- Department of Clinical Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Thomas L Nickolas
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Emily M Stein
- Division of Endocrinology, Hospital for Special Surgery, New York, NY, USA
| | - Robert R Recker
- Department of Medicine, Division of Endocrinology, Creighton University school of Medicine, Omaha, NE, USA
| | - Joan M Lappe
- Department of Medicine and College of Nursing, Creighton University school of Medicine, Omaha, NE, USA
| | - Elizabeth Shane
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
27
|
Coşgunarslan A, Canger EM, Soydan Çabuk D, Kış HC. The evaluation of the mandibular bone structure changes related to lactation with fractal analysis. Oral Radiol 2019; 36:238-247. [DOI: 10.1007/s11282-019-00400-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/07/2019] [Indexed: 11/30/2022]
|
28
|
Cooke-Hubley S, Kirby BJ, Valcour JE, Mugford G, Adachi JD, Kovacs CS. Spine bone mineral density increases after 6 months of exclusive lactation, even in women who keep breastfeeding. Arch Osteoporos 2017; 12:73. [PMID: 28815389 DOI: 10.1007/s11657-017-0368-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/07/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED This pilot study enrolled 31 women who had breastfed exclusively for 6 months. Lumbar and thoracic BMD increased 4 and 5%, respectively. Femoral neck and total body BMD did not change. Return of menses and progestin-only pill use were two potential signals that predicted a greater increase in BMD. PURPOSE/INTRODUCTION The skeleton is resorbed during lactation to provide much of the calcium content of milk. After lactation ceases, these deficits in skeletal mineral content are largely restored, such that lactation has a neutral or protective effect against the long-term risk of low bone mineral density (BMD), osteoporosis, and fragility fractures. We hypothesized that a large observational study may identify the factors that predict a greater increase in BMD after lactation ceases. A pilot study was first needed to test feasibility and the magnitude of expected BMD change. METHODS We undertook Factors Affecting Bone formation after Breastfeeding Pilot (FABB Pilot), which enrolled women who had breastfed exclusively for 6 months and planned to wean soon. The main outcome was change in BMD between enrolment and 6 months later. RESULTS Thirty-one women were recruited and completed both time points. Lumbar and thoracic spine BMD increased 4 and 5%, respectively; there was no significant change in femoral neck and total body BMD. Most women did not wean their babies as planned but continued to breastfeed multiple times per day. Despite this, a significant increase in BMD was seen in the subsequent 6 months. Return of spontaneous menses and use of a progestin-only pill at recruitment were two potential signals that predicted a greater increase in BMD during the 6 months after exclusive lactation. CONCLUSIONS Spine BMD increased significantly during 6 months following exclusive lactation and despite continued lactation. The factors that stimulate skeletal recovery remain to be identified.
Collapse
Affiliation(s)
- Sandra Cooke-Hubley
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Beth J Kirby
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - James E Valcour
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Gerald Mugford
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Jonathan D Adachi
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Christopher S Kovacs
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada. .,Health Sciences Centre, 300 Prince Philip Drive, St. John's, NL, A1B 3V6, Canada.
| |
Collapse
|
29
|
Abstract
Most premenopausal women with low trauma fracture(s) or low bone mineral density have a secondary cause of osteoporosis or bone loss. Where possible, treatment of the underlying cause should be the focus of management. Premenopausal women with an ongoing cause of bone loss and those who have had, or continue to have, low trauma fractures may require pharmacologic intervention. Clinical trials provide evidence of benefits of bisphosphonates and teriparatide for bone mineral density in several types of premenopausal osteoporosis, but studies are small and do not provide evidence regarding fracture risk reduction.
Collapse
Affiliation(s)
- Adi Cohen
- Division of Endocrinology, Department of Medicine, Columbia University Medical Center, Columbia University, College of Physicians & Surgeons, PH8-864, 630 West 168th Street, New York, NY 10032, USA.
