lectured delivered by Dr Sujoy Dasgupta in the CME on "High Risk Pregnancy" organized by the BOGS (Bengal Obettric snd Gynaecological Society) and Wanburry Pharma

1. Role of Calcium
Supplementation and
Vitamin D3 in
Pregnancy

2. Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons) MS (Obst & Gynae- Gold Medalist)
DNB, FIAOG
Consultant:
RSV Hospital, Kolkata
Iris Hospital, Kolkata
Behala Balananda Brahmachary Hospital, Kolkata
Secretary, Website and Bulletin Committee: Bengal
Obstetric and Gynaecological Society (BOGS)- 2017-
18
Managing Committee Member: BOGS- 2017-18
15 Publications: National and International Journals

3. Best Obligate Parasite

4. 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

5. 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

6. Mother will try to compensate
for this by
• Increasing intestinal absorption
• Decreasing renal excretion
• Increasing bone turnover

7. Recommended daily
Allowance
Non pregnant 800 mg/d

8. Recommended daily
Allowance
Non pregnant 800 mg/d
Pregnant 1100 mg/d

9. Recommended daily
Allowance
Non pregnant 800 mg/d
Pregnant 1100 mg/d
Lactation 1300 mg/d

11. Indian women
• Decreased body store
• Poor dietary intake
• Vitamin D deficient

12. WHO. Guideline: Calcium supplementation in pregnant women. Geneva, 2013.

13. Calcium Physiology

14. 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
+

15. 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

16. How calcium is deposited on bone?
Ca2
+
Ca2
+
Ca2
+
Osteoblast
Ca
PO4
Bone
Ca
PO4
 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
PO4
PO4

17. 18
Conventional Ca Supplements : Absorption
Calcium Carbonate
Ca citrate maleate
Ionized calcium
Ca+2
CaCO3
HClHCl
Dissociate in stomach into
calcium ions

18. 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, Vitamins
Ca
Fe
Conventional Calcium Supplements : Limitations

19. 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.

20. Aspartate Orotate
Calcium Absorption :
85%
Calcium Absorption :
95%
Difference between Mineral transporters

21. 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.

23. Offers highest calcium absorption
www. Firstclassarticles.net
Agressologie 1970; 11(6):495-502

24. Offers highest elemental calcium absorption
www. Firstclassarticles.net
Agressologie 1970; 11(6):495-502

25. 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.

26. Vitamin D
• Not required for calcium orotate
absorption
• Vitamin D is essential in pregnancy

27. Vitamin Hormone

28. UV radiation
Vitamin Hormone

29. 7-dehydro-cholesterol in skin Cholecalciferol (Vitamin D3)
UV radiation
Vitamin Hormone

30. 7-dehydro-cholesterol in skin Cholecalciferol (Vitamin D3)
UV radiation
Vitamin Hormone
25-OH-Cholecalfiferol/ Calcidiol/ 25-OH-D3
Liver

31. 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

32. 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

33. 34
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%

35. Recommendation of Vit. D3
1,000 IU/day of vitamin D3 is safe in pregnancy
Obstet Gynecol 2011 Jul;118(1):197-8

36. 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

37. Safety of Vitamin D in
pregnancy
• Hungry Bone syndrome, hypercalcaemia
• Supraventricular aortic stenosis
• Sarcoidosis
• Absolutely safe, up to 4000 IU/d
Hollis 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.

38. Composition:
Each tablet contains
Calcium Orotate...............740 mg
(Elemental calcium 20.6% i.e. 152.44 mg/tab)
Vitamin D3 ......................1000 IU
Presenting
Cdense

39. • Pregnancy & lactation
• Low back pain
Dosage : 1 tablet once daily after lunch
Indications

40. Calcium Orotate vs Others
Amount 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

41. • Rangaraj P, Dhembare P. Obstetrics &
Gynecology Today vol. XIV (10) 10 Dec. 2009
• Open label, balanced, randomised, three
treatment, crossover study

42. 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
percent(%)
Significant rise in serum calcium compared to calcium carbonate
+ Vit. D3

43. Postdose comparison for serum iPTHPostdose comparison for serum iPTH
levelslevels
Significant decrease in circulating iPTH
9
3
-2
-41
-19
-71-80
-70
-60
-50
-40
-30
-20
-10
0
10
20
Placebo Caco3 Cdense
0.5 hrs
4.5 hrs

44. 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

45. Co-administration
Calcium Orotate
Highest 95% absorption,
bioavailability much higher
than calcium carbonate +
vitamin D3, proven in Indian
subjects
Calcium absorption
Tolerability

46. Calcium Absorption
Co-administration
Tolerability
Calcium Orotate
No chance of Magma formation
So can be safely co-administered
with iron, magnesium, vitamin
supplements

47. Thank You