This document discusses the importance of calcium, vitamin D, and vitamin K2 for pregnancy nutrition. It notes that calcium is essential for fetal bone growth and development and helps reduce risks of pregnancy complications like preeclampsia. The recommended daily calcium intake increases during pregnancy. Vitamin D aids calcium absorption and vitamin K2 directs calcium to the bones. Together calcium, vitamin D and K2 support strong bones and healthy blood vessels in both mother and baby. Calcium deficiency during pregnancy can lead to issues like preeclampsia, while meeting calcium needs helps support the growth and health of both mother and fetus.

2. Infant nutrition depends upon
mother’s nutrition, so eating takes on
a whole new meaning for pregnant
moms and women who are trying to
conceive.

3. Malnutrition among Women (BMI) – Over 47 % are
Malnourished 2010-2011

4. Vitamin-D deficiency (pregnant
women)
National Nutrition Survey 2011((Principal Survey Lead Institution: Aga Khan University, Pakistan )

5. Calcium deficiency (pregnant women)
National Nutrition Survey 2011((Principal Survey Lead Institution: Aga Khan University, Pakistan )

6. Calcium supplement consumption
during pregnancy in Pakistan

7. Role of Calcium In Pregnancy
• Calcium decrease risk of:
1. Pre-eclampsia.
2. Low birth weight.
• Increase chances of normal delivery.
• Further:
1. Maintaining bone/teeth strength
2. Proper muscle contraction
3. In secretion of hormones as insulin
4. In cell division
5. In nerve impulse transmission
6. Cell membrane function
7. Calcium also helps your baby grow a healthy heart, nerves, and muscles as well as develop a
normal heart rhythm and blood-clotting abilities.

8. Calcium Halves Risk in Pregnancy
• Met analysis of studies from developing countries
• Pooled analysis showed that calcium supplementation
during pregnancy reduce risk of
• Gestational hypertension 45%
• Preeclampsia 59%
Ref: BMC Public health 2011
• Cochrane Review
• Calcium supplementation (greater then or equal to
1000mg/day) is associated with reduction in pre-eclampsia,
particularly for women with low calcium diet.
Ref: Cochrane database syst Rev 2014 June

9. Importance of Calcium in Pregnancy
• 1st trimester:
• 0-13 weeks gestation.
• Calcium (500-800 mg) – Vitamin D (5 mg)
Needed for regulate heart rhythm, for blood clotting, for regulating nerve and muscle activity and
for absorbing iron.
2nd trimester:
• 14-26 weeks gestation
• 1,200 milligrams of calcium per day.
• Calcium is very important during pregnancy, because it helps make your baby's teeth and bones.
Calcium may also prevent leg and muscle cramps in pregnant women. If you don't get enough
calcium, your body takes this mineral from your bones to get the baby what it needs. This may
contribute to osteoporosis as you age.
• Calcium deficiency in pregnant women cause increased blood pressure, myocyte contraction and
arteriolar constriction.
• Baby I.Q level disturb
3rd trimester:
Chance of rickets increase because of calcium and vitamin D deficiency.

10. Importance of Calcium in Pregnancy
• During gestation the average foetus requires
about 30 g of calcium to mineralize its skeleton
and maintain normal physiological process.
• The suckling neonates requires more than this
amount in breast milk during six month of
exclusive lactation.
• About 80 % of the accretion occurs rapidly during
third trimester.
• Daily accretion rate of about 250-300mg calcium
by the foetal skeleton during the third trimester.

