Calcium and Vitamin D Supplementation in Pregnancy
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Transcript of Calcium and Vitamin D Supplementation in Pregnancy
Role of Calcium Supplementation and
Vitamin D3 in Pregnancy
Dr Sujoy DasguptaMBBS (Gold Medalist, Hons) MS (Obst & Gynae- Gold Medalist)
DNB, FIAOG
Consultant: RSV Hospital, KolkataIris Hospital, KolkataBehala Balananda Brahmachary Hospital, Kolkata
Secretary, Website and Bulletin Committee: Bengal Obstetric and Gynaecological Society (BOGS)- 2017-18Managing Committee Member: BOGS- 2017-18
15 Publications: National and International Journals
Best Obligate Parasite
Calcium demand for the baby
• A growing fetus needs 30 gram of calcium in total(80% in 3rd trimester)
• A suckling neonate requires even more calcium
• If not met→ draws maternal calcium→ makes maternal bone and teeth vulnerable
Calcium demand for the woman
• Each day 200-300 mg of Ca is transferred through the placenta or breast milk
• Increased demand for maternal altered physiology
Mother will try to compensate for this by
• Increasing intestinal absorption
• Decreasing renal excretion
• Increasing bone turnover
Recommended daily Allowance
Non pregnant 800 mg/d
Recommended daily Allowance
Non pregnant 800 mg/d
Pregnant 1100 mg/d
Recommended daily Allowance
Non pregnant 800 mg/d
Pregnant 1100 mg/d
Lactation 1300 mg/d
Indian women
• Decreased body store
• Poor dietary intake
• Vitamin D deficient
WHO. Guideline: Calcium supplementation in pregnant women. Geneva, 2013.
Calcium Physiology
How calcium is absorbed from intestine to enter blood ?
IntestineCalcium ( Ca2+ )
+ Vit D3
Vit D3
Vit D3 acts as mineral transporter (carrier ) and helps calcium ions to pass trough intestinal mucosa and reach in blood
Blood
+ Vit D3
Intestinal Moucosal cells
Vit D3
Vit D3
Ca2+
Ca2+
How calcium enters the bone?
Osteocalcin
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
OsteoblastBlood
Calcium gets coavalently bound to osteocalcin (protein) and gets transferred to osteoblast cells
Vat D3 is required by osteoblast to produce osteocalcin
How calcium is deposited on bone?
Ca2+
Ca2+
Ca2+
Osteoblast
Ca
PO4
Bone
CaPO4
Within osteoblast cells, calcium and phosphate unite. The calcium phosphate thus formed is deposited on bone
matrix. This completes deposition of calcium in bone
PO4
PO4PO4
18
Conventional Ca Supplements : Absorption
Calcium Carbonate
Ca citrate maleate
Ionized calcium Ca+2
CaCO3
HClHCl
Dissociate in stomach into calcium ions
19
• Magma formation- less calcium absorption
• Interferes with absorption of Fe, Mg, vitamins
• GI intolerance• Needs Vitamin D3 for
absorption
Ca+2
Combines with-
Fe, Mg, VitaminsCa
Fe
Conventional Calcium Supplements : Limitations
Mineral transporters (Carrier-mediated transport)
• Calcium chelates with transporter• Orotic acid, Aspartic acid
• The chelate does not break in the acidic medium of stomach and this prevents magma formation in the intestine.
• Thus chelated calcium reaches intestine through which it is absorbed as such
• Further in the blood, calcium chelate travels intact and is delivered to the target site.
Aspartate Orotate
Calcium Absorption : 85%
Calcium Absorption : 95%
Difference between Mineral transporters
Calcium Orotate dissociates inside osteoblast
Calcium aspartate dissociates in the cell membrane of osteoblast
In osteoporosis and calcium deficiency conditions, defective transport through cell membrane is reported.
Ensures calcium delivery to the target site.
Offers highest calcium absorption
www. Firstclassarticles.net Agressologie 1970; 11(6):495-502
Offers highest elemental calcium absorption
www. Firstclassarticles.net Agressologie 1970; 11(6):495-502
Calcium orotate
• Absorption is independent of gastric HCl
• Very high absorption rate
• Absorption does not need vitamin D
• No loss of calcium- better GI tolerance
• Can be concomitantly administered with iron, vitamins etc.