| |
Collapse
|
30
|
Brembeck P, Winkvist A, Ohlsson C, Lorentzon M, Augustin H. Determinants of microstructural, dimensional and bone mineral changes postpartum in Swedish women. Br J Nutr 2016; 116:1-9. [PMID: 27876110 DOI: 10.1017/s0007114516003998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
During lactation, areal (a) and volumetric (v) bone mineral density (BMD) are known to temporarily decrease. Factors that affect skeletal changes postpartum are not fully elucidated. The aim was to study determinants of the previously observed changes in aBMD at lumbar spine, and cortical vBMD, microstructure and dimensions at ultra-distal tibia postpartum. Women (25-40 years) were studied longitudinally at 2 weeks (baseline) and 4 months (n 81), 12 months (n 79) and 18 months (n 58) postpartum. At each visit, blood samples were collected, body weight and height were measured and information about lactation habits, oestrogen contraceptives and physical activity was obtained. Ca intake was measured using 4-d food diaries at 4 months postpartum. Serum 25-hydroxyvitamin D (25OHD) was analysed by liquid chromatography-tandem MS. Skeletal changes were assessed with dual-energy X-ray absorptiometry and high-resolution peripheral quantitative computed tomography. Mean baseline BMI was 24·8 (sd 3·1) kg/m2. Median (quartiles 1-3) duration of total lactation was 8·1 (6·8-10·4) months. Longer duration of full lactation was associated with larger decreases of lumbar spine aBMD and tibia vBMD and microstructure. Higher baseline body weight was associated with smaller decreases in tibia vBMD and microstructure. Higher Ca intake was associated with smaller decreases in tibia cortical vBMD and thickness. Higher baseline 25OHD was only associated with larger decreases in lumbar spine aBMD. In conclusion, lactation and body weight were the main determinants of skeletal changes during the first 18 months postpartum. Ca intake and serum concentrations of 25OHD appear to have different associations with cortical and trabecular bone.
Collapse
Affiliation(s)
- Petra Brembeck
- Department of Internal Medicine and Clinical Nutrition,Institute of Medicine,Sahlgrenska Academy,University of Gothenburg,Box 459, 405 30 Gothenburg,Sweden
| | - Anna Winkvist
- Department of Internal Medicine and Clinical Nutrition,Institute of Medicine,Sahlgrenska Academy,University of Gothenburg,Box 459, 405 30 Gothenburg,Sweden
| | - Claes Ohlsson
- Department of Internal Medicine and Clinical Nutrition,Institute of Medicine,Sahlgrenska Academy,University of Gothenburg,Box 459, 405 30 Gothenburg,Sweden
| | - Mattias Lorentzon
- Department of Internal Medicine and Clinical Nutrition,Institute of Medicine,Sahlgrenska Academy,University of Gothenburg,Box 459, 405 30 Gothenburg,Sweden
| | - Hanna Augustin
- Department of Internal Medicine and Clinical Nutrition,Institute of Medicine,Sahlgrenska Academy,University of Gothenburg,Box 459, 405 30 Gothenburg,Sweden
| |
Collapse
|
31
|
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.
Collapse
Affiliation(s)
- Christopher S Kovacs
- Faculty of Medicine-Endocrinology, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| |
Collapse
|
32
|
The effects of different levels of calcium supplementation on the bone mineral status of postpartum lactating Chinese women: a 12-month randomised, double-blinded, controlled trial. Br J Nutr 2015; 115:24-31. [DOI: 10.1017/s0007114515003967] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIncreasing dietary Ca intake may prevent the excessive mobilisation of bone mineral in nursing mothers. We aimed to investigate whether higher Ca intake could positively modulate the bone mineral changes in Chinese postpartum lactating women. The study was a 12-month randomised, double-blinded, parallel group trial conducted over 12 months. A total of 150 postpartum women were randomly selected to receive either 40 g of milk powder containing 300 mg of Ca and 5 μg of vitamin D (Low-Ca group) or same milk powder additionally fortified with 300 mg of Ca (Mid-Ca group) or 600 mg of Ca (High-Ca group). Bone mineral density (BMD) for the whole body, the lumbar spine, the total left hip and its sub-regions was measured using dual-energy X-ray absorptiometry. A total of 102 subjects completed the whole trial. The duration of total lactating time was 7·9 (sd 2·8) months on average. The intention-to-treat analysis yielded the following mean percentage changes in BMD for the whole body, the lumbar spine and the total left hip, respectively: −0·93 (sd 1·97), 2·11 (sd 4·90) and −1·60 (sd 2·65) % for the Low-Ca group; −0·56 (sd 1·89), 2·21 (sd 3·77) and −1·43 (sd 2·30) % for the Mid-Ca group; and −0·44 (sd 1·67), 2·32 (sd 4·66) and −0·95 (sd 4·08) % for the High-Ca group. The differences between the groups were not statistically significant (P: 0·5–0·9). The results of the complete case analysis were similar. In sum, we found no significant differences in the bone mineral changes from baseline to 12 months in postpartum lactating women consuming milk powder fortified with different levels of Ca.