11. Calcium-supplementation in pregnancy--is
it a must?.
Beinder E.
• Ther Umsch. 2007 May;64(5):243-7.
Abstract
• The pregnant woman's body provides daily doses between 50 and 330 mg to support the developing fetal
skeleton. This high fetal demand for calcium in pregnancy is facilitated by profound physiological
interactions between mother and fetus. The D-A-CH organization (which represents the German, Austrian
and Swiss Nutrition Offices) and the Institute of Medicine (IOM) of the US recommend a daily
consumption of 1000 mg calcium for pregnant and lactating women at an age over 19 years. The average
consumption of calcium in western countries is about 800 mg in young women. Therefore calcium
consumption in pregnancy should be encouraged, especially during the second and third trimester of
pregnancy and during lactation. Proper calcium consumption can be attained by diet with healthy
nourishment including 3-4 snacks of milk or milk-derived products such as yogurt and cheese and calcium-
rich mineral waters. In these women calcium-supplementation in pregnancy is not necessary. In women
with chronic autoimmunologic disorders, low-molecular-weight-heparin therapy during pregnancy, lactose
intolerance or in women who prefer to skip milk and milk products due to personal preference the
supplementation of 500 to 1000 mg calcium in addition to dietary measures is recommended. Calcium
supplementation in pregnancy has been associated with a reduced risk of pregnancy-induced
hypertension, but this effect is only seen in persons with a low basal calcium intake. There are reports in
literature that calcium supplementation in pregnancy protects against low-birthweight in newborns,
which is defined as a birthweight of < 2500 g or that calcium supplementation lowers offspring blood
pressure thus helping to prevent hypertension in the next generation. Calcium supplementation is only
recommended in order to achieve a daily uptake of at least 1000 mg/day in pregnant women.

12. Contrasting Calcium Homeostasis in
Pregnancy and Lactation

13. Maternal calcium excretion
Physiological hypercalciuria occurs during pregnancy as
a result of increased maternal calcium absorption.
Interestingly, urinary calcium is within normal limits
during fasting but increases postprandially, indicating
that elevated excretion is related to the increase in
calcium absorption.
Urinary calcium excretion has been shown to increase
by as much as 43% between prepregnancy and the
third trimester, reflecting the 50% increase in the
glomerular filtration rate (GFR) that also occurs during
pregnancy.

14. Transfer of Calcium in breast milk
• Calcium transfer between the mother and infant
averages about 200 mg/day during full breast-
feeding. There is wide variability in the amount of
calcium secreted daily into breast milk, even
among women who are exclusively breast-
feeding, and can be as high as 400 mg/day in
some individuals. For mothers who breast-feed
for more than 3–6 months, the total calcium
transfer via breast milk in one lactation period is
greater than that transferred across the placenta
during the whole of pregnancy

15. Preeclampsia and pregnancy-induced
hypertension
• There is an inverse relationship between calcium intake and pregnancy-induced hypertension (PIH), it has been
estimated to complicate 5% of all pregnancies and 11% of first pregnancies.
• Low calcium intakes during pregnancy may
1) stimulate PTH secretion, increasing intracellular calcium and smooth musclecontractibility
2) release renin from the kidney, leading to vasoconstriction and retention of sodium and fluid. These
physiological changes can lead to the development of PIH and preeclampsia.
A meta-analysis of the role of calcium supplementation during pregnancy in the prevention of gestational
hypertensive disorders found a 45% reduction in the development of PIH in women receiving calcium versus
placebo.
Ref:Imdad A, Jabeen A, Bhutta ZA. Role of calcium supplementation during pregnancy in reducing risk of developing
gesSuppl 3):S18tational hypertensive disorders: a meta-analysis of studies from developing countries. BMC Public
Health. 2011; 11

16. Maternal Bone-Mineral Status
• Studies have demonstrated that lactation is accompanied by significant
reductions in maternal bone mineral content during the first
3–6 months .The reductions are most marked in the axial skeleton, where
average decreases of 3%–5% have been observed at the spine and hip.
• These rates of change are remarkable, given the fact that rates of
postmenopausal bone loss at these sites are typically 1%–3% per annum.

17. LONG-TERM EFFECTS ON THE MOTHER
• The possibility that the calcium requirements
of human reproduction may be met by
mobilization of calcium from the maternal
skeleton has led to concerns that a woman’s
risk of osteoporosis in later life may be
increased as a result of pregnancy and
lactation, especially if her dietary calcium
supply is poor.

