Role of Ca++ & Vit-D in Pregnancy & Lactation.pptx

Role of Ca++ & Vit-D in Pregnancy & Lactation

1. Role of calcium & V it -D in pregnancy& Lactation Dr. XYZ

2. Health news Calcium & Vitamin D insufficiency

3. married women age 15-19 are undernourished (BMI <18.5 kg/m2). 2016 31% BMI over 18.5 to 24.9 is considered to be at a healthy weight. Calcium plays an important role in increasing the BMI directly . According to - VITAMIN D 3 STATUS AMONG BANGLADESHI WOMEN research 81% of the females were below (60 nmol /L) the normal level (75 nmol /L) of vitamin D 3

4. According to Research on BANGLADESHI WOMEN 40 % of pregnant women suffers preeclampsia due to Calcium & Vitamin D 3 deficiency PMS (Pre-menstrual Syndrome) affects almost 7.1 million women due to Calcium & Vitamin D 3 deficiency

5. 2016 Causes death of 29 baby out of per 1000 baby. Due to lack of proper nutrition for not only baby but also mother in pregnancy . Early marriage

6. Neonatal mortality (61% of all under-5 age deaths) 2016 28 per 1,000 dies . Majority of death is caused of Malnutrition and the important causes of malnutrition is lack of Calcium intake .

7. C a++ Deficiency During Pregnancy During gestation the average foetus requires about 30 g of calcium to mineralize its skeleton and maintain normal physiological processes. The suckling neonate requires more than this amount in breast milk during six months of exclusive lactation Although pregnant and lactating women face a comparable demand in the amount of calcium

8. During pregnancy and lactation, 200–300 mg Ca/d is either transferred via the placenta to the foetus or excreted in breast milk. The provision of calcium during pregnancy and lactation requires Physiologic adaptation of calcium homeostatic mechanisms. Including intestinal calcium absorption urinary calcium excretion maternal bone calcium turnover

9. Calcium stress of pregnancy is relatively similar among women The amount of calcium secreted during lactation can be highly variable, depending on Amount of breast-milk produced Breast-milk calcium concentration Length of the lactation period

10. Ca l c ium Calcium is important for a number of functions in the body It is essential for Growth Maintenance of bones and teeth Nerve transmission Muscle contraction Number of other cell processes

11. The body has increased calcium needs during growth spurts, pregnancy and lactation An inadequate calcium intake can therefore cause a number of problems In growing children and adolescents, this can lead to stunted growth, and a reduced peak bone density increasing the risk of osteoporosis later in life In pregnancy, the unborn child will draw on the mother’s calcium stores to meet its needs, putting the condition of the mother’s bones and teeth at risk

12. Recommended Daily Intake Population Group RDI Adults 800 mg/day Pregnancy 1100 mg/day Lactation 1300 mg/day Elderly 1000 mg/day

13. If dairy foods are not consumed there are many other ways to incorporate calcium into your diet: Try some calcium-enriched soymilk with muesli Have tuna and tomato on toast for breakfast Use calcium-fortified bread to make a sandwich Snack on a handful of nuts Have a stirfry of Asian green vegies

14. P r e g n a n cy The normal foetal skeleton has accreted about 30 g calcium by the end of gestation About 80% of the accretion occurs rapidly during the third trimester Daily accretion rate ofabout 250–300 mg calcium by the foetal skeleton during the third trimester

15. The mother could theoretically meet this demand by  Increasing the intestinal absorption  Decreasing renal calcium losses  Increasing the resorption of calcium from the maternal skeleton

16. Minerals and hormones Earliest apparent changes in calcium balance in pregnancy is a fall in total serum calcium Serum calcitonin levels are increased during pregnancy PTHrP levels have been increased during pregnancy Other hormones are clearly in flux during pregnancy

17. Intestinal calcium absorption Intestinal absorption of calcium is doubled during pregnancy The increase in intestinal calcium absorption is associated with Doubling of 1,25-dihydroxyvitamin D levels Increased intestinal expression of the vitamin D- dependent calcium-binding protein calbindin-D

18. Renal calcium excretion The 24-h urine calcium excretion is typically increased as early as the 12th week of gestation This increase is likely a consequence of Increased intestinal absorption of calcium Increased renal filtered load of calcium Increased glomerular filtration rate In the fasted state, the calcium excretion is normal or even low.

19. Osteoporosis in pregnancy Occasionally, a woman will suffer an apparent fragility fracture during pregnancy or in the first few weeks after delivery low bonemineral density reading will be obtained Focal, transient osteoporosis of the hip is a rare

20. Lactation The typical daily loss of calcium in breast milk has been estimated to range from 280– 400 mg Although daily losses as great as 1000 mg A temporary demineralization of the skeleton seems to be the main mechanism

21. Again, the mother could theoretically meet this demand by increasing the intestinal absorption of calcium decreasing renal calcium losses increasing the resorption of calcium from the maternal skeleton

22. Intestinal calcium absorption The intestinal absorption of calcium is equal to the no pregnant state – Decreased from pregnancy This change coincides with the fall in 1,25- dihydroxyvitamin D levels to normal.