Collapse
|
33
|
Shagina NB, Tolstykh EI, Fell TP, Smith TJ, Harrison JD, Degteva MO. Strontium biokinetic model for the lactating woman and transfer to breast milk: application to Techa River studies. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2015; 35:677-694. [PMID: 26295519 DOI: 10.1088/0952-4746/35/3/677] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This paper presents a biokinetic model for strontium metabolism in the lactating woman and transfer to breast milk for members of Techa River communities exposed as a result of discharges of liquid radioactive wastes from the Mayak plutonium production facility (Russia) in the early 1950s. This model was based on that developed for the International Commission for Radiological Protection with modifications to account for population specific features of breastfeeding and maternal bone mineral metabolism. The model is based on a biokinetic model for the adult female with allowances made for changes in mineral metabolism during periods of exclusive and partial breast-feeding. The model for females of all ages was developed earlier from extensive data on (90)Sr-body measurements for Techa Riverside residents. Measurements of (90)Sr concentrations in the maternal skeleton and breast milk obtained in the1960s during monitoring of global fallout in the Southern Urals region were used for evaluation of strontium transfer to breast and breast milk. The model was validated with independent data from studies of global fallout in Canada and measurements of (90)Sr body-burden in women living in the Techa River villages who were breastfeeding during maximum (90)Sr-dietary intakes. The model will be used in evaluations of the intake of strontium radioisotopes in breast milk by children born in Techa River villages during the radioactive releases and quantification of (90)Sr retention in the maternal skeleton.
Collapse
Affiliation(s)
- N B Shagina
- Urals Research Center for Radiation Medicine, Chelyabinsk, 454076, Russia
| | | | | | | | | | | |
Collapse
|
34
|
Kovacs CS, Ralston SH. Presentation and management of osteoporosis presenting in association with pregnancy or lactation. Osteoporos Int 2015; 26:2223-41. [PMID: 25939309 DOI: 10.1007/s00198-015-3149-3] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 04/22/2015] [Indexed: 01/15/2023]
Abstract
In this review, we summarize our current understanding of the pathophysiology of fragility fractures that occur for the first time during pregnancy and lactation, and provide guidance on appropriate investigations and treatment strategies. Most affected women will have had no prior bone density reading, and so the extent of bone loss that may have occurred during pregnancy or lactation is uncertain. During pregnancy, intestinal calcium absorption doubles in order to meet the fetal demand for calcium, but if maternal intake of calcium is insufficient to meet the combined needs of the mother and baby, the maternal skeleton will undergo resorption during the third trimester. During lactation, several hormonal changes, independent of maternal calcium intake, program a 5-10 % loss of trabecular mineral content in order to provide calcium to milk. After weaning the baby, the maternal skeleton is normally restored to its prior mineral content and strength. This physiological bone resorption during reproduction does not normally cause fractures; instead, women who do fracture are more likely to have additional secondary causes of bone loss and fragility. Transient osteoporosis of the hip may affect one or both femoral heads during pregnancy but it involves localized edema and not skeletal resorption. Case reports have described the use of calcitonin, bisphosphonates, strontium ranelate, teriparatide, vertebroplasty, and kyphoplasty to treat post-partum vertebral fractures. However, the need for such treatments is uncertain given that a progressive increase in bone mass subsequently occurs in most women who present with a fracture during pregnancy or lactation.