18. Causes of Ca2+ deficiency
• Low Ca2+ intake
• Vitamin D deficiency
• Vitamin K2 deficiency
• Vegetarian diet
• Obesity
• Black skin
• Insufficiency or failure of parathyroid gland
• Chronic kidney failure
• Low blood magnesium level (in cases with severe
alcoholism)
• Diet high in phytate

19. Adequate daily intake (AI)
Life Stage Age Males (mg/day) Females (mg/day)
Infants 0-6 months 210 210
Infants 7-12 months 270 270
Children 1-3 years 500 500
Children 4-8 years 800 800
Children 9-13 years 1,300 1,300
Adolescents 14-18 years 1,300 1,300
Adults 19-50 years 1,000 1,000
Adults 51 years and older 1,200 1,200
Pregnancy 18 years and younger - 1,300
Pregnancy 19 years and older - 1,000
Breastfeeding 18 years and younger - 1,300
Breastfeeding 19 years and older - 1,000

20. Role of Vitamin D
• Function of vitamin D:
1. Absorption of calcium in blood
2. Deposition of calcium on bones.
3. During pregnancy, increased intestinal absorption of
calcium from the gut mainly due to higher generation
of calcitriol (1,25 dihydroxy vitamin D) helps in
maintaining maternal calcium levels.
• Compensatory responses to decreased
plasma ionized calcium concentration
mediated by PTH & vitamin D
• PTH regulates through 3 main effects:
- By stimulating bone resorption
- By stimulating activation of vitamin D → ↑
intestinal Ca reabsorption
- By directly increasing renal tubular calcium
reabsorption

21. keeps the calcium in its right place
• When you take vitamin D, your body creates
more of these vitamin K2-dependent proteins,
the proteins that will move the calcium
around.
• if you're taking vitamin D, you're creating an
increased demand for K2. And vitamin D and
K2 work together to strengthen your bones
and improve your heart health.

22. POWERFUL SYNERGISTIC EFFECT
VITAMIN K2
(MK7)
VITAMIN
D
CALCIUM

23. What's So Special About Vitamin K2?
Vitamin K is actually a group of fat-soluble vitamins.
Types of vitamin K are:
• Vitamin K1, or phylloquinone, is found naturally in plants, especially green vegetables; K1 goes
directly to your liver and helps you maintain healthy blood clotting
• Vitamin K2, also called menaquinone, is made by the bacteria that line your gastrointestinal tract; ,
but unfortunately is not absorbed from there and passes out in your stool. K2 goes straight to your
blood vessel walls, bones, and tissues other than your liver.It also plays a role in removing calcium
from areas where it shouldn't be, such as in your arteries and soft tissues.
• "K2 is really critical for keeping your bones strong
and your arteries clear," Rheaume-Bleue says.
Vitamin K2 can be broken into two additional categories, called:
• MK-4 (menaquinone-4), a short-chain form of vitamin K2 found in butter, egg yolks, and animal-
based foods
• MK-7 (menaquinone-7), longer-chain forms found in fermented foods. There's a variety of these
long-chain forms but the most common one is MK-7. This is the one you'll want to look for in
supplements, because in a supplement form, the MK-7 products are actually synthetic. They are not
derived from natural food products containing MK-4.

24. How Vitamin K2 Works?

25. Osteocalcin: the vitamin K-dependent Ca2+-
binding protein of bone matrix.
Hauschka PV.
• Abstract
• Osteocalcin is an abundant Ca2+-binding protein indigenous to the organic matrix
of bone, dentin, and possibly other mineralized tissues. This protein contains 47-50
amino acid residues (molecular weight 5,200-5,900) depending on the species.
Osteocalcin is distinguished by its content of three gamma-carboxyglutamic (Gla)
residues. The vitamin-K-dependent biosynthesis of osteocalcin occurs in bone, and
the protein is not homologous to the Gla-containing regions of known vitamin-K-
dependent blood coagulation proteins. The two major structural features of
osteocalcin which appear to control its function include: the 'Gla helix', a compact
Ca2+-dependent alpha-helical conformation, in which the three Gla residues are
aligned to facilitate adsorption to hydroxyapatite, and the 'COOH-terminal beta-
sheet' which exhibits chemoattractant activity toward mononuclear leukocytes,
specifically monocytes, the putative precursors of osteoclasts. While the biological
function of osteocalcin is unknown, it appears to be a highly specific osteoblastic
marker produced during bone formation, and is rapidly becoming a clinically
important diagnostic parameter of bone pathology.
Nature. 2003 Oct 30;425(6961):977-80.