23. Renal calcium excretion The GFR falls during lactation to a level below the pregnant and pre pregnant value Tubular reabsorption of calcium must be increased Renal excretion of calcium is typically reduced to levels as low as 50 mg/24 h increased serum calcium

24. Acute estrogen deficiency ( e.g. GnRH analog therapy) → increases skeletal resorption and → raises the blood calcium; → in turn, PTH is suppressed and → renal calcium losses are increased.

25. During lactation, the combined effects of PTHrP (secreted by the breast) and estrogen deficiency → increase skeletal resorption → reduce renal calcium losses, and → raise the blood calcium, → but calcium is directed into breast milk.

26. Acute estrogen deficiency ( e.g. GnRH analog therapy) increases skeletal resorption and raises the blood calcium; in turn, PTH is suppressed and renal calcium losses are increased. During lactation, the combined effects of PTHrP (secreted by the breast) and estrogen deficiency increase skeletal resorption, reduce renal calcium losses, and raise the blood calcium, but calcium is directed into breast milk.

27. Osteoporosis of lactation Like osteoporosis in pregnancy Woman may have had low bone density before conception PTHrP levels were high in one case of lactational osteoporosis

28. CALCIUM PHYSIOLOGY DURING PREGNANCY Calcium provided from the maternal deciduas aids in fertilization of the egg and implantation of the blastocyst About 80% of the calcium present in the foetal skeleton at the end of gestation crossed the placenta during the third trimester Intestinal calcium absorption doubles during pregnancy

29. Bone mobilization Investigated changes in bone mineral content during pregnancy and lactation Bone loss at certain skeletal sites, such as the lumbar spine and femoral neck

30. Mineral Ions Several characteristic changes in maternal serum chemistries and calciotropic hormones during pregnancy Serum albumin and hemoglobin fall during pregnancy due to hemodilution Serum phosphate and magnesium levels remain normal during pregnancy.

31. Schematic illustration of the longitudinal changes in calcium during pregnancy and lactation.

32. Schematic illustration of the longitudinal changes in phosphate PTH during pregnancy and lactation.

33. Schematic illustration of the longitudinal changes in 25-hydroxyvitamin D or calcifediol (25-D), Calcitonin during pregnancy and lactation.

34. Schematic illustration of the longitudinal changes in calcium during pregnancy and lactation.

35. Parathyroid Hormone Parathyroid hormone (PTH) was first measured with assays that reported high circulating levels during pregnancy Those early-generation PTH assays measured many biologically inactive fragments of PTH In contrast, in women from Asia and Gambia who have very low dietary calcium intakes

36. Vitamin D Metabolites A common concern is that the placenta and fetus will deplete maternal 25-D stores, but this does not appear to be the case Even in severely vitamin D deficient women there was either no change or at most a nonsignificant decline in maternal 25-D levels during pregnancy.

37. Calcitonin Serum calcitonin levels are increased during pregnancy and may derive from Maternal Thyroid Breast Decidua Placenta Calcitonin plays an important role in the physiological responses to the calcium demands of pregnancy

38. P T H rP PTHrP levels are increased during the third trimester – but whether this occurs earlier in pregnancy PTHrP is produced by many tissues in the fetus and mother and it is unknown which source(s) account for the rise in PTHrP 1-86 detected in the maternal circulation

39. Other Hormones Calciotropic hormones – Response to challenges such as hypocalcemia Steroids Prolactin Placental lactogen IGF-1

40. R e n al H a n d l in g of C a l c ium Renal calcium excretion is increased as early as the 12th week of gestation and 24 hour urine values (corrected for creatinine excretion) can exceed the normal range. Conversely, fasting urine calcium values are normal or low, confirming that the hypercalciuria is a consequence of the enhanced intestinal calcium absorption.

41. Consequences of bone loss during pregnancy and Lactation Maternal bone loss during pregnancy or lactation might lead to osteoporosis and fracture either contemporaneously or, by reducing peak bone mass, in later life. Severe bone loss leading to osteoporosis and fracture is a well recognized but rare complication of pregnancy and lactation

42. Influence of calcium intakes on breast-milk calcium secretion Breast-milk calcium secretion is known to be independent of recent maternal calcium intake No relationships between breast-milk calcium concentrations and maternal calcium intakes However, there have been no definitive investigations in women with low calcium intakes.