Collapse
Affiliation(s)
- C S Kovacs
- Faculty of Medicine-Endocrinology, Memorial University of Newfoundland, St. John's, Newfoundland, Canada, A1B 3V6,
| | | |
Collapse
|
35
|
Brembeck P, Lorentzon M, Ohlsson C, Winkvist A, Augustin H. Changes in cortical volumetric bone mineral density and thickness, and trabecular thickness in lactating women postpartum. J Clin Endocrinol Metab 2015; 100:535-43. [PMID: 25387262 DOI: 10.1210/jc.2014-2825] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Lactation is associated with decreased areal bone mineral density (aBMD). Replenishment occurs especially after ceased lactation. Changes in volumetric bone mineral density (vBMD), microstructure, and dimensional parameters are unknown and may clarify the role of lactation for skeletal health. OBJECTIVE AND MAIN OUTCOMES: The objective of the study was to test the hypothesis that lactation is associated with changes in aBMD, vBMD, microstructure, and dimensional parameters. DESIGN At baseline (0.5 mo after delivery) and 4, 12, and 18 months thereafter, bone was assessed using dual-energy x-ray absorptiometry and high-resolution peripheral quantitative computed tomography. PARTICIPANTS AND SETTING Eighty-one fair-skinned postpartum women and 21 controls aged 25-40 years were recruited. The completion ratio was 73%. Postpartum women were categorized depending on duration of lactation: 0-3.9, 4-8.9, and 9 months or longer. RESULTS During the first 4 months, aBMD decreased at several sites (geometric mean ± SE; -0.73% ± 0.21% to -3.98% ± 0.76%) in women lactating at least 4 months. During the same time, cortical vBMD at the ultradistal tibia decreased in women lactating 4-8.9 months (-0.26% ± 0.08%) and 9 months or longer (-0.49% ± 0.10%). At 12 months postpartum, cortical thickness (≥ 9 mo, -2.48% ± 0.41%) and trabecular thickness (4-8.9 mo, -2.14% ± 0.92%; ≥ 9 mo, -2.56% ± 1.21%) also were lower than baseline. No decreases were found in women lactating less than 4 months or in controls in these parameters. At 18 months postpartum, both cortical vBMD (≥ 9 mo, -0.77% ± 0.17%) and trabecular thickness (4-8.9 mo, -2.25% ± 1.25%; ≥ 9 mo, -3.21% ± 1.41%) were lower in women with long lactation. CONCLUSIONS Decreases in cortical vBMD, thickness, and trabecular thickness at the ultradistal tibia were found in women lactating 4 months or longer. Longer follow-up is needed to confirm whether women with extended lactation recover fully or whether the changes could potentially lead to an increased risk of fracture in later life.
Collapse
Affiliation(s)
- P Brembeck
- Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
| | | | | | | | | |
Collapse
|
36
|
Abstract
PURPOSE OF REVIEW To describe our current state of knowledge about the pathophysiology, incidence, and treatment of osteoporosis that presents during pregnancy, puerperium, and lactation. RECENT FINDINGS When vertebral fractures occur in pregnant or lactating women, it is usually unknown whether the skeleton was normal before pregnancy. Maternal adaptations increase bone resorption modestly during pregnancy but markedly during lactation. The net bone loss may occasionally precipitate fractures, especially in women who have underlying low bone mass or skeletal fragility prior to pregnancy. Bone mass and strength are normally restored postweaning. Transient osteoporosis of the hip is a sporadic disorder localized to one or both femoral heads; it is not due to generalized skeletal resorption. Anecdotal reports have used bisphosphonates, strontium ranelate, teriparatide, or vertebroplasty/kyphoplasty to treat postpartum vertebral fractures, but it is unclear whether these therapies had any added benefit over the spontaneous skeletal recovery that normally occurs after weaning. SUMMARY These relatively rare fragility fractures result from multifactorial causes, including skeletal disorders that precede pregnancy, and structural and metabolic stresses that can compromise skeletal strength during pregnancy and lactation. Further study is needed to determine when pharmacological or surgical therapy is warranted instead of conservative or expectant management.
Collapse
Affiliation(s)
- Christopher S Kovacs
- Faculty of Medicine - Endocrinology, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| |
Collapse
|
37
|
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.
