Physiol Rev 96: 449 547, 2016

Published February 17, 2016; doi:10.1152/physrev.00027.2015

MATERNAL MINERAL AND BONE METABOLISM

DURING PREGNANCY, LACTATION, AND
POST-WEANING RECOVERY
X Christopher S. Kovacs

Faculty of Medicine-Endocrinology, Memorial University of Newfoundland, St. Johns, Newfoundland, Canada

Kovacs CS. Maternal Mineral and Bone Metabolism During Pregnancy, Lacta-

L
tion, and Post-Weaning Recovery. Physiol Rev 96: 449 547, 2016. Published
February 17, 2016; doi:10.1152/physrev.00027.2015.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

Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017

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 require-
ments 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 absorp-
tion 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.

I. INTRODUCTION 449 ash weight and mineral content of fetal cadavers between
II. SKELETAL AND MINERAL PHYSIOLOGY... 451 24 wk and term. Multiple studies have demonstrated that
III. DISORDERS OF BONE AND MINERAL... 471 the average full-term fetus has 30 g calcium (77, 196, 289,
IV. SKELETAL AND MINERAL PHYSIOLOGY... 486 332, 868, 930, 982984, 1022), 20 g phosphorus (289,
V. DISORDERS OF BONE AND MINERAL... 510 984, 1022), and 0.80 g magnesium (289, 332, 984, 1022).
VI. CONCLUSIONS 521 However, that fetal mineral content is not obtained at a
constant rate during pregnancy; instead, at least 80% of the
I. INTRODUCTION calcium, phosphorus, and magnesium present in a human
term fetus is accreted during the third trimester (77, 196,
During pregnancy and lactation, female physiology must 332, 868, 930, 982, 984, 1022). This corresponds to a
adapt to meet the added nutritional demands of the fetus mean calcium transfer rate of 100 150 mg/kg per day (77,
and neonate. How much of a demand is there for delivery of 332, 868, 930, 983, 984, 1022), which, for an average-sized
calcium and other minerals? What adaptations are invoked fetus, is 60 mg/day at week 24 and 300 350 mg/day
during pregnancy and lactation to meet these demands? Do between the 35th and 40th week of gestation (1022). Sim-
these adaptations alter normal biochemical and hormonal ilarly, the rate of phosphorus transport is 40 mg/day at
parameters of mineral and skeletal metabolism? What im- week 24 and increases to 200 mg/day over the last 5 wk of
pact do these adaptations have during pregnancy and lactation gestation (1022). The rate of magnesium transfer increases
on preexisting disorders of mineral and bone metabolism? Are more modestly from 1.8 to 5.0 7.5 mg/day over the last 5
there any long-term beneficial or adverse consequences of wk (1022). When expressed as hourly rates, during the
pregnancy and lactation on the skeletal health of women? All third trimester the fetal demand for calcium and phospho-
of these questions are addressed in this review. rus represent between 5 and 10% of the amounts present in
the mothers plasma (196, 982). This means that the fetal
The fetal requirement for mineral, which the pregnant demand for calcium and phosphorus has the potential to
woman must supply, has been determined by measuring the provoke maternal hypocalcemia and hypophosphatemia.

449
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
The neonatal requirement for mineral, which may be sup-
plied through breastfeeding, has largely been inferred from
studies in which healthy neonates are weighed before and
after each feed; a few studies have measured change in
weight of the mother or the volume of milk that can be
manually expressed. The calcium intake has been the main
parameter considered in these calculations. Such studies
reveal an average intake of 780 ml of human milk per day
(20, 138, 376, 653), which, combined with an average cal-
cium content in milk of 260 mg/l during the first 6 mo
postpartum (41), reveals a total calcium intake of 200
mg/day. Estimates of fractional calcium absorption from
metabolic balance studies have shown that neonates absorb
60 70% of calcium from human milk (5, 8, 289, 382),
thereby making 120 140 mg of calcium available for the
skeleton to potentially take up each day. Fractional calcium
absorption is proportional to intake and facilitated by lac-
tose in neonates and infants (479, 480), and can be as low as
30 40% when formula (which has twice the calcium con-
tent as human milk) is consumed (6).
Estimates of neonatal mineral accretion are another indica-
tion of how much mineral is truly required, but the results
have been much more variable due to different techniques,
variable body sizes, ethnicity, cross-sectional versus longi-
tudinal studies, small sample sizes, and other factors. For
example, direct measurements of ash weight and mineral
content have been made in cross-sectional studies of cadav-
eric specimens, whereas indirect measurements of mineral
content (such as through radiological techniques) have
been made in vivo in longitudinal studies of healthy ne-
onates and infants. One widely quoted study lacked any
neonatal cadavers, but extrapolated from the mineral
content of newborn, childhood, and adult cadavers to
infer that the calcium content (the most abundant min-
eral in bone) increased 50 g by the end of the first year,
which corresponds to a daily accretion rate of 140 mg
(546). However, other assessments of cadaveric speci-
mens have suggested lower accretion rates of 30 50 mg/
day during the first 6 mo (289, 487). When mineral con-
tent has been inferred from peripheral radiographs or by
dual X-ray absorptiometry (DXA), the daily accretion
rates have ranged from 80 mg (317, 976) to an unrealistic
380 mg (870); the latter study indicates problems in cal-
ibrating DXA against true mineral content of neonates
and infants.
A general consensus is that average milk output, and its
average calcium content, are more robust indicators of the
average neonatal requirement for calcium (430). The Insti-
tute of Medicine used these calculations to determine the
estimated average requirement (EAR) for calcium intake,
and concluded that breastfeeding requires that an average
of 200 mg calcium be provided daily through milk to a
singleton during the first 6 mo (430). From this intake the
neonatal skeleton is expected to accrete 100 mg of cal-
450 Physiol Rev VOL 96 APRIL 2016 www.prv.org
cium daily (430). However, the output of milk on an indi-
vidual basis is determined by the suckling demands of the
neonate and can certainly markedly exceed these values.
Women who nurse twins and triplets can have, respectively,
more than double and triple the milk output of women
nursing singletons (233, 792). Individual cases of women
nursing singletons have documented milk output of up to
2.4 3.1 liters per day that was sustained for more than 12
mo of lactation (583, 838). The composition of milk is
similar between women with average and high outputs
(233, 792), and so producing more milk will cause greater
maternal losses of calcium.
Between 6 and 12 mo of age, more infant nutrition comes
from solid food despite continued breastfeeding. Fewer
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
studies have examined this time frame, so the data are less
robust. The average calcium content of human milk is
somewhat lower at 200 mg/l (41), and the intake is less at
600 ml/day (246), which means that the infant has an
estimated calcium intake of 120 mg/day from human milk.
An additional 140 mg/day of calcium is estimated to come
from solid foods to bring the total infant calcium intake to
260 mg/day (430). Of previously cited cadaveric studies,
one indicated a continued daily accretion rate of 140 mg
during the 7th to 12th months (546), whereas the other
suggested that calcium accretion is 50 mg/day during this
time (289). An expected average accretion of 100 mg/day
has been assumed by the Institute of Medicine from the
available data (430).
Overall, these studies indicate that pregnant women do not
provide much calcium or other minerals to their fetuses
until the third trimester, when the peak rate of calcium
transfer exceeds 300 mg/day on average. Data for lactating
women and their babies are more variable, but suggest that
the average calcium requirement is more modest, at 200
mg daily during the first 6 mo, and 120 mg daily during
the second 6 mo. All of these values, from 300 mg daily
during the third trimester to 120 mg daily during late lac-
tation, may seem achievable given normal intake of calcium
and normal efficiency of intestinal calcium absorption.
However, fractional calcium absorption is normally 25%
of intake in healthy adults who consume adequate calcium
(420). If normal efficiency of intestinal calcium absorption
were relied upon, pregnant women would have to consume
an extra 1,200 mg/day during the third trimester, whereas
lactating women would have to consume an extra 800 mg
daily during the first 6 mo and 480 mg daily during the
second 6 mo.
These estimated calcium demands during pregnancy and
lactation should also be considered in the context of data
from the United States National Health and Nutrition Ex-
amination Survey (NHANES) and Statistics Canada, in
which actual calcium intakes have been determined for
American and Canadian women. Between ages 18 and 50,
 CHRISTOPHER S. KOVACS
the 50th percentile for calcium intake ranges from 800-
1,000 mg daily in both populations (430), for an expected
fractional absorption of 200 250 mg daily. The 25th per-
centile of intake is 600 700 mg daily, while the 5th per-
centile is about 400 mg daily, in both populations (430).
Consequently, if normal intestinal calcium absorption were
relied upon, most women do not consume sufficient calcium
to meet the combined needs of their babies and themselves.
However, increased intakes are not required in women who
consume adequate calcium because of several adaptations
that are invoked during pregnancy and lactation. During
pregnancy, the efficiency of intestinal calcium absorption
doubles to meet the fetal requirement for calcium, whereas
during lactation, skeletal resorption increases to provide
calcium to milk. It is unclear why different adaptations are
invoked during these two reproductive periods. These hor-
mone-mediated adaptations normally meet the daily min-
eral requirements of the fetus and infant without adverse
long-term consequences to the maternal skeleton. How-
ever, exceptions do occur, especially in women with habit-
ually very low intakes of mineral, or preexisting disorders
that cause skeletal fragility.
Having established the magnitude of the demands for min-
eral that are placed on pregnant and breastfeeding women,
the body of this review will address our current stage of
knowledge regarding the maternal adaptations in mineral
and skeletal homeostasis that occur during pregnancy, lac-
tation, and post-lactation recovery. Also considered are the
impacts that these adaptations have on normal biochemical
and hormonal parameters of mineral homeostasis, the pre-
sentation and management of preexisting disorders of min-
eral and bone homeostasis, and long-term skeletal health of
women.
This paper is a companion to a recent review of fetal and
neonatal mineral and skeletal homeostasis (492), which
may be consulted for additional details and references
that are pertinent to mineral and bone homeostasis of the
offspring. This paper is also a substantial update and
rethinking on the topic since the previous review in 1997
(499).
In the subsequent sections, animal data are discussed first
and followed by relevant human data. Although the focus is
on understanding human mineral and skeletal physiology
during reproduction, it is necessary to discuss animal data
because ethical and practical considerations prevent certain
aspects of the reproductive time frame from being studied in
women. As will be made clear, much of what has been
found in the animal models has been directly or indirectly
confirmed in human studies, but there remain important
areas where this has yet to be done or where it may never be
possible to do so.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
The original data are described and cited in necessary detail
to justify the conclusions, but each section is followed by a
short summary so that the reader can glean key points at a
glance.
The term phosphorus is used for consistency and simplicity,
and because that is what is measured. It is acknowledged
that in serum phosphorus largely exists as inorganic phos-
phates (dihydrogen and monohydrogen phosphate), in
bone it is largely in the form of hydroxyapatite, while in soft
tissues and extracellular fluid there are an abundance of
organic phosphates complexed with carbohydrates, lipids,
and proteins (53).
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
II. SKELETAL AND MINERAL PHYSIOLOGY
DURING PREGNANCY
As noted in the introduction, pregnancy requires that a
woman deliver by term to her baby an average of 30 g
calcium, 20 g phosphorus, and 0.8 g magnesium. About
80% or more of these amounts are provided during the third
trimester. Therefore, any adaptations to meet the fetal demand
for mineral are most needed during the third trimester. One
may anticipate finding increased intestinal calcium absorp-
tion, decreased renal calcium excretion, and increased skeletal
resorption of calcium. However, as the studies reviewed in this
section will reveal, the dominant adaptation is a twofold in-
crease in intestinal calcium absorption. The kidneys waste cal-
cium in the urine rather than conserving it, and there is usually
at most only a very modest contribution of calcium from skel-
etal resorption.
Pregnant rats and mice have been commonly used to model
maternal adaptations in mineral homeostasis during preg-
nancy, while pregnant ewes and pigs have been studied to a
lesser extent. The rat has a much shorter gestation period
(22 days) and may bear 6 12 fetuses in each litter. The
calcium demands on the pregnant rat are proportionately
greater than in women who typically bear a singleton dur-
ing a far longer gestational period. The pregnant rat delivers
12 mg calcium per fetus between day 17 of gestation and
term, or more than 95% of mineral during the equivalent of
a rodents third trimester (196). Extrapolating from these
studies, the pregnant mouse likely delivers more than 95%
of the mineral content to its fetuses during the last 5 days of
a 19-day gestation. The proportional demand on pregnant
rodents is even more striking when it is considered that the
amount of calcium transferred to a litter of rat fetuses each
hour represents 80% of the amount of calcium present in
the maternal circulation (196), whereas a human fetus re-
ceives only 510% of the amount of calcium present each
hour in the mothers circulation (196, 982). Consequently,
pregnancy is far more capable of provoking hypocalcemia
and secondary hyperparathyroidism in rodents than in
women.
451
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION

A. Changes in Mineral Ions and Calciotropic

and Phosphotropic Hormones
2.7
Total Ca
(mmol/l) Progressive changes in serum calcium, phosphorus, and cal-
ciotropic hormone levels during human pregnancy are sche-
matically depicted in FIGURE 1. Important differences
2.1
among human, rat, and mouse pregnancies are listed in
1.6 TABLE 1.
Ionized Ca2+
(mmol/l)

1. Calcium and phosphorus

A) ANIMAL DATA. Serum calcium declines during late preg-

0.9
nancy in rats (90, 105, 117, 313, 315, 425, 519, 714, 735),
1.7 guinea pigs (958), sheep (21, 257, 269), goats (21), cows
Phosphorus

(21), and white-tailed deer (170). It has commonly been

(mmol/l)

Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017

measured without correcting for any change in the protein
or albumin concentration, even though a progressive 10
0.9 25% fall in protein and albumin has been found in pregnant
rats (44, 315, 519), guinea pigs (958), and sheep (257). The
5.0
drop in serum albumin causes a fall in serum calcium; how-
ever, a decrease in serum calcium does not necessarily indi-
(pmol/l)
PTH

cate a change in ionized calcium, which is the physiologi-

cally important fraction of extracellular calcium. One study
0.0
in rats consuming a 0.75% calcium diet found that the
300 ionized calcium progressively increased while the serum cal-
cium was falling (735), whereas rats given a 0.4% calcium
Calcitriol
(pmol/l)

diet were found to have a significant fall in the ionized

calcium during late pregnancy (90). The observed declines
0.0
in serum calcium during pregnancy generally represent the
effect of reductions in the albumin-bound fraction, while
20.0 the ionized calcium may be unchanged unless a lower cal-
Calcitonin

cium diet is consumed (such as 0.4% calcium).

(pmol/l)

A confounding problem in published rat studies during

0.0 pregnancy and lactation is the calcium content of diet. The
original 1976 and subsequently reformulated 1993 stan-
5.0
dard rodent diets of the American Institute of Nutrition
(pmol/l)
PTHrP

indicate a 0.50% content of calcium (749). In older studies,

it is typical to see diets with 0.4, 0.45, and 0.5% calcium.
However, a 1% calcium diet is now more commonly used in
0.0
rats, and in most studies of mice, and that impacts such
100.0 parameters as serum calcium, parathyroid hormone (PTH),
bone turnover, etc., as will be discussed.
Estradiol
(nmol/l)

Mice may differ from rats in their blood calcium parameters

0.0 during pregnancy. In multiple studies wherein wild-type

150.0
Prolactin
(ng/ml)

FIGURE 1. Schematic depiction of longitudinal changes in calcium,

phosphorus, and calciotropic hormone levels during human preg-
nancy. Shaded regions depict the approximate normal ranges. PTH
0.0 does not decline in women with low calcium or high phytate intakes
and may even rise above normal. Calcidiol (25OHD) values are not
1st 2nd 3rd depicted; most longitudinal studies indicate that the levels are un-
Trimesters of Pregnancy changed by pregnancy, but may vary due to seasonal variation in
sunlight exposure and changes in vitamin D intake. FGF23 values
cannot be plotted due to lack of data. The data from which this
summary figure has been derived are cited in section IIA.

452 Physiol Rev VOL 96 APRIL 2016 www.prv.org

 CHRISTOPHER S. KOVACS

Table 1. Key differences in mineral physiology of human and rodent pregnancy

Human Rat Mouse

Serum calcium Low Low Normal

Albumin-adjusted calcium Normal Low Normal
Ionized calcium Normal Low Normal
Phosphorus Normal Normal Normal
Magnesium Normal Normal Normal
PTH Low or low-normal* Increased Low or normal
Calcitonin Increased Increased Increased
PTHrP Increased Increased Increased
Calcitriol Increased Increased Increased
FGF23 No data No data Increased
Estradiol Increased Increased Increased

Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017

Intestinal calcium absorption Increased Increased Increased
Urinary calcium excretion Increased Increased Increased
Change in bone mass Slight loss Small loss Increased or no change

*Women with low calcium or high phytate intakes have normal or increased PTH.

(WT) mice consumed a standard 1% calcium diet, there was
no change in the ionized calcium or the serum calcium dur-
ing pregnancy (296, 477, 478, 992, 994). One study mea-
sured the ionized calcium every other day in the same mice
from the time of mating and noted no change during preg-
nancy (827). Fewer studies have assessed the serum albu-
min, but it was unchanged in pregnant mice compared with
nonpregnant controls and did not decline during the last 7
days of pregnancy (154, 175, 197).
Serum phosphorus remains normal during pregnancy in
rats (117, 314, 718) and mice (477, 478, 580), but may be
modestly reduced in guinea pigs (958), sheep (21, 57), goats
(21, 55), and cows (21). It is especially low during milk
fever of cows (613). One study of pregnant rats differed by
reporting a reduction in serum phosphorus (425). Serum
magnesium has been less commonly measured but is unal-
tered in pregnant rats (315, 425), mice (580), and goats
(55).

Physiologically important hypocalcemia can occur during
pregnancy when the fetal demand for calcium exceeds the
mothers ability to maintain her own serum calcium. This
may be especially true in rats where the hourly fetal demand
for calcium almost equals the amount of calcium present in
the maternal circulation (196). Consistent with this, in-
creased litter number and weight are associated with a
lower serum calcium in the mother (90), while pregnant rats
fed a low-calcium (0.1%) diet experienced a marked decline
in both serum calcium and ionized calcium during the last
several days before delivery (321). A low-calcium diet sim-
ilarly provoked hypocalcemia in pregnant ewes compared
with consumption of a usual and a high-calcium diet (69).
In pregnant or lactating cows, such hypocalcemia is termed
milk fever when it occurs near parturition or during lacta-
tion and provokes symptoms such as paresis (21). During
milk fever the serum calcium can be 50% of normal or even
lower despite a compensatory rise in PTH (613); the cal-
cium demand of the fetuses is the precipitating factor. Sud-
den deaths during late pregnancy from presumed severe
hypocalcemia have occurred in rats rendered severely vita-
min D deficient (359, 361363), and in Vdr null (296, 502)
and Cyp27b1 null mice (330) maintained on a normal 1%
calcium diet.
B) HUMAN DATA. The earliest studies in pregnant women
found a progressive 510% decrease in serum calcium such
that the mean value fell below the normal range, thereby
indicating biochemical hypocalcemia (641, 674). Such re-
sults confirmed what had already been observed in animal
models, and suggested that the human fetus drains calcium
from the maternal circulation in sufficient amounts to pro-
voke maternal hypocalcemia and secondary hyperparathy-
roidism (15). It was not until later that it was better appre-
ciated that the serum albumin falls during pregnancy due to
normal expansion of the intravascular volume, thereby pro-
voking a decline in the albumin-bound fraction of calcium
(720). The decline in the albumin-bound fraction of serum
calcium is physiologically unimportant.
When it became possible to measure the ultrafiltrable frac-
tion of serum calcium (which includes both complexed and
ionized calcium, but not albumin-bound calcium), no
change was seen when prepregnancy and pregnancy mea-
surements were compared (471). Later innovations resulted
in the ability to measure the ionized calcium with ion-spe-
cific electrodes. Both cross-sectional (210, 227, 324) and
longitudinal studies (221, 294, 721, 739, 791, 809, 813)
have shown that the ionized calcium does not change during