43. Effect of maternal calcium intake on foetal and infant growth Marginal calcium deficiency may be associated with reduced bone mineral content The influence of maternal calcium intakes during pregnancy and lactation on the growth and bone development of the foetus and breast-fed baby is not known

44. Calcium intakes and hypertensive disorders of pregnancy A potential connection between low calcium intakes and hypertensive disorders in pregnancy was suggested by the fact that the incidence of eclampsia is highest in countries where calcium intakes are low. Several well-conducted trials have studied the efficacy of calcium supplements in preventing preeclampsia, gestational hypertension, and premature delivery, as summarized in Table

45. Biochemical changes during pregnancy and lactation Calcium absorption is increased in pregnant women. The role of parathyroid hormone is unclear, since recent use of a more specific radioimmunoassay has cast doubt on previous reports of increased parathyroid hormone concentrations in pregnancy

46. During lactation…………. Urinary calcium excretion is generally decreased. Increased calcium absorption may occur. No differences in fractional absorption have been found during established lactation between breast-feeding mothers and control subjects

47. Adverse effects of increases in calcium intakes Very high calcium intakes are believed to increase the risk of kidney stones Renal calculi occur in 1/1500 pregnancies The potential for urinary tract infection may be increased when urinary calcium excretion rises as a result of calcium supplementation

48. In addition, increases in dietary calcium consumption have been associated with reduced absorption of other minerals such as – Iron – Zinc – Magnesium

49. DISORDERS OF CALCIUM AND BONE METABOLISM DURING PREGNANCY & LACTATION

50. Osteoporosis in Pregnancy In such cases it is not possible to exclude the possibility that low bone density or skeletal fragility preceded pregnancy Osteoporosis in pregnancy usually presents in a first pregnancy at age 27-28 and there is no increased risk with higher parity Fractures tend not to recur in subsequent pregnancies

51. Other disorders Low Calcium Intake Hypoparathyroidism Primary Hyperparathyroidism

52. During pregnancy there is increased demand of C a by the growing fetus to the extent of 28g, 80% of which is needed in last trimester. Calcium decreases the risk of Pregnancy induced hypertension, Pre eclampsia Pre term delivery Chronic hypertension in children. Long term morbidity like bone loss. Other benefits like Proper muscle contraction Blood clotting Cell membrane function Healthy teeth

53. Why you need calcium during pregnancy Baby needs calcium to build strong bones and teeth Grow a healthy heart, nerves, and muscles Develop a normal heart rhythm and blood-clotting abilities Reduce bone resorption

54. Calcium is a mineral that mostly works on body’s bone and teeth(99%) Rest works on blood and soft tissue(1 %) 5 th most abundant element of earth’s crust 3 rd most abundant metal.

55. Source of calcium Dairy products:Milk,cheese,butter Vegetable:broccoli,cabbage,nuts,avocado F ish:sardines

56. Calcium homeostasis 3 tissue involved: Bone Kidney Small intestine 3 hormones required: PTH Active vitD3 Calcitonin

57. Association of Ca deficiency with PIH : Low Ca intake in pregnancy may 1) stimulates PTH secretion,increasing intracellular Ca and smooth muscle contractility 2)Release renin from kidney leading to vaso constriction and Na,water retention.

58. WHO recommendations In populations with low dietary calcium intake, daily calcium supplementation (1.5 g–2.0 g oral elemental calcium) is recommended for pregnant women to reduce the risk of pre- eclampsia Started from 2 nd trimester.

59. Calcium supplementation has shown effectiveness in reducing the risk of pre term delivery,Low birth weight,chronic hypertension in children. Study showed there was 24% reduced risk of pre term birth and pre maturity in those who took 1000 mg Calcium daily. Fetal bone mineralization is also dependent on maternal Calcium store.

60. During lactation Nursing mothers provide an average of 200 to 250 mg of calcium per day to their infants, and as much as 400 mg per day. Given that women absorb only about a third of the calcium they consume,  they should  increase their calcium intake by 400 to 800 mg per day Typically, during three to six months of lactation, bone mineral density is reduced by 3 to 5 percent at the lumbar spine and femoral neck and by 1 to 2 percent in the whole body.  If not supplemented with calcium lactating mother will suffer from Low bone mass Low immunity Hormonal imbalance Early ageing

61. Calcitriol (1,25-(OH) 2 D 3 ) Vit D enters circulation after synthesis in the skin or consumption in the diet Vit D is transported through the body bound to a vitamin D-binding protein Vit D is taken to the liver, undergoes hydroxylation  forms 25(OH)D 25 (OH)D is bound again to the binding protein  kidney where it is further hydroxylated  1,25(OH) 2 D 3 , the most active vitamin D metabolite

62. Calcitriol (1,25-(OH) 2 D 3 ) In Ca deficiency, more 1,25 (OH) 2 D 3 is produced causing enhanced * intestinal absorption of Ca * renal reabsorption of Ca * ↑ bone formation & resorption

63. All this function depends upon dietary intake of calcium and vitamin D as well as gut absorption and bone metabolism. An adequate intake of Vit -D is necessary to absorb calcium.

64. Vitamin D Metabolism

65. Necessity of Vitamin D 3 Increase the absorption rate of calcium up to 70-80%. Helps to build strong bones. 68

66. Take home message Each Pregnancy deserves a healthy baby and no detrimental effect on mother’s health. Calcium supplementation ensures healthy bone and teeth of baby. Calcium supplementation is recommended to prevent PIH,PE. During lactation Calcium supplementation will prevent osteoporosis,Low bone mineral density.