Collapse
Affiliation(s)
- Corrie M Whisner
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | | | | | | | | | | | | |
Collapse
|
38
|
Osteoprotegerin in pregnant adolescents differs by race and is related to infant birth weight z-score. J Dev Orig Health Dis 2014; 2:272-9. [PMID: 25141264 DOI: 10.1017/s2040174411000511] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Osteoprotegerin (OPG) is involved in the regulation of bone turnover, but little is known about this protein during pregnancy or among neonates. We undertook a prospective longitudinal study to identify relationships between OPG, markers of bone turnover and birth outcomes in 155 pregnant adolescents (13-18 years) and their newborns. Maternal blood samples were collected at mid-gestation and at delivery. Cord blood was obtained at delivery. Serum OPG, estradiol and markers of bone formation (osteocalcin) and resorption (N-telopeptide) were assessed in all samples. Placental OPG expression was assessed in placental tissue obtained at delivery. Bone markers and OPG increased significantly from mid-gestation (26.0 ± 3.4 weeks) to delivery (39.3 ± 2.6 weeks). Neonatal OPG was significantly lower, but bone turnover markers were significantly higher than maternal values at mid-gestation and at parturition (P < 0.001). African-American adolescents had higher concentrations of OPG than Caucasian adolescents at mid-gestation (P = 0.01) and delivery (P = 0.04). Gestational age and estradiol were also predictors of maternal OPG at mid-gestation and delivery. OPG concentrations in cord blood were correlated with maternal OPG concentrations and were negatively associated with infant birth weight z-score (P = 0.02) and ponderal index (P = 0.02). In conclusion, maternal OPG concentrations increased across gestation and were significantly higher than neonatal OPG concentrations. Maternal and neonatal OPG concentrations were not associated with markers of bone turnover or placental OPG expression, but neonatal OPG was inversely associated with neonatal anthropometric measures. Additional research is needed to identify roles of OPG during pregnancy.
Collapse
|
39
|
Tolstykh EI, Shagina NB, Degteva MO. Increase in accumulation of strontium-90 in the maternal skeleton during pregnancy and lactation: analysis of the Techa River data. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2014; 53:551-557. [PMID: 24861824 DOI: 10.1007/s00411-014-0548-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 04/27/2014] [Indexed: 06/03/2023]
Abstract
The unique contamination of the Techa River (Southern Urals, Russia) in the 1950s by long-lived (90)Sr allows investigation of the accumulation of bone-seeking elements in humans. This study is based on information compiled at the Urals Research Center for Radiation Medicine (Chelyabinsk, Russia) over a long period of time. It includes the results of in vivo measurements of (90)Sr-body burden with a whole body counter (WBC), data on personal medical examinations and residence and family histories. Data on 185 women from two Techa riverside villages Muslyumovo and Brodokalmak were selected. The settlements differ in terms of (90)Sr diet intake (higher in Muslyumovo than in Brodokalmak) and ethnicity (residents were mainly Slavs in Brodokalmak and Turkic in Muslyumovo). Results of a total of 555 WBC measurements performed in 1974-1997 were available for the women studied; maximum measured values reached 40 kBq/body. The women from each settlement were subdivided into three groups according to their childbearing history: pregnancy and lactation occurred (1) during the period of maximal (90)Sr intake (1950-1951); (2) after the period of maximal intake and (3) before this period or women who were childless. An increase was found in accumulation of (90)Sr in maternal skeleton during pregnancy and lactation (group 1) by a factor of 1.5-2 in comparison with non-pregnant, non-lactating women. This result was found in both Muslyumovo and Brodokalmak samples. An increase in accumulation of toxic elements in pregnant/lactating women is associated with increased radiation/toxic doses and risk for the women's health.
Collapse
Affiliation(s)
- Evgenia I Tolstykh
- Urals Research Center for Radiation Medicine, 68-A, Vorovsky Street, Chelyabinsk, 454076, Russia,
| | | | | |
Collapse
|
40
|
Kovacs CS. The Role of PTHrP in Regulating Mineral Metabolism During Pregnancy, Lactation, and Fetal/Neonatal Development. Clin Rev Bone Miner Metab 2014. [DOI: 10.1007/s12018-014-9157-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
41
|
Sawo Y, Jarjou LMA, Goldberg GR, Laskey MA, Prentice A. Bone mineral changes after lactation in Gambian women accustomed to a low calcium intake. Eur J Clin Nutr 2013; 67:1142-6. [PMID: 24084511 PMCID: PMC3898312 DOI: 10.1038/ejcn.2013.162] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 07/11/2013] [Accepted: 07/12/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES Previous studies in Gambian women with a low calcium intake have described decreases in whole-body and regional bone mineral content (BMC) and areal bone mineral density (aBMD) during the first year of lactation. The aim of this study was to examine whether these effects are reversed after lactation. SUBJECTS/METHODS Thirty-three Gambian women who had a previous dual-energy X-ray absorptiometry (DXA) scan at 52 weeks lactation (L52) were invited to participate in a follow-up study when neither pregnant nor lactating (NPNL) for ≥3 months and/or when 52 weeks postpartum in a subsequent lactation (F52). Whole body, lumbar spine and hip bone mineral were measured by DXA. Anthropometry and dietary assessments were also conducted. Repeated-measures analysis of covariance was used to determine differences from L52 at NPNL and F52. RESULTS Twenty-eight women were scanned at NPNL and 20 at F52. The mean±s.d. calcium intake of the 33 women at NPNL and F52 was 360±168 mg/day. BMC, aBMD and size-adjusted BMC (SA-BMC) at all sites were higher at NPNL than L52. Percent increases in SA-BMC (mean±s.e.m.) were significant (P<0.0001): whole body=2.7±0.4%; lumbar spine=4.9±1.0%; total hip=3.7±1.0%. There were no significant differences in any measurements between the two lactation time points (L52 and F52). CONCLUSIONS This study of Gambian women with low calcium intakes demonstrates that bone mineral mobilised during lactation is recovered after lactation. Successive periods of long lactation are not associated with progressive skeletal depletion.