Physiol Rev VOL 96 APRIL 2016 www.prv.org 453

 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
human pregnancy, even though the mean serum calcium
simultaneously drops 10% into the hypocalcemic range
(221).
The albumin-corrected serum calcium is a reasonable sub-
stitute for the ionized calcium, as several longitudinal and
cross-sectional studies have shown it to remain stable across
all three trimesters, despite the concurrent fall in serum
albumin (85, 599, 632, 646, 778).
Twin pregnancy does not impair the ability of a woman to
maintain a normal serum calcium, as shown in a compara-
tive study of women bearing twins versus singletons (646).
Serum phosphorus shows no change in most studies during
human pregnancy (33, 207, 221, 294, 468, 632, 641, 674,
791) and was similarly unchanged during twin pregnancies
(646). There is also no change in the renal tubular reabsorp-
tion of phosphorus (207, 329, 468). Serum magnesium is
similarly unaltered during pregnancy (33, 207, 221, 294,
721).
C) SUMMARY. Expansion of the intravascular volume during
normal human pregnancy causes a fall in serum albumin
and, thereby, the serum calcium. However, the ionized cal-
cium and albumin-corrected serum calcium do not change,
confirming that the physiologically relevant circulating
fraction of calcium concentration remains normal. Either
the ionized calcium or the albumin-corrected serum calcium
may be reliably used to assess adequacy of the blood cal-
cium concentration during pregnancy. Animal models
show a similar albumin-related fall in serum calcium,
whereas both the serum and ionized calcium levels appear
to stay constant in pregnant mice, likely because albumin
does not decline. Ionized calcium is more likely to fall in
rodents when challenged by larger litters, low calcium diets,
or disorders of vitamin D physiology.
2. PTH
A) ANIMAL DATA. Rodents have generally been described as
developing secondary hyperparathyroidism during normal
pregnancy (499), although the extent to which this occurs
depends on the calcium content of the diet. One of the
earliest studies of pregnant rats found that both COOH-
terminal and NH2-terminal PTH concentrations declined
between gestational days 16.5 to 21.5 to reach the lower
end of the normal range (NH2-terminal values became un-
detectable) before increasing significantly postpartum (the
calcium content of the diet was not specified) (309, 311).
However, several other studies in rats used 0.4 to 0.75%
calcium diets and found that PTH is modestly increased in
late pregnancy compared with nonpregnant rats (90, 105,
735); one of these studies simultaneously found increased
PTH bioactivity (105). A more recent study used a 1.18%
calcium diet and found lower baseline PTH levels that al-
most tripled by late pregnancy (920). Parathyroid gland
454 Physiol Rev VOL 96 APRIL 2016 www.prv.org
volume is doubled in normal pregnant rats compared with
virgins (784, 842), while in vitro studies suggest that, for
any level of extracellular calcium, parathyroids from preg-
nant rats secrete more PTH than those from virgin rats
(806). In addition to the obvious effect of the varying cal-
cium content of the rodent diets, there may be additional
variability between studies due to rats strains, and differing
NH2-terminal or COOH-terminal radioimmunoassays
(RIAs) that were designed to detect human PTH. In most of
these studies the serum calcium alone was measured with-
out correction for the lower serum albumin. But a 0.4%
calcium diet provoked a decrease in the ionized calcium
together with an increase in PTH in pregnant rats (90),
while more marked hypocalcemia and secondary hyper-
parathyroidism developed when pregnant rats were chal-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
lenged by a 0.1% calcium-restricted diet (321).
More recently, pregnant mice consuming a standard 1%
calcium diet have been consistently found to have mean
PTH values reduced to 20% of the nonpregnant value,
with many individual values being undetectable, as deter-
mined by rodent or mouse-specific PTH immunoradiomet-
ric assays (IRMAs) and enzyme-linked immunoassays (ELI-
SAs or EIAs) (477, 478, 992, 994). Consumption of a 2%
calcium diet resulted in even lower PTH levels in nonpreg-
nant mice that declined slightly but nonsignificantly during
pregnancy (296, 330).
These findings confirm that whether the PTH concentration
changes during pregnancy, and the direction of that change,
are dependent on the rodents dietary calcium intake. Rats
appear more prone to develop secondary hyperparathy-
roidism than mice during pregnancy. As will be made clear
in subsequent sections, the proportionately greater calcium
demand faced by the pregnant rodent mandates that cal-
cium be provided from both intestinal absorption and skel-
etal resorption. Secondary hyperparathyroidism enables the
rodent to upregulate both routes of mineral delivery, espe-
cially when the fetal demand is at its peak during late preg-
nancy.
B) HUMAN DATA. The earliest data on PTH measurements in
pregnant women used first-generation radioimmunoassays
that yielded inconsistent results (23, 209, 219, 255, 329,
387, 721, 754, 760, 876, 975, 981, 985), with many of
these studies finding significantly increased PTH concentra-
tions in the latter half of pregnancy (209, 219, 255, 721,
754, 760, 975). Taken together with the concurrent decline
in serum calcium, this resulted in the concept that preg-
nancy represents a physiological state of secondary hyper-
parathyroidism. It was not until some years later that it
became clear that this conclusion was erroneous. As noted
above, the fall in serum calcium is caused by a fall in albu-
min levels, while the ionized calcium remains normal during
human pregnancy. Furthermore, these early, insensitive
 CHRISTOPHER S. KOVACS
PTH radioimmunoassays measured multiple biologically
inactive fragments of PTH (725, 959).
Two-site immunoradiometric (IRMA) PTH assays are more
sensitive and accurate (725). In cross-sectional studies of
North American and European women consuming a diet
adequate in calcium, PTH is typically suppressed to the
lower end of the normal range during all three trimesters
(207, 227, 294, 324, 791, 809, 905). In longitudinal studies
from North America, Europe, and Asia, the mean PTH level
was suppressed to the lower end of the normal range or
below it during the first trimester, and either remained sup-
pressed or increased to mid-normal by the end of pregnancy
(33, 85, 207, 221, 304, 632, 739, 813). Twin pregnancy did
not change the serum PTH value compared with women
bearing singletons (646).
Newer bio-intact assays exclude NH2-terminal trun-
cated, inactive PTH7 84 fragments that accumulate in
chronic renal failure patients (931), but no studies have
reported use of these assays in pregnant women. It is ex-
pected that these assays would similarly demonstrate low
concentrations of PTH during pregnancy.
Despite the preponderance of evidence that PTH becomes
suppressed during human pregnancy, some modern medi-
cal textbooks still claim incorrectly that pregnancy repre-
sents a state of physiological hyperparathyroidism (899).
Although suppression of PTH with modern assays has also
been shown in pregnant women from Asia and Africa (11,
33, 813, 826), several cohort and longitudinal studies from
these regions have found that PTH did not decline during
pregnancy and in some cases it rose above normal (585,
601, 778, 805, 844). The lack of suppression of PTH during
pregnancy in women from these regions is likely the conse-
quence of diets that are traditionally low in vitamin D or
calcium, and high in phytate (which blocks calcium absorp-
tion). Low calcium intake or absorption will provoke com-
pensatory secondary hyperparathyroidism during preg-
nancy.
C) SUMMARY. During normal human pregnancy, serum or
plasma PTH typically declines to low levels early on, before
returning to the mid-normal range by term. This suppres-
sion may not occur (and secondary hyperparathyroidism
may develop) in women who have especially low intakes of
calcium or vitamin D, or high intakes of phytate; such diets
are more common in certain regions of Asia and Africa. In
rodents, the ambient PTH level is influenced by the dietary
intake of calcium, with rats typically having increased PTH
during pregnancy that rises even higher with a calcium-
restricted diet, whereas mice typically have reduced PTH
levels on a standard diet that fall even further on a high-
calcium diet.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
The influence of PTH in regulating mineral metabolism dur-
ing pregnancy is further discussed in subsequent sections
that address the synthesis of calcitriol (sect. IIA4) and the
adaptations that occur in the intestines (sect. IIB), kidneys
(sect. IIC), and bone (sect. IID). PTHs role is also illumi-
nated by data on the effects of primary hyperparathyroid-
ism (sect. IIIB), hypoparathyroidism (sect. IIID), and pseu-
dohypoparathyroidism (sect. IIIE) during pregnancy.
3. Parathyroid hormone-related protein
A) ANIMAL DATA. Parathyroid hormone-related protein
(PTHrP) was first cloned in 1987 from human tumors that
cause humoral hypercalcemia of malignancy (593, 882,
889). It is a prohormone that is processed into several moi-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
eties, each of which has been postulated to have its own
receptor and function(s) (682). The NH2-terminal region of
PTHrP has partial homology to PTH within its first 13
amino acids, and a similar structure within the first 34
amino acids, which enables it to activate the common PTH/
PTHrP receptor and have near-identical functions as PTH
(494). The mid-molecular region of PTHrP has been shown
to stimulate placental calcium transport in fetuses, but
whether it has any role in the mother is unknown (152,
500). The COOH-terminal regions of PTHrP have been
shown to inhibit osteoclast-mediated bone resorption both
in vitro (280, 281) and in vivo (202), so it is conceivable that
this portion of PTHrP could act to prevent excessive resorp-
tion of the maternal skeleton during pregnancy. The mid-
molecular and COOH-terminal regions of PTHrP have no
homology to PTH.
PTHrP conceivably reaches the maternal circulation from
several sources, including the parathyroids, placenta (496,
817), mammary tissue (738), and uterus (66). Its expression
in rat mammary tissue is increased by prolactin (906), while
its expression within the uterine myometrium of the rat
increases in response to estradiol (909). Consequently, high
prolactin and estradiol levels associated with pregnancy
may drive increased expression of PTHrP within these tis-
sues. Although PTHrP is expressed by day 14 of pregnancy
in rat mammary glands (738), the level remains quite low
compared with the expression achieved in the immediate
postpartum (738, 1004) and with suckling (907, 911).
Studies in sheep have determined that clearance of PTHrP1
1 86
34, PTHrP , or PTHrP1141 do not change during preg-
nancy (741, 743).
PTHrP has been assumed to circulate at increased levels in
pregnant animals because it does so in humans, but surpris-
ingly few measurements have been made in animals. No
significant increase in PTHrP was detected in one study of
pregnant versus nonpregnant mice (956). In another study,
PTHrP was detected in the circulation of pregnant rats, and
the value did not change over the last 5 days of pregnancy,
but no measurements were done in nonpregnant rats, so it is
unclear if the concentration was increased (364). PTHrP
455
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
increased in pregnant goats beginning a day or two before
expected delivery and even further during parturition (744,
771) compared with nonpregnant animals. Most of the
measurements were with assays designed to detect human
PTHrP1 86 (364, 744, 956) rather than species-specific as-
says, and such assays will not detect the potentially more
abundant (and biologically active) PTHrP136 (this issue is
discussed in more detail in the next section).
B) HUMAN DATA. Before discussing data on circulating PTHrP
values during human pregnancy, it is important to review
common problems of sample collection and preparation,
and available assays.
First, PTHrP is rapidly cleaved and degraded in serum. Ap-
propriate samples for PTHrP measurement should be col-
lected as EDTA plasma in a chilled tube that also contains a
protease inhibitor (such as aprotinin), kept chilled on ice
during transport to the laboratory, and (within 15 min)
spun in a refrigerated centrifuge, separated, and frozen.
Even with these rigorous steps taken to reduce proteolytic
cleavage, PTHrP begins to degrade in EDTA-aprotinin
plasma within 15 min of sample collection (423). In con-
trast to this ideal sample collection and processing, many
studies used stored sera that had been allowed to clot at
room temperature for 60 min before routine processing
(925). Improper sample collection and processing leads to
failure to detect the true concentration of PTHrP, and may
even result in undetectable values when high values of
PTHrP are likely to be present (such as in lactation or hu-
moral hypercalcemia of malignancy). These issues con-
found individual case reports and small case series, wherein
a clinicians request for a PTHrP level on a patient is likely
to lead to routinely collected and processed sera or EDTA-
plasma being sent out to a reference laboratory, and an
undetectable result obtained despite the likely presence of
PTHrP in that patients circulation.
Second, the most widely used assays in clinical studies are
those that measure PTHrP1 86. Such a length does not exist
in humans (or animals) based on the predicted cleavage sites
of the translated product (494, 682). There are three pre-
dicted full-length forms of human PTHrP that arise through
alternative splicing, including PTHrP1139, PTHrP1141, or
PTHrP1173 (rodents have only a single full-length form)
(682). A PTHrP1 86 assay will detect all three of these
forms, but it will not detect PTHrP136. This is a significant
problem because PTHrP136 is expected to derive in vivo
from posttranslational processing of all three full-length
forms of PTHrP (682), and conceivably may be the most
abundant of the biologically active NH2-terminal forms of
PTHrP. The presence of PTHrP136 has been confirmed in
the media of cultured human and rodent cell lines (682,
853, 1007), but the relative abundance of PTHrP136 versus
the other circulating forms has not been determined in hu-
mans [PTHrP3774 was shown to be 9-fold higher than
456 Physiol Rev VOL 96 APRIL 2016 www.prv.org
PTHrP174 in plasma of patients with humoral hypercalce-
mia of malignancy, but PTHrP136 was not assayed in that
study (137)]. This problem may be less of a concern in
rodents since there is no alternative splicing and only one
full-length form. A PTHrP134 assay should detect each of
PTHrP136, PTHrP1139, PTHrP1141, and PTHrP1173, and
may be the preferred assay to use but only with optimally
collected and processed plasma samples.
As noted earlier, there are predicted mid-molecular and
COOH-terminal forms of biologically active PTHrP. In the
human these include PTHrP3894, PTHrP38101, PTHrP107139,
and possibly PTHrP141173, each of which may have its own
receptor and distinct role (494, 682, 712, 996). The clini-
cally available PTHrP134 and PTHrP1 86 assays do not
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
detect these forms. Consequently, no data are available on
concentrations of mid-molecular or COOH-terminal
PTHrP during pregnancy.
Despite the aforementioned problems with the PTHrP1 86
assay, four longitudinal studies have shown a significant
increase in PTHrP across the three trimesters, beginning as
early as 313 wk of gestation and reaching up to triple the
first-trimester value by term (33, 75, 304, 1001). A cross-
sectional study found that the PTHrP level in women at
term was twice that of nonpregnant controls (333). Other
studies have found elevated levels at term based on the
expected values in nonpregnant adults, but did not include
a nonpregnant control group (111, 278). These results con-
trast with smaller cross-sectional studies that found
PTHrP134 (473) or PTHrP1 86 (262, 697) concentrations
were no different than in unrelated nonpregnant controls or
the expected normal range, and two longitudinal studies
that found a nonsignificant increase (390) and no change
(85) in PTHrP1 86. In the latter study, all PTHrP1 86 values
were undetectable, which raises the concern that improper
methodology was the cause (sample type, collection, and
processing were not specified) (85).
Longitudinal studies are more sensitive and robust in de-
tecting differences in a time course compared with cross-
sectional studies. With the assumption that the four longi-
tudinal studies (33, 75, 304, 1001) are correct in demon-
strating a gestational increase in PTHrP that reaches peak
levels in the third trimester, PTHrP may importantly con-
tribute to the regulation of maternal mineral homeostasis
during pregnancy, including an upregulation in calcitriol
(see sect. IIA4) and suppression of PTH.
Which tissue sources contribute to the increasing concen-
trations of PTHrP in the maternal circulation during human
pregnancy has not been established. Candidate sites include
the placenta, breasts, parathyroids (39, 222, 252, 426,
610), amnion (278, 283), decidua and myometrium (283),
umbilical cord (284), and other fetal tissues. The potential
importance of placental sources of PTHrP has been illus-
 CHRISTOPHER S. KOVACS
trated by two clinical cases. One woman experienced a
late-term hypercalcemic crisis with a high plasma concen-
tration of PTHrP; an urgent C-section was followed within
6 h by symptomatic hypocalcemia and an undetectable
PTHrP level (270). A second woman with known hypo-
parathyroidism was able to gradually eliminate use of cal-
citriol and halve the dose of calcium taken during her preg-
nancy. Immediately after delivery, she developed sudden
and symptomatic hypocalcemia that resolved after breast-
feeding was initiated (890). In both cases, removal of pla-
cental PTHrP was the likely factor causing a rapid fall in
serum calcium, and in the first case a rapid and marked
decline in circulating PTHrP was confirmed.
Other clinical cases have demonstrated that the breasts are
also a physiologically relevant source of PTHrP during
pregnancy, and can provoke hypercalcemia when PTHrP
production is overabundant. Such hypercalcemia has devel-
oped in late pregnancy and the puerperium, and even in
nonpregnant women who simply have large breasts (603,
800). In one case of marked hypercalcemia during preg-
nancy, serum PTH was undetectable, PTHrP expression
was increased within the mammary tissue, and a bilateral
mastectomy was required in the second trimester to correct
the hypercalcemia (435, 474). A postpartum PTHrP-medi-
ated hypercalcemic crisis has also occurred when a woman
was unable to breastfeed because her newborn baby was in
an intensive care unit (800). The hypercalcemia was first
noted on the second postpartum day, and persisted into the
third day with a plasma PTHrP concentration that was
markedly elevated at 28.4 pM (normal 1.1 pM). The de-
layed time course with elevated PTHrP on the third post-
partum day did not implicate the placenta because of
PTHrPs short half-life of minutes in the circulation. In
another longitudinal study the plasma PTHrP level rose
higher by 48 h after delivery rather than declining, which
supports sustained PTHrP production by the breasts that
rises further with the onset of lactation (1001). Colostrum
and milk expressed from pregnant women have also been
show to contain PTHrP, with the content in colostrum be-
ing no different from breastfeeding women, whereas the
PTHrP content rises in milk during each breastfeeding epi-
sode (575).
The gradual rise in PTHrP across the trimesters, as dem-
onstrated in four longitudinal studies (33, 75, 304,
1001), parallels a progressive increase in serum calcitriol
to peak levels in the third trimester (see sect. IIA4). The
increase in PTHrP may imply that it is responsible for
stimulating renal 1-hydroxylase (Cyp27b1). However,
other data suggest that PTHrP may not be as potent as
PTH in stimulating Cyp27b1 in vivo (308, 413, 414, 494,
988). The extent to which PTHrP stimulates the rise in
calcitriol during pregnancy remains to be tested in animal
models.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
The high levels of estradiol may be contributing to stimula-
tion of PTHrP production during pregnancy. In vitro stud-
ies have demonstrated that estradiol increases PTHrP
mRNA expression from cultured human myometrial cells
(160), but it did not stimulate mammary epithelial cells to
produce PTHrP (808).
There are no data on blood levels or potential roles of
mid-molecular and COOH-terminal PTHrP during preg-
nancy. Fetal-placental calcium transport is regulated by
mid-molecular PTHrP within the fetal circulation, but
whether maternal PTHrP plays a role in regulating this
process is unknown (2, 152, 500).
That the rise in PTHrP during normal pregnancy is physio-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
logically important has been made most evident in hypo-
parathyroid women, as discussed in sections IIID and VD.
C) SUMMARY. PTHrP reaches the maternal circulation during
pregnancy, most likely from the placenta and breasts, as
well as possibly the uterus and fetal tissues. PTHrP1 86
progressively increases in maternal plasma to reach peak
levels in the third trimester, and likely contributes to the
normal regulation of mineral homeostasis during preg-
nancy. This includes maintenance of the ionized calcium,
stimulation of Cyp27b1 to produce increased levels of cal-
citriol (see sect. IIA4), and suppression of PTH. Several case
reports support these findings.
PTHrPs role in regulating mineral metabolism during preg-
nancy is further addressed in section III, D and F. Its role to
regulate placental calcium transport and fetal mineral ho-
meostasis has been addressed in the companion review
(492)
4. Calcitriol and calcidiol
A) ANIMAL DATA. Serum calcitriol concentrations increase
two- to sevenfold during normal pregnancy in rats, mice,
sheep, guinea pigs, and rabbits (90, 92, 358, 477, 478, 502,
512, 718, 735, 775, 1021). The vitamin D binding protein
level increased slightly in mice and declined modestly in rats
and guinea pigs (104, 478, 958). This confirms that the free
concentration of calcitriol must be substantially increased
during late pregnancy in these species. Longitudinal studies
in rats have shown that the increase in total calcitriol does
not occur until the last several days of pregnancy (90, 358,
735), during which time fetal mineral accretion is rapidly
occurring. Larger litter sizes or weights correlate with
higher maternal calcitriol (90). In guinea pigs, the free level
of calcitriol increased before the third trimester and before
total calcitriol increased (958).
The rise in serum calcitriol is the result of upregulated syn-
thesis of calcitriol, and not reduced catabolism or metabolic
clearance, as confirmed by studies in pregnant rats, sheep,
and rabbits (238, 702, 775, 776). Renal Cyp27b1 has been
457
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
shown to be upregulated two- to fivefold from in vitro anal-
ysis of homogenates obtained from kidneys of pregnant
rabbits and guinea pigs (282, 512). Consequently, the ma-
ternal kidneys are likely the source of increased production
of calcitriol, as they are in the nonpregnant adult.
However, the maternal decidua, placenta, and fetus are also
potential sources of calcitriol due to expression of Cyp27b1
in these tissues (334, 346, 896, 977, 978). The placenta has
often been assumed to account for the rise in maternal cal-
citriol during pregnancy, but this appears to be incorrect.
The same gene is responsible for renal, decidual, placental,
and fetal expression of Cyp27b1 (334). The ability of non-
renal tissues to contribute to the production of calcitriol has
been tested by administering tritiated 25-hydroxyvitamin D
(calcidiol or 25OHD) immediately after nephrectomy to
pregnant and nonpregnant rats. Some tritiated calcitriol
appeared in the circulation of pregnant nephrectomized
dams (much reduced compared with normal), whereas
none appeared in the circulation of nonpregnant nephrec-
tomized dams (345, 978). Additional studies examined 5/6-
nephrectomized rats, a model of chronic renal insufficiency,
which as virgins have marked secondary hyperparathyroid-
ism and calcitriol concentrations that are reduced 40%
compared with intact virgin rats (89). During subsequent
pregnancies, calcitriol tripled in the 5/6-nephrectomized
rats to the same high level achieved by intact pregnant rats,
while PTH decreased by 80% in the 5/6-nephrectomized
rats to near-normal values (89).
The authors of the 5/6 nephrectomy study concluded that
the rise in calcitriol during pregnancy could only be due to
contributions from extra-renal sources of 1-hydroxylase.
However, the result is still compatible with the remnant
kidneys, which achieved a calcitriol level 60% of normal in
the nonpregnant state, being able to increase calcitriol pro-
duction in response to the increased stimulation that occurs
during pregnancy. The normal peak calcitriol level achieved
in 5/6-nephrectomized pregnant rats (89) contrasts with the
substantial reduction in calcitriol production during preg-
nancy in completely nephrectomized rats (345), and sup-
ports that the 1/6 remnant kidney was likely responsible for
the increased production of calcitriol during pregnancy.
Subsequent studies in the 5/6 nephrectomy model have
shown that it creates only mild renal insufficiency with cre-
atinine clearance reduced 50% of normal in nonpregnant
or pregnant rats (794).
Taken together, these studies in partly and completely ne-
phrectomized rats showed that extra-renal tissues can con-
tribute some calcitriol to the maternal circulation, but
whether this means the placenta, fetus, or other maternal
tissues was not ascertained. These extra-renal sources likely
do not explain the high calcitriol levels that are normally
achieved during pregnancy in rodents. Additional studies in
1-hydroxylase null Hannover pigs also support that the
458 Physiol Rev VOL 96 APRIL 2016 www.prv.org
fetus and placenta likely do not contribute substantial cal-
citriol to the maternal circulation, because maternal cal-
citriol levels are very low during pregnancy and similar to
nonpregnant values, even when bearing heterozygous fe-
tuses that produce calcitriol (520, 521). Furthermore, in a
preliminary study, Cyp27b1 null mice had calcitriol levels
near the detection limit during prepregnancy, and these val-
ues were not significantly different during pregnancy de-
spite the presence of Cyp27b1/ placentas (330). Addi-
tionally, the expression of Cyp27b1 mRNA is 35-fold
higher in maternal kidneys during pregnancy compared
with placentas obtained from the same mouse (478). This
suggests that the relative activity of Cyp27b1 in the placenta
is too low to account for the rise in calcitriol in the maternal
circulation. However, the expression of Cyp24a1 (24-hy-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
droxylase) in normal mouse placentas was about one-third
the level of expression in maternal kidneys; therefore, the
multiple placentas in one pregnant rodent may substantially
contribute to the conversion of calcitriol and 25OHD into
24-hydroxylated forms (478).
What is driving the increased production of calcitriol during
pregnancy? Circulating PTH is increased at this time in
some but not all studies of pregnant rats (90, 105, 309,
735), yet there was no correlation between the PTH con-
centration and the achieved calcitriol level (90). Moreover,
PTH fell over 80% in 5/6-nephrectomized rats during
which time the calcitriol level tripled (89). PTH is reduced
in pregnant mice (296, 330, 477, 478, 992, 994), which
achieve up to sevenfold increases in serum calcitriol. These
finding suggest that PTH is not responsible for stimulating
the Cyp27b1 to increase the concentration of calcitriol in
the maternal circulation.
This hypothesis has been confirmed through two indepen-
dent lines of investigation. First, despite parathyroidectomy
in rats, there was a threefold increase in calcitriol during
pregnancy to achieve peak levels nonsignificantly lower
than in intact rats (658). Second, when the Pth gene was
ablated, such Pth null mice have undetectable circulating
PTH but achieve a fivefold increase in calcitriol during preg-
nancy that is modestly but not significantly lower than that
achieved by their pregnant WT sisters (478).
Pregnant Pth null and WT mothers had similarly increased
expression of Cyp27b1 mRNA in the kidneys compared
with their nonpregnant counterparts, whereas 24-hydroxy-
lase (Cyp24a1) mRNA expression was fivefold higher in
pregnant Pth null mice compared with their WT sisters
(478). These results are consistent with the known role of
PTH to suppress Cyp24a1 activity and expression (752,
835, 1023, 1024); therefore, in the absence of PTH,
Cyp24a1 expression and activity increase. Parathyroidecto-
mized rats also had consistently higher 24,25-hydroxyvita-
min D concentrations throughout pregnancy compared
with intact rats (658). Consequently, the modest blunting of
 CHRISTOPHER S. KOVACS
the peak calcitriol level during pregnancy in parathyroidec-
tomized rats and Pth null mice may be the result of in-
creased 24-hydroxylation of calcitriol and 25OHD, and not
reduced synthesis of calcitriol (478, 658). Therefore, al-
though PTH is the dominant stimulator of Cyp27b1 in
nonpregnant rodents, it clearly does not have this role dur-
ing pregnancy.
If not PTH, what stimulates the renal expression and activ-
ity of Cyp27b1 during pregnancy? Among known hor-
mones that could be potential regulators are PTHrP, estra-
diol, calcitonin, placental lactogen, and prolactin. How-
ever, very few studies have tested the roles of these
hormones. As mentioned, PTHrP mimics the actions of
PTH on the PTH/PTHrP receptor and likely contributes to
the stimulation of Cyp27b1 activity and expression. How-
ever, other investigators have suggested that PTHrP is less
potent than PTH at stimulating Cyp27b1 due to PTHrPs
somewhat different receptor binding, signaling characteris-
tics, and crystal structure (308, 494, 988). Estradiol (51),
calcitonin (464), placental lactogen (866), and prolactin
(866, 867) have acutely stimulated renal Cyp27b1 in vitro,
whereas placental lactogen increased calcitriol in hypophy-
sectomized, nonpregnant rats in vivo (894). Calcitriol has
also been shown to have the reciprocal effect of suppressing
calcitonin (647, 840). It is conceivable that a combination
of factors (increasing concentrations of PTHrP, estradiol,
calcitonin, and placental lactogen, for example) contribute
to upregulation of Cyp27b1 during pregnancy, rather than
one factor being primarily responsible. It is also possible
that an unidentified factor stimulates Cyp27b1 during preg-
nancy.
The multiple fetuses in rodent pregnancies represent a po-
tential drain on maternal stores of 25OHD, the substrate
for calcitriol, since 25OHD readily crosses the placenta
(353) whereas calcitriol does not (665). The concentration
of 25OHD decreased 50% on day 20 of pregnancy in rats
consuming a vitamin D-replete diet (358, 735), which ap-
pears to confirm that rodent fetuses are a significant drain
on the maternal supply of 25OHD. However, in guinea pigs
that bore 3 4 pups/litter, there was no decline in 25OHD
during pregnancy (960). Two cross-sectional studies found
that the 25OHD level was 20 30% lower in pregnant ver-
sus nonpregnant sheep (57, 703).
B) HUMAN DATA. Similar to the findings in the animal models,
cross-sectional studies have found a doubling or tripling of
serum calcitriol that begins early in the first trimester and
reaches the highest levels in the third trimester (81, 207,
287, 324, 387, 578, 599, 632, 764, 981, 987). Longitudinal
studies have confirmed a progressive increase in free and
bound calcitriol that is maintained to term (33, 81, 764,
809, 813, 959, 987). Free calcitriol was reported to be in-
creased in the third trimester in one study (81). However,
the more modest (20 40%) increase in vitamin D binding
Physiol Rev VOL 96 APRIL 2016 www.prv.org
protein during pregnancy, and the decline in serum albu-
min, indicate that free calcitriol is likely increased in all
three trimesters (33, 399, 599, 764, 1019).
In a large cross-sectional study, serum calcitriol increased
threefold in women with singleton and twin pregnancies,
and there was no difference between the two groups (646).
There was also no difference in vitamin D binding protein
and albumin levels, which means that singleton and twin
pregnancies likely resulted in identical increases in free cal-
citriol (646). A smaller longitudinal study also found no
difference in serum calcitriol between twin and singleton
pregnancies at any time point during pregnancy (746).
PTH is normally the dominant regulator of Cyp27b1 in
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
adults, and without it (such as in hypoparathyroidism), cal-
citriol levels are quite low (782). A substantial curiosity
about the marked pregnancy-related increase in calcitriol is
that it occurs while PTH is often suppressed to low levels,
which suggests that PTH is not responsible for the upregu-
lation of Cyp27b1.
Estradiol, prolactin, and placental lactogen levels are high
during human pregnancy and may in part stimulate
Cyp27b1, as suggested by data from animals cited above.
The potential role of estradiol is supported by the finding
that estrogen replacement therapy in postmenopausal
women causes an increase in free and total calcitriol levels
in serum (172). Conversely, the elevated prolactin levels of
pregnancy seems unlikely to stimulate Cyp27b1 because
chronic hyperprolactinemia in nonpregnant individuals does
not alter calcitriol (514). However, chronic hyperprolactine-
mia differs in that estradiol levels are low, in contrast to the
high levels during pregnancy. The possibility that high estra-
diol and high prolactin (or placental lactogen) act in concert
during pregnancy to stimulate Cyp27b1 has not been exam-
ined in any human studies. An additional analysis in pregnant
women found that the increased calcitriol did not correlate
with PTH, prolactin, estrone, estradiol, estriol, or human pla-
cental lactogen (746).
That the placenta and other extrarenal sources of Cyp27b1
do not contribute a substantial amount of calcitriol to the
maternal circulation is supported by the finding that an
anephric woman on dialysis had low calcitriol levels before
and during a pregnancy (937). The author is aware of other
unpublished cases in which calcitriol remained low in preg-
nant anephric women.
There is conflicting evidence as to whether serum 25OHD
changes during human pregnancy. In several large studies
there was no significant change (121, 200, 386, 399, 764,
778, 809, 966) or even a slight increase (637). This includes
the placebo arm of a study in which women were vitamin
D-deficient at baseline (mean 25OHD level of 20 nM or 8
ng/ml) (121), and two studies in which women had a mean
459
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
25OHD of about 60 nM (24 ng/ml) prior to being random-
ized to receive up to 4,000 IU of vitamin D per day (399,
966). Conversely, two longitudinal studies found a modest
but significant decline in total 25OHD (33, 1019) or calcu-
lated free 25OHD values (1019) during pregnancy. These
latter studies were smaller and may have been influenced by
seasonal and late-pregnancy alterations in sunlight expo-
sure and diet. The bulk of the data indicate that maternal
25OHD is not substantially drained into the fetal circula-
tion, or consumed by conversion into calcitriol.
A large cross-sectional study found that the maternal
25OHD was also stable across all trimesters in both single-
ton and twin pregnancies; however, the 25OHD level was
30% lower in women carrying twins at all time points
(646). It is unknown whether this difference was due to
twin babies draining the maternal supply of 25OHD, or
lower sunlight exposure or vitamin D intake in women
bearing twins. The lack of a progressive change in 25OHD
during pregnancy, especially a progressive difference be-
tween mean values in women bearing singletons versus
twins, makes it less likely that two babies represent a drain
on the maternal supply of 25OHD. A smaller longitudinal
study found no difference in 25OHD levels between women
bearing twins versus singletons (746), which may be an
indication that the larger cross-sectional study was con-
founded by inherent differences between the two groups of
mothers rather than demonstrating an effect of twin preg-
nancy. There are no data from women bearing triplets.
While the threshold level of 25OHD that indicates optimal
vitamin D sufficiency during pregnancy continues to be de-
bated (401, 430, 495, 773), it should be clear that the ob-
served suppression of PTH and doubling or tripling of cal-
citriol during pregnancy are not attributable to maternal
vitamin D deficiency. Moreover, supplementation with
the equivalent of 1,000 to as much as 5,000 IU vitamin D
daily during pregnancy did not alter maternal serum cal-
cium, albumin-corrected calcium, phosphorus, or PTH,
nor did it blunt the rise in calcitriol (239, 399, 778, 966).
The increase in free and bound calcitriol, despite a de-
cline in PTH, is evidently a programmed response to
pregnancy, with the key stimulators of Cyp27b1 remain-
ing unidentified. In a study in which intakes of 400 IU,
2,000 IU, and 4,000 IU vitamin D were compared, mean
calcitriol levels reached a plateau at a 25OHD level of
100 nM regardless of vitamin D intake (399). This pla-
teau may indicate the maximal capacity of renal
Cyp27b1 to convert 25OHD into calcitriol, balanced
against probable upregulation of Cyp24a1 to catabolize
25OHD and calcitriol. Moreover, the plateau does not
necessarily mean that 100 nM is the target level of
25OHD to be achieved in pregnancy, as the authors of
that study concluded (399), since no benefit of this high
level of 25OHD or calcitriol has been demonstrated.
460 Physiol Rev VOL 96 APRIL 2016 www.prv.org
C) SUMMARY. Total and likely free levels of calcitriol begin to
increase in the first trimester and may reach triple or more
the nonpregnant value by the third trimester. This increase
likely contributes to upregulation of intestinal calcium ab-
sorption during pregnancy and, indirectly, to suppression
of PTH. Increased production of calcitriol comes almost
entirely from maternal kidneys and not the placenta or fe-
tus, but the factors that stimulate renal Cyp27b1 during
pregnancy remain to be elucidated. 25OHD levels are stable
during pregnancy despite increased conversion to calcitriol
and transplacental passage of 25OHD to the baby, and
even in the face of a twin pregnancy. Conversely, 25OHD
has been shown to decline by 50% in rats that bear large
litters, with more modest to no change in animals bearing
several pups (pigs) or singletons (sheep).
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
The influence of calcitriol in regulating mineral metabolism
during pregnancy is further discussed in the sections that
address adaptations that occur in the intestines (see sect.
IIB) and bone (see sect. IID). Calcitriols role is also illumi-
nated by data on the effects of vitamin D deficiency and
genetic vitamin D resistance syndromes (see sect. IIIG) dur-
ing pregnancy.
5. Calcitonin
A) ANIMAL DATA. Serum calcitonin is increased during preg-
nancy in rats (315), mice (615), monkeys (759), sheep (58,
310, 316), deer (170), and goats (58, 310). In addition to
increased production by the C-cells of the thyroid (316),
additional sources of expression that may contribute to the
circulating level of calcitonin include mammary tissue (450,
938), placenta (450, 496), and pituitary (755, 887). In-
creased synthesis of calcitonin reasonably explains the
higher levels, but clearance of calcitonin has not been mea-
sured. Studies in pregnant rhesus monkeys support that
synthesis is likely increased, since acute calcium infusions
caused a progressively greater calcitonin increment during
pregnancy (760). This increase in calcitonin occurs despite
high levels of calcitriol, which has been shown to suppress
calcitonin (647, 840). Estradiol stimulates calcitonin ex-
pression in the rat thyroid (840), so the high levels of estra-
diol during pregnancy may contribute to increased calci-
tonin in the circulation.
B) HUMAN DATA. Serum levels of calcitonin generally increase
during pregnancy compared with nonpregnant values and
may exceed the normal range (33, 221, 255, 388, 503, 797,
839, 981, 985, 990). But the evidence is not entirely consis-
tent, since other longitudinal studies have found no changes
(764) or decreased calcitonin in all three trimesters (632).
Several longitudinal studies found no increase in pregnancy
compared with postpartum values (209, 721, 813). How-
ever, since calcitonin has also been shown to be elevated
postpartum (see sect. IVA4), the lack of change compared
with postpartum does not rule out an increase during preg-
nancy.
 CHRISTOPHER S. KOVACS
Higher estradiol, estrone, and estriol levels during preg-
nancy may stimulate calcitonin synthesis. This is supported
by the observation that in reproductive-age women, mean
plasma calcitonin was three to five times higher in women
who were pregnant or taking oral contraceptives, compared
with nonpregnant women who did not use oral contracep-
tives (388). Moreover, treatment of postmenopausal
women with either estradiol or a synthetic estrogen (ethi-
nylestradiol) resulted in a significant increase in plasma cal-
citonin (877).
The thyroid C-cells are often assumed to be the only site of
calcitonin synthesis, but the breast and placenta become
significant production sites during pregnancy (52, 131).
This has been most clearly demonstrated in women who
have previously undergone a total thyroidectomy. During
subsequent pregnancies the mean serum calcitonin has risen
from undetectable to 16 pg/ml, and exceeded the value of
11 pg/ml in nonpregnant women with intact thyroids (131).
The potency of the breasts is indicated by the finding of
calcitonin in colostrum and milk at 45 times its concentra-
tion in serum, with no difference in the values between
thyroidectomized and intact women (131).
C) SUMMARY. Calcitonin increases during pregnancy in
women and animals, evidently coming from placenta and
breasts in addition to the C-cells of the thyroid. Calcitonins
possible physiological role in protecting the maternal skel-
eton during pregnancy is discussed in section IIIH.
6. Fibroblast growth factor-23
A) ANIMAL DATA. Fibroblast growth factor-23 (FGF23) is
predominantly expressed in osteocytes and osteoblasts
(841); a low level of Fgf23 mRNA expression was also
found in the murine placenta when WT and Fgf23 null
placentas were compared (581). FGF23s apparent function
is to control the availability of phosphorus at mineralizing
surfaces of bone, and it does so by regulating the serum
phosphorus through actions on the kidneys, intestines, and
parathyroids (841). It downregulates the expression of so-
dium-phosphate cotransporters 2a and 2c (NaPi2a and
NaPi2c) in proximal renal tubules (834), thereby causing
excretion of phosphorus into the urine. It inhibits Cyp27b1
and increases expression of Cyp24a1, which will respec-
tively decrease synthesis and increase catabolism of cal-
citriol, thereby leading to reduced calcitriol concentrations
in the circulation (834). By lowering serum calcitriol and
also by directly reducing the intestinal expression of
NaPi2b, FGF23 should also lead to reduced intestinal phos-
phorus absorption (834). FGF23 also inhibits PTH release
from the parathyroids (834). High circulating levels of
FGF23 cause hypophosphatemia characterized by renal
phosphate wasting and low calcitriol, while absence of
FGF23 causes hyperphosphatemia with impaired renal
phosphate excretion and inappropriately elevated calcitriol
(70).
Physiol Rev VOL 96 APRIL 2016 www.prv.org
Longitudinal studies in several mouse models have shown
that FGF23 increases twofold during pregnancy over non-
pregnant values (198, 478). The physiological significance
of this increase is unclear given that serum phosphorus
shows no change during pregnancy in mice. Moreover, al-
though increased levels of FGF23 have been shown to re-
duce serum calcitriol in nonpregnant Phex (Hyp) null mice
(564) and in Fgf23 overexpressing mice (531), no effect on
calcitriol concentrations was seen from increased or de-
creased FGF23 during pregnancy. Specifically, the serum
calcitriol was no different among pregnant Phex null, WT,
or Fgf23/ mothers (581, 679).
B) HUMAN DATA. No published data are available on intact
FGF23 levels during human pregnancy. One study did re-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
port intact FGF23 values obtained within 24 h after deliv-
ery (678). The mean values were similar to the levels ob-
served in unrelated adult controls, and about three times the
values obtained in cord blood from the mothers babies. But
FGF23 levels obtained within 24 h after delivery may no
longer reflect what was present during late pregnancy.
C) SUMMARY. FGF23 doubles its concentration in the moth-
ers circulation during murine pregnancy; whether it has a
similar increase in women is unknown. Its physiological
importance during pregnancy is uncertain given the un-
changing serum phosphorus in human and rodent pregnan-
cies, and because markedly increased FGF23 in Phex null
mice did not blunt the pregnancy-related rise in calcitriol.
X-linked hypophosphatemic (XLH) rickets is a disorder of
FGF23 excess caused by an inactivating mutation in PHEX
(the equivalent of the Phex null mice); any known effects of
XLH during pregnancy are addressed in section IIIK.
7. Sex steroids and other hormones
A) ANIMAL DATA. Pregnancy induces changes in other hor-
mones that may influence bone metabolism. Estradiol, es-
triol, estrone, progesterone, prolactin, placental lactogen,
and placental growth hormone each increases significantly
(232, 268, 852, 979). Conversely, IGF-I decreases during
late pregnancy in rats, consistent with a suppression in pi-
tuitary growth hormone (268, 645). Oxytocin increases
fivefold during pregnancy in rats and reaches its highest
levels during parturition (1010).
B) HUMAN DATA. During human pregnancy there are similar
changes in these hormones that may influence skeletal me-
tabolism and mineral homeostasis. Estradiol increases up to
100-fold, accompanied by lesser increases in estriol and
estrone (632, 670, 933), while progesterone increases up to
10-fold (670, 933). Prolactin increases 10-fold or more (33,
207, 632, 670, 695), placental lactogen increases 10- to
100-fold (33, 649, 695), and these similar hormones will
each activate prolactin receptors. Placental growth hor-
mone increases 25-fold while pituitary growth hormone
461
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
becomes suppressed (174). IGF-I may decrease to as low as
50% of basal values during the second trimester before
rising two- to threefold above nonpregnant values by term
(85, 174, 632, 649). In one study the rise in IGF-I during the
third trimester correlated with the increase in bone turnover
markers, and the rise in placental lactogen paralleled the
increase in IGF-I, leading the authors to infer that placental
lactogen was driving the increases in IGF-I and bone turn-
over (649). Oxytocin shows a slow but modest increase
during pregnancy to reach peak levels near term (231).
Prolactin and placental lactogen have been shown to stim-
ulate synthesis of PTHrP in human cultures of extraembry-
onic membranes (262). Beyond this, no clinical studies have
tested whether these pregnancy-related hormones play an
important role in regulating maternal bone metabolism.
C) SUMMARY. Numerous hormones show progressive in-
creases or decreases in their circulating concentrations dur-
ing pregnancy. But the extent to which these hormones may
have direct or indirect effects on skeletal and mineral ho-
meostasis during human pregnancy has been largely unex-
plored. Within animal models, limited data about these hor-
mones are discussed in the relevant sections. Prolactin and
placental lactogen have been shown to stimulate intestinal
calcium transport (see sect. IIB), reduce urinary calcium
excretion (see sect. IIC), and stimulate both PTHrP and
calcitriol (see sect. II, A3 and A4, respectively). Oxytocin
and its receptor have been proposed to have possible effects
on bone formation and resorption (see sects. IID and IVD).
B. Upregulation of Intestinal Absorption of
Calcium and Phosphorus
1. Animal data
The two main routes of calcium absorption are an active,
saturable, transcellular pathway that is stimulated by cal-
citriol and a passive, nonsaturable, paracellular pathway
that is also stimulated in part by calcitriol (181, 247). Rapid
and active calcium absorption is thought to represent
20% of net absorption, and it takes place largely in the
duodenum of the rodent, while 80% of calcium absorp-
tion occurs through slower, passive mechanisms in the je-
junum and ileum, with lesser amounts in the colon (181,
694). Active intestinal calcium absorption is more impor-
tant when dietary intake of calcium is limited.
Studies using 45Ca have demonstrated that the fractional
absorption of calcium doubles in pregnant rats. Three-day
metabolic balance studies found that fractional 45Ca ab-
sorption doubled at days 20 22 of gestation compared with
nonpregnant controls (173). At days 1315 in that study,
net 45Ca absorption was 20% higher and urinary excretion
of 45Ca was double that in nonpregnant controls, confirm-
ing that intestinal calcium absorption was also increased at
462 Physiol Rev VOL 96 APRIL 2016 www.prv.org
mid-pregnancy (173). When the absorption of 45Ca in 15
min across an in situ isolated loop of duodenum was mea-
sured, the value was increased 30% at day 14 and doubled
at day 20 of pregnancy, similar to the results of the meta-
bolic balance studies (735). 45Ca absorption across everted
gut sacs in rats also revealed that calcium absorption at day
20 of pregnancy was double that of nonpregnant controls
(360).
An increase in intestinal calcium absorption beginning at
mid-pregnancy may enable the pregnant rodent to accrete
mineral in advance of the peak demands that occur during
late pregnancy and lactation. Balance studies have shown
pregnant rats to achieve a net gain in calcium at mid-preg-
nancy that is sustained to term (339). Consistent with this,
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
an increase in femoral ash weight and calcium content has
been found in rats and sheep at mid-pregnancy and term
(69, 629), which correlates with an increasing calcium con-
tent of the diet (818), while a progressive 10 15% increase
in total body mineral content during pregnancy has been
observed by DXA in normal Black Swiss mice (296, 478,
827, 994). However, not all studies are consistent with this
since no change in femoral or tibial ash weight or calcium
content was observed in several studies of rats (362, 598,
628, 972), decreases in lumbar spine BMD by DXA and
histomorphometry have been observed at mid-pregnancy
and term in rats (408), and BMD of the whole body and
lumbar spine decreases by DXA in C57BL/6J mice (477,
580). Some of these differences are likely due to differing
calcium contents of the diet, with dietary calcium restriction
consistently causing reduced skeletal mineral content by the
end of pregnancy in rats (64, 271, 740) and goats (55). The
differences between Black Swiss and C57BL/6J mice must
be due to genetic differences because both strains were
maintained on the same 1% calcium diet in the authors
laboratory. It has been estimated from radioisotope studies
that 92% of fetal skeletal calcium content is absorbed from
the maternal diet of the rat during pregnancy while consum-
ing a 1% calcium diet (974), but this will likely vary by
dietary calcium intake. Clearly if calcium intake is insuffi-
cient to meet the needs of the fetuses, then increased skeletal
resorption will occur.
In the transcellular pathway, calcium enters enterocytes
through apical calcium channels (TRPV6, TRPV5), is shut-
tled through the cytoplasm while bound to proteins (calbin-
din-D9k), and is extruded from the cell under the actions of
Ca2-ATPase (PMCA1) and the sodium-calcium exchanger
NCX1 (247). Each of these factors is dependent on cal-
citriol for normal expression in nonpregnant animals (127,
181, 182, 596, 854). Each is upregulated in the intestines of
pregnant mice and rats, and reaches the highest levels of
expression by mid to late pregnancy (126, 237, 949, 1021).
Taken together with the observation that calcitriol also
reaches peak levels in the last few days of pregnancy, and
that duodenal expression of VDR increases at the same time
 CHRISTOPHER S. KOVACS
(1021), these findings are compatible with the doubling of
intestinal calcium absorption being the result of increased
calcitriol-mediated effects. However, the increase in intesti-
nal calcium transport precedes the rise in calcitriol by at
least 1 wk in pregnant rats (735), and in another study the
increment in calcitriol was concluded to be insufficient to
explain the magnitude of increase in intestinal calcium
transport during pregnancy (360).
Calcitriol regulates that paracellular or passive route of cal-
cium absorption by stimulating the expression of claudin-2
and claudin-12, which form tight junctions between intes-
tinal epithelial cells (181). These claudins are expressed in
the jejunum, ileum, and colon, but most abundantly in the
ileum where the bulk of calcium is absorbed (298, 406).
Expression of claudin-2 and claudin-12 are reduced in Vdr
null mice (298).
A pregnancy-induced increase in fractional calcium absorp-
tion occurs despite severe vitamin D deficiency in rats (116,
360), absence of the vitamin D receptor in mice (296), or
maternal parathyroidectomy in rats (425). In severely vita-
min D-deficient pregnant rats, a doubling to tripling in the
efficiency of intestinal calcium, phosphorus, and magne-
sium absorption was observed that reached levels equiva-
lent to normal (116), which suggests that full upregulation
occurs during pregnancy despite the absence of calcitriol. In
another study intestinal calcium absorption doubled over
baseline in severely vitamin D-deficient rats, but reached
two-thirds of the value achieved by pregnant vitamin D-re-
plete rats (360). And so the pregnancy-related increase may
not always fully compensate for the absence of calcitriol.
The upregulation in intestinal calcium and phosphorus ab-
sorption that occurs in severely vitamin D-deficient rats is
physiologically important because by the end of pregnancy,
significant increases were seen in femoral ash weight and
calcium content (362) and serum calcium and phosphorus
(915). Moreover, Vdr null mice (Boston strain) increased
their skeletal mineral content by 55% as assessed by DXA,
had a marked reduction in secondary hyperparathyroidism,
normalized serum calcium, and increased renal calcium ex-
cretion during pregnancy (296). In a separate study of Vdr
null mice (Leuven strain), pregnancy resulted in an in-
creased serum calcium, a reduction in calcitriol from higher
levels, an increase in trabecular BMD of the femur by quan-
titative computed tomography (QCT) an increase in femo-
ral ash weight, and reduced osteoid and osteoclast param-
eters as assessed by histomorphometry (786).
In both Vdr null models (i.e., both Boston and Leuven
strains), a calcium-enriched diet had been started at the time
of mating, and this partly confounded the increase in bone
mass and some of the improvements in mineral homeostasis
that were observed (296, 786). More recently, a preliminary
report in pregnant Cyp27b1 null mice, which lack the abil-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
ity to make calcitriol, has shown a 45% increase in bone
mineral content by DXA, a marked lessening of secondary
hyperparathyroidism, and normalization of serum calcium
and phosphorus (330). Intestinal calcium absorption has
not yet been measured but is likely to be increased, based on
these observed changes. The Cyp27b1 null mice had been
maintained on the same diet since 3 wk of age, so all of the
improvements in skeletal mineral metabolism are attribut-
able to pregnancy.
Not all studies agree with the findings of skeletal improve-
ments during pregnancy in severely vitamin D-deficient
rats, Vdr null mice, and Cyp27b1 null mice. Two histomor-
phometric studies in pregnant vitamin D-deficient rats
found significant decreases in mineralized bone, increased
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
unmineralized osteoid, and increased resorptive parameters
(598, 628). The calcium content of the diet (0.45%) was the
same among the rat studies but the rat strains differed, and
that may account for the varying skeletal response to preg-
nancy.
The increment in calcitriol was prevented in pregnant rats
by administering ketoconazole, which blocks the steroid
synthesis pathway. This resulted in an 80% reduction in
serum calcitriol of pregnant rats and a 50% reduction in
intestinal calcium absorption, which suggests that intestinal
calcium absorption is partly dependent on calcitriol during
pregnancy (92). The serum calcium of the mothers and
weight of the pups were unaffected. The finding of reduced
intestinal calcium absorption contrasts with negative find-
ings from the same study during lactation (see sect. IVC).
What could explain calcitriol-independent upregulation of
intestinal calcium absorption during pregnancy? Vdr null
mice show downregulation of intestinal TRPV6 when non-
pregnant but a marked upregulation during pregnancy
while on a calcium-enriched rescue diet (296, 949),
whereas upregulation in calbindin-D9k was found during
pregnancy on a normal-calcium diet (786). Prolactin, pla-
cental lactogen, and growth hormone have been shown to
stimulate intestinal calcium absorption independently of
calcitriol, possibly through actions to increase expression of
TRPV6, TRPV5, calbindin-D9k, and PMCA1 (12, 171,
586, 690, 894, 901). As noted above, growth hormone is
normally suppressed during pregnancy, but placental
growth hormone is increased and may stimulate intestinal
calcium absorption. Prolactins effect to increase intestinal
calcium absorption was confirmed in pregnant, severely vi-
tamin D-deficient rats (690). An effect of prolactin and
placental lactogen was also observed in everted gut sacs of
nonpregnant, hypophysectomized rats, which thereby re-
moved the confounding effects of prolactin release from the
pituitary (586, 894). Estradiol also has effects independent
of calcitriol to stimulate intestinal calcium absorption and
expression of TRPV6 and TRPV5 (192, 949). Calcitonin
stimulated intestinal calcium absorption although the
463
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
mechanism appeared to be through increased production of
calcitriol, rather than being independent of it (436).
The implication of these studies is not to suggest that cal-
citriol plays no role in upregulating intestinal calcium ab-
sorption during pregnancy. Instead, it is quite likely that the
two- to fivefold increase in calcitriol contributes to the dou-
bling in the efficiency of intestinal calcium absorption in
normal, vitamin D-replete animals. Additional factors (pos-
sibly prolactin, placental lactogen, placental growth hor-
mone) likely contribute to the normal upregulation of intes-
tinal calcium absorption during pregnancy. What may be
indicated by these findings in severe vitamin D-deficient
rats, Vdr null mice, and Cyp27b1 null mice is that in the
absence of calcitriol (or the inability to respond to it), these
pregnancy-related factors compensate to upregulate intesti-
nal calcium absorption, with the resulting efficiency of cal-
cium absorption reaching the normal peak levels of preg-
nancy in some rodents, but falling below it in others.
2. Human data
In humans active transport of calcium occurs in the duode-
num and proximal jejunum, with passive absorption in the
distal jejunum and ileum accounting for the bulk of calcium
absorption (181, 247). Active transport is more rapid and
becomes especially important when the dietary supply of
calcium is low. Stable calcium isotopes (48Ca, 44Ca, 42Ca)
and mineral balance studies have consistently determined
that women are in a positive calcium balance during early
pregnancy, with fractional absorption of calcium doubling
by as early as 12 wk of gestation and maintained to term
(207, 324, 372, 467, 469, 764).
The doubling to tripling of serum calcitriol, with increased
free calcitriol, has also been assumed to explain the in-
creased efficiency of intestinal calcium absorption during
human pregnancy. Compelling animal data described in the
preceding section support that this increase in intestinal
calcium absorption may not be fully due to calcitriol, and
have raised the possibility that prolactin, placental lacto-
gen, growth hormone, and other factors stimulate calcium
absorption by enterocytes. However, there are no compel-
ling clinical data because few studies have examined the
mechanism of calcium absorption during human preg-
nancy.
An independent effect of prolactin to stimulate intestinal
calcium absorption was not evident when seven hyperpro-
lactinemic subjects were found to have intestinal calcium
absorption within the expected normal range (514); how-
ever, estradiol should be low in these patients, in contrast to
the high levels during pregnancy. Intestinal calcium absorp-
tion has not been formally measured during pregnancy in
women who are severely vitamin D-deficient or who have
genetic disorders of impaired vitamin D physiology. How-
ever, the first-trimester rise in intestinal calcium absorption
464 Physiol Rev VOL 96 APRIL 2016 www.prv.org
precedes the more marked increase in calcitriol and free
calcitriol during the third trimester, which may indicate that
the early increase is not wholly driven by calcitriol. More-
over, the extremes of severe vitamin D deficiency or genetic
disorders of vitamin D physiology in the mother do not alter
serum calcium, ionized calcium, phosphorus, PTH, or skel-
etal mineral content of the baby, as detailed in the compan-
ion review (492). These normal fetal parameters imply that
maternal delivery of mineral is normal, or that the placenta
is capable of extracting needed mineral regardless of a def-
icit in the maternal supply.
3. Summary
Intestinal calcium absorption increases twofold beginning
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
in the first trimester of human pregnancy, and a similar
doubling of intestinal calcium and phosphorus absorption
occurs by mid-pregnancy in rats. The increase in calcium
absorption is probably mediated in part by calcitriol-in-
duced increases in TRPV5/6, calbindin-D9k, PMCA1,
NCX1, claudin-2, and claudin-12. Many but not all studies
in rodents have shown that a normal or near-normal in-
crease in intestinal calcium and phosphorus absorption oc-
curs during pregnancy without requiring calcitriol. Prolac-
tin, placental lactogen, growth hormone, and other factors
may contribute to the normal pregnancy-related doubling
of fractional calcium absorption. An increase in intestinal
calcium absorption early in pregnancy may allow the ma-
ternal skeleton to store calcium in advance of peak demands
that occur later in pregnancy and during lactation.
Overall, this doubling in the fractional absorption of cal-
cium from the intestines appears to be the major maternal
adaptation to meet the fetal requirement for calcium in
humans and rodents. In rats it accounts for more than 90%
of the mineral present in the fetus at birth.
C. Altered Renal Mineral Handling
1. Animal data
Glomerular filtration rate and creatinine clearance increase
during rodent pregnancy (65). In 3-day metabolic studies in
rats, a twofold increase in urinary calcium excretion has
been observed by mid-pregnancy that rises even higher by
late pregnancy (173). This hypercalciuria develops concur-
rently with the significant increase in intestinal calcium ab-
sorption (173), confirming that hypercalciuria is a conse-
quence of the increased renal filtered load, or absorptive
hypercalciuria. Such 24-h renal calcium excretion studies
have not been done in pregnant mice. However, in longitu-
dinal studies carried out in the authors laboratory, the
calcium-to-creatinine ratio in a spot urine is normal or sig-
nificantly increased during pregnancy when the samples are
obtained from nonfasted mice (296, 477, 994), whereas the
result is reduced below the nonpregnant level when the mice
 CHRISTOPHER S. KOVACS
are fasted overnight (478, 580). This supports that absorp-
tive hypercalciuria also occurs in pregnant mice. Additional
evidence in support of this comes from pregnant Vdr null
mice, which had significantly increased urine calcium/cre-
atinine ratios, concurrent with their increase in intestinal
calcium absorption (296).
Prolactin and placental lactogen reduce urinary calcium ex-
cretion in nonpregnant rabbits (135, 136). Whether these
hormones are helping the kidneys conserve calcium during
pregnancy has not been tested. An increase in urine calcium
excretion during pregnancy suggests that the kidneys are
not conserving calcium; the suppressed PTH levels may be a
contributing factor. This is supported by the observation
that urinary calcium excretion was no different in pregnant
Pth nulls and their WT sisters, despite the lower filtered
load of calcium in Pth nulls (478). An additional consider-
ation is that intestinal calcium absorption increases before
the fetal demand for calcium; consequently, the excess ab-
sorbed calcium must be excreted.
2. Human data
As in rodents, pregnancy causes increased creatinine clear-
ance and glomerular filtration rate (303). As early as the
12th week of gestation, the 24-h urine calcium excretion
increases significantly, with mean values reaching the upper
limit of normal, and values in the hypercalciuric range often
observed (18, 207, 221, 324, 707, 764, 809). Fasting urine
calcium concentrations are normal or low, confirming that
the increase in 24-h urine calcium is due to absorptive hy-
percalciuria, i.e., that increased intestinal calcium absorp-
tion leads to an increased renal filtered load and excretion
of calcium (304, 324, 468). Since the fetal demand for cal-
cium does not occur until the third trimester, but intestinal
calcium absorption increases in the first trimester, this ex-
plains why absorptive hypercalciuria is an obligatory, phys-
iological consequence of pregnancy. It is one of the factors
that contributes to an increased risk of kidney stones during
pregnancy (815).
Many recent clinical studies have eschewed the use of 24-h
urine collections during pregnancy and have relied solely on
calcium/creatinine values in spot urines to assess renal cal-
cium excretion. When second morning void spot urines
were obtained in longitudinal studies from women who
were not required to fast, the Ca/Cr ratios during pregnancy
reached double the value of those obtained prior to preg-
nancy (85, 632), and the mean values were at the upper end
of the normal range in one of the studies (85). Conversely,
fasting Ca/Cr ratios were no different between singleton
and twin pregnancies, and the mean values showed no
change between 10 and 38 wk of pregnancy, consistent
with failure to detect absorptive hypercalciuria on fasted
urine specimens (646).
Physiol Rev VOL 96 APRIL 2016 www.prv.org
The Ca/Cr ratio in a random spot urine has been used in
several recent randomized trials that studied the apparent
safety of high-dose vitamin D supplementation during preg-
nancy. No adverse increase in Ca/Cr ratio was reported
when 5,000 IU vitamin D per day was compared with pla-
cebo (778), when 4,000 IU daily and 400 IU daily were
compared (399), or when 4,000 IU daily and 2,000 IU daily
were compared (966). These findings have been interpreted
to mean that high-dose vitamin D supplementation does not
cause hypercalciuria during pregnancy (399, 778, 966).
However, since it is absorptive hypercalciuria that occurs
during pregnancy, and random spot urines are neither sen-
sitive enough nor timed appropriately to detect absorptive
hypercalciuria, the available data have not adequately ex-
cluded whether hypercalciuria worsens during pregnancy
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
when high-dose vitamin D is taken. Twenty-four hour urine
collections are needed.
In this context, it is relevant to mention that hypocalciuria
during pregnancy has been associated with preeclampsia
and pregnancy-induced hypertension (42, 293, 524, 707,
810). In turn, the hypocalciuria has been reported in asso-
ciation with low serum calcitriol (293, 524, 707, 810),
whereas PTH, calcitonin, and ionized calcium are normal
(42, 293, 707, 810). The calcitriol levels are reduced to
values seen in nonpregnant women. The possibility that low
maternal 25OHD or low vitamin D intake could explain
the increased risk of preeclampsia (and, thereby, low cal-
citriol) has been investigated with a similar number of stud-
ies supporting (46, 95, 370, 768) and refuting (294, 726,
810, 823) an association.
The low calcitriol, hypocalciuria, and reduced creatinine
clearance that occur in preeclampsia and PIH are likely
secondary to disturbed renal function, rather than being
causes of the hypertension (293). Consistent with this, in a
longitudinal study, calcitriol levels were normal earlier in
pregnancy and became low only after hypertension and
proteinuria developed (357). Another study found that se-
rum levels of the fat-soluble vitamins A, D, and E were each
lower in preeclamptic women compared with normotensive
pregnant and nonpregnant controls (485), which raises the
possibility that confounding from overweight, obesity, and
poor nutrition may explain why the levels of several fat-
soluble vitamins were all lowered in preeclamptic women.
A placental abnormality has been hypothesized to explain
lower calcitriol levels in preeclampsia, with conflicting re-
sults obtained showing decreased (248) and increased (286)
placental expression of Cyp27b1. However, since the pla-
centa contributes very little calcitriol to the circulation of
pregnant women (see sect. IIA4), it is unlikely that loss of
placental Cyp27b1 leads to reduced serum calcitriol in pre-
eclamptic women. Alternatively, abnormal placental func-
tion could indirectly reduce maternal calcitriol concentra-
tions if placental hormones (such as placental lactogen) are
important stimulators of Cyp27b1 in the maternal kidneys.
465
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
However, plasma concentrations and placental expression
of placental lactogen are not reduced in preeclamptic
women (73, 74, 561, 595, 623, 675, 1027).
Numerous clinical trials have been carried out to assess the
efficacy of calcium supplementation at preventing pre-
eclampsia or pregnancy-induced hypertension, and a net
benefit has been seen for women with the lowest intakes of
calcium, whereas no effect is evident for women with ade-
quate calcium intake (398). In multiple clinical trials, no
effect of high-dose vitamin D supplementation has been
seen on the incidence of preeclampsia in pregnant women
(183, 184, 399, 710, 966).
3. Summary
Increased intestinal calcium absorption during pregnancy
leads to increased urine calcium excretion, with 24-h urine
values near or above the upper limit of normal. This is
absorptive hypercalciuria, which will not be present on
Ca/Cr ratios in fasting urine specimens, and not well dis-
criminated from Ca/Cr ratios obtained from random spot
urine samples. The pregnancy-related suppression of PTH
to low values may contribute to increased renal calcium
excretion. Hypocalciuria with low calcitriol occurs in pre-
eclampsia, likely as a consequence of disturbed renal func-
tion. Calcium supplementation reduces the risk of pre-
eclampsia in women with the lowest calcium intakes, while
vitamin D supplementation has had no effect.
D. Altered Skeletal Turnover and Mineral
Metabolism
1. Animal data
The maternal skeleton is a storehouse of mineral that can be
resorbed during pregnancy if needed to provide mineral to
the fetuses. Earlier it was cited that 92% of fetal skeletal
calcium content has been estimated to come from the ma-
ternal diet of the rat during pregnancy (974). Additional
radioisotope studies have confirmed that some calcium in
the maternal skeleton will be resorbed to enter the fetal
skeleton, especially during the last few days of gestation
(706). However, much less 45Ca from the maternal skeleton
ends up in the fetuses compared with how much enters the
milk and the pups during lactation, which confirms that
skeletal resorption during pregnancy is quite modest com-
pared with that during lactation (706).
The extent to which bone turnover is altered during preg-
nancy may be deduced from relative changes in biochemical
markers of bone formation and resorption. These measure-
ments are fraught with confounding problems of changes in
intravascular volume and glomerular filtration rate (dis-
cussed in section IID2). In most studies they were measured
in late pregnancy only. The available indices suggest at most
466 Physiol Rev VOL 96 APRIL 2016 www.prv.org
a mild uncoupling in favor of resorption during pregnancy
in mice, as indicated by normal to modestly increased de-
oxypyridinoline and CTX, normal P1NP, and decreased
osteocalcin (296, 477, 478, 580, 994). A decline in osteo-
calcin has also been noted during pregnancy in guinea pigs
(958) and sheep (277), and contrasts with increased osteo-
calcin found in rats during early pregnancy and at term
(816, 961).
The effect that pregnancy has on bone mass or mineraliza-
tion has been serially assessed by DXA measurements done
every day (827) and every other day (993) during reproduc-
tive cycles in outbred Black Swiss mice. There is a progres-
sive 10 20% increase in whole body mineral content that
begins early in pregnancy and reaches a peak on the day
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
before birth (827, 993). The hindlimb increases by a similar
amount while the lumbar spine remains unchanged. The
increase in whole body bone mineral content is not attrib-
utable to calcium in the fetuses since the maternal value
increases further by the second postpartum day, while in
control experiments, removal of fetuses at C-section re-
vealed that they accounted for 2% of the maternal min-
eral content at term (827). This increase in whole body bone
mineral content is consistent with the previously noted up-
regulation of intestinal calcium absorption and positive cal-
cium balance. It is noteworthy, in these studies at least, that
the maternal skeleton continues to accrete mineral during
the last 5 days of gestation despite calcium being transferred
to the fetuses at a peak rate.
Apart from serial assessment of bone mineral content by
DXA at multiple time points during pregnancy in Black
Swiss mice, most studies in rodents have simply compared
end-of-pregnancy BMC or BMD to prepregnancy in the
same mice, or to age-matched virgin mice, without deter-
mining whether any changes in bone mass occurred earlier
in pregnancy. This approach has shown that bone mass or
mineral content at the end of pregnancy varies significantly
by skeletal site and genetic background in mice. Outbred
Black Swiss mice consistently show a 10 20% increase in
whole body bone mineral content at the end of pregnancy,
the lumbar spine remains unchanged, and the hindlimb may
gain 10 15% (296, 478, 827, 994). Conversely, inbred
C57BL/6J mice show a 5% decline in whole body bone
mineral content, a 15% drop in lumbar spine bone mineral
content, and a 10 20% gain in the hindlimb (477, 580).
CD-1 mice show no significant changes in mineral content
during pregnancy at any skeletal site (35, 956). Rats
showed no change in whole body BMD and nonsignificant
declines in BMD of femora and tibiae at the end of preg-
nancy (816), whereas another study found a modest but
significant decline in lumbar spine BMD (920), and a third
study found a gain in femoral and vertebral BMC and BMD
(888). Another study found that femoral calcium content at
the end of pregnancy was linearly related to the calcium
content of the diet (818). Overall, apart from the serial
 CHRISTOPHER S. KOVACS
studies in Black Swiss mice, none of the other studies in
rodents can confirm or refute whether bone mass increases
earlier in pregnancy before declining.
Static and dynamic histomorphometry have been carried
out in the femora of pregnant rats and compared with age-
matched virgins. The results are inconsistent across studies
and not clearly explainable by variations in the calcium
content of the diet or the strain of rat. One reported marked
increases in bone resorption (osteoclast number, resorptive
surfaces) and bone formation (osteoblast number, osteo-
blast surface, osteoid volume) during pregnancy in Cobs
rats consuming a 0.45% calcium diet (598). Another found
that osteoclast parameters increased three- to sixfold while
bone formation parameters were unchanged in Sprague-
Dawley rats on a 1.2% calcium diet (920). A third study
used a 1.1% calcium diet in Sprague-Dawley rats and found
divergent effects with reduced bone formation parameters
in the vertebrae but increased bone formation parameters
within cortical bone of the femora; bone resorption param-
eters were not assessed (947). Pregnant beagles consuming a
2% calcium diet also showed significantly increased bone
formation parameters in the ilium, whereas bone resorption
parameters were not assessed (300). In all four studies bone
turnover was found to be increased on the basis of at least
one parameter (i.e., either bone resorption or formation),
but the failure to assess bone resorptive parameters in two
of the studies makes it difficult to be certain whether net
bone formation or resorption is occurring in these pregnant
animals.
Histomorphometry and DXA studies have not been carried
out in pregnant sheep; however, calcium balance studies
inferred that a 20% decrease in skeletal calcium content
occurs by the end of pregnancy (108), consistent with net
bone resorption. A calcium-restricted diet in ewes leads to
increased resorption and reduced ash weight, particularly
within the vertebrae and the pelvis by the end of pregnancy,
with relative sparing of the long bones (69). A high calcium
diet prevents these changes.
In most histomorphometry, microCT, and electron micros-
copy studies, despite this apparent increase in bone turn-
over, there was no net change in femoral or tibial bone mass
at the end of pregnancy in Cobs, Holtzman, Lister, and
Sprague-Dawley rats on a 0.45% calcium diet (362, 598,
628, 972) or in beagles on a 2% calcium diet (300). Excep-
tions include reduced bone volumes and trabecular thick-
ness in the lumbar spine at the end of pregnancy in Sprague-
Dawley rats consuming 1.2% calcium (920), and the oppo-
site result of increased trabecular number, thickness, and
bone volume of the vertebrae, and increased calcein labeling
and bone formation rates throughout the vertebrae, in
Wistar rats on a 0.88% calcium diet (822). Other studies
have found increases in cortical volumes of the femora (106,
548, 947), increased cortical porosity in the femora (548),
Physiol Rev VOL 96 APRIL 2016 www.prv.org
and reduced trabecular bone volumes of the tibiae (107), all
in Sprague-Dawley rats with no correlation to the dietary
calcium content. A microCT study found that C57BL/6
mice consuming 2% calcium increased cortical area and
trabecular volume of the femora at day 16 of pregnancy
compared with day 9 (489).
The available data discussed in this section may seem incon-
sisent and contradictory. For example, within some of these
studies there is histomorphometric evidence of markedly
increased bone turnover in late pregnancy but little or no
change in bone mass. A problem contributing to the incon-
sistency is the comparison of a single time point (end of
pregnancy) to prepregnancy or age-matched virgins, with-
out any assessment at intermediate time points. If a net
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
increase in bone mass and mineralization occurs earlier in
pregnancy (as suggested by calcium balance studies, up-
regulated intestinal calcium absorption, and serial DXA
studies in Black Swiss mice), and is then followed by up-
regulated bone resorption with net bone loss during the
latter third of pregnancy (corresponding to when fetal de-
mand for mineral is at its peak), then that can certainly
explain why bone mass may appear relatively unchanged at
the end of pregnancy despite objective evidence of signifi-
cantly increased bone resorption. Furthermore, even if there
was no increase in bone mass earlier in pregnancy, if bone
resorption increases only in late pregnancy, that may be too
short of a duration to detect a loss in bone volumes by
histomorphometry. There are likely site-specific differences
as well, with trabecular-rich vertebrae possibly differing in
their response to pregnancy compared with more cortical-
rich sites such as the tibiae and femora. Increased weight-
bearing during pregnancy may contribute to a gain in bone
mass of the limbs, as shown in some of the studies.
As noted earlier, when a low calcium diet is consumed, the
skeleton will be markedly resorbed, leading to consistently
reduced bone mass by the end of pregnancy in rats (64, 271,
740) and goats (55). This resorption is mediated in part by
compensatory secondary hyperparathyroidism, which is
more marked on a calcium-restricted diet (see sect. IIA2).
Conversely, a high-calcium diet (1.6 or 1.2% calcium) leads
to a higher femoral calcium content at the end of pregnancy
in rats compared with consuming 0.5% calcium (719, 818),
which is compatible with the high-calcium diet facilitating
reduced resorption of the maternal skeleton.
Does the lack of change or small net change in bone mass or
volumes at the end of pregnancy have any effect on bone
strength? No differences have been found in the biome-
chanical properties of the trabecular bone in the vertebrae
(crush test) of Sprague-Dawley rats (947), or the cortical
bone of the femora (3-point bend test and rotational stress)
of C57BL/6 mice and Sprague-Dawley rats (489, 548, 947).
However, the material properties of rat femora were de-
duced to show reduced shear stress and increased stiffness
467
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
when subjected to rotational stress (548). Two studies from
the same investigator provided contradictory results in that
load to failure in the three-point bend test was increased
(216) and reduced (217) at the end of pregnancy in Wistar
rats compared with age-matched virgins. The work to fail-
ure did not differ between pregnant and age-matched vir-
gins in both studies (216, 217), suggesting that there was no
real change in bone strength.
Although there may be no net change or modest changes in
bone mass by the end of pregnancy when a calcium-replete
diet is consumed by rodents, there is other evidence that the
macro structure of bone may be altered. In Sprague-Dawley
rats, an increase in femoral cortical bone volumes, radii,
and cortical thickness have been found at the end of preg-
nancy, which appear to result from increased periosteal
bone formation during pregnancy (106, 216, 548, 947).
These changes are conceivably a compensatory response to
the increased weight bearing during pregnancy and the re-
sorption of trabecular bone. The change in bone volumes
and radii may become more marked during lactation (see
sect. IVG).
Bone turnover during pregnancy may be impacted by di-
verse hormones, including the previously noted increases in
estradiol, PTHrP, prolactin, placental lactogen and growth
hormone, and oxytocin. That prolactin or placental lacto-
gen may influence bone metabolism directly has been sug-
gested by the finding that osteoblasts express prolactin re-
ceptors (188, 888), and prolactin receptor deficient mice
exhibit decreased bone formation (188). Furthermore,
when the prolactin increase during pregnancy was reduced
by treating Sprague-Dawley rats with bromocriptine, it
blunted the pregnancy-related gain in femoral and vertebral
bone mineral content (888).
The oxytocin receptor is expressed by osteoclasts and os-
teoblasts (195), which may enable oxytocin to regulate
bone metabolism during pregnancy. In support of this, oxy-
tocin and oxytocin receptor-null mice of both sexes have
reduced bone formation and an osteoporotic phenotype
(895). Oxytocin also stimulates osteoblast differentiation
and function, whereas it stimulates osteoclast formation
but inhibits osteoclast function and skeletal resorption
(565, 895). An in vivo role for oxytocin has not been exam-
ined in these mice.
2. Human data
Intestinal calcium absorption increases in the first trimester,
months before the fetal demand for mineral in the third
trimester. Metabolic studies have shown that women are in
a positive calcium balance by mid-pregnancy (372), so skel-
etal mineral content may become increased at that time-
point to explain where that calcium is stored. However,
mid-pregnancy remains a relative black box due to the
468 Physiol Rev VOL 96 APRIL 2016 www.prv.org
absence of data on bone mass, structure, or mineralization
at this time point.
Some maternal bone resorption during late pregnancy may
contribute mineral to the fetus. This has shown by study of
women living near the Techa River in Russia, who inadver-
tently ingested 90Sr from water contaminated by nuclear
waste during the 1950s. Years after the exposure ended,
90
Sr could be detected in the skeletons of their fetuses,
which could only have come from resorption of 90Sr that
had been previously fixed in the maternal skeleton (921,
922). But women who ingested 90Sr during pregnancy, es-
pecially during the third trimester, gave birth to babies with
10-fold higher 90Sr content, consistent with dietary absorp-
tion of mineral being responsible for much more of the
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
mineral content of the fetal skeleton (819, 921, 922).
The sole study reporting iliac crest histomorphometry dur-
ing human pregnancy was carried out in 15 women who
planned to have elective first trimester abortions, 13 women
scheduled to have C-sections in the third trimester, and 40
nonpregnant women (some living and some cadaveric spec-
imens) (732). At the first trimester time point, bone resorp-
tion indexes were increased, bone formation indexes were
decreased, and trabecular bone volume was significantly
lower, compared with nonpregnant women (732). Con-
versely, the third-trimester biopsies were no different from the
nonpregnant values for bone mass and indexes of bone resorp-
tion and formation (732). Taken at face value, these results
suggest that early pregnancy is a bone-resorptive state, which
induces bone loss that is later recovered by the end of preg-
nancy. That interpretation does not fit easily with the fact that
little transfer of calcium is occurring from mother to offspring
during the first trimester; consequently, skeletal resorption
should not be increased at this time point, especially given that
intestinal calcium absorption is already upregulated. Instead,
increased bone resorption is more likely to occur in the third
trimester when the fetal demand for mineral is at its peak. The
observed differences may be the result of small sample sizes
with confounding among the groups. Age matching was poor
and may have contributed to apparent differences, with mean
ages of 22.4 in the first trimester group, 25.1 in the late preg-
nancy group, and 32.6 in the nonpregnant group. More his-
tomorphometric data from pregnant women are needed.
Cross-sectional and serial measurement of bone turnover
markers have been carried out in pregnant women. These
indexes are generally considered more accurate at detecting
changes in bone resorption compared with bone formation
and are subject to diurnal variation as well as differences
between fasted and postprandial values (142, 235, 570).
Pregnant women were often compared with nonpregnant
controls or normal ranges, rather than prepregnancy mea-
surements from the same women. Additional potential con-
founders include hemodilution affecting serum measure-
ments (confirmed to affect osteocalcin and CTX, Ref. 461),
 CHRISTOPHER S. KOVACS
increased GFR and altered creatinine excretion affecting
urinary measurements, possible contributions from pla-
centa and other tissues, increased degradation or clearance
by the placenta (confirmed to affect osteocalcin, Ref. 769),
and lack of fasted or diurnally timed specimens.
Given these caveats, several markers of bone resorption
[urine N-telopetide (NTX) or C-telopeptide (CTX), serum
CTX, tartrate-resistant alkaline phosphatase, deoxypyr-
idinoline/creatinine, pyridinoline/creatinine, and hydroxy-
proline/creatinine] have been found to be low in the first
trimester but to increase steadily thereafter, rising to as
much as twice normal in the third trimester (85, 206, 207,
304, 461, 632, 695, 764, 1002). Correcting for the decline
in serum albumin obliterated the apparent fall in serum
CTX earlier in pregnancy (461). Osteocalcin has been the
most widely used marker of bone formation, and its values
have been low to undetectable in the first trimester, after
which it may stay low or rise to normal values by term (33,
329, 458, 632, 695, 764, 769, 813, 1002). Its apparent
decline early in pregnancy was attributable to hemodilution
of pregnancy in one study (461), whereas a surge in osteo-
calcin after delivery of the placenta is compatible with loss
of placental degradation or clearance (769). Procollagen I
N-telopeptides (P1NP) and carboxypeptides, and bone spe-
cific alkaline phosphatase, are also low in the first trimester,
and have either remained low (304), or risen to normal or
above by term (85, 206, 207, 461, 632). Total alkaline
phosphatase increases mainly due to the placental fraction
and is not a useful indicator of the relative changes in bone
formation during pregnancy (33, 85, 221, 304, 769).
The overall pattern of results suggests that bone turnover
may be relatively normal earlier in pregnancy but that it
increases during the third trimester to create a net resorptive
state. Such a pattern would be consistent with the expected
late-pregnancy demand for mineral and, thereby, a concur-
rent need to resorb from the maternal skeleton, especially if
intestinal absorption of mineral is not sufficient to meet the
combined needs of mother and fetus. Consistent with this, a
randomized trial found that consuming a mean 2,300 mg of
calcium daily resulted in a 15% lower NTX level during the
second and third trimesters compared with women con-
suming 1,100 mg calcium daily (274). Twin pregnancy re-
sulted in slightly higher urinary NTX and CTX, and
a slightly increased bone-specific alkaline phosphatase at
term; these findings are compatible with further increased
resorption to meet the needs of two fetuses (646).
Cross-sectional and serial studies of areal bone mineral den-
sity have been carried out in pregnant women. Most studies
have been done before and after a planned pregnancy to
avoid fetal radiation exposure, so very limited information
is available about changes in maternal BMD during preg-
nancy. The readings may also be affected by altered body
composition, weight, and skeletal volumes during preg-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
nancy. An early study used X-ray spectrophotometry of the
radius and femur during the first or second trimester and
found that trabecular but not cortical bone density had
decreased by the time of a postpartum measurement (526).
Several prospective studies used single- or dual-photon ab-
sorptiometry (SPA or DPA) of the forearm serially during
and after pregnancy (18, 185, 468), or of the femur before
and after a planned pregnancy, and found no significant
changes in cortical or trabecular bone density (858). An-
other study compared preconception SPA and DPA mea-
surements to those taken 6 wk postpartum and found a
2.4% decrease in the femoral neck, a 2.2% decrease in
radial shaft, a 3.4% increase in the tibiae, and no change in
lumbar BMD (256).
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
More modern studies have used DXA at two time-points,
1 8 mo before planned pregnancy and 1 6 wk after deliv-
ery (85, 462, 633, 649, 705, 764, 943). These generally
small studies found 0% to at most a 5% decrease in lumbar
spine bone density between the two measurements, and
little to no change at other skeletal sites. However, the larg-
est study involved 92 women who had DXA of hip, spine,
and radius done at baseline (up to 8 mo prior to planned
pregnancy); DXA of the forearm repeated during each tri-
mester; and DXA of hip, spine, and radius repeated 15 days
postpartum. Seventy-three women completed the postpar-
tum visit and were compared with 57 nonpregnant women
who had DXA measurements done at similar intervals. The
findings included that BMD decreased during pregnancy by
4% at the ultradistal radius but increased by 0.5% at the
proximal one-third of the forearm (633). At the total fore-
arm a 1% lower value in pregnant women versus nonpreg-
nant controls became discernible with the third trimester
measurement, coinciding with the peak interval of placen-
tal-fetal calcium transfer. When the prepregnancy to post-
pregnancy readings were compared, BMD was reduced by
1.8% at the lumbar spine, 3.2% at the total hip, and 2.4%
at the whole body (633). Overall, this study found statisti-
cally significant but small declines in BMD at several skel-
etal sites. For perspective, it is important to realize that such
changes would not be distinguishable from error of mea-
surement in an individual subject, but were resolvable in
this study due to the large cohort. Whether all of these small
changes in BMD are attributable to pregnancy is also un-
clear, because all women went on to breastfeed before the
day 15 7 postpartum measurement, and bone loss occurs
rapidly during lactation (see sect. IVE). In contrast, radial
BMD was measured in a longitudinal study of 22 women
and a cross-sectional study of 75 women, and no change
was seen across the three trimesters in either study (609).
Peripheral ultrasound has been used during pregnancy.
Cross-sectional (307, 698) and longitudinal studies (234,
307, 378, 504, 722, 918, 1002) have found lower apparent
BMD in the os calcis or phalanges at the end of pregnancy,
but no effect was seen on the mid-tibial shaft (1015). How
469
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
relevant peripheral ultrasound at the heel or a finger during
pregnancy is for revealing changes in bone mass or miner-
alization at the spine or hip is uncertain. Notably, although
bone mass declines significantly during lactation, with the
most marked changes in the lumbar spine (see sect. IVE),
ultrasound of the os calcis and mid-tibial shaft showed no
changes (533, 917, 1015).
Overall, available data suggest that bone turnover increases
during pregnancy, especially during the third trimester.
There are real but small declines in BMD throughout the
skeleton that require a sufficiently large cohort to be de-
tected with confidence.
Are there any long-term impacts of skeletal changes induced
by pregnancy? This has been examined through numerous
epidemiological studies that have ascertained whether par-
ity confers any risk of lower BMD, an osteoporotic level of
BMD, or fragility fractures. The majority of such studies
have found either a neutral effect of parity (16, 38, 63, 71, 83,
144, 158, 162, 203, 212, 356, 368, 374, 383, 443 445, 457,
463, 482, 506, 507, 509, 525, 541, 547, 619, 636, 648, 683,
704, 715, 761, 770, 828, 833, 845, 846, 861, 864, 865, 935,
951, 969) or that parity confers greater BMD (27, 215, 244,
290, 292, 336, 341, 365, 522, 597, 611, 642, 661, 700, 804,
864, 879, 881, 934). Additional studies have reported that
parity decreases the risk of hip fractures (384, 397, 421, 460,
625, 689, 869, 997). One of the studies reporting a protective
effect of parity was particularly strong because it involved
1,852 twins and their female relatives, including 83 identical
twins who were discordant for ever being pregnant (700).
For balance, a few studies have found that parity is associ-
ated with reduced BMD (17, 80, 375, 472, 559, 686, 699)
or increased vertebral (97) or hip fracture risk (299). How-
ever, these reports are substantially outnumbered by the
aforementioned studies that found a neutral or protective
effect of parity. There are also divergent effects seen among
the different studies. For example, one study reported that
parity reduces femoral neck BMD but had no effect on
lumbar spine (416). Another found that parity reduces total
hip and femoral neck BMD in postmenopausal women, but
not in premenopausal women who are closer in time to the
event and therefore less likely to show confounding (1020).
Several studies also found that adolescent pregnancy was
associated with decreased bone density (292, 861, 864),
even though parity was not a significant factor in the overall
cohort. However, an NHANES study of 819 women ages
20 25 found that adolescent pregnancy did not reduce
peak bone mass as previously feared, since BMD was no
different regardless of whether these women had experi-
enced an adolescent pregnancy, an adult pregnancy, or no
prior pregnancies (169).
These epidemiological studies have a number of limitations.
It is difficult to separate the effects of parity from those of
470 Physiol Rev VOL 96 APRIL 2016 www.prv.org
lactation. Decades have passed in some cases between the
reproductive years and the time of the first BMD measure-
ment or fracture, such that confounding factors and events
in the elapsed time may have influenced the outcome. Such
confounding may be less likely in the NHANES study in-
volving women ages 20 25 since the pregnancies were only
a few years earlier, wherein no detrimental effect of parity
was seen. Overall, it seems most likely that parity has no
long-term adverse effect on BMD or fracture risk for most
women. It is not recognized as a significant factor for esti-
mating 10-yr risk of fracture in FRAX (929). However,
there may be a subset of women in whom parity does ad-
versely affect bone mass. These may include women in
whom significant nutritional deficiencies lead to increased
skeletal resorption during pregnancy to meet the fetal min-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
eral requirements, and some of these women may present
with fractures from pregnancy-associated osteoporosis (see
sect. IIIA).
3. Summary
Animal models suggest that bone mass may increase earlier
in pregnancy, whereas by the end of pregnancy bone mass is
approximately equal to or slightly lower than prepregnancy
or age-matched virgin values. Bone turnover (as assessed by
histomorphetry and bone resorption and formation mark-
ers) increases during late pregnancy in a pattern that pre-
dicts that some degree of bone loss has occurred in these
animal models. Whether there is any net loss of bone mass
by the end of pregnancy depends on the degree to which
bone mass increased earlier in pregnancy. Late pregnancy is
the interval of increased secondary hyperparathyroidism in
rat studies. Bone strength is probably unchanged at the end
of pregnancy. Some inconsistencies among the rat data (in-
creased, decreased, or no change in bone turnover, mass, or
strength) are not obviously explainable by the calcium con-
tent of the diet or the rat strain used. However, it is clear
that skeletal resorption and net bone loss increase in animal
models when a calcium-restricted diet is given during preg-
nancy.
Available data from pregnant women indicate that a posi-
tive calcium balance also occurs by mid-pregnancy, but
whether BMD is objectively increased at this time point has
not been determined. Upregulation of bone resorption oc-
curs in the third trimester and likely causes some bone loss,
with most women ending up with either no change or a very
modest decrease in BMD by term. Increased resorption and
net bone loss are more likely to occur in women who do not
absorb sufficient calcium to meet the combined needs of
themselves and their babies. Inadequate dietary calcium in-
take probably contributes to an increased risk of pregnan-
cy-associated osteoporosis (see sect. IIIA). In the long term,
these pregnancy-related changes in bone metabolism or
bone mass appear to have no adverse effect on the calcium
content or strength of the maternal skeleton, and may even
 CHRISTOPHER S. KOVACS
have a protective effect against low BMD and future risk of
fractures.
III. DISORDERS OF BONE AND MINERAL
METABOLISM DURING PREGNANCY
A. Osteoporosis in Pregnancy
1. Animal data
Fragility fractures do not normally occur as a result of preg-
nancy in animal models. This is consistent with upregula-
tion of intestinal calcium absorption usually being sufficient
to meet the mineral requirements of the fetuses, and the
finding that bone strength is unchanged at term. However,
it is clear that the maternal skeleton will be resorbed when
the maternal diet is inadequate. A low-calcium diet pro-
vokes marked secondary hyperparathyroidism during preg-
nancy (321), but even then, spontaneous fractures have not
been noted until lactation (350).
2. Human data
Osteoporotic fractures during pregnancy are very uncom-
mon, but they do occur. They have probably been occurring
in association with reproduction for the past five millennia,
because vertebral compression fractures and low BMD
have been found in Egyptian mummies and other archaeo-
logical skeletons of women who were 16 30 yr of age when
they died (883).
Osteoporosis presenting in pregnancy has been reviewed in
depth recently (501), and will be covered more briefly here.
There are two main presentations: vertebral fractures and
so-called transient osteoporosis of the hip.
A) VERTEBRAL AND OTHER FRACTURES IN PREGNANCY. Fragility
fractures of the spine (and less commonly other skeletal
sites) have occurred during the third trimester, and in the
puerperium of women who did not breastfeed. In both sit-
uations these fractures may be considered to have been
provoked by pregnancy (fractures during lactation are con-
sidered separately in sect. VA). In most affected women
there is no preceding bone mineral density (BMD) reading
because of no prior indication for it to have been done.
Serum chemistries and calciotropic hormone levels are usu-
ally unremarkable. However, bone loss is likely a factor in
pregnancy-related vertebral fractures, because the BMD is
usually low at presentation (475, 713, 849, 1005), and it
spontaneously improves afterward (259, 433, 713). In the
few cases where bone biopsies were done, mild osteoporosis
was observed (849, 850, 1005).
Insufficient calcium absorption (from dietary calcium defi-
ciency, lactose intolerance, celiac disease, other malabsorp-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
tive disorders, and vitamin D deficiency) is likely to induce
resorption of the maternal skeleton during the third trimes-
ter. A recent report described a woman with a calcium
intake of 229 mg daily, who developed multiple vertebral
compression fractures during pregnancy (501). Since that
amount was insufficient for her own nonpregnant needs,
the normal upregulation of intestinal calcium absorption
during pregnancy would not have benefited her. Significant
skeletal resorption was an inevitable consequence of her
pregnancy.
Another potential cause of physiological bone loss during
pregnancy is greater than normal release of PTHrP from the
placenta and breasts. The gradual rise in plasma PTHrP
(sect. IIA3) likely contributes to upregulation of calcitriol
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
synthesis, intestinal calcium absorption, and bone turnover
in all pregnant women. However, in individual reported
cases, high circulating levels of PTHrP have arisen from the
breasts or placenta and led to pseudohyperparathyroidism,
which is characterized by increased bone resorption and
severe hypercalcemia (see sect. IIIF) (270, 435, 474, 549).
High circulating levels of PTHrP that contributed to bone
resorption have also been noted in women who presented
with fragility fractures weeks after delivery (29, 751); such
high levels may have begun in pregnancy and contributed to
bone loss before delivery.
Additional factors that contribute to fracture risk during
pregnancy include increased weight-bearing (average
weight gain of 12 kg), lordotic posture, reduced bone mass
or strength that precedes pregnancy, and conditions that
cause bone loss during pregnancy. Published cases have
revealed such diverse conditions as anorexia, longstanding
hypomenorrhea or relative estradiol deficiency, premature
ovarian failure, petite stature or body frame, mild osteogen-
esis imperfecta, inactivating mutations in LRP5, dietary
calcium deficiency, renal calcium leak (hypercalciuria),
bedrest and inactivity, and pharmacotherapy before or
during pregnancy that may induce bone loss [heparin,
oral glucocorticoids, gonadotropin releasing hormone
(GnRH) analogs, depot medroxyprogesterone acetate,
and certain anticonvulsants] (501). A maternal family
history of severe osteoporosis is likely to be present in
women with pregnancy-associated fragility fractures
(259), which implies that genetic causes of low bone mass
or skeletal fragility may be present.
Pregnancy-associated osteoporosis typically occurs in a first
pregnancy, higher parity does not increase the risk, and
fractures usually do not recur in subsequent pregnancies
(243, 259, 475, 666, 713). These observations imply that in
many cases reversible factors (such as nutritional deficien-
cies) may have been corrected after the first pregnancy.
Permanent disorders such as osteogenesis imperfecta or
LRP5 mutations should be anticipated to maintain an in-
471
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
creased risk of vertebral and other fractures in subsequent
pregnancies.
Many uncontrolled treatments [nasal calcitonin (263, 687,
885), bisphosphonates (43, 143, 178, 263, 438, 475, 671,
677, 685, 799, 885, 897), strontium ranelate (897, 1016),
and teriparatide (98, 178, 377, 527, 544, 885)] have been
reported in various case series. Most of the authors of these
reports evidently did not appreciate that substantial spon-
taneous recovery of bone mass occurs even in women who
fractured, with BMD increases in the range of 20 70% in
individual cases. For example, a 50% increase in BMD
demonstrated by QCT in a woman who presented with a
compression fracture 1 wk postpartum (556). Therefore,
the attributable effect of pharmacological therapy may have
been greatly overestimated. It may be reasonable to wait
1218 mo for spontaneous recovery to occur before evalu-
ating whether the fracture risk remains high enough to war-
rant pharmacological therapy (501).
B) TRANSIENT OSTEOPOROSIS OF THE HIP. Transient osteoporosis
of the hip in pregnancy (also known as bone marrow edema
syndrome) is a rare condition of skeletal fragility. It appears
to be a form of chronic regional pain syndrome 1 or reflex
sympathetic dystrophy that most often involves the hips
(112, 147, 335, 351, 571). When it occurs in association
with pregnancy, its onset is usually during the third trimes-
ter or the puerperium with unilateral hip pain, limp, or a hip
fracture; it can also be bilateral at presentation (112, 272,
301, 335, 573, 688). The femoral head and neck are os-
teopenic and radiolucent on plain radiographs (147, 218,
571), while DXA suggests that the hip BMD is quite low
(301). The lumbar spine BMD is usually normal but if it is
also low, it is usually substantially higher than the femoral
neck BMD (31). Magnetic resonance imaging (MRI) studies
have revealed that the radiolucent femoral head and neck
are edematous, which suggests that the low DXA values in
the hip may be an artifact of that increased water content
(31, 523, 688, 892). Nevertheless, that bone marrow edema
is still an indication of fragility in the affected femora, and
prophylactic arthroplasties have been carried out in women
in whom the fracture risk was considered to be high. In
women who do not fracture, the MRI and DXA abnormal-
ities typically resolve rapidly within several months to a
year, leading to a 20 40% increase in femoral neck BMD
as the edema subsides (31, 43, 128, 147, 301, 335, 573,
892). Whether that is a real increase in mineralization or
removal of an artifact from bone marrow edema remains
uncertain.
The etiology of this condition is uncertain. It occurs
equally in men and women, and its occurrence during
pregnancy may simply be by chance. It might also be
triggered by pregnancy-related factors. Femoral venous
stasis caused by pressure from the pregnant uterus, rela-
tive immobilization from bed rest, and fetal pressure on
472 Physiol Rev VOL 96 APRIL 2016 www.prv.org
the obturator nerve are among the theories proposed to
explain its occurrence in pregnant women (112, 147,
218, 335, 499, 571). It is considered separately here be-
cause, unlike the vertebral and other fractures that some-
times occur during pregnancy, it does not seem to result
from systemic bone resorption. It also has different epi-
demiological characteristics, including that it can occur
in any pregnancy, and it has recurred in the other hip
either during a subsequent pregnancy or when not preg-
nant.
On the other hand, some patients who clearly had transient
osteoporosis of the hip also had very low spine BMD, ver-
tebral fractures, severe vitamin D deficiency, and prolonged
pregnancy/lactation cycles that may have caused general-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
ized bone loss (43, 48, 98, 691). Therefore, the two condi-
tions can coincide, despite evidence that they appear to have
a different pathogenesis and outcome.
3. Summary
Vertebral and (less commonly) other fractures may occur
during pregnancy in women with preexisting disorders of
skeletal fragility, and in women who experience greater
than expected skeletal resorption during gestation. Nutri-
tional deficiencies and malabsorptive disorders are particu-
larly likely to cause problems because insufficient mineral
delivery to the fetus will prompt compensatory resorption
of the maternal skeleton. Transient osteoporosis of the hip
may be a distinct disorder that does not occur from gener-
alized bone resorption, but instead results in focal edema
and fragility of the femoral head and neck.
B. Primary Hyperparathyroidism
1. Animal data
Several mouse models for primary hyperparathyroidism,
such as mutations in Men1, have been created, but as yet
none has been studied during pregnancy. Maternal hyper-
calcemia induced by calcium infusions causes increased fe-
tal calcium and suppressed fetal PTH concentrations in
ewes, confirming that maternal hypercalcemia adversely af-
fects fetal and neonatal parathyroid function (456).
Heterozygous inactivating mutations in the calcium sensing
receptor (CaSR) create a condition similar to primary hy-
perparathyroidism, and relevant data from pregnant
Casr/ mice are discussed in section IIIC. A postpartum
surge in serum calcium occurs in normal rodents, and the
peak serum calcium should be even higher in rodents with
underlying primary hyperparathyroidism.
2. Human data
The exact prevalence of primary hyperparathyroidism dur-
ing pregnancy is uncertain. A recent retrospective series
 CHRISTOPHER S. KOVACS
found that it occurred in 0.03% of reproductive age women
who underwent routine screening of serum calcium (391).
Several hundred cases have been described in English-lan-
guage medical journals (354, 391, 466), while the authors
advice has been sought for several cases each year by clini-
cians around the globe. Primary hyperparathyroidism is
10 20 times more likely to occur in women over age 45
than in women of child-bearing age (373, 980), but in two
case series, 1% of all parathyroidectomies were done in
pregnant women (466, 490). The pathology is similar to
nonpregnant cases: a predominance of single adenomas fol-
lowed by four-gland hyperplasia (267, 466).
The dilutional fall in serum albumin and calcium (see sect.
IIA1) and suppression of PTH (see sect. IIA2) during nor-
mal pregnancy may mask the hypercalcemia and delay the
diagnosis. An elevation in ionized or albumin-corrected cal-
cium, combined with a nonsuppressed PTH level, confirms
the presence of primary hyperparathyroidism during preg-
nancy.
The physiology of normal pregnancy can worsen hypercal-
cemia caused by primary hyperparathyroidism since both
conditions cause increased intestinal calcium absorption,
hypercalciuria, and some degree of increased bone resorp-
tion. This may explain the perceived increased risks of se-
vere hypercalcemia, pancreatitis, and kidney stones when
primary hyperparathyroidism occurs during pregnancy.
Conversely, rapid placental calcium transfer and uptake of
calcium by the fetal skeleton during the third trimester may
help protect against severe hypercalcemia in the mothers.
Loss of outflow to the placenta likely explains why hyper-
calcemic crises have occurred after delivery of the placenta
(612, 662, 701, 795). Physical inactivity and bedrest will
add an additional component of skeletal resorption. Con-
sistent with the animal models, maternal hypercalcemia will
increase the flow of calcium across the placenta, thereby
suppressing the developing fetal parathyroids. The in-
creased fetal serum calcium may in turn cause increased
renal water excretion, thereby explaining association of
maternal primary hyperparathyroidism with polyhydram-
nios (825).
Historically, primary hyperparathyroidism had been con-
sidered to be an adverse condition that should be dealt with
during pregnancy. Older cases series suggested that signifi-
cant maternal morbidity and mortality occurred in up to
67% of mothers, while up to 80% of fetuses and neonates
experienced morbidity or mortality (803). Hypercalcemia
causes nonspecific, constitutional symptoms that are diffi-
cult to distinguish from normal symptoms encountered dur-
ing pregnancy, including nausea, hyperemesis, constipa-
tion, fatigue, weakness, and mental symptoms (508). More
marked hypercalcemia during pregnancy has been associ-
ated with hyperemesis, weight loss, seizures, and pre-
eclampsia (418, 466, 490). Additional maternal morbidity
Physiol Rev VOL 96 APRIL 2016 www.prv.org
includes nephrocalcinosis, nephrolithiasis, urinary tract in-
fections, acute pancreatitis, and increased bone loss (508,
824). Fractures are uncommon but have occurred with
more severe primary hyperparathyroidism and parathyroid
carcinoma (381, 651). In up to 15% of cases women pre-
sented with pancreatitis during the second or third trimester
(153, 186, 205, 429, 508, 511). Hypercalcemic crises have
occurred during the third trimester (153, 186, 662, 795),
which coincides with peak release of PTHrP by the placenta
and breasts. There are risks to the fetus and neonate that
must be considered, including miscarriage, stillbirth, and
hypoparathyroidism, and these are discussed in more detail
in the companion review (492).
This historic view has led to a general preference for para-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
thyroidectomy to be done during the second trimester to
prevent fetal and neonatal morbidity and mortality, and a
postpartum parathyroid crisis in the mother. There are no
randomized trials comparing surgical, medical, and obser-
vational approaches, while consensus guidelines for the man-
agement of primary hyperparathyroidism have not addressed
pregnancy (82). A retrospective review found significantly
fewer neonatal deaths and complications in surgically treated
mothers compared with the medically managed group (466).
The second trimester is considered to have a lower risk of
anesthetic or surgical complications, precipitated delivery, and
neonatal death, compared with surgery during the third tri-
mester (153, 236, 508, 824), although individual case reports
have supported the apparent safety of third trimester surgery
(354, 662, 711, 802).
A more modern view is that the maternal and fetal risks of
primary hyperparathyroidism may have been exaggerated
by reporting bias of more severe cases in the older literature,
with the often milder cases seen today not necessarily re-
quiring intervention during pregnancy. However, the most
recent consensus guidelines for management of asymptom-
atic primary hyperparathyroidism recommend surgery for
all individuals under age 50, which should encompass all
pregnant women (82). From that perspective the only ques-
tion is whether surgery should be done during the second
trimester or postpartum.
A recent retrospective analysis of a database registry found
1,057 reproductive-aged women with primary hyperpara-
thyroidism, of whom 60% had been pregnant before the
diagnosis and 15% had been pregnant after the diagnosis
(3). Compared with 3,171 age-matched women, there was
no apparent difference in the incidence of spontaneous
abortions, but the rate of C-sections was twice that of con-
trols in women who had a pregnancy after the diagnosis
was known (3). That study is limited because no data were
available on the mothers during the pregnancies or on neo-
natal complications. Another retrospective study reported
on 74 women with primary hyperparathyroidism who had
had 134 pregnancies and who were compared with 175
473
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
normocalcemic women who had experienced 431 pregnan-
cies over the same interval (391). There was no difference in
the rate of spontaneous abortions or pregnancy-related
complications between women with and without primary
hyperparathyroidism during pregnancy, but neonatal com-
plications were not reported (391). Additional cases suggest
that the rate of still birth, neonatal death, and neonatal
tetany are far less with modern compared with older case
series (824). But even in modern cases fetal death still oc-
curs, such as in 30/62 medically managed cases that ended
in a late spontaneous abortion (the risk correlated with the
level of maternal serum calcium), whereas no complications
were seen in 15 cases operated upon during the second
trimester (667). Neonatal hypocalcemia and tetany still oc-
cur after supposed mild primary hyperparathyroidism in
the mothers (716) and the hypoparathyroidism can be pro-
longed and permanent (125, 576, 824). A twin pregnancy
illustrated the variability of responses to maternal primary
hyperparathyroidism, with one neonate having hypocalce-
mic seizures and the other staying normocalcemic (616).
3. Summary
Key points about primary hyperparathyroidism during
pregnancy are that maternal and fetal complications appear
to be less likely with the milder forms of the condition that
are usually encountered today; however, the risks are not
absent. If surgery is to be carried out it should be safer to do
this in the second trimester. In cases that are only observed,
the clinician should be aware of the potential for a hyper-
calcemic crisis to occur during the third trimester and even
more abruptly after delivery. The baby must be watched for
neonatal hypocalcemia that can have a delayed onset, a
prolonged course, and even be permanent (492).
C. Familial Hypocalciuric Hypercalcemia
1. Animal data
Casr/ mice have an inactivating mutation in one allele of
the gene encoding the CaSR and are the murine equivalent
of familial hypocalciuric hypercalcemia (FHH). They have
classical findings of chronic hypercalcemia, relative hy-
pocalciuria, and increased PTH (394); the condition devel-
ops in utero with hypercalcemia (498). Pregnancies are un-
eventful, but maternal hypercalcemia leads to suppressed
PTH in the fetuses compared with offspring of the same
genotype borne by their WT sisters (498). Homozygous
offspring provide a model for neonatal severe hypercalce-
mia in humans, and die within 3 wk after birth unless res-
cued by surgical parathyroidectomy or genetic ablation of
Pth or Gcm2 (394, 491, 498, 562, 932).
2. Human data
FHH is caused by autosomal dominant, inactivating muta-
tions in CASR that lead to chronic hypercalcemia, hypocal-
474 Physiol Rev VOL 96 APRIL 2016 www.prv.org
ciuria, and nonsuppressed PTH (122). It is asymptomatic
because its origin in utero causes all tissues to be fully adapted
to a higher level of calcium, while the relative hypocalciuria
protects against nephrocalcinosis and nephrolithiasis. The hy-
percalcemia with elevated PTH persists during pregnancy as
expected (727); however, increased intestinal calcium absorp-
tion during pregnancy causes absorptive hypercalciuria and
not the expected diagnostic finding of hypocalciuria (638,
968). Consequently, the diagnostic criteria for FHH can be
confounded during pregnancy by results that suggest primary
hyperparathyroidism may be present. Pregnancies in affected
women are uneventful; in fact, many documented cases in-
volve the diagnosis being made in the mothers only after their
babies presented with neonatal hypocalcemia or seizures (727,
913, 914). This neonatal hypoparathyroidism originates in
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
utero with increased flux of calcium across the placenta caus-
ing suppression of the fetal parathyroids (as in the animal
model), and that suppression can last for days to months after
birth. Suppression has even occurred in a baby carrying the
inactivating CASR mutation, who presented with neonatal
hypocalcemia, but later went on to develop the expected hy-
percalcemia with high PTH (912). Babies who are homozy-
gous or compound heterozygous for inactivating CASR
mutations (297, 579), and occasionally babies with only a
single known mutation that may exert a dominant-negative
effect (45, 673), develop life-threatening neonatal severe
hypercalcemia that can be rescued by three-and-a-half
gland parathyroidectomy.
It is important to consider the possibility of FHH whenever
a woman presents with hypercalcemia during pregnancy,
and to be wary that the urine calcium excretion will not be
reduced as expected. Surgery is not indicated for FHH, and
if the serum calcium were to be reduced to normal, it
would cause symptomatic hypocalcemia. Unfortunately, at
least one woman with FHH underwent a three-and-a-half
gland parathyroidectomy during the second trimester when
she presented with marked hypercalcemia and hypercalci-
uria, and she was only recognized to have FHH when hy-
percalcemia persisted and her baby was affected too (968).
3. Summary
Key points about FHH in pregnancy are that it is uneventful
in the mother, it may be confused with primary hyperpara-
thyroidism because the normal physiological changes of
pregnancy lead to hypercalciuria, and it is not necessarily
benign for the offspring who are at risk for developing
neonatal hypocalcemia.
D. Hypoparathyroidism
1. Animal data
The role that PTH might play in regulating maternal min-
eral and bone homeostasis during pregnancy has been in-
 CHRISTOPHER S. KOVACS
vestigated by studies in parathyroidectomized rats and Pth
null mice.
When hypocalcemic, parathyroidectomized Sprague-Daw-
ley rats maintained on a 1.2% calcium diet became preg-
nant, the serum calcium increased to near-normal, serum
phosphorus reduced to normal, and intestinal calcium ab-
sorption more than doubled compared with nonpregnant,
parathyroidectomized rats (425). In fact, the increased rate
of intestinal calcium absorption during pregnancy was not
significantly different between intact and parathyroidecto-
mized rats (425). Similarly, studies in pregnant Pth null
mice consuming a 1% calcium diet found that serum cal-
cium increased to normal, serum phosphorus normalized,
serum calcitriol increased over fivefold, and bone mineral
content increased by 15% over prepregnancy values (478).
The mean peak serum calcitriol concentration was nonsig-
nificantly lower than in pregnant WT mice, while increased
renal expression of Cyp24a1 in Pth nulls suggested that
increased catabolism of calcitriol likely explained any re-
duction in its peak level (478). In these studies in rats and
mice, the sole intervention was that the animals became
pregnant; there was no change in diet to explain the ob-
served biochemical and physiological changes. These find-
ings indicate that PTH is not essential for regulating mineral
homeostasis during pregnancy, and that in particular, other
factors stimulate synthesis of calcitriol and upregulation of
intestinal calcium absorption in the absence of PTH.
On the other hand, in a series of related studies from one
laboratory, parathyroidectomized Wistar rats on a 0.9%
calcium diet developed worsening hypocalcemia and hyper-
phosphatemia between 16.5 and 21.5 days of gestation, and
up to 40% experienced tetany or sudden death either dur-
ing late pregnancy or while giving birth (163, 313, 314,
328). Serum calcitriol and intestinal expression of
calbindin9K-D levels in parathyroidectomized rats were
50% of the values in intact rats at day 21.5 of pregnancy
(313), but no earlier measurements were done. Therefore,
whether the calcitriol level or calbindin9K-D expression had
increased from earlier in pregnancy in parathyroidecto-
mized or intact rats remains unknown.
Parathyroidectomized Sprague-Dawley rats maintained on
a 0.75% calcium diet also became hypocalcemic in late
gestation, but serum calcitriol more than tripled over the
last several days of pregnancy, and achieved a mean value
that was modestly but not significantly lower than the cal-
citriol level of intact pregnant rats (658). Moreover, 24,24-
dihydroxyvitamin D, a product of the Cyp24a1 enzyme,
showed consistently higher levels in parathyroidectomized
rats throughout pregnancy (658). This is consistent with the
known effect of PTH to suppress Cyp24a1 activity and
expression (752, 835, 1023, 1024); consequently, loss of
PTH causes increased Cyp24a1-mediated catabolism of 25-
hydroxyvitamin D and calcitriol.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
A set of studies done in 1936 remain illuminating. When para-
thyroidectomized rats from an unspecified strain consumed a
1.2% calcium diet with low phosphorus content, the serum
calcium at term was normal or elevated (94). On the other
hand, when a 0.45% calcium diet was provided, the serum
calcium in pregnant parathyroidectomized rats was 50% of
the value of intact rats on the same diet (94).
Collectively these studies support that PTH-independent
upregulation of calcitriol synthesis and intestinal calcium
absorption occur during pregnancy, but they differ in
whether the parathyroidectomized rodents ability to main-
tain her own serum calcium is improved or worsened during
pregnancy. Since late pregnancy is the interval when rapid
fetal accretion of calcium is occurring, it is clear that flux of
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
calcium to the fetuses provokes some parathyroidectomized
rats to become hypocalcemic, whereas others normalize se-
rum calcium.
Why do some PTH-depleted rodents become hypocalcemic
while others become normocalcemic during pregnancy?
Genetic differences may account for Sprague-Dawley rats
and Black Swiss mice upregulating calcitriol synthesis and
intestinal calcium absorption through PTH-independent
mechanisms during pregnancy, whereas Wistar rats may
not do this. However, another relevant factor is the calcium
content of the diet, with parathyroidectomized rats more
likely to have hypocalcemia during pregnancy when con-
suming a moderately restricted (0.45%) calcium diet. De-
spite increased intestinal calcium absorption, intact rats
consuming a 0.45% calcium diet have secondary hyper-
parathyroidism with increased skeletal resorption during
the last several days of pregnancy (see sect. II, A2 and D),
but parathyroidectomized rats lack the ability to upregulate
PTH-mediated skeletal resorption. Instead, parathyroidec-
tomized rats must rely on dietary calcium intake alone to
meet the fetal demand for mineral. A 0.45% calcium diet is
clearly insufficient despite any upregulation of intestinal
calcium absorption and calcitriol that may occur in the
absence of PTH. A previously cited study showed that a
1.0% calcium diet enables 92% of the calcium in the fetuses
to come from the maternal diet during pregnancy in intact
rats (974), but on a 0.45% calcium diet, more of the cal-
cium in the fetuses must have been resorbed from the ma-
ternal skeleton.
A series of studies in an unspecified rat strain, likely con-
suming a 0.45% calcium diet, found that thyroparathyroid-
ectomy reduced the number of implantations, embryos, and
live pups. The mothers also had a lower unadjusted serum
calcium at day 14 and 20 of pregnancy compared with
sham-operated rats (49, 50). Sequential treatments with
PTH, calcitonin, and thyroid hormone revealed that these
reductions in offspring numbers were due to the hypothy-
roidism, whereas the hypoparathyroidism itself had no ef-
fect (49, 50).
475
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
2. Human data
Hypoparathyroidism is usually known to be present prior
to pregnancy. However, in specific cases, asymptomatic
women have not been recognized until the newborn pre-
sented with severe secondary hyperparathyroidism, hyper-
calcemia, increased bone resorption, and fractures (242,
912). If the mother remains hypocalcemic during preg-
nancy, maternal hypoparathyroidism can have a serious
adverse impact on the fetus and neonate (492).
The animal data discussed above indicate that hypopara-
thyroidism can improve or worsen during pregnancy, and
the same divergent outcomes are true for hypoparathyroid-
ism in women.
Multiple case reports described that hypoparathyroidism
improves during pregnancy, with subjective evidence of
fewer hypocalcemic symptoms or objective evidence of re-
duced maternal requirement for calcitriol, 1-hydroxyvita-
min D, vitamin D, and supplemental calcium (88, 120, 213,
285, 340, 343, 747, 777, 785, 890). In the most well doc-
umented of these cases, calcitriol had to be progressively
decreased and then stopped due to recurrent hypercalcemia,
and the patient was then managed solely on 1.2 g calcium
daily during the third trimester (890). The author is aware
of other unpublished cases in which hypoparathyroidism
improved during pregnancy and calcitriol was either signif-
icantly decreased or stopped. A report of 10 cases of hypo-
parathyroidism found that the ionized calcium was normal
during pregnancy with 2 g supplemental calcium and either
vitamin D2 or D3 but no calcitriol, and that the only change
that occurred was a marked decrease in the albumin-bound
fraction of serum calcium (340). These improvements in
hypoparathyroidism during pregnancy imply that upregu-
lation of calcitriol and/or intestinal calcium absorption oc-
curs, which is consistent with the rodent models. However,
in at least one case where subjective improvement in mater-
nal symptoms was reported but no objective monitoring of
serum calcium had been done, a fetus had secondary hyper-
parathyroidism, which implied that maternal serum cal-
cium was not optimal (120).
Some reports have found no change in the serum calcium
during pregnancy while on a stable dose of calcium with
vitamin D or calcitriol (213, 264, 995), with two of these
reporting a small increase in serum calcium in the last few
days before delivery (264, 995). Since the serum calcium
was not adjusted for the serum albumin in these cases (213,
264, 995), the lack of fall in unadjusted serum calcium
during pregnancy may indicate that the ionized calcium had
increased. Two reports found that the ionized calcium did
not change throughout pregnancy (30, 302), but in one of
these cases it abruptly fell and became symptomatic during
labor (302).
476 Physiol Rev VOL 96 APRIL 2016 www.prv.org
In contrast to these reports of improved or stable calcium
metabolism, other reports have found that hypoparathy-
roidism significantly worsens during pregnancy: serum cal-
cium falls, hypocalcemic symptoms may or may not in-
crease, and the doses of supplemental calcium and vitamin
D, 1-hydroxyvitamin D, or calcitriol have been increased
(96, 141, 148, 411, 434, 510, 517, 600, 669, 790, 796, 821,
837, 884, 936). In one woman the endogenous calcitriol
level was low at mid-pregnancy, but measurements in the
third trimester were not reported (510). In most cases cal-
citriol levels cannot be interpreted due to ongoing treatment
with exogenous calcitriol or 1-hydroxyvitamin D (endog-
enous and exogenous calcitriol are indistinguishable).
Among some of the reports suggesting that hypoparathy-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
roidism may worsen during pregnancy, it appears that the
normal dilutional fall in serum calcium during pregnancy
prompted an increase in doses of calcium, vitamin D, or
vitamin D analogs. For example, in one case in which a
significant fall in serum calcium had been inferred, and
increases in both calcium and calcitriol intakes were done,
the albumin had fallen from 4.2 to 2.0 g/dl (837). With the
use of the data in that report, it is evident that the albumin-
corrected serum calcium was 9.5 mg/dl (normal) when
pregnancy was diagnosed and 10.2 mg/dl (normal) 2 wk
before delivery, with an increase and not a decline evident.
Treatment of the albumin-related fall in serum calcium re-
sulted in a woman being made iatrogenically hypercalcemic
(2.80 4.0 mM) for the duration of pregnancy (600), while
another woman became hypercalcemic in late gestation
(411). This iatrogenic hypercalcemia must be avoided since
maternal hypercalcemia suppresses the fetal parathyroids
and increases the risk of spontaneous abortion (492). In
another case the physiological, absorptive hypercalciuria of
pregnancy was misinterpreted as evidence of worsening hy-
poparathyroidism, and resulted not only in increases to the
calcium and calcitriol doses, but the addition of a thiazide
diuretic to reduce renal calcium excretion (thiazides are
category C medications for pregnancy) (517). Clear wors-
ening of hypoparathyroidism during pregnancy occurred in
a woman taking high-dose prednisone and azathioprine due
to a kidney transplant (736), and it is likely that the effect of
high-dose prednisone to reduce intestinal calcium absorp-
tion was a significant factor in the apparent worsening dur-
ing pregnancy.
Why do hypoparathyroid women exhibit such markedly
different responses to pregnancy, with evidence of clear
improvement in some cases and clear worsening in others?
This may be explained in part by variations in the adaptive
responses or achieved concentrations of other hormones
that are thought to stimulate intestinal calcium absorption
or calcitriol synthesis. For example, high estradiol concen-
trations of pregnancy may cause more suppression of bone
turnover in some women, and more potent stimulation of
Cyp27b1 in other women. Calcium intake is likely an im-
 CHRISTOPHER S. KOVACS
portant factor, as it is in the rodent models, with the ideal
minimum intake considered to be 1.2 g daily based on the
Institute of Medicine guidelines (774). In half of the reports
in which hypoparathyroidism appeared to worsen during
pregnancy, either no supplemental calcium or at most 300
mg daily was being taken, and the dietary intake of calcium
was unknown (96, 411, 434, 510, 600, 669, 790, 936).
Lack of adequate intake of calcium in the first half of preg-
nancy likely prevents the net positive calcium balance being
achieved that most women experience during pregnancy,
and increases the likelihood of problems in the third trimes-
ter. There may be variations in the degree to which PTHrP
release from breasts and placenta, or increases in other
pregnancy hormones (placental lactogen, oxytocin, etc.),
contribute to regulating maternal mineral homeostasis dur-
ing pregnancy. A more recent series of 10 cases from one
group of investigators suggests the same variability in re-
sponse to the challenge of pregnancy (369).
To avoid confusion, the ionized calcium or albumin-cor-
rected calcium must be followed during pregnancy. Adjust-
ments will need to be made to calcitriol and calcium intake
as determined by the individual womans response to preg-
nancy, with some women requiring decreases in both sup-
plements, others requiring progressive increases, and still
others requiring no changes. PTH itself is not normally
replaced because of its expense and short half-life, but one
case demonstrated that a continuous infusion of teripa-
ratide can normalize calcium homeostasis during preg-
nancy (427).
The treatment target in nonpregnant adults is to maintain
the albumin-adjusted calcium at or just below the lower end
of normal, to minimize symptoms while protecting the kidneys
from an increased filtered load of calcium and consequent
nephrocalcinosis. However, for the 9 mo of pregnancy, the
target should be to maintain the ionized or albumin-corrected
calcium within the normal range, thereby minimizing the risk
of fetal and neonatal complications from maternal hypocalce-
mia, including premature labor and severe secondary hyper-
parathyroidism (492, 528). Conversely, hypercalcemia must
also be avoided because of the adverse effects that it has on
fetal development (492).
3. Summary
Available animal and human data indicate that two polar
opposite outcomes can occur with hypoparathyroidism
during pregnancy: it can become objectively improved (nor-
malization of serum calcium and phosphorus with reduced
need for supplemental calcium and calcitriol) or worsen
(more marked hypocalcemia requiring significant increases
in supplemental calcium and calcitriol). It may also exhibit
no significant changes during pregnancy. Furthermore, re-
liance on the unadjusted serum calcium has led to unneeded
interventions in some cases where clinicians did not appre-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
ciate that the serum calcium normally falls during preg-
nancy.
The variability in responses to pregnancy may be related to
the calcium content of the diet, contributions of PTHrP and
other pregnancy-related hormones to regulating maternal
mineral homeostasis, and genetic or ethnic differences. Sig-
nificant maternal hypocalcemia must be avoided during
pregnancy because it increases the risk of fetal mortality
(spontaneous abortion and still birth) and severe secondary
hyperparathyroidism with fractures in the fetus and neo-
nate. Iatrogenic hypercalcemia should also be avoided. The
albumin-corrected or ionized calcium should be monitored
for certainty about when a change in therapy is needed.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
E. Pseudohypoparathyroidism
1. Animal data
A mouse model of pseudohypoparathyroidism has not been
studied during pregnancy (322).
2. Human data
Pseudohypoparathyroidism results from genetically inher-
ited, post-receptor defects in Gs that create end-organ resis-
tance to PTH (61). Characteristic findings include hypocalce-
mia, hyperphosphatemia, blunted phosphaturic response to
PTH, and high concentrations of PTH. Type I demonstrates
blunting of PTH-induced urinary excretion of both phosphate
and cAMP, while type II has blunting of PTH-induced urinary
excretion of phosphate only.
Type I pseudohypoparathyroidism appeared to improve
during pregnancy in two women who maintained 1 g sup-
plemental calcium intake daily during four pregnancies, in-
cluding that hypocalcemic symptoms abated, normocalce-
mia was achieved, PTH levels decreased to near-normal,
calcitriol levels increased three- to fourfold, urinary excre-
tion of calcium after a 1 g calcium load normalized (an
indicator of normal intestinal calcium absorption), and sup-
plemental vitamin D or vitamin D analogs were no longer
required (110). In both women the hypocalcemic symptoms
promptly returned within 3 wk after delivery (they did not
breastfeed) (110). These reports suggest that PTH-indepen-
dent increases in intestinal calcium absorption and calcitriol
synthesis occur during pregnancy in pseudohypoparathy-
roidism type I, and that the effects are sustained for some
time after delivery.
On the other hand, four case reports involving seven preg-
nancies in women with types I and II pseudohypoparathy-
roidism found that the dose of calcium, calcitriol, or 1-
calcidiol had to be increased to maintain a normal serum
calcium during pregnancy (668, 676, 793, 814). In the first
report involving two pregnancies in type I pseudohypopara-
477
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
thyroidism complicated by severe nausea and vomiting, a
woman experienced an asymptomatic drop in the unad-
justed serum calcium during a first pregnancy that
prompted an increase in both calcium and calcitriol, while
during her second pregnancy she proved intolerant of more
than 500 mg calcium per day and had a modest decline in
the ionized calcium during the third trimester (668). In the
second report a woman who was diagnosed to have type II
pseudohypoparathyroidism years after her two pregnan-
cies, recalled that worsening of hypocalcemic-like symp-
toms had occurred during the second half of each preg-
nancy, and a single low value of serum calcium from the
second pregnancy (left untreated) was found in an old doc-
ument to corroborate her statement (793). She had not
taken any calcium supplements during those pregnancies.
The third report involved two pregnancies in the same
woman with type I pseudohypoparathyroidism who took a
fixed dose of 1-calcidiol but no supplemental calcium
throughout each pregnancy, and the albumin-adjusted se-
rum calcium declined in the latter half of both (814). In the
second pregnancy serum calcitriol doubled during the first
half, before declining to the prepregnancy value in the sec-
ond half, accompanied by the fall in albumin-adjusted cal-
cium and a rise in PTH (814). In a fourth case, the protein-
adjusted serum calcium was followed during a pregnancy of
a woman with type I pseudohypoparathyroidism, the dose
of calcitriol remained unchanged, but the dose of calcium
was increased from 250 mg in the first trimester to a median
1 g during the third trimester (676). There is a fifth report
involving a woman with type I pseudohypoparathyroidism
who presented at the 24th week of pregnancy and was
placed on calcium and calcitriol, but the lack of baseline
data means that it is unknown whether the condition was
altered at all by pregnancy (843).
An older case predating the availability of calcitriol in-
volved a woman who presented in the second trimester, had
normal serum calcium and phosphorus, and was prospec-
tively given 4 g calcium daily. Her unadjusted serum cal-
cium remained normal, but the supplemental calcium was
increased to 5 g daily, and 1,000 IU vitamin D daily was
added when she reported intermittent mild paresthesias
(323).
As with hypoparathyroidism, PTH-independent upregula-
tion of calcitriol synthesis or intestinal calcium absorption
could explain why pseudohypoparathyroidism may im-
prove during pregnancy. Calcitriol doubled during the sec-
ond and third trimester for two women in which pseudo-
hypoparathyroidism improved and supplemental calcitriol
was stopped (110). In one woman whose serum calcium
was stable in the first two trimesters before hypocalcemia
occurred in the third trimester, this was paralleled by in-
creases in endogenous calcitriol during the first two trimes-
ters and a decline to prepregnancy values in the third tri-
mester (814). The change in serum calcitriol among these
478 Physiol Rev VOL 96 APRIL 2016 www.prv.org
women suggests that whether or not the expected pregnan-
cy-related increase in serum calcitriol occurs during the
third trimester predicts whether pseudohypoparathyroid-
ism objectively improves or worsens during pregnancy.
In addition to the possibility that hormones of pregnancy
stimulate Cyp27b1 or intestinal calcium absorption di-
rectly, it is possible that the hormonal changes during preg-
nancy (such as higher estradiol levels) could improve post-
receptor signaling. The level of calcium intake is likely an
important variable. In the four pregnancies in which pseu-
dohypoparathyroidism objectively improved, 1 g supple-
mental calcium was taken throughout (110), whereas in
four of the pregnancies where it worsened, the women took
no supplemental calcium (793, 814), and in the remaining
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
three pregnancies the worsening occurred when the supple-
mental intake was 250 or 500 mg daily (668, 676). In none
of these pregnancies was the dietary intake of calcium re-
ported. As noted in sections I and IIB, the normal physiol-
ogy of pregnancy means that recommended dietary intake
of calcium (1.25 g daily) (430), combined with doubling of
efficiency of intestinal calcium absorption, should be more
than sufficient to meet the combined needs of mother and
fetus during the third trimester. Women normally achieve a
positive calcium balance in the first half of pregnancy which
likely facilitates meeting the fetal demand for calcium in the
third trimester. But if calcium intake is below 1.25 g daily in
normal women, then secondary hyperparathyroidism must
be invoked to provide additional mineral, so it should not
be surprising that pseudohypoparathyroidism will worsen
if calcium intake is inadequate during pregnancy.
Placental production of calcitriol is unlikely to improve
pseudohypoparathyroidism, given the evidence cited in sec-
tion IIA4 that the placenta contributes little to the rise in
calcitriol during human pregnancy. This was further con-
firmed by analysis of placentas from four pseudohypopara-
thyroid women, which revealed that calcitriol production
was no different than in placentas from normal women
(1017).
3. Summary
As with hypoparathyroidism, it seems that pseudohypo-
parathyroidism can have polar opposite outcomes during
pregnancy: objectively improved or objectively worsened.
In the absence of dietary intake data, a minimum supple-
mental calcium intake of 1 g taken throughout pregnancy is
likely necessary for the physiological adaptations of preg-
nancy to be able to meet the fetal demand for mineral.
Additional variability may be due to relative contributions
of pregnancy-related hormones to regulating maternal min-
eral homeostasis, and genetic or ethnic differences that in-
fluence the pregnancy-related adaptations and the pheno-
type of pseudohypoparathyroidism. PTHrP may work on
bone but would not be expected to contribute to the in-
crease in renal Cyp27b1 activity because of the absence of
 CHRISTOPHER S. KOVACS
Gs activity in the proximal tubule of women with pseudo-
hypoparathyroidism.
The goal of management during pregnancy should be to
maintain a normal ionized or albumin-corrected serum cal-
cium in the mother, thereby minimizing the risk of fetal and
neonatal complications from maternal hypocalcemia or hy-
percalcemia (492). This means expectant management with
appropriate increases or decreases in calcium and calcitriol
as required during each pregnancy.
F. Pseudohyperparathyroidism
1. Animal data
Animal models have confirmed the production of PTHrP by
mammary tissue and placenta, but the extent to which these
sites contribute to mineral homeostasis during pregnancy
has not been determined. Conversely, it is clear from animal
models that PTHrP derived from mammary tissue is an
important regulator during lactation, as discussed in sec-
tions IV, A3, B, DF, and VD.
2. Human data
As noted in section IIA3, the breasts and placenta are
sources of PTHrP in the maternal circulation during preg-
nancy. The achieved release of PTHrP appears to be rela-
tively autonomous, independent of serum calcium but cor-
relating with the amount of mammary tissue.
Pseudohyperparathyroidism is PTHrP-mediated hypercal-
cemia. Its occurrence during pregnancy confirms the poten-
tial physiological importance of the breasts and placenta in
contributing to the regulation of maternal mineral homeo-
stasis.
Separating out the potential effects of breasts and placenta
as sources of excess PTHrP has been possible based on
individual case reports. PTHrP-mediated hypercalcemia
has occurred in women with massive mammary hyperplasia
while pregnant or nonpregnant, and in pregnant women
with normal-sized breasts (435, 474, 549, 603, 639, 800).
In several cases hypercalcemia became evident during preg-
nancy, serum PTH was undetectable, PTHrP was either
increased in plasma or high levels of PTHrP expression were
found in the breasts, and the hypercalcemia resolved only
after bilateral mastectomy or weaning (435, 474, 549). In
another case a woman with normal-sized breasts was un-
able to breastfeed because her neonate was critically ill, and
she went into a postpartum hypercalcemic crisis (800). The
cord blood serum calcium was higher than normal, con-
firming that mother and baby had been hypercalcemic prior
to delivery (800). Furthermore, the mother was hypercalce-
mic 3 days after delivery with a PTHrP level of 28.4 pM.
Since PTHrP has a half-life of minutes in the circulation,
Physiol Rev VOL 96 APRIL 2016 www.prv.org
similar to PTH, this confirms that the breasts must have
been the sustained source of PTHrP, and not (as the authors
of that report inferred) the placenta. Another pregnant
woman presented with marked hypercalcemia (serum cal-
cium 4.00 mM) associated with high calcium intake and
elevated PTHrP of 34.9 pM (639). The hypercalcemia re-
solved promptly, and she did not breastfeed, but the ele-
vated PTHrP did not become undetectable until 3 mo post-
partum.
Pseudohyperparathyroidism also occurs during lactation,
and the ability of breast-derived PTHrP to normalize min-
eral homeostasis in lactating women with hypoparathy-
roidism is further validation of the importance of the
breasts as a physiologically relevant source of PTHrP (see
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
sections IVA3 and V, D and F).
But pseudohyperparathyroidism has also occurred from ex-
cess PTHrP that clearly originated from the placenta. This
has been demonstrated in a woman with normal-sized
breasts who developed severe hypercalcemia (21 mg/dl or
5.25 mM), undetectable PTH, and a serum PTHrP of 21
pM in the third trimester (270). Six hours after an urgent
C-section, she was profoundly hypocalcemic with undetect-
able PTHrP and elevated PTH (270). The rapid reversal in
status is most consistent with placental-derived PTHrP
causing hypercalcemia.
3. Summary
Hypercalcemia can occur during pregnancy as a result of
excess physiological release of PTHrP from the breasts and
placenta; this differs from pathological release that occurs
in hypercalcemia of malignancy (see sect. IIIJ). When the
placenta is the cause, the hypercalcemia should be corrected
within hours of delivery, whereas production by the breasts
is more likely to lead to sustained hypercalcemia after de-
livery.
G. Vitamin D Deficiency and Genetic
Disorders of Vitamin D Physiology
1. Animal data
Calcitriol regulates the active, saturable, transcellular
mechanism of intestinal calcium delivery, as well as the
passive, paracellular mechanism of absorption (181). After
pups are weaned and in adult animals, severe vitamin D
deficiency and genetic absence of either calcitriol or VDR
lead to the common phenotype of reduced intestinal cal-
cium absorption, hypocalcemia, hypophosphatemia, and
rickets. Intestinal mineral delivery appears to be the main
route through which calcitriol has direct and indirect ac-
tions on mineral and bone metabolism. Several lines of ev-
idence have confirmed this, including that the abnormal
mineral homeostasis and rachitic phenotype of Vdr null
479
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
mice is rescued by expressing Vdr in intestinal cells (555,
1000), whereas selective ablation of Vdr from intestinal
cells (555) or dietary calcium restriction create the rachitic
phenotype (555). Moreover, ablating Vdr from chondro-
cytes, osteoblasts, or osteocytes, or Cyp27b1 from chon-
drocytes, do not cause rickets either (555, 606, 644, 1006).
Also, a high calcium diet bypasses the need for calcitriol and
intestinal expression of its receptor, and normalizes serum
chemistries, skeletal morphology, and skeletal mineral con-
tent in severely vitamin D-deficient, Cyp27b1 null, and Vdr
null models (28, 102, 103, 224, 241, 273, 553, 554, 693,
874, 875, 948, 1011). However, remaining evidence for a
direct role of calcitriol or VDR in regulating bone cells is
that Cyp27b1/Vdr null double mutants have a skeletal phe-
notype that is not fully prevented by a high-calcium diet
(692).
What is the impact of disordered vitamin D physiology on
rodent pregnancy? In several models the mothers conceive
less frequently and bear fewer pups in each liter. This in-
cludes severely vitamin D-deficient rats (359, 361363),
Cyp27b1 null mice that cannot make calcitriol (330), and
Vdr null mice that lack the receptor for calcitriol (296, 502),
but not Cyp27b1 null (Hannover) pigs which have either
singleton or twin pregnancies (520, 521). The low concep-
tion rate and smaller litter sizes of rodents are rescued by
administering a high-calcium diet (223, 330, 446, 502, 553,
693, 886), which indicates that calcium and not calcitriol is
the missing component responsible for these fertility issues.
Normal pregnancies still occur in Vdr null mice maintained
on a normal-calcium diet (502), but the increased frequency
of pregnancies on the high calcium diet facilitates their
study during reproductive cycles.
What is the role of calcitriol in regulating intestinal calcium
absorption and mineral metabolism about during preg-
nancy? This has been studied in severely vitamin D-deficient
rats (117, 358, 362, 363), Cyp27b1 null pigs (520, 521),
Cyp27b1 null mice (330), and Vdr null mice (296, 1026). In
these models occasional sudden deaths occur during late
pregnancy, suggesting that rapid placental calcium transfer
can overwhelm the ability of the mother to maintain her
own ionized calcium level. The pregnancies are otherwise
uneventful and result in fetuses that have normal ionized
calcium, phosphorus, PTH, weight, skeletal development,
and mineralization (see companion review for details, Ref.
492). A notable abnormality is that offspring of Vdr null
females were globally but proportionately smaller than off-
spring of their WT and Vdr/ sisters, a difference that was
not seen between offspring of vitamin D-deficient and re-
plete rats. This may indicate that maternal absence of VDR
affects offspring growth independent of the fetal genotypes
and that it is exerted by the receptor but not calcitriol.
More recently, severe vitamin D deficiency has been studied
in mice, which had identical litter sizes but bore pups of
480 Physiol Rev VOL 96 APRIL 2016 www.prv.org
modestly greater weights and slightly increased lengths,
compared with vitamin D-sufficient mothers (563). The diet
was deficient in vitamin D but not enriched in calcium. No
mention was made as to whether maternal vitamin D defi-
ciency led to a reduced conception rate, and no measure-
ments of bone mass or mineralization were performed. The
placentas from vitamin D-deficient pregnancies were of
identical weight but had smaller diameters, and histological
evidence of reduced vascular diameters within the labyrin-
thine placenta, compared with pregnancies from vitamin
D-sufficient mothers (563).
As noted earlier, severely vitamin D-deficient rats, Vdr null
mice, and Cyp27b1 null mice achieve significant gains in
bone mineral content during pregnancy, with reduced sec-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
ondary hyperparathyroidism and increased mineralization
of osteoid (296, 362, 489, 786). An increase in intestinal
calcium absorption during pregnancy has been confirmed in
severely vitamin D-deficient rats (116, 360) and Vdr null
mice (296), and inferred to be present but not yet studied in
Cyp27b1 null mice (330). During pregnancy serum calcium
and phosphorus increased in severely vitamin D-deficient
rats (915), Vdr null mice (Boston and Leuven strains) nor-
malized serum calcium and increased renal calcium excre-
tion (296, 786, 1026), and Cyp27b1 null mice also normal-
ized serum calcium and phosphorus (330). In all of these
studies the main intervention was that the animals became
pregnant, thus confirming that pregnancy invokes improve-
ments in intestinal calcium absorption and mineral homeo-
stasis that are independent of vitamin D, calcitriol, and
VDR.
Nonskeletal outcomes of pregnancy have received little at-
tention in these animal studies, but the recent study of vita-
min D-deficient mice found higher systolic and diastolic
blood pressure, and upregulation of renal expression of
renin and angiotensin II receptor mRNA, compared with
vitamin D-sufficient mice (563). These findings support the
possibility that vitamin D deficiency may increase the risk of
pregnancy-induced hypertension.
2. Human data
As in rodents, calcitriol-dependent active absorption of cal-
cium represents 20% of net calcium absorption, with the
rest occurring by passive, nonsaturable mechanisms. Active
absorption is considered to be more important when dietary
intake of calcium is limited. Multiple dual or single isotope
studies carried out in adults and adolescents have examined
the level of 25OHD at which intestinal calcium absorption
is maximized or reaches a plateau, and have established that
a plateau occurs below 20 nM 25OHD, with very little
increase (if any) in intestinal calcium absorption above that
value (7, 24, 26, 306, 650, 774). Secondary hyperparathy-
roidism occurs at lower levels of 25OHD and maintains
high levels of calcitriol despite the reduced availability of
substrate, which may be why vitamin D deficiency does not
 CHRISTOPHER S. KOVACS
impair intestinal calcium absorption until the 25OHD level
is below 20 nM (650).
What evidence is there that maternal vitamin D deficiency,
or genetic disorders causing loss of calcitriol or VDR, affect
maternal mineral metabolism and obstetrical or fetal out-
comes?
Unfortunately, no study has measured intestinal calcium
absorption during pregnancy in vitamin D-deficient com-
pared with vitamin D-sufficient women, so it remains un-
known whether or not intestinal calcium absorption dou-
bles in pregnant, vitamin D-deficient women.
The most robust clinical data generally come from large,
randomized, blinded clinical trials, which control for con-
founding through the randomization of subjects into two or
more treatment groups. Several modestly sized clinical trials
have examined the effects of vitamin D supplementation on
obstetrical and fetal/neonatal outcomes, and the maternal
results will be discussed in the following paragraphs. The
fetal and neonatal outcomes of these studies have been de-
scribed in the companion review (492); in brief, no consis-
tent change in cord blood calcium, phosphorus, PTH, birth
weight, or anthropometric measurements were observed
when babies of vitamin D-supplemented mothers were
compared with babies of placebo-treated mothers. Several
studies did note a reduction in the incidence of neonatal
hypocalcemia after 48 h when the babies of placebo-treated
mothers had cord blood 25OHD levels below 20 nM (492).
This is consistent with the aforementioned adult data that
intestinal calcium absorption is reduced when the 25OHD
level is below 20 nM. However, calcium absorption across
the fetal intestines is a trivial circuit not relevant to fetal
mineral homeostasis, whereas the main route of calcium
delivery is transportation across the placenta through
mechanisms that do not require calcitriol (492).
Because the potential adverse effects of vitamin D deficiency
during pregnancy have garnered much recent attention, the
individual studies will be described in sufficient detail to
understand the doses of vitamin D tested, the sizes of the
studies, the achieved increment in 25OHD between groups,
and any obstetrical (maternal) benefit observed. The com-
panion review should be consulted for details of any fetal or
neonatal benefits (492).
Brooke et al. (121) studied 126 severely vitamin D-deficient
Asian women living in England, beginning at 28 32 wk of
gestation. At term the mean serum 25OHD was 16 nM (6.4
ng/ml) in the placebo group and an exuberant 168 nM (67
ng/ml) in women who received 1,000 IU vitamin D daily
(the dose was likely higher given the 25OHD increment
achieved). By comparing these two extremes of severe vita-
min D deficiency versus repletion to a high 25OHD level,
this study was well poised to demonstrate any obvious ma-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
ternal benefit of vitamin D repletion. A greater weight gain
and a small increase in the unadjusted serum calcium were
observed in the vitamin D-treated group, but no other ob-
stetrical benefit was seen (121).
Cockburn et al. (191) randomized 164 women to 400 IU
vitamin D versus placebo beginning at the 12th week of
pregnancy, and achieved maternal 25OHD of 42.8 vs.
32.5 nM (17 vs. 13 ng/ml) at term, but no obstetrical
benefit was described (191). Mallet et al. (588) random-
ized 77 women to receive 1,000 IU vitamin D2 daily
during the third trimester, or 200,000 IU vitamin D2 at
the start of the third trimester, or no supplementation
(588). The respective maternal 25OHD levels were 25.3,
26.0, and 9.4 nM (10, 10.4, and 3.8 ng/ml) with no effect
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
on maternal serum calcium or calcitriol, and no obstet-
rical benefit reported.
Delvin et al. (239) randomized 40 women in France to
1,000 IU vitamin D3 daily versus placebo beginning at 6 mo
of pregnancy. Maternal 25OHD increased to 56 nM (22
ng/ml) compared with 27.5 nM (11 ng/ml) in the placebo
group, but there was no difference in ionized calcium, se-
rum calcium, calcitriol, or PTH, and no reported obstetrical
benefit.
Marya and co-workers (604, 605) performed two studies in
vitamin D-deficient Asian women in India. In each of these,
severe vitamin D deficiency was presumed to be present on
the basis of estimated dietary intakes of vitamin D at 35
IU/day, but 25OHD was not measured and sunlight expo-
sure leading to vitamin D formation was not considered.
The first study involved 20 women who received 800,000
IU vitamin D2 in the seventh and eighth months of preg-
nancy, 25 women who received 1,200 IU vitamin D2 per
day during the third trimester, and 75 women who received
nothing (605). No significant effect on serum calcium or
phosphorus was noted, but the alkaline phosphatase was
reduced in vitamin D-treated subjects. The second study
gave 100 women 600,000 IU of vitamin D2 in the seventh
and eighth months of pregnancy and compared the results
to 100 women who received nothing (604). The unadjusted
serum calcium and phosphorus were slightly but statisti-
cally significantly higher in the women who received vita-
min D, and the alkaline phosphatase was lower, but there
were no significant differences in reported constitutional
symptoms.
In the studies cited thus far, there are concerns as to whether
or not subjects were properly blinded and randomized, the
sample sizes were small, and obstetrical data were not fully
reported. In contrast, the following studies were carried out
within the past decade, used modern randomization meth-
ods and clinical trial protocols, and reported more obstet-
rical outcomes.
481
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
Yu et al. (1013) randomized 180 women in London to
receive unblinded treatment beginning at week 27 of preg-
nancy: 800 IU vitamin D2 per day, a single dose of 200,000
IU vitamin D2, or no treatment (1013). Mean 25OHD in-
creased to 42 and 34 nM (16.8 and 13.6 ng/ml) in the
respective treatment groups at term compared with 27 nM
(10.8 ng/ml) in the untreated women. There was no effect
on preterm delivery and no other obstetrical outcomes.
Roth et al. (778) randomized 160 women in Bangladesh
(NCT01126528) to receive 35,000 IU vitamin D3 per week
or placebo beginning at 26 29 wk. Maternal 25OHD was
134 nM (53.6 ng/ml) in the supplemented women versus 38
nM (15.2 ng/ml) in the placebo group. There was no effect
on maternal serum calcium, but a borderline significant
increase in albumin-adjusted calcium and decrease in PTH
were found (779). There was no effect on mode of delivery,
C-section rates, adverse events, live versus stillbirths, or
gestational age at delivery.
Hashemipour et al. (367) randomized 160 women in Iran to
receive 50,000 IU vitamin D per week or 400 IU daily
beginning at 26 28 wk. Maternal 25OHD was 120 nM (48
ng/ml) versus 40 nM (16 ng/ml), and the unadjusted serum
calcium was modestly higher in the vitamin D-treated
women. There was no difference in gestational age of deliv-
ery; no other obstetrical outcomes were reported.
Grant et al. (342) randomized 260 women in New Zealand
(ACTRN12610000483055) to placebo, 1,000 IU vitamin
D daily, or 2,000 IU vitamin D daily. Maternal 25OHD
levels at term were 50, 98, and 103 nM (20, 39, and 41
ng/ml), respectively. There was no difference in serum cal-
cium or gestational age of delivery; no other obstetrical data
were reported (342).
Kalra et al. (455) randomized 97 women in India to one
dose of 60,000 IU vitamin D in the second trimester or
120,000 IU vitamin D in each of the second and third tri-
mesters; 43 usual care women were the controls. Mater-
nal 25OHD levels at term were 26.2, 58.7, and 39.2 nM
(10.5, 23.5, and 15.7 ng/ml), respectively (455). There were
no differences in obstetrical outcomes, including gesta-
tional age at delivery, intrauterine death, pregnancy-in-
duced hypertension, cephalopelvic disproportion, nonpro-
gression of labor, cesarean section, and placenta previa
(455).
Hollis and Wagner (399) reported on 350 women
(NCT00292591) randomized at 1216 wk of gestation to
receive 400, 2,000, or 4,000 IU vitamin D3 per day. Mater-
nal 25OHD levels at term were 79, 98, and 111 nM (31.6,
39.2, and 44.4 ng/ml), respectively. There was no signifi-
cant difference in serum calcium across the treatment
groups, but there was a borderline-significant reduction in
PTH when the high-dose and low-dose groups were com-
482 Physiol Rev VOL 96 APRIL 2016 www.prv.org
pared. There were no differences in any obstetrical out-
comes, including mode of delivery, gestational age at deliv-
ery, preterm birth, preterm labor, preeclampsia, and infec-
tion (399, 963).
A second study by Hollis and Wagner and co-workers (966)
reported on 160 women (NCT00412087) randomized at
1216 wk to receive 2,000 or 4,000 IU vitamin D3 daily.
Achieved maternal 25OHD was 90.5 nM (36.2 ng/ml) and
94.8 nM (37.9 ng/ml), respectively. There was no effect on
any obstetrical outcome, including mode of delivery, pre-
term labor, preterm delivery, hypertension, infection, ges-
tational diabetes, or combinations of these outcomes (966).
Hollis and Wagner have subsequently carried out several
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
post-hoc analyses of these two trials, including analyses in
which selective data from both studies were pooled, out of
which some borderline significant results have been ob-
tained (399, 401, 963, 964, 967). However, these analyses
suffer from lack of adjustment for multiple comparisons,
arbitrary grouping of outcomes, and exclusion of some eth-
nicities from the analysis. For example, the combination of
infection/preterm labor/preterm birth/gestational diabetes/
preeclampsia/hypertension/HELLP had a P value of 0.03
(not adjusted for multiple comparisons), whereas excluding
preterm labor (which is linked to preterm birth and likely
means women are counted twice) resulted in a P value of
0.06, including all ethnicities resulted in a P value of 0.17,
while multiple other subgroupings and the individual out-
comes were not statistically significant (401, 963).
Dawodu et al. (229) studied Arab women who had mean
25OHD concentrations of 20.5 nM (8.2 ng/ml) at baseline
and were randomized to 400, 2,000, or 4,000 IU vitamin
D/day. Achieved 25OHD levels at delivery were 40 nM
(19.3 ng/ml), 65 nM (25.9 ng/ml), and 90 nM (35.9 ng/ml),
respectively (229). There were no differences in maternal
serum calcium or urine calcium/creatinine between groups
at any time point during pregnancy, PTH was reduced in
the high-dose group but correlated poorly with 25OHD, no
effect was seen on gestational age at delivery or the babies
anthropometric parameters at birth, and no other obstetri-
cal outcomes were reported.
Most recently, Cooper and Harvey and co-workers (199,
200) provided preliminary results of the MAVIDOS study
from the United Kingdom. The 900 women who completed
the study randomly received either 1,000 IU vitamin D or
placebo beginning at 14 wk of pregnancy. Baseline 25OHD
was 45 nM (18 ng/ml), did not change in placebo-treated
women, and rose to 68 nM (27 ng/ml) near term in the
vitamin D-supplemented women. During the oral and
poster presentation of results (199, 200), the study was
revealed to be negative in its primary outcome (neonatal
bone area, bone mineral content, and bone mineral density
within the first 14 days after birth) and secondary outcome
 CHRISTOPHER S. KOVACS
(anthropometric and body composition parameters within
48 h of birth). No obstetrical benefit was reported. A post-
hoc analysis, which was not prespecified in the clinical trial
registrations (ISRCTN 82927713 and EUDRACT 2007-
001716-23), suggested a possible benefit on bone mineral
content of winter-born babies. If the apparent benefit on
winter-born babies is real and not a chance result, it may
not be an indication of an effect on the fetus but instead a
postnatal effect, since (as noted earlier) the neonatal skele-
ton should gain 100 mg calcium per day over the first 14
days after birth. A measurement at 14 days does not indi-
cate bone mineral content at term.
Overall, these studies have largely examined women who,
prior to the intervention, had 25OHD values well above the
20 nM threshold that has been shown to result in normal
intestinal calcium absorption. Only Brookes study (and
possibly Maryas two studies, although 25OHD levels were
not measured) compared true vitamin D deficiency to a
vitamin D-replete state, and an increase in maternal serum
calcium was observed. No obstetrical outcome differences
were reported, but it is unclear that the authors of that
report were looking for any. It may take a study of that
extreme to determine if there are differences in obstetrical
outcomes, but ethical considerations may prevent it being
carried out in the modern day. Among the modern studies,
Dawodus began with vitamin D-deficient women but at the
end of pregnancy the mean 25OHD level was in the insuf-
ficient range at 40 nM (229). In that arm of the study, 79%
of women had a 25OHD value 50 nM, so it contained
many vitamin D-deficient women, but still no significant
maternal or fetal/neonatal differences were seen apart from
an increase in serum 25OHD.
Pregnancies have been unremarkable in women with ge-
netic absence of Cyp27b1 (vitamin D-dependent rickets
type 1, VDDR-I) or relatively inactive VDRs (VDDR-II)
(266, 589, 602). In one case of VDDR-II, the pregnancy was
unremarkable while the woman was maintained on her
prepregnancy doses of calcium (800 mg) and high-dose cal-
citriol (602). The clinicians did increase the dose of cal-
citriol during that pregnancy because of the knowledge
that the circulating 1,25-(OH)2D concentration normally
rises during pregnancy, but not because of any change in
the albumin-adjusted serum calcium (602). In multiple
cases of VDDR-I, the dose of calcitriol was unchanged in
one-third of pregnancies and increased 1.5- to 2-fold in
others (266). In both disorders, calcium and calcitriol or
1-cholecalciferol should be adjusted as needed to maintain
a normal ionized or albumin-corrected serum calcium.
More recently, hereditary absence of Cyp24a1 has been
shown to lead to maternal and fetal hypercalcemia (249,
820), likely because reduced catabolism of calcitriol leads to
relatively unopposed actions of the active hormone to stim-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
ulate intestinal calcium absorption and potentially induce
osteoclast-mediated bone resorption.
On the basis of associational studies, vitamin D deficiency
has been suggested to have nonskeletal effects during preg-
nancy, such as increasing the risk of preterm delivery, C-
sections, low birth weight, preeclampsia/pregnancy-in-
duced hypertension, and vaginal infections. One can find
approximately as many studies suggesting these associa-
tions (46, 95, 370, 622, 768, 832) as there are studies indi-
cating no association (47, 276, 294, 618, 726, 810, 823).
Each of these studies has low power and are confounded by
factors that may lead to lower 25OHD levels and the out-
come in question, including race/ethnicity, maternal over-
weight/obesity, lower socioeconomic status, poor nutrition,
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
etc. For example, maternal overweight/obesity is a signifi-
cant risk factor for preterm delivery, C-sections, low birth
weight, preeclampsia/pregnancy-induced hypertension,
vaginal infections, and other adverse obstetrical outcomes
(542). But maternal overweight/obesity also causes low
25OHD by binding the fat-soluble vitamin D into the
maternal fat stores, and by additional associations with
reduced vitamin D intake, less time spent outdoors, etc.
Consequently, the studies reporting associations between
vitamin D intake or 25OHD levels and obstetrical out-
comes may really be demonstrating residual confounding
from the link between obesity and these outcomes, and
also need to consider that the results of the existing ran-
domized trials did not find these outcomes in their pri-
mary analyses (183, 184, 367, 399, 455, 710, 779, 966,
1013). Larger randomized trials that compare truly vita-
min D-deficient to sufficient mothers are needed to prop-
erly test the hypothesis, and eliminate the confounding
caused by maternal overweight and obesity.
3. Summary
Several animal models (severe vitamin D deficiency and ab-
sence of VDR or Cyp27b1) have demonstrated improved to
near-normalized mineral homeostasis and intestinal cal-
cium absorption during pregnancy, suggesting that cal-
citriol is not required for the adaptations that are invoked
during pregnancy, or that other physiological mechanisms
are able to compensate for its absence. Clinical data are not
as extensive, but the results of available clinical trials do not
show a clear benefit of high-dose vitamin D supplementa-
tion on maternal mineral or skeletal homeostasis, or obstet-
rical and fetal outcomes. Most of the clinical trials did not
enroll women who were vitamin D deficient, so the ability
to detect any benefit was likely lost.
H. Calcitonin Deficiency
1. Animal data
Early attempts to create experimental models of calcitonin
deficiency did not appreciate that there are extrathyroidal
483
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
sites of calcitonin synthesis during pregnancy, including the
mammary glands and placenta. In pregnant goats or rats,
calcitonin deficiency was created by a complete thyropara-
thyroidectomy followed by parathyroid gland autotrans-
plantation and treatment with exogenous thyroid hormone
(55, 58, 163, 551, 900). Serum calcitonin, TSH, PTH, and
ionized calcium were not measured, so it is uncertain
whether a calcitonin-deficient, euthyroid, euparathyroid
state was achieved. In three studies the animals were killed
the day before expected delivery (55, 58, 163), whereas two
other studies reporting a pregnancy-related effect must be
excluded because the animals were killed after 3 wk of
lactation (551, 900) (see sect. VH). Among the three preg-
nancy studies, the ash weight and calcium content were
510% lower in thyroidectomized compared with sham-
operated animals at the end of pregnancy; these differences
were statistically significant in goat metacarpals and meta-
tarsals (55, 58), but not in rat femora (163). The spine is the
potential site of greatest bone loss during pregnancy, but it
was not examined in these studies.
In contrast to these surgical models, Ctcgrp null mice rep-
resent true calcitonin deficiency because the gene encoding
calcitonin and calcitonin gene-related peptide has been ab-
lated, but they are also confounded by loss of CGRP-
(394). At the end of pregnancy there were no differences
from WT sisters in BMC of the whole body, lumbar spine,
or hindlimb, suggesting that loss of calcitonin does not im-
pair the ability of the mother to gain bone mass during
pregnancy (992, 994). These mice received standard 1%
calcium intake and have not been studied on a calcium-
restricted diet.
Overall, the surgical models suggested that an intact thyroid
gland may protect the maternal skeleton from loss of bone
mineral during pregnancy and that this effect is attributable
to calcitonin, assuming that parathyroid and thyroid func-
tion remained normal. However, Ctcgrp null mice did not
display excess bone loss during pregnancy.
2. Human data
Increased serum calcitonin has been proposed to protect the
skeletons of women from excessive resorption during preg-
nancy, but this concept has not been directly tested. Totally
thyroidectomized women have placenta and breasts as
sources of calcitonin production during pregnancy, so they
are not truly calcitonin deficient. No women with genetic
loss of calcitonin or its receptor have been identified or
studied during pregnancy.
Nevertheless, several studies have looked at the long-term
effects of total thyroidectomy on bone density and risk of
fractures in both men and women, with some studies sug-
gesting an increased risk and others finding none (326, 338,
422, 630, 659). Studies from the last decade are confounded
by the common practice to treat with suppressive doses of
484 Physiol Rev VOL 96 APRIL 2016 www.prv.org
thyroid hormone to reduce the risk of cancer recurrence,
but even in those studies bone loss has not been consistently
found (476, 543). None of these studies looked at the effects
of pregnancy, during which the women may not have been
calcitonin deficient anyway.
It is notable that with modern calcitonin assays, the basal
calcitonin level is unchanged before and after total thyroid-
ectomy in patients without medullary thyroid cancer; it is
only the calcium-stimulated or pentagastrin-stimulated cal-
citonin that is lost (513). This suggests that extrathyroidal
calcitonin sources are functional in nonpregnant, nonlac-
tating women.
3. Summary
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
Thyroidectomy to create partial calcitonin deficiency dur-
ing pregnancy led to bone loss at term compared with sham-
operated animals; however, no effect was seen in pregnant
mice lacking the calcitonin gene. There are no comparable
human data for the surgical or genetic models of calcitonin
deficiency during pregnancy.
I. Low or High Calcium Intake
1. Animal data
As noted earlier (sect. II, A1, A2, and D), a calcium-re-
stricted diet provokes marked hypocalcemia and secondary
hyperparathyroidism in pregnant rats; it also leads to com-
pensatory secondary hyperparathyroidism and skeletal re-
sorption in the fetuses (492). In pregnant ewes it causes
hypocalcemia and bone resorption, but the birth weights of
offspring are unaffected (detailed analysis of the fetal bones
was not done) (69). Conversely, high calcium intake pre-
vents hypocalcemia and secondary hyperparathyroidism,
and enables most of the calcium transported to the fetuses
to come from the maternal diet rather than her skeleton. It
also reduces the likelihood of net loss of calcium from the
skeleton and may enable a net gain. Rats consuming a 1.6%
and 1.4% calcium diet had a higher femoral calcium con-
tent at the end of pregnancy compared with rats that con-
sumed 0.5% calcium (719, 818).
2. Human data
Pregnancy is normally a state of absorptive hypercalciuria
with suppressed PTH, which implies that for most women
calcium is absorbed in excess of maternal and fetal require-
ments. But as noted earlier (sect. II, A1, A2, and D), PTH
does not fall and may rise above normal in women with low
dietary intakes of calcium or high intake of phytate (which
blocks calcium absorption). However, in some women with
chronically low calcium intakes, the efficiency of intestinal
calcium absorption may be greater than normal, as sug-
gested by a study in which most women with a dietary
 CHRISTOPHER S. KOVACS
intake of less than 420 mg were in a positive calcium bal-
ance in all three trimesters (830). A lower calcium intake is
more likely to induce bone loss during pregnancy (10) and
has been associated with increased risk of osteoporosis de-
veloping during pregnancy (501). Whether the mother ob-
tains the needed mineral from her diet or skeleton may be of
no consequence to the fetus, although a randomized trial
found that 2 g of supplemental calcium versus placebo im-
proved the BMC of babies whose mothers were in the low-
est quintile of dietary calcium intake (600 mg/day) (488).
Significant maternal hypocalcemia impairs the delivery of
calcium to the fetuses, who may develop secondary hyper-
parathyroidism, skeletal demineralization, and fractures, as
has occurred in cases of poorly treated maternal hypopara-
thyroidism during pregnancy (492). The lowest quintile of
maternal calcium intake is also associated with increased
risk of preeclampsia, whereas calcium supplementation re-
duces that risk (see sect. IIC).
In contrast to low calcium intake, excessively high intake
will create similar effects as primary hyperparathyroidism
in pregnancy: increased net absorption of calcium, maternal
hypercalcemia, increased maternal to fetal transfer of cal-
cium, and suppression of the fetal parathyroids (100, 483,
767). Neonatal hypoparathyroidism has resulted from
women consuming 3 6 g elemental calcium daily to treat
nausea of pregnancy (100, 767).
3. Summary
Extremes of low and high calcium intake should both be
avoided in pregnancy due to adverse effects that each can
have on the mother and the fetus. Low calcium intake
causes secondary hyperparathyroidism in mother and fetus
and resorption of the maternal and fetal skeletons with
consequent fragility. Conversely, high calcium intake leads
to increased flow of calcium across the placenta, suppres-
sion of the fetal parathyroids, and a predisposition to neo-
natal hypoparathyroidism with hypocalcemia.
J. Hypercalcemia of Malignancy
1. Animal data
No animal models have been studied during pregnancy.
2. Human data
There are over a dozen published cases of hypercalcemia of
malignancy during pregnancy, which is usually due to
PTHrP overproduction (4, 211, 325, 424, 428, 608, 614,
634, 898, 945). This is usually but not always a terminal
condition, so the first decision is whether to terminate the
pregnancy to enable chemotherapy to be administered, de-
fer such treatment until the baby is born, or (as has also
been reported, Ref. 614) to proceed with chemotherapy
Physiol Rev VOL 96 APRIL 2016 www.prv.org
during pregnancy regardless of its potential teratogenic ef-
fects. In about half of case reports, the babys outcome is
not mentioned, but the cord blood calcium is likely to be
high and followed by neonatal hypocalcemia and tetany.
Treatment options include debulking or curative surgery,
hydration, diuresis, and possibly calcitonin or bisphospho-
nates. There are potential teratogenic effects of calcitonin
and bisphosphonates (492), but they have been used during
pregnancy to treat this condition.
3. Summary
Hypercalcemia of malignancy causes severe and potentially
terminal maternal hypercalcemia; if the baby survives, it is
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
at high risk for neonatal hypocalcemia.
K. Fibroblast Growth Factor 23-Related
Disorders
1. Animal data
Pregnancies are unremarkable in Phex/Hyp/ mice, a
model of XLH that leads to FGF23 excess (240, 581, 679).
Despite very high levels of FGF23 in pregnant Phex/
females (581, 679), which normally downregulate calcitriol
synthesis and increase its catabolism, maternal serum cal-
citriol increases to the expected high levels of pregnancy
(581, 679), and likely contributes to pregnancy-related in-
creases in intestinal calcium and phosphorus absorption.
Despite the maternal hypophosphatemia, the fetuses dis-
play normal serum mineral and calciotropic hormone con-
centrations, lengths, placental phosphorus transport, skel-
etal development, and mineralization (581).
Since phosphorus is actively transported across the pla-
centa, maternal hyperphosphatemia can be expected to in-
crease the flow of phosphorus and, thereby, potentially af-
fect fetal mineralization. Hyperphosphatemic disorders due
to absence of FGF23 have not been studied during preg-
nancy because Fgf23 null mice die by several weeks of age
(848), whereas Klotho null mice have marked hypogonad-
ism and die by 9 10 wk of age (516). Experimental renal
failure in rats has shown that maternal hyperphosphatemia
does not impair skeletal development or mineralization
(765, 766); however, there is a modest reduction in fetal
weight and length that has been attributed to decreased
food intake in uremic mothers (664, 765).
2. Human data
Isolated case reports have confirmed that hypophos-
phatemia persists during pregnancy in women with XLH
(447, 745), but the lack of adverse outcomes from untreated
pregnancies has made it uncertain whether the hypophos-
phatemia needs to be treated. Nevertheless, the general
485
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
principle is to maintain calcitriol and phosphorus supple-
mentation throughout pregnancy to ensure adequate deliv-
ery of phosphorus to the fetus (538).
There are no published reports on pregnancies in women
with hyperphosphatemic disorders caused by deficiency of
FGF23 or its co-receptor. Large case series of pregnancies in
women on dialysis have shown increased obstetrical risks of
gestational hypertension, preeclampsia, eclampsia, and ma-
ternal mortality, and increased adverse fetal outcomes in-
cluding premature birth, intrauterine growth restriction,
low birth weight, stillbirth, and neonatal mortality (139,
594, 656). These outcomes may relate more to the maternal
renal failure than the hyperphosphatemia per se. No data
have been reported about cord blood chemistries or skeletal
development and mineralization in the fetuses or neonates
of these hyperphosphatemic mothers.
3. Summary
Hypophosphatemic and hyperphosphatemic disorders in
the pregnant mother have the potential to adversely affect
the fetus. There are insufficient human data to know for
certain, but the limited animal data are reassuring that fetal
mineral and bone metabolism may be unaffected by ex-
tremes of low and high serum phosphorus in the mother.
IV. SKELETAL AND MINERAL PHYSIOLOGY
DURING LACTATION AND POST-
WEANING RECOVERY
In their widely quoted seminal text The Parathyroid Glands
and Metabolic Bone Disease (15), Albright and Reifenstein
used data from several sources (77, 407, 836) to estimate
that maternal losses of calcium are fourfold higher during 9
mo of lactation than in pregnancy, or 80 g in milk versus
20 g in the fetal skeleton. This means an output of more
than 300 mg of calcium in milk each day. However, the
authors misread source data that showed closer to 30 g of
calcium in a term fetus (77), used an overestimate of milk
production (407), and lacked any skeletal calcium content
data at 9 mo. Modern studies, referred to earlier in the
overall introduction, have shown that the average full-term
fetus has 30 g of calcium and that another 30 g (100
mg/day) is added by 9 mo. Consequently, the calcium re-
quired by the neonate during 9 mo of lactation equals that
required by a fetus during all of pregnancy and does not
exceed it. However, as explained in the following para-
graphs, maternal losses of calcium during 9 mo of lactation
are about double that of pregnancy.
Other older studies similarly overestimated average daily
loss of calcium into milk due to overgenerous estimates of
milk volumes. In a large study of 200 women who ex-
pressed milk manually for 24 h, the volume ranged from 0.8
to 1.8 liters for a mean daily loss of 400 mg calcium (582,
486 Physiol Rev VOL 96 APRIL 2016 www.prv.org
584). Individual women were identified who had sustained
production of up to 3 liters of milk per day during 6 12 mo
of lactation (419, 583, 838); analysis of their milk revealed
daily calcium losses of 500-1,200 mg (419, 838). However,
manual expression of milk can yield much greater volumes
than a suckling baby demands, thereby overestimating milk
production. Further bias was introduced by studying
women known to produce large volumes of milk, some of
whom were employed as wet nurses.
As noted in the overall introduction, more recent studies
have relied on weighing the baby before and after feeds,
whereas analyses of milk calcium content at different stages
of lactation revealed similar results to older studies. An
average daily output of 780 ml milk (20, 138, 376, 653)
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
with an average calcium content of 260 mg/l during the first
6 mo of lactation (41) results in a more realistic average
calcium loss of 200 210 mg/day (774), from which the
baby is expected to accrete 100 mg daily.
These are average amounts, and it is recognized that indi-
vidual daily losses can vary considerably. Losses have been
much higher in the more extreme examples cited above, and
in women nursing twins who generally produce about dou-
ble the amount of milk of women who nurse singletons
(233, 792). The composition of milk also varies within and
between feedings (536, 654), between an individuals
breasts (654), and between mothers and different ethnic
groups (536). The calcium content of milk is higher at 3 mo
than at 6 mo postpartum (459, 536, 856, 957), but the
volume of milk per feed is higher at 6 mo (856). Conse-
quently, daily maternal loss of calcium could be greater at 6
mo and beyond, compared with the first 3 mo of lactation
(856). However, the number of feeds is usually fewer after 6
mo, thereby leading to an overall decline in daily calcium
losses.
Maternal milk output also increases in proportion to litter
number and weight in lactating animals, thereby maintain-
ing a similar weight of pups regardless of their number. In
mice, for example, the weight of individual pups at 12 days
of age shows 10% variation from a litter of 4 versus a
litter of 12. But the combined weight of a litter of 12 is three
times that of a litter of 4, confirming that a larger litter
means a greater maternal output of milk and calcium (87).
A similar constancy of neonatal pup weight has been seen in
pigs whose litter sizes range from 5 to 12 at 8 wk of age (87).
Ewes suckling twins produce about double the amount of
milk of ewes nursing singletons (970).
To meet the mineral requirements of lactation, maternal
adaptations might include increased intestinal absorption
of calcium, renal conservation of calcium, and increased
skeletal resorption of calcium. Studies reviewed in this sec-
tion reveal that the main adaptation is a temporary demin-
eralization of the skeleton, which appears to meet the cal-
 CHRISTOPHER S. KOVACS