Vitamin D
• Not required for calcium orotate absorption
• Vitamin D is essential in pregnancy
Vitamin Hormone
UV radiation
Vitamin Hormone
7-dehydro-cholesterol in skin Cholecalciferol (Vitamin D3)
UV radiation
Vitamin Hormone
7-dehydro-cholesterol in skin Cholecalciferol (Vitamin D3)
UV radiation
Vitamin Hormone
25-OH-Cholecalfiferol/ Calcidiol/ 25-OH-D3
Liver
7-dehydro-cholesterol in skin Cholecalciferol (Vitamin D3)
UV radiation
Vitamin Hormone
25-OH-Cholecalfiferol/ Calcidiol/ 25-OH-D3
1,25-OH-Cholecalfiferol/ Calcitriol/ DHCC/ 1,25-(OH)2-D3
Liver
Kidney
Causes of vitamin D3 deficiency
• Limited sun exposure (Modernization that has increased hours spent indoor)
• Culture and clothing style
• Increased pollution that hampers ultraviolet rays, hence synthesis of vitamin D3
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Incidence of Vitamin D deficiency in pregnant women - India
• Study done by AIIMS
Urvashi Mehlawat, et al., IPP, Vol 2 (2), 328-335, 2014 329
Incidence of vitamin D deficiency in pregnant mothers ranging from 67% to 96%
Recommendation of Vit. D3
1,000 IU/day of vitamin D3 is safe in pregnancy
Obstet Gynecol 2011 Jul;118(1):197-8
RCOG Recommendations
All women 400 IU/d
Women at risk (obese, skin pigmentation, decreased sunlight exposure)
1000 IU/d
High risk of preeclampsia 800 IU/d
Safety of Vitamin D in pregnancy
• Hungry Bone syndrome, hypercalcaemia
• Supraventricular aortic stenosis
• Sarcoidosis
• Absolutely safe, up to 4000 IU/dHollis BW, Johnson D, Hulsey TC, Ebeling M, Wagner CL. Vitamin D
supplementation during pregnancy: double-blind, randomized clinical trial of safety and effectiveness. J Bone Miner Res 2011;26:2341–57.
Composition:
Each tablet contains
Calcium Orotate...............740 mg
(Elemental calcium 20.6% i.e. 152.44 mg/tab)
Vitamin D3 ......................1000 IU
Presenting
Cdense
• Pregnancy & lactation• Low back pain
Dosage : 1 tablet once daily after lunch
Indications
Calcium Orotate vs OthersAmount of elemental calcium absorbed is HIGHEST
with calcium orotate Weight of
Tablet%
elemental calcium
Amount of elemental calcium (mg) in each
tablet
% of calcium
absorbed
Amt of calcium (mg)
absorbed from each tab
CaCO3
(1250mg)40 500 8 40
Ca citrate maleate
(1250mg)
20 250 40 100
Ca aspartate (560 mg)
12.5 70 85 59.5
Ca orotate (cdense)
(740 mg)
20.6 152.44 95 145
www.vitaminexpress.com/encyclopedia.php , http://www.ghchealth.com/forum/viewtopic
• Rangaraj P, Dhembare P. Obstetrics & Gynecology Today vol. XIV (10) 10 Dec. 2009
• Open label, balanced, randomised, three treatment, crossover study
Post dose comparison for serum calcium levelsPost dose comparison for serum calcium levels
Percent change in serum calcium levels
1
6
19
0
5
10
15
20
Placebo Caco3 Cdense
pe
rce
nt
(%)
Significant rise in serum calcium compared to calcium carbonate
+ Vit. D3
Postdose comparison for serum iPTH Postdose comparison for serum iPTH levelslevels
Significant decrease in circulating iPTH
93
-2
-41
-19
-71-80
-70
-60
-50
-40
-30
-20
-10
0
10
20
Placebo Caco3 Cdense
0.5 hrs
4.5 hrs
Algal source calcium
Coral calcium Calcium orotate
Source Made by heating Oyster (a type of animal) shell mixing with heated seaweed (Algae)
Not preferred by Vegetarians
Marine Animal (coral reef) also called coral calcium.
Not preferred by Vegetarians
Concern of contamination with lead and mercury
Synthetic Made by a chemical reaction of Calcium hydroxide or calcium chloride with orotic acid
Type of calcium
Calcium Hydroxide, calcium oxide and calcium carbonate
Elemental Calcium present is 150 mg
Calcium carbonate
Elemental Calcium present is 225 mg
Calcium orotate
Elemental Calcium present is 152.44 mg
% Calcium absorbed
No data available 8% = 18mg 95% =145mg
Co-administration
Calcium Orotate
Highest 95% absorption, bioavailability much higher than calcium carbonate + vitamin D3, proven in Indian subjects
Calcium absorption
Tolerability
Calcium Absorption
Co-administration
Tolerability
Calcium Orotate
No chance of Magma formation
So can be safely co-administered
with iron, magnesium, vitamin
supplements
Thank Yo u