Collapse
Affiliation(s)
- Y Sawo
- MRC Keneba, West Kiang, The Gambia
| | | | - G R Goldberg
- MRC Keneba, West Kiang, The Gambia
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
| | - M A Laskey
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
| | - A Prentice
- MRC Keneba, West Kiang, The Gambia
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
| |
Collapse
|
42
|
Jarjou LMA, Sawo Y, Goldberg GR, Laskey MA, Cole TJ, Prentice A. Unexpected long-term effects of calcium supplementation in pregnancy on maternal bone outcomes in women with a low calcium intake: a follow-up study. Am J Clin Nutr 2013; 98:723-30. [PMID: 23902782 PMCID: PMC3743734 DOI: 10.3945/ajcn.113.061630] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Calcium supplementation of pregnant Gambian women with a low calcium intake results in lower maternal bone mineral content in the subsequent lactation. OBJECTIVE The objective was to investigate whether the lower bone mineral content persists long term. DESIGN All women in the calcium supplementation trial (International Trial Registry ISRCTN96502494) who had been scanned with dual-energy X-ray absorptiometry at 52 wk of lactation (L52; n = 79) were invited for follow-up when neither pregnant nor lactating for ≥3 mo (NPNL) or at 52 wk postpartum in a future lactation (F52). Bone scans and anthropometric and dietary assessments were conducted. RESULTS Sixty-eight women participated (35 at both NPNL and F52 and 33 at only one time point): n = 59 NPNL (n = 31 calcium, n = 28 placebo) and n = 44 F52 (n = 24 calcium, n = 20 placebo). The mean (±SD) time from L52 was 4.9 ± 1.9 y for NPNL and 5.0 ± 1.3 y for F52. Size-adjusted bone mineral content (SA-BMC) was greater at NPNL than at L52 in the placebo group (P ≤ 0.001) but not in the calcium group (P for time-by-group interaction: lumbar spine, 0.002; total hip, 0.03; whole body, 0.03). No significant changes in SA-BMC from L52 to F52 were observed in either group. Consequently, the lower SA-BMC in the calcium group at L52 persisted at NPNL and F52 (P ≤ 0.001): NPNL (lumbar spine, -7.5 ± 0.7%; total hip, -10.5 ± 1.0%; whole body, -3.6 ± 0.5%) and F52 (lumbar spine, -6.2 ± 0.9%; total hip, -10.3 ± 1.4%; whole body, -3.2 ± 0.6%). CONCLUSION In rural Gambian women with a low-calcium diet, a calcium supplement of 1500 mg/d during pregnancy resulted in lower maternal bone mineral content in the subsequent lactation that persisted long term. This trial was registered at www/controlled-trials.com/mrct/ as ISRCTN96502494.