cium requirements of milk production. Two processes,

osteoclast-mediated bone resorption and osteocytic osteol-
2.7
ysis, are responsible for mobilizing skeletal calcium. Con-
Total Ca
servation of calcium by the kidneys is also evident (in con-
(mmol/l)
trast to pregnancy), but intestinal calcium absorption falls
to normal in lactating women from the elevated values of
pregnancy (it remains elevated in lactating rodents). PTH
2.1
and calcitriol do not appear to be the main regulators of
1.6 these processes; instead, secretion of PTHrP by breast tissue
Ionized Ca2+

and systemically low estradiol levels are two of the key

(mmol/l)

factors that stimulate bone resorption, while PTHrP also

stimulates renal calcium conservation. So it is evident that
0.9 the maternal adaptations during lactation differ from those
that are invoked during pregnancy, which in turn means
1.7
different consequences for normal women, and for women
Phosphorus
(mmol/l)

Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017

who have disorders of bone and mineral metabolism.

0.9 A. Changes in Mineral Ions and Calciotropic

5.0
Hormones
(pmol/l)

Progressive changes in serum calcium, phosphorus, and

PTH

calciotropic hormone levels during human lactation are

schematically depicted in FIGURE 2. Important differ-
0.0
ences among human, rat, and mouse lactation are listed
300 in TABLE 2.
Calcitriol
(pmol/l)

1. Calcium and phosphorus

0.0 A) ANIMAL DATA. The serum calcium of lactating rats has been

20.0
quite variable in published reports, and not clearly ex-
plained by the calcium content of the diet: hypercalcemia on
Calcitonin
(pmol/l)

1.5 or 1.2% calcium (86, 318); normocalcemia on 1.6%

(568), 1% (991), 0.5% (114), 0.4% calcium (91, 318, 569),
and an unspecified diet (337); low blood calcium on 1.2,
0.0
0.9, 0.8, and 0.4% calcium (76, 90, 320, 321, 568, 718,
5.0 920, 927, 989); and marked hypocalcemia on 0.1, 0.04,
and 0.01% calcium (32, 320, 321, 568, 991). The ionized
(pmol/l)
PTHrP

calcium has been low on a 1.6% calcium diet (568), high on

a 1.2% calcium diet (318), low on a 0.8% calcium diet
0.0 (989), normal (318) and low on a 0.4% calcium diet (90,
568, 569), and low on a 0.1% calcium diet (32, 568).
100.0
Estradiol
(nmol/l)

FIGURE 2. Schematic depiction of longitudinal changes in calcium,

0.0 phosphorus, and calciotropic hormone levels during lactation and
150.0
post-weaning skeletal recovery in women. Normal adult values are
indicated by the shaded areas. PTH does not decline in women with
Prolactin

low calcium or high phytate intakes and may even rise above normal.
(ng/ml)

Calcidiol (25OHD) values are not depicted; most longitudinal studies

indicate that the levels are unchanged by lactation, but may vary due
0.0 to seasonal variation in sunlight exposure and changes in vitamin D
intake. PTHrP and prolactin surge with each suckling episode, and
this is represented by upward spikes. FGF23 values cannot be plot-
Lactation Weaning Post- ted due to lack of data. Very limited data suggest that calcitriol and
Weaning
PTH may increase during post-weaning, and the lines are dashed to
reflect the uncertainty. The data from which this summary figure has
been derived are cited in section IVA.

Physiol Rev VOL 96 APRIL 2016 www.prv.org 487

 MINERAL METABOLISM DURING PREGNANCY AND LACTATION

Table 2. Key differences in mineral physiology of human and rodent lactation

Human Rat Mouse

Serum calcium Normal Low Normal

Albumin-corrected calcium Normal to slightly increased Low Normal
Ionized calcium Normal to slightly increased Low Normal
Phosphorus Normal to increased Variable Variable
Magnesium Normal to increased Normal Normal
PTH Low to low-normal* Increased Low to normal
Calcitriol Normal Increased Increased
Calcitonin Increased Increased Increased
PTHrP Increased Increased Increased
FGF23 No data No data No data
Estradiol Low ? Low ? Low

Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017

Intestinal calcium absorption Normal Increased Increased
Urinary calcium excretion Decreased Decreased Decreased
Trabecular bone losses 510% 2535% 2535%

*Women with low calcium or high phytate intakes have normal or increased PTH.

Differences in rat strains, litter sizes, and whether the sam-
ples were drawn fasted or not likely contribute to the vari-
ation in results. Greater demands for milk production (such
as larger litter number and combined weight of all pups)
provoke a lower maternal serum calcium (90, 320, 567,
708). Abrupt weaning causes the serum calcium to rebound
into the hypercalcemic range for several days (76, 86, 396,
718). This is likely due to sudden loss of the outflow of
calcium into milk while increased bone resorption and in-
testinal calcium absorption persist (see sect. IV, B and E).
An increase in serum calcium after abrupt weaning oc-
curred even when dietary intake of calcium was negligible
on a 0.02% calcium diet (396), which confirms that in-
creased skeletal resorption is a driver of the post-weaning
rebound in calcium.
Serum calcium declined a greater amount during lactation
in vitamin D-deficient rats (91), indicating that vitamin D
deficiency impairs the ability of the mother to maintain her
serum calcium during lactation. This contrasts with preg-
nancy in which the same vitamin D-deficient rats achieved a
significant increase in serum calcium (915). In the first 3
days after weaning, serum calcium rebounded twofold
higher to near-normal values in severely vitamin D-deficient
rats before declining significantly to the prepregnancy value
(915). This is also consistent with persistent upregulation of
intestinal calcium absorption and bone resorption for some
days after the outflow into milk has ceased.
In multiple studies from the authors laboratory wherein
WT Black Swiss or C57BL/6 mice consumed a standard 1%
calcium diet, there was no change in the ionized calcium or
the serum calcium during lactation regardless of whether
the samples were drawn nonfasting or fasting (296, 330,
477, 478, 580, 992, 994). The ionized calcium was also
measured every other day in the same mice from the time of
mating, and no change occurred during pregnancy or lac-
tation (827, 992). These findings suggest that a normal
mouse may be more capable of maintaining her serum cal-
cium in the normal range than a rat during reproductive
cycles. However, CD1 mice maintained on a 1% calcium
diet showed a modest but statistically significant decline in
serum calcium during lactation (34). Consequently, there
may be strain differences in the ability of mice to maintain
normal serum calcium during lactation. More marked hy-
pocalcemia was provoked in CD1 mice on a 0.01% calcium
diet (37).
In lactating ewes serum calcium rose after delivery and de-
clined as lactation progressed, with a low-calcium diet caus-
ing a steeper decline in serum calcium (69). Deer maintained
an increased albumin-corrected serum calcium during lac-
tation (170). Serum calcium remained normal in lactating
goats (55).
Serum phosphorus has also shown widely variable re-
sponses in lactating rats, with increases above normal (320,
568, 718), normal values (76, 114, 337, 568), and signifi-
cant decreases (86, 319). Phosphorus rose during the first
several days after abrupt weaning, simultaneous with the
spike in serum calcium (86, 718). It either remained normal
or declined modestly in lactating mice (477, 478, 580),
declined in lactating goats (55), and increased above normal
in deer (170).
Serum magnesium is unaltered or modestly reduced in lac-
tating rats (86, 132), and unchanged in mice (580) and
goats (55). Magnesium also increases abruptly after forced
weaning in rats (86).