Collapse
|
43
|
Kirby BJ, Ma Y, Martin HM, Buckle Favaro KL, Karaplis AC, Kovacs CS. Upregulation of calcitriol during pregnancy and skeletal recovery after lactation do not require parathyroid hormone. J Bone Miner Res 2013; 28:1987-2000. [PMID: 23505097 DOI: 10.1002/jbmr.1925] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 02/16/2013] [Accepted: 03/04/2013] [Indexed: 12/14/2022]
Abstract
Pregnancy invokes a doubling of intestinal calcium absorption whereas lactation programs skeletal resorption to provide calcium to milk. Postweaning bone formation restores the skeleton's bone mineral content (BMC), but the factors that regulate this are not established. We used Pth-null mice to test whether parathyroid hormone (PTH) is required for postweaning skeletal recovery. On a normal 1% calcium diet, wild-type (WT) and Pth-null mice each gained BMC during pregnancy, declined 15% to 18% below baseline during lactation, and restored the skeleton above baseline BMC within 14 days postweaning. A 2% calcium diet reduced the lactational decline in BMC without altering the gains achieved during pregnancy and postweaning. The hypocalcemia and hyperphosphatemia of Pth-null mice normalized during lactation and serum calcium remained normal during postweaning. Osteocalcin and propeptide of type 1 collagen (P1NP) each rose significantly after lactation to similar values in WT and Pth-null. Serum calcitriol increased fivefold during pregnancy in both genotypes whereas vitamin D binding protein levels were unchanged. Absence of PTH blocked a normal rise in fibroblast growth factor-23 (FGF23) during pregnancy despite high calcitriol. A 30-fold higher expression of Cyp27b1 in maternal kidneys versus placenta suggests that the pregnancy-related increase in calcitriol comes from the kidneys. Conversely, substantial placental expression of Cyp24a1 may contribute significantly to the metabolism of calcitriol. In conclusion, PTH is not required to upregulate renal expression of Cyp27b1 during pregnancy or to stimulate recovery from loss of BMC caused by lactation. A calcium-rich diet in rodents suppresses skeletal losses during lactation, unlike clinical trials that showed no effect of supplemental calcium on lactational decline in BMC.
Collapse
Affiliation(s)
- Beth J Kirby
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | | | | | | | | | | |
Collapse
|
44
|
Yumusakhuylu Y, Turgut ST, Icagasioglu A, Baklacioglu HS, Atlig RS, Murat S, Suer N. Bone mineral changes during pregnancy and lactation. Gynecol Endocrinol 2013; 29:763-6. [PMID: 23815509 DOI: 10.3109/09513590.2013.801444] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Significant calcium transfer from the mother to the fetus and infant occurs during pregnancy and lactation, theoretically placing the mother at an increased risk for osteoporosis. The relationship between pregnancy, breast-feeding and low bone mass is controversial. In this study we aimed to elucidate the relationship between pregnancy, breast-feeding and bone mass in third trimester pregnants, at least 3 months lactating mothers, and healthy young nulliporous women by using quantitative ultrasonometry. METHOD The study included 120 women divided in three groups: third trimester pregnants, at least 3 months lactating mothers and healthy young nulliporous women. Demographics, total lactation time, number of pregnancies, births and miscarriages-abortions were recorded. Study groups underwent quantitative ultrasonometry measurement at midtibial shaft. Values of the ultrasonometry variables were calculated and compared for groups. RESULTS There were no significant differences among the groups with respect to parameters of age, age at menarche, smoking, alcohol intake and physical exercise in all of the three groups (p > 0.05). No differences were found among the three groups in analyzed variables, when comparing SOS, T- and Z-scores mid-tibial shaft quantitative ultrasonometry. CONCLUSION No statistically significant associations were found between ultrasonometry variables and pregnancy, breast-feeding or nulliparity.
Collapse
Affiliation(s)
- Yasemin Yumusakhuylu
- Istanbul Medeniyet University, Goztepe Training and Research Hospital, Department of Physical Medicine and Rehabilitation, Goztepe-Istanbul, Turkey.
| | | | | | | | | | | | | |
Collapse
|
45
|
Mays S. The Effects of Infant Feeding Practices on Infant and Maternal Health in a Medieval Community. ACTA ACUST UNITED AC 2013. [DOI: 10.1179/cip.2010.3.1.63] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
46
|
Abstract
Parathyroid disorders are not common among pregnant women, but harbor a significant morbidity and mortality potential if they remain unrecognized and untreated. The symptoms caused by abnormally low or high blood free calcium level are mostly non-specific in the initial stages, thus when recognized might pose a real danger. Here we will survey the alterations in calcium metabolism induced by pregnancy, and describe the clinical manifestations, diagnosis and treatment of parathyroid and other calcium metabolism disorders during pregnancy. The current literature on the impact of calcium and vitamin D deficiency during pregnancy will also be reviewed.
Collapse
Affiliation(s)
- Ilana Parkes
- Department of Obstetrics & Gynecology, Hadassah Ein Kerem University Hospital, Jerusalem, Israel
| | | | | |
Collapse
|
47
|
Mora S, Diceglie C, Viganò A, Giacomet V, Manfredini V, Stucchi S, Fabiano V, Mameli C, Coletto S, Zuccotti GV. Antiretroviral therapy and pregnancy: effect on cortical bone status of human immunodeficiency virus-infected Caucasian women as assessed by quantitative ultrasonography. Calcif Tissue Int 2013; 92:394-8. [PMID: 23307187 DOI: 10.1007/s00223-013-9696-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 12/26/2012] [Indexed: 11/28/2022]
Abstract
Treatment with antiretroviral agents (ARVs) during pregnancy is important to prevent mother-to-child transmission of the human immunodeficiency virus (HIV), but their use has been associated with low bone mineral density in adult patients. Currently, there are no data regarding the bone status of HIV-infected women who received ARV during pregnancy. The aim of this study was to evaluate cortical bone status at delivery in a group of HIV-infected women who received ARV during pregnancy and to monitor the changes occurring during the first year postpartum. We studied 33 HIV-infected and 116 HIV-uninfected healthy Caucasian women within 4 days from delivery. Follow-up measurements were performed at 4 and 12 months postpartum in 17 HIV-infected and 55 healthy women. Cortical bone status was evaluated by quantitative ultrasonography at the mid-tibia, and bone measurements were expressed as the speed of sound (SOS). HIV-infected women after delivery had a median SOS of 3,985 (3,567-4,242) m/s, while the median SOS of healthy women was 4,025 (3,643-4,250) m/s. The difference was not significant (t = 0.39, P = 0.69). No significant differences were observed between ARV-exposed and control subjects at 4 and 12 months. Our data suggest that ARV during pregnancy and the first year after delivery does not affect negatively cortical bone status.
Collapse
Affiliation(s)
- Stefano Mora
- Laboratory of Pediatric Endocrinology, BoNetwork, Division of Metabolic and Cardiovascular Sciences, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
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.
Collapse
|
49
|
Madimenos FC, Snodgrass JJ, Liebert MA, Cepon TJ, Sugiyama LS. Reproductive effects on skeletal health in Shuar women of Amazonian Ecuador: A life history perspective. Am J Hum Biol 2012; 24:841-52. [DOI: 10.1002/ajhb.22329] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 08/07/2012] [Accepted: 08/29/2012] [Indexed: 01/09/2023] Open
|
50
|
O'Brien KO, Donangelo CM, Ritchie LD, Gildengorin G, Abrams S, King JC. Serum 1,25-dihydroxyvitamin D and calcium intake affect rates of bone calcium deposition during pregnancy and the early postpartum period. Am J Clin Nutr 2012; 96:64-72. [PMID: 22648718 PMCID: PMC3374733 DOI: 10.3945/ajcn.111.029231] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 05/01/2012] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Factors affecting bone calcium deposition across pregnancy and lactation are not well characterized. OBJECTIVE The impact of maternal age, calcium intake, race-ethnicity, and vitamin D status on the rate of bone calcium deposition (VO+) was assessed across pregnancy and lactation. DESIGN Stable calcium isotopes were given to 46 women at pre- or early pregnancy (trimester 1), late pregnancy (trimester 3), and 3-10 wk postpartum. Three cohorts were included: 23 adolescents from Baltimore (MD), aged 16.5 ± 1.4 y (mean ± SD; Baltimore cohort); 13 adults from California, aged 29.5 ± 2.6 y (California cohort); and 10 adults from Brazil, aged 30.4 ± 4.0 y (Brazil cohort). The total exchangeable calcium pool, VO+, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D [1,25(OH)₂D], parathyroid hormone, and calcium intake were evaluated. RESULTS At trimester 3, inverse associations between 1,25(OH)₂D and VO+ were evident in the Baltimore (P = 0.059) and Brazil (P = 0.008) cohorts and in the whole group (P = 0.029); calcium intake was not a significant determinant of VO+ in any group during pregnancy. At postpartum, a significant positive association was evident between VO+ and calcium intake (P ≤ 0.002) and between VO+ and African ethnicity (P ≤ 0.004) in the whole group and within the Baltimore and Brazil cohorts. CONCLUSIONS Elevated 1,25(OH)₂D was associated with decreased rates of bone calcium deposition during late pregnancy, a finding that was particularly evident in pregnant adolescents and adult women with low calcium intakes. Higher dietary calcium intakes and African ethnicity were associated with elevated rates of bone calcium deposition in the postpartum period.
Collapse
|