488 Physiol Rev VOL 96 APRIL 2016 www.prv.org

 CHRISTOPHER S. KOVACS
B) HUMAN DATA. Multiple cross-sectional and longitudinal
studies have consistently shown that the serum calcium,
whether adjusted for albumin or not, is normal or slightly
increased in breastfeeding women (9, 156, 157, 164, 168,
207, 221, 348, 349, 385, 453, 454, 468, 470, 558, 641,
721, 757, 764, 805, 871); one exception is a study that
found a decrease in the albumin-adjusted serum calcium
(632). The ionized calcium has similarly been shown to be
either increased slightly (221, 251, 470, 497, 757) or un-
changed (157, 294, 453, 558, 721, 805, 871) in lactating
women compared with themselves or with controls. Moth-
ers nursing twins had higher serum calcium than mothers
nursing singletons in one study (347) but not in another
report (646). In studies in which serum calcium and ionized
calcium were modestly but significantly increased, mean
serum calcium remained within the normal range. How-
ever, substantial hypercalcemia can occur during lactation
and resolve with weaning (see sect. V, D and F) (549).
Numerous studies have shown that serum phosphorus in-
creases during lactation, with mean values exceeding the
upper limit of normal in some studies (33, 156, 157, 164,
207, 221, 294, 453, 454, 468, 470, 497, 558, 632, 721,
757, 805, 871). Phosphorus rose higher in women nursing
twins in one study (646) but not in another (347). Renal
tubular reabsorption of phosphorus also increases (156,
157, 206, 207, 468, 470, 558). Given that intestinal absorp-
tion of phosphorus is likely normal (sect. IVC), this increase
in serum phosphorus in breastfeeding women likely results
from the effects of increased skeletal resorption (sect. IVE)
combined with relatively decreased renal phosphorus ex-
cretion (sect. IVD).
Serum magnesium is normal or modestly increased during
lactation (33, 164, 207, 221, 294, 348, 505, 721, 871), with
no consistent difference between women nursing twins and
singletons (347).
C) SUMMARY. Serum calcium, ionized calcium, and phospho-
rus are usually normal in lactating mice, but these values
may be increased, normal, or decreased in lactating rats,
likely due to variable effects of diet, litter size, rat strain, and
whether samples were drawn fasting or not. Milk produc-
tion imposes a high rate of efflux of calcium from the rodent
circulation, such that the serum calcium can be low during
suckling but rebound above normal with forced weaning. In
breastfeeding women, the ionized and albumin-adjusted
calcium are normal to slightly increased, while serum phos-
phorus increases and may exceed the normal range.
2. PTH
A) ANIMAL DATA. In most studies of lactating rats PTH has
increased across a wide range of diets containing 0.4 1.4%
calcium (32, 90, 254, 318, 320, 337, 627, 807, 920); how-
ever, PTH remained unchanged in lactating rats on 1.6, 0.4,
and 0.1% calcium in one study (568), and on an unspecified
Physiol Rev VOL 96 APRIL 2016 www.prv.org
diet (337). A low-calcium diet (320, 321) and nursing larger
litters (320, 708) cause higher PTH concentrations,
whereas if only three pups are nursed PTH is normal (320).
After weaning, PTH falls within 6 h and becomes normal by
24 48 h (321).
In contrast to the studies in rats, longitudinal studies of
Black Swiss and C57BL/6 mice consuming a 1% calcium
diet have found that PTH is suppressed during lactation
from prepregnancy values, and similar to low values of
pregnancy (330, 477, 478, 994). A 2% calcium diet sup-
presses PTH further (330, 478), whereas fasting overnight
leads to nonsuppressed PTH (580). Conversely in lactating
CD1 mice consuming a 1% calcium diet, the serum PTH
was no different than in virgin mice, whereas a 0.01% cal-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
cium diet caused a marked rise in PTH (34).
These findings suggest that PTH is needed to support the
delivery of calcium during lactation, such as by stimulating
bone resorption, Cyp27b1 expression and activity, and re-
nal calcium conservation. Low dietary calcium intake and
larger litter sizes provoke higher PTH to stimulate these
processes, whereas high calcium intake and smaller litter
sizes prevent the need for PTH to increase. Rats may be
more dependent on PTH than mice, given that lactating rats
have been consistently found to have elevated PTH despite
even high calcium intake, while lactating mice may have
suppressed PTH unless fasted. The role that PTH plays in
regulating mineral homeostasis during lactation, as re-
vealed through studies of parathyroidectomized rats and
Pth null mice, is discussed in more detail in sections IV,
CE, and VD.
B) HUMAN DATA. Lactation was originally thought to repre-
sent a state of secondary hyperparathyroidism (15), but
although some early-generation PTH assay results ap-
peared to confirm this hypothesis (757), most found normal
levels (219, 348, 385, 578). Modern intact PTH assays have
generally revealed that PTH is suppressed toward the lower
end of the normal range and may become undetectable
during lactation (9, 157, 206, 207, 251, 294, 349, 454, 497,
505, 558, 871, 1025). This suppression is not seen with
COOH-terminal or mid-molecule assays (221, 871).
Women nursing twins had increased PTH in one study
(347) while another found no difference (646).
In contrast to these studies, others have reported increased
PTH during lactation in women from regions of Africa and
Asia in which low calcium, high phytate, and low vitamin D
intakes are more prevalent (168, 228, 439, 601, 805). Such
a difference has also been seen when African American and
Caucasian women, all from North America, have been
compared (156).
The influence of PTH in regulating mineral metabolism dur-
ing lactation is further discussed in subsequent sections that
489
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
address the synthesis of calcitriol (sect. IIA4) and the adap-
tations that occur in the intestines (sect. IVB), kidneys (sect.
IVC) and bone (sect. IVD). PTHs role is also illuminated by
data on the effects of hyperparathyroidism (sect. VB) and
hypoparathyroidism (sect. VD) in breastfeeding women.
PTH rises to normal (206, 558) or above normal (207, 470,
632, 871) during the post-weaning interval. This elevation
corresponds to the time when bone mineral is restored to
the skeleton (see sect. IVG) (27, 410).
C) SUMMARY. PTH is generally suppressed in lactating mice
unless the samples are drawn fasting, whereas PTH is al-
most invariably elevated in lactating rats regardless of the
calcium content of the diet. In largely Caucasian women
from North America and Europe who are consuming ade-
quate calcium, PTH is typically suppressed during lacta-
tion, so the original hypothesis of hyperparathyroidism in
lactation has not been substantiated. However, PTH is ele-
vated in women from certain regions of Asia and Africa, as
well as in African American women from North America,
so lactation does represent a state of physiological second-
ary hyperparathyroidism in some women. A rise in PTH
during lactation is attributable to lower calcium and higher
phytate intakes, as well as probable ethnic differences.
3. PTHrP
A) ANIMAL DATA. Few measurements of plasma PTHrP have
been made in mice due to the lack of rodent-specific assays
and the large samples sizes required for the human assays.
Nevertheless, PTHrP is increased in the circulation of lac-
tating mice (37, 530, 953, 956, 989, 994). The source is
largely mammary tissue, in which PTHrP mRNA and pro-
tein become substantially upregulated during lactation
(738, 992, 994). The fall in progesterone and estradiol after
delivery, and surge in prolactin, are thought to accelerate
PTHrP production (737, 906, 916, 940, 956). Suckling in-
duces expression of PTHrP mRNA and protein within rat
mammary tissue (906, 1004); this effect is partly mediated
by prolactin and blocked by bromocriptine (906), whereas
oxytocin has no effect (906). In the goat, prolactin also
stimulates PTHrP, while treatment with bromocriptine re-
duces the PTHrP content of milk (744). Studies of cultured
rat mammary epithelial cells found that PTHrP production
was increased by low progesterone but not responsive to
prolactin or estradiol (940). The PTHrP content of milk is
higher at the end of lactation in rats, by which time prolac-
tin has been normal for days, which suggests that prolactin
is not required for sustained PTHrP synthesis and secretion
during lactation (129).
Loss of calcitonin in Ctcgrp null mice resulted in upregula-
tion of PTHrP mRNA and protein expression within mam-
mary tissue (992, 994), but whether this was a direct effect
of loss of calcitonin signaling within mammary tissue, or
secondary to other systemic changes in those mice (see sect.
490 Physiol Rev VOL 96 APRIL 2016 www.prv.org
VH), is unknown. Serotonin increases during lactation in
mice (101) and may stimulate mammary gland PTHrP,
since increased dietary intake of a serotonin precursor
raised PTHrP mRNA and protein expression in the mam-
mary glands, and also increased plasma PTHrP significantly
(530). Conversely, deletion of tryptophan hydroxylase-1 in
mice results in global serotonin deficiency, and reduced
PTHrP expression in mammary tissue during lactation
(380). This was reversed in a dose-dependent fashion by a
serotonin receptor agonist and worsened by a serotonin
receptor antagonist (380).
Local factors are important for stimulating PTHrP, since
milking one goat mammary gland increases the PTHrP con-
centration in milk from that gland but not the contralateral
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
gland (916).
Higher PTHrP concentrations in the venous outflow of goat
mammary glands was the first confirmation that PTHrP
reaches the maternal circulation from this source (744). A
suckling-induced phosphaturia and increase in nephrog-
enous cAMP, which persists in parathyroidectomized,
lactating rats, appears to be a physiological response to
systemic release of PTHrP (1004). Similarly in cows, a
milking-induced phosphaturia blocked by a PTH/PTHrP
receptor antagonist implicated PTHrP as the culprit (56).
Definitive confirmation that PTHrP reaches the maternal
circulation from mammary tissue came from a mouse
model in which the Pthrp gene was deleted from mam-
mary tissue at the onset of lactation, and this reduced the
plasma PTHrP concentration (953). Moreover, in these
mice lacking mammary-derived PTHrP, bone resorption
was decreased and less bone was lost by the end of lactation
(953). Conversely, Ctcgrp null mice had increased mam-
mary expression of PTHrP and lost twice as much bone
mineral content during lactation as their WT sisters (994).
Collectively, these findings confirm that through its expres-
sion of PTHrP, mammary tissue plays a central role in reg-
ulating bone resorption during lactation (see sects. IV, E
and F, and V, D and F). In addition to affecting skeletal
metabolism, mammary-derived PTHrP also appears to lo-
cally regulate the fluid and mineral content of milk, as dis-
cussed in section IVB.
B) HUMAN DATA. PTHrP was originally cloned from small
amounts expressed by tumors causing humoral hypercalce-
mia of malignancy, and shown to circulate in picomolar
amounts in the blood of affected patients. But it later be-
came apparent that 1,000 10,000 times the concentration
of the elusive protein was readily available in milk, whether
produced by breastfeeding women or obtained from the
corner store (134, 208, 473, 681, 742, 812). Milk was
tested in part because it had been known for some time that
hypoparathyroid and aparathyroid women normalize min-
eral homeostasis or even become hypercalcemic while
 CHRISTOPHER S. KOVACS
breastfeeding, which suggested the presence of a PTH-like
factor during lactation (see sect. VD).
In section IIA3B, the inherent problems with measuring
PTHrP in serum as opposed to plasma, and limitations of
the available assays, apply to published studies of lactating
women. Despite these problems, and with few exceptions
(473), most studies have found the circulating PTHrP1 86
or PTHrP134 level to be significantly increased in lactating
women vs. nonpregnant women or bottle-feeding controls
(251, 349, 497, 558, 863). An assay directed against a mid-
region sequence (PTHrP6377) also found PTHrP to be ele-
vated in the blood of lactating women (130).
Circulating PTHrP increases after suckling (251, 557, 558);
together with its very high content in milk, this confirms
that the breasts must be the source. PTHrP may not be
elevated in the first 3 days postpartum before lactation is
fully established (151). PTHrP immunoreactivity rises
steadily in breast milk over the first few days postpartum,
and subsequently declines as lactation wanes (129, 208,
251). PTHrP concentrations correlate positively with ion-
ized calcium and negatively with PTH of lactating women
(251, 497). Increased plasma PTHrP correlates with a
greater loss of bone mineral density during lactation (863).
Furthermore, there have been several cases of excess pro-
duction of PTHrP by the breasts during lactation that have
caused hypercalcemia (pseudohyperparathyroidism) (see
sect. VF).
PTHrP declines significantly during the post-weaning inter-
val (558). Exactly when it disappears from the maternal
circulation have not been established, but the variable re-
sponse of hypoparathyroid women to weaning indicates
that it may be gone by weaning or persist for up to many
months (see sect. VD).
C) SUMMARY. Lactating mammary tissue upregulates expres-
sion of PTHrP, some of which is secreted into the maternal
circulation to alter mineral and skeletal homeostasis. In a
real sense the breasts become accessory parathyroids by
producing substantial amounts of PTHrP. As discussed in
sections IV, BF, release of PTHrP into the maternal circu-
lation has systemic effects to alter milk composition, intes-
tinal mineral absorption, renal mineral handling, and skel-
etal resorption. The most convincing evidence comes from
aparathyroid or hypoparathyroid women who release
PTHrP from the breasts and normalize mineral homeostasis
during lactation (see sect. VD) (148 150, 213, 785) and
pseudohyperparathyroid women who become hypercalce-
mic while breastfeeding (see sect. VF).
4. Calcitriol
A) ANIMAL DATA. Serum calcitriol increases twofold or more
in lactating rats (90, 92, 93, 114, 718, 1021), and higher
levels are achieved with larger litters or more intense lacta-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
tion (90, 567). The fall in serum and ionized calcium and
rise in PTH, observed in most studies of lactating rats, likely
contribute to the increase in calcitriol. This increase is also
influenced by the diet, rising higher with a 0.1% calcium
diet and being prevented by a 1.6% calcium diet (568). In
that study PTH was no different between lactating and
nonlactating rats despite the three different diets, indicating
that the changes in calcitriol were independent of changes in
PTH (568). Another set of analyses also indicated that PTH
is not a significant predictor of the calcitriol level in lactat-
ing rats (90, 567). But PTH must account for some of the
increase in calcitriol during lactation since two studies
found that serum calcitriol in lactating parathyroidecto-
mized rats was only half the concentration of lactating in-
tact rats, although the achieved level was at least double
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
that of nonlactating rats (569, 718). In normal rats calcitriol
falls below normal by 2 days after weaning, simultaneous
with a rise in calcium and phosphorus, before increasing to
normal values by 7 days after weaning (718).
25OHD is likely not altered during lactation, as suggested
by studies of rats on three different calcium diets (568). But
in two other studies from one lab the 25OHD level in lac-
tating rats was significantly lower than in control rats (114,
115).
B) HUMAN DATA. Free and total calcitriol falls to normal dur-
ing postpartum (206, 439, 578, 746, 809, 987) and remains
normal throughout lactation and postweaning (156, 157,
206, 207, 348, 385, 470, 505, 632, 764, 805, 871, 987).
One study found that extended lactation (6 mo) was as-
sociated with higher calcitriol (348), another report found
that calcitriol increased during the postweaning interval of
bone recovery (871), and a third report found that calcitriol
was 10% higher during lactation and that this persisted
during the post-weaning interval (454). Women nursing
twins had higher calcitriol levels than women nursing sin-
gletons in one study (347) but not in another (646).
25OHD levels do not appear to be altered by up to 12 mo of
breastfeeding in most studies (33, 156, 157, 165167, 470,
505, 558, 764, 780, 805, 862, 871). This is consistent with
milk normally containing very low amounts of vitamin D
and 25OHD (see sects. IVB and VG).
The decline to normal concentrations of calcitriol may re-
sult from pregnancy-related factors being lost at parturi-
tion, such as high levels of estradiol and placental lactogen.
PTHrP reaches peak levels during lactation and likely stim-
ulates Cyp27b1, but there is some evidence that it may be
less potent than PTH in stimulating Cyp27b1 (308, 413,
414, 494, 988).
C) SUMMARY. Calcitriol remains elevated in lactating rats and
mice, whereas in breastfeeding women the level promptly
declines to nonpregnant values. These differences between
491
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
rodents and women are consistent with indications that
rodents require increases in both intestinal calcium absorp-
tion and skeletal resorption to meet the mineral require-
ments of lactation, whereas women require only increases
in skeletal resorption (see sect. IV, C and E).
5. Calcitonin
A) ANIMAL DATA. Similar to serum calcium and PTH, serum
calcitonin levels in lactating rats have been quite variable,
including low values on a 1.4 and 1.5% calcium (86, 627);
high levels on 1.2% and 0.9% calcium (76, 926) and an
unspecified diet (201); and normal values on an unspecified
diet (337). Calcitonin levels are higher in fed versus fasted
lactating rats (201). In ewes, calcitonin drops to nonpreg-
nant levels at delivery, rises early in lactation, and declines
to normal as lactation progresses (312). Deer show in-
creased calcitonin during lactation which rises further dur-
ing post-weaning before it declines (170). No measure-
ments have been published in lactating mice.
Calcitonin has been shown to inhibit lactation by acting on
suckling-induced prolactin release by pituitary lactotrophs
(177, 680, 756, 919). Calcitonin is also expressed by pitu-
itary gonadotrophs (755), wherein its targeted overexpres-
sion leads to hypoprolactinemia (1014). This leads to con-
sideration of a physiological negative-feedback loop during
lactation in which calcitonin inhibits the release of prolactin
by the pituitary, thereby reducing milk production, releas-
ing the inhibition of ovarian function, and inhibiting PTHrP
release by mammary tissue.
Calcitonin surges within 24 h after abrupt weaning in rats,
at a time when osteoclasts are undergoing widespread apo-
ptosis (627), so calcitonin may be one of the signals that
contributes to the sudden downregulation of osteoclast-
mediated bone resorption. Alternatively, it may simply be
responding to the post-weaning spike in serum calcium.
B) HUMAN DATA. Few studies have measured calcitonin in
breastfeeding women. Available data show high levels
throughout lactation (221, 878) but also normal values be-
tween 6 wk and 12 mo postpartum (347, 385, 505, 632,
764). There was no difference in serum calcium among
these studies that could explain the variable calcitonin val-
ues. Women nursing twins had higher serum calcitonin than
women nursing singletons, but mean values were normal
(347).
The breast is an important extrathyroidal source of calci-
tonin. It is secreted into breast milk at 45 times its concen-
tration in blood, such that during lactation, totally thyroid-
ectomized women and women with intact thyroids have the
same mean calcitonin concentration (131).
The effect of calcitonin to inhibit prolactin in rodents, and
similar findings in human studies (155, 431), led to a com-
492 Physiol Rev VOL 96 APRIL 2016 www.prv.org
mon warning in prescribing information that calcitonin
should not be used in breastfeeding women because of its
potential to inhibit lactation.
C) SUMMARY. Calcitonin may be normal or increased in lac-
tating rodents and breastfeeding women. Although largely
considered a vestigial hormone, there is convincing evi-
dence from animal models that calcitonin protects against
excess skeletal resorption during lactation (sects. IVE and
VH). It surges to high levels at weaning, which may point to
a functional role in inducing osteoclast apoptosis, or it may
simply be responding to the post-weaning spike in serum
calcium. Calcitonin can also inhibit prolactin and lactation
in women and animal models when administered at phar-
macological doses.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
6. FGF23
A) ANIMAL DATA. There are no published data of circulating
FGF23 concentrations in lactating animals. The physiolog-
ical importance of FGF23 is uncertain given the variable
changes in serum phosphorus during lactation in rodents.
The effect of excess FGF23 on serum minerals and milk
composition is discussed in sections IVB and VJ.
B) HUMAN DATA. No measurements of FGF23 in breastfeed-
ing women have been reported. The relative hyperphos-
phatemia of lactation could conceivably cause a compensa-
tory increase in FGF23. The influence of excess FGF23 on
milk composition is discussed in sections IVB and VJ.
C) SUMMARY. There are insufficient data to know whether
serum FGF23 concentrations are altered in lactating ro-
dents or humans.
7. Sex steroids and other hormones
A) ANIMAL DATA. Lactation induces a surge in prolactin and a
fall in estradiol and progesterone in the rat, mouse, and
ewe; the fall in progesterone and estradiol are triggers of
lactogenesis (655).
In mice, serum estradiol is usually near the detection limit of
available assays. Although it has been shown to be low in
lactating mice in one study (34), in most studies serum
estradiol is not significantly different from prepregnancy,
pregnancy, or virgin measurements (627, 956, 992, 1026).
It is unclear whether the lack of suppressed levels during
lactation is because estradiol is not low or because the as-
says are not sensitive enough to detect differences. More-
over, lactating mice go through estrus cycles and can be-
come pregnant while lactating, so estradiol levels may not
be sufficiently low in lactating mice to cause bone resorp-
tion.
Prolactin levels surge during early lactation as it exerts its
role in initiating milk production; dopaminergic agents in-
 CHRISTOPHER S. KOVACS
hibit prolactin and stop milk production. Prolactin and pro-
lactin receptor null mice cannot be studied because they are
infertile, but loss of one allele of the prolactin receptor
causes impaired lactation (465). Prolactin has been pro-
posed to directly stimulate osteoblasts and osteoclasts dur-
ing lactation, but inhibiting prolactin with bromocriptine
achieved inconsistent results (888). Moreover, inhibiting
prolactin does not necessarily test a direct role of prolactin
on bone, since loss of prolactin will inhibit milk production,
reduce ovarian suppression, and reduce PTHrP production
by mammary tissue.
Oxytocin is required to cause contraction of myoepithelial
cells within mammary tissue, thereby causing milk ejection.
Oxytocin has also been proposed to regulate osteoblasts
and osteoclasts during lactation (565, 895), but this has not
been studied. Oxytocin null mice are unable to lactate be-
cause lack of milk ejection causes apoptosis of mammary
cells (663).
IGF-I did not change in lactating mice compared with age-
matched virgins, but approximately doubled by the third
week of post-lactation recovery (101). As noted above, se-
rotonin increased during lactation and may stimulate
PTHrP production; there was a further increase during
post-weaning recovery (101).
B) HUMAN DATA. Human lactation is also characterized by
increased prolactin, and reduced estradiol and progester-
one. Delivery of the placenta is responsible for the fall in
progesterone and estradiol, which in turn trigger lactogen-
esis (617, 655). Failure to drain the breasts of milk (via
suckling or pumping) leads to milk stasis, apoptosis of
mammary cells, and cessation of lactation.
Estradiol is suppressed to menopausal levels during early
lactation (157, 409, 505, 695, 764), especially when basal
levels of prolactin are elevated (409, 695). Low estradiol
may persist throughout lactation or recover to normal val-
ues after several months. It likely contributes to bone re-
sorption during lactation, as discussed in section IVE. Pro-
lactin declines as the postpartum days pass but continues to
spike upwards with each suckling episode (409, 505, 655,
695). Any effect of low estradiol may be lessened during
prolonged lactation in women whose menses resume.
Oxytocin spikes in the maternal circulation within a few
minutes of the baby being put to the breast (230, 655).
C) SUMMARY. Continuously low estradiol, and intermittently
high prolactin and oxytocin levels, characterize the hor-
monal milieu of lactation. Low estradiol contributes to skel-
etal resorption, but the extent to which prolactin and oxy-
tocin have direct or indirect effects to regulate skeletal me-
tabolism during lactation is uncertain. Lactation also causes
changes in luteinizing and follicle stimulating hormone,
Physiol Rev VOL 96 APRIL 2016 www.prv.org
progesterone, testosterone, inhibins, and activins. Whether
these play direct or indirect roles in regulating maternal
skeletal metabolism during lactation is uncertain.
B. Calcium Pumping and Secretion in
Mammary Tissue
1. Animal data
The process by which calcium enters mammary epithelial
cells and is eventually secreted into milk is incompletely
understood (FIGURE 3). Calcium appears to enter the baso-
lateral membranes of mammary epithelial cells via stretch-
activated and other calcium channels. A low concentration
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
of calcium is maintained within the cytoplasm by PMCA1
actively pumping calcium into the Golgi apparatus, wherein
calcium becomes bound to proteins (casein and -lactalbu-
min) or complexed to phosphate and citrate. Calcium is also
bound to carrier proteins such as calbindin-D9k within the
cytoplasm (442) and transported to the apical membrane.
Calcium is extruded from the Golgi apparatus into milk
through transepithelial secretion (617, 652), a process that
accounts for 30% of calcium transport into milk. About
70% of calcium entry into milk results from plasma mem-
brane calcium ATPase isoform 2 (PMCA2) pumping cal-
cium across the apical membranes directly into milk (753,
954).
The calcium and fluid content of milk are tightly regulated.
Identified regulatory factors include suckling, the calcium
receptor, PTHrP, prolactin, calcitriol, and others (442, 655,
952, 953). Lactating mammary epithelial cells also express
numerous genes and proteins that are involved in calcium
homeostasis elsewhere in the organism, including the cal-
cium receptor, PTHrP, calcitonin, the calcitonin receptor,
Cyp27b1, VDR, and calbindin-D9k; however, TRPV5 and
TRPV6 are not expressed (938, 952, 1026).
PTHrP plays a key role in the embryonic and adolescent
development of the mammary glands (99, 258, 389, 999),
so its later expression by lactating mammary tissue and
breast cancers is understandable. The intense expression of
PTHrP in lactating mammary tissue, and its secretion into
milk at high concentrations, have prompted investigations
to determine whether PTHrP regulates the calcium content
of milk. Early studies showed that the PTHrP concentration
in milk was positively correlated with calcium content of
milk from cows (539, 681) and rats (989), but not in all
studies from rats (738, 1004). One study found that with
time since suckling, PTHrP content of milk decreased while
the calcium content increased (1004). Treatment of lactat-
ing goats with bromocriptine reduced the milk content of
both PTHrP and calcium (744). PTHrP also has vasodila-
tory effects on mammary vessels, through which it may
regulate mammary blood flow (907, 908). PTHrPs expres-
sion in mammary tissue is increased by low estradiol, low
493
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION

Basolateral
surface ADP FIGURE 3. Calcium transport across mam-
Ca2+ ATP mary epithelial cells into milk. The basolateral
Ca2+ Mammary (left) and apical (right) basement membranes
Ca2+ PMCA1 epithelial cell Apical of a mammary epithelial cell are depicted.
Ca2+ surface
Ca2+ Calcium enters the cell through channels that
Ca2+ have not been defined; TRPV6 and TRPV5
Ca2+
Ca2+ Ca2+ are not expressed. About 20 30% of cal-
Ca2+
Ca2+ cium destined for secretion into milk is
Ca2+ Ca2+
pumped into the Golgi apparatus via PMCA1,
Ca2+ Ca2+ Ca2+ Ca2+ wherein it is packaged into secretory gran-
Ca2+ Ca2+
Ca2+ Ca2+ ules containing proteins (casein and -lactal-
~2.2 mM <1 mM ~3 mM bumin) and complexes of calcium with phos-
[Ca2+] in blood [Ca2+] in cytoplasm Ca2+ [Ca2+] in milk phate and citrate. These granules are ex-
truded from the Golgi apparatus into milk
Ca2+ through transepithelial secretion at the apical
Ca2+
Ca2+ Ca2+ Ca2+ membrane. About 70 80% of calcium en-
2+ tering the cell becomes bound to carrier pro-
Ca2+ Ca2+ Ca2+ Calbindin-D9k Ca2+ Ca2+ Ca

Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017

2+ teins such as calbindin-D9k and is shuttled to
Ca Ca2+
Ca2+ Ca2+ Ca2+ the apical membrane in the transcellular
+
PMCA2 Ca2+ pathway, from where PMCA2 actively pumps
the calcium into milk. Calcium ions binding to
Ca2+
the calcium receptor on the basolateral
ADP Ca2+
ATP membrane inhibit PTHrP and stimulate
Calcitonin PMCA2 to pump calcium into milk. Calcitonin
Ca2+ ?
may also influence these processes, perhaps
through regulation by the calcium receptor
Ca2+ ?
(which regulates calcitonin in C-cells of the
Ca2+ thyroid), since absence of calcitonin causes
upregulation of PTHrP within mammary epi-
PTHrP thelial cells, and milk calcium concentration is
Into blood Into milk
also increased. PTHrP is released into milk at
higher concentrations than it is released into
the maternal circulation.

progesterone, low dietary calcium, systemic hypocalcemia,
high prolactin, and suckling (737, 906, 910, 916, 940, 952,
956, 1003, 1004). Each of these stimulatory factors sup-
ports a role for PTHrP in regulating mammary gland and
mineral physiology during lactation. On the other hand, an
early study failed to detect a change in milk calcium content
when lactating mice were passively immunized with anti-
PTHrP antibody (620).
The role of PTHrP has been further explored through the
use of gene deletion models in mice. Selective deletion of
Pthrp from mammary epithelial cells at the onset of lacta-
tion resulted in reduced milk calcium content (953). How-
ever, this may have been an indirect effect because the sup-
ply of calcium to mammary tissue was also reduced, as
indicated by reduced bone turnover markers and less bone
resorbed by the end of lactation (953). Conversely, signifi-
cant upregulation of PTHrP mRNA and protein occurred
within mammary epithelial cells of Ctcgrp null mice (which
lack calcitonin), and the milk calcium content was signifi-
cantly doubled at day 14 of lactation (994), and nonsignifi-
cantly increased at day 7 of lactation (992). Again, this may
have been an indirect effect because in these mice the supply
of calcium to mammary tissue was significantly increased,
as shown by increased bone turnover markers and a dou-
bling of net bone lost by the end of lactation (992, 994).
Further studies that examined the effect of calcimimetic
agents, and selective deletion of the calcium receptor, have
clarified the role of PTHrP within mammary tissue. It is the
calcium receptor, expressed by mammary epithelial cells,
which appears to directly regulate production of PTHrP,
and the fluid and calcium content of milk (36, 591, 952).
While a low calcium diet increases mammary production of
PTHrP, this effect is blocked by a calcimimetic drug, which
activates the calcium receptor to downregulate PTHrP
(952). Ablation of the calcium receptor globally, or selec-
tively within mammary epithelial cells, upregulates mam-
mary gland PTHrP expression and reduces calcium trans-
port into milk (36, 591). Moreover, selective ablation of the
calcium receptor from mammary epithelial cells raises the
plasma PTHrP level, induces hypercalcemia, and causes in-
creased bone resorption and net loss of bone by the end of
lactation (591). But despite systemic hypercalcemia and in-
creased bone resorption, the milk calcium content remains
low because of loss of the calcium receptors actions to
promote calcium entry into milk (591).
The calcium receptor also upregulates expression of
PMCA2, expressed on the apical plasma membranes of
mammary epithelial cells, to stimulate calcium secretion
into milk (952, 954). The importance of PMCA2 has been
revealed by a spontaneous loss of function mutation of

494 Physiol Rev VOL 96 APRIL 2016 www.prv.org

 CHRISTOPHER S. KOVACS

Pmca2 in deafwaddler mice, which produce milk of low
calcium content (753, 954). Deletion of the calcium recep-
tor from mammary epithelial cells did not affect expression
of PMCA2, thereby confirming that it is loss of the calcium
receptor function that specifically leads to the low calcium
content of milk (591), perhaps by reduced activity but not
expression of PMCA2.
Studies in goats have revealed that the calcium receptor and
PTHrP may play opposing roles with respect to mammary
epithelial cell survival. Activation of the calcium receptor by
calcium or a calcimimetic drug inhibited proliferation and
induced apoptosis of mammary epithelial cells, whereas
overexpression of PTHrP had the opposite effect to inhibit
apoptosis and promote proliferation (552).
when the calcium supply is insufficient (FIGURE 4). In this
model, PTHrPs role is to maintain systemic delivery of
calcium to the mammary epithelial cells by resorbing cal-
cium from the skeleton and reabsorbing calcium from the
kidney tubules. Thereby, PTHrP plays an indirect but key
role in determining the calcium content of milk.
This model implies a negative feedback loop that will enable
milk production to decrease or cease if the serum calcium
becomes dangerously low for the mother (955). However, it
is not a fail-safe loop because hypocalcemia leading to tet-
any and death can occur during lactation in rats and mice
that nurse large litters, and in dairy cows (milk fever).
Blocking the effect of PTHrP to resorb bone through use of
a bisphosphonate or osteoprotegerin (OPG) treatment in

Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017

Putting these observations together, it appears that mam-
mary epithelial cells utilize the calcium receptor to sense the
availability of calcium for milk production. The calcium
receptor will promote calcium secretion into milk when the
supply is adequate, and stimulate production of PTHrP
lactating mice did not cause a compensatory increase in
PTHrP (37, 956), but this might be explained in part be-
cause the serum calcium did not decrease. In a separate
study, a fall in serum calcium and an increase in calcitriol
were observed in bisphosphonate-treated rats which may
imply increased PTHrP activity (115), but PTHrP was not

A Increased maternal serum calcium B Reduced maternal serum calcium

Ca2+
Ca2+
Ca2+
Ca2+ Ca2+
Ca2+
Ca2+ Ca2+

Ca2+
H2O Ca2+ H2O
+ +
Calcium and H2O Ca2+ Calcium and H2O Ca2+
PTHrP Ca2+ PTHrP Ca2+
(milk) Ca2+ (milk)
Ca2+
Ca2+ Ca2+
Ca2+
PTHrP PTHrP

PTHrP PTHrP
(maternal plasma) (maternal plasma)

FIGURE 4. The role of PTHrP and calcium receptor (CaSR) within the lactating breast. The calcium receptor
(represented schematically) is expressed by lactating mammary epithelial cells. It monitors the systemic
concentration of calcium to control PTHrP synthesis and, thereby, the supply of calcium to the breast. An
increase in serum calcium or administration of a calcimimetic inhibits PTHrP expression (A), whereas a
decrease in serum calcium or ablation of the calcium receptor from mammary epithelial cells stimulates PTHrP
expression (B). The calcium receptor also directly regulates the calcium and fluid composition of milk indepen-
dent of PTHrP. Administration of a calcimimetic stimulates calcium and water transport into the breast, while
ablation of the calcium receptor results in low milk calcium despite increased PTHrP and systemic hypercal-
cemia. PTHrP produced by mammary epithelial cells enters the maternal circulation to stimulate maternal
bone resorption and renal calcium conservation. It also enters milk at 1,000- to 10,000-fold higher concen-
trations, from where it may influence neonatal accrual of calcium.

Physiol Rev VOL 96 APRIL 2016 www.prv.org 495

 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
measured. Moreover, several additional physiological obser-
vations suggest that the mammary gland calcium receptor has
quite limited ability to prevent systemic hypocalcemia. In se-
verely vitamin D-deficient rats, which have a serum calcium
50% of normal, the calcium content of milk was unchanged
compared with normocalcemic, vitamin D-sufficient mothers
(91). In cows, the calcium content of milk is unaffected by low,
normal, or high dietary calcium content, or low to high milk
output (204).
Notably, the effect of the calcium receptor to inhibit mam-
mary gland production of PTHrP is reversed in certain ma-
lignant breast cancers, such that altered G protein coupling
causes the calcium receptor to stimulate rather than inhibit
the production of PTHrP (592). This may explain why a
positive feedback loop results when certain breast cancers
produce PTHrP to resorb bone, and the released calcium
acts through the calcium receptor to stimulate more PTHrP
rather than inhibiting it. Altered G protein coupling is also
a potential explanation for why lactation may lead to
PTHrP-mediated hypercalcemia in some women (see sect.
VF).
Other work has established that serotonin stimulates not
only rat mammary gland expression of PTHrP, but milk
PTHrP content, plasma PTHrP, systemic bone resorption,
and milk calcium content (530). These findings confirm an
important physiological role for serotonin in regulating
mammary gland physiology during lactation, but also im-
ply that increased expression of PTHrP causes increased
milk calcium content. However, expression of PMCA2
more than doubled in mammary tissue in these studies
(530), and that can be expected to increase milk calcium
independent of PTHrP. It is unclear whether the increase in
PMCA2 resulted from increased serotonin signaling or the
increase in PTHrP expression.
Although Cyp27b1 and VDR are expressed in mammary
epithelial cells and increase their expression 20- and 50-
fold, respectively, during late pregnancy and lactation
(1026), their relative roles are uncertain and the data are
conflicting. In Vdr null mice, the milk calcium content was
no different than in WT, although the mice were studied on
a high-calcium diet that maintained normocalcemia (1026).
Vdr null mice did display accelerated glandular develop-
ment and early casein expression during pregnancy, in-
creased milk output, and delayed involution of the mam-
mary tissue after weaning (1026). Conversely, Cyp27b1
null mice were also studied on the same rescue diet but
remained hypocalcemic, and produced milk with reduced
calcium content (442). Mammary gland expression of
PTHrP, PMCA2 and calbindin-D9k was also significantly
reduced in Cyp27b1 nulls (442). It is unclear whether the
reduced milk calcium content resulted from systemic hy-
pocalcemia or the loss of calcitriol within mammary tissue.
If it is the loss of calcitriol, the lack of alteration in milk
496 Physiol Rev VOL 96 APRIL 2016 www.prv.org
calcium in Vdr null mice may mean that this effect of cal-
citriol is not mediated by VDR. Additional studies in se-
verely vitamin D-deficient mice and rats also found that the
calcium content of milk was normal (19, 119).
Phosphorus is also subjected to regulated pumping and se-
cretion into breast milk, although less is known about the
regulatory factors involved. The FGF23 target NaPi2b is
coexpressed with VDR in mammary epithelial cells of the
goat and mouse (417, 631, 643), and NaPi2b expression
decreased in response to lower dietary phosphorus intake
(643). Expression of Klotho and FGF receptors by lactating
mammary tissue has evidently not been studied. Systemic
hypophosphatemia in Phex/Hyp mice did not alter the
phosphorus or calcium content of milk (240), but this dif-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
fers from findings in women (see below).
PTH likely plays a supportive role in milk production by
helping to maintain the maternal serum calcium near the
normal range, and this may explain why PTH is often ele-
vated in normal lactating rats. In Ctcgrp null mice that had
elevated mammary expression of PTHrP and increased milk
calcium content, serum PTH was also increased above nor-
mal and may have contributed to the milk calcium level
(992, 994). Milk calcium content was normal in parathy-
roidectomized rats, but the study was confounded by the
serum calcium remaining in the normal range on a 1.2%
calcium diet (319).
2. Human data
Fewer studies of calciotropic factors affecting milk content
have been done in women. The PTHrP concentration of
milk (245, 812, 941) and in the maternal circulation (245)
correlates positively with total milk calcium content. A ran-
domized trial found no effect of calcium supplementation
on milk PTHrP content, but there may be a diurnal varia-
tion with more PTHrP in milk obtained in the morning
compared with the afternoon (208). Diets that are high
(206, 452, 484, 723) or low (728 731) in calcium, or high
(60) or low (731) in vitamin D, do not affect milk calcium
content.
The vitamin D content of milk is normally quite low, and
this is why breastfeeding is a risk factor for vitamin D defi-
ciency and rickets in neonates and infants. It is a curiosity as
to why the vitamin D content is so low. It is not possible for
humans to develop vitamin D toxicity from sunlight expo-
sure due to limited substrate produced in skin each day, but
it is possible to become vitamin D toxic from overingestion
of vitamin D from supplements and vitamin D-fortified
foods. Therefore, a teleological argument is that neonatal
physiology was designed to obtain sufficient vitamin D
from sunlight exposure, with milk content of vitamin D
kept low to prevent excess intake by the baby, and also to
prevent excess loss of 25OHD from the mother.
 CHRISTOPHER S. KOVACS
Two cases of women with hypophosphatemia due to XLH
found that the phosphorus content of milk was reduced to
about half the normal value (447, 745). The reduced serum
phosphorus in these women may explain the low phospho-
rus content of milk, without requiring a direct role of
FGF23 to regulate the phosphorus content of milk.
3. Summary
The calcium receptor appears to directly control the cal-
cium content of milk by inhibiting PTHrP and stimulating
PMCA2. There is also evidence that PMCA2 may be locally
regulated by PTHrP, serotonin, and calcitriol. PTHrP is
expressed by mammary epithelial cells wherein it plays a
supportive role in regulating the calcium content of milk,
largely by stimulating systemic bone resorption and renal
tubular conservation of calcium. The calcium receptor may
inhibit PTHrP release to prevent maternal hypocalcemia,
but this effect must be modest since lactation-induced hy-
pocalcemia occurs in rodents and cows, and extremes of
low and high dietary calcium intake do not alter milk cal-
cium content in women. XLH in women results in milk with
low phosphorus content.
C. Intestinal Mineral Absorption
1. Animal data
Lactating rodents maintain an increased rate of intestinal
calcium absorption accompanied by high serum calcitriol,
compared with nonpregnant values (93, 114, 360, 718).
Duodenal expression of calbindin-D9k, PMCA1, and VDR
are higher in lactating compared with virgin rats (949,
1021). Lactating mice similarly maintain increased circulat-
ing levels of calcitriol and presumably have increased intes-
tinal calcium absorption as well. These findings indicate
that increased intestinal calcium absorption and increased
skeletal resorption are both invoked to meet the calcium
demands imposed by a rodents relatively large litters, and a
short (3 wk) duration of lactation.
On the other hand, although reducing either the dietary
intake of calcium or skeletal resorption during lactation will
cause maternal hypocalcemia, neither manipulation re-
duces the calcium content of milk. It is only when both are
reduced, such as a calcium-restricted diet in mice also
treated with OPG to block bone resorption, that more pro-
found maternal hypocalcemia and reduced milk calcium
content result (see also sect. IVE). These findings indicate
that the rodent balances input from both skeletal resorption
and increased intestinal absorption of calcium, and that
either route of delivery can make up for the other during
lactation. It is only when both are impaired that systemic
hypocalcemia and reduced milk calcium content will result.
As with studies in pregnancy, factors other than calcitriol
may stimulate intestinal calcium absorption during lacta-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
tion, since severely vitamin D-deficient rats increase duode-
nal calcium absorption to a value equal to that of vitamin
D-sufficient rats; they also raise their serum calcium signif-
icantly but not to normal (93, 360). When these severely
vitamin D-deficient rats were also parathyroidectomized
and transferred to a high-calcium diet, an increased rate of
intestinal calcium absorption was maintained despite ab-
sence of both calcitriol and PTH, and it was no different
from the rate achieved in intact, vitamin D-sufficient rats
(93). Moreover, ketoconazole treatment reduced serum cal-
citriol by half in lactating rats, but this had no effect on the
efficiency of intestinal calcium absorption (92), confirming
that calcitriol is not necessary for an increased rate of ab-
sorption to be achieved during lactation. Intestinal calcium
absorption has not been measured in lactating Vdr null and
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
Cyp27b1 null mice.
The increased intestinal calcium absorption contributes to
the rebound hypercalcemia after abrupt weaning (396,
718), which also persists in severely vitamin D-deficient rats
(915). However, rebound hypercalcemia may have a
greater contribution from increased skeletal resorption,
which also does not require calcitriol or VDR (see sects. IVE
and VG).
Estradiol has been proposed to contribute to the stimula-
tion of intestinal calcium absorption during pregnancy be-
cause its levels are high, but estradiol is unlikely to be a
factor during lactation because its levels are reduced. More-
over, intestinal calcium absorption was unaffected by ovari-
ectomy on the second day after delivery (32).
Intestinal phosphorus and magnesium absorption are both
significantly increased during lactation in rats (113, 114).
Intestinal phosphorus absorption remains high despite se-
vere vitamin D deficiency (93), confirming that it is inde-
pendent of calcitriol. During post-weaning recovery, intes-
tinal calcium and phosphorus absorption fall to virgin val-
ues in rats (93, 360).
2. Human data
Multiple studies have demonstrated that intestinal calcium
absorption is normal (equivalent to nonpregnant values)
during lactation, reduced from the doubled rate that occurs
during pregnancy (324, 372, 453, 467 469, 764, 873).
This fall in the rate coincides with calcitriol also declining to
normal (sect. IVA) and supports that calcitriol contributes
to the increased efficiency of calcium absorption during
pregnancy.
Even when lactating and control women were randomized
to receive 1 g calcium or placebo to take daily, no difference
in fractional absorption of calcium was evident across the
groups (453). A small increase in intestinal calcium absorp-
tion occurs in women whose menses have resumed while
497
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
they are still lactating (453), which supports a role for
higher estradiol levels boosting calcium absorption.
Women often increase dietary or supplemental intake of
calcium while breastfeeding, and this will increase the total
amount of calcium absorbed, even though the efficiency of
absorption is not altered (453). However, randomized trials
and cohort studies have found that this increases urine cal-
cium excretion without affecting milk calcium or the
amount of bone resorbed during lactation (206, 452, 484,
723, 729, 730) (see sects. IVE and VI).
The failure of intestinal calcium absorption to increase dur-
ing lactation does not imply inadequacy of vitamin D in-
take. Clinical trials of high-dose vitamin D (4,000 6,400
IU daily) resulted in a very high mean 25OHD level of 160
nM (64 ng/ml), but there was no effect on breast milk cal-
cium content (60, 402, 965).
A post-weaning 20% increase in intestinal absorption of
calcium has been observed in one study (453), whereas
another found a nonsignificant 9% increase (764). These
values are well below the doubling that is achieved during
pregnancy but may still facilitate restoration of the skeleton
after lactation.
3. Summary
Intestinal absorption of calcium and phosphorus was in-
creased during pregnancy, and these high rates continue in
rodents throughout lactation. This is likely mediated in part
by high levels of calcitriol, but its persistence despite severe
vitamin D deficiency indicates that calcitriol-independent
mechanisms also stimulate intestinal calcium absorption
during lactation.
In contrast, intestinal calcium absorption falls to nonpreg-
nant values during lactation in women, accompanied by a
fall in calcitriol. High or low calcium intakes, and high
vitamin D intakes, do not seem to alter this rate in lactating
women. A modest increase in intestinal calcium absorption
may occur during post-weaning recovery.
D. Reduced Renal Excretion of Calcium
1. Animal data
Renal conservation of calcium occurs during lactation in
the lactating rat and mouse, with urine calcium concentra-
tions falling to low levels even when a high-calcium diet is
consumed (34, 291, 330, 477, 580, 994). Rendering rats
severely vitamin D-deficient did not impair the ability of the
kidneys to conserve calcium compared with vitamin D-re-
plete rats (93). Similarly, absence of calcitriol, PTH, or cal-
citonin did not alter urine calcium excretion in the respec-
tive mouse models (330, 478, 994).
498 Physiol Rev VOL 96 APRIL 2016 www.prv.org
This relative hypocalciuria is consistently accompanied by
phosphaturia in mice (330, 477, 478, 580, 994), which is
likely a demonstration of the physiological actions of
PTHrP to conserve calcium and excrete phosphorus. A
suckling-induced phosphaturia attributable to PTHrP has
also been demonstrated in rats, goats, cows, and sheep (56,
226, 907, 1003).
In rats, the persistence of elevated PTH during lactation (see
sect. IVA2) likely complements the actions of PTHrP to
conserve calcium and excrete phosphorus.
2. Human data
The glomerular filtration rate declines during lactation
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
from the increased rate of pregnancy, the tubular maximum
for calcium increases, while fractional excretion of calcium
(especially on 24 h collections) falls and may reach hypocal-
ciuric values (18, 168, 207, 221, 304, 439, 454, 467, 468,
470, 632, 757, 764). This is more readily seen in longitudi-
nal studies in which lactating women were compared with
themselves at earlier time points, and has also been demon-
strated by the urinary response to an oral calcium load in
pregnant, lactating, and control women (805). The increase
in tubular reabsorption of calcium is attributable to PTHrP.
Fractional excretion of calcium did not appear to be re-
duced in two recent cross-sectional studies from the same
authors; however, the results were confounded by the lac-
tating women consuming 60 and 80% more calcium than
the unrelated controls (156, 157).
Urine phosphorus excretion may be normal or increased in
24-h urine collections due to the increased filtered load of
phosphorus and the phosphaturic actions of PTHrP (206,
207, 439, 454, 468, 470, 757), whereas morning spot
urines corrected for creatinine may show decreased values
(168). Multiple studies have calculated a significant in-
crease in tubular maximum for phosphate (18, 156, 157,
206, 324, 468, 470, 558), which suggests that the kidneys
are actively conserving phosphorus despite the phosphatu-
ric actions of PTHrP and overt phosphaturia. This may
imply the presence of an anti-phosphaturic factor during
lactation or low levels of FGF23.
The relative hypocalciuria and renal calcium conservation
persists during the postweaning interval in some studies
(207, 470, 558), whereas the tubular maximum for phos-
phorus declines to normal (206, 207, 470, 558).
3. Summary
Urine calcium excretion decreases and urine phosphorus
excretion may increase during lactation. These actions con-
serve calcium to provide it to milk while excreting unneeded
phosphorus generated from skeletal resorption and intesti-
nal phosphorus absorption. An increase in the renal tubular
 CHRISTOPHER S. KOVACS
maximum for phosphorus suggests the presence of an anti-
phosphaturic factor (or low FGF23) despite the increased
urine phosphorus excretion.
E. Increased Skeletal Resorption and
Osteocytic Osteolysis During Lactation
1. Animal data
Multiple lines of evidence have demonstrated that the ma-
ternal skeleton is significantly resorbed during lactation to
provide calcium and other minerals to milk. Osteoclast-
mediated bone resorption is upregulated to resorb mainly
trabecular bone and endocortical surfaces, while osteocytic
osteolysis is upregulated to resorb mineral from cortical and
trabecular bone. Since lactation is a state of rapid bone loss,
bone turnover is uncoupled in favor of resorption.
One of the earliest demonstrations that the maternal skeleton
provides mineral during lactation involved fixing radioiso-
topes of calcium and strontium into maternal bone during
pregnancy. When the mice later lactated, isotopes appeared in
milk and the bodies of cross-fostered pups, with the amount
and timing of release of radioactivity suggesting that the last
calcium fixed into bone during pregnancy is the first to be
removed during lactation (706).
Objective evidence of bone resorption during lactation, and
variations in the extent of it among skeletal sites, has come
from measurements of bone turnover markers, histomor-
phometric and electron microscopy studies, ash weight,
bone mineral content by DXA, material properties of bone,
and bone structure by microCT.
Bone turnover markers are increased during lactation, with
bone resorption markers generally showing proportion-
ately greater increases than in bone formation markers (35,
101, 330, 477, 478, 580, 956, 994). These alterations in
bone turnover markers can be prevented by treatment with
a bisphosphonate, OPG, and high-dose estradiol treatment
(37, 956).
Histomorphometric studies have shown that osteoclast-me-
diated bone resorption is increased primarily in trabecular
compartments during lactation in rats (271, 408, 629, 920,
972), beagles (300, 626), and mice (34, 194, 956). Increases
in osteoblast number, osteoblast surface, osteoid thickness,
osteoclast number, and resorptive surfaces are noted, with
the increases being more marked in the resorptive parame-
ters (34, 194, 626, 956). The resorption is particularly
marked within the trabecular compartments of the verte-
brae and the ends of the long bones, resulting in reduced
mineralized tissue volumes, thinning of trabeculae, and de-
creased trabecular number (34, 194, 626, 956). These his-
tomorphometric changes could be completely prevented by
treatment with a bisphosphonate or OPG, and blunted by
Physiol Rev VOL 96 APRIL 2016 www.prv.org
fivefold physiological levels of estradiol (37, 115, 956). But
osteoclast-mediated bone resorption is not the only mecha-
nism by which bone is resorbed to release calcium during
lactation. More recent histomorphometric and electron mi-
croscopy assessments have shown that osteocytic osteolysis
also occurs during lactation, in both trabecular and cortical
bone (904, 998). Because cortical bone makes up more than
90% of the skeleton, there is the potential for substantial
mineral to be mobilized through osteocytic osteolysis.
Visible enlargement of osteocyte lacunae in certain human
pathological states was first described by Rigal and Vignal
in 1881 (763). This was reaffirmed by von Recklinghaus-
ens observations in 1910 (962), who proposed that osteo-
cytes digest their surrounding bone matrix when stressed by
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
such conditions as severe osteomalacia and rickets.
Belanger and co-workers (67, 68) rediscovered this concept
in the 1960s, named it osteocytic osteolysis, and carried out
a detailed series of experiments that confirmed objective
loss of mineral and protein content from the enlarged os-
teocytic lacunae. Furthermore, osteocytic osteolysis was
shown to be inhibited by interventions known to suppress
bone resorption (calcitonin or a high-calcium diet), and
exacerbated by factors known to stimulate bone resorption
in rodents (low-calcium diet, parathyroid extract, second-
ary hyperparathyroidism, pregnancy) and humans (hyper-
parathyroidism and Pagets disease) (67, 68). Belanger (67)
also recognized that the combined surface area of osteocyte
lacunae is 10 times the trabecular bone surface in humans,
which thereby represents a significant storehouse of mineral
to be resorbed when needed.
Unfortunately, the concept that osteocytes can function like
osteoclasts was disbelieved by many investigators and
largely overlooked for decades. More recently, the Bone-
wald lab has revisited this concept and confirmed with mod-
ern techniques that osteocytes express osteoclast-related
genes and enzymes, and resorb the mineral and protein-
aceous matrix that fills their lacunae (733, 734). Moreover,
they showed that this process occurs during lactation in
mice (733, 734, 998), and when it was blocked by condi-
tional ablation of the PTH/PTHrP receptor from osteo-
cytes, the amount of mineral lost during lactation was 50%
of normal (733). This finding may at first glance be an
indication that osteocytic osteolysis contributes 50% of
the mineral that is resorbed from the skeleton during lacta-
tion, with the balance achieved by osteoclast-mediated re-
sorption of trabeculae (FIGURE 5). However, loss of PTH
signaling in osteocytes also affects nuclear factor kappa-
ligand (RANKL) production and the number and activity of
osteoclasts, so osteoclast-mediated bone resorption may
have been reduced as well.
The objective loss of bone mass and mineral content from
the maternal skeleton has also been demonstrated by bone
ash weight measurements, analysis of the calcium content
499
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION

FIGURE 5. Osteocytic osteolysis and osteoclast-mediated bone resorption. A: quiescent bone with an
osteocyte surrounded by its lacuna and canaliculi (gray halo and tentacles). B: lactation with an osteoclast
resorbing bone (resorption pit) while an osteocyte resorbs mineral from its lacuna and pericanalicular spaces
(surrounding white regions). C: post-weaning phase, during which osteoblasts restore bone in areas previously
resorbed by osteoclasts (hatched resorption pit), and osteocytes remineralize their lacuna and pericanalicular

Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017

spaces (surrounding black regions). Evidence from osteocyte-specific ablation of the PTH/PTHrP receptor in
mice suggests that bone resorption and osteocytic osteolysis may each account for 50% of the mineral lost
from the skeleton during lactation. [From Kovacs and Ralston (501). Copyright 2015, with kind permission
from Springer Science Business Media.]

of the ash, and radiological assessment of mineral content
by DXA. Lactating rats and mice normally resorb 25
35% of bone mineral, primarily from trabecular-rich verte-
brae, to a lesser extent from trabecular bone of the femora
and tibiae, and much less from purely cortical bone (34, 35,
101, 176, 271, 296, 320, 330, 337, 392, 408, 477, 478,
486, 518, 580, 628, 629, 708, 740, 772, 920, 972, 991,
994). Ewes resorb bone preferentially from the vertebrae
and pelvis, resulting in reduced ash weight, while the limbs
and digits are relatively spared (69). The African green
monkey, which may resemble the human condition more
closely, loses 20% of bone mineral density of the lumbar
spine during 20 wk of lactation (393). The greater losses of
mineral content from trabecular bone demonstrate the abil-
ity of osteoclasts to resorb mineral from bone that has the
greatest surface area. The proportionately smaller losses of
mineral from cortical bone may be due to osteocytic oste-
olysis.
In rats and mice, the material properties of bone are ad-
versely impacted by the resorption of bone during lactation.
The strength, stiffness, and toughness of vertebrae, tibiae,
and femora are reduced while ductility is increased (489,
518, 580, 708, 709, 947).
MicroCT measurements of the lumbar vertebrae of lactat-
ing mice have revealed 30 50% reductions in trabecular
bone volumes, 20% lower trabecular thickness, trabecular
perforations, reductions in tissue density, and progression
to more rodlike than platelike structures (34, 35, 566). The
tibiae and femora show similar changes in trabecular bone,
while cortical bone displays reductions in cortical thickness,
cross-sectional area, and tissue mineral density, and an in-
crease in cortical porosity and endosteal perimeter (35, 101,
566, 580). However, another microCT study from the same
investigators found no significant change in cortical parame-
ters in the femora except for an increase in tissue density (34),
while a peripheral QCT (pQCT) study found that lactation
increased tibial mid-shaft cortical width, area, periosteal cir-
cumference, and cross-sectional moment of inertia in frontal,
sagittal, and torsional planes (772). The latter two studies
suggest that the weight-bearing limbs have a compensatory
improvement in bone volumes and strength during lactation
that may offset the potential loss of strength induced by re-
sorption of trabecular microarchitecture.
That resorption of bone during lactation is needed to sup-
port milk production has been confirmed by finding that a
low-calcium diet initiated at delivery causes greater skeletal
losses that can exceed 43% of trabecular bone mineral con-
tent in rats and mice (37, 271, 320, 350, 355, 708, 991).
Furthermore, nursing larger numbers of pups, which means
increased milk production, causes greater resorption of
bone in rats (320, 708). Bone strength assessments have
demonstrated that a low-calcium diet or nursing more pups
each leads to weaker bone at the end of lactation compared
with a normal-calcium diet or fewer pups (708). MicroCT
studies have confirmed that calcium restriction results in
greater reductions in bone volumes, trabecular number and
thickness, and tissue density (37). In ewes, a low-calcium
diet exacerbates the decline in ash weight (69). Treating
lactating rats with a bisphosphonate causes maternal hy-
pocalcemia that is not seen in control rats (115), confirming
that skeletal resorption of mineral is required to maintain
maternal serum calcium in the setting of milk production.
However, this effect was not seen in one study of lactating
mice (956).
Conversely, a high-calcium diet may blunt but not prevent
bone loss during lactation, confirming that it is hormonally
programmed independent of maternal serum calcium or
dietary calcium intake. When lactating rats were studied on
diets ranging from 1.2 to 0.3% calcium, there was no
change in resorption of skeletal calcium (271, 318),

500 Physiol Rev VOL 96 APRIL 2016 www.prv.org

 CHRISTOPHER S. KOVACS
whereas when lactating mice were studied on a 2 versus 1%
calcium diet there was definite blunting of mineral content
loss (478). In lactating ewes, a high-calcium diet also
blunted the decline in ash weight (69). Bone loss was com-
pletely blocked with OPG treatment in mice, but even then
milk production remained normal, likely from upregulated
intestinal calcium absorption (37). It took the combined
effects of OPG treatment and a 0.01% calcium diet to dis-
rupt lactation, resulting in maternal hypocalcemia and
deaths in 41% of the mothers by day 12 of lactation (37).
The classic calciotropic hormones do not appear to be re-
quired for increased osteoclast-mediated bone resorption
and osteocytic osteolysis to occur during lactation. Parathy-
roidectomy in rats did not blunt the lactational fall in skel-
etal mineral content (319, 395), while lactating Pth null
mice lost the same bone mineral content from whole body,
spine, and hindlimb as their WT sisters (478). Vitamin D-
deficient and vitamin D-replete rats each resorbed a similar
amount of calcium from the femora in two separate studies
(362, 598). In one of these cross-sectional studies, the au-
thors concluded that vitamin D-deficient rats lost twice as
much mineral compared with unmated rats, but compared
with their respective peak values at the end of pregnancy,
vitamin D-deficient and vitamin D-replete rats lost a similar
amount (598). Similarly, Vdr null mice and their WT sisters
lost the same amount of BMC from whole body, lumbar
spine, and hindlimb (296, 489). In a preliminary report, the
magnitude of bone loss during lactation in Cyp27b1 null
females is equivalent to that of their WT sisters (330).
Lactational losses of bone mass were not affected by ovari-
ectomy, adrenalectomy, or immediate pregnancy in rats
(32, 118). When ovariectomized, sham-operated, and in-
tact lactating rats were each stressed by a 0.1% calcium
diet, there was no difference in the reduction of femoral ash
weight among the groups (32). Ovariectomy to create es-
tradiol deficiency leads to modest and slow bone loss in
rodents, and not to the rapid loss that occurs during lacta-
tion (22, 34, 260). Conversely, treatment with estradiol to
achieve fivefold higher levels than normal during lactation
blunted bone loss and caused a small decline in milk cal-
cium (956).
Several older studies tested whether calcitonin deficiency,
created through thyroidectomy followed by thyroid hor-
mone replacement, causes greater loss of bone in lactating
goats and rats. The results were contradictory, with evi-
dence of increased loss versus no difference between thy-
roidectomized animals and sham-operated controls (58,
392, 551, 900). These models were confounded by ex-
trathyroidal production of calcitonin in the mammary
glands (131, 938) and pituitary (755), which was not ap-
preciated at the time. A more recent study examined global
calcitonin and CGRP- deficiency in Ctcgrp null mice and
found that bone loss increased twofold, accompanied by
Physiol Rev VOL 96 APRIL 2016 www.prv.org
histomorphometric evidence of increased osteoclast num-
ber and activity, and reduced osteoblast parameters (194,
992, 994) (see sect. VH).
Collectively these data show that PTH, calcitriol, VDR, low
or high estradiol, and adrenal hormones are not needed for
the normal mobilization of skeletal calcium during lacta-
tion, but loss of calcitonin can lead to more severe losses of
bone mass during lactation. Since ovariectomy in lactating
rodents does not increase the amount of bone lost, this
implies that estradiol is already low in lactating rodents or
that low estradiol is not a relevant stimulus for bone loss
during lactation. The comparatively slow bone loss after
ovariectomy alone indicates that low estradiol cannot ac-
count for the rapidity and extent of bone loss that occurs
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
during lactation. From earlier observations in some of the
surgical and vitamin D deficiency models, Brommage and
DeLuca (118) correctly proposed in 1985 that the putative
hypercalcemia of malignancy factor (PTHrP) might regu-
late bone resorption during lactation.
PTHrP and low estradiol have subsequently been shown to
play significant roles in increasing skeletal resorption dur-
ing lactation. Conditional ablation of Pthrp from mam-
mary tissue resulted in reduced bone turnover markers and
less bone loss during lactation (953). Conversely, ablation
of the calcium receptor from mammary epithelial cells re-
sulted in reduced calcium content of milk, increased mam-
mary gland and circulating PTHrP, markedly increased
bone resorption, and greater bone loss compared with nor-
mal (591). As noted previously, pharmacological treatment
with estradiol reduced bone loss during lactation but did
not obliterate it (956). The combined effects of ovariectomy
and continuous PTHrP infusions administered through a
mini-pump led to more bone loss in the lumbar spine and
femora than with either treatment alone in nonlactating
mice (34). However, the magnitude of bone loss in this
model (ovariectomy continuous PTHrP infusion) was
less than what occurs during lactation (34), which could be
an indication that PTHrP and estradiol deficiency do not
completely explain lactational bone resorption. However,
the combination of ovariectomy with a continuous PTHrP
infusion provided no drain for calcium to escape the
mouse (there was no milk production), so there was no net
loss of calcium. Instead, systemic hypercalcemia resulted,
which likely had a dampening effect on further bone loss
(34).
Another recent study found that FGF21 circulates at high
levels in lactating mice (101). This is a counterregulatory
factor that stimulates gluconeogenesis and fatty acid oxida-
tion during substrate deficiency, and a member of a subfam-
ily that includes FGF23 (724). Intriguingly, Fgf21 null mice
do not resorb bone during lactation, as shown by microCT
of the proximal tibiae, histomorphometric analysis of fem-
ora, and a lack of increase in bone resorptive markers (101).
501
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
The mechanism that leads to the failure to resorb bone is
unknown. It may be due to altered energy metabolism or
some interaction with PTHrP, which was not measured.
Finally, increased weight bearing has been theorized to re-
duce skeletal losses during lactation. This was assessed by
DXA and pQCT at multiple skeletal sites in rats forced to
stand erect to reach their food and water from time of
mating through the end of pregnancy, and then switched to
cages of normal height, compared with rats housed in cages
of normal height (772). Skeletal losses in the lumbar spine,
femora, tibiae, and whole body were unaffected by in-
creased weight-bearing, except for a borderline statistically
significant and very small relative improvement in mineral-
ization and strength parameters of the tibial diaphysis
(772).
2. Human data
The available data from breastfeeding women confirm that
hormonally programmed resorption of the maternal skele-
ton occurs, similar to what has been demonstrated in ro-
dents, sheep, goats, and primates. Careful metabolic studies
have shown that women are in a markedly negative calcium
balance while breastfeeding, especially during the interval
of greatest milk production, and despite any supplemental
calcium intake (253, 419).
That the maternal skeleton contributes mineral to breast
milk has been inadvertently confirmed by Techa River res-
idents in Russia, who released 90Sr into breast milk years
after their exposure from ingestion of contaminated river
water (924). Observational data and mathematical models
predict that the amounts of 90Sr, 45Ca, 131I, and other iso-
topes in breast milk will be highest when maternal exposure
occurs in late pregnancy or while lactating, confirming that
dietary intake remains a significant contributor to breast
milk (1, 366, 851, 924).
There are no histomorphometric data from lactating wom-
en; instead, serial measurement of bone turnover markers,
bone density, and bone structure by high-resolution pQCT
(HR-pQCT) has been carried out.
Bone resorption markers (NTX, CTX, tartrate-resistant
acid phosphatase, deoxypyridinoline/creatinine, hydroxy-
proline/creatinine) are elevated severalfold during lactation,
above the levels attained in the third trimester and in con-
trols (9, 123, 124, 156, 157, 206, 207, 251, 454, 468, 470,
572, 695, 764, 805, 859, 1002, 1009). Bone formation
markers (P1NP, bone-specific alkaline phosphatase, osteo-
calcin) have been normal in a few studies (207, 769), but
generally are also high during lactation, and increased over
third trimester values or controls (9, 123, 124, 156, 157,
206, 251, 409, 454, 468, 470, 572, 695, 764, 805, 859,
1002, 1009). Total alkaline phosphatase loses the placental
fraction at delivery and falls markedly, but may remain
502 Physiol Rev VOL 96 APRIL 2016 www.prv.org
above normal due to the increased bone-specific fraction
(769, 1002). These values confirm that bone turnover is
significantly increased during lactation in women.
One of the earliest longitudinal studies to assess skeletal
changes during lactation used a 241Am source and found
that the femoral shaft BMC declined 2.2% over the first 100
days of lactation (40). Since that time, multiple longitudinal
studies (observational studies and clinical trials) have been
carried using SPA, DPA, or DXA. A consistent decline in
BMD or BMC has been reported, with mean values ranging
from 3 to 10.0% after 3 6 mo of lactation. The greatest
(510%) losses occur in the lumbar spine, with more mod-
est (0 5%) losses at less-trabecular-rich sites (hip, femur
and distal radius), and the smallest (0 2%) changes at
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
purely cortical sites such as the whole body (9, 18, 109, 123,
124, 140, 165168, 180, 193, 206, 251, 256, 371, 403
405, 409, 412, 452, 457, 468, 470, 484, 505, 526, 533
535, 560, 572, 574, 609, 621, 633, 635, 705, 723, 729,
764, 855, 857, 859, 1009). Collectively, these studies sug-
gest that 6 mo of exclusive lactation will result in a median
loss of 6 8% of BMD from the lumbar spine, with half or
less those amounts lost from the appendicular skeleton.
It is important to emphasize that these are mean changes
from the cohorts of each study; responses of individual
women to lactation can vary from a small gain to a 20%
decline in the lumbar spine BMD (405, 705). Some women
start pregnancy with normal BMD but reach an osteopo-
rotic level (2.5 SD) at the spine or hip during lactation
(705). Some observational studies have included postpar-
tum controls who do not breastfeed; these women do not
lose lumbar spine BMD but may show small (0 2%) but
statistically significant gains in BMD over the postpartum
interval, suggesting a recovery from small losses incurred
during pregnancy (9, 140, 371, 412, 451, 505, 572, 633).
Women who breastfeed for more prolonged periods, such
as a year or more, may experience even greater bone loss
(379, 857, 860). However, this should be mitigated by the
infant consuming solid foods by 6 mo of age and a reduc-
tion in the amount of milk produced. On the other hand, a
professional wet nurse can have high volumes of milk
output that are sustained for long intervals (419, 583, 838),
so ongoing bone loss seems inevitable. However, no bone
density data have been reported for such women.
HR-pQCT has been used in very few studies to date, and the
only sites that can be assessed by this technology are periph-
eral appendicular sites such as the radius and distal femur,
sites that lose much less mineral content than the lumbar
spine. These studies have confirmed 0 2% reductions in
trabecular thickness, and cortical thickness and volume,
with the losses being greater in those who lactate longer (84,
109). Trabecular number and volumetric BMD appeared to
 CHRISTOPHER S. KOVACS
increase, which may be an artifact from trabecularization of
cortical bone (84, 109).
Peripheral ultrasound is not a useful technique to assess
bone loss during lactation. Although DXA and HR-pQCT
have confirmed that bone mass declines significantly during
lactation, ultrasound of the os calcis or midtibial shaft
showed no changes (533, 917, 1015).
Few studies have looked at lactating adolescents. A 15%
decrease in radial BMC over 16 wk of lactation was found
in teenaged mothers whose calcium intake was below the
recommended amount, whereas lactating adults showed no
change in radial BMC; the lumbar spine was not assessed
(166, 167). A follow-up study of lactating adolescents
found that a calcium intake of 900 mg daily led to a 10%
loss of radial BMC over 16 wk compared with no loss when
1,600 mg calcium was consumed; lactating adults who con-
sumed 1,500 mg calcium daily also lost no radial BMD
(164). A more recent study of lactating adolescents (mean
age 16 yr) found no significant changes in BMD of the
lumbar spine, femoral neck, and total hip by 6 mo of lacta-
tion with a calcium intake of 1,200 mg daily (590). Another
study of lactating adolescents (mean age 17) found that
randomization to a supplement containing 500 mg calcium
and 200 IU vitamin D resulted in a higher lumbar spine
BMD by 20 wk of lactation compared with placebo; how-
ever, women receiving the supplement had significantly re-
duced their breastfeeding frequency and intensity, and
twice as many of them had resumed menses, compared with
the placebo group (250). These differences mean that the
women in the treatment arm would have lost less bone due
to reduced breast milk output and recovery from low estra-
diol, and not necessarily as a direct result of the supplement.
Two small studies by the same investigators in Spain re-
ported contradictory results when lactating adolescents and
adults were compared. The first reported that adolescents
and adults lost a similar amount of BMD during lactation
but had recovered it fully by 9 mo postpartum (159). The
second study reported that adolescent lumbar spine BMD
increased by 9% at 3 mo and 15% by 12 mo postpartum,
compared with adult women who lost only 2% of lumbar
spine BMD at 3 mo and achieved a net increase of 4% by 12
mo postpartum (798). The second study implies that ado-
lescent accrual of bone mass is not impaired by simultane-
ous lactation, but the marked differences between the two
studies are unexplained. Lactation in adolescents has been
an ongoing concern with regard to poor dietary intake of
calcium, and potential interference in reaching peak bone
mass (see sect. IVG).
The studies in adolescents indicate that a higher calcium
intake prevents bone resorption in the radius during lacta-
tion, a site that normally shows proportionately little re-
sorption during lactation. Several blinded, randomized in-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
terventional studies have shown that the lumbar spine and
hip are preferentially resorbed during lactation such that
taking a 1 g calcium supplement in addition to usual intake
will not reduce the amount of bone lost. One study com-
pared 1,800 to 800 mg calcium intake daily and the lumbar
spine declined 4% over 6 mo of lactation with no differ-
ence between the groups (452). A second compared with
2,400 to 1,200 mg calcium daily, and the lumbar spine,
radius, and ulna declined 6% in both groups (206). A
third study compared 1,400 to 300 mg calcium, and the
intervention caused an increase in urinary calcium excre-
tion but neither group lost radial BMD or experienced a
change in markers of bone resorption during up to 18 mo of
lactation (the spine was not assessed) (729, 730). A fourth
also used a 1 g supplement but did not measure dietary
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
calcium intake; the women lost 4% of lumbar spine BMD
with no difference between the groups (723). In two obser-
vational cohort studies in which the lumbar spine declined
4% during 3 mo of lactation (535) and 6% during 6 mo of
lactation (484), the relative losses were not affected by ma-
ternal calcium intake. One of these cohort studies found
that the skeletal losses were inversely proportionate to
breast milk output and, thereby, maternal calcium losses
(535), whereas the other noted a significant correlation to
duration of lactation and time to resumption of menses
(484). A randomized study using ultrasound of the os calcis
compared 2,400 with 1,200 mg calcium and noted a 15%
reduction in urinary NTX, but no change in apparent bone
loss after 1 mo of lactation (post hoc analyses suggested that
higher compliers had a significant increase in SOS of the
heel) (274). Another randomized study compared calcium
intakes of 1,850 to 850 mg, and although PTH and cal-
citriol were lower in the calcium-supplemented women,
there was no effect of calcium supplementation on bone
turnover markers during 6 mo of lactation (454). Overall,
the results of these randomized interventions and cohort
studies indicate that increased skeletal resorption seems to
be programmed during lactation and, unlike rodents, not
suppressible by high calcium intakes.
Conversely, low calcium intakes (300 mg/day) do not
appear to increase maternal bone loss or markers of bone
resorption during lactation, nor do they alter breast milk
calcium content (728 731). These findings are consistent
with most of the milk calcium content programmed to come
from resorption of the maternal skeleton, such that calcium
intakes ranging from low to high do not affect these param-
eters. However, greater intensity (number of feeds per day)
and exclusivity (all of babys nutrition comes from milk) of
lactation, which are indicators of increased breast milk out-
put, lead to greater loss of maternal bone mass (535).
Intervening to correct calcium intake in women who habit-
ually consume low calcium may be detrimental. A random-
ized intervention administered 1,500 mg calcium or pla-
cebo during pregnancy but not postpartum to Gambian
503
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
women with habitual intakes of 350 mg calcium. There
was no effect on bone density at any skeletal site at the end
of pregnancy, but during 12 mo of lactation, the women
who had received the calcium supplement during pregnancy
more than doubled their losses in BMD of the lumbar spine,
total hip, and distal radius and had greater increases in bone
turnover markers (439). A followup study showed that
these effects persisted long term, including through a sub-
sequent pregnancy and lactation cycle (441). These results
suggest that Gambian women are beneficially adapted to
their low calcium intakes, while use of a calcium supple-
ment during pregnancy disrupts this adaptation to create an
adverse response when the supplement is subsequently
withheld during lactation.
Weight-bearing exercise has been proposed to reduce the
amount of bone resorbed during lactation. A small random-
ized trial of 20 lactating women found a small benefit on
lumbar spine BMD (4.8 vs. 7.0% loss in the usual activity
group), but no effect on whole body or total hip BMD
(574). However, a subsequent study by the same investiga-
tors found no beneficial effect of exercise on any skeletal site
(193). A cohort study comparing exercising to sedentary
women also showed no impact of exercise on lactational
BMD losses (560).
Deficiency of estradiol contributes to bone loss during lac-
tation, but the extent to which it does so is uncertain. Some
analyses have suggested that low estradiol, and a longer
duration of lactational amenorrhea, predict the speed and
magnitude of bone loss during lactation (140, 301, 409,
451, 484, 723, 857, 863, 1025). Earlier resumption of men-
ses or use of an oral contraceptive are associated with re-
duced skeletal losses, while bone turnover markers normal-
ize after recovery of menses and bone loss at the lumbar
spine slows or begins to reverse (140, 451, 484, 723, 764,
863). On the other hand, in another study there was no
difference in calciotropic hormones, bone turnover mark-
ers, bone density, and intensity of lactation between amen-
orrheic and eumenorrheic women during lactation, suggest-
ing that resumption of menses does not predict reduced
bone loss during lactation (572). Bone density has also con-
Table 3. Comparison of the effects of 6 months of lactation versus 6 months of GnRH agonist therapy
Lactation
Serum calcium Increased
Serum phosphorus Increased
PTH Decreased
Calcitriol Normal
24-h urine calcium Decreased
Urinary Ca/Cr Decreased
Bone resorption markers Increased
aBMD changes (DXA) 510% at trabecular-rich sites; less at cortical
Recovery of aBMD at 1 yr Complete in most
504 Physiol Rev VOL 96 APRIL 2016 www.prv.org
tinued to decline in women who breastfed for an extended
period after their menses resumed (301, 857).
It is difficult to analyze the independent effects of low estra-
diol on bone turnover during lactation. More intense lacta-
tion causes more breast milk output and bone loss, but
more intense lactation is also associated with lower estra-
diol and prolonged amenorrhea. The impact of isolated low
estradiol is that it causes 12% annual losses of BMD in
recently menopausal women (331), but the older ages of
these women may not reflect what happens to reproductive
age women with low estradiol.
In this context the effects of GnRH analog-induced estra-
diol deficiency in reproductive-age women are illuminat-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
ing. This treatment induces marked estradiol deficiency,
which can be beneficial to treat endometriosis, uterine
leiomyomata, and premenstrual syndrome. However, its
effects differ from what is observed during lactation
(TABLE 3). Six months of acute estradiol deficiency causes
2 4% reductions in BMD of the spine with no losses at
cortical sites (288, 415, 640, 657, 684, 696, 758, 762,
781, 891, 942). This is accompanied by increased serum
calcium and phosphorus (265, 288, 640, 657, 781), in-
creased fractional excretion of calcium (265, 288, 640,
657, 781, 891, 942), and low PTH and calcitriol (265,
657, 781). In contrast, 6 mo of lactation typically causes
greater loss of BMD from both trabecular and cortical
sites, low PTH but normal calcitriol, and reduced frac-
tional excretion of calcium.
In summary, clinical data are consistent with low estra-
diol playing a permissive role in bone loss during lacta-
tion, but with the more excessive bone loss and other
changes in calcium metabolism likely contributed to by
high circulating levels of PTHrP (FIGURE 6). This would
explain the increased bone turnover markers, accelerated
bone loss, and reduced urinary calcium excretion, while
the normal calcitriol and intestinal calcium absorption
may be explained by PTHrPs apparent reduced efficacy
at stimulating these relative to PTH. Consistent with this,
higher plasma PTHrP predicted greater loss of BMD at
GnRH Agonist
Increased
Increased
Decreased
Decreased
Increased
Increased
Increased
24% at trabecular-rich sites
Incomplete in most
 CHRISTOPHER S. KOVACS
the lumbar spine and femoral neck in breastfeeding
women, after adjusting for low estradiol, PTH, and in-
tensity of breastfeeding (863). Higher plasma PTHrP in
turn was predicted by more intense lactation, higher pro-
lactin, and lower estradiol (863). Some studies of men
and nonlactating women have found that hyperpro-
lactinemia due to pituitary adenomas is associated with
elevated PTHrP, and that increased PTHrP predicts a
higher serum calcium, and lower PTH and lumbar spine
BMD (497, 880).
3. Summary
Bone turnover is markedly increased during lactation,
but uncoupled to cause net resorption. Mean losses of
2535% occur in the lumbar spine during 3 wk of lacta-
tion in rodents, while 510% losses at the lumbar spine
are induced by 6 mo of breastfeeding, with smaller losses
at other skeletal sites. Bone loss results from a combina-
tion of osteoclast-mediated bone resorption and osteo-
cytic osteolysis; how much each contributes to the de-
cline in BMD during lactation is uncertain. The very
modest to zero change in BMD at cortical sites in lactat-
ing women may mean that osteocytic osteolysis is less
important in humans compared with osteoclast-mediated
bone resorption. Bone loss during lactation is driven by
the combined effects of low estradiol and increased cir-
culating PTHrP. Animal data support that both of these
factors are important in regulating skeletal homeostasis
during lactation. Conversely in women, the more modest
effects of isolated low estradiol, ongoing bone loss de-
spite resumption of menses or use of an oral contracep-
tive, and the effects of lactational release of PTHrP to
normalize hypoparathyroidism (see sect. VD) and induce
pseudohyperparathyroidism (see sect. VF) may all point
to PTHrP having a greater effect on regulating skeletal
metabolism during lactation.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
FIGURE 6. Schematic depiction of the effects of acute,
isolated estradiol deficiency from GnRH analog therapy
versus lactation. Acute estradiol deficiency increases
skeletal resorption and the serum calcium; PTH be-
comes suppressed and renal calcium losses increase.
During lactation, PTHrP (secreted by the breast) and low
estradiol increase skeletal resorption and raise serum
calcium, but the resorbed calcium is directed into breast
milk. Although PTH is suppressed during lactation, renal
calcium conservation occurs, likely stimulated by PTHrP.
[Adapted from Kovacs and Konenberg (499). Copyright
1997 The Endocrine Society. Permission conveyed
through Copyright Clearance Center, Inc.]
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
F. Breast-Brain-Bone Circuit Controlling
Bone Metabolism During Lactation
The preceding animal and human data are consistent
with an important physiological interaction and cross-
talk among breast, brain, and bone during lactation. The
breast may be the central driver of this interaction. The
summary model (FIGURE 7), which also draws on data
discussed in sections IV and V, is as follows.
High prolactin and suckling-induced reflex arcs each act
on the GnRH pulse center in the hypothalamus to sup-
press the pituitary gonadotropins [luteinizing hormone
(LH) and follicle stimulating hormone (FSH)] and, in
turn, ovarian function. This leads to low estradiol levels
in early lactation that may persist or normalize despite
ongoing lactation. Low estradiol upregulates RANKL
and downregulates OPG in osteoblasts; consequently,
differentiation, recruitment, and function of osteoclasts
are stimulated, thereby resulting in increased bone re-
sorption. Suckling, prolactin, and low estradiol also
stimulate mammary epithelial cells to produce PTHrP.
While most of the PTHrP is released into milk, some of it
is released into the maternal bloodstream, both continu-
ously and with additional surges induced by suckling.
Increased PTHrP synergizes with the effects of low estra-
diol to stimulate osteoclast-mediated bone resorption
and osteocytic osteolysis. The calcium receptor may
modulate the release of PTHrP from breast tissue some-
what to reduce the likelihood that milk production pro-
duces systemic hypocalcemia; however, it is clear from
some clinical cases that mammary tissue PTHrP produc-
tion may be autonomous.
That mammary tissue plays a central role in regulating
skeletal physiology during lactation has been made most
clear by the finding that mammary-specific ablation of
505
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION

Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017

FIGURE 7. Breast-brain-bone circuit controls lactation. Suckling and prolactin (PRL) both inhibit the hypo-
thalamic gonadotropin-releasing hormone (GnRH) pulse center, which in turn suppresses the gonadotropins
[luteinizing hormone (LH) and follicle-stimulating hormone (FSH)], leading to low levels of the ovarian sex
steroids [estradiol (E2) and progesterone (PROG)]. Prolactin may also have direct effects on its receptor in bone
cells. PTHrP production and release from the breast are stimulated by suckling, prolactin, low estradiol, and
the calcium receptor. PTHrP enters the bloodstream and combines with systemically low estradiol levels to
markedly upregulate bone resorption and (at least in rodents) osteocytic osteolysis. Increased bone resorption
releases calcium and phosphate into the bloodstream, which then reaches the breast ducts and is actively
pumped into the breast milk. PTHrP also passes into milk at high concentrations, but whether swallowed
PTHrP plays a role in regulating calcium physiology of the neonate is uncertain. In addition to stimulating milk
ejection, oxytocin (OT) may directly affect osteoblast and osteoclast function (dashed line). Calcitonin (CT) may
inhibit skeletal responsiveness to PTHrP and low estradiol given that mice lacking calcitonin lose twice the amount
of bone during lactation as normal mice. Not depicted is that calcitonin may also act on the pituitary to suppress
prolactin release, and within breast tissue to reduce PTHrP expression and lower the milk calcium content (see
text). [Adapted from Kovacs (493). Copyright 2005, with kind permission from Springer Science Business
Media.]

PTHrP reduces bone turnover and loss, while mammary-
specific ablation of the calcium receptor leads to mark-
edly increased mammary expression of PTHrP, higher
systemic PTHrP levels, increased bone turnover, and
greater net bone loss (591, 953). Suckling induces pro-
duction and release of PTHrP, whereas milk stasis causes
the entire process to shut down.
Lactating mammary epithelial cells also produce high
concentrations of calcitonin, which may act locally to
reduce the calcium content of milk or inhibit PTHrP, as
suggested by Ctcgrp null mice (see sect. VH). Calcitonin
also has systemic actions to suppress osteoclast-mediated
bone resorption and osteocytic osteolysis in bone. Fur-
thermore, calcitonin may inhibit the pituitary lac-
totrophs and reduce the release of prolactin, which in
turn would lessen ovarian suppression and inhibit pro-
duction of PTHrP. A conditional deletion of calcitonin
from mammary tissue is needed to determine its role
during lactation.
Additional players in the cross-talk among breast, brain,
and bone include oxytocin and calcitonin, and there may
be others. In addition to its critical role in stimulating
milk ejection, oxytocin may affect the differentiation and
function of osteoblasts and osteoclasts. Serotonin may
stimulate the production of PTHrP and have other di-
rect and indirect effects on bone metabolism during
lactation.

506 Physiol Rev VOL 96 APRIL 2016 www.prv.org

 CHRISTOPHER S. KOVACS
G. Bone Formation and Skeletal Recovery
Post-Weaning
1. Animal data
After the pups are weaned, the maternal skeleton undergoes
a rapid phase of remineralization. Bone turnover continues
to be increased over nonpregnant values, but it is now un-
coupled in the opposite direction from lactation, favoring
net bone gain.
When weaning is forced by the sudden removal of pups
before the natural end of lactation, within 24 48 h there is
widespread apoptosis of osteoclasts that prompts a fall in
osteoclast number and activity below prepregnant values, a
marked decrease in RANKL and RANK expression, and a
substantial increase in osteoblast precursors, osteoblast
number, osteoid surface, and bone formation rate (35, 107,
194, 627). Transient hypercalcemia can occur over the first
several days due to continued increased levels of bone re-
sorption and intestinal calcium absorption despite loss of
milk output (35, 396, 718), during which time PTH and
calcitriol fall and calcitonin surges (35, 627, 718). Bone
resorption markers decline rapidly while bone formation
markers increase (35, 477, 478, 580, 956, 992, 994). Os-
teocytic osteolysis also ceases, but now osteocytes express
osteoblast-specific genes, tetracycline-labeled bands be-
come evident in their lacunae, and the matrix is restored to
its prior mineral content (FIGURE 5) (733, 734). This ana-
bolic activity of osteoblasts and osteocytes is sustained for
several weeks, as a result of which bone strength, mineral-
ization, and microarchitecture improve and may reach
prepregnancy values or better.
The extent of skeletal recovery has been documented in
several ways.
Serial studies using DXA, and cross-sectional studies using
skeletal ash weight, indicate that rodents restore skeletal
mineral content within 2 4 wk after weaning (35, 362,
994). Black Swiss and C57BL/6 mice regain their prepreg-
nancy BMC in whole body, lumbar spine, and hindlimb
within 14 days of weaning (296, 477, 478, 580, 992, 994),
whereas CD1 mice regain their prepregnancy BMD by 28
days after weaning, but remain below the values for age-
matched virgin mice (35, 37). The most remarkable change
occurs in Ctcgrp null mice, which lose 55% of trabecular
(lumbar spine) BMC and 30% of cortical (whole body and
hindlimb) BMC during lactation, but restore this within 18
days of weaning, taking just 4 days longer than their WT
sisters that experienced half the losses (992, 994).
Histomorphometry has revealed increased osteoid seams
covering 50 70% of bone surfaces, while dynamic histo-
morphometry has shown widely spaced tetracycline labels
(107, 194, 628, 947). The combination of increased osteoid
surface and widened seams corresponds to a markedly in-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
creased bone formation rate. Bone volumes, trabecular
thickness, and mineral content are recovered within 2 4 wk
of weaning in the mouse and 4 8 wk of weaning in the rat
(107, 194, 628, 947). Detailed histomorphometric assess-
ment of vertebrae and cortical bone of femora at 8 wk after
weaning in rats showed that bone formation rates and min-
eralizing surfaces on trabecular, periosteal, and endosteal
surfaces had declined to age-matched nulliparous values,
while bone mass, cortical thickness, and cortical area had
increased to virgin values (947).
Microradiographs, scanning electron microscopy, and mi-
croCT have been used to assess recovery of microarchitec-
ture, which have revealed normalization at some sites, and
permanent alterations at others. The vertebrae fully recover
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
their microarchitecture, including bone volumes, trabecular
number and thickness, mineralization, stiffness, and rever-
sion from a rodlike back to a platelike structure (35, 566).
The femora and tibiae significantly improve trabecular
number and thickness, bone volumes, mineralization, cor-
tical thickness, porosity, and stiffness (35, 106, 107, 355,
566, 628, 947, 994). In some studies, the values in tibiae
and femora become equivalent to age-matched virgins (35,
628), whereas in other studies there were permanent reduc-
tions in these parameters compared with virgin mice or
prepregnancy values (566, 628). Recovery is full or better
when the end-of-pregnancy value is the baseline measure-
ment (107). There are also region-specific differences in the
degree of recovery, since in rats the proximal and distal
femora regained the mineral content of nulliparous controls
while the femoral midshaft did not completely recover
(355), and there was a permanent reduction in the trabec-
ular content of the femora (355, 628).
Intriguingly, in some studies the cross-sectional diameters,
cortical perimeters, and volumes of the tibiae or femora
were significantly greater at post-weaning compared with
prepregnancy, or post-weaning compared with age-
matched controls (106, 947, 994). Such changes in the mac-
ro-architecture of bone, especially the cortical diameter,
will increase the cross-sectional and polar moments of in-
ertia, and, thereby, the breaking strength in bending and
torsion (FIGURE 8). This may contribute to maintenance of
bone strengths of the tibiae and femora despite any failure
to fully recover the trabecular microarchitecture (477).
Other biomechanical testing has shown vertebral and fem-
oral strength and stiffness parameters to improve signifi-
cantly in rats by 8 wk after weaning, and to equal the values
of nulliparous controls (947).
The rapidity and relative completeness of this post-weaning
phase of bone recovery has prompted numerous ap-
proaches to try to identify the factors that stimulate bone
formation and post-weaning recovery. Severely vitamin D-
deficient rats improve bone mass and architecture after lac-
507
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
A B
Ro Ro
Ri Ri
FIGURE 8. Post-recovery increase in cross-sectional diameter im-
proves skeletal resistance to bending and torsion. A and B represent
hypothetical cross-sections of circular bone shafts that have the
same cortical area or bone mass. The ability to resist bending in a
hollow cylinder is related to the moment of inertia I m(Ri2 Ro2),
where m is the mass of the cylinder and Ri and Ro are measure-
ments of the inner and outer radii, respectively. Ability to resist
torsional stress is related to the polar moment of inertia J
(Ro4 Ri4)/32. Therefore, despite its thinner cortical shell, the
increased radius in B will result in significantly increased moments
of inertia, and resistance to bending or torsional stresses, com-
pared with the thicker cortical shell in A. In this manner, an
increase in cross-sectional diameters of the long bones after
weaning will increase bone strength and may compensate for
resorbed trabeculae that have not been replaced. [From Kovacs
and Ralston (501). Copyright 2015, with kind permission from
Springer Science Business Media.]
tation, appearing to regain the amount that was lost during
lactation (628); however, an earlier study from the same
investigators suggested that there was no recovery of ash
weight or calcium content (362). Vdr null mice and
Cyp27b1 null mice display osteomalacia and reduced bone
mass before pregnancy, but after lactation they upregulate
bone formation markers and increase BMC substantially to
values 40 50% higher than prior to pregnancy (296, 330).
Pth null mice have low bone turnover prior to pregnancy,
but upregulate bone formation markers normally during
post-weaning, and increase BMC after lactation to values
20% higher than prepregnancy (478). Ctcgrp null mice lose
55% of skeletal mineral content during lactation but fully
regain it post-weaning (194, 992, 994). Osteoblast-specific
ablation of Pthrp results in an osteoporotic phenotype in
adult mice, but these obPthrp null mice lactate normally
and have full recovery of bone mass afterward (477). Col-
lectively these studies indicate that PTH, osteoblast-derived
PTHrP, vitamin D, VDR, calcitriol, and calcitonin are not
required full remineralization of the maternal skeleton to be
achieved after lactation (194, 296, 477, 478, 992, 994).
Adequate calcium is required, since a low-calcium diet pre-
vented skeletal recovery in rats, whereas normalizing the
diet 3 wk later allowed normal recovery to occur (355). An
increased rate of mineral absorption is evidently not re-
quired since both intestinal calcium and phosphorus ab-
sorption are normal during post-weaning recovery in rats
(93, 360). The marked increase in bone mass of Vdr nulls
and Cyp27b1 nulls (296, 330) may imply that intestinal
calcium absorption is increased, since these mice have a
reduced, rachitic bone structure on the same diet when non-
508 Physiol Rev VOL 96 APRIL 2016 www.prv.org
pregnant. However, measurements of intestinal calcium ab-
sorption have not been done in mice during this interval.
Theoretically, increased weight bearing during this ana-
bolic phase might lead to a greater increment in bone mass.
In a preliminary report, rats forced to stand upright to reach
their food during lactation and 6 wk of post-weaning
showed significantly higher femoral BMD and a trend to-
ward increased tibial bone volumes, compared with rats
housed in normal cages (829).
In rats that are not permitted to lactate, normalization of
BMD and skeletal microarchitecture (as assessed by histo-
morphometry) has been observed within a week of parturi-
tion (408). This is evidence of skeletal recovery from losses
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
incurred during pregnancy. Conversely, no post-weaning
improvement resulted after lactational bone loss was com-
pletely blocked by treatment with OPG (37). This may sim-
ply mean that if no bone is lost during lactation, then there
is nothing to restore, and no signal is sent to upregulate
bone formation.
2. Human data
Women also undergo a substantial increase in bone mass
and mineralization after weaning, evidently reversing the
losses that transiently occur during lactation. There are no
histomorphometric studies or direct tests of bone strength
in women, as there are in the rodent models. Instead, skel-
etal recovery after lactation has largely been determined by
longitudinal assessment of bone mass and mineralization
during lactation and post-weaning by DXA at the total
body, lumbar spine, and hip. More recently, changes in
microarchitecture by HR-pQCT have been assessed at pe-
ripheral sites. Many dozens of studies have examined the
effect that lactation has on predicting future risk of low
bone density, osteoporosis, or fracture.
Analysis of women who inadvertently ingested isotopes
while living near the Techa River in Russia revealed that
women who were pregnant and lactated during the time of
exposure had a greater content of 90Sr in the maternal skel-
eton years after the exposure, compared with women living
in the region who were pregnant prior to the exposure or
had never been pregnant (923). This result is compatible
with increased uptake of isotope into the maternal skeleton
during post-weaning recovery.
The available DXA data suggest that lactational loss of
bone density is completely reversed by 12 mo after weaning
in most women (140, 168, 206, 379, 403 405, 412, 452,
457, 470, 484, 505, 532, 572, 635, 705, 723, 729, 764,
856, 857, 860, 1009), whereas recovery has been incom-
plete at some skeletal sites when assessed at 6 mo or less
after weaning the baby (9, 123, 124, 168, 403 405, 457,
484, 532, 633, 635, 1009). A small longitudinal study of 22
women found a marked loss of 8% in the distal radius that
 CHRISTOPHER S. KOVACS
was still reduced 5% by 12 mo after weaning (609), which
suggests that the radius is slower to recover BMD. Note that
these studies report the mean responses of a cohort; the
response of individual women will vary, such that some
women may not return to baseline after lactation, while
others may end up with a BMD even higher than prior to
pregnancy. Recovery is fast enough that women who
breastfeed for 6 mo or more and have a second pregnancy
within 18 mo do not have reduced BMD of the spine or hip
at the end of the second pregnancy (534, 860).
A study from China took a different approach of doing a
baseline BMD reading in 40 women with habitually low
calcium intakes, who had either stopped lactating or were
still lactating but had recovered their menses. They were
randomized to receive 600 mg of calcium versus placebo,
and subgrouped by genotyping for a VDR polymorphism
(FokI) (1012). A second BMD was obtained a year later and
revealed a net increase in bone mass with additional benefits
attributable to calcium supplementation and the FF geno-
type. BMD of the lumbar spine increased by as little as
7.9% in the placebo group with ff genotype to as great as
17.4% in the FF genotype receiving calcium, while the fem-
oral neck BMD increased 4.4% in the ff genotype on pla-
cebo versus 14.7% in FF genotype on calcium. This study
provides confirmation that a substantial increase can occur
in BMD post-weaning. The suggested additional benefits of
calcium supplementation and the VDR polymorphism re-
quire independent confirmation.
HR-pQCT of the radius and ultradistal femur reveal recov-
ery of trabecular microarchitecture and cortical parameters
in women who lactate for shorter intervals, but incomplete
recovery in women who lactate for longer (84, 109). How-
ever, follow-up in these studies was for less than 6 mo after
lactation ended for women who lactated for a longer dura-
tion, which is not sufficient time for recovery or to deter-
mine if permanent changes in structure resulted. Similar to
studies in animals, some clinical studies have found that
the cross-sectional diameter of the femur increased after
lactation or post-weaning recovery, and that cortical
bone area is restored or increased (869, 986). An increase
in bone volumes will improve bone strength and may
compensate for any permanent loss of trabecular micro-
architecture (FIGURE 8).
Hip structural analysis of data from DXA scans provides
direct measurements of femoral geometry and derived mea-
sures of femoral strength. A longitudinal study obtained
these measurements at 2 wk, 6 mo, and 12 mo postpartum
in lactating women, while similar timing of measurements
were carried out in nonpregnant, nonlactating women
(537). In lactating women there was an 3% decrease in
cross-sectional area, a 1.7% decline in cortical thickness, a
2.1% decrease in section modulus (bending strength), and a
2.3% increase in buckling ratio (instability) by 6 mo of
Physiol Rev VOL 96 APRIL 2016 www.prv.org
lactation. These changes reversed by 6 mo after lactation
ceased, during which no changes were seen in the controls
(537).
If a permanent reduction in BMD or skeletal strength were
to occur from lactation, then lactation should be a strong
risk factor for low BMD or fracture in women of all ages.
However, over five dozen epidemiologic studies of pre-,
peri-, and postmenopausal women have found a neutral
effect (16, 38, 63, 158, 203, 214, 215, 290, 292, 299, 341,
356, 368, 379, 383, 397, 444, 445, 448, 463, 481, 506,
509, 541, 547, 611, 619, 625, 636, 648, 683, 700, 761,
828, 845, 846, 861, 864, 865, 869, 879, 934, 935, 944,
951, 969, 1020) or a protective effect (25, 27, 71, 83, 144,
169, 212, 244, 279, 327, 365, 416, 421, 482, 507, 700,
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
804, 833, 879, 986, 1018) of lactation on peak bone mass,
BMD, and fracture risk. This includes a study in which
extended duration of breastfeeding per child conferred a
progressively greater protection against hip fractures (421).
A study of 1,852 twins and their females relatives, including
83 twins who were discordant for pregnancy and lactation,
found no effect of breastfeeding history on BMD or BMC
between twins, but that parous women who had breastfed
had higher BMC and BMD than parous women who had
never breastfed (700). A study of 30 women who had had at
least six pregnancies, and breastfed each child for at least 6
mo, found no effect of lactation on BMD (379).
A previously cited NHANES study of 819 women ages
20 25 yr found that women who had breastfed as adoles-
cents had higher bone mass than those who had not breast-
fed, indicating a protective effect (169). This study is par-
ticularly informative because of the shorter interval of time
elapsed between lactation and measurement of BMD, com-
pared with most of the dozens of studies that examined
women decades later. It also suggests that adolescent preg-
nancy does not adversely impact the achievement of peak
bone mass, as previously feared.
There are, of course, a few contrary studies that suggest
lactation predicts lower BMD (261, 336, 352, 472, 559,
686, 770, 946, 971, 973) or increases the risk of fracture
(97, 525, 559, 699). Smoking may cause breastfeeding to
have a negative effect on BMD that is not seen in nonsmok-
ers who breastfed (448).
Fractures do occur rarely during lactation while bone mass
and strength are temporarily reduced, so these lactational
losses of bone structure are not always benign in the short
term (see sect. VA). Overall, it appears that any harm of
lactational bone loss is transient in most women, such that
lactation generally confers a long-term neutral or protective
effect on future risk of fracture. The fewer studies suggest-
ing a long-term adverse effect may point to ethnic or other
differences among the cohorts that remain to be explained;
509
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
for example, low calcium intake or vitamin D deficiency
may impair skeletal recovery post-lactation.
Recovery of estradiol to normal during post-weaning likely
facilitates skeletal recovery but cannot explain it fully. Es-
tradiol suppresses bone formation and resorption when ad-
ministered as replacement therapy in peri- and postmeno-
pausal women (305, 750); it is not a potent stimulator of
bone formation. Moreover, when reproductive-age women
experience temporary estradiol deficiency induced by
GnRH analog treatment, they lose a small amount of BMD
and (unlike after lactation) most do not restore it afterwards
(288, 415, 640, 657, 684, 696, 758, 762, 781, 891, 942).
Earlier resumption of menses has correlated with an earlier
apparent increase in bone mass after lactation (484, 764),
which suggests a benefit of higher estradiol. But this is con-
founded by the fact that resumption of menses is an indica-
tor of less intense lactation and, thereby, less bone lost and
an earlier start to postlactation recovery. Other studies have
found no effect of resumption of menses on bone loss dur-
ing lactation or recovery afterward (572).
It is evident from the many longitudinal DXA studies that
women who lactate for shorter intervals recover sooner,
and this is also likely because they lost less bone.
A small but statistically significant benefit on bone mass
gained during post-weaning was conferred by randomiza-
tion to a 1 g calcium supplementation versus placebo, de-
spite no beneficial effect of the supplement during lactation
(452). No study has prospectively examined the potential
benefit of weight-bearing exercise to increase BMD gains
after weaning. However, in retrospective studies of pre-
menopausal women in which breastfeeding conferred a
higher lumbar spine BMD, increased weight-bearing also
conferred a significant, independent benefit (327, 1018).
No other studies have examined factors that may stimulate
post-weaning skeletal recovery. As noted earlier, one study
found a modest increase in intestinal calcium absorption
during post-weaning (453), whereas another study found
no significant increase (764).
3. Summary
Extensive animal data and human data indicate that bone
turnover is also increased during the post-weaning phase,
but uncoupled in the reverse direction from lactation to
favor bone formation. The maternal skeleton undergoes
substantial improvements in bone mass, mineralization,
and strength. Rodents appear to fully regain mineralization
and strength within 2 8 wk, whereas women likely achieve
this closer to 1 yr after weaning. In both the animal and
human studies, there may be incomplete recovery of the
trabecular microarchitecture of the femora and tibiae, the
effects of which may be offset by an increase in the cross-
sectional diameters of these bones. Although no formal
measurements of bone strength after weaning have been
510 Physiol Rev VOL 96 APRIL 2016 www.prv.org
done in women, the fact that more than five dozen epide-
miological studies found that lactation confers a neutral or
protective effect against low BMD and fragility suggests
that recovery is effectively complete, without long-term ad-
verse effects on bone strength. Some data are compatible
with the possibility that weight-bearing exercise and in-
creased calcium intake during post-weaning may contribute
to an even greater BMD being achieved.
The question arises as to whether or not the skeletal losses
invoked by lactation and the recovery post-weaning are the
same in a first compared with a second or third reproductive
cycle, or in younger versus older mothers. In areas where
the trabecular microarchitecture is not completely restored,
such as the tibia or femur, there may be less resorption of
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
bone in subsequent lactation cycles. Conversely, the trabec-
ular microarchitecture is completely restored in the spine,
so subsequent lactation cycles can be expected to result in a
similar magnitude of resorption and recovery. Available
data from human studies are consistent with a similar de-
gree of skeletal resorption occurring in all lactation epi-
sodes, and a similar degree of recovery occurring afterwards
regardless of maternal age. This includes observational
studies that included women of various reproductive ages
and parity, and the dozens of epidemiological studies that
have not found an association among parity, lifetime extent
of lactation, and risk of osteoporosis or fractures. However,
there have been no systematic comparisons in animal or
human studies of younger versus older mothers, or primip-
aras versus multiparas, so differences in the skeletal re-
sponses to lactation and recovery invoked by age or parity
cannot be ruled out.
V. DISORDERS OF BONE AND MINERAL
METABOLISM DURING LACTATION
A. Osteoporosis of Lactation
1. Animal data
Despite significant skeletal resorption during lactation that
is most marked in the lumbar spine, it is unusual for frac-
tures to be found. This is likely because the rodent ambu-
lates on four limbs, thereby not loading the spine in the
same orientation or to the same degree as in a bipedal hu-
man.
2. Human data
Multiple case reports and series have confirmed that, al-
though rare, osteoporotic fractures can occur in breastfeed-
ing women (501). Consistent with most bone loss occurring
in the axial spine, vertebral compression fractures have
been reported, sometimes with as many as 6 10 such frac-
tures evident at presentation in one individual (98, 501,
 CHRISTOPHER S. KOVACS
677, 687). These fractures can be quite debilitating. The
literature is confusing because many cases are described as
pregnancy-associated osteoporosis despite the fractures
occurring several months into lactation.
In some breastfeeding women, the physiological bone re-
sorption induced by PTHrP and low estradiol may be a
sufficient explanation for reduced skeletal strength that pre-
disposes to fragility fractures. As noted earlier, in some
individuals the lumbar spine BMD has been shown to drop
from normal to osteoporotic values during otherwise nor-
mal lactation. In some instances release of PTHrP by the
breasts may be more exuberant than normal, leading to
more marked resorption of bone. Three such breastfeeding
women presented with hypercalcemia, increased PTHrP,
and vertebral compression fractures (29, 751). The hyper-
calcemia and increased PTHrP resolved in all three women
after weaning (29, 751), but in one woman the plasma
PTHrP level remained elevated for at least 4 mo after lac-
tation ceased (751). Three other cases of compression frac-
tures during lactation also had hypercalcemia that resolved
after weaning, which is suspicious for elevated PTHrP as the
cause (928). PTHrP was undetectable in one case and ap-
propriate for lactation in two others, but common problems
with sample collection and processing (detailed in sect.
IIA3B) may explain why high levels of PTHrP were not
found. It is also conceivable that relative sensitivity to the
skeletal-resorptive effects of PTHrP may differ among
women, thereby contributing to differences in the amount
of bone lost during lactation.
On the other hand, review of the individual cases indicates
that in many women there are additional factors that con-
tribute to skeletal fragility, including causes of low bone
mass or fragility that precede pregnancy, and bone loss that
likely occurs during pregnancy (such as with very low cal-
cium intake). This leads to the consideration that if a
woman is known to have skeletal fragility or very low bone
mass prior to pregnancy or at delivery, it may be reasonable
to advise against breastfeeding in case the programmed
skeletal resorption proves to be too much for that womans
skeleton (501).
When fractures do occur, it may also be reasonable to ad-
vise that breastfeeding cease to stop further bone loss and
initiate the expected post-weaning skeletal recovery. Indi-
vidual cases have reported spontaneous improvements in
bone density by 20 70% (29, 433, 713, 811, 928), so phar-
macological therapy may be reasonably withheld for 1218
mo to determine the magnitude of spontaneous recovery
(501). An anti-remodeling agent such as a bisphosphonate
or denosumab might blunt the spontaneous bone formation
that is expected during the post-weaning interval.
As noted earlier, individual case reports have described use
of nasal calcitonin (263, 687, 885), bisphosphonates (43,
Physiol Rev VOL 96 APRIL 2016 www.prv.org
143, 178, 263, 438, 475, 671, 677, 685, 799, 885, 897),
strontium ranelate (897, 1016), and teriparatide (98, 178,
377, 527, 544, 885) to treat osteoporosis diagnosed during
pregnancy or lactation. In each of these uncontrolled cases,
the achieved BMD increase was assumed to be due to phar-
macological therapy, but remained within the expected
range of increase that can occur spontaneously during post-
weaning recovery.
3. Summary
Fragility fractures of the spine and other sites rarely occur
during lactation and may result from the normal physiolog-
ical resorption of the skeleton during lactation, combined
with effects of low bone mass or skeletal fragility that pre-
ceded pregnancy, and skeletal resorption that may have
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
occurred during pregnancy (501). A spontaneous and sub-
stantial improvement in bone mass occurs after weaning
even in women who have fractured, so pharmacological
therapy should probably be withheld for at least a year to
determine if it is really needed.
B. Primary Hyperparathyroidism
1. Animal data
Animal models of primary hyperparathyroidism have not
been studied during lactation, although studies in Casr/
mice are relevant (see sect. VC). As described earlier, re-
bound hypercalcemia occurs after delivery and again at
weaning in normal rodents; the increase in serum calcium
may be even greater in rodents that are hypercalcemic from
primary hyperparathyroidism.
2. Human data
Severe hypercalcemia, also termed a parathyroid crisis, has
occurred during the postpartum interval in women with
primary hyperparathyroidism who were not operated on
during pregnancy, and in some women who go on to breast-
feed (54, 153, 186, 612, 662, 795). The sudden rise in
serum calcium likely results from several factors, including
abrupt loss of the placenta (a significant route of calcium
loss), the initiation of low estradiol and PTHrP-induced
skeletal resorption to support milk production, the effect of
low estradiol to increase skeletal sensitivity to excess PTH,
and physiological resorption induced by physical inactivity
and bedrest during the puerperium. Consequently, signifi-
cant worsening of hypercalcemia has occurred after deliv-
ery and in women who go on to breastfeed. However, there
is variability in everything, and in at least one case the serum
calcium improved during lactation, likely because milk pro-
duction drains calcium from the maternal circulation (511).
3. Summary
Primary hyperparathyroidism can worsen significantly
postpartum, with variable effects in women who breast-
511
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
feed. The clinician should be alert to this and consider
whether parathyroidectomy or medical therapy might be
needed during the postpartum interval.
C. Familial Hypocalciuric Hypercalcemia
1. Animal data
Casr/ mice have life-long hypercalcemia and hypocalci-
uria and mimic the human condition of FHH (394). They
lactate normally, and their pups grow at the expected rate.
However, mammary tissue shows twofold increased PTHrP
expression while milk has twice the normal content of
PTHrP but modestly reduced calcium content (36). These
results imply that skeletal resorption increases to com-
pensate for reduced entry of the calcium into milk. A
mammary-specific deletion of Casr confirmed this by
finding increased PTHrP in mammary tissue, plasma, and
milk; suppressed PTH; reduced milk calcium content;
reduced bone volumes and BMD; and increased urine
calcium excretion, compared with lactating controls
(591). These findings point to a central role of the CaSR
in mammary tissue to control skeletal resorption during
lactation, and the milk content of PTHrP and calcium.
Treatment of mammary epithelial cells with a calcimimetic
drug that activates the calcium receptor results in increased
milk calcium content and reduced PTHrP content (36, 952).
Therefore, activating mutations of the calcium receptor,
which cause systemic hypocalcemia, may be expected to
result in milk with increased calcium but reduced PTHrP
content.
2. Human data
The available mouse data predict that women with FHH
who breastfeed will have increased PTHrP, more bone loss,
increased renal calcium excretion, but a lower calcium con-
tent of milk. However, there are no published case reports
describing changes in serum minerals, bone density, or milk
composition in these women.
3. Summary
FHH likely causes increased PTHrP-mediated bone loss and
reduced milk calcium content, but confirmatory human
data are lacking.
D. Hypoparathyroidism
1. Animal data
Lactation appears to improve mineral and skeletal homeo-
stasis in rodents that lack PTH. This has been most clearly
shown in Pth null mice, which lactate normally on a stan-
512 Physiol Rev VOL 96 APRIL 2016 www.prv.org
dard 1% calcium diet, normalize serum calcium and phos-
phorus, and experience a normal loss of BMC at whole
body, lumbar spine, and hindlimb (478). After weaning,
they fully regain the mineral content lost during lactation,
reach a BMC that is 10 15% higher than the prepregnancy
baseline value, and redevelop hypocalcemia and hyper-
phosphatemia. They are somewhat more prone to anesthet-
ic-related deaths associated with serial DXA readings (133).
A 2% calcium diet blunted the lactational decline in BMC
but did not reduce the post-lactation gain in BMC (478).
Overall, the studies in Pth null mice indicate that loss of
PTH has no significant effect on lactational or post-weaning
mineral homeostasis. Calcitriol, PTHrP, and intestinal cal-
cium absorption have not been measured in lactating Pth
null mice.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
Parathyroidectomy has been carried out during established
lactation in rats, resulting in sudden PTH deficiency that
was not present prior to pregnancy or lactation. As dis-
cussed in the following paragraphs, parathyroidectomy re-
sults in improved values compared with nonlactating, para-
thyroidectomized rats, but worsening of some parameters
compared with intact or sham-operated rats. The calcium
content of the diet appears to be an important confounding
variable.
In a series of experiments carried out by one team of inves-
tigators, lactating, parathyroidectomized rats consuming a
2% calcium diet had normal serum calcium and phospho-
rus that was also no different from values in lactating, intact
rats on the same diet (395). On this diet the femoral ash
weight declined 40% during lactation in both intact and
parathyroidectomized rats, confirming that resorption of
bone during lactation does not require PTH and is not made
worse by its absence (395). Substitution of a 0.02% calcium
diet caused the serum calcium to fall to half normal in
lactating, parathyroidectomized rats, and 60% of them
died suddenly from presumed tetany or arrhythmias. In
contrast, none of the nonlactating parathyroidectomized
rats died, nor did any intact rats (395).
In other studies, parathyroidectomy in rats during lactation
caused a 50% fall in serum or ionized calcium and an in-
crease in serum phosphorus when 0.4 and 1% calcium diets
were consumed (295, 569, 718). The magnitude of hyper-
phosphatemia in parathyroidectomized rats lessened as lac-
tation progressed (295). Calcitriol increased in lactating,
parathyroidectomized rats to at least double the value of
nonlactating, parathyroidectomized rats and nonlactating,
sham-operated rats, but remained below the concentration
of lactating sham-operated rats (569, 718). Intestinal cal-
cium absorption increased normally during lactation de-
spite simultaneous parathyroidectomy and vitamin D defi-
ciency (93). Milk calcium content was significantly higher
at day 6 of lactation and normal during the remainder of
lactation in parathyroidectomized rats, despite the serum
 CHRISTOPHER S. KOVACS
calcium being 50% of normal (295). This confirms that
achieving a normal calcium content in milk does not require
PTH. Based on studies in mice, systemic hypocalcemia may
cause increased milk PTHrP content (36, 952).
Weight gain of the pups was normal when lactating, para-
thyroidectomized rats consumed a 2% calcium diet (395),
whereas weight gain was modestly reduced as early as 24 h
after parathyroidectomy when the mothers consumed 1 or
0.4% calcium diets (295, 569). This reduced weight gain
was not seen in pups nursed by Pth null mice compared with
WT mice; the ash weight and calcium content were no dif-
ferent at the end of 3 wk of lactation (133). Since the cal-
cium content of milk is normal in parathyroidectomized
rats, other factor(s) must be contributing to reduced weight
gain in their pups. Since the parathyroidectomized mothers
are hypocalcemic on the diets associated with reduced pup
weight gain, maternal tetany may be preventing prolonged
suckling, or causing reduced milk volume. Another possi-
bility is that the expected increased milk PTHrP content
(36, 952) is causing reduced weight gain, because milk con-
tent of PTHrP has been shown to be inversely related to the
rate of skeletal mineral accrual in nursed pups, and inde-
pendent of milk calcium content (591). The physiological
role of PTHrP in milk may be to reduce or modulate skeletal
mineral accrual in the neonate (492).
2. Human data
Since the 1970s it has been appreciated that mineral and
skeletal metabolism substantially improves in hypoparathy-
roid women who are breastfeeding (30, 148, 161, 607, 790,
796, 811, 837, 890, 1008), and these observations contrib-
uted to the hypothesis that the lactating breast expresses a
PTH-like hormone. Occasionally women have been diag-
nosed to have hypoparathyroidism due to abrupt onset of
hypocalcemia when lactation ceases (72), which is also
compatible with loss of a calciotropic hormone produced
by the breasts.
That hypothesis proved to be correct when PTHrP was
identified and confirmed to be expressed at high levels in
lactating mammary tissue, the maternal circulation, and
milk. Furthermore, the animal data previously discussed
have confirmed the physiological role of PTHrP during lac-
tation. One clinical case documented that hypoparathyroid
women can experience transient hypocalcemia in the first
day or two postpartum, presumably from the abrupt loss of
placental PTHrP (890). This hypocalcemia resolves as lac-
tation, and expression of PTHrP in the breast, becomes
more fully established. However, most published cases of
hypoparathyroidism have not reported such a worsening
during the puerperium, but instead have noted that the
requirement for supplemental calcium and calcitriol drops
substantially as milk production is upregulated. Significant
iatrogenic hypercalcemia and vertebral compression frac-
tures have occurred when attention has not been paid to
Physiol Rev VOL 96 APRIL 2016 www.prv.org
monitoring the serum calcium and the anticipated require-
ment for the doses of calcium and calcitriol to be decreased
(148, 161, 790, 796, 811, 837, 1008). In some women
calcium and calcitriol both need to be stopped, whereas in
other women reduced doses may be all that is required.
The reason for the improvement in mineral and skeletal
homeostasis is that PTHrP, released from lactating breast
tissue, stimulates bone turnover, renal tubular calcium con-
servation, and production of calcitriol by the kidneys (148,
607, 837). Calcitriol does not increase above normal, and
this may be because in some studies PTHrP appears less
potent than PTH in activating the PTH/PTHrP receptor and
stimulating Cyp27b1 (308, 413, 414, 494, 988). Another
potential reason is that the hormonal milieu of lactation,
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
including high prolactin and low estradiol, conceivably al-
ters how Cyp27b1 responds to PTHrP during lactation.
Since the identification of PTHrP, many clinical reports
have deduced the presence of increased circulating PTHrP
but have not measured it (30, 890, 1008). However, a rise
and decline in plasma PTHrP has been shown to correspond
to the rise and decline in serum calcium, calcitriol, and bone
turnover markers (607, 811, 837). In all published cases,
the improvement in mineral homeostasis and decline after-
wards correlates respectively with the increasing and less-
ening intensity of lactation. The less exclusively or inten-
sively a hypoparathyroid woman breastfeeds, the more
likely it is that supplemental calcium and calcitriol are still
needed.
The ameliorating effect of breast-derived PTHrP wanes at
varying rates as lactation lessens and the baby is weaned. In
some women the calcium and calcitriol has to be reinsti-
tuted while breastfeeding was still ongoing, whereas in oth-
ers it may not be required until days, weeks, or months after
lactation has ceased. In most cases the need to reinstitute or
increase the doses of calcium and calcitriol occurs within
days prior to or after weaning, but in one unpublished case
that the author was involved in, serum calcium remained
normal off all supplements for more than 1 yr post-wean-
ing, before hypocalcemia abruptly recurred.
One clinical report documented a spontaneous 40% in-
crease in lumbar spine BMD and 7.5% increase in femoral
neck BMD in a surgically hypoparathyroid woman after
lactation, confirming that substantial skeletal recovery is
possible after weaning without PTH (811).
3. Summary
Animal and human data are consistent with mammary-
derived PTHrP stimulating bone turnover, renal calcium
conservation, and synthesis of calcitriol during lactation.
Rodents require both increased intestinal calcium absorp-
tion and skeletal resorption to meet the calcium require-
513
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
ments of lactation. A standard 1% calcium diet is sufficient
for lactating mice to normalize mineral homeostasis with-
out PTH, whereas lactating rats appear to need a 2% cal-
cium diet for normalization to occur without PTH. There
may be species differences that contribute to why mice and
rats do not have identical responses to absence of PTH.
Women rely mainly on skeletal resorption to meet the cal-
cium requirements of lactation. The available case reports
make very clear that lactation usually results in normaliza-
tion or near-normalization of mineral and skeletal homeo-
stasis in hypoparathyroid women. It is hazardous to blindly
maintain prepregnancy doses of calcitriol and calcium in
hypoparathyroid women who plan to breastfeed; the albu-
min-adjusted calcium or ionized calcium must be followed
so that appropriate reductions in the doses of these supple-
ments can be made. As lactation lessens, and especially after
it ceases, the requirement for calcium and calcitriol can be
expected to revert to prepregnancy levels.
E. Pseudohypoparathyroidism
1. Animal data
A mouse model of pseudohypoparathyroidism has not been
studied during lactation (322).
2. Human data
There are no animal or human data regarding mineral ho-
meostasis and bone metabolism in animal models or
women with pseudohypoparathyroidism. It is expected that
lactation should lead to an overall improvement due to the
release of PTHrP from mammary tissue. Since pseudohypo-
parathyroidism leads largely to renal but not skeletal resis-
tance to PTH, it is possible that lactation may lead to in-
creased skeletal resorption compared with normal when the
effects of PTH and PTHrP are combined.
3. Summary
Pseudohypoparathyroidism can be anticipated to improve
during lactation, mimicking the clinical experience with hy-
poparathyroidism, but this has not been documented.
F. Pseudohyperparathyroidism
1. Animal data
Preceding sections have confirmed that lactating mammary
tissue produces PTHrP, and that suckling leads to increased
release of PTHrP and systemic effects on mineral homeo-
stasis. However, there are no data on pseudohyperparathy-
roidism from lactating animals.
514 Physiol Rev VOL 96 APRIL 2016 www.prv.org
2. Human data
The physiological release of PTHrP from lactating breasts
alters mineral and skeletal homeostasis, thereby contribut-
ing to a small increase in serum calcium and phosphorus,
suppression of PTH, increased bone resorption, and re-
duced renal calcium excretion. But most women and their
clinicians are unaware of the presence of PTHrP or its ef-
fects, because these physiological changes are silent and
without consequences. As noted in section VD, the presence
of PTHrP becomes apparent in hypoparathyroid women
who normalize mineral and skeletal homeostasis, and will
become hypercalcemic if the doses of calcium and calcitriol
are not decreased or stopped.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
Occasionally the effects of breast-derived PTHrP become
symptomatically obvious in otherwise normal breastfeed-
ing women. PTHrP-mediated hypercalcemia is called pseu-
dohyperparathyroidism because it mimics the effects of pri-
mary hyperparathyroidism but is not due to excess PTH. It
has developed during normal lactation (179, 549, 751,
847), in a woman who recently delivered a baby but was
unable to breastfeed because of a critical illness in the baby
(800), and even in nonlactating women who simply have
large breasts (435, 474, 603, 950). The mechanism is that
high levels of PTHrP cause excess skeletal resorption of
calcium and renal reabsorption of calcium; intestinal cal-
cium absorption may also be increased if the achieved levels
of PTHrP are sufficient to cause high levels of calcitriol.
One woman developed hypercalcemia during each of two
pregnancies; it worsened and persisted while she breastfed
and resolved with weaning. During the second lactation
interval, high circulating levels of PTHrP were confirmed,
which normalized as the hypercalcemia resolved (549). A
second woman had lactation-induced hypercalcemia and
vertebral compression fractures, high PTHrP of 10.9 pg/ml,
low calcitriol, and undetectable PTH. The hypercalcemia
improved with weaning while the PTHrP level stayed ele-
vated for several months before becoming undetectable
(751). In a third case, severe postpartum hypercalcemia
(4.85 mM) worsened over the first 3 days postpartum, ac-
companied by a very high plasma PTHrP (28.4 pM) with
undetectable PTH (800). The hypercalcemia persisted for
10 days despite treatment with intravenous pamidronate,
before subsiding to normal, accompanied by a fall in PTHrP
to undetectable, and a rise in PTH to normal. The authors
of that report incorrectly attributed placental PTHrP as the
explanation for her hypercalcemia (800). However, PTHrP
has a half-life of minutes in the circulation, and its placental
source was abruptly lost with the afterbirth; therefore, pla-
cental PTHrP cannot explain maternal hypercalcemia that
worsened over the first 3 days after delivery and persisted
for 10 days. The time course is consistent with release of
PTHrP from the breasts, which upregulates in response to
regulatory cues during late gestation and parturition, and
subsides when breastfeeding does not occur. A fourth case
 CHRISTOPHER S. KOVACS
involved a woman who developed hypercalcemia with sup-
pressed PTH during two successive lactation episodes
(179). The hypercalcemia resolved and PTH rose to normal
with weaning each time; no measurements of PTHrP were
done. A fifth and much older case from 1981 (prior to the
discovery of PTHrP) also involved lactational hypercalce-
mia with low PTH; a bone biopsy revealed active skeletal
resorption suggestive of hyperparathyroidism (847). The
hypercalcemia resolved after weaning, and the authors cor-
rectly deduced that the breasts must be producing a PTH-
like hormone.
These cases emphasize the extreme of women developing
symptomatic hypercalcemia during lactation. This appears
to be uncommon; however, some cases may go undiagnosed
because hypercalcemia causes nonspecific constitutional
symptoms that will not be obviously different from normal
symptoms in a woman who is feeding a baby on demand
around the clock. Recall that the serum calcium and ionized
calcium have both been shown to rise during lactation in
longitudinal studies, so the prevalence of high serum cal-
cium during lactation may be more common than what
these isolated cases would otherwise suggest.
Weaning the baby, combined with judicious use of breast
binders or dopaminergic medications that suppress prolac-
tin (cabergoline, bromocriptine), should reverse the excess
production of PTHrP and consequent hypercalcemia. A bi-
sphosphonate or denosumab may be needed to acutely shut
down the increased bone turnover. However, excess pro-
duction of PTHrP can last for months or longer, which
explains why a few cases have even required bilateral mas-
tectomies to correct the problem (435, 474, 603, 950).
3. Summary
Release of PTHrP from lactating breast tissue causes the
serum and ionized calcium to rise slightly in most women;
uncommonly, this has caused symptomatic hypercalcemia.
The prevalence of PTHrP-mediated hypercalcemia during
lactation may be underestimated since serum calcium is not
normally measured, and symptoms of hypercalcemia may
be misattributed to other aspects of life with a new baby.
When hypercalcemia does occur, it should resolve with
weaning, but occasionally surgical reduction in the amount
of breast tissue may be necessary.
G. Vitamin D Deficiency and Genetic Vitamin
D Resistance Syndromes
1. Animal data
The effect of extreme disturbances in maternal vitamin D
physiology during lactation and post-weaning recovery
have been investigated in Vdr null and Cyp27b1 null mice
as well as vitamin D-deficient mice and rats.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
In longitudinal studies wherein Vdr null mice were raised on
a standard 1% calcium diet to allow them to develop rick-
ets, but switched to a 2% calcium diet prior mating to
maximize fertility, Vdr null mice increased BMC by 55%
during pregnancy, and lactated normally, losing a normal
amount of BMC compared with their WT sisters on the
same diet (296). Serum calcium and phosphorus remained
normal throughout lactation and post-weaning. Within 14
days after weaning, the Vdr null mice restored all that had
been lost to achieve a BMC that was 50% higher than their
prepregnant baseline but equal to the WT value. Histomor-
phometry during late pregnancy compared with prepreg-
nancy showed that the pregnancy-related increase in BMC
was largely attributable to mineralization of osteoid (296).
The subsequent increase in BMC after weaning implies that
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
new bone formation has occurred; however, histomorpho-
metric studies have not yet been carried out in this time
frame. Preliminary and ongoing studies in the authors lab
have shown that the post-weaning increase in BMC is no
different between WT and Vdr null mice when both are
switched to a 1% calcium diet after delivery, confirming
that the high calcium content of the diet is not required for
skeletal recovery to occur after weaning.
The same Vdr null mice have also been studied after being
raised on a 2% calcium diet from 3 wk of age (489), so
they did not have rickets prior to pregnancy. Micro-CT
studies, biomechanical tests, and femoral ash weight
were carried out during pregnancy and lactation. WT
mice gained trabecular bone volume and thickness during
pregnancy while the Vdr nulls did not, and this difference
persisted to day 5 of lactation but was gone by day 10
(489). By the end of lactation, WT and Vdr nulls resorbed
a similar amount of bone as determined by microCT and
ash weight studies, lost a similar amount of femoral bone
strength, and showed no significant differences between
the genotypes (489).
Milk calcium content was normal in Vdr null mice com-
pared with WT (1026). But after weaning, Vdr nulls show
delayed involution and apoptosis of mammary epithelial
cells (1026). This suggests that calcitriol plays a role in
regulating involution after lactation.
In a preliminary report, Cyp27b1 null mice raised on a 2%
calcium diet from the time of weaning had reduced BMC
and microCT evidence of rickets prior to mating, gained
40% BMC during pregnancy, and lost a normal amount of
BMC during lactation (330). After weaning, they regained
what was lost during lactation and reached a higher BMC
value than prior to pregnancy (330). Serum calcium nor-
malized during pregnancy but fell sharply during lactation
before recovering slowly to normal during post-weaning. In
contrast, phosphorus was low during lactation but normal
throughout post-weaning recovery.
515
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
Vitamin D-deficient mice from the CD1 background, kept
on a 1.2% calcium diet, had normal serum calcium and
ionized calcium but lower serum phosphorus during lacta-
tion (19). Their pups grew at the same rate as pups from
vitamin D-replete mice (19). Milk from these mice showed
normal nutritional and calcium content, but there was a
15% lower lactose content (19). Conversely, vitamin D-de-
ficient mice in the Swiss background had mild (20% lower)
hypocalcemia and normal phosphorus (79). Analysis of
milk from these mice, and from vitamin D-deficient rats,
showed reduced protein content; the calcium content was
not measured (79).
Severely vitamin D-deficient rats have also been studied
during lactation and post-weaning skeletal recovery. On
diets ranging from 0.47 to 1.7% calcium, lactating vitamin
D-deficient rats are consistently hypocalcemic (values 50%
of normal and usually lower than in pregnancy) with serum
phosphorus that ranges from normal to modestly reduced
(93, 146, 360, 362, 598, 628), whereas during post-wean-
ing recovery, hypocalcemia lessened and phosphorus was
consistently normal (93, 360, 362, 628). Lactation pro-
ceeds normally, with vitamin D-deficient and vitamin D-re-
plete rats each resorbing a similar amount of calcium from
the femora compared with the peak value of pregnancy
(362, 598, 628). Histomorphometry revealed that lactating
vitamin D-deficient rats have significantly widened osteoid
seams as well as increased osteoblast surface, osteoclast
number, and resorptive surface (146). After weaning, se-
verely vitamin D-deficient Holtzman rats on a 0.47% cal-
cium diet recovered lactational losses in mineralized bone
volumes and cortical width, thereby achieving values that
equaled or exceeded those prior to pregnancy (628). But in
an earlier study from the same investigators, there was no
recovery of ash weight or mineral content at 3 wk (362).
The discrepancy in post-weaning skeletal recovery between
these two studies is unexplained.
Intestinal absorption of calcium doubled during lactation
and declined to virgin values during the recovery phase in
rats consuming 0.47 to 1.21.7% calcium diets (93, 360).
Intestinal phosphorus absorption also doubled on the 1.2
1.7% calcium diet (93). Serum calcium and phosphorus
were normal, and intestinal calcium absorption was no dif-
ferent between vitamin D-deficient and replete rats either
during lactation or post-weaning on the 1.21.7% calcium
diet (93). On the 0.47% calcium diet, vitamin D-deficient
rats had lower serum calcium and phosphorus, and
achieved a doubling of intestinal calcium absorption during
lactation; they were studied separately from vitamin D-re-
plete rats and may have had a slightly lower peak efficiency
of intestinal calcium absorption (360). These results indi-
cate that calcitriol is not required for a doubling of effi-
ciency of intestinal calcium and phosphorus absorption to
occur during lactation; however, the lower (0.47%) cal-
cium diet likely reduces passive absorption of calcium (360)
516 Physiol Rev VOL 96 APRIL 2016 www.prv.org
compared with the 1.21.7.% calcium diet (360). Both
studies indicate that the normal rate of intestinal mineral
absorption in virgin rats is sufficient to facilitate skeletal
recovery during post-weaning (93, 360).
In one study, vitamin D-deficient rats produced only 20%
of the volume of milk of vitamin D-replete rats, as deter-
mined by injecting the rats with oxytocin and then manually
expressing the milk. The nutritional content of the milk was
normal to enhanced, since it contained more protein, cal-
cium, phosphorus, but somewhat less carbohydrate than
normal milk (119). Pups of vitamin D-deficient rats had
modestly reduced weight gain, but this was corrected by
giving the mothers fewer pups to nurse, confirming that the
mother may be producing milk of insufficient quantity to
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
meet the demands of larger litters (119). However, the
markedly reduced volume of expressed milk was out of
keeping with the modest reduction in pup weight gain, so
the experimental technique may have overestimated any
difference in milk volumes produced. Hypocalcemic vita-
min D-deficient rats may, for example, differ from vitamin
D-replete rats in their response to exogenous oxytocin, but
not in their response to suckling.
Rat milk contains a very low concentration of vitamin D
and 25OHD, which together total 312 IU/liter (190).
This is similar to the low vitamin D content of human milk.
Overall, the rodent studies indicate that disrupted vitamin
D physiology is more likely to cause hypocalcemia in rats
than in mice, regardless of dietary calcium content. Lacta-
tion otherwise proceeds normally despite maternal loss of
calcitriol, VDR, or vitamin D, with the amount of bone
resorbed being comparable to that of their respective WT or
vitamin D-sufficient controls. Post-weaning, skeletal recov-
ery occurs at a normal rate in Vdr null mice and (in a
preliminary report) Cyp27b1 mice, whereas vitamin D-de-
ficient rats have been found to have discrepant results of
both normal skeletal recovery and failure to recover. In
vitamin D-deficient mice and rats, and in Vdr null mice,
milk content of calcium is normal, but the volume of milk
produced was reduced in one study of vitamin D-deficient
rats. A reduction in milk volume could explain a reduction
in pup growth rate that was seen in some but not all studies.
2. Human data
Observational cohort studies (145, 731, 862, 893) and ran-
domized interventional trials (13, 14, 60, 402, 453, 672,
780, 788, 789, 965) have not shown any effect of higher
25OHD concentrations or vitamin D supplementation to
alter maternal mineral or skeletal homeostasis in otherwise
healthy, lactating women across a broad range of vitamin D
intakes and 25OHD levels. Vitamin D supplementation
raises maternal 25OHD levels with a similar dose-response
effect as in nonpregnant or nonlactating women. Many of
 CHRISTOPHER S. KOVACS
the randomized trials measured only the achieved 25OHD
level as the outcome of interest (13, 60, 402, 780, 788, 965).
Milk normally contains little vitamin D or 25OHD,
30 40 IU/liter in total, while calcitriol is usually very low
to undetectable (400, 410, 515, 545, 587, 748, 872, 939).
Consequently, maternal 25OHD should not decline signif-
icantly as a consequence of milk production, and this has
been confirmed by multiple studies (156, 157, 165167,
470, 505, 558, 764, 805, 862, 871). Moreover, this means
that breast milk is normally not a good source of vitamin D
for the neonate or infant. These facts are often disbelieved
because marketed milk and other dairy products in the
United States and Canada contain 10 times the concen-
tration of vitamin D, i.e., 400 IU/liter or 100 IU/standard
serving (250 ml or cup). However, that is a synthetic vita-
min D supplement, which is added to milk and dairy prod-
ucts after pasteurization. It is not put there by the cow or
goat.
Although milk vitamin D and 25OHD content are low,
there is a correlation between milk 25OHD and neonatal
25OHD after the first month of lactation, indicating that
despite its low content of vitamin D, breast milk is an im-
portant determinant of neonatal vitamin D stores (145,
540, 780). The estimated half-life of 25OHD in infants is
23 wk (717), similar to values in adults (59, 62, 189, 344,
449), which means that a higher cord blood 25OHD will
only influence neonatal levels over about the first 6 wk.
Randomized intervention studies indicate that typical ma-
ternal vitamin D doses of 400-1,000 IU/day do not consis-
tently increase breast milk content of vitamin D or 25OHD,
whereas with maternal vitamin D doses of 2,000 4,000
IU/day, an increase in milk content of vitamin D and
25OHD and neonatal 25OHD can be demonstrated (13,
14, 402, 780). Additional randomized trials have shown
that even higher maternal vitamin D intake increases the
amount of vitamin D and 25OHD in milk (also called anti-
rachitic activity of milk) (60, 672, 788, 965). A dose of
6,400 IU/day raises the milk vitamin D content sufficiently
so that the babies achieved 25OHD values of 115 nM (46
ng/ml), the same level reached by babies who received 300
IU of vitamin D directly in the form of oral drops (965). A
daily maternal dose of 5,000 IU/day raised maternal
25OHD to 400 nM (160 ng/ml) and neonatal 250HD to 98
nM (39 ng/ml), while a single maternal dose of 150,000 IU
had a similar effect (672).
These high levels of maternal and neonatal 25OHD have
been targeted without evidence that they confer a specific
benefit. It is relevant to recall that multiple stable isotope-
based studies in children, adolescents, and adults have
shown that on an adequate calcium diet, intestinal calcium
absorption is already maximal with a 25OHD level above
20 nM (7, 24, 26, 306, 650, 774). Moreover, intestinal
calcium absorption in the breastfed neonate and infant is
Physiol Rev VOL 96 APRIL 2016 www.prv.org
boosted by the lactose content of milk, which increases
passive, paracellular absorption of calcium (479, 480).
Therefore, a 25OHD level of 100 nM is far above the value
at which intestinal calcium absorption maximizes, and is
unlikely to confer any additional benefit on intestinal cal-
cium absorption or bone metabolism in the neonate or in-
fant.
Moreover, in areas where severe vitamin D deficiency rick-
ets is endemic, it has been effectively treated with breast
milk as the only form of nutrition in mothers who received
150,000 IU vitamin D every 3 mo, or 1,800 IU/day (902,
903). These babies and their mothers were protected from
sun exposure and had negligible vitamin D in the diet, so a
maternal supplement was the main source. Starting
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
25OHD values were 6 nM (2 ng/ml) or lower in mothers
and babies, consistent with extreme vitamin D deficiency.
Achieved 25OHD values were 50 nM (20 ng/ml) in the
mothers and 40 nM (16 ng/ml) in their babies, both of
which are above the 20 nM threshold that appears to max-
imize intestinal calcium absorption. The far higher breast
milk vitamin D content and infant 25OHD levels achieved
by giving a 5,000 or 6,400 IU supplement daily to the
mother greatly exceed what has been shown to treat rickets,
the severe manifestation of vitamin D deficiency. Therefore,
such high doses may be superfluous if no additional benefit
is provided to mineral or skeletal metabolism. The question
remains as to whether such high vitamin D intakes or
achieved 25OHD levels in breastfed babies confer any non-
skeletal benefits (773).
Breast milk calcium content is unaffected by maternal
25OHD over a wide range from 25 nM (10 ng/ml) to 160
nM (64 ng/ml) (60, 731). This includes cohort studies that
have examined low maternal vitamin D intakes and
25OHD concentrations (731), and randomized interven-
tions which found that maternal intake of 2,000 6,400 IU
vitamin D/day failed to change the calcium content of milk
compared with an intake of 400 IU/day (60, 402, 965), even
though the 6,400 IU dose raised maternal 25OHD to 160
nM (64 ng/ml) (965). On the other hand, several individual
cases from India revealed that milk calcium content was
lower in mothers presenting with overt vitamin D deficiency
with mean 25OHD values of 6 nM (2.5 ng/ml), hypocalce-
mia, hypophosphatemia, and markedly elevated PTH
(903). These results confirm that calcitriol likely does not
play a direct role in causing calcium to enter milk, but
extremes of vitamin D deficiency (25OHD closer to 6 nM)
will impair milk production. As noted earlier, calcium in-
take does not alter breast milk calcium content (206, 452,
484, 723). Instead, the calcium content of milk is largely
regulated by the calcium receptor and PTHrP, with the
supply being the maternal skeleton and a lesser contribution
from diet. In extreme vitamin D deficiency, there is skeletal
resistance to the resorptive actions of PTH (550, 577, 624,
517
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
783), which likely contributes to maternal hypocalcemia
and low breast milk calcium content.
The effect of vitamin D deficiency or insufficiency has not
been explicitly examined during the recovery phase from
lactation. This is when calcitriol may be especially impor-
tant to ensure adequate delivery of mineral to the rebuilding
skeleton. One study suggested that the FokI polymorphism
in Chinese women interacted with calcium intake to deter-
mine the magnitude of BMD increase 1 yr after lactation
ended or menses resumed, but the study was too small (40
subjects) to make generalizations to larger populations and
other ethnicities, or to know if it confirms an effect of cal-
citriol to directly or indirectly regulate skeletal recovery.
Vitamin D deficiency and insufficiency also have not been
explicitly examined in any of the cohort studies or large
epidemiological studies that looked at the effect of prior
lactation history on BMD or fracture risk. However, since
those studies largely found a neutral or even a protective
effect of lactation on long-term BMD and fracture risk, and
the majority of women in those studies are considered to be
vitamin D insufficient or deficient by some modern experts,
it seems probable that skeletal recovery after weaning is not
impaired by vitamin D insufficiency either. Direct studies of
the effect of vitamin D supplementation during post-wean-
ing recovery are needed. In the absence of such data, it is
prudent to recommend the same intake of vitamin D as in
nonpregnant women.
Hereditary absence of Cyp24a1 reduces calcitriol catabo-
lism and has been shown to lead to marked maternal hyper-
calcemia during pregnancy accompanied by high calcitriol.
While breastfeeding, hypercalcemia was milder and serum
calcitriol was normal (820). This is consistent with
Cyp27b1 stimulation being reduced to nonpregnant levels
during lactation.
3. Summary
The animal data indicate that resorption of bone and milk
calcium content may be unaffected by extremes of vitamin
D physiology, including absence of VDR, calcitriol, and
vitamin D. Post-weaning recovery of bone mass also occurs
despite absence of VDR, calcitriol, and vitamin D, although
data from vitamin D-deficient rats are inconsistent.
Clinical data are largely similar, suggesting that maternal
vitamin D stores are not adversely impacted by lactation,
that milk calcium content is unaffected by extremes of se-
vere vitamin D deficiency and excess, and that lactational
bone loss is likely also unaffected. Given the prevalence of
insufficient to low levels of 25OHD in the normal popula-
tion, the epidemiological studies also suggest that post-
weaning recovery of bone mass is also likely not impaired.
Overall, there is no clear evidence that the requirement for
vitamin D increases during lactation to meet maternal
518 Physiol Rev VOL 96 APRIL 2016 www.prv.org
needs. Since milk normally contains little vitamin D or
25OHD, a theoretical benefit of high-dose vitamin D sup-
plementation is that all of a babys nutrition could then
come from breast milk, rather than requiring that breast-fed
babies alone be stigmatized to receive vitamin D supple-
ments. Further study is needed of the effectiveness, safety,
and adherence to this route of delivery compared with giv-
ing vitamin D supplements directly to the baby. The high
doses used in some of these studies are not needed if the
neonatal goal is a 25OHD level of only 50 nM, as the
Institute of Medicine and pediatric societies have suggested
(430).
H. Calcitonin Deficiency
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
1. Animal data
As noted earlier (sect. IIIH), the theory that calcitonin pro-
tects against excessive resorption of the skeleton during
pregnancy was originally tested by removing the thyroid
glands of goats and rats, autotransplanting the parathy-
roids, and providing thyroid hormone replacement. The
same approach was used for lactation.
In two studies such thyroidectomized rats had 10% lower
femoral ash weight, calcium, and phosphorus content than
sham-operated rats after 3 wk of lactation (551, 900). Al-
though there was no difference in basal serum calcium be-
tween groups during lactation (900), there was a greater
surge in serum calcium after gavage in thyroidectomized
compared with sham-operated rats (927), suggesting that
calcitonin modulates the postprandial calcemic response
during lactation. Intestinal calcium absorption was also re-
duced 20% in thyroidectomized rats (551). These were
small studies and described only at abstract length, with few
methodological details and some relevant data not dis-
closed (551, 900). Whether the surgically altered animals
were euparathyroid and euthyroid was not determined, and
that may have confounded the results.
These results were refuted by a later study that used a larger
sample size of rats, and confirmed that serum thyroxin and
calcium were no different between thyroidectomized and
sham-operated rats during lactation. Both groups resorbed
bone, but there was no difference between them in femoral
ash weight or calcium content at the end of lactation (392).
Similar experiments were carried out in lactating, thyroid-
ectomized, thyroxin-replaced goats but without confirma-
tion of thyroid or parathyroid status. The thyroidectomized
goats lost 9% more ash weight and calcium from metatar-
sals and metacarpals compared with sham-operated ani-
mals (55). The sample size was quite small, consisting of
only five thyroidectomized and four intact goats.
None of these studies in rats or goats examined the trabec-
ular bone of the spine, which is the site that loses the most
 CHRISTOPHER S. KOVACS
mineral during lactation. Moreover, extrathyroidal sources
of calcitonin synthesis were not appreciated when these
models were created; lactating mammary tissue is a potent
source of calcitonin, and there is additional expression in
the pituitary.
The postulated physiological role of calcitonin to protect
the maternal skeleton during lactation was reexamined in
Ctcgrp null mice, which lack calcitonin and calcitonin gene-
related peptide-, but retain calcitonin gene-related pep-
tide- (394). This global calcitonin deficiency resulted in
lactating Ctcgrp null mice losing double the BMC as their
WT sisters from whole body, lumbar spine, and hindlimb,
with the losses reaching 55% of lumbar spine BMC (994).
Treatment with calcitonin through 3 wk of lactation pre-
vented the excess bone loss, whereas CGRP- had no effect,
confirming that loss of calcitonin led to the skeletal pheno-
type. Increased expression of PTHrP in mammary tissue
and increased circulating PTH likely combined to cause
increased bone resorption and exaggerated net bone loss in
Ctcgrp null mice (992, 994). Histomorphometric studies
showed that Ctcgrp nulls had a doubling of osteoclast num-
ber and resorptive surfaces, and a halving of osteoblast
number and osteoid surface (194). Intestinal calcium ab-
sorption was no different between lactating Ctcgrp nulls
and WT (994). A doubling of milk calcium content was
found that was nonsignificant in early lactation (994) but
statistically significant at mid-lactation (992). It remains
undetermined whether the primary response to loss of cal-
citonin is increased bone resorption that leads to increased
flux of calcium into mammary tissue and milk, or loss of
calcitonin in mammary tissue that increases calcium trans-
port into milk and, thereby, a compensatory increase in
PTHrP and PTH. It is also possible that both pathways are
involved, and that loss of calcitonin signaling in the pitu-
itary contributes to increased prolactin, which in turn stim-
ulates PTHrP and inhibits ovarian function. Lactating
Ctcgrp null mice did not have higher prolactin levels com-
pared with WT (994), while serum estradiol was at the
detection limit of the assay in both genotypes at all time
points (992). The postulated role of calcitonin to inhibit
prolactin is not supported by Ctcgrp null mice.
Remarkably, the 55% loss of BMC during lactation was
completely recovered within 18 days of weaning (994). This
was accompanied by histomorphometric evidence of a
marked reduction in osteoclasts, and a surge in osteoblast
numbers and surface to the same values of their WT sisters
during the post-weaning recovery phase (194). Marked
downregulation of Sost and Dkk1 expression occurred
within bone but was reduced even further in Ctcgrp null
mice, which likely contributed to the upregulation in osteo-
blast number and function (194).
The Ctcgrp null model confirms that physiological levels of
calcitonin protect the rodent skeleton from excessive re-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
sorption during lactation, but it remains to be determined
how much of calcitonins actions are at the level of oste-
oclasts, mammary epithelial cells, and pituitary lactotrophs
(994). Moreover, the model is confounded by loss of
CGRP-, which may contribute to the phenotype of altered
mineral and skeletal homeostasis. A mouse model in which
CGRP- only was deleted, apparently leaving calcitonin
expression intact, resulted in osteopenia and reduced bone
formation (801). These mice have not been studied during
lactation. A mouse model with selective deletion of calci-
tonin has not been created. It would be especially informa-
tive to selectively delete calcitonin from mammary epithe-
lial cells at the onset of lactation.
Calcitonin acts on the calcitonin receptor, which is ex-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
pressed by osteoclasts (660), lactating mammary epithelial
cells (432, 938), and pituitary (831), as well as numerous
other tissues during embryonic and fetal development
(437). Pharmacological doses of CGRP and amylin can ac-
tivate the CTR, but at physiological doses they act on dif-
ferent receptors (787). It is not possible to study the effect of
global loss of the calcitonin receptor during lactation be-
cause Ctr null mice usually die at the embryonic stage (220,
529), a lethality that is not seen in Ctcgrp null mice. WT and
Ctr/ mice were no different in their responses to lactation
(580).
More recently a conditional knockout using a CMV pro-
moter has enabled deletion of Ctr at a later stage in devel-
opment (225). This results in 90% but not 100% loss of
CTR expression in kidneys and osteoclasts; expression in
other tissues relevant to lactation, especially mammary tis-
sue and pituitary, were not assessed. During lactation these
conditionally deleted Ctr null mice show a greater increase
in osteocyte lacunar size compared with WT, suggesting
that loss of calcitonin signaling leads to increased osteocytic
osteolysis (187). However, there were no significant differ-
ences in bone structure by microCT or histomorphometry
between Ctr nulls and WT (187). Moreover, prolactin was
significantly reduced, which is the opposite of what was
expected given that targeted overexpression of calcitonin in
the pituitary, and pharmacological treatment with calci-
tonin, both reduce prolactin. A lower serum prolactin also
indicates relative inhibition of lactation in these condition-
ally deleted Ctr nulls and, therefore, the potential for re-
duced bone loss as a consequence, but milk calcium content
was normal and no significant disturbance in pup growth
was noted.
Overall, the conditional knockout of Ctr incompletely re-
sembles the lactational phenotype of Ctcgrp null mice. It
remains to be determined if these differences are due to
insufficient deletion of CTRs from relevant tissues during
lactation; loss of actions of other ligands that may be me-
diated by CTR; physiological effects of calcitonin that are
mediated by other receptors; or that loss of two ligands in
519
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
Ctcgrp nulls leads to effects that loss of CTR cannot repro-
duce. Since the breast appears to be a key controller of the
skeletal response to lactation, as explained in section IVF, if
CTR is not ablated in mammary tissue or if calcitonins
actions within mammary tissue are not mediated by CTR,
then that could explain the more modest phenotype of the
conditional Ctr knockout during lactation.
There is some consistency to the evidence that calcitonin
inhibits bone resorption during lactation. Global loss of
calcitonin and CGRP- leads to more marked bone loss
than the surgical models, which may be explainable by re-
tention of extrathyroidal (especially mammary) sources of
calcitonin in the surgical models. Conditional but incom-
plete deletion of CTR leads to increased osteocytic osteoly-
sis but does not fully reproduce the phenotype of the Ctcgrp
null.
2. Human data
No clinical studies have specifically tested whether calci-
tonin deficiency leads to increased bone resorption during
lactation. No individuals with inactivating mutations of
calcitonin or its receptor have been identified. However, it
is intriguing to speculate that such women may be among
the extreme cases of more marked bone loss or multiple
vertebral compression fractures that have been seen dur-
ing lactation (501). In one report a thyroidectomized
woman nursing twins experienced multiple vertebral
compression fractures and had marked bone loss con-
firmed by DXA; the authors speculated that calcitonin
deficiency was to blame (811). But thyroidectomized
women are not expected to be calcitonin deficient while
breastfeeding because calcitonin produced by breast tis-
sue leads to normal circulating calcitonin levels (52, 131,
755).
As noted earlier, long-term followup of thyroidectomized
men and women has yielded conflicting results as to
whether or not there is increased risk of bone loss and
fractures (326, 338, 422, 630, 659). More recent studies are
confounded by the use of high doses of thyroid hormone to
suppress TSH and reduce the risk of recurrence of thyroid
cancer.
3. Summary
Surgical models in rats and goats have provided evidence
that loss of thyroidal calcitonin leads to increased bone loss
during lactation compared with sham-operated animals;
however, these effects were not confirmed by a larger study.
More recent use of gene ablation techniques has shown that
global loss of calcitonin and CGRP- leads to a doubling of
bone loss during lactation but full recovery afterward. This
confirms that calcitonin is needed in the short term to pre-
vent excessive skeletal resorption, but not in the long term
520 Physiol Rev VOL 96 APRIL 2016 www.prv.org
since the skeleton recovers fully from these extreme losses of
bone. Conditional deletion of CTR did not fully reproduce
the effects of loss of calcitonin and CGRP-. No human
studies have tested whether calcitonin deficiency causes ex-
cess bone loss during lactation, but it may contribute to
some of the extreme cases of lactational bone loss and frac-
tures that have been reported in the literature.
I. Low or High Calcium Intake
1. Animal data
The preceding sections have made clear that lactating ro-
dents require abundant calcium from multiple sources, me-
diated by increases in intestinal calcium absorption, skeletal
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
resorption, and renal tubal calcium reabsorption. But
within some limits, the rodent is capable of extracting more
from the skeleton when the diet is deficient, or more from
the diet when the skeleton cannot be resorbed. Conse-
quently, a calcium-restricted diet increases skeletal losses
and also can lead to hypocalcemia and sudden death from
tetany; conversely, a high-calcium diet reduces skeletal
losses. Similarly in ewes, a calcium-restricted diet causes a
lower serum calcium, increased resorption, and reduced
skeletal ash weight within the vertebrae and pelvis by the
end of lactation, with relative sparing of the long bones
(69). A high-calcium diet reduces the amount of skeletal
resorption. In these studies there was no impact on the
offspring unless the mother died of hypocalcemia, because
the milk calcium content was maintained. Similarly, block-
ing bone resorption by treating with OPG did not affect
milk calcium content unless the animal was also given a low
calcium diet, thereby blocking the delivery of needed cal-
cium to mammary tissue (37). These results confirm that
rodents and sheep rely on both compartments (skeleton and
intestines) to get needed calcium, but can get by with one of
these compartments alone. However, if mobilization of cal-
cium from both compartments is blocked, then milk cannot
be produced adequately and severe maternal hypocalcemia
is inevitable.
Low calcium intake in the post-weaning phase has been
shown to impair skeletal recovery in rats, but full recovery
was achieved when a normal calcium diet was administered
later (355).
2. Human data
The calcium content of milk appears to be largely derived
from skeletal resorption. Low calcium intake does not re-
duce breast milk calcium, nor does it lead to increased re-
sorption of the maternal skeleton during lactation (440,
535, 728 731). Conversely, high calcium intake similarly
fails to increase breast milk calcium or reduce skeletal re-
sorption during lactation (206, 275, 440, 452, 484, 535,
723, 729, 730); its only effect may be to increase urinary
 CHRISTOPHER S. KOVACS
calcium excretion. These data from randomized clinical tri-
als and cohort studies indicate that it does not matter how
much calcium is consumed during lactation because mater-
nal skeletal resorption is hormonally programmed to sup-
ply needed calcium. There is no evidence that women re-
quire a higher intake of calcium during lactation compared
with nonpregnant women.
No studies have examined calcium requirements during
post-weaning, which may be the more critical time for ad-
equate calcium intake. However, a study of adolescents
recovering from lactation found that there was a substantial
increment in bone mass despite a habitual intake of 500
mg calcium/day (78). Randomization to a 1 g calcium sup-
plement conferred a small benefit in bone mass gain during
6 mo of recovery (452), which confirms that calcium intake
can have a positive impact on bone mass accrual during this
interval.
3. Summary
Whereas rodents will increase or decrease skeletal resorp-
tion during lactation in inverse proportion to calcium in-
take, in breastfeeding women the magnitude of skeletal re-
sorption appears to be independent of the extremes of low
and high calcium intake. Consequently, it is quite evident
that women do not require increased intakes of calcium
during lactation because there is no benefit on the skeletal
response or on the calcium content of milk. Maintaining
adequate calcium intake is probably more crucial during the
post-weaning phase when the skeleton is reversing the un-
coupled state of bone turnover from net resorption to net
formation.
J. FGF23-Related Disorders
1. Animal data
Phex/ females remain hypophosphatemic and normocal-
cemic during lactation, nurse the same number of pups as
normal controls, and their pups gain weight normally
(240). Analysis of expressed milk from Phex/ females has
shown normal phosphorus, calcium, and protein content
(240).
Hyperphosphatemic disorders due to absence of FGF23
have not been studied during lactation because of the inabil-
ity to obtain pregnancies in Fgf23 null or Klotho null mice.
The effects of experimental renal failure causing maternal
hyperphosphatemia have not been studied during lactation.
2. Human data
Serum phosphorus was low during pregnancy and immedi-
ately postpartum in a woman with XLH, but normalized
once lactation was fully established (447). This supports the
Physiol Rev VOL 96 APRIL 2016 www.prv.org
idea that skeletal resorption is responsible for the increase in
serum phosphorus that normally occurs during lactation.
However, despite normalization of serum phosphorus, the
phosphorus content in expressed milk was 50% of normal
in two cases, whereas the calcium content was modestly
reduced in one but normal in the other (447, 745). Oral
phosphorus supplementation normalized the milk compo-
sition (447). In both cases, the babies inherited XLH and
subsequently became hypophosphatemic with skeletal evi-
dence of rickets, which was likely due to the combined
effects of the mutation and the low phosphorus content of
milk (447, 745). This contrasts with apparently normal
milk phosphorus content in the mouse model.
There are no data from lactating women with hyperphos-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
phatemic disorders, but it is conceivable that phosphorus
content of milk will be elevated.
3. Summary
Although hypophosphatemic mice produce milk with nor-
mal mineral composition, XLH in women reduces the phos-
phorus content of milk by 50%, and inconsistently reduces
the calcium content. These changes will contribute to the
development of neonatal rickets. However, the phosphorus
content of milk can be normalized with oral phosphorus
supplementation.
VI. CONCLUSIONS
Pregnancy and lactation invoke novel regulatory systems in
women to meet the challenges for increased delivery of min-
erals (FIGURE 9).
A doubling of intestinal calcium and phosphorus absorp-
tion during pregnancy meets the fetal mineral demand. This
adaptation may be only partially explained by a severalfold
increase in calcitriol and may persist despite vitamin D de-
ficiency and inherited disorders of vitamin D physiology.
Minimal skeletal calcium is normally resorbed during preg-
nancy, but this will increase significantly and lead to skele-
tal fragility if maternal calcium intake is very low, because
the placenta acts to maintain calcium delivery to the fetus
even if the mother is hypocalcemic. The maternal kidneys,
not the placenta, supply most of the increased calcitriol
output during pregnancy, but do not seem to aid calcium
conservation because absorptive hypercalciuria is com-
monly found. Spot and fasting urines will not detect this
hypercalciuria.
A marked uncoupling of bone turnover to favor skeletal
resorption is the main mechanism by which calcium is sup-
plied to the breast milk, aided by renal calcium conservation
and (in women) independent of dietary calcium intake. The
lactational response is driven by breast-produced PTHrP in
the setting of low estradiol, while PTH, vitamin D, and
521
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
calcitriol are not required. Osteoclast-mediated bone re-
sorption and (at least in rodents) osteocytic osteolysis con-
tribute to the loss of skeletal mineral content. A similar
magnitude of bone loss occurs during lactation in women
with very low or high calcium intakes. In some women the
normal skeletal resorption during lactation may be suffi-
cient to cause fragility fractures, whereas for the majority of
women it is a silent process that they are never aware of.
There is normally very little vitamin D or 25OHD in milk,
which explains why breast-fed babies are at higher risk for
rickets than formula-fed babies. Very high intakes of vita-
min D will increase the breast milk content of vitamin D,
but will not alter breast milk calcium content.
After weaning the baby, an uncoupling of bone turnover in
the reverse direction from lactation is initiated, thereby fa-
voring net bone formation. Osteoblasts upregulate number
and function while (at least in rodents) osteocytes function
like osteoblasts to remineralize their lacunae. The maternal
skeleton rapidly restores itself such that by 6 12 mo after
lactation, the bone density has usually returned to baseline
or better, even in women who suffered fragility fractures.
This is an otherwise unprecedented interval of recovery
since most causes of bone loss in adults, once the insult is
removed, result in slow and partial recovery of bone mass
and structure. It appears that weaning triggers a pro-
grammed, sustained interval of bone formation, but the
mechanisms that regulate this recovery remain to be eluci-
dated.
In the long term, most studies show that parity and lacta-
tion pose no adverse risk of low bone mass or fractures, and
in fact a number of studies have suggested that parity and
lactation confer a protective effect. These results may imply
that the cyclical resorption and rebuilding of the maternal
522 Physiol Rev VOL 96 APRIL 2016 www.prv.org
FIGURE 9. Comparison of the adaptive pro-
cesses of calcium and bone homeostasis during
human pregnancy and lactation, compared with
normal (nonpregnant, nonlactating). The thick-
ness of arrows indicates a relative increase or
decrease with respect to normal. [Adapted from
Kovacs and Kronenberg (499). Copyright 1997
The Endocrine Society. Permission conveyed
through Copyright Clearance Center, Inc.]
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
skeleton leads to beneficial changes in bone structure and
strength that are not seen in women who never bear a child
or breastfeed.
There are important differences among the various animal
models and in how they compare to and inform about the
human condition (TABLES 1 and 2). These issues must be
considered whenever animal studies are used to model the
response of women to pregnancy or lactation.
Lastly, these adaptations during pregnancy and lactation
have important effects on preexisting disorders of bone and
mineral metabolism. The presenting symptoms, signs, diag-
nostic indices, and treatment thresholds may be altered.
This is best exemplified by the normalization in mineral
homeostasis that occurs in hypoparathyroid women during
lactation, but which has led to iatrogenic and life-threaten-
ing hypercalcemia when unappreciated and left unmoni-
tored.
ACKNOWLEDGMENTS
I thank Dr. Henry M. Kronenberg for providing critical
feedback on the manuscript and Drs. Scott Miller, Mary
Wlodek, and John Wysolmerski for clarifying the calcium
content of the diet used in some of their studies.
Address for reprint requests and other correspondence: C.
Kovacs, Health Sciences Centre, 300 Prince Philip Dr., St.
Johns, NL A1B 3V6 Canada (e-mail ckovacs@mun.ca).
GRANTS
This work was supported by Canadian Institutes of Health
Research Grants 133413, 126469, and 84253 and by Re-
 CHRISTOPHER S. KOVACS
search & Development Corporation of Newfoundland and
Labrador Grant 5404.1145.102.
DISCLOSURES
No conflicts of interest, financial or otherwise, are declared
by the author.
REFERENCES
1. A report of: doses to infants from ingestion of radionuclides in mothers milk. Ann
ICRP 34: iii, 15267, 280449 269, 2004.
2. Abbas SK, Pickard DW, Rodda CP, Heath JA, Hammonds RG, Wood WI, Caple IW,
Martin TJ, Care AD. Stimulation of ovine placental calcium transport by purified
natural and recombinant parathyroid hormone-related protein (PTHrP) prepara-
tions. Q J Exp Physiol 74: 549 552, 1989.
3. Abood A, Vestergaard P. Pregnancy outcomes in women with primary hyperpara-
thyroidism. Eur J Endocrinol 171: 69 76, 2014.
4. Abraham P, Ralston SH, Hewison M, Fraser WD, Bevan JS. Presentation of a PTHrP-
secreting pancreatic neuroendocrine tumour, with hypercalcaemic crisis, pre-ec-
lampsia, and renal failure. Postgrad Med J 78: 752753, 2002.
5. Abrams SA. Calcium absorption in infants and small children: methods of determi-
nation and recent findings. Nutrients 2: 474 480, 2010.
6. Abrams SA, Griffin IJ, Davila PM. Calcium and zinc absorption from lactose-contain-
ing and lactose-free infant formulas. Am J Clin Nutr 76: 442 446, 2002.
7. Abrams SA, Hicks PD, Hawthorne KM. Higher serum 25-hydroxyvitamin D levels in
school-age children are inconsistently associated with increased calcium absorption.
J Clin Endocrinol Metab 94: 24212427, 2009.
8. Abrams SA, Wen J, Stuff JE. Absorption of calcium, zinc, and iron from breast milk by
five- to seven-month-old infants. Pediatr Res 41: 384 390, 1997.
9. Affinito P, Tommaselli GA, di Carlo C, Guida F, Nappi C. Changes in bone mineral
density and calcium metabolism in breastfeeding women: a one year follow-up
study. J Clin Endocrinol Metab 81: 2314 2318, 1996.
10. Aguado F, Revilla M, Hernandez ER, Menendez M, Cortes-Prieto J, Villa LF, Rico H.
Ultrasonographic bone velocity in pregnancy: a longitudinal study. Am J Obstet Gy-
necol 178: 1016 1021, 1998.
11. Ainy E, Ghazi AA, Azizi F. Changes in calcium, 25(OH) vitamin D3 and other bio-
chemical factors during pregnancy. J Endocrinol Invest 29: 303307, 2006.
12. Ajibade DV, Dhawan P, Benn BS, Meyer MB, Pike JW, Christakos S. Evidence for a
role of prolactin in calcium homeostasis: regulation of intestinal transient receptor
potential vanilloid type 6, intestinal calcium absorption, and the 25-hydroxyvitamin
D(3)1alpha hydroxylase gene by prolactin. Endocrinology 151: 2974 2984, 2010.
13. Ala-Houhala M. 25-Hydroxyvitamin D levels during breast-feeding with or without
maternal or infantile supplementation of vitamin D. J Pediatr Gastroenterol Nutr 4:
220 226, 1985.
14. Ala-Houhala M, Koskinen T, Parviainen MT, Visakorpi JK. 25-Hydroxyvitamin D and
vitamin D in human milk: effects of supplementation and season. Am J Clin Nutr 48:
10571060, 1988.
15. Albright F, Reifenstein EC. Parathyroid Glands and Metabolic Bone Disease. Baltimore,
MD: Williams & Wilkins, 1948.
16. Alderman BW, Weiss NS, Daling JR, Ure CL, Ballard JH. Reproductive history and
postmenopausal risk of hip and forearm fracture. Am J Epidemiol 124: 262267, 1986.
17. Allali F, Maaroufi H, Aichaoui SE, Khazani H, Saoud B, Benyahya B, Abouqal R,
Hajjaj-Hassouni N. Influence of parity on bone mineral density and peripheral frac-
ture risk in Moroccan postmenopausal women. Maturitas 57: 392398, 2007.
18. Allen J, Kent N, Price R, Gutteridge D, Blakeman S, Rosman K, Bhagat C, Smith M.
Calcium and phosphate metabolism in human pregnancy and lactation. Bone Miner
10: S317, 1990.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
19. Allen JC. Effect of vitamin D deficiency on mouse mammary gland and milk. J Nutr
114: 42 49, 1984.
20. Allen JC, Keller RP, Archer P, Neville MC. Studies in human lactation: milk compo-
sition and daily secretion rates of macronutrients in the first year of lactation. Am J
Clin Nutr 54: 69 80, 1991.
21. Allen WM, Sansom BF. Parturient paresis (milk fever) and hypocalcemia (cows,
ewes, and goats). In: Current Veterinary Therapy: Food Animal Practice 2, edited by
Howard JL. Philadelphia, PA: Saunders, 1986, p. 311320.
22. Alles N, Soysa NS, Hayashi J, Khan M, Shimoda A, Shimokawa H, Ritzeler O, Akiyoshi
K, Aoki K, Ohya K. Suppression of NF-kappaB increases bone formation and ame-
liorates osteopenia in ovariectomized mice. Endocrinology 151: 4626 4634, 2010.
23. Allgrove J, Adami S, Manning RM, ORiordan JL. Cytochemical bioassay of parathy-
roid hormone in maternal and cord blood. Arch Dis Child 60: 110 115, 1985.
24. Aloia JF, Chen DG, Yeh JK, Chen H. Serum vitamin D metabolites and intestinal
calcium absorption efficiency in women. Am J Clin Nutr 92: 835 840, 2010.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
25. Aloia JF, Cohn SH, Vaswani A, Yeh JK, Yuen K, Ellis K. Risk factors for postmeno-
pausal osteoporosis. Am J Med 78: 95100, 1985.
26. Aloia JF, Dhaliwal R, Shieh A, Mikhail M, Fazzari M, Ragolia L, Abrams SA. Vitamin D
supplementation increases calcium absorption without a threshold effect. Am J Clin
Nutr 99: 624 631, 2014.
27. Aloia JF, Vaswani AN, Yeh JK, Ross P, Ellis K, Cohn SH. Determinants of bone mass
in postmenopausal women. Arch Intern Med 143: 1700 1704, 1983.
28. Amling M, Priemel M, Holzmann T, Chapin K, Rueger JM, Baron R, Demay MB.
Rescue of the skeletal phenotype of vitamin D receptor-ablated mice in the setting of
normal mineral ion homeostasis: formal histomorphometric and biomechanical anal-
yses. Endocrinology 140: 4982 4987, 1999.
29. Anai T, Tomiyasu T, Arima K, Miyakawa I. Pregnancy-associated osteoporosis with
elevated levels of circulating parathyroid hormone-related protein: a report of two
cases. J Obstet Gynecol Res 25: 63 67, 1999.
30. Anai T, Tomiyasu T, Takai N, Miyakawa I. Remission of idiopathic hypoparathyroid-
ism during lactation: a case report. J Obstet Gynecol Res 25: 271273, 1999.
31. Anai T, Urata K, Mori A, Miyazaki F, Okamoto S. Transient osteoporosis of the hip
in pregnancy associated with generalized low bone mineral densitya case report.
Gynecol Obstet Invest 76: 133138, 2013.
32. Anderson JJB, Garner SC, Mar MH, Boass A, Toverud SU, Parikh I. The ovariecto-
mized, lactating rat as an experimental model for osteopenia: calcium metabolism
and bone changes. Bone and Mineral 11: 4353, 1990.
33. Ardawi MS, Nasrat HA, HSBAA. Calcium-regulating hormones and parathyroid hor-
mone-related peptide in normal human pregnancy and postpartum: a longitudinal
study. Eur J Endocrinol 137: 402 409, 1997.
34. Ardeshirpour L, Brian S, Dann P, VanHouten J, Wysolmerski J. Increased PTHrP and
decreased estrogens alter bone turnover but do not reproduce the full effects of
lactation on the skeleton. Endocrinology 151: 55915601, 2010.
35. Ardeshirpour L, Dann P, Adams DJ, Nelson T, VanHouten J, Horowitz MC, Wysol-
merski JJ. Weaning triggers a decrease in receptor activator of nuclear factor-kappaB
ligand expression, widespread osteoclast apoptosis, and rapid recovery of bone
mass after lactation in mice. Endocrinology 148: 38753886, 2007.
36. Ardeshirpour L, Dann P, Pollak M, Wysolmerski J, VanHouten J. The calcium-sensing
receptor regulates PTHrP production and calcium transport in the lactating mam-
mary gland. Bone 38: 787793, 2006.
37. Ardeshirpour L, Dumitru C, Dann P, Sterpka J, VanHouten J, Kim W, Kostenuik P,
Wysolmerski J. OPG treatment prevents bone loss during lactation but does not
affect milk production or maternal calcium metabolism. Endocrinology 156: 2762
2773, 2015.
38. Armamento-Villareal R, Villareal DT, Avioli LV, Civitelli R. Estrogen status and he-
redity are major determinants of premenopausal bone mass. J Clin Invest 90: 2464
2471, 1992.
39. Asa SL, Henderson J, Goltzman D, Drucker DJ. Parathyroid hormone-like peptide in
normal and neoplastic human endocrine tissues. J Clin Endocrinol Metab 71: 1112
1118, 1990.
523
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
40. Atkinson PJ, West RR. Loss of skeletal calcium in lactating women. J Obstet Gynaecol
Br Commonw 77: 555560, 1970.
41. Atkinson S, Alston-Mills B, Lnnerdal B, Neville MC. Major minerals and ionic con-
stituents of human and bovine milk. In: Handbook of Milk Composition, edited by
Jensen RG. New York: Academic, 1995, p. 593 619.
42. August P, Marcaccio B, Gertner JM, Druzin ML, Resnick LM, Laragh JH. Abnormal
1,25-dihydroxyvitamin D metabolism in preeclampsia. Am J Obstet Gynecol 166:
12951299, 1992.
43. Aynaci O, Kerimoglu S, Ozturk C, Saracoglu M. Bilateral non-traumatic acetabular
and femoral neck fractures due to pregnancy-associated osteoporosis. Arch Orthop
Trauma Surg 128: 313316, 2008.
44. Badawy AA. Effects of pregnancy on tryptophan metabolism and disposition in the
rat. Biochem J 255: 369 372, 1988.
45. Bai M, Pearce SH, Kifor O, Trivedi S, Stauffer UG, Thakker RV, Brown EM, Stein-
mann B. In vivo and in vitro characterization of neonatal hyperparathyroidism result-
ing from a de novo, heterozygous mutation in the Ca2-sensing receptor gene:
normal maternal calcium homeostasis as a cause of secondary hyperparathyroidism
in familial benign hypocalciuric hypercalcemia. J Clin Invest 99: 88 96, 1997.
46. Baker AM, Haeri S, Camargo CA Jr, Espinola JA, Stuebe AM. A nested case-control
study of midgestation vitamin D deficiency and risk of severe preeclampsia. J Clin
Endocrinol Metab 95: 51055109, 2010.
47. Baker AM, Haeri S, Camargo CA Jr, Stuebe AM, Boggess KA. A nested case-control
study of first-trimester maternal vitamin D status and risk for spontaneous preterm
birth. Am J Perinatol 28: 667 672, 2011.
48. Baki ME, Uygun H, Ari B, Aydin H. Bilateral femoral neck insufficiency fractures in
pregnancy. Joint Dis Related Surg 25: 60 62, 2014.
49. Baksi SN. Effect of maternal thyroparathyroidectomy during gestation on feto-pla-
cental development in rats. Indian J Exp Biol 16: 12811283, 1978.
50. Baksi SN. Effects of thyroparathyroidectomy on implantation and early gestation in
rats. J Reprod Fertil 32: 513516, 1973.
51. Baksi SN, Kenny AD. Acute effect of estradiol on the renal vitamin D hydroxylases in
Japanese quail. Biochem Pharmacol 27: 27652768, 1978.
52. Balabanova S, Kruse B, Wolf AS. Calcitonin secretion by human placental tissue. Acta
Obstet Gynecol Scand 66: 323326, 1987.
53. Bansal VK. Serum inorganic phosphorus. In: Clinical Methods: The History, Physical,
and Laboratory Examinations, edited by Walker HK, Hall WD, and Hurst JW. Boston:
Butterworths, 1990.
54. Baretic M, Tomic Brzac H, Dobrenic M, Jakovcevic A. Parathyroid carcinoma in
pregnancy. World J Clin Cases 2: 151156, 2014.
55. Barlet JP. Role physiologique de la calcitonine chez la chvre gestante ou allaitante.
Ann Biol Anim Biochim Biophys 14: 447 457, 1974.
56. Barlet JP, Abbas SK, Care AD, Davicco MJ, Rouffet J. Parathyroid hormone-related
peptide and milking-induced phosphaturia in dairy cows. Acta Endocrinol 129: 332
336, 1993.
57. Barlet JP, Argemi B, Davicco MJ, Lefaivre J. Plasma concentrations of 25-hydroxy
vitamin D in pregnant and lactating ewes and foetal and newborn lambs. J Endocrinol
79: 149 150, 1978.
58. Barlet JP, Garel JM. Physiological role of calcitonin in pregnant goats and ewes. In:
Calcium Regulating Hormones: Proceedings of the Fifth Parathyroid Conference, Oxford,
United Kingdom, July 2126, 1974, edited by Talmage RV, Owen M, and Parsons A.
Amsterdam: Excerpta Medica, 1975, p. 119 121.
59. Barragry JM, France MW, Corless D, Gupta SP, Switala S, Boucher BJ, Cohen RD.
Intestinal cholecalciferol absorption in the elderly and in younger adults. Clin Sci Mol
Med 55: 213220, 1978.
60. Basile LA, Taylor SN, Wagner CL, Horst RL, Hollis BW. The effect of high-dose
vitamin D supplementation on serum vitamin D levels and milk calcium concentra-
tion in lactating women and their infants. Breastfeed Med 1: 2735, 2006.
61. Bastepe M. Genetics and epigenetics of parathyroid hormone resistance. Endocr Dev
24: 1124, 2013.
524 Physiol Rev VOL 96 APRIL 2016 www.prv.org
62. Batchelor AJ, Compston JE. Reduced plasma half-life of radio-labelled 25-hydroxyvi-
tamin D3 in subjects receiving a high-fibre diet. Br J Nutr 49: 213216, 1983.
63. Bauer DC, Browner WS, Cauley JA, Orwoll ES, Scott JC, Black DM, Tao JL, Cum-
mings SR. Factors associated with appendicular bone mass in older women. The
study of osteoporotic fractures research. Group Ann Intern Med 118: 657 665, 1993.
64. Bawden JW, Wolkoff AS. Distribution of 45Ca during pregnancy under conditions of
calcium deficiency in rats. J Dent Res 43: 563567, 1964.
65. Baylis C. Glomerular filtration and volume regulation in gravid animal models. Bail-
lieres Clin Obstet Gynaecol 8: 235264, 1994.
66. Beck F, Tucci J, Senior PV. Expression of parathyroid hormone-related protein
mRNA by uterine tissues and extraembryonic membranes during gestation in rats. J
Reprod Fertil 99: 343352, 1993.
67. Belanger LF. Osteocytic osteolysis. Calcif Tissue Res 4: 112, 1969.
68. Belanger LF, Robichon J, Migicovsky BB, Copp DH, Vincent J. Resorption without
osteoclasts (osteolysis). In: Mechanism of Hard Tissue Destruction, edited by Sognn-
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
aes RF. Washington, DC: AAAS, 1963, p. 531556.
69. Benzie D, Boyne AD, Dalgarno AC, Duckworth J, Hill R, Walker DM. Studies of the
skeleton of the sheep. 1. The effect of different level of dietary calcium during
pregnancy and lactation on individual bone. J Agric Sci 46: 425 444, 1955.
70. Bergwitz C, Juppner H. Regulation of phosphate homeostasis by PTH, vitamin D,
and FGF23. Annu Rev Med 61: 91104, 2010.
71. Berning B, van Kuijk C, Schutte HE, Kuiper JW, Drogendijk AC, Fauser BC. Deter-
minants of lumbar bone mineral density in normal weight, non-smoking women soon
after menopause. A study using clinical data and quantitative computed tomography.
Bone Miner 21: 129 139, 1993.
72. Bernstein A. Idiopathic hypoparathyroidism manifesting after lactation. Postgrad Med
J 43: 422 424, 1967.
73. Bersinger NA, Groome N, Muttukrishna S. Pregnancy-associated and placental pro-
teins in the placental tissue of normal pregnant women and patients with pre-
eclampsia at term. Eur J Endocrinol 147: 785793, 2002.
74. Bersinger NA, Odegard RA. Second- and third-trimester serum levels of placental
proteins in preeclampsia and small-for-gestational age pregnancies. Acta Obstet Gy-
necol Scand 83: 37 45, 2004.
75. Bertelloni S, Baroncelli GI, Pelletti A, Battini R, Saggese G. Parathyroid hormone-
related protein in healthy pregnant women. Calcif Tissue Int 54: 195197, 1994.
76. Besnard P, Garel JM. Plasma concentrations of immunoreactive calcitonin in rats
during lactation. C R Acad Sci III 299: 311314, 1984.
77. Best CH, Taylor NB. The parathyroid glands and calcium metabolism. In: The Phys-
iological Basis of Medical Practice (3rd ed.), edited by Best CH, Taylor NB. Baltimore:
Williams & Wilkins, 1940, p. 1124 1159.
78. Bezerra FF, Mendonca LM, Lobato EC, OBrien KO, Donangelo CM. Bone mass is
recovered from lactation to postweaning in adolescent mothers with low calcium
intakes. Am J Clin Nutr 80: 13221326, 2004.
79. Bhattacharjee M, Wientroub S, Vonderhaar BK. Milk protein synthesis by mammary
glands of vitamin D-deficient mice. Endocrinology 121: 865 874, 1987.
80. Biberoglu KO, Yildiz A, Kandemir O. Bone mineral density in Turkish postmeno-
pausal women. Int J Gynaecol Obstet 41: 153157, 1993.
81. Bikle DD, Gee E, Halloran B, Haddad JG. Free 1,25-dihydroxyvitamin D levels in
serum from normal subjects, pregnant subjects, and subjects with liver disease. J Clin
Invest 74: 1966 1971, 1984.
82. Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C, Potts JT Jr.
Guidelines for the management of asymptomatic primary hyperparathyroidism:
summary statement from the Fourth International Workshop. J Clin Endocrinol
Metab 99: 35613569, 2014.
83. Bjornerem A, Ahmed LA, Jorgensen L, Stormer J, Joakimsen RM. Breastfeeding
protects against hip fracture in postmenopausal women: the Tromso study. J Bone
Miner Res 26: 28432850, 2011.
 CHRISTOPHER S. KOVACS
84. Bjrnerem A, Ghasem-Zadeh A, Vu T, Seeman E. Bone microstructure during and
after lactation (Abstract). J Bone Miner Res 25 Suppl 1: S121, 2010.
85. Black AJ, Topping J, Durham B, Farquharson RG, Fraser WD. A detailed assessment
of alterations in bone turnover, calcium homeostasis, and bone density in normal
pregnancy. J Bone Miner Res 15: 557563, 2000.
86. Blahosova A, Neradilova M, Velicky J, Titlbach M, Marsikova L, Reisenauer R. Dy-
namics of changes of calcium and phosphorus metabolism in relation to the mor-
phology of parafollicular thyroid cells in rats during lactation and forced weaning.
Endokrinologie 63: 122136, 1974.
87. Blaxter KL. Lactation and growth of the young. In: Milk: The Mammary Gland and Its
Secretion, edited by Kon SK, Cowie AT. New York: Academic, 1961, vol. II, p.
305361.
88. Blohm RW, Wurl OA, Gillespie JO, Escamilla RF. Refractoriness to antitetanic ther-
apy in a case of surgical hypoparathyroidism. J Clin Endocrinol Metab 13: 519 533,
1953.
89. Blum M, Weisman Y, Turgeman S, Cabili S, Wollman Y, Peer G, Stern N, Silverberg
D, Schwartz D, Iaina A. Pregnancy decreases immunoreactive parathyroid hormone
level in rats with chronic renal failure. Clin Sci 96: 427 430, 1999.
90. Boass A, Garner SC, Schultz VL, Toverud SU. Regulation of serum calcitriol by serum
ionized calcium in rats during pregnancy and lactation. J Bone Miner Res 12: 909 914,
1997.
91. Boass A, Ramp WK, Toverud SU. Hypocalcemic, hypophosphatemic rickets in rat
pups suckling vitamin D-deprived mothers. Endocrinology 109: 505512, 1981.
92. Boass A, Toverud SU. Suppression of circulating calcitriol and duodenal active Ca
transport by ketoconazole in pregnant rats. Am J Physiol Endocrinol Metab 269:
E934 E939, 1995.
93. Boass A, Toverud SU, Pike JW, Haussler MR. Calcium metabolism during lactation:
enhanced intestinal calcium absorption in vitamin D-deprived, hypocalcemic rats.
Endocrinology 109: 900 907, 1981.
94. Bodansky M, Duff VB. Regulation of the level of calcium in the serum during preg-
nancy. J Am Med Assoc 112: 223229, 1939.
95. Bodnar LM, Catov JM, Simhan HN, Holick MF, Powers RW, Roberts JM. Maternal
vitamin D deficiency increases the risk of preeclampsia. J Clin Endocrinol Metab 92:
35173522, 2007.
96. Bolen JW. Hypoparathyroidism in pregnancy. Am J Obstet Gynecol 117: 178 179,
1973.
97. Bolzetta F, Veronese N, De Rui M, Berton L, Carraro S, Pizzato S, Girotti G, De
Ronch I, Manzato E, Coin A, Sergi G. Duration of breastfeeding as a risk factor for
vertebral fractures. Bone 68: 41 45, 2014.
98. Bonacker J, Janousek M, Krober M. Pregnancy-associated osteoporosis with eight
fractures in the vertebral column treated with kyphoplasty and bracing: a case re-
port. Arch Orthop Trauma Surg 134: 173179, 2014.
99. Boras-Granic K, Dann P, Vanhouten J, Karaplis A, Wysolmerski J. Deletion of the
nuclear localization sequences and C-terminus of PTHrP impairs embryonic mam-
mary development but also inhibits PTHrP production. PLoS One 9: e90418, 2014.
100. Borkenhagen JF, Connor EL, Stafstrom CE. Neonatal hypocalcemic seizures due to
excessive maternal calcium ingestion. Pediatr Neurol 48: 469 471, 2013.
101. Bornstein S, Brown SA, Le PT, Wang X, DeMambro V, Horowitz MC, MacDougald
O, Baron R, Lotinun S, Karsenty G, Wei W, Ferron M, Kovacs CS, Clemmons D, Wan
Y, Rosen CJ. FGF-21 and skeletal remodeling during and after lactation in C57BL/6J
Mice. Endocrinology 155: 3516 3526, 2014.
102. Bouillon R, Carmeliet G, Verlinden L, van Etten E, Verstuyf A, Luderer HF, Lieben L,
Mathieu C, Demay M. Vitamin D and human health: lessons from vitamin D receptor
null mice. Endocr Rev 29: 726 776, 2008.
103. Bouillon R, Lieben L, Mathieu C, Verstuyf A, Carmeliet G. Vitamin D action: lessons
from VDR and Cyp27b1 null mice. Pediat Endocrinol Rev 10 Suppl 2: 354 366, 2013.
104. Bouillon R, Vandoren G, Van Baelen H, De Moor P. Immunochemical measurement
of the vitamin D-binding protein in rat serum. Endocrinology 102: 1710 1715, 1978.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
105. Bourdeau A, Manganella G, Thil-Trubert CL, Sachs C, Cournot G. Bioactive para-
thyroid hormone in pregnant rats and fetuses. Am J Physiol Endocrinol Metab 258:
E549 E554, 1990.
106. Bowman BM, Miller SC. Skeletal adaptations during mammalian reproduction. J
Musculoskelet Neuronal Interact 1: 347355, 2001.
107. Bowman BM, Siska CC, Miller SC. Greatly increased cancellous bone formation with
rapid improvements in bone structure in the rat maternal skeleton after lactation. J
Bone Miner Res 17: 1954 1960, 2002.
108. Braithwaite GD. Calcium and phosphorus requirements of the ewe during preg-
nancy and lactation. 1. Calcium. Br J Nutr 50: 711722, 1983.
109. 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 100: 535543, 2015.
110. Breslau NA, Zerwekh JE. Relationship of estrogen and pregnancy to calcium homeo-
stasis in pseudohypoparathyroidism. J Clin Endocrinol Metab 62: 4551, 1986.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
111. Briana DD, Boutsikou M, Baka S, Hassiakos D, Gourgiotis D, Marmarinos A, Iacovi-
dou N, Malamitsi-Puchner A. N-terminal parathyroid hormone-related protein lev-
els in human intrauterine growth restricted pregnancies. Acta Obstet Gynecol Scand
86: 945949, 2007.
112. Brodell JD, Burns JE Jr, Heiple KG. Transient osteoporosis of the hip of pregnancy
Two cases complicated by pathological fracture. J Bone Joint Surg 71: 12521257,
1989.
113. Brommage R. Magnesium fluxes during lactation in the rat. Magnes Res 2: 253255,
1989.
114. Brommage R. Measurement of calcium and phosphorus fluxes during lactation in the
rat. J Nutr 119: 428 438, 1989.
115. Brommage R, Baxter DC. Inhibition of bone mineral loss during lactation by Cl2MBP.
Calcif Tissue Int 47: 169 172, 1990.
116. Brommage R, Baxter DC, Gierke LW. Vitamin D-independent intestinal calcium and
phosphorus absorption during reproduction. Am J Physiol Gastrointest Liver Physiol
259: G631G638, 1990.
117. Brommage R, DeLuca HF. Placental transport of calcium and phosphorus is not
regulated by vitamin D. Am J Physiol Renal Fluid Electrolyte Physiol 246: F526 F529,
1984.
118. Brommage R, DeLuca HF. Regulation of bone mineral loss during lactation. Am J
Physiol Endocrinol Metab 248: E182E187, 1985.
119. Brommage R, DeLuca HF. Vitamin D-deficient rats produce reduced quantities of a
nutritionally adequate milk. Am J Physiol Endocrinol Metab 246: E221E226, 1984.
120. Bronsky D, Kiamko RT, Moncada R, Rosenthal IM. Intra-uterine hyperparathyroid-
ism secondary to maternal hypoparathyroidism. Pediatrics 42: 606 613, 1968.
121. Brooke OG, Brown IR, Bone CD, Carter ND, Cleeve HJ, Maxwell JD, Robinson VP,
Winder SM. Vitamin D supplements in pregnant Asian women: effects on calcium
status and fetal growth. Br Med J 280: 751754, 1980.
122. Brown EM. The calcium-sensing receptor: physiology, pathophysiology and CaR-
based therapeutics. Subcell Biochem 45: 139 167, 2007.
123. Brown SA, Guise TA, Siega-Riz AM, Caminiti MJ, Rosen CJ. Extended lactation is
associated with failure to restore BMD 6 months after resumption of menstrual cycle
(Abstract). J Bone Miner Res 23: S449, 2008.
124. Brown SA, Guise TA, Yarde ER, Rosen CJ. Bone recovery after lactation: bone
formation markers are elevated during weaning and are correlated with elevations in
IGFBP-2 (Abstract). J Bone Miner Res 24: S311S312, 2009.
125. Bruce J, Strong JA. Maternal hyperparathyroidism and parathyroid deficiency in the
child, with account of effect of parathyroidectomy on renal function, and of attempt
to transplant part of tumor. Q J Med 24: 307319, 1955.
126. Bruns ME, Vollmer S, Wallshein V, Bruns DE. Vitamin D-dependent calcium-binding
protein. Immunochemical studies and synthesis by placental tissue in vitro. J Biol
Chem 256: 4649 4653, 1981.
525
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
127. Bruns ME, Wallshein V, Bruns DE. Regulation of calcium-binding protein in mouse
placenta and intestine. Am J Physiol Endocrinol Metab 242: E47E52, 1982.
128. Bruscas Izu C, San Juan de la Parra S. Transient osteoporosis of both hips in preg-
nancy. Reumatol Clin 10: 58 59, 2014.
129. Bucht E, Carlqvist M, Hedlund B, Bremme K, Torring O. Parathyroid hormone-
related peptide in human milk measured by a mid-molecule radioimmunoassay.
Metabolism 41: 1116, 1992.
130. Bucht E, Rong H, Bremme K, Granberg B, Rian E, Torring O. Midmolecular para-
thyroid hormone-related peptide in serum during pregnancy, lactation and in umbil-
ical cord blood. Eur J Endocrinol 132: 438 443, 1995.
131. Bucht E, Telenius-Berg M, Lundell G, Sjoberg HE. Immunoextracted calcitonin in
milk and plasma from totally thyroidectomized women. Evidence of monomeric
calcitonin in plasma during pregnancy and lactation. Acta Endocrinol 113: 529 535,
1986.
132. Buck DR, Bales J. Maternal dietary magnesium effects on lactation success and on
milk yield and composition in the rat. J Nutr 113: 24212431, 1983.
133. Buckle KL. Lactational changes in bone metabolism in mice lacking parathyroid
hormone (PTH). In: Biomedical Sciences, Faculty of Medicine. St. Johns, Newfound-
land: Memorial University of Newfoundland, 2006, p. 104.
134. Budayr AA, Halloran BP, King JC, Diep D, Nissenson RA, Stewler GJ. High levels of
parathyroid-like protein in milk. Proc Natl Acad Sci USA 86: 71837185, 1989.
135. Burstyn PG, Lloyd IJ, McKillop W. The effect of human placental lactogen on the
renal excretion of calcium in the rabbit. IRCS J Med Sci 3: 30, 1975.
136. Burstyn PG, McKillop W, Lloyd IJ. The effects of prolactin on the renal excretion of
water, sodium, potassium and calcium in the rabbit. J Int Res Commun 2: 1474, 1974.
137. Burtis WJ, Dann P, Gaich GA, Soifer NE. A high abundance midregion species of
parathyroid hormone-related protein: immunological and chromatographic charac-
terization in plasma. J Clin Endocrinol Metab 78: 317322, 1994.
138. Butte NF, Garza C, Smith EO, Nichols BL. Human milk intake and growth in exclu-
sively breast-fed infants. J Pediatr 104: 187195, 1984.
139. Cabiddu G, Castellino S, Gernone G, Santoro D, Giacchino F, Credendino O, Dai-
done G, Gregorini G, Moroni G, Attini R, Minelli F, Manisco G, Todros T, Piccoli GB.
Best practices on pregnancy on dialysis: the Italian Study Group on Kidney and
Pregnancy. J Nephrol 28: 279 288, 2015.
140. Caird LE, Reid-Thomas V, Hannan WJ, Gow S, Glasier AF. Oral progestogen-only
contraception may protect against loss of bone mass in breast-feeding women. Clin
Endocrinol 41: 739 745, 1994.
141. Callies F, Arlt W, Scholz HJ, Reincke M, Allolio B. Management of hypoparathyroid-
ism during pregnancyreport of twelve cases. Eur J Endocrinol 139: 284 289, 1998.
142. Calvo MS, Eyre DR, Gundberg CM. Molecular basis and clinical application of bio-
logical markers of bone turnover. Endocr Rev 17: 333368, 1996.
143. Campos-Obando N, Oei L, Hoefsloot LH, Kiewiet RM, Klaver CC, Simon ME,
Zillikens MC. Osteoporotic vertebral fractures during pregnancy: be aware of a
potential underlying genetic cause. J Clin Endocrinol Metab 99: 11071111, 2014.
144. Canal-Macias ML, Roncero-Martin R, Moran JM, Lavado-Garcia JM, Costa-Fernan-
dez Mdel C, Pedrera-Zamorano JD. Increased bone mineral density is associated
with breastfeeding history in premenopausal Spanish women. Arch Med Sci 9: 703
708, 2013.
145. Cancela L, Le Boulch N, Miravet L. Relationship between the vitamin D content of
maternal milk and the vitamin D status of nursing women and breast-fed infants. J
Endocrinol 110: 4350, 1986.
146. Cancela L, Marie PJ, Le Boulch N, Miravet L. Influence of vitamin D on mineral
metabolism, hormonal status and bone histology in lactating rats and their pups. J
Endocrinol 105: 303309, 1985.
147. Cano-Marquina A, Tarin JJ, Garcia-Perez MA, Cano A. Transient regional osteopo-
rosis. Maturitas 77: 324 329, 2014.
148. Caplan RH, Beguin EA. Hypercalcemia in a calcitriol-treated hypoparathyroid
woman during lactation. Obstet Gynecol 76: 485 489, 1990.
526 Physiol Rev VOL 96 APRIL 2016 www.prv.org
149. Caplan RH, Miller CD, Silva PD. Severe hypercalcemia in a lactating woman in
association with moderate calcium carbonate supplementation: a case report. J
Reprod Med 49: 214 217, 2004.
150. Caplan RH, Wickus GG. Reduced calcitriol requirements for treating hypoparathy-
roidism during lactation. A case report. J Reprod Med 38: 914 918, 1993.
151. Caplan RH, Wickus GG, Sloane K, Silva PD. Serum parathyroid hormone-related
protein levels during lactation. J Reprod Med 40: 216 218, 1995.
152. Care AD, Abbas SK, Pickard DW, Barri M, Drinkhill M, Findlay JB, White IR, Caple
IW. Stimulation of ovine placental transport of calcium and magnesium by mid-
molecule fragments of human parathyroid hormone-related protein. Exp Physiol 75:
605 608, 1990.
153. Carella MJ, Gossain VV. Hyperparathyroidism and pregnancy: case report and re-
view. J Gen Intern Med 7: 448 453, 1992.
154. Carlier Y, Rivera MT, Truyens C, Goldman M, Lambert P, Flament J, Bauwens D,
Vray B. Pregnancy and humoral immune response in mice chronically infected by
Trypanosoma cruzi. Infect Immun 55: 2496 2501, 1987.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
155. Carman JS, Wyatt RJ. Reduction of serum-prolactin after subcutaneous salmon cal-
citonin. Lancet 1: 12671268, 1977.
156. Carneiro RM, Prebehalla L, Tedesco MB, Sereika SM, Gundberg CM, Stewart AF,
Horwitz MJ. Evaluation of markers of bone turnover during lactation in African-
Americans: a comparison with Caucasian lactation. J Clin Endocrinol Metab 98: 523
532, 2013.
157. Carneiro RM, Prebehalla L, Tedesco MB, Sereika SM, Hugo M, Hollis BW, Gundberg
CM, Stewart AF, Horwitz MJ. Lactation and bone turnover: a conundrum of marked
bone loss in the setting of coupled bone turnover. J Clin Endocrinol Metab 95: 1767
1776, 2010.
158. Carranza-Lira S, Mera JP. Influence of number of pregnancies and total breast-
feeding time on bone mineral density. Int J Fertil Womens Med 47: 169 171, 2002.
159. Casanueva E, Flores-Quijano ME, Frike E, Samano R, De Santiago S. Bone mineral
density and bone turnover in adolescent mothers after lactation. Adv Exp Med Biol
554: 341343, 2004.
160. Casey ML, Mibe M, MacDonald PC. Regulation of parathyroid hormone-related
protein gene expression in human endometrial stromal cells in culture. J Clin Endo-
crinol Metab 77: 188 194, 1993.
161. Cathebras P, Cartry O, Sassolas G, Rousset H. Hypercalcemia induced by lactation
in 2 patients with treated hypoparathyroidism. Rev Med Intern 17: 675 676, 1996.
162. Cauley JA, Wu L, Wampler NS, Barnhart JM, Allison M, Chen Z, Jackson R, Robbins
J. Clinical risk factors for fractures in multi-ethnic women: the Womens Health
Initiative. J Bone Miner Res 22: 1816 1826, 2007.
163. Chalon S, Garel JM. Plasma calcium control in the rat fetus. I. Influence of maternal
hormones. Biol Neonate 48: 313322, 1985.
164. Chan GM, McMurry M, Westover K, Engelbert-Fenton K, Thomas MR. Effects of
increased dietary calcium intake upon the calcium and bone mineral status of lactat-
ing adolescent and adult women. Am J Clin Nutr 46: 319 323, 1987.
165. Chan GM, Roberts CC, Folland D, Jackson R. Growth and bone mineralization of
normal breast-fed infants and the effects of lactation on maternal bone mineral
status. Am J Clin Nutr 36: 438 443, 1982.
166. Chan GM, Ronald N, Slater P, Hollis J, Thomas MR. Decreased bone mineral status
in lactating adolescent mothers. J Pediatr 101: 767770, 1982.
167. Chan GM, Slater P, Ronald N, Roberts CC, Thomas MR, Folland D, Jackson R. Bone
mineral status of lactating mothers of different ages. Am J Obstet Gynecol 144: 438
441, 1982.
168. Chan SM, Nelson EA, Leung SS, Cheng JC. Bone mineral density and calcium me-
tabolism of Hong Kong Chinese postpartum womena 1-yr longitudinal study. Eur J
Clin Nutr 59: 868 876, 2005.
169. Chantry CJ, Auinger P, Byrd RS. Lactation among adolescent mothers and subse-
quent bone mineral density. Arch Pediatr Adolesc Med 158: 650 656, 2004.
170. Chao CC, Brown RD, Deftos LJ. Metabolism of calcium and phosphorus during
pregnancy and lactation in white-tailed deer. Acta Endocrinol 109: 269 275, 1985.
 CHRISTOPHER S. KOVACS
171. Charoenphandhu N, Nakkrasae LI, Kraidith K, Teerapornpuntakit J, Thongchote K,
Thongon N, Krishnamra N. Two-step stimulation of intestinal Ca2 absorption
during lactation by long-term prolactin exposure and suckling-induced prolactin
surge. Am J Physiol Endocrinol Metab 297: E609 E619, 2009.
172. Cheema C, Grant BF, Marcus R. Effects of estrogen on circulating free and total
1,25-dihydroxyvitamin D and on the parathyroid-vitamin D axis in postmenopausal
women. J Clin Invest 83: 537542, 1989.
173. Chef R. Metabolisme du calcium chez la ratte en gestation. Etude cinetique par le
45
Ca. C R Seances Soc Biol Fil 163: 541545, 1969.
174. Chellakooty M, Vangsgaard K, Larsen T, Scheike T, Falck-Larsen J, Legarth J, Ander-
sson AM, Main KM, Skakkebaek NE, Juul A. A longitudinal study of intrauterine
growth and the placental growth hormone (GH)-insulin-like growth factor I axis in
maternal circulation: association between placental GH and fetal growth. J Clin
Endocrinol Metab 89: 384 391, 2004.
175. Chernoff N, Rogers EH, Zehr RD, Gage MI, Malarkey DE, Bradfield CA, Liu Y,
Schmid JE, Jaskot RH, Richards JH, Wood CR, Rosen MB. Toxicity and recovery in
the pregnant mouse after gestational exposure to the cyanobacterial toxin, cylindro-
spermopsin. J Appl Toxicol 31: 242254, 2011.
176. Chesney RW, Specker BL, Mimouni F, McKay CP. Mineral metabolism during preg-
nancy and lactation. In: Disorders of Bone and Mineral Metabolism, edited by Coe FL,
Favus MJ. New York: Raven, 1992, p. 383393.
177. Chihara K, Iwasaki J, Minamitani N, Kobayashi Y, Fujita T. Suppression by intrave-
nous injection of [Asu(1),(7)]-Eel calcitonin of suckling-induced prolactin release in
rats. Horm Metab Res 13: 535536, 1981.
178. Choe EY, Song JE, Park KH, Seok H, Lee EJ, Lim SK, Rhee Y. Effect of teriparatide on
pregnancy and lactation-associated osteoporosis with multiple vertebral fractures. J
Bone Miner Metab 30: 596 601, 2012.
179. Chosich N, Long F, Wong R, Topliss DJ, Stockigt JR. Post-partum hypercalcemia in
hereditary hyperphosphatasia (juvenile Pagets disease). J Endocrinol Invest 14: 591
597, 1991.
180. Chou TW, Chan GM, Moyer-Mileur L. Postpartum body composition changes in
lactating and non-lactating primiparas. Nutrition 15: 481 484, 1999.
181. Christakos S. Mechanism of action of 1,25-dihydroxyvitamin D3 on intestinal calcium
absorption. Rev Endocr Metab Disorders 13: 39 44, 2012.
182. Christakos S, Seth T, Hirsch J, Porta A, Moulas A, Dhawan P. Vitamin D biology
revealed through the study of knockout and transgenic mouse models. Annu Rev Nutr
33: 71 85, 2013.
183. Christian P, Khatry SK, Katz J, Pradhan EK, LeClerq SC, Shrestha SR, Adhikari RK,
Sommer A, West KP Jr. Effects of alternative maternal micronutrient supplements
on low birth weight in rural Nepal: double blind randomised community trial. BMJ
326: 571, 2003.
184. Christian P, West KP, Khatry SK, Leclerq SC, Pradhan EK, Katz J, Shrestha SR,
Sommer A. Effects of maternal micronutrient supplementation on fetal loss and
infant mortality: a cluster-randomized trial in Nepal. Am J Clin Nutr 78: 1194 1202,
2003.
185. Christiansen C, Rodbro P, Heinild B. Unchanged total body calcium in normal human
pregnancy. Acta Obstet Gynecol Scand 55: 141143, 1976.
186. Clark D, Seeds JW, Cefalo RC. Hyperparathyroid crisis and pregnancy. Am J Obstet
Gynecol 140: 840 842, 1981.
187. Clarke MV, Russell PK, Findlay DM, Sastra S, Anderson PH, Skinner JP, Atkins GJ,
Zajac JD, Davey RA. A role for the calcitonin receptor to limit bone loss during
lactation in female mice by inhibiting osteocytic osteolysis. Endocrinology en2015345,
2015.
188. Clement-Lacroix P, Ormandy C, Lepescheux L, Ammann P, Damotte D, Goffin V,
Bouchard B, Amling M, Gaillard-Kelly M, Binart N, Baron R, Kelly PA. Osteoblasts
are a new target for prolactin: analysis of bone formation in prolactin receptor
knockout mice. Endocrinology 140: 96 105, 1999.
189. Clements MR, Davies M, Hayes ME, Hickey CD, Lumb GA, Mawer EB, Adams PH.
The role of 1,25-dihydroxyvitamin D in the mechanism of acquired vitamin D defi-
ciency. Clin Endocrinol 37: 1727, 1992.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
190. Clements MR, Fraser DR. Vitamin D supply to the rat fetus and neonate. J Clin Invest
81: 1768 1773, 1988.
191. Cockburn F, Belton NR, Purvis RJ, Giles MM, Brown JK, Turner TL, Wilkinson EM,
Forfar JO, Barrie WJ, McKay GS, Pocock SJ. Maternal vitamin D intake and mineral
metabolism in mothers and their newborn infants. Br Med J 281: 1114, 1980.
192. Colin EM, Van Den Bemd GJ, Van Aken M, Christakos S, De Jonge HR, Deluca HF,
Prahl JM, Birkenhager JC, Buurman CJ, Pols HA, Van Leeuwen JP. Evidence for
involvement of 17beta-estradiol in intestinal calcium absorption independent of
1,25-dihydroxyvitamin D3 level in the Rat. J Bone Miner Res 14: 57 64, 1999.
193. Colleran HL, Wideman L, Lovelady CA. Effects of energy restriction and exercise on
bone mineral density during lactation. Med Sci Sports Exercise 44: 1570 1579, 2012.
194. Collins JN, Kirby BJ, Woodrow JP, Gagel RF, Rosen CJ, Sims NA, Kovacs CS. Lac-
tating Ctcgrp nulls lose twice the normal bone mineral content due to fewer osteo-
blasts and more osteoclasts, whereas bone mass is fully restored after weaning in
association with up-regulation of Wnt signaling and other novel genes. Endocrinology
154: 1400 1413, 2013.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
195. Colucci S, Colaianni G, Mori G, Grano M, Zallone A. Human osteoclasts express
oxytocin receptor. Biochem Biophys Res Commun 297: 442 445, 2002.
196. Comar CL. Radiocalcium studies in pregnancy. Ann NY Acad Sci 64: 281298, 1956.
197. Cons JM, Glass LE. Electrophoresis of serum proteins and selected enzymes in
males, non-pregnant, pregnant, and lactating female mice. Proc Soc Exp Biol Med 113:
893 897, 1963.
198. Cooke-Hubley S, Kirby BJ, Suppiah S, Simmonds CS, Karaplis AC, Kovacs CS. Cir-
culating FGF23 is regulated by PTH and calcitriol during fetal development but low
FGF23 does not significantly alter fetal phosphorus metabolism. IBMS BoneKEy 10:
S95, 2013.
199. Cooper C, Harvey NC, Bishop NJ, Kennedy S, Papageorghiou AT, Fraser R, Gandhi
SV, DAngelo A, Crozier SR, Moon RJ, Arden NK, Dennison EM, Godfrey KM, Inskip
HM, Schoenmakers I, Prentice A, Mughal Z, Eastell R, Reid DM, Javaid MK. Maternal
gestational vitamin d supplementation and offspring bone mass: a multicentre ran-
domised, double-blind, placebo-controlled trial (MAVIDOS). J Bone Miner Res 2015:
FR0052, 2015.
200. Cooper C, Harvey NC, Javaid MK, Bishop NJ, Kennedy S, Papageorghiou AT, Fraser
R, Gandhi SV, DAngelo A, Crozier SR, Moon RJ, Arden NK, Dennison EM, Godfrey
KM, Inskip HM, Schoenmakers I, Prentice A, Mughal Z, Eastell R, Reid DM. Effec-
tiveness of maternal vitamin D supplementation: a multicentre randomized, double-
blind, placebo controlled trial (MAVIDOS). Osteoporos Int 26: C40, 2015.
201. Cooper CW, Obie JF, Toverud SU, Munson PL. Elevated serum calcitonin and serum
calcium during suckling in the baby rat. Endocrinology 101: 16571664, 1977.
202. Cornish J, Callon KE, Nicholson GC, Reid IR. Parathyroid hormone-related protein-
(107139) inhibits bone resorption in vivo. Endocrinology 138: 1299 1304, 1997.
203. Cox ML, Khan SA, Gau DW, Cox SA, Hodkinson HM. Determinants of forearm
bone density in premenopausal women: a study in one general practice. Br J Gen
Pract 41: 194 196, 1991.
204. Cox WM, Imboden M. The role of calcium and phosphorus in determining repro-
ductive success. J Nutr 11: 147176, 1936.
205. Croom RD, Thomas CG. Primary hyperparathyroidism during pregnancy. Surgery
96: 1109 1118, 1984.
206. Cross NA, Hillman LS, Allen SH, Krause GF. Changes in bone mineral density and
markers of bone remodeling during lactation and postweaning in women consuming
high amounts of calcium. J Bone Miner Res 10: 13121320, 1995.
207. Cross NA, Hillman LS, Allen SH, Krause GF, Vieira NE. Calcium homeostasis and
bone metabolism during pregnancy, lactation, and postweaning: a longitudinal study.
Am J Clin Nutr 61: 514 523, 1995.
208. Cross NA, Hillman LS, Forte LR. The effects of calcium supplementation, duration of
lactation, and time of day on concentrations of parathyroid hormone-related protein
in human milk: a pilot study. J Hum Lactation 14: 111117, 1998.
209. Cruikshank DP, Pitkin RM, Reynolds WA, Williams GA, Hargis GK. Altered maternal
calcium homeostasis in diabetic pregnancy. J Clin Endocrinol Metab 50: 264 267,
1980.
527
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
210. Cruikshank DP, Pitkin RM, Reynolds WA, Williams GA, Hargis GK. Calcium-regu-
lating hormones and ions in amniotic fluid. Am J Obstet Gynecol 136: 621 625, 1980.
211. Culbert EC, Schfirin BS. Malignant hypercalcemia in pregnancy: effect of pamidro-
nate on uterine contractions. Obstet Gynecol 108: 789 791, 2006.
212. Cumming RG, Klineberg RJ. Breastfeeding and other reproductive factors and the
risk of hip fractures in elderly women. Int J Epidemiol 22: 684 691, 1993.
213. Cundy T, Haining SA, Guilland-Cumming DF, Butler J, Kanis JA. Remission of hypo-
parathyroidism during lactation: evidence for a physiological role for prolactin in the
regulation of vitamin D metabolism. Clin Endocrinol 26: 667 674, 1987.
214. Cure CC, Ramirez PC, Lopez-Jaramillo P. Osteoporosis, pregnancy, and lactation.
Lancet 352: 12271228, 1998.
215. Cure-Cure C, Cure-Ramirez P, Teran E, Lopez-Jaramillo P. Bone-mass peak in
multiparity and reduced risk of bone-fractures in menopause. Int J Gynaecol Obstet
76: 285291, 2002.
216. Currey JD. Interactions between age, pregnancy and lactation, and some mechanical
properties, of the femora of rats. Calcif Tissue Res 13: 99 112, 1973.
217. Currey JD, Hughes SM. The effects of pregnancy and lactation on some mechanical
properties of the femora of the rat. Calcif Tissue Res 11: 112123, 1973.
218. Curtiss PH Jr, Kincaid WE. Transitory demineralization of the hip in pregnancy. A report
of three cases. J Bone Joint Surg 41-A: 13271333, 1959.
219. Cushard WG Jr, Creditor MA, Canterbury JM, Reiss E. Physiological hyperparathy-
roidism in pregnancy. J Clin Endocrinol Metab 34: 767771, 1972.
220. Dacquin R, Davey RA, Laplace C, Levasseur R, Morris HA, Goldring SR, Gebre-
Medhin S, Galson DL, Zajac JD, Karsenty G. Amylin inhibits bone resorption while
the calcitonin receptor controls bone formation in vivo. J Cell Biol 164: 509 514,
2004.
221. Dahlman T, Sjoberg HE, Bucht E. Calcium homeostasis in normal pregnancy and
puerperium. A longitudinal study. Acta Obstet Gynecol Scand 73: 393398, 1994.
222. Danks JA, Ebeling PR, Hayman JA, Diefenbach-Jagger H, Collier FM, Grill V, Southby
J, Moseley JM, Chou ST, Martin TJ. Immunohistochemical localization of parathyroid
hormone-related protein in parathyroid adenoma and hyperplasia. J Pathol 161:
2733, 1990.
223. Dardenne O, Prudhomme J, Hacking SA, Glorieux FH, St-Arnaud R. Correction of
the abnormal mineral ion homeostasis with a high-calcium, high-phosphorus, high-
lactose diet rescues the PDDR phenotype of mice deficient for the 25-hydroxyvita-
min D-1alpha-hydroxylase (CYP27B1). Bone 32: 332340, 2003.
224. Dardenne O, Prudhomme J, Hacking SA, Glorieux FH, St-Arnaud R. Rescue of the
pseudo-vitamin D deficiency rickets phenotype of CYP27B1-deficient mice by treat-
ment with 1,25-dihydroxyvitamin D3: biochemical, histomorphometric, and biome-
chanical analyses. J Bone Miner Res 18: 637 643, 2003.
225. Davey RA, Turner AG, McManus JF, Chiu WS, Tjahyono F, Moore AJ, Atkins GJ,
Anderson PH, Ma C, Glatt V, MacLean HE, Vincent C, Bouxsein M, Morris HA,
Findlay DM, Zajac JD. Calcitonin receptor plays a physiological role to protect
against hypercalcemia in mice. J Bone Miner Res 23: 11821193, 2008.
226. Davicco MJ, Coxam V, Lefaivre J, Barlet JP. Parathyroid hormone-related peptide
increases urinary phosphate excretion in fetal lambs. Exp Physiol 77: 377383, 1992.
227. Davis OK, Hawkins DS, Rubin LP, Posillico JT, Brown EM, Schiff I. Serum parathyroid
hormone (PTH) in pregnant women determined by an immunoradiometric assay for
intact PTH. J Clin Endocrinol Metab 67: 850 852, 1988.
228. Dawodu A, Agarwal M, Hossain M, Kochiyil J, Zayed R. Hypovitaminosis D and
vitamin D deficiency in exclusively breast-feeding infants and their mothers in sum-
mer: a justification for vitamin D supplementation of breast-feeding infants. J Pediatr
142: 169 173, 2003.
229. Dawodu A, Saadi HF, Bekdache G, Javed Y, Altaye M, Hollis BW. Randomized
controlled trial (RCT) of vitamin D supplementation in pregnancy in a population
with endemic vitamin D deficiency. J Clin Endocrinol Metab 98: 23372346, 2013.
230. Dawood MY, Khan-Dawood FS, Wahi RS, Fuchs F. Oxytocin release and plasma
anterior pituitary and gonadal hormones in women during lactation. J Clin Endocrinol
Metab 52: 678 683, 1981.
528 Physiol Rev VOL 96 APRIL 2016 www.prv.org
231. Dawood MY, Ylikorkala O, Trivedi D, Fuchs F. Oxytocin in maternal circulation and
amniotic fluid during pregnancy. J Clin Endocrinol Metab 49: 429 434, 1979.
232. De Lauzon S, Uhrich F, Vandel S, Cittanova N, Jayle MF. Determination of proges-
terone and of free and conjugated estrogens in pregnant and peudo-pregnant rats.
Steroids 24: 31 40, 1974.
233. Deem HE. Observations on the Milk of New Zealand Women. Arch Dis Child 6:
5370, 1931.
234. Della Martina M, Biasioli A, Vascotto L, Rinuncini D, Adorati Menegato A, Liva S,
Londero AP, Driul L, Marchesoni D. Bone ultrasonometry measurements during
pregnancy. Arch Gynecol Obstet 281: 401 407, 2010.
235. Delmas PD. Markers of bone formation and resorption. In: Primer on the Metabolic
Bone Diseases and Disorders of Mineral Metabolism, edited by Favus MJ. New York:
Raven, 1993, p. 108 112.
236. Delmonico FL, Neer RM, Cosimi AB, Barnes AB, Russell PS. Hyperparathyroidism
during pregnancy. Am J Surg 131: 328 337, 1976.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
237. Delorme AC, Marche P, Garel JM. Vitamin D-dependent calcium-binding protein.
Changes during gestation, prenatal and postnatal development in rats. J Dev Physiol 1:
181194, 1979.
238. Delvin EE, Gilbert M, Pere MC, Garel JM. In vivo metabolism of calcitriol in the
pregnant rabbit doe. J Dev Physiol 10: 451 459, 1988.
239. Delvin EE, Salle BL, Glorieux FH, Adeleine P, David LS. Vitamin D supplementation
during pregnancy: effect on neonatal calcium homeostasis. J Pediatr 109: 328 334,
1986.
240. Delzer PR, Meyer RA Jr. Normal milk composition in lactating X-linked hypophos-
phatemic mice despite continued hypophosphatemia. Calcif Tissue Int 35: 750 754,
1983.
241. Demay MB. Physiological insights from the vitamin D receptor knockout mouse.
Calcif Tissue Int 92: 99 105, 2013.
242. Demirel N, Aydin M, Zenciroglu A, Okumus N, Cetinkaya S, Yildiz YT, Ipek MS.
Hyperparathyroidism secondary to maternal hypoparathyroidism and vitamin D
deficiency: an uncommon cause of neonatal respiratory distress. Ann Trop Paediatr
29: 149 154, 2009.
243. Dent CE, Friedman M. Pregnancy and idiopathic osteoporosis. Q J Med 34: 341357,
1965.
244. Dequeker J, Tobing L, Rutten V, Geusens P. Relative risk factors for osteoporotic
fracture: a pilot study of the MEDOS questionnaire. Clin Rheumatol 10: 49 53, 1991.
245. DeSantiago S, Alonso L, Halhali A, Larrea F, Isoard F, Bourges H. Negative calcium
balance during lactation in rural Mexican women. Am J Clin Nutr 76: 845 851, 2002.
246. Dewey KG, Finley DA, Lonnerdal B. Breast milk volume and composition during late
lactation (720 months). J Pediatr Gastroenterol Nutr 3: 713720, 1984.
247. Diaz de Barboza G, Guizzardi S, Tolosa de Talamoni N. Molecular aspects of intes-
tinal calcium absorption. World J Gastroenterol 21: 71427154, 2015.
248. Diaz L, Arranz C, Avila E, Halhali A, Vilchis F, Larrea F. Expression and activity of
25-hydroxyvitamin D-1 alpha-hydroxylase are restricted in cultures of human syn-
cytiotrophoblast cells from preeclamptic pregnancies. J Clin Endocrinol Metab 87:
3876 3882, 2002.
249. Dinour D, Davidovits M, Aviner S, Ganon L, Michael L, Modan-Moses D, Vered I,
Bibi H, Frishberg Y, Holtzman EJ. Maternal and infantile hypercalcemia caused by
vitamin-D-hydroxylase mutations and vitamin D intake. Pediatr Nephrol 30: 145152,
2015.
250. Diogenes ME, Bezerra FF, Rezende EP, Taveira MF, Pinhal I, Donangelo CM.
Effect of calcium plus vitamin D supplementation during pregnancy in Brazilian
adolescent mothers: a randomized, placebo-controlled trial. Am J Clin Nutr 98:
8291, 2013.
251. Dobnig H, Kainer F, Stepan V, Winter R, Lipp R, Schaffer M, Kahr A, Nocnik S,
Patterer G, Leb G. Elevated parathyroid hormone-related peptide levels after hu-
man gestation: relationship to changes in bone and mineral metabolism. J Clin Endo-
crinol Metab 80: 3699 3707, 1995.
 CHRISTOPHER S. KOVACS
252. Docherty HM, Ratcliffe WA, Heath DA, Docherty K. Expression of parathyroid
hormone-related protein in abnormal human parathyroids. J Endocrinol 129: 431
438, 1991.
253. Donelson E, Nims B, Hunscher HA, Macy IG. Metabolism of women during the
reproductive cycle. IV. Calcium and phosphorus utilization in late lactation and dur-
ing subsequent reproductive rest. J Biol Chem 91: 675 686, 1931.
254. Douard V, Suzuki T, Sabbagh Y, Lee J, Shapses S, Lin S, Ferraris RP. Dietary fructose
inhibits lactation-induced adaptations in rat 1,25-(OH)2D3 synthesis and calcium
transport. FASEB J 26: 707721, 2012.
255. Drake TS, Kaplan RA, Lewis TA. The physiologic hyperparathyroidism of pregnancy.
Is it primary or secondary? Obstet Gynecol 53: 746 749, 1979.
256. Drinkwater BL, Chesnut CH. Bone density changes during pregnancy and lactation
in active women: a longitudinal study. Bone Miner 14: 153160, 1991.
257. Dubreuil P, Arsenault J, Belanger D. Biochemical reference ranges for groups of
ewes of different ages. Vet Rec 156: 636 638, 2005.
258. Dunbar ME, Dann PR, Robinson GW, Hennighausen L, Zhang JP, Wysolmerski JJ.
Parathyroid hormone-related protein signaling is necessary for sexual dimorphism
during embryonic mammary development. Development 126: 34853493, 1999.
259. Dunne F, Walters B, Marshall T, Heath DA. Pregnancy associated osteoporosis. Clin
Endocrinol 39: 487 490, 1993.
260. Duque G, Huang DC, Dion N, Macoritto M, Rivas D, Li W, Yang XF, Li J, Lian J,
Marino FT, Barralet J, Lascau V, Deschenes C, Ste-Marie LG, Kremer R. Interferon-
gamma plays a role in bone formation in vivo and rescues osteoporosis in ovariec-
tomized mice. J Bone Miner Res 26: 14721483, 2011.
261. Dursun N, Akin S, Dursun E, Sade I, Korkusuz F. Influence of duration of total
breast-feeding on bone mineral density in a Turkish population: does the priority of
risk factors differ from society to society? Osteoporos Int 17: 651 655, 2006.
262. Dvir R, Golander A, Jaccard N, Yedwab G, Otremski I, Spirer Z, Weisman Y. Am-
niotic fluid and plasma levels of parathyroid hormone-related protein and hormonal
modulation of its secretion by amniotic fluid cells. Eur J Endocrinol 133: 277282,
1995.
263. Dytfeld J, Horst-Sikorska W. Pregnancy associated osteoporosisa case report.
Ginekologia Polska 83: 377379, 2012.
264. Eastell R, Edmonds CJ, de Chayal RC, McFadyen IR. Prolonged hypoparathyroidism
presenting eventually as second trimester abortion. Br Med J 291: 955956, 1985.
265. Eckstein N, Foldes J, Feinstein Y, Vagman I, Eshel A, Steinberg R, Statter M, Limor R,
Ayalon D. Calcium homeostasis, bone metabolism and safety aspects during long-
term treatment with a GnRH agonist. Maturitas 15: 2532, 1992.
266. Edouard T, Alos N, Chabot G, Roughley P, Glorieux FH, Rauch F. Short- and long-
term outcome of patients with pseudo-vitamin D deficiency rickets treated with
calcitriol. J Clin Endocrinol Metab 96: 82 89, 2011.
267. El-Hajj Fuleihan G, Arnold A. Pathogenesis and etiology of primary hyperparathy-
roidism. In: UpToDate 214, edited by Rosen CJ, Basow DS. Waltham, MA: UpTo-
Date, 2013.
268. El-Kasti MM, Christian HC, Huerta-Ocampo I, Stolbrink M, Gill S, Houston PA,
Davies JS, Chilcott J, Hill N, Matthews DR, Carter DA, Wells T. The pregnancy-
induced increase in baseline circulating growth hormone in rats is not induced by
ghrelin. J Neuroendocrinol 20: 309 322, 2008.
269. Elias E, Shainkin-Kestenbaum R. Hypocalcaemia and serum levels of inorganic phos-
phorus, magnesium parathyroid and calcitonin hormones in the last month of preg-
nancy in Awassi fat-tail ewes. Reprod Nutr Dev 30: 693 699, 1990.
270. Eller-Vainicher C, Ossola MW, Beck-Peccoz P, Chiodini I. PTHrP-associated hyper-
calcemia of pregnancy resolved after delivery: a case report. Eur J Endocrinol 166:
753756, 2012.
271. Ellinger GM, Duckworth J. Skeletal changes during pregnancy and lactation in the rat:
effect of different levels of dietary calcium. Br J Nutr 6: 235253, 1952.
272. Emami MJ, Abdollahpour HR, Kazemi AR, Vosoughi AR. Bilateral subcapital femoral
neck fractures secondary to transient osteoporosis during pregnancy: a case report.
J Orthopaedic Surg 20: 260 262, 2012.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
273. Erben RG, Soegiarto DW, Weber K, Zeitz U, Lieberherr M, Gniadecki R, Moller G,
Adamski J, Balling R. Deletion of deoxyribonucleic acid binding domain of the vitamin
D receptor abrogates genomic and nongenomic functions of vitamin D. Mol Endo-
crinol 16: 1524 1537, 2002.
274. Ettinger AS, Lamadrid-Figueroa H, Mercado-Garcia A, Kordas K, Wood RJ, Peterson
KE, Hu H, Hernandez-Avila M, Tellez-Rojo MM. Effect of calcium supplementation
on bone resorption in pregnancy and the early postpartum: a randomized controlled
trial in Mexican women. Nutr J 13: 116, 2014.
275. Fairweather-Tait S, Prentice A, Heumann KG, Jarjou LM, Stirling DM, Wharf SG,
Turnlund JR. Effect of calcium supplements and stage of lactation on the calcium
absorption efficiency of lactating women accustomed to low calcium intakes. Am J
Clin Nutr 62: 1188 1192, 1995.
276. Farrant HJ, Krishnaveni GV, Hill JC, Boucher BJ, Fisher DJ, Noonan K, Osmond C,
Veena SR, Fall CH. Vitamin D insufficiency is common in Indian mothers but is not
associated with gestational diabetes or variation in newborn size. Eur J Clin Nutr 63:
646 652, 2009.
277. Farrugia W, Fortune CL, Heath J, Caple IW, Wark JD. Osteocalcin as an index of
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
osteoblast function during and after ovine pregnancy. Endocrinology 125: 17051710,
1989.
278. Farrugia W, Ho PW, Rice GE, Moseley JM, Permezel M, Wlodek ME. Parathyroid
hormone-related protein(134) in gestational fluids and release from human gesta-
tional tissues. J Endocrinol 165: 657 662, 2000.
279. Feldblum PJ, Zhang J, Rich LE, Fortney JA, Talmage RV. Lactation history and bone
mineral density among perimenopausal women. Epidemiology 3: 527531, 1992.
280. Fenton AJ, Kemp BE, Hammonds RG Jr, Mitchelhill K, Moseley JM, Martin TJ, Nich-
olson GC. A potent inhibitor of osteoclastic bone resorption within a highly con-
served pentapeptide region of parathyroid hormone-related protein; PTHrP[107
111]. Endocrinology 129: 3424 3426, 1991.
281. Fenton AJ, Kemp BE, Kent GN, Moseley JM, Zheng MH, Rowe DJ, Britto JM, Martin
TJ, Nicholson GC. A carboxyl-terminal peptide from the parathyroid hormone-
related protein inhibits bone resorption by osteoclasts. Endocrinology 129: 1762
1768, 1991.
282. Fenton E, Britton HG. 25-Hydroxycholecalciferol 1 alpha-hydroxylase activity in the
kidney of the fetal, neonatal and adult guinea pig. Biol Neonate 37: 254 256, 1980.
283. Ferguson JE, Gorman JV, Bruns DE, Weir EC, Burtis WJ, Martin TJ, Bruns ME.
Abundant expression of parathyroid hormone-related protein in human amnion and
its association with labor. Proc Natl Acad Sci USA 89: 8384 8388, 1992.
284. Ferguson JE, Seaner R, Bruns DE, Redick JA, Mills SE, Jppner H, Segre GV, Bruns
ME. Expression of parathyroid hormone-related protein and its receptor in human
umbilical cord: evidence for a paracrine system involving umbilical vessels. Am J
Obstet Gynecol 170: 1018 1024, 1994.
285. Findley T. Failure of irradiated ergosterol to relieve parathyroid tetany. Ann Intern
Med 4: 1144 1153, 1931.
286. Fischer D, Schroer A, Ludders D, Cordes T, Bucker B, Reichrath J, Friedrich M.
Metabolism of vitamin D3 in the placental tissue of normal and preeclampsia com-
plicated pregnancies and premature births. Clin Exp Obstet Gynecol 34: 80 84, 2007.
287. Fleischman AR, Rosen JF, Cole J, Smith CM, DeLuca HF. Maternal and fetal serum
1,25-dihydroxyvitamin D levels at term. J Pediatr 97: 640 642, 1980.
288. Fogelman I, Fentiman I, Hamed H, Studd JW, Leather AT. Goserelin (Zoladex) and
the skeleton. Br J Obstet Gynaecol 101 Suppl 10: 19 23, 1994.
289. Fomon SJ, Nelson SE. Calcium, phosphorus, magnesium, sulfur. In: Nutrition of
Normal Infants, edited by Fomon SJ. St. Louis, MO: Mosby, 1993, p. 192211.
290. Forsmo S, Schei B, Langhammer A, Forsen L. How do reproductive and lifestyle
factors influence bone density in distal and ultradistal radius of early postmenopausal
women? The Nord-Trondelag Health Survey, Norway. Osteoporos Int 12: 222229,
2001.
291. Fournier P, Susbielle H. Calcium exchanges in the rat during pregnancy, lactation and
weaning. 1. The effect of a calcium rich diet. J Physiol Paris 44: 123134, 1952.
292. Fox KM, Magaziner J, Sherwin R, Scott JC, Plato CC, Nevitt M, Cummings S. Repro-
ductive correlates of bone mass in elderly women. Study of Osteoporotic Fractures
Research Group. J Bone Miner Res 8: 901908, 1993.
529
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
293. Frenkel Y, Barkai G, Mashiach S, Dolev E, Zimlichman R, Weiss M. Hypocalciuria of
preeclampsia is independent of parathyroid hormone level. Obstet Gynecol 77: 689
691, 1991.
294. Frolich A, Rudnicki M, Fischer-Rasmussen W, Olofsson K. Serum concentrations of
intact parathyroid hormone during late human pregnancy: a longitudinal study. Eur J
Obstet Gynecol Reprod Biol 42: 85 87, 1991.
295. Fry JM, Curnow DH, Gutteridge DH, Retallack RW. Effect of chronic parathyroid-
ectomy on calcium metabolism in the lactating rat. J Endocrinol 82: 323330, 1979.
296. Fudge NJ, Kovacs CS. Pregnancy up-regulates intestinal calcium absorption and
skeletal mineralization independently of the vitamin D receptor. Endocrinology 151:
886 895, 2010.
297. Fujimoto Y, Hazama H, Oku K. Severe primary hyperparathyroidism in a neonate
having a parent with hypercalcemia: treatment by total parathyroidectomy and si-
multaneous heterotopic autotransplantation. Surgery 108: 933938, 1990.
298. Fujita H, Sugimoto K, Inatomi S, Maeda T, Osanai M, Uchiyama Y, Yamamoto Y,
Wada T, Kojima T, Yokozaki H, Yamashita T, Kato S, Sawada N, Chiba H. Tight
junction proteins claudin-2 and -12 are critical for vitamin D-dependent Ca2 ab-
sorption between enterocytes. Mol Biol Cell 19: 19121921, 2008.
299. Fujiwara S, Kasagi F, Yamada M, Kodama K. Risk factors for hip fracture in a Japanese
cohort. J Bone Miner Res 12: 998 1004, 1997.
300. Fukuda S, Iida H. Histomorphometric changes in iliac trabecular bone during preg-
nancy and lactation in beagle dogs. J Vet Med Sci 55: 565569, 1993.
301. Funk JL, Shoback DM, Genant HK. Transient osteoporosis of the hip in pregnancy:
natural history of changes in bone mineral density. Clin Endocrinol 43: 373382, 1995.
302. Furui T, Imai A, Tamaya T. Successful outcome of pregnancy complicated with
thyroidectomy-induced hypoparathyroidism and sudden dyspnea. A case report.
Gynecol Obstet Invest 35: 5759, 1993.
303. Gaboury CL, Woods LL. Renal reserve in pregnancy. Semin Nephrol 15: 449 453,
1995.
304. Gallacher SJ, Fraser WD, Owens OJ, Dryburgh FJ, Logue FC, Jenkins A, Kennedy J,
Boyle IT. Changes in calciotrophic hormones and biochemical markers of bone
turnover in normal human pregnancy. Eur J Endocrinol 131: 369 374, 1994.
305. Gallagher JC. Effect of estrogen on bone. In: Primer on the Metabolic Bone Diseases
and Disorders of Mineral Metabolism (5th ed.), edited by Favus MJ. Washington, DC:
ASBMR Press, 2003, p. 327330.
306. Gallagher JC, Yalamanchili V, Smith LM. The effect of vitamin D on calcium absorp-
tion in older women. J Clin Endocrinol Metab 97: 3550 3556, 2012.
307. Gambacciani M, Spinetti A, Gallo R, Cappagli B, Teti GC, Facchini V. Ultrasono-
graphic bone characteristics during normal pregnancy: longitudinal and cross-sec-
tional evaluation. Am J Obstet Gynecol 173: 890 893, 1995.
308. Gardella T, Jppner H, Bringhurst FR, Potts JT Jr. Receptors for parathyroid hor-
mone (PTH) and PTH-related protein. In: Principles of Bone Biology (3rd ed.), edited
by Bilezikian JP, Raisz LG, Martin TJ. New York: Academic, 2008, p. 555576.
309. Garel JM. Parathyroid hormone, calcitonin and mineral metabolism in the mamma-
lian fetus and neonate. In: Perinatal Calcium and Phosphorus Metabolism, edited by
Hollick MF, Anast CS, Gray TK. Amsterdam: Excerpta Medica, 1983, p. 71104.
310. Garel JM, Barlet JP. Calcitonin in the mother, fetus and newborn. Ann Biol Anim
Biochim Biophys 18: 53 68, 1978.
311. Garel JM, Besnard P, Chalon S, Jullienne A, Rebut-Bonneton C. Concentrations
plasmatiques dhormone parathyroidienne au cours de la gestation et de la lactation
chez le rat (mere et progeniture). Ann Endocrinol 42: 9C, 1981.
312. Garel JM, Care AD, Barlet JP. A radioimmunoassay for ovine calcitonin: an evaluation
of calcitonin secretion during gestation, lactation and foetal life. J Endocrinol 62:
497509, 1974.
313. Garel JM, Delorme AC, Marche P, Nguyen TM, Garabedian M. Vitamin D3 metab-
olite injections to thyroparathyroidectomized pregnant rats: effects on calcium-
binding proteins of maternal duodenum and of fetoplacental unit. Endocrinology 109:
284 289, 1981.
530 Physiol Rev VOL 96 APRIL 2016 www.prv.org
314. Garel JM, Gilbert M, Besnard P. Fetal growth and 1,25-dihydroxyvitamin D3 injec-
tions into thyroparathyroidectomized pregnant rats. Reprod Nutr Dev 21: 961968,
1981.
315. Garel JM, Jullienne A. Plasma calcitonin levels in pregnant and newborn rats. J Endo-
crinol 75: 373382, 1977.
316. Garel JM, Savajol H, Barlet JP. Plasma immunoreactive calcitonin levels in pregnant
ewes and their lambs. Biol Neonate 28: 207218, 1976.
317. Garn SM. The course of bone gain and the phases of bone loss. Orthop Clin North Am
3: 503520, 1972.
318. Garner SC, Boass A, Toverud SU. Hypercalcemia fails to suppress elevated serum
parathyroid hormone concentrations during lactation in rats. J Bone Miner Res 4:
577583, 1989.
319. Garner SC, Boass A, Toverud SU. Parathyroid hormone is not required for normal
milk composition or secretion or lactation-associated bone loss in normocalcemic
rats. J Bone Miner Res 5: 69 75, 1990.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
320. Garner SC, Peng TC, Hirsch PF, Boass A, Toverud SU. Increase in serum parathy-
roid hormone concentration in the lactating rat: effects of dietary calcium and lacta-
tional intensity. J Bone Miner Res 2: 347352, 1987.
321. Garner SC, Peng TC, Toverud SU. Modulation of serum parathyroid hormone and
ionized calcium concentrations during reproduction in rats fed a low calcium diet. J
Bone Miner Res 3: 319 323, 1988.
322. Germain-Lee EL, Schwindinger W, Crane JL, Zewdu R, Zweifel LS, Wand G, Huso
DL, Saji M, Ringel MD, Levine MA. A mouse model of albright hereditary osteodys-
trophy generated by targeted disruption of exon 1 of the Gnas gene. Endocrinology
146: 4697 4709, 2005.
323. Gershberg H, Weseley AC. Pseudohypoparathyroidism and pregnancy. Is pseudo-
pseudohypoparathyroidism a mild form of pseudohypoparathyroidism? J Pediatr 56:
383386, 1960.
324. Gertner JM, Coustan DR, Kliger AS, Mallette LE, Ravin N, Broadus AE. Pregnancy as
state of physiologic absorptive hypercalciuria. Am J Med 81: 451 456, 1986.
325. Ghazi AA, Boustani I, Amouzegar A, Attarian H, Pourafkari M, Gashti HN, Sabetian
T, Tirgari F, Ghazi S, Kovacs K. Postpartum hypercalcemia secondary to a neuroen-
docrine tumor of pancreas; a case report and review of literature. Iran J Med Sci 36:
217221, 2011.
326. Giannini S, Nobile M, Sartori L, Binotto P, Ciuffreda M, Gemo G, Pelizzo MR,
DAngelo A, Crepaldi G. Bone density and mineral metabolism in thyroidectomized
patients treated with long-term L-thyroxine. Clin Sci 87: 593597, 1994.
327. Gibson JH, Harries M, Mitchell A, Godfrey R, Lunt M, Reeve J. Determinants of bone
density and prevalence of osteopenia among female runners in their second to
seventh decades of age. Bone 26: 591598, 2000.
328. Gilbert M, Besnard P, Garel JM. Effects of maternal parathyroid glands and vitamin
D3 metabolites on fetal growth and fetal liver glycogen stores in thyro-parathyroid-
ectomized pregnant rats. Biomedicine 32: 9399, 1980.
329. Gillette ME, Insogna KL, Lewis AM, Baran DT. Influence of pregnancy on immuno-
reactive parathyroid hormone levels. Calcif Tissue Int 34: 9 12, 1982.
330. Gillies B, Tonkin BA, Ma Y, Kirby BJ, St-Arnaud R, Sims NA, Kovacs CS. Pregnancy
and post-lactation recovery rescue low bone mass and hypocalcemia in Cyp27b1 null
mice that cannot make calcitriol (Abstract). J Bone Miner Res 302015.
331. Giske LE, Hall G, Rud T, Landgren BM. The effect of 17beta-estradiol at doses of 0.5,
1 and 2 mg compared with placebo on early postmenopausal bone loss in hysterec-
tomized women. Osteoporos Int 13: 309 316, 2002.
332. Givens MH, Macy IC. The chemical composition of the human fetus. J Biol Chem 102:
717, 1933.
333. Glerean M, Furci A, Galich AM, Fama B, Plantalech L. Bone and mineral metabolism
in primiparous women and its relationship with breastfeeding: a longitudinal study.
Medicina 70: 227232, 2010.
334. Glorieux FH, Arabian A, Delvin EE. Pseudo-vitamin D deficiency: absence of 25-
hydroxyvitamin D 1 alpha-hydroxylase activity in human placenta decidual cells. J Clin
Endocrinol Metab 80: 22552258, 1995.
 CHRISTOPHER S. KOVACS
335. Goldman GA, Friedman S, Hod M, Ovadia J. Idiopathic transient osteoporosis of the
hip in pregnancy. Int J Gynaecol Obstet 46: 317320, 1994.
336. Goldsmith NF, Johnston JO. Bone mineral: effects of oral contraceptives, pregnancy,
and lactation. J Bone Joint Surg 57: 657 668, 1975.
337. Gonen E, Sahin I, Ozbek M, Kovalak E, Yologlu S, Ates Y. Effects of pregnancy and
lactation on bone mineral density, and their relation to the serum calcium, phospho-
rus, calcitonin and parathyroid hormone levels in rats. J Endocrinol Invest 28: 322
326, 2005.
338. Gonzalez DC, Mautalen CA, Correa PH, el Tamer E, el Tamer S. Bone mass in totally
thyroidectomized patients. Role of calcitonin deficiency and exogenous thyroid
treatment. Acta Endocrinol 124: 521525, 1991.
339. Goss H, Schmidt CL. Calcium and phosphorus metabolism in rats during pregnancy
and lactation and the influence of the reaction of the diet thereon. J Biol Chem 86:
1930.
340. Graham WP, III, Gordon CS, Loken HF, Blum A, Halden A. Effect of pregnancy and
of the menstrual cycle on hypoparathyroidism. J Clin Endocrinol Metab 24: 512516,
1964.
341. Grainge MJ, Coupland CA, Cliffe SJ, Chilvers CE, Hosking DJ. Reproductive, men-
strual and menopausal factors: which are associated with bone mineral density in
early postmenopausal women? Osteoporos Int 12: 777787, 2001.
342. Grant CC, Stewart AW, Scragg R, Milne T, Rowden J, Ekeroma A, Wall C, Mitchell
EA, Crengle S, Trenholme A, Crane J, Camargo CA Jr. Vitamin D during pregnancy
and infancy and infant serum 25-hydroxyvitamin D concentration. Pediatrics 133:
e143153, 2014.
343. Grant DK. Papilloedema and fits in hypoparathyroidism. Q J Med 22: 243259, 1953.
344. Gray RW, Weber HP, Dominguez JH, Lemann J Jr. The metabolism of vitamin D3
and 25-hydroxyvitamin D3 in normal and anephric humans. J Clin Endocrinol Metab
39: 10451056, 1974.
345. Gray TK, Lester GE, Lorenc RS. Evidence for extra-renal 1?-hydroxylation of 25-
hydroxyvitamin D3 in pregnancy. Science 204: 13111313, 1979.
346. Gray TK, Lowe W, Lester GE. Vitamin D and pregnancy: the maternal-fetal metab-
olism of vitamin D. Endocr Rev 2: 264 274, 1981.
347. Greer FR, Lane J, Ho M. Elevated serum parathyroid hormone, calcitonin, and
1,25-dihydroxyvitamin D in lactating women nursing twins. Am J Clin Nutr 40: 562
568, 1984.
348. Greer FR, Tsang RC, Searcy JE, Levin RS, Steichen JJ. Mineral homeostasis during
lactation-relationship to serum 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D,
parathyroid hormone, and calcitonin. Am J Clin Nutr 36: 431 437, 1982.
349. Grill V, Hillary J, Ho PM, Law FM, MacIsaac RJ, MacIsaac IA, Moseley JM, Martin TJ.
Parathyroid hormone-related protein: a possible endocrine function in lactation. Clin
Endocrinol 37: 405 410, 1992.
350. Gruber HE, Stover SJ. Maternal and weanling bone: the influence of lowered calcium
intake and maternal dietary history. Bone 15: 167176, 1994.
351. Guerra JJ, Steinberg ME. Distinguishing transient osteoporosis from avascular necro-
sis of the hip. J Bone Joint Surg 77: 616 624, 1995.
352. Gur A, Cevik R, Nas K, Sarac AJ, Ataoglu S, Karakoc M, Can A, Gurkan F. The
influence of duration of breastfeeding on bone mass in postmenopausal women of
different age groups. Int J Clin Pract 57: 82 86, 2003.
353. Haddad JG Jr, Boisseau V, Avioli LV. Placental transfer of vitamin D3 and 25-hydroxy-
cholecalciferol in the rat. J Lab Clin Med 77: 908 915, 1971.
354. Haenel LC, Mayfield RK. Primary hyperparathyroidism in a twin pregnancy and
review of fetal/maternal calcium homeostasis. Am J Med Sci 319: 191194, 2000.
355. Hagaman JR, Ambrose WW, Hirsch PF. A scanning electron microscopic and photon
absorptiometric study of the development, prolongation, and pattern of recovery
from lactation-induced osteopenia in rats. J Bone Miner Res 5: 123132, 1990.
356. Hagemans ML, van der Schouw YT, de Kleijn MJ, van Staveren WA, Pop VJ, Leusink
GL, Grobbee DE. Indicators for the total duration of premenopausal endogenous
estrogen exposure in relation to BMD. Hum Reprod 19: 21632169, 2004.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
357. Halhali A, Villa AR, Madrazo E, Soria MC, Mercado E, Diaz L, Avila E, Garabedian M,
Larrea F. Longitudinal changes in maternal serum 1,25-dihydroxyvitamin D and insulin
like growth factor I levels in pregnant women who developed preeclampsia: comparison
with normotensive pregnant women. J Steroid Biochem Mol Biol 89 90: 553556, 2004.
358. Halloran BP, Barthell EN, DeLuca HF. Vitamin D metabolism during pregnancy and
lactation in the rat. Proc Natl Acad Sci USA 76: 5549 5553, 1979.
359. Halloran BP, De Luca HF. Effect of vitamin D deficiency on skeletal development
during early growth in the rat. Arch Biochem Biophys 209: 714, 1981.
360. Halloran BP, DeLuca HF. Calcium transport in small intestine during pregnancy and
lactation. Am J Physiol Endocrinol Metab 239: E64 E68, 1980.
361. Halloran BP, DeLuca HF. Effect of vitamin D deficiency on fertility and reproductive
capacity in the female rat. J Nutr 110: 15731580, 1980.
362. Halloran BP, DeLuca HF. Skeletal changes during pregnancy and lactation: the role of
vitamin D. Endocrinology 107: 19231929, 1980.
363. Halloran BP, DeLuca HF. Vitamin D deficiency and reproduction in rats. Science 204:
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
7374, 1979.
364. Hamilton K, Tein M, Glazier J, Mawer EB, Berry JL, Balment RJ, Boyd RD, Garland
HO, Sibley CP. Altered calbindin mRNA expression and calcium regulating hor-
mones in rat diabetic pregnancy. J Endocrinol 164: 6776, 2000.
365. Hansen MA, Overgaard K, Riis BJ, Christiansen C. Potential risk factors for develop-
ment of postmenopausal osteoporosis examined over a 12-year period. Osteoporos
Int 1: 95102, 1991.
366. Harrison JD, Smith TJ, Phipps AW. Infant doses from the transfer of radionuclides in
mothers milk. Radiat Prot Dosimetry 105: 251256, 2003.
367. Hashemipour S, Lalooha F, Zahir Mirdamadi S, Ziaee A, Dabaghi Ghaleh T. Effect of
vitamin D administration in vitamin D-deficient pregnant women on maternal and
neonatal serum calcium and vitamin D concentrations: a randomised clinical trial. Br
J Nutr 110: 16111616, 2013.
368. Hassa H, Tanir HM, Senses T, Oge T, Sahin-Mutlu F. Related factors in bone mineral
density of lumbal and femur in natural postmenopausal women. Arch Gynecol Obstet
273: 86 89, 2005.
369. Hatswell BL, Allan CA, Teng J, Wong P, Ebeling PR, Wallace EM, Fuller PJ, Milat F.
Management of hypoparathyroidism in pregnancy and lactation: a report of 10 cases.
Bone Reports 3: 1519, 2015.
370. Haugen M, Brantsaeter AL, Trogstad L, Alexander J, Roth C, Magnus P, Meltzer HM.
Vitamin D supplementation and reduced risk of preeclampsia in nulliparous women.
Epidemiology 20: 720 726, 2009.
371. Hayslip CC, Klein TA, Wray HL, Duncan WE. The effects of lactation on bone
mineral content in healthy postpartum women. Obstet Gynecol 73: 588 592, 1989.
372. Heaney RP, Skillman TG. Calcium metabolism in normal human pregnancy. J Clin
Endocrinol Metab 33: 661 670, 1971.
373. Heath H, Hodgson SF, Kennedy MA. Primary hyperparathyroidism. Incidence, mor-
bidity, and potential economic impact in a community. N Engl J Med 302: 189 193,
1980.
374. Heidari B, Heidari P, Nourooddini HG, Hajian-Tilaki KO. Relationship between
parity and bone mass in postmenopausal women according to number of parities and
age. J Reprod Med 58: 389 394, 2013.
375. Heidari B, Hosseini R, Javadian Y, Bijani A, Sateri MH, Nouroddini HG. Factors
affecting bone mineral density in postmenopausal women. Arch Osteoporosis 10: 217,
2015.
376. Heinig MJ, Nommsen LA, Peerson JM, Lonnerdal B, Dewey KG. Energy and protein
intakes of breast-fed and formula-fed infants during the first year of life and their
association with growth velocity: the DARLING Study. Am J Clin Nutr 58: 152161,
1993.
377. Hellmeyer L, Boekhoff J, Hadji P. Treatment with teriparatide in a patient with
pregnancy-associated osteoporosis. Gynecol Endocrinol 26: 725728, 2010.
378. Hellmeyer L, Ossendorf A, Ziller V, Tekesin I, Schmidt S, Hadji P. Quantitative
ultrasonometry of the phalanges during pregnancy: a longitudinal study. Climacteric
9: 446 451, 2006.
531
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
379. Henderson PH 3rd, Sowers M, Kutzko KE, Jannausch ML. Bone mineral density in
grand multiparous women with extended lactation. Am J Obstet Gynecol 182: 1371
1377, 2000.
380. Hernandez LL, Gregerson KA, Horseman ND. Mammary gland serotonin regulates
parathyroid hormone-related protein and other bone-related signals. Am J Physiol
Endocrinol Metab 302: E1009 E1015, 2012.
381. Hess HM, Dickson J, Fox HE. Hyperfunctioning parathyroid carcinoma presenting as
acute pancreatitis in pregnancy. J Reprod Med 25: 83 87, 1980.
382. Hicks PD, Hawthorne KM, Berseth CL, Marunycz JD, Heubi JE, Abrams SA. Total
calcium absorption is similar from infant formulas with and without prebiotics and
exceeds that in human milk-fed infants. BMC Pediatr 12: 118, 2012.
383. Hill DD, Cauley JA, Bunker CH, Baker CE, Patrick AL, Beckles GL, Wheeler VW,
Zmuda JM. Correlates of bone mineral density among postmenopausal women of
African Caribbean ancestry: Tobago womens health study. Bone 43: 156 161,
2008.
384. Hillier TA, Rizzo JH, Pedula KL, Stone KL, Cauley JA, Bauer DC, Cummings SR.
Nulliparity and fracture risk in older women: the study of osteoporotic fractures. J
Bone Miner Res 18: 893 899, 2003.
385. Hillman L, Sateesha S, Haussler M, Wiest W, Slatopolsky E, Haddad J. Control of
mineral homeostasis during lactation: interrelationships of 25-hydroxyvitamin D,
24,25-dihydroxyvitamin D, 1,25-dihydroxyvitamin D, parathyroid hormone, calci-
tonin, prolactin, and estradiol. Am J Obstet Gynecol 139: 471 476, 1981.
386. Hillman LS, Haddad JG. Human perinatal vitamin D metabolism. I. 25-Hydroxyvita-
min D in maternal and cord blood. J Pediatr 84: 742749, 1974.
387. Hillman LS, Slatopolsky E, Haddad JG. Perinatal vitamin D metabolism. IV. Maternal
and cord serum 24,25-dihydroxyvitamin D concentrations. J Clin Endocrinol Metab
47: 10731077, 1978.
388. Hillyard CJ, Stevenson JC, MacIntyre I. Relative deficiency of plasma-calcitonin in
normal women. Lancet 1: 961962, 1978.
389. Hiremath M, Wysolmerski J. Role of PTHrP in mammary gland development and
breast cancer. Clin Rev Bone Miner Metab 12: 178 189, 2014.
390. Hirota Y, Anai T, Miyakawa I. Parathyroid hormone-related protein levels in mater-
nal and cord blood. Am J Obstet Gynecol 177: 702706, 1997.
391. Hirsch D, Kopel V, Nadler V, Levy S, Toledano Y, Tsvetov G. Pregnancy outcomes
in women with primary hyperparathyroidism. J Clin Endocrinol Metab 100: 2115
2122, 2015.
392. Hirsch PF, Hagaman JR. Reduced bone mass in calcitonin-deficient rats whether
lactating or not. J Bone Miner Res 1: 199 206, 1986.
393. Hiyaoka A, Yoshida T, Cho F, Yoshikawa Y. Changes in bone mineral density of
lumbar vertebrae after parturition in African green monkeys (Cercopithecus ae-
thiops). Exp Anim 45: 257259, 1996.
394. Ho C, Conner DA, Pollak MR, Ladd DJ, Kifor O, Warren HB, Brown EM, Seidman
JG, Seidman CE. A mouse model of human familial hypocalciuric hypercalcemia and
neonatal severe hyperparathyroidism. Nat Genet 11: 389 394, 1995.
395. Hodnett DW, DeLuca HF, Jorgensen NA. Bone mineral loss during lactation occurs
in absence of parathyroid tissue. Am J Physiol Endocrinol Metab 262: E230 E233,
1992.
396. Hodnett DW, DeLuca HF, Jorgensen NA. Intestine, bone, and mammary gland
contributions to maternal plasma calcium increase after abrupt weaning. Proc Soc Exp
Biol Med 199: 332336, 1992.
397. Hoffman S, Grisso JA, Kelsey JL, Gammon MD, OBrien LA. Parity, lactation and hip
fracture. Osteoporos Int 3: 171176, 1993.
398. Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L, Torloni MR. Calcium supplementation
during pregnancy for preventing hypertensive disorders and related problems. Co-
chrane Database Syst Rev 6: CD001059, 2014.
399. Hollis BW, Johnson D, Hulsey TC, Ebeling M, Wagner CL. Vitamin D supplementa-
tion during pregnancy: double-blind, randomized clinical trial of safety and effective-
ness. J Bone Miner Res 26: 23412357, 2011.
532 Physiol Rev VOL 96 APRIL 2016 www.prv.org
400. Hollis BW, Roos BA, Draper HH, Lambert PW. Vitamin D and its metabolites in
human and bovine milk. J Nutr 111: 1240 1248, 1981.
401. Hollis BW, Wagner CL. Vitamin D and pregnancy: skeletal effects, nonskeletal ef-
fects, and birth outcomes. Calcif Tissue Int 92: 128 139, 2013.
402. Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal
supplementation as therapy to prevent hypovitaminosis D for both the mother and
the nursing infant. Am J Clin Nutr 80: 1752S1758S, 2004.
403. Holmberg-Marttila D, Leino A, Sievanen H. Bone turnover markers during lactation,
postpartum amenorrhea and resumption of menses. Osteoporos Int 14: 103109,
2003.
404. Holmberg-Marttila D, Sievanen H, Laippala P, Tuimala R. Factors underlying changes
in bone mineral during postpartum amenorrhea and lactation. Osteoporos Int 11:
570 576, 2000.
405. Holmberg-Marttila D, Sievanen H, Tuimala R. Changes in bone mineral density
during pregnancy and postpartum: prospective data on five women. Osteoporos Int
10: 41 46, 1999.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
406. Holmes JL, Van Itallie CM, Rasmussen JE, Anderson JM. Claudin profiling in the
mouse during postnatal intestinal development and along the gastrointestinal tract
reveals complex expression patterns. Gene Expression Patterns 6: 581588, 2006.
407. Holt LE, Howland J. Chapter II: the infants dietary. In: The Diseases of Infancy and
Childhood (8th ed.), edited by Holt LE, Howland J. New York: Appleton, 1922.
408. Honda A, Kurabayashi T, Yahata T, Tomita M, Matsushita H, Takakuwa K, Tanaka K.
Effects of pregnancy and lactation on trabecular bone and marrow adipocytes in rats.
Calcif Tissue Int 67: 367372, 2000.
409. Honda A, Kurabayashi T, Yahata T, Tomita M, Takakuwa K, Tanaka K. Lumbar bone
mineral density changes during pregnancy and lactation. Int J Gynaecol Obstet 63:
253258, 1998.
410. Hoogenboezem T, Degenhart HJ, de Muinck Keizer-Schrama SM, Bouillon R, Grose
WF, Hackeng WH, Visser HK. Vitamin D metabolism in breast-fed infants and their
mothers. Pediatr Res 25: 623 628, 1989.
411. Hoper K, Pavel M, Dorr HG, Kandler C, Kruse K, Wildt L, Hensen J. Calcitriol
administration during pregnancy in a partial DiGeorge anomaly. Dtsch Med Wochen-
schr 119: 1776 1780, 1994.
412. Hopkinson JM, Butte NF, Ellis K, Smith EO. Lactation delays postpartum bone
mineral accretion and temporarily alters its regional distribution in women. J Nutr
130: 777783, 2000.
413. Horwitz MJ, Tedesco MB, Sereika SM, Hollis BW, Garcia-Ocana A, Stewart AF.
Direct comparison of sustained infusion of human parathyroid hormone-related
protein-(136). J Clin Endocrinol Metab 88: 16031609, 2003.
414. Horwitz MJ, Tedesco MB, Sereika SM, Syed MA, Garcia-Ocana A, Bisello A, Hollis
BW, Rosen CJ, Wysolmerski JJ, Dann P, Gundberg C, Stewart AF. Continuous PTH
and PTHrP infusion causes suppression of bone formation and discordant effects on
1,25(OH)2 vitamin D. J Bone Miner Res 20: 17921803, 2005.
415. Howell R, Edmonds DK, Dowsett M, Crook D, Lees B, Stevenson JC. Gonadotro-
pin-releasing hormone analogue (goserelin) plus hormone replacement therapy for
the treatment of endometriosis: a randomized controlled trial. Fertil Steril 64: 474
481, 1995.
416. Hreshchyshyn MM, Hopkins A, Zylstra S, Anbar M. Associations of parity, breast-
feeding, and birth control pills with lumbar spine and femoral neck bone densities.
Am J Obstet Gynecol 159: 318 322, 1988.
417. Huber K, Muscher A, Breves G. Sodium-dependent phosphate transport across the
apical membrane of alveolar epithelium in caprine mammary gland. Comp Biochem
Physiol A Mol Integr Physiol 146: 215222, 2007.
418. Hultin H, Hellman P, Lundgren E, Olovsson M, Ekbom A, Rastad J, Montgomery SM.
Association of parathyroid adenoma and pregnancy with preeclampsia. J Clin Endo-
crinol Metab 94: 3394 3399, 2009.
419. Hunscher HA. Metabolism of women during the reproductive cycle. II. Calcium and
phosphorus utilization in two successive lactation periods. J Biol Chem 86: 3757,
1930.
 CHRISTOPHER S. KOVACS
420. Hunt CD, Johnson LK. Calcium requirements: new estimations for men and women
by cross-sectional statistical analyses of calcium balance data from metabolic studies.
Am J Clin Nutr 86: 1054 1063, 2007.
421. Huo D, Lauderdale DS, Li L. Influence of reproductive factors on hip fracture risk in
Chinese women. Osteoporos Int 14: 694 700, 2003.
422. Hurley DL, Tiegs RD, Wahner HW, Heath H. Axial and appendicular bone mineral
density in patients with long-term deficiency or excess of calcitonin. N Engl J Med
317: 537541, 1987.
423. Hutchesson AC, Hughes SV, Bowden SJ, Ratcliffe WA. In vitro stability of endoge-
nous parathyroid hormone-related protein in blood and plasma. Ann Clin Biochem 31:
3539, 1994.
424. Hwang CS, Park SY, Yu SH, Park JY, Park CT, Han KO. Hypercalcemia induced by
ovarian clear cell carcinoma producing all transcriptional variants of parathyroid
hormone-related peptide gene during pregnancy. Gynecol Oncol 103: 740 744,
2006.
425. Ibrahim MM, Thomas ML, Forte LR. Maternal-fetal relationships in the parathyroid-
ectomized rat. Intestinal calcium transport, serum calcium, immunoreactive para-
thyroid hormone and calcitonin. Biol Neonate 46: 89 97, 1984.
426. Ikeda K, Weir EC, Mangin M, Dannies PS, Kinder B, Deftos LJ, Brown EM, Broadus
AE. Expression of messenger ribonucleic acids encoding a parathyroid hormone-like
peptide in normal human and animal tissues with abnormal expression in human
parathyroid adenomas. Mol Endocrinol 2: 1230 1236, 1988.
427. Ilany J, Vered I, Cohen O. The effect of continuous subcutaneous recombinant PTH
(134) infusion during pregnancy on calcium homeostasis: a case report. Gynecol
Endocrinol 29: 807 810, 2013.
428. Illidge TM, Hussey M, Godden CW. Malignant hypercalcaemia in pregnancy and
antenatal administration of intravenous pamidronate. Clin Oncol 8: 257258, 1996.
429. Inabnet WB, Baldwin D, Daniel RO, Staren ED. Hyperparathyroidism and pancre-
atitis during pregnancy. Surgery 119: 710 713, 1996.
430. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washing-
ton, DC: The National Academies Press, 2011.
431. Isaac R, Merceron R, Caillens G, Raymond JP, Ardaillou R. Effects of calcitonin on
basal and thyrotropin-releasing hormone-stimulated prolactin secretion in man. J
Clin Endocrinol Metab 50: 10111015, 1980.
432. Ishii A, Nakamura M, Nakamura A, Takeda K, Han B, Kakudo K. Expression of
calcitonin receptor in rat mammary gland during lactation. Endocr J 53: 317324,
2006.
433. Iwamoto J, Sato Y, Uzawa M, Matsumoto H. Five-year follow-up of a woman with
pregnancy and lactation-associated osteoporosis and vertebral fractures. Therapeu-
tics Clinical Risk Management 8: 195199, 2012.
434. Jabbar A, Samad L, Akhter J, Khan MA. Pregnancy unmasking hypoparathyroidism.
JPMA 48: 250 251, 1998.
435. Jackson IT, Saleh J, van Heerden JA. Gigantic mammary hyperplasia in pregnancy
associated with pseudohyperparathyroidism. Plastic Reconstructive Surg 84: 806
810, 1989.
436. Jaeger P, Jones W, Clemens TL, Hayslett JP. Evidence that calcitonin stimulates
1,25-dihydroxyvitamin D production and intestinal absorption of calcium in vivo. J
Clin Invest 78: 456 461, 1986.
437. Jagger C, Chambers T, Pondel M. Transgenic mice reveal novel sites of calcitonin
receptor gene expression during development. Biochem Biophys Res Commun 274:
124 129, 2000.
438. Jang JY, Lee JG, Jeong IK, Ahn KJ, Chung HY, Yang HI, Lee SH. A case of post-
pregnancy osteoporosis combined with ankylosing spondylitis. Rheumatol Int 29:
1359 1362, 2009.
439. Jarjou LM, Laskey MA, Sawo Y, Goldberg GR, Cole TJ, Prentice A. Effect of calcium
supplementation in pregnancy on maternal bone outcomes in women with a low
calcium intake. Am J Clin Nutr 92: 450 457, 2010.
440. Jarjou LM, Prentice A, Sawo Y, Laskey MA, Bennett J, Goldberg GR, Cole TJ. Ran-
domized, placebo-controlled, calcium supplementation study in pregnant Gambian
women: effects on breast-milk calcium concentrations and infant birth weight,
Physiol Rev VOL 96 APRIL 2016 www.prv.org
growth, and bone mineral accretion in the first year of life. Am J Clin Nutr 83:
657 666, 2006.
441. Jarjou LM, Sawo Y, Goldberg GR, Laskey MA, Cole TJ, Prentice A. Unexpected
long-term effects of calcium supplementation in pregnancy on maternal bone out-
comes in women with a low calcium intake: a follow-up study. Am J Clin Nutr 98:
723730, 2013.
442. Ji J, Lu R, Zhou X, Xue Y, Shi C, Goltzman D, Miao D. 1,25-Dihydroxyvitamin D3
contributes to regulating mammary calcium transport and modulates neonatal skel-
etal growth and turnover cooperatively with calcium. Am J Physiol Endocrinol Metab
301: E889 E900, 2011.
443. Johansson C, Mellstrom D, Milsom I. Reproductive factors as predictors of bone
density and fractures in women at the age of 70. Maturitas 17: 39 50, 1993.
444. Johnell O, Gullberg B, Kanis JA, Allander E, Elffors L, Dequeker J, Dilsen G, Gennari
C, Lopes Vaz A, Lyritis G. Risk factors for hip fracture in European women: the
MEDOS Study. Mediterranean Osteoporosis Study. J Bone Miner Res 10: 18021815,
1995.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
445. Johnell O, Nilsson BE. Life-style and bone mineral mass in perimenopausal women.
Calcif Tissue Int 36: 354 356, 1984.
446. Johnson LE, DeLuca HF. Vitamin D receptor null mutant mice fed high levels of
calcium are fertile. J Nutr 131: 17871791, 2001.
447. Jonas AJ, Dominguez B. Low breast milk phosphorus concentration in familial hy-
pophosphatemia. J Pediatr Gastroenterol Nutr 8: 541543, 1989.
448. Jones G, Scott FS. A cross-sectional study of smoking and bone mineral density in
premenopausal parous women: effect of body mass index, breastfeeding, and sports
participation. J Bone Miner Res 14: 1628 1633, 1999.
449. Jones KS, Assar S, Vanderschueren D, Bouillon R, Prentice A, Schoenmakers I.
Predictors of 25(OH)D half-life and plasma 25(OH)D concentration in The Gambia
and the UK. Osteoporos Int 26: 11371146, 2015.
450. Jousset V, Legendre B, Besnard P, Segond N, Jullienne A, Garel JM. Calcitonin-like
immunoreactivity and calcitonin gene expression in the placenta and in the mam-
mary gland of the rat. Acta Endocrinol 119: 443 451, 1988.
451. Kalkwarf HJ, Specker BL. Bone mineral loss during lactation and recovery after
weaning. Obstet Gynecol 86: 26 32, 1995.
452. Kalkwarf HJ, Specker BL, Bianchi DC, Ranz J, Ho M. The effect of calcium supple-
mentation on bone density during lactation and after weaning. N Engl J Med 337:
523528, 1997.
453. Kalkwarf HJ, Specker BL, Heubi JE, Vieira NE, Yergey AL. Intestinal calcium absorp-
tion of women during lactation and after weaning. Am J Clin Nutr 63: 526 531, 1996.
454. Kalkwarf HJ, Specker BL, Ho M. Effects of calcium supplementation on calcium
homeostasis and bone turnover in lactating women. J Clin Endocrinol Metab 84:
464 470, 1999.
455. Kalra P, Das V, Agarwal A, Kumar M, Ramesh V, Bhatia E, Gupta S, Singh S, Saxena
P, Bhatia V. Effect of vitamin D supplementation during pregnancy on neonatal
mineral homeostasis and anthropometry of the newborn and infant. Br J Nutr 108:
10521058, 2012.
456. Kaplan EL, Burrington JD, Klementschitsch P, Taylor J, Deftos L. Primary hyperpara-
thyroidism, pregnancy, and neonatal hypocalcemia. Surgery 96: 717722, 1984.
457. Karlsson C, Obrant KJ, Karlsson M. Pregnancy and lactation confer reversible bone
loss in humans. Osteoporos Int 12: 828 834, 2001.
458. Karlsson R, Eden S, Eriksson L, von Schoultz B. Osteocalcin 24-hour profiles during
normal pregnancy. Gynecol Obstet Invest 34: 197201, 1992.
459. Karra MV, Udipi SA, Kirksey A, Roepke JL. Changes in specific nutrients in breast
milk during extended lactation. Am J Clin Nutr 43: 495503, 1986.
460. Kauppi M, Heliovaara M, Impivaara O, Knekt P, Jula A. Parity and risk of hip fracture
in postmenopausal women. Osteoporos Int 22: 17651771, 2011.
461. Kaur M, Godber IM, Lawson N, Baker PN, Pearson D, Hosking DJ. Changes in
serum markers of bone turnover during normal pregnancy. Ann Clin Biochem 40:
508 513, 2003.
533
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
462. Kaur M, Pearson D, Godber I, Lawson N, Baker P, Hosking D. Longitudinal changes
in bone mineral density during normal pregnancy. Bone 32: 449 454, 2003.
463. Kawada T, Ikagawa T, Ikeda E. Factors affecting bone mineral density in the general
adult female population in Japan. Percept Mot Skills 97: 723730, 2003.
464. Kawashima H, Torikai S, Kurokawa K. Calcitonin selectively stimulates 25-hy-
droxyvitamin D3-1 alpha-hydroxylase in proximal straight tubule of rat kidney. Na-
ture 291: 327329, 1981.
465. Kelly PA, Bachelot A, Kedzia C, Hennighausen L, Ormandy CJ, Kopchick JJ, Binart N.
The role of prolactin and growth hormone in mammary gland development. Mol Cell
Endocrinol 197: 127131, 2002.
466. Kelly TR. Primary hyperparathyroidism during pregnancy. Surgery 110: 1028 1034,
1991.
467. Kent GN, Price RI, Gutteridge DH, Allen JR, Blakeman SL, Bhagat CI, St. John A,
Barnes MP, Smith M, Evans DV. Acute effects of an oral calcium load in pregnancy
and lactation: findings on renal calcium conservation and biochemical indices of bone
turnover. Miner Electrolyte Metab 17: 17, 1991.
468. Kent GN, Price RI, Gutteridge DH, Allen JR, Rosman KJ, Smith M, Bhagat CI, Wilson
SG, Retallack RW. Effect of pregnancy and lactation on maternal bone mass and
calcium metabolism. Osteoporos Int 3 Suppl 1: 44 47, 1993.
469. Kent GN, Price RI, Gutteridge DH, Rosman KJ, Smith M, Allen JR, Hickling CJ,
Blakeman SL. The efficiency of intestinal calcium absorption is increased in late
pregnancy but not in established lactation. Calcif Tissue Int 48: 293295, 1991.
470. Kent GN, Price RI, Gutteridge DH, Smith M, Allen JR, Bhagat CI, Barnes MP, Hickling
CJ, Retallack RW, Wilson SG. Human lactation: forearm trabecular bone loss, in-
creased bone turnover, and renal conservation of calcium and inorganic phosphate
with recovery of bone mass following weaning. J Bone Miner Res 5: 361369, 1990.
471. Kerr C, Loken HF, Glendening MB, Gordon CS, Page EW. Calcium and phosphorus
dynamics in pregnancy. Am J Obstet Gynecol 83: 2 8, 1962.
472. Khoo CC, Woo J, Leung PC, Kwok A, Kwok T. Determinants of bone mineral
density in older postmenopausal Chinese women. Climacteric 14: 378 383, 2011.
473. Khosla S, Johansen KL, Ory SJ, OBrien PC, Kao PC. Parathyroid hormone-related
peptide in lactation and in umbilical cord blood. Mayo Clin Proc 65: 1408 1414, 1990.
474. Khosla S, van Heerden JA, Gharib H, Jackson IT, Danks J, Hayman JA, Martin TJ.
Parathyroid hormone-related protein and hypercalcemia secondary to massive
mammary hyperplasia. N Engl J Med 322: 1157, 1990.
475. Khovidhunkit W, Epstein S. Osteoporosis in pregnancy. Osteoporos Int 6: 345354,
1996.
476. Kim MK, Yun KJ, Kim MH, Lim DJ, Kwon HS, Song KH, Kang MI, Baek KH. The
effects of thyrotropin-suppressing therapy on bone metabolism in patients with
well-differentiated thyroid carcinoma. Bone 71: 101105, 2015.
477. Kirby BJ, Ardeshirpour L, Woodrow JP, Wysolmerski JJ, Sims NA, Karaplis AC,
Kovacs CS. Skeletal recovery after weaning does not require PTHrP. J Bone Miner
Res 26: 12421251, 2011.
478. 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 28: 19872000, 2013.
479. Kobayashi A, Kawai S, Obe Y, Nagashima Y. Effects of dietary lactose and lactase
preparation on the intestinal absorption of calcium and magnesium in normal infants.
Am J Clin Nutr 28: 681 683, 1975.
480. Kocian J, Skala I, Bakos K. Calcium absorption from milk and lactose-free milk in
healthy subjects and patients with lactose intolerance. Digestion 9: 317324, 1973.
481. Koetting CA, Wardlaw GM. Wrist, spine, and hip bone density in women with
variable histories of lactation. Am J Clin Nutr 48: 1479 1481, 1988.
482. Kojima N, Douchi T, Kosha S, Nagata Y. Cross-sectional study of the effects of
parturition and lactation on bone mineral density later in life. Maturitas 41: 203209,
2002.
483. Kolnick L, Harris BD, Choma DP, Choma NN. Hypercalcemia in pregnancy: a case
of milk-alkali syndrome. J Gen Intern Med 26: 939 942, 2011.
534 Physiol Rev VOL 96 APRIL 2016 www.prv.org
484. Kolthoff N, Eiken P, Kristensen B, Nielsen SP. Bone mineral changes during preg-
nancy and lactation: a longitudinal cohort study. Clin Sci 94: 405 412, 1998.
485. Kolusari A, Kurdoglu M, Yildizhan R, Adali E, Edirne T, Cebi A, Demir H, Yoruk IH.
Catalase activity, serum trace element and heavy metal concentrations, and vitamin
A, D and E levels in pre-eclampsia. J Int Med Res 36: 13351341, 2008.
486. Komrkov A, Zhor Z, Czabanov V. The effect of lactation on the composition of
long bones in rats. J Lab Clin Med 69: 102109, 1967.
487. Koo WW, Tsang RC. Building better bones: calcium, magnesium, phosphorus, and
vitamin D. In: Nutrition During Infancy: Principles and Practice (2nd ed.), edited by
Tsang RC, Zlotkin SH, Nichols BL, Hansen JW. Cincinnati, OH: Digital Education
Publishing, 1997, p. 175207.
488. Koo WW, Walters JC, Esterlitz J, Levine RJ, Bush AJ, Sibai B. Maternal calcium
supplementation and fetal bone mineralization. Obstet Gynecol 94: 577582, 1999.
489. Korecki CL, Zinser G, Liu X, Siedler J, Welsh J, Niebur GL. Effect of the vitamin D
receptor on bone geometry and strength during gestation and lactation in mice.
Calcif Tissue Int 85: 405 411, 2009.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
490. Kort KC, Schiller HJ, Numann PJ. Hyperparathyroidism and pregnancy. Am J Surg
177: 66 68, 1999.
491. Kos CH, Karaplis AC, Peng JB, Hediger MA, Goltzman D, Mohammad KS, Guise TA,
Pollak MR. The calcium-sensing receptor is required for normal calcium homeostasis
independent of parathyroid hormone. J Clin Invest 111: 10211028, 2003.
492. Kovacs CS. Bone development and mineral homeostasis in the fetus and neonate:
roles of the calciotropic and phosphotropic hormones. Physiol Rev 94: 11431218,
2014.
493. Kovacs CS. Calcium and bone metabolism during pregnancy and lactation. J Mam-
mary Gland Biol Neoplasia 10: 105118, 2005.
494. Kovacs CS. Interactions of PTHrP with receptors and signaling. In: The Parathyroids
(3rd ed.), edited by Bilezikian JP, Marcus R, Levine MA, Marcocci C, Potts JTJr.,
Silverberg SJ. San Diego, CA: Elsevier, 2014, p. 8199.
495. Kovacs CS. The role of vitamin D in pregnancy and lactation: insights from animal
models and clinical studies. Annu Rev Nutr 32: 9.1.27819, 2012.
496. Kovacs CS, Chafe LL, Woodland ML, McDonald KR, Fudge NJ, Wookey PJ. Calcit-
ropic gene expression suggests a role for intraplacental yolk sac in maternal-fetal
calcium exchange. Am J Physiol Endocrinol Metab 282: E721E732, 2002.
497. Kovacs CS, Chik CL. Hyperprolactinemia caused by lactation and pituitary adeno-
mas is associated with altered serum calcium, phosphate, parathyroid hormone
(PTH), and PTH-related peptide levels. J Clin Endocrinol Metab 80: 3036 3042,
1995.
498. Kovacs CS, Ho-Pao CL, Hunzelman JL, Lanske B, Fox J, Seidman JG, Seidman CE,
Kronenberg HM. Regulation of murine fetal-placental calcium metabolism by the
calcium-sensing receptor. J Clin Invest 101: 28122820, 1998.
499. Kovacs CS, Kronenberg HM. Maternal-fetal calcium and bone metabolism during
pregnancy, puerperium, and lactation. Endocr Rev 18: 832 872, 1997.
500. Kovacs CS, Lanske B, Hunzelman JL, Guo J, Karaplis AC, Kronenberg HM. Parathy-
roid hormone-related peptide (PTHrP) regulates fetal-placental calcium transport
through a receptor distinct from the PTH/PTHrP receptor. Proc Natl Acad Sci USA
93: 1523315238, 1996.
501. Kovacs CS, Ralston SH. Presentation and management of osteoporosis presenting in
association with pregnancy or lactation. Osteoporos Int 26: 22232241, 2015.
502. Kovacs CS, Woodland ML, Fudge NJ, Friel JK. The vitamin D receptor is not required
for fetal mineral homeostasis or for the regulation of placental calcium transfer. Am
J Physiol Endocrinol Metab 289: E133E144, 2005.
503. Kovarik J, Woloszczuk W, Linkesch W, Pavelka R. Calcitonin in pregnancy (Letter).
Lancet 1: 199 200, 1980.
504. Kraemer B, Schneider S, Rothmund R, Fehm T, Wallwiener D, Solomayer EF.
Influence of pregnancy on bone density: a risk factor for osteoporosis? Measure-
ments of the calcaneus by ultrasonometry. Arch Gynecol Obstet 285: 907912,
2012.
 CHRISTOPHER S. KOVACS
505. Krebs NF, Reidinger CJ, Robertson AD, Brenner M. Bone mineral density changes
during lactation: maternal, dietary, and biochemical correlates. Am J Clin Nutr 65:
1738 1746, 1997.
506. Kreiger N, Gross A, Hunter G. Dietary factors and fracture in postmenopausal
women: a case-control study. Int J Epidemiol 21: 953958, 1992.
507. Kreiger N, Kelsey JL, Holford TR, OConnor T. An epidemiologic study of hip
fracture in postmenopausal women. Am J Epidemiol 116: 141148, 1982.
508. Kristoffersson A, Dahlgren S, Lithner F, Jarhult J. Primary hyperparathyroidism in
pregnancy. Surgery 97: 326 330, 1985.
509. Kritz-Silverstein D, Barrett-Connor E, Hollenbach KA. Pregnancy and lactation as
determinants of bone mineral density in postmenopausal women. Am J Epidemiol
136: 10521059, 1992.
510. Krysiak R, Kobielusz-Gembala I, Okopien B. Hypoparathyroidism in pregnancy. Gy-
necol Endocrinol 27: 529 532, 2011.
511. Krysiak R, Wilk M, Okopien B. Recurrent pancreatitis induced by hyperparathyroid-
ism in pregnancy. Arch Gynecol Obstet 284: 531534, 2011.
512. Kubota M, Ohno J, Shiina Y, Suda T. Vitamin D metabolism in pregnant rabbits:
differences between the maternal and fetal response to administration of large
amounts of vitamin D3. Endocrinology 110: 1950 1956, 1982.
513. Kudo T, Miyauchi A, Ito Y, Yabuta T, Inoue H, Higashiyama T, Tomoda C, Hirokawa
M, Amino N. Serum calcitonin levels with calcium loading tests before and after total
thyroidectomy in patients with thyroid diseases other than medullary thyroid carci-
noma. Endocr J 58: 217221, 2011.
514. Kumar R, Abboud CF, Riggs BL. The effect of elevated prolactin levels on plasma
1,25-dihydroxyvitamin D and intestinal absorption of calcium. Mayo Clin Proc 55:
5153, 1980.
515. Kunz C, Niesen M, von Lilienfeld-Toal H, Burmeister W. Vitamin D, 25-hydroxy-
vitamin D and 1,25-dihydroxy-vitamin D in cows milk, infant formulas and breast
milk during different stages of lactation. Int J Vitamin Nutr Res 54: 141148, 1984.
516. Kuro-o M. Klotho and aging. Biochim Biophys Acta 1790: 1049 1058, 2009.
517. Kurzel RB, Hagen GA. Use of thiazide diuretics to reduce the hypercalciuria of
hypoparathyroidism during pregnancy. Am J Perinatol 7: 333336, 1990.
518. Kusy RP, Peng TC, Hirsch PF, Garner SC. Interrelationships of bone ash and whole
bone properties in the lactating and parous rat. Calcif Tissue Int 41: 337341, 1987.
519. LaBorde JB, Wall KS, Bolon B, Kumpe TS, Patton R, Zheng Q, Kodell R, Young JF.
Haematology and serum chemistry parameters of the pregnant rat. Lab Anim 33:
275287, 1999.
520. Lachenmaier-Currle U, Breves G, Harmeyer J. Role of 1,25-(OH)2D3 during preg-
nancy; studies with pigs suffering from pseudo-vitamin D-deficiency rickets, type I. Q
J Exp Physiol 74: 875 881, 1989.
521. Lachenmaier-Currle U, Harmeyer J. Placental transport of calcium and phosphorus
in pigs. J Perinat Med 17: 127136, 1989.
522. Laitinen K, Valimaki M, Keto P. Bone mineral density measured by dual-energy X-ray
absorptiometry in healthy Finnish women. Calcif Tissue Int 48: 224 231, 1991.
523. Lakhanpal S, Ginsburg WW, Luthra HS, Hunder GG. Transient regional osteoporo-
sis. A study of 56 cases and review of the literature. Ann Intern Med 106: 444 450,
1987.
524. Lalau JD, Jans I, el Esper N, Bouillon R, Fournier A. Calcium metabolism, plasma
parathyroid hormone, and calcitriol in transient hypertension of pregnancy. Am J
Hypertens 6: 522527, 1993.
525. Lambrinoudaki I, Flokatoula M, Armeni E, Pliatsika P, Augoulea A, Antoniou A,
Alexandrou A, Creatsa M, Panoulis C, Dendrinos S, Papacharalambous X. Vertebral
fracture prevalence among Greek healthy middle-aged postmenopausal women:
association with demographics, anthropometric parameters, and bone mineral den-
sity. Spine J 15: 86 94, 2015.
526. Lamke B, Brundin J, Moberg P. Changes of bone mineral content during pregnancy
and lactation. Acta Obstet Gynecol Scand 56: 217219, 1977.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
527. Lampropoulou-Adamidou K, Trovas G, Stathopoulos IP, Papaioannou NA. Case
report: teriparatide treatment in a case of severe pregnancy- and lactation-associ-
ated osteoporosis. Hormones 11: 495500, 2012.
528. Landing BH, Kamoshita S. Congenital hyperparathyroidism secondary to maternal
hypoparathyroidism. J Pediatr 77: 842 847, 1970.
529. Laplace C, Li X, Goldring SR, Galson DL. Homozygous deletion of the murine
calcitonin receptor gene is an embryonic lethal (Abstract). J Bone Miner Res 17 Suppl:
S166, 2002.
530. Laporta J, Peters TL, Weaver SR, Merriman KE, Hernandez LL. Feeding 5-hydroxy-
L-tryptophan during the transition from pregnancy to lactation increases calcium
mobilization from bone in rats. Domest Anim Endocrinol 44: 176 184, 2013.
531. Larsson T, Marsell R, Schipani E, Ohlsson C, Ljunggren O, Tenenhouse HS, Juppner
H, Jonsson KB. Transgenic mice expressing fibroblast growth factor 23 under the
control of the alpha1(I) collagen promoter exhibit growth retardation, osteomalacia,
and disturbed phosphate homeostasis. Endocrinology 145: 30873094, 2004.
532. Laskey MA, Prentice A. Bone mineral changes during and after lactation. Obstet
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
Gynecol 94: 608 615, 1999.
533. Laskey MA, Prentice A. Do appendicular bone measurements reflect changes in the
axial skeleton?: the use of dual-energy X-ray absorptiometry and ultrasound mea-
surements during lactation. J Clin Densitom 7: 296 301, 2004.
534. Laskey MA, Prentice A. Effect of pregnancy on recovery of lactational bone loss
(Letter). Lancet 349: 1518 1519, 1997.
535. Laskey MA, Prentice A, Hanratty LA, Jarjou LM, Dibba B, Beavan SR, Cole TJ. Bone
changes after 3 mo of lactation: influence of calcium intake, breast-milk output, and
vitamin D-receptor genotype. Am J Clin Nutr 67: 685 692, 1998.
536. Laskey MA, Prentice A, Shaw J, Zachou T, Ceesay SM, Vasquez-Velasquez L, Fraser
DR. Breast-milk calcium concentrations during prolonged lactation in British and
rural Gambian mothers. Acta Paediatr Scand 79: 507512, 1990.
537. Laskey MA, Price RI, Khoo BC, Prentice A. Proximal femur structural geometry
changes during and following lactation. Bone 48: 755759, 2011.
538. Latta K, Hisano S, Chan JC. Therapeutics of X-linked hypophosphatemic rickets.
Pediatr Nephrol 7: 744 748, 1993.
539. Law FM, Moate PJ, Leaver DD, Diefenbach-Jagger H, Grill V, Ho PW, Martin TJ.
Parathyroid hormone-related protein in milk and its correlation with bovine milk
calcium. J Endocrinol 128: 2126, 1991.
540. Le Boulch N, Cancela L, Miravet L. Calcidiol in human milk. The effect of prohor-
mone on vitamin D status of breast fed unsupplemented infants. Endocrinol Exp 20:
325328, 1986.
541. Lebel E, Mishukov Y, Babchenko L, Samueloff A, Zimran A, Elstein D. Bone mineral
density in gravida: effect of pregnancies and breast-feeding in women of differing
ages and parity. J Osteoporos 2014: 897182, 2014.
542. Lee CY, Koren G. Maternal obesity: effects on pregnancy and the role of pre-
conception counselling. J Obstet Gynaecol 30: 101106, 2010.
543. Lee MY, Park JH, Bae KS, Jee YG, Ko AN, Han YJ, Shin JY, Lim JS, Chung CH, Kang
SJ. Bone mineral density and bone turnover markers in patients on long-term sup-
pressive levothyroxine therapy for differentiated thyroid cancer. Ann Surg Treat Res
86: 55 60, 2014.
544. Lee SH, Hong MK, Park SW, Park HM, Kim J, Ahn J. A case of teriparatide on
pregnancy-induced osteoporosis. J Bone Metab 20: 111114, 2013.
545. Leerbeck E, Sondergaard H. The total content of vitamin D in human milk and cows
milk. Br J Nutr 44: 712, 1980.
546. Leitch I, Aitken FC. The estimation of calcium requirement: a re-examination. Nutr
Abstr Rev Ser Hum Exp 29: 393 411, 1959.
547. Lenora J, Lekamwasam S, Karlsson MK. Effects of multiparity and prolonged breast-
feeding on maternal bone mineral density: a community-based cross-sectional study.
BMC Womens Health 9: 19, 2009.
548. Leopold SS, Boskey AL, Doty SB, Gertner JM, Peterson MG, Torzilli PA. Diminished
material properties and altered bone structure in rat femora during pregnancy. J
Orthop Res 13: 41 49, 1995.
535
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
549. Lepre F, Grill V, Ho PW, Martin TJ. Hypercalcemia in pregnancy and lactation
associated with parathyroid hormone-related protein (Letter). N Engl J Med 328:
666 667, 1993.
550. Lewin IG, Papapoulos SE, Hendy GN, Tomlinson S, ORiordan JL. Reversible resis-
tance to the renal action of parathyroid hormone in human vitamin D deficiency. Clin
Sci 62: 381387, 1982.
551. Lewis P, Rafferty B, Shelley M, Robinson CJ. A suggested physiological role of calci-
tonin: the protection of the skeleton during pregnancy and lactation. J Endocrinol 49:
ixx, 19710.
552. Li H, Sun Y, Zheng H, Li L, Yu Q, Yao X. Parathyroid hormone-related protein
overexpression protects goat mammary gland epithelial cells from calcium-sensing
receptor activation-induced apoptosis. Mol Biol Rep 42: 233243, 2015.
553. Li YC, Amling M, Pirro AE, Priemel M, Meuse J, Baron R, Delling G, Demay MB.
Normalization of mineral ion homeostasis by dietary means prevents hyperparathy-
roidism, rickets, and osteomalacia, but not alopecia in vitamin D receptor-ablated
mice. Endocrinology 139: 4391 4396, 1998.
554. Li YC, Pirro AE, Amling M, Delling G, Baron R, Bronson R, Demay MB. Targeted
ablation of the vitamin D receptor: an animal model of vitamin D dependent rickets
type II with alopecia. Proc Natl Acad Sci USA 94: 98319835, 1997.
555. Lieben L, Masuyama R, Torrekens S, Van Looveren R, Schrooten J, Baatsen P,
Lafage-Proust MH, Dresselaers T, Feng JQ, Bonewald LF, Meyer MB, Pike JW,
Bouillon R, Carmeliet G. Normocalcemia is maintained in mice under conditions of
calcium malabsorption by vitamin D-induced inhibition of bone mineralization. J Clin
Invest 122: 18031815, 2012.
556. Liel Y, Atar D, Ohana N. Pregnancy-associated osteoporosis: preliminary densito-
metric evidence of extremely rapid recovery of bone mineral density. South Med J 91:
3335, 1998.
557. Lippuner K, Zehnder HJ, Casez JP, Takkinen R, Jaeger P. Effects of PTH-related
protein (PTH-rP) on calcium-phosphate metabolism in nursing mothers (Abstract).
Bone 16 Suppl 1: 209S, 1995.
558. Lippuner K, Zehnder HJ, Casez JP, Takkinen R, Jaeger P. PTH-related protein is
released into the mothers bloodstream during lactation: Evidence for beneficial
effects on maternal calcium-phosphate metabolism. J Bone Miner Res 11: 1394
1399, 1996.
559. Lissner L, Bengtsson C, Hansson T. Bone mineral content in relation to lactation
history in pre- and postmenopausal women. Calcif Tissue Int 48: 319 325, 1991.
560. Little KD, Clapp JF 3rd. Self-selected recreational exercise has no impact on early
postpartum lactation-induced bone loss. Med Sci Sports Exercise 30: 831 836, 1998.
561. Liu C, Zhang N, Yu H, Chen Y, Liang Y, Deng H, Zhang Z. Proteomic analysis of
human serum for finding pathogenic factors and potential biomarkers in preeclamp-
sia. Placenta 32: 168 174, 2011.
562. Liu J, Lv F, Sun W, Tao C, Ding G, Karaplis A, Brown E, Goltzman D, Miao D. The
abnormal phenotypes of cartilage and bone in calcium-sensing receptor deficient
mice are dependent on the actions of calcium, phosphorus, and PTH. PLoS Genet 7:
e1002294, 2011.
563. Liu NQ, Ouyang Y, Bulut Y, Lagishetty V, Chan SY, Hollis BW, Wagner C, Equils O,
Hewison M. Dietary vitamin D restriction in pregnant female mice is associated with
maternal hypertension and altered placental and fetal development. Endocrinology
154: 2270 2280, 2013.
564. Liu S, Zhou J, Tang W, Jiang X, Rowe DW, Quarles LD. Pathogenic role of Fgf23 in
Hyp mice. Am J Physiol Endocrinol Metab 291: E38 E49, 2006.
565. Liu X, Shimono K, Zhu LL, Li J, Peng Y, Imam A, Iqbal J, Moonga S, Colaianni G, Su C,
Lu Z, Iwamoto M, Pacifici M, Zallone A, Sun L, Zaidi M. Oxytocin deficiency impairs
maternal skeletal remodeling. Biochem Biophys Res Commun 388: 161166, 2009.
566. Liu XS, Ardeshirpour L, VanHouten JN, Shane E, Wysolmerski JJ. Site-specific
changes in bone microarchitecture, mineralization, and stiffness during lactation and
after weaning in mice. J Bone Miner Res 27: 865 875, 2012.
567. Lobaugh B, Boass A, Garner SC, Toverud SU. Intensity of lactation modulates renal
1-hydroxylase and serum 1,25(OH)2D in rats. Am J Physiol Endocrinol Metab 262:
E840 E844, 1992.
536 Physiol Rev VOL 96 APRIL 2016 www.prv.org
568. Lobaugh B, Boass A, Lester GE, Toverud SU. Regulation of serum 1,25-dihydroxyvi-
tamin D3 in lactating rats. Am J Physiol Endocrinol Metab 259: E665E671, 1990.
569. Lobaugh B, Garner SC, Lovdal JA, Boass A, Toverud SU. Parathyroidectomy abol-
ishes the increase of renal 25-hydroxyvitamin D-1 alpha-hydroxylase in lactating rats.
Am J Physiol Endocrinol Metab 264: E981E985, 1993.
570. Lombardi G, Lanteri P, Colombini A, Banfi G. Blood biochemical markers of bone
turnover: pre-analytical and technical aspects of sample collection and handling. Clin
Chem Lab Med 50: 771789, 2012.
571. Longstreth PL, Malinak LR, Hill CS Jr. Transient osteoporosis of the hip in pregnancy.
Obstet Gynecol 41: 563569, 1973.
572. Lopez JM, Gonzalez G, Reyes V, Campino C, Diaz S. Bone turnover and density in
healthy women during breastfeeding and after weaning. Osteoporos Int 6: 153159,
1996.
573. Lose G, Lindholm P. Transient painful osteoporosis of the hip in pregnancy. Int J
Gynaecol Obstet 24: 1316, 1986.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
574. Lovelady CA, Bopp MJ, Colleran HL, Mackie HK, Wideman L. Effect of exercise
training on loss of bone mineral density during lactation. Med Sci Sports Exercise 41:
19021907, 2009.
575. Lubetzky R, Weisman Y, Dollberg S, Herman L, Mandel D. Parathyroid hormone-
related protein in preterm human milk. Breastfeed Med 5: 67 69, 2010.
576. Ludwig GD. Hyperparathyroidism in relation to pregnancy. N Engl J Med 267: 637
642, 1962.
577. Lumb GA, Stanbury SW. Parathyroid function in human vitamin D deficiency and
vitamin D deficiency in primary hyperparathyroidism. Am J Med 56: 833 839, 1974.
578. Lund B, Selnes A. Plasma 1,25-dihydroxyvitamin D levels in pregnancy and lactation.
Acta Endocrinol 92: 330 335, 1979.
579. Lutz P, Kane O, Pfersdorff A, Seiller F, Sauvage P, Levy JM. Neonatal primary
hyperparathyroidism: total parathyroidectomy with autotransplantation of cryopre-
served parathyroid tissue. Acta Paediatr Scand 75: 179 182, 1986.
580. Ma Y. Lactational changes in the bone metabolism of mice lacking one copy of the
calcitonin receptor gene (MSc Thesis). In: Biomedical Sciences, Faculty of Medicine. St.
Johns, Newfoundland: Memorial University of Newfoundland, 2012, p. 125.
581. Ma Y, Samaraweera M, Cooke-Hubley S, Kirby BJ, Karaplis AC, Lanske B, Kovacs
CS. Neither absence nor excess of FGF23 disturbs murine fetal-placental phospho-
rus homeostasis or prenatal skeletal development and mineralization. Endocrinology
155: 1596 1605, 2014.
582. Macy IG. Composition of human colostrum and milk. Am J Dis Child 78: 589 603,
1949.
583. Macy IG, Hunscher HA, Donelson E, Nims B. Human milk flow. Am J Dis Child 39:
1186 1204, 1930.
584. Macy IG, Kelly HJ, Sloan RE. The Composition of Milks: A Compilation of the Compar-
ative Composition and Properties of Human, Cow, and Goat Milk, Colostrum, and Tran-
sitional Milk: Publication 254. Washington, DC: National Academy of Sciences-Na-
tional Research Council, 1953.
585. Madar AA, Stene LC, Meyer HE. Vitamin D status among immigrant mothers from
Pakistan, Turkey and Somalia and their infants attending child health clinics in Nor-
way. Br J Nutr 101: 10521058, 2009.
586. Mainoya JR. Effects of bovine growth hormone, human placental lactogen and ovine
prolactin on intestinal fluid and ion transport in the rat. Endocrinology 96: 11651170,
1975.
587. Makin HL, Seamark DA, Trafford DJ. Vitamin D and its metabolites in human breast
milk. Arch Dis Child 58: 750 753, 1983.
588. Mallet E, Gugi B, Brunelle P, Henocq A, Basuyau JP, Lemeur H. Vitamin D supple-
mentation in pregnancy: a controlled trial of two methods. Obstet Gynecol 68: 300
304, 1986.
589. Malloy PJ, Tiosano D, Feldman D. Hereditary 1,25-dihydroxyvitamin-D-resistant
rickets. In: Vitamin D (3rd ed.), edited by Feldman D, Pike JW, Adams JS. San Diego,
CA: Academic, 2011, p. 11971232.
 CHRISTOPHER S. KOVACS
590. Malpeli A, Apezteguia M, Mansur JL, Armanini A, Macias Couret M, Villalobos R,
Kuzminczuk M, Gonzalez HF. Calcium supplementation, bone mineral density and
bone mineral content. Predictors of bone mass changes in adolescent mothers
during the 6-month postpartum period. Arch Latinoam Nutr 62: 30 36, 2012.
591. Mamillapalli R, VanHouten J, Dann P, Bikle D, Chang W, Brown E, Wysolmerski J.
Mammary-specific ablation of the calcium-sensing receptor during lactation alters
maternal calcium metabolism, milk calcium transport, and neonatal calcium accrual.
Endocrinology 154: 30313042, 2013.
592. Mamillapalli R, VanHouten J, Zawalich W, Wysolmerski J. Switching of G-protein
usage by the calcium-sensing receptor reverses its effect on parathyroid hormone-
related protein secretion in normal versus malignant breast cells. J Biol Chem 283:
2443524447, 2008.
593. Mangin M, Webb AC, Dreyer BE, Posillico JT, Ikeda K, Weir EC, Stewart AF, Bander
NH, Milstone L, Barton DE, Francke U, Broadus AE. Identification of a cDNA
encoding a parathyroid hormone-like peptide from a human tumor associated with
humoral hypercalcemia of malignancy. Proc Natl Acad Sci USA 85: 597 601, 1988.
594. Manisco G, Poti M, Maggiulli G, Di Tullio M, Losappio V, Vernaglione L. Pregnancy in
end-stage renal disease patients on dialysis: how to achieve a successful delivery. Clin
Kidney J 8: 293299, 2015.
595. Mannik J, Vaas P, Rull K, Teesalu P, Laan M. Differential placental expression profile
of human Growth Hormone/Chorionic Somatomammotropin genes in pregnancies
with pre-eclampsia and gestational diabetes mellitus. Mol Cell Endocrinol 355: 180
187, 2012.
596. Marche P, Delorme A, Cuisinier-Gleizes P. Intestinal and placental calcium-binding
proteins in vitamin D-deprived or -supplemented rats. Life Sci 23: 25552561, 1978.
597. Mariconda M, Pavia M, Colonna A, Angelillo IF, Marsico O, Sanzo F, Mancuso C,
Milano C. Appendicular bone density, biochemical markers of bone turnover and
lifestyle factors in female teachers of Southern Italy. Eur J Epidemiol 13: 909 917,
1997.
598. Marie PJ, Cancela L, Le Boulch N, Miravet L. Bone changes due to pregnancy and
lactation: influence of vitamin D status. Am J Physiol Endocrinol Metab 251: E400
E406, 1986.
599. Markestad T, Ulstein M, Aksnes L, Aarskog D. Serum concentrations of vitamin D
metabolites in vitamin D supplemented pregnant women. A longitudinal study. Acta
Obstet Gynecol Scand 65: 63 67, 1986.
600. Markestad T, Ulstein M, Bassoe HH, Aksnes L, Aarskog D. Vitamin D metabolism in
normal and hypoparathyroid pregnancy and lactation. Case report. Br J Obstet
Gynaecol 90: 971976, 1983.
601. Marwaha RK, Tandon N, Chopra S, Agarwal N, Garg MK, Sharma B, Kanwar RS,
Bhadra K, Singh S, Mani K, Puri S. Vitamin D status in pregnant Indian women across
trimesters and different seasons and its correlation with neonatal serum 25-hy-
droxyvitamin D levels. Br J Nutr 106: 13831389, 2011.
602. Marx SJ, Swart EG Jr, Hamstra AJ, DeLuca HF. Normal intrauterine development of
the fetus of a woman receiving extraordinarily high doses of 1,25-dihydroxyvitamin
D3. J Clin Endocrinol Metab 51: 1138 1142, 1980.
603. Marx SJ, Zusman RM, Umiker WO. Benign breast dysplasia causing hypercalcemia. J
Clin Endocrinol Metab 45: 1049 1052, 1977.
604. Marya RK, Rathee S, Dua V, Sangwan K. Effect of vitamin D supplementation during
pregnancy on foetal growth. Indian J Med Res 88: 488 492, 1988.
605. Marya RK, Rathee S, Lata V, Mudgil S. Effects of vitamin D supplementation in
pregnancy. Gynecol Obstet Invest 12: 155161, 1981.
606. Masuyama R, Stockmans I, Torrekens S, Van Looveren R, Maes C, Carmeliet P,
Bouillon R, Carmeliet G. Vitamin D receptor in chondrocytes promotes osteoclas-
togenesis and regulates FGF23 production in osteoblasts. J Clin Invest 116: 3150
3159, 2006.
607. Mather KJ, Chik CL, Corenblum B. Maintenance of serum calcium by parathyroid
hormone-related peptide during lactation in a hypoparathyroid patient. J Clin Endo-
crinol Metab 84: 424 427, 1999.
608. Matsen SL, Yeo CJ, Hruban RH, Choti MA. Hypercalcemia and pancreatic endocrine
neoplasia with elevated PTH-rP: report of two new cases and subject review. J
Gastrointest Surg 9: 270 279, 2005.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
609. Matsumoto I, Kosha S, Noguchi S, Kojima N, Oki T, Douchi T, Nagata Y. Changes of
bone mineral density in pregnant and postpartum women. J Obstet Gynaecol 21:
419 425, 1995.
610. Matsushita H, Hara M, Honda K, Kuroda M, Usui M, Nakazawa H, Hara S, Shishiba
Y. Inhibition of parathyroid hormone-related protein release by extracellular calcium
in dispersed cells from human parathyroid hyperplasia secondary to chronic renal
failure and adenoma. Am J Pathol 146: 15211528, 1995.
611. Matsushita H, Kurabayashi T, Tomita M, Honda A, Takakuwa K, Tanaka K. The
effect of multiple pregnancies on lumbar bone mineral density in Japanese women.
Calcif Tissue Int 71: 10 13, 2002.
612. Matthias GS, Helliwell TR, Williams A. Postpartum hyperparathyroid crisis. Case
report. Br J Obstet Gynaecol 94: 807 810, 1987.
613. Mayer GP, Ramberg CF Jr, Kronfeld DS, Buckle RM, Sherwood LM, Aurbach GD,
Potts JT Jr. Plasma parathyroid hormone concentration in hypocalcemic parturient
cows. Am J Vet Res 30: 15871597, 1969.
614. McCormick TC, Muffly T, Lu G, Shoup B. Aggressive small cell carcinoma of the
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
ovary, hypercalcemic type with hypercalcemia in pregnancy, treated with conserva-
tive surgery and chemotherapy. Int J Gynecol Cancer 19: 1339 1341, 2009.
615. McDonald KR, Fudge NJ, Woodrow JP, Friel JK, Hoff AO, Gagel RF, Kovacs CS.
Ablation of calcitonin/calcitonin gene related peptide- impairs fetal magnesium but
not calcium homeostasis. Am J Physiol Endocrinol Metab 287: E218 E226, 2004.
616. McDonnell CM, Zacharin MR. Maternal primary hyperparathyroidism: discordant
outcomes in a twin pregnancy. J Paediatr Child Health 42: 70 71, 2006.
617. McManaman JL, Neville MC. Mammary physiology and milk secretion. Adv Drug Deliv
Rev 55: 629 641, 2003.
618. Mehta S, Hunter DJ, Mugusi FM, Spiegelman D, Manji KP, Giovannucci EL, Hertz-
mark E, Msamanga GI, Fawzi WW. Perinatal outcomes, including mother-to-child
transmission of HIV, and child mortality and their association with maternal vitamin
D status in Tanzania. J Infect Dis 200: 10221030, 2009.
619. Melton LJ, Bryant SC, Wahner HW, OFallon WM, Malkasian GD, Judd HL, Riggs BL.
Influence of breastfeeding and other reproductive factors on bone mass later in life.
Osteoporos Int 3: 76 83, 1993.
620. Melton ME, DAnza JJ, Wimbiscus SA, Grill V, Martin TJ, Kukreja SC. Parathyroid
hormone-related protein and calcium homeostasis in lactating mice. Am J Physiol
Endocrinol Metab 259: E792E796, 1990.
621. Mendez RO, Gallegos AC, Cabrera RM, Quihui L, Zozaya R, Morales GG, Valencia
ME, Mendez M. Bone mineral density changes in lactating adolescent mothers during
the first postpartum year. Am J Hum Biol 25: 222224, 2013.
622. Merewood A, Mehta SD, Chen TC, Bauchner H, Holick MF. Association between
vitamin D deficiency and primary cesarean section. J Clin Endocrinol Metab 94: 940
945, 2009.
623. Merviel P, Muller F, Guibourdenche J, Berkane N, Gaudet R, Breart G, Uzan S.
Correlations between serum assays of human chorionic gonadotrophin (hCG) and
human placental lactogen (hPL) and pre-eclampsia or intrauterine growth restriction
(IUGR) among nulliparas younger than 38 years. Eur J Obstet Gynecol Reprod Biol 95:
59 67, 2001.
624. Metz SA, Baylink DJ, Hughes MR, Haussler MR, Robertson RP. Selective deficiency of
1,25-dihydroxycholecalciferol. A cause of isolated skeletal resistance to parathyroid
hormone. N Engl J Med 297: 1084 1090, 1977.
625. Michaelsson K, Baron JA, Farahmand BY, Ljunghall S. Influence of parity and lactation
on hip fracture risk. Am J Epidemiol 153: 1166 1172, 2001.
626. Miller MA, Omura TH, Miller SC. Increased cancellous bone remodeling during
lactation in beagles. Bone 10: 279 285, 1989.
627. Miller SC, Bowman BM. Rapid inactivation and apoptosis of osteoclasts in the ma-
ternal skeleton during the bone remodeling reversal at the end of lactation. Anat Rec
290: 6573, 2007.
628. Miller SC, Halloran BP, DeLuca HF, Jee WS. Role of vitamin D in maternal skeletal
changes during pregnancy and lactation: a histomorphometric study. Calcif Tissue Int
34: 245252, 1982.
537
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
629. Miller SC, Shupe JG, Redd EH, Miller MA, Omura TH. Changes in bone mineral and
bone formation rates during pregnancy and lactation in rats. Bone 7: 283287, 1986.
630. Mirzaei S, Krotla G, Knoll P, Koriska K, Kohn H. Possible effect of calcitonin defi-
ciency on bone mass after subtotal thyroidectomy. Acta Med Austriaca 26: 29 31,
1999.
631. Miyoshi K, Shillingford JM, Smith GH, Grimm SL, Wagner KU, Oka T, Rosen JM,
Robinson GW, Hennighausen L. Signal transducer and activator of transcription
(Stat) 5 controls the proliferation and differentiation of mammary alveolar epithe-
lium. J Cell Biol 155: 531542, 2001.
632. Moller UK, Streym S, Mosekilde L, Heickendorff L, Flyvbjerg A, Frystyk J, Jensen LT,
Rejnmark L. Changes in calcitropic hormones, bone markers and insulin-like growth
factor I (IGF-I) during pregnancy and postpartum: a controlled cohort study. Osteo-
poros Int 24: 13071320, 2013.
633. Moller UK, Vi Streym S, Mosekilde L, Rejnmark L. Changes in bone mineral density
and body composition during pregnancy and postpartum. A controlled cohort study.
Osteoporos Int 23: 12131223, 2012.
634. Montoro MN, Paler RJ, Goodwin TM, Mestman JH. Parathyroid carcinoma during
pregnancy. Obstet Gynecol 96: 841, 2000.
635. More C, Bettembuk P, Bhattoa HP, Balogh A. The effects of pregnancy and lactation
on bone mineral density. Osteoporos Int 12: 732737, 2001.
636. Mori T, Ishii S, Greendale GA, Cauley JA, Ruppert K, Crandall CJ, Karlamangla AS.
Parity, lactation, bone strength, and 16-year fracture risk in adult women: findings
from the Study of Womens Health Across the Nation (SWAN). Bone 73: 160 166,
2015.
637. Morley R, Carlin JB, Pasco JA, Wark JD. Maternal 25-hydroxyvitamin D and parathy-
roid hormone concentrations and offspring birth size. J Clin Endocrinol Metab 91:
906 912, 2006.
638. Morton A. Altered calcium homeostasis during pregnancy may affect biochemical
differentiation of hypercalcaemia. Intern Med J 34: 655 657, 2004.
639. Morton A. Milk-alkali syndrome in pregnancy, associated with elevated levels of
parathyroid hormone-related protein. Intern Med J 32: 492 493, 2002.
640. Mukherjee T, Barad D, Turk R, Freeman R. A randomized, placebo-controlled study
on the effect of cyclic intermittent etidronate therapy on the bone mineral density
changes associated with six months of gonadotropin-releasing hormone agonist
treatment. Am J Obstet Gynecol 175: 105109, 1996.
641. Mull JW, Bill AH. Variations in serum calcium and phosphorus during pregnancy. Am
J Obstet Gynecol 27: 510 517, 1934.
642. Murphy S, Khaw KT, May H, Compston JE. Parity and bone mineral density in
middle-aged women. Osteoporos Int 4: 162166, 1994.
643. Muscher A, Breves G, Huber K. Modulation of apical Na/Pi cotransporter type IIb
expression in epithelial cells of goat mammary glands. J Anim Physiol Anim Nutr 93:
477 485, 2009.
644. Naja RP, Dardenne O, Arabian A, St Arnaud R. Chondrocyte-specific modulation of
Cyp27b1 expression supports a role for local synthesis of 1,25-dihydroxyvitamin D3
in growth plate development. Endocrinology 150: 4024 4032, 2009.
645. Nakago S, Funakoshi T, Ueda Y, Maruo T. Regulation of circulating levels of IGF-I in
pregnant rats: changes in nitrogen balance correspond with changes in serum IGF-I
concentrations. J Endocrinol 163: 373377, 1999.
646. Nakayama S, Yasui T, Suto M, Sato M, Kaji T, Uemura H, Maeda K, Irahara M.
Differences in bone metabolism between singleton pregnancy and twin pregnancy.
Bone 49: 513519, 2011.
647. Naveh-Many T, Raue F, Grauer A, Silver J. Regulation of calcitonin gene expression
by hypocalcemia, hypercalcemia, and vitamin D in the rat. J Bone Miner Res 7:
12331237, 1992.
648. Naves M, Diaz-Lopez JB, Gomez C, Rodriguez-Rebollar A, Cannata-Andia JB. De-
terminants of incidence of osteoporotic fractures in the female Spanish population
older than 50. Osteoporos Int 16: 20132017, 2005.
649. Naylor KE, Iqbal P, Fledelius C, Fraser RB, Eastell R. The effect of pregnancy on bone
density and bone turnover. J Bone Miner Res 15: 129 137, 2000.
538 Physiol Rev VOL 96 APRIL 2016 www.prv.org
650. Need AG, OLoughlin PD, Morris HA, Coates PS, Horowitz M, Nordin BE. Vitamin
D metabolites and calcium absorption in severe vitamin D deficiency. J Bone Miner
Res 23: 1859 1863, 2008.
651. Negishi H, Kobayashi M, Nishida R, Yamada H, Ariga S, Sasaki F, Fujimoto S. Primary
hyperparathyroidism and simultaneous bilateral fracture of the femoral neck during
pregnancy. J Trauma 52: 367369, 2002.
652. Neville MC. Calcium secretion into milk. J Mammary Gland Biol Neoplasia 10: 119
128, 2005.
653. Neville MC, Keller R, Seacat J, Lutes V, Neifert M, Casey C, Allen J, Archer P. Studies
in human lactation: milk volumes in lactating women during the onset of lactation and
full lactation. Am J Clin Nutr 48: 13751386, 1988.
654. Neville MC, Keller RP, Seacat J, Casey CE, Allen JC, Archer P. Studies on human
lactation. I. Within-feed and between-breast variation in selected components of
human milk. Am J Clin Nutr 40: 635 646, 1984.
655. Neville MC, McFadden TB, Forsyth I. Hormonal regulation of mammary differenti-
ation and milk secretion. J Mammary Gland Biol Neoplasia 7: 49 66, 2002.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
656. Nevis IF, Reitsma A, Dominic A, McDonald S, Thabane L, Akl EA, Hladunewich M,
Akbari A, Joseph G, Sia W, Iansavichus AV, Garg AX. Pregnancy outcomes in women
with chronic kidney disease: a systematic review. Clin J Am Soc Nephrol 6: 2587
2598, 2011.
657. Newhall-Perry K, Holloway L, Osburn L, Monroe SE, Heinrichs L, Henzl M, Marcus
R. Effects of a gonadotropin-releasing hormone agonist on the calcium-parathyroid
axis and bone turnover in women with endometriosis. Am J Obstet Gynecol 173:
824 829, 1995.
658. Nguyen TM, Halhali A, Guillozo H, Garabedian M, Balsan S. Thyroid and parathy-
roid-independent increase in plasma 1,25-dihydroxyvitamin D during late pregnancy
in the rat. J Endocrinol 116: 381385, 1988.
659. Nguyen TT, Heath H 3rd, Bryant SC, OFallon WM, Melton LJ 3rd. Fractures after
thyroidectomy in men: a population-based cohort study. J Bone Miner Res 12: 1092
1099, 1997.
660. Nicholson GC, Moseley JM, Sexton PM, Mendelsohn FA, Martin TJ. Abundant cal-
citonin receptors in isolated rat osteoclasts. Biochemical and autoradiographic char-
acterization. J Clin Invest 78: 355360, 1986.
661. Nilsson BE. Parity and osteoporosis. Surg Gynecol Obstet 129: 2728, 1969.
662. Nilsson IL, Adner N, Reihner E, Palme-Kilander C, Edstrom G, Degerblad M. Pri-
mary hyperparathyroidism in pregnancy: a diagnostic and therapeutic challenge. J
Womens Health 19: 11171121, 2010.
663. Nishimori K, Young LJ, Guo Q, Wang Z, Insel TR, Matzuk MM. Oxytocin is required
for nursing but is not essential for parturition or reproductive behavior. Proc Natl
Acad Sci USA 93: 11699 11704, 1996.
664. Nitzan M, Orloff S, Chrzanowska BL, Schulman JD. Intrauterine growth retardation
in renal insufficiency: an experimental model in the rat. Am J Obstet Gynecol 133:
40 43, 1979.
665. Noff D, Edelstein S. Vitamin D and its hydroxylated metabolites in the rat. Placental
and lacteal transport, subsequent metabolic pathways and tissue distribution. Horm
Res 9: 292300, 1978.
666. Nordin BE, Roper A. Post-pregnancy osteoporosis; a syndrome? Lancet 268: 431
434, 1955.
667. Norman J, Politz D, Politz L. Hyperparathyroidism during pregnancy and the effect
of rising calcium on pregnancy loss: a call for earlier intervention. Clin Endocrinol 71:
104 109, 2009.
668. ODonnell D, Costa J, Meyers AM. Management of pseudohypoparathyroidism in
pregnancy. Case report. Br J Obstet Gynaecol 92: 639 641, 1985.
669. OLeary JA, Klainer LM, Neuwirth RS. The management of hypoparathyroidism in
pregnancy. Am J Obstet Gynecol 94: 11031107, 1966.
670. OLeary P, Boyne P, Flett P, Beilby J, James I. Longitudinal assessment of changes in
reproductive hormones during normal pregnancy. Clin Chem 37: 667 672, 1991.
671. OSullivan SM, Grey AB, Singh R, Reid IR. Bisphosphonates in pregnancy and lacta-
tion-associated osteoporosis. Osteoporos Int 17: 1008 1012, 2006.
 CHRISTOPHER S. KOVACS
672. Oberhelman SS, Meekins ME, Fischer PR, Lee BR, Singh RJ, Cha SS, Gardner BM,
Pettifor JM, Croghan IT, Thacher TD. Maternal vitamin D supplementation to im-
prove the vitamin D status of breast-fed infants: a randomized controlled trial. Mayo
Clin Proc 88: 1378 1387, 2013.
673. Obermannova B, Banghova K, Sumnik Z, Dvorakova HM, Betka J, Fencl F, Kolous-
kova S, Cinek O, Lebl J. Unusually severe phenotype of neonatal primary hyperpara-
thyroidism due to a heterozygous inactivating mutation in the CASR gene. Eur J
Pediatr 168: 569 573, 2009.
674. Oberst WF, Plass ED. The variations in serum calcium, protein, and inorganic phos-
phorus in early and late pregnancy, during parturition and the puerperium, and in
non-pregnant women. J Clin Invest 11: 123127, 1932.
675. Obiekwe BC, Sturdee D, Cockrill BL, Chard T. Human placental lactogen in pre-
eclampsia. Br J Obstet Gynaecol 91: 10771080, 1984.
676. Ochiai D, Uchino H, Ikeda T, Yakubo K, Fukuiya T. Pseudohypoparathyroidism type
1a in pregnancy. J Obstet Gynaecol 33: 900, 2013.
677. Ofluoglu O, Ofluoglu D. A case report: pregnancy-induced severe osteoporosis with
eight vertebral fractures. Rheumatol Int 29: 197201, 2008.
678. Ohata Y, Arahori H, Namba N, Kitaoka T, Hirai H, Wada K, Nakayama M, Michigami
T, Imura A, Nabeshima Y, Yamazaki Y, Ozono K. Circulating levels of soluble alpha-
Klotho are markedly elevated in human umbilical cord blood. J Clin Endocrinol Metab
96: E943E947, 2011.
679. Ohata Y, Yamazaki M, Kawai M, Tsugawa N, Tachikawa K, Koinuma T, Miyagawa K,
Kimoto A, Nakayama M, Namba N, Yamamoto H, Okano T, Ozono K, Michigami T.
Elevated fibroblast growth factor 23 exerts its effects on placenta and regulates
vitamin d metabolism in pregnancy of hyp mice. J Bone Miner Res 29: 16271638,
2014.
680. Olgiati VR, Netti C, Guidobono F, Pecile A. High sensitivity to calcitonin of prolactin-
secreting control in lactating rats. Endocrinology 111: 641 644, 1982.
681. Onda K, Sato A, Yamaguchi M, Matsuki N, Ono K, Wada Y. Parathyroid hormone-
related protein (PTHrP) and Ca levels in the milk of lactating cows. J Vet Med Sci 68:
709 713, 2006.
682. Orloff JJ, Reddy D, de Papp AE, Yang KH, Soifer NE, Stewart AF. Parathyroid
hormone-related protein as a prohormone: posttranslational processing and recep-
tor interactions. Endocr Rev 15: 40 60, 1994.
683. Orwoll ES, Bauer DC, Vogt TM, Fox KM. Axial bone mass in older women. Study of
Osteoporotic Fractures Research Group. Ann Intern Med 124: 187196, 1996.
684. Orwoll ES, Yuzpe AA, Burry KA, Heinrichs L, Buttram VC Jr, Hornstein MD. Na-
farelin therapy in endometriosis: long-term effects on bone mineral density. Am J
Obstet Gynecol 171: 12211225, 1994.
685. Ozcelik B, Ozcelik A, Debre M. Postpartum depression co-occurring with lactation-
related osteoporosis. Psychosomatics 50: 155158, 2009.
686. Ozdemir F, Demirbag D, Rodoplu M. Reproductive factors affecting the bone min-
eral density in postmenopausal women. Tohoku J Exp Med 205: 277285, 2005.
687. Ozturk C, Atamaz FC, Akkurt H, Akkoc Y. Pregnancy-associated osteoporosis pre-
senting severe vertebral fractures. J Obstet Gynaecol Res 40: 288 292, 2014.
688. Pabinger C, Heu C, Frohner A, Dimai HP. Pregnancy- and lactation-associated
transient osteoporosis of both hips in a 32 year old patient with osteogenesis imper-
fecta. Bone 51: 142144, 2012.
689. Paganini-Hill A, Chao A, Ross RK, Henderson BE. Exercise and other factors in the
prevention of hip fracture: the Leisure World study. Epidemiology 2: 16 25, 1991.
690. Pahuja DN, DeLuca HF. Stimulation of intestinal calcium transport and bone calcium
mobilization by prolactin in vitamin D-deficient rats. Science 214: 1038 1039, 1981.
691. Pallavi P, Padma S, Vanitha Anna Selvi D. Transient osteoporosis of hip and lumbar
spine in pregnancy. J Obstet Gynaecol India 62: 8 9, 2012.
692. Panda DK, Miao D, Bolivar I, Li J, Huo R, Hendy GN, Goltzman D. Inactivation of the
25-hydroxyvitamin D 1alpha-hydroxylase and vitamin D receptor demonstrates in-
dependent and interdependent effects of calcium and vitamin D on skeletal and
mineral homeostasis. J Biol Chem 279: 16754 16766, 2004.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
693. Panda DK, Miao D, Tremblay ML, Sirois J, Farookhi R, Hendy GN, Goltzman D.
Targeted ablation of the 25-hydroxyvitamin D 1alpha-hydroxylase enzyme: evi-
dence for skeletal, reproductive, and immune dysfunction. Proc Natl Acad Sci USA 98:
7498 7503, 2001.
694. Pansu D, Bellaton C, Roche C, Bronner F. Duodenal and ileal calcium absorption in
the rat and effects of vitamin D. Am J Physiol Gastrointest Liver Physiol 244: G695
G700, 1983.
695. Paoletti AM, Orru M, Floris L, Guerriero S, Ajossa S, Romagnino S, Melis GB. Pattern
of bone markers during pregnancy and their changes after delivery. Horm Res 59:
2129, 2003.
696. Paoletti AM, Serra GG, Cagnacci A, Vacca AM, Guerriero S, Solla E, Melis GB.
Spontaneous reversibility of bone loss induced by gonadotropin-releasing hormone
analog treatment. Fertil Steril 65: 707710, 1996.
697. Papantoniou NE, Papapetrou PD, Antsaklis AJ, Kontoleon PE, Mesogitis SA, Ara-
vantinos D. Circulating levels of immunoreactive parathyroid hormone-related pro-
tein and intact parathyroid hormone in human fetuses and newborns. Eur J Endocrinol
134: 437 442, 1996.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
698. Paparella P, Giorgino R, Maglione A, Lorusso D, Scirpa P, Del Bosco A, Mancuso S.
Maternal ultrasound bone density in normal pregnancy. Clin Exp Obstet Gynecol 22:
268 278, 1995.
699. Parra-Cabrera S, Hernandez-Avila M, Tamayo-y-Orozco J, Lpez-Carrillo L, Mene-
ses-Gonzlez F. Exercise and reproductive factors as predictors of bone density
among osteoporotic women in Mexico City. Calcif Tissue Int 59: 89 94, 1996.
700. Paton LM, Alexander JL, Nowson CA, Margerison C, Frame MG, Kaymakci B, Wark
JD. Pregnancy and lactation have no long-term deleterious effect on measures of
bone mineral in healthy women: a twin study. Am J Clin Nutr 77: 707714, 2003.
701. Paul RG, Elston MS, Gill AJ, Marsh D, Beer I, Wolmarans L, Conaglen JV, Meyer-
Rochow GY. Hypercalcaemia due to parathyroid carcinoma presenting in the third
trimester of pregnancy. Aust N Z J Obstet Gynaecol 52: 204 207, 2012.
702. Paulson SK, Ford KK, Langman CB. Pregnancy does not alter the metabolic clear-
ance of 1,25-dihydroxyvitamin D in rats. Am J Physiol Endocrinol Metab 258: E158
E162, 1990.
703. Paulson SK, Langman CB. Plasma vitamin D metabolite levels in pregnant and non-
pregnant ewes. Comp Biochem Physiol A 96: 347349, 1990.
704. Pearce MS, Birrell FN, Francis RM, Rawlings DJ, Tuck SP, Parker L. Lifecourse study
of bone health at age 49 51 years: the Newcastle thousand families cohort study. J
Epidemiol Community Health 59: 475 480, 2005.
705. Pearson D, Kaur M, San P, Lawson N, Baker P, Hosking D. Recovery of pregnancy
mediated bone loss during lactation. Bone 34: 570 578, 2004.
706. Pecher C, Pecher J. Radioactive calcium and radioactive strontium metabolism in
pregnant mice. Proc Soc Exp Biol Med 46: 9194, 1941.
707. Pedersen EB, Johannesen P, Kristensen S, Rasmussen AB, Emmertsen K, Moller J,
Lauritsen JG, Wohlert M. Calcium, parathyroid hormone and calcitonin in normal
pregnancy and preeclampsia. Gynecol Obstet Invest 18: 156 164, 1984.
708. Peng TC, Garner SC, Kusy RP, Hirsch PF. Effect of number of suckling pups and
dietary calcium on bone mineral content and mechanical properties of femurs of
lactating rats. Bone Miner 3: 293304, 1988.
709. Peng TC, Kusy RP, Garner SC, Hirsch PF, De Blanco MC. Influence of lactation and
pregnancy lactation on mechanical properties and mineral content of the rat
femur. J Bone Miner Res 2: 249 257, 1987.
710. Perez-Lopez FR, Pasupuleti V, Mezones-Holguin E, Benites-Zapata VA, Thota P,
Deshpande A, Hernandez AV. Effect of vitamin D supplementation during pregnancy
on maternal and neonatal outcomes: a systematic review and meta-analysis of ran-
domized controlled trials. Fertil Steril 103: 1278 1288, 2015.
711. Petousis S, Kourtis A, Anastasilakis CD, Makedou K, Giomisi A, Kalogiannidis I,
Margioula-Siarkou C, Xanthopoulou E, Rousso D. Successful surgical treatment of
primary hyperparathyroidism during the third trimester of pregnancy. J Musculosk-
elet Neuronal Interact 12: 43 45, 2012.
712. Philbrick WM, Wysolmerski JJ, Galbraith S, Holt E, Orloff JJ, Yang KH, Vasavada RC,
Weir EC, Broadus AE, Stewart AF. Defining the roles of parathyroid hormone-
related protein in normal physiology. Physiol Rev 76: 127173, 1996.
539
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
713. Phillips AJ, Ostlere SJ, Smith R. Pregnancy-associated osteoporosis: does the skele-
ton recover? Osteoporos Int 11: 449 454, 2000.
714. Pic P. Evolution of calcemia in the rat fetus at the end of pregnancy. C R Seances Soc
Biol Fil 163: 10331038, 1969.
715. Picard D, Ste-Marie LG, Coutu D, Carrier L, Chartrand R, Lepage R, Fugere P,
DAmour P. Premenopausal bone mineral content relates to height, weight and
calcium intake during early adulthood. Bone Miner 4: 299 309, 1988.
716. Pieringer H, Hatzl-Griesenhofer M, Shebl O, Wiesinger-Eidenberger G, Maschek W,
Biesenbach G. Hypocalcemic tetany in the newborn as a manifestation of unrecog-
nized maternal primary hyperparathyroidism. Wien Klin Wochenschr 119: 129 131,
2007.
717. Pietrek J, Otto-Buczkowska E, Kokot F, Karpiel R, Cekanski A. Concentration of
25-hydroxyvitamin D in serum of infants under the intermittent high-dose vitamin
D3 prophylactic treatment. Arch Immunol Ther Exp 28: 805 814, 1980.
718. Pike JW, Parker JB, Haussler MR, Boass A, Toverud SV. Dynamic changes in circu-
lating 1,25-dihydroxyvitamin D during reproduction in rats. Science 204: 14271429,
1979.
719. Pinkham CS, Kubena KS. Consequences of low dietary magnesium and high dietary
calcium on pregnancy outcome and tissue mineralization in rats. Magnes Res 1:
147153, 1988.
720. Pitkin RM, Gebhardt MP. Serum calcium concentrations in human pregnancy. Am J
Obstet Gynecol 127: 775778, 1977.
721. Pitkin RM, Reynolds WA, Williams GA, Hargis GK. Calcium metabolism in normal
pregnancy: a longitudinal study. Am J Obstet Gynecol 133: 781790, 1979.
722. Pluskiewicz W, Drozdzowska B, Stolecki M. Quantitative ultrasound at the hand
phalanges in pregnancy: a longitudinal study. Ultrasound Med Biol 30: 13731378,
2004.
723. Polatti F, Capuzzo E, Viazzo F, Colleoni R, Klersy C. Bone mineral changes during
and after lactation. Obstet Gynecol 94: 5256, 1999.
724. Potthoff MJ, Inagaki T, Satapati S, Ding X, He T, Goetz R, Mohammadi M, Finck BN,
Mangelsdorf DJ, Kliewer SA, Burgess SC. FGF21 induces PGC-1alpha and regulates
carbohydrate and fatty acid metabolism during the adaptive starvation response.
Proc Natl Acad Sci USA 106: 1085310858, 2009.
725. Potts JT Jr, Bringhurst FR, Gardella T, Nussbaum S, Segre G, Kronenberg HM.
Parathyroid hormone: physiology, chemistry, biosynthesis, secretion, metabolism,
and mode of action. In: Endocrinology, edited by DeGroot LJ. Philadelphia: Saunders,
1995, p. 920 966.
726. Powe CE, Seely EW, Rana S, Bhan I, Ecker J, Karumanchi SA, Thadhani R. First
trimester vitamin D, vitamin D binding protein, and subsequent preeclampsia. Hy-
pertension 56: 758 763, 2010.
727. Powell BR, Buist NR. Late presenting, prolonged hypocalcemia in an infant of a
woman with hypocalciuric hypercalcemia. Clin Pediatr 29: 241243, 1990.
728. Prentice A. Calcium in pregnancy and lactation. Annu Rev Nutr 20: 249 272, 2000.
729. Prentice A, Jarjou LM, Cole TJ, Stirling DM, Dibba B, Fairweather-Tait S. Calcium
requirements of lactating Gambian mothers: effects of a calcium supplement on
breast-milk calcium concentration, maternal bone mineral content, and urinary cal-
cium excretion. Am J Clin Nutr 62: 58 67, 1995.
730. Prentice A, Jarjou LM, Stirling DM, Buffenstein R, Fairweather-Tait S. Biochemical
markers of calcium and bone metabolism during 18 months of lactation in Gambian
women accustomed to a low calcium intake and in those consuming a calcium
supplement. J Clin Endocrinol Metab 83: 1059 1066, 1998.
731. Prentice A, Yan L, Jarjou LM, Dibba B, Laskey MA, Stirling DM, Fairweather-Tait S.
Vitamin D status does not influence the breast-milk calcium concentration of lactat-
ing mothers accustomed to a low calcium intake. Acta Paediatr 86: 1006 1008, 1997.
732. Purdie DW, Aaron JE, Selby PL. Bone histology and mineral homeostasis in human
pregnancy. Br J Obstet Gynaecol 95: 849 854, 1988.
733. Qing H, Ardeshirpour L, Pajevic PD, Dusevich V, Jahn K, Kato S, Wysolmerski J,
Bonewald LF. Demonstration of osteocytic perilacunar/canalicular remodeling in
mice during lactation. J Bone Miner Res 27: 1018 1029, 2012.
540 Physiol Rev VOL 96 APRIL 2016 www.prv.org
734. Qing H, Bonewald LF. Osteocyte remodeling of the perilacunar and pericanalicular
matrix. Int J Oral Sci 1: 59 65, 2009.
735. Quan-Sheng D, Miller SC. Calciotrophic hormone levels and calcium absorption
during pregnancy in rats. Am J Physiol Endocrinol Metab 257: E118 E123, 1989.
736. Rabau-Friedman E, Mashiach S, Cantor E, Jacob ET. Association of hypoparathyroid-
ism and successful pregnancy in kidney transplant recipient. Obstet Gynecol 59:
126 128, 1982.
737. Rabbani SA, Khalili P, Arakelian A, Pizzi H, Chen G, Goltzman D. Regulation of
parathyroid hormone-related peptide by estradiol: effect on tumor growth and
metastasis in vitro and in vivo. Endocrinology 146: 28852894, 2005.
738. Rakopoulos M, Vargas SJ, Gillespie MT, Ho PW, Diefenbach-Jagger H, Leaver DD,
Grill V, Moseley JM, Danks JA, Martin TJ. Production of parathyroid hormone-
related protein by the rat mammary gland in pregnancy and lactation. Am J Physiol
Endocrinol Metab 263: E1077E1085, 1992.
739. Rasmussen N, Frolich A, Hornnes PJ, Hegedus L. Serum ionized calcium and intact
parathyroid hormone levels during pregnancy and postpartum. Br J Obstet Gynaecol
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
97: 857 859, 1990.
740. Rasmussen P. Calcium deficiency, pregnancy, and lactation in rats. Some effects on
blood chemistry and the skeleton. Calcif Tissue Res 23: 8794, 1977.
741. Ratcliffe WA, Abbas SK, Care AD. Clearance of parathyroid hormone-related pro-
tein in pregnant, non-pregnant and fetal sheep, goats and pigs. J Endocrinol 138:
459 465, 1993.
742. Ratcliffe WA, Green E, Emly J, Norbury S, Lindsay M, Heath DA, Ratcliffe JG. Iden-
tification and partial characterization of parathyroid hormone-related protein in
human and bovine milk. J Endocrinol 127: 167176, 1990.
743. Ratcliffe WA, Thompson GE, Abbas SK, Care AD. Studies on the metabolic clearance
of parathyroid hormone-related protein in pregnant, nonpregnant and fetal animals.
In: Calcium Regulating Hormones and Bone Metabolism: Basic and Clinical Aspects,
edited by Cohn DV, Gennari C, Tashjian AHJr. Amsterdam: Excerpta Medica, 1992,
p. 69 75.
744. Ratcliffe WA, Thompson GE, Care AD, Peaker M. Production of parathyroid hor-
mone-related protein by the mammary gland of the goat. J Endocrinol 133: 8793,
1992.
745. Reade TM, Scriver CR. Hypophosphatemic rickets and breast milk. N Engl J Med 300:
1397, 1979.
746. Reddy GS, Norman AW, Willis DM, Goltzman D, Guyda H, Solomon S, Philips DR,
Bishop JE, Mayer E. Regulation of vitamin D metabolism in normal human pregnancy.
J Clin Endocrinol Metab 56: 363370, 1983.
747. Redell G. Parathyroprival tetany and pregnancy. Acta Obstet Gynecol Scand 26: 110,
1946.
748. Reeve LE, Chesney RW, DeLuca HF. Vitamin D of human milk: identification of
biologically active forms. Am J Clin Nutr 36: 122126, 1982.
749. Reeves PG, Nielsen FH, Fahey GC Jr. AIN-93 purified diets for laboratory rodents:
final report of the American Institute of Nutrition ad hoc writing committee on the
reformulation of the AIN-76A rodent diet. J Nutr 123: 1939 1951, 1993.
750. Reid IR. Menopause. In: Primer on the Metabolic Bone Diseases and Disorders of
Mineral Metabolism (5th ed.), edited by Favus MJ. Washington, DC: ASBMR Press,
2003, p. 86 89.
751. Reid IR, Wattie DJ, Evans MC, Budayr AA. Post-pregnancy osteoporosis associated
with hypercalcaemia. Clin Endocrinol 37: 298 303, 1992.
752. Reinhardt TA, Horst RL. Parathyroid hormone down-regulates 1,25 dihydroxyvita-
min D receptors (VDR) and VDR messenger ribonucleic acid in vitro and blocks
homologous up-regulation of VDR in vivo. Endocrinology 127: 942948, 1990.
753. Reinhardt TA, Lippolis JD, Shull GE, Horst RL. Null mutation in the gene encoding
plasma membrane Ca2-ATPase isoform 2 impairs calcium transport into milk. J Biol
Chem 279: 42369 42373, 2004.
754. Reitz RE, Daane TA, Woods JR, Weinstein RL. Calcium, magnesium, phosphorus,
and parathyroid hormone interrelationships in pregnancy and newborn infants. Ob-
stet Gynecol 50: 701705, 1977.
 CHRISTOPHER S. KOVACS
755. Ren Y, Chien J, Sun YP, Shah GV. Calcitonin is expressed in gonadotropes of the
anterior pituitary gland: its possible role in paracrine regulation of lactotrope func-
tion. J Endocrinol 171: 217228, 2001.
756. Ren Y, Sun YP, Shah GV. Calcitonin inhibits prolactin promoter activity in rat pituitary
GGH3 cells: evidence for involvement of p42/44 mitogen-activated protein kinase in
calcitonin action. Endocrine 20: 1322, 2003.
757. Retallack RW, Jeffries M, Kent GN, Hitchcock NE, Gutteridge DH, Smith M. Physi-
ological hyperparathyroidism in human lactation. Calcif Tissue Res 22 Suppl: 142
146, 1977.
758. Revilla R, Revilla M, Hernandez ER, Villa LF, Varela L, Rico H. Evidence that the loss
of bone mass induced by GnRH agonists is not totally recovered. Maturitas 22:
145150, 1995.
759. Reynolds WA, Pitkin RM, Williams GA, Bauman AF, Hargis GK, Beluhan FZ, Kawa-
hara W. Calcitonin responsiveness in the primate fetus. J Clin Endocrinol Metab 51:
595598, 1980.
760. Reynolds WA, Williams GA, Pitkin RM. Calcitropic hormone responsiveness during
pregnancy. Am J Obstet Gynecol 139: 855 862, 1981.
761. Ribot C, Tremollieres F, Pouilles JM, Albarede JL, Mansat M, Utheza G, Bonneu M,
Bonnissent P, Ricoeur C. Risk factors for hip fracture. MEDOS study: results of the
Toulouse Centre. Bone 14 Suppl 1: S77S80, 1993.
762. Rico H, Arnanz F, Revilla M, Perera S, Iritia M, Villa LF, Arribas I. Total and regional
bone mineral content in women treated with GnRH agonists. Calcif Tissue Int 52:
354 357, 1993.
763. Rigal A, Vignal W. Recherches exprimentales sur la formation du cal et sur les modifi-
cations des tissus dans les pseudoarthroses. Arch Physiol Ser II: 419 458, 1881.
764. Ritchie LD, Fung EB, Halloran BP, Turnlund JR, Van Loan MD, Cann CE, King JC. A
longitudinal study of calcium homeostasis during human pregnancy and lactation and
after resumption of menses. Am J Clin Nutr 67: 693701, 1998.
765. Ritz E, Krempien B, Klefisch G, Ritter T, Krause E. Fetal development in experimen-
tal uremia. Virchows Arch A Pathol Anat Histol 376: 145157, 1977.
766. Ritz E, Krempien B, Strobel Z, Zimmermann H, Mehls O. Foetal development in
experimental uraemia. Proc Eur Dial Transplant Assoc 10: 127135, 1973.
767. Robertson WC Jr. Calcium carbonate consumption during pregnancy: an unusual
cause of neonatal hypocalcemia. J Child Neurol 17: 853 855, 2002.
768. Robinson CJ, Alanis MC, Wagner CL, Hollis BW, Johnson DD. Plasma 25-hydroxyvi-
tamin D levels in early-onset severe preeclampsia. Am J Obstet Gynecol 203: e361
366, 2010.
769. Rodin A, Duncan A, Quartero HW, Pistofidis G, Mashiter G, Whitaker K, Crook D,
Stevenson JC, Chapman MG, Fogelman I. Serum concentrations of alkaline phospha-
tase isoenzymes and osteocalcin in normal pregnancy. J Clin Endocrinol Metab 68:
11231127, 1989.
770. Rojano-Mejia D, Aguilar-Madrid G, Lopez-Medina G, Cortes-Espinosa L, Hernan-
dez-Chiu MC, Canto-Cetina T, Vergara-Lopez A, Coral-Vazquez RM, Canto P. Risk
factors and impact on bone mineral density in postmenopausal Mexican mestizo
women. Menopause 18: 302306, 2011.
771. Rong H, Hydbring E, Olsson K, Burtis WJ, Rankin W, Grill V, Bucht E. Parathyroid
hormone-related protein in neonatal and reproductive goats determined by a sen-
sitive time-resolved immunofluorometric assay. Eur J Endocrinol 136: 546 551,
1997.
772. Rosa BV, Blair HT, Vickers MH, Morel PC, Cockrem JF, Firth EC. Voluntary exercise
in pregnant rats improves post-lactation maternal bone parameters but does not
affect offspring outcomes in early life. J Musculoskelet Neuronal Interact 12: 199 208,
2012.
773. Rosen CJ, Adams JS, Bikle D, Black DM, Demay MB, Manson JE, Murad MH, Kovacs
CS. The nonskeletal effects of vitamin D: an endocrine society scientific statement.
Endocr Rev 33: 456 492, 2012.
774. Ross AC, Abrams SA, Aloia JF, Brannon PM, Clinton SK, Durazo-Arvizu RA, Gal-
lagher JC, Gallo RL, Jones G, Kovacs CS, Manson JE, Mayne ST, Rosen CJ, Shapses
SA. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: Institute of
Medicine, 2011.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
775. Ross R, Dorsey J, Ellis K. Progressive increases in 1,25-dihydroxyvitamin D3 produc-
tion rate in multiple ovine pregnancy are independent of changes in the metabolic
clearance rate (Abstract). Pediatr Res 27: 192A, 1990.
776. Ross R, Halbert K, Tsang RC. Determination of the production and metabolic clear-
ance rates of 1,25-dihydroxyvitamin D3 in the pregnant sheep and its chronically
catheterized fetus by primed infusion technique. Pediatr Res 26: 633 638, 1989.
777. Rossi R. Maternal hypoparathyroidism and pregnancy. Presentation of a clinical case.
Rev Clin Pediatr 66: 417 428, 1960.
778. Roth DE, Al Mahmud A, Raqib R, Akhtar E, Perumal N, Pezzack B, Baqui AH.
Randomized placebo-controlled trial of high-dose prenatal third-trimester vitamin
D3 supplementation in Bangladesh: the AViDD trial. Nutr J 12: 47, 2013.
779. Roth DE, Perumal N, Al Mahmud A, Baqui AH. Maternal vitamin D3 supplementa-
tion during the third trimester of pregnancy: effects on infant growth in a longitudinal
follow-up study in Bangladesh. J Pediatr 163: 16051611, 2013.
780. Rothberg AD, Pettifor JM, Cohen DF, Sonnendecker EW, Ross FP. Maternal-infant
vitamin D relationships during breast-feeding. J Pediatr 101: 500 503, 1982.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
781. Roux C, Pelissier C, Listrat V, Kolta S, Simonetta C, Guignard M, Dougados M, Amor
B. Bone loss during gonadotropin releasing hormone agonist treatment and use of
nasal calcitonin. Osteoporos Int 5: 185190, 1995.
782. Rubin MR, Levine MA. Hypoparathyroidism and pseudohypoparathyroidism. In:
Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism (8th ed.),
edited by Rosen CJ. Ames, Iowa: Wiley-Blackwell, 2013, p. 579 589.
783. Rubinger D, Friedlaender MM, Silver J, Wald H, Shumart T, Popovtzer MM. Impaired
production and decreased urinary excretion of adenosine 3,5-monophosphate in
primary hyperparathyroidism with vitamin D deficiency. Miner Electrolyte Metab 14:
283287, 1988.
784. Rucart G, Gagnon PM. Modifications des parathyroides sous linfluence de la gesta-
tion. C R Seances Soc Biol Fil 153: 11021103, 1959.
785. Rude RK, Haussler MR, Singer FR. Postpartum resolution of hypocalcemia in a
lactating hypoparathyroid patient. Endocrinol Jpn 31: 227233, 1984.
786. Rummens K, van Cromphaut SJ, Carmeliet G, van Herck E, van Bree R, Stockmans
I, Bouillon R, Verhaeghe J. Pregnancy in mice lacking the vitamin D receptor: normal
maternal skeletal response, but fetal hypomineralization rescued by maternal cal-
cium supplementation. Pediatr Res 54: 466 473, 2003.
787. Russell FA, King R, Smillie SJ, Kodji X, Brain SD. Calcitonin gene-related peptide:
physiology and pathophysiology. Physiol Rev 94: 1099 1142, 2014.
788. Saadi HF, Dawodu A, Afandi B, Zayed R, Benedict S, Nagelkerke N, Hollis BW.
Effect of combined maternal and infant vitamin D supplementation on vitamin D
status of exclusively breastfed infants. Maternal Child Nutr 5: 2532, 2009.
789. Saadi HF, Dawodu A, Afandi BO, Zayed R, Benedict S, Nagelkerke N. Efficacy of
daily and monthly high-dose calciferol in vitamin D-deficient nulliparous and lactating
women. Am J Clin Nutr 85: 15651571, 2007.
790. Sadeghi-Nejad A, Wolfsdorf JI, Senior B. Hypoparathyroidism and pregnancy. Treat-
ment with calcitriol. JAMA 243: 254 255, 1980.
791. Saggese G, Baroncelli GI, Bertelloni S, Cipolloni C. Intact parathyroid hormone levels
during pregnancy, in healthy term neonates and in hypocalcemic preterm infants.
Acta Paediatr Scand 80: 36 41, 1991.
792. Saint L, Maggiore P, Hartmann PE. Yield and nutrient content of milk in eight women
breast-feeding twins and one woman breast-feeding triplets. Br J Nutr 56: 49 58,
1986.
793. Saito H, Saito M, Saito K, Terauchi A, Kobayashi T, Tominaga T, Hosoi E, Senoo M,
Saito T. Subclinical pseudohypoparathyroidism type II: evidence for failure of phys-
iologic adjustment in calcium metabolism during pregnancy. Am J Med Sci 297: 247
250, 1989.
794. Salas SP, Giacaman A, Vio CP. Pregnant rats with 5/6 nephrectomy have normal
volume expansion despite lower renin and kallikrein. Hypertension 42: 744 748,
2003.
795. Salem R, Taylor S. Hyperparathyroidism in pregnancy. Br J Surg 66: 648 650, 1979.
541
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
796. Salle BL, Berthezene F, Glorieux FH, Delvin EE, Berland M, David L, Varenne JP,
Putet G. Hypoparathyroidism during pregnancy: treatment with calcitriol. J Clin
Endocrinol Metab 52: 810 813, 1981.
797. Samaan NA, Anderson GD, Adam-Mayne ME. Immunoreactive calcitonin in the
mother, neonate, child and adult. Am J Obstet Gynecol 121: 622 625, 1975.
798. Samano R, Morales RM, Flores-Garcia A, Lira J, Isoard F, de Santiago S, Casanueva E.
Adolescents do not lose bone mineral density postpartum: comparative study with
adult women. Salud Publica Mex 53: 210, 2011.
799. Sarikaya S, Ozdolap S, Acikgoz G, Erdem CZ. Pregnancy-associated osteoporosis
with vertebral fractures and scoliosis. Joint Bone Spine 71: 84 85, 2004.
800. Sato K. Hypercalcemia during pregnancy, puerperium, and lactation: review and a
case report of hypercalcemic crisis after delivery due to excessive production of
PTH-related protein (PTHrP) without malignancy (humoral hypercalcemia of preg-
nancy). Endocr J 55: 959 966, 2008.
801. Schinke T, Liese S, Priemel M, Haberland M, Schilling AF, Catala-Lehnen P, Blicharski
D, Rueger JM, Gagel RF, Emeson RB, Amling M. Decreased bone formation and
osteopenia in mice lacking alpha-calcitonin gene-related peptide. J Bone Miner Res 19:
2049 2056, 2004.
802. Schnatz PF. Surgical treatment of primary hyperparathyroidism during the third
trimester. Obstet Gynecol 99: 961963, 2002.
803. Schnatz PF, Curry SL. Primary hyperparathyroidism in pregnancy: evidence-based
management. Obstet Gynecol Surv 57: 365376, 2002.
804. Schnatz PF, Marakovits KA, OSullivan DM. Assessment of postmenopausal women
and significant risk factors for osteoporosis. Obstet Gynecol Surv 65: 591596, 2010.
805. Schoenmakers I, Jarjou LM, Goldberg GR, Tsoi K, Harnpanich D, Prentice A. Acute
response to oral calcium loading in pregnant and lactating women with a low calcium
intake: a pilot study. Osteoporos Int 24: 23012308, 2013.
806. Schultz VL, Boass A, Garner SC, Toverud SU. Altered regulation of parathyroid
hormone secretion by calcium in pregnant and lactating rats. J Bone Miner Res 12:
903908, 1997.
807. Schultz VL, Garner SC, Lavigne JR, Toverud SU. Determination of bioactive rat
parathyroid hormone (PTH) concentrations in vivo and in vitro by a 2-site homolo-
gous immunoradiometric assay. Bone Miner 27: 121132, 1994.
808. Sebag M, Henderson J, Goltzman D, Kremer R. Regulation of parathyroid hormone-
related peptide production in normal human mammary epithelial cells in vitro. Am J
Physiol Cell Physiol 267: C723C730, 1994.
809. Seely EW, Brown EM, DeMaggio DM, Weldon DK, Graves SW. A prospective study
of calciotropic hormones in pregnancy and post partum: reciprocal changes in serum
intact parathyroid hormone and 1,25-dihydroxyvitamin D. Am J Obstet Gynecol 176:
214 217, 1997.
810. Seely EW, Wood RJ, Brown EM, Graves SW. Lower serum ionized calcium and
abnormal calciotropic hormone levels in preeclampsia. J Clin Endocrinol Metab 74:
1436 1440, 1992.
811. Segal E, Hochberg I, Weisman Y, Ish-Shalom S. Severe postpartum osteoporosis
with increased PTHrP during lactation in a patient after total thyroidectomy and
parathyroidectomy. Osteoporos Int 22: 29072911, 2011.
812. Seki K, Kato T, Sekiya S, Makimura N, Kudoh K, Furuya K, Nagata I. Parathyroid-
hormone-related protein in human milk and its relation to milk calcium. Gynecol
Obstet Invest 44: 102106, 1997.
813. Seki K, Makimura N, Mitsui C, Hirata J, Nagata I. Calcium-regulating hormones and
osteocalcin levels during pregnancy: a longitudinal study. Am J Obstet Gynecol 164:
1248 1252, 1991.
814. Seki K, Osada H, Yasuda T, Sekiya S. Pseudohypoparathyroidism type 1b in preg-
nancy. Gynecol Obstet Invest 47: 278 280, 1999.
815. Semins MJ, Matlaga BR. Kidney stones during pregnancy. Nat Rev Urol 11: 163168,
2014.
816. Sengupta S, Arshad M, Sharma S, Dubey M, Singh MM. Attainment of peak bone
mass and bone turnover rate in relation to estrous cycle, pregnancy and lactation in
colony-bred Sprague-Dawley rats: suitability for studies on pathophysiology of bone
542 Physiol Rev VOL 96 APRIL 2016 www.prv.org
and therapeutic measures for its management. J Steroid Biochem Mol Biol 94: 421
429, 2005.
817. Senior PV, Heath DA, Beck F. Expression of parathyroid hormone-related protein
mRNA in the rat before birth: demonstration by hybridization histochemistry. J Mol
Endocrinol 6: 281290, 1991.
818. Shackelford ME, Collins TF, Black TN, Ames MJ, Dolan S, Sheikh NS, Chi RK,
ODonnell MW. Mineral interactions in rats fed AIN-76A diets with excess calcium.
Food Chem Toxicol 32: 255263, 1994.
819. Shagina NB, Tolstykh EI, Fell TP, Harrison JD, Phipps AW, Degteva MO. In utero and
postnatal haemopoietic tissue doses resulting from maternal ingestion of strontium
isotopes from the Techa River. Radiat Prot Dosimetry 127: 497501, 2007.
820. Shah AD, Hsiao EC, ODonnell B, Salmeen K, Nussbaum R, Krebs M, Baumgartner-
Parzer S, Kaufmann M, Jones G, Bikle DD, Wang Y, Mathew AS, Shoback D, Block-
Kurbisch I. Maternal hypercalcemia due to failure of 1,25-dihydroxyvitamin-D3 ca-
tabolism in a patient with CYP24A1 mutations. J Clin Endocrinol Metab 100: 2832
2836, 2015.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
821. Shah KH, Bhat S, Shetty S, Umakanth S. Hypoparathyroidism in pregnancy. BMJ Case
Reports 2015: 2015.
822. Shahtaheri SM, Aaron JE, Johnson DR, Paxton SK. The impact of mammalian repro-
duction on cancellous bone architecture. J Anat 194: 407 421, 1999.
823. Shand AW, Nassar N, Von Dadelszen P, Innis SM, Green TJ. Maternal vitamin D
status in pregnancy and adverse pregnancy outcomes in a group at high risk for
pre-eclampsia. BJOG 117: 15931598, 2010.
824. Shangold MM, Dor N, Welt SI, Fleischman AR, Crenshaw MC Jr. Hyperparathyroid-
ism and pregnancy: a review. Obstet Gynecol Surv 37: 217228, 1982.
825. Shani H, Sivan E, Cassif E, Simchen MJ. Maternal hypercalcemia as a possible cause of
unexplained fetal polyhydramnion: a case series. Am J Obstet Gynecol 199: 410 415,
2008.
826. Shao H, Tao M, Fan Y, Jing J, Lu J. Vitamin D levels and other factors related to bone
mineral density during pregnancy. Aust N Z J Obstet Gynaecol 52: 571575, 2012.
827. Sharpe CJ, Fudge NJ, Kovacs CS. A rapid 35% flux in bone mass occurs during
pregnancy and lactation cycles in mice (Abstract). International Bone and Mineral
Society Meeting, Osaka, Japan, June 37, 2003. Bone 32 Suppl: S227, 2003.
828. Shaw CK. An epidemiologic study of osteoporosis in Taiwan. Ann Epidemiol 3: 264
271, 1993.
829. Shea JE, Doody SL, Eisenman PA, Miller SC. Augmentation of bone gains during the
anabolic post-lactation recovery period utilizing a rat bipedal stance model. J Bone
Miner Res 20 Suppl 1: S135, 2005.
830. Shenolikar IS. Absorption of dietary calcium in pregnancy. Am J Clin Nutr 23: 63 67,
1970.
831. Sheward WJ, Lutz EM, Harmar AJ. The expression of the calcitonin receptor gene in
the brain and pituitary gland of the rat. Neurosci Lett 181: 3134, 1994.
832. Shibata M, Suzuki A, Sekiya T, Sekiguchi S, Asano S, Udagawa Y, Itoh M. High
prevalence of hypovitaminosis D in pregnant Japanese women with threatened pre-
mature delivery. J Bone Miner Metab 29: 615 620, 2011.
833. Shilbayeh S. Prevalence of osteoporosis and its reproductive risk factors among
Jordanian women: a cross-sectional study. Osteoporos Int 14: 929 940, 2003.
834. Shimada T, Hasegawa H, Yamazaki Y, Muto T, Hino R, Takeuchi Y, Fujita T, Naka-
hara K, Fukumoto S, Yamashita T. FGF-23 is a potent regulator of vitamin D metab-
olism and phosphate homeostasis. J Bone Miner Res 19: 429 435, 2004.
835. Shinki T, Jin CH, Nishimura A, Nagai Y, Ohyama Y, Noshiro M, Okuda K, Suda T.
Parathyroid hormone inhibits 25-hydroxyvitamin D3-24-hydroxylase mRNA ex-
pression stimulated by 1 alpha,25-dihydroxyvitamin D3 in rat kidney but not in
intestine. J Biol Chem 267: 1375713762, 1992.
836. Shohl AT. Secretions and excretions. In: Mineral Metabolism, edited by Shohl AT.
New York: Reinhold, 1939, p. 57104.
837. Shomali ME, Ross DS. Hypercalcemia in a woman with hypoparathyroidism associ-
ated with increased parathyroid hormone-related protein during lactation. Endocr
Pract 5: 198 200, 1999.
 CHRISTOPHER S. KOVACS
838. Shukers CF, Macy IG, Nims B, Donelson E, Hunscher HA. A quantitative study of the
dietary of the human mother with respect to the nutrients secreted into breast milk.
J Nutr 5: 127139, 1932.
839. Silva OL, Titus-Dillon P, Becker KL, Snider RH, Moore CF. Increased serum calci-
tonin in pregnancy. J Natl Med Assoc 73: 649 652, 1981.
840. Silver J, Naveh-Many T. Calcitonin gene regulation in vivo. Horm Metab Res 25:
470 472, 1993.
841. Silver J, Naveh-Many T. FGF23 and the parathyroid glands. Pediatr Nephrol 25:
22412245, 2010.
842. Sinclair JG. Fetal rat parathyroids as affected by changes in maternal serum calcium
and phosphorus through parathyroidectomy and dietary control. J Nutr 23: 141152,
1942.
843. Singh A, Agarwal N, Chopra S, Sikka P, Suri V, Kumar B, Dutta P. Management of
pseudohypoparathyroidism type 1a during pregnancy and labor: a case report. Case
Reports Obstet Gynecol 2012: 629583, 2012.
844. Singh HJ, Mohammad NH, Nila A. Serum calcium and parathormone during normal
pregnancy in Malay women. J Matern Fetal Med 8: 95100, 1999.
845. Sinigaglia L, Varenna M, Binelli L, Gallazzi M, Calori G, Ranza R. Effect of lactation on
postmenopausal bone mineral density of the lumbar spine. J Reprod Med 41: 439
443, 1996.
846. Sioka C, Fotopoulos A, Georgiou A, Xourgia X, Papadopoulos A, Kalef-Ezra JA. Age
at menarche, age at menopause and duration of fertility as risk factors for osteopo-
rosis. Climacteric 13: 6371, 2010.
847. Siskind MS, Popovtzer MM. Postpartum hypercalcemia in a patient with medullary
sponge kidneys. Am J Kidney Dis 17: 588 590, 1991.
848. Sitara D, Razzaque MS, Hesse M, Yoganathan S, Taguchi T, Erben RG, Jppner H,
Lanske B. Homozygous ablation of fibroblast growth factor-23 results in hyperphos-
phatemia and impaired skeletogenesis, and reverses hypophosphatemia in Phex-
deficient mice. Matrix Biol 23: 421 432, 2004.
849. Smith R, Athanasou NA, Ostlere SJ, Vipond SE. Pregnancy-associated osteoporosis.
Q J Med 88: 865 878, 1995.
850. Smith R, Stevenson JC, Winearls CG, Woods CG, Wordsworth BP. Osteoporosis of
pregnancy. Lancet 1: 1178 1180, 1985.
851. Smith TJ, Phipps AW, Fell TP, Harrison JD. Transfer of alkaline earth elements in
mothers milk and doses from 45Ca, 90Sr and 226Ra. Radiat Prot Dosimetry 105:
273277, 2003.
852. Soares MJ, Colosi P, Talamantes F. The development and characterization of a
homologous radioimmunoassay for mouse placental lactogen. Endocrinology 110:
668 670, 1982.
853. Soifer NE, Dee KE, Insogna KL, Burtis WJ, Matovcik LM, Wu TL, Milstone LM,
Broadus AE, Philbrick WM, Stewart AF. Parathyroid hormone-related protein. Evi-
dence for secretion of a novel mid-region fragment by three different cell types. J Biol
Chem 267: 18236 18243, 1992.
854. Song Y, Peng X, Porta A, Takanaga H, Peng JB, Hediger MA, Fleet JC, Christakos S.
Calcium transporter 1 and epithelial calcium channel messenger ribonucleic acid are
differentially regulated by 1,25 dihydroxyvitamin D3 in the intestine and kidney of
mice. Endocrinology 144: 38853894, 2003.
855. Sorenson JA, Cameron JR. A reliable in vivo measurement of bone mineral content.
J Bone Joint Surg 49: 481 497, 1967.
856. Sowers M. Pregnancy and lactation as risk factors for subsequent bone loss and
osteoporosis. J Bone Miner Res 11: 10521060, 1996.
857. Sowers M, Corton G, Shapiro B, Jannausch ML, Crutchfield M, Smith ML, Randolph
JF, Hollis B. Changes in bone density with lactation. JAMA 269: 3130 3135, 1993.
858. Sowers M, Crutchfield M, Jannausch M, Updike S, Corton G. A prospective evalua-
tion of bone mineral change in pregnancy. Obstet Gynecol 77: 841 845, 1991.
859. Sowers M, Eyre D, Hollis BW, Randolph JF, Shapiro B, Jannausch ML, Crutchfield M.
Biochemical markers of bone turnover in lactating and nonlactating postpartum
women. J Clin Endocrinol Metab 80: 2210 2216, 1995.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
860. Sowers M, Randolph J, Shapiro B, Jannausch M. A prospective study of bone density
and pregnancy after an extended period of lactation with bone loss. Obstet Gynecol
85: 285289, 1995.
861. Sowers M, Wallace RB, Lemke JH. Correlates of forearm bone mass among women
during maximal bone mineralization. Prev Med 14: 585596, 1985.
862. Sowers M, Zhang D, Hollis BW, Shapiro B, Janney CA, Crutchfield M, Schork MA,
Stanczyk F, Randolph J. Role of calciotrophic hormones in calcium mobilization of
lactation. Am J Clin Nutr 67: 284 291, 1998.
863. Sowers MF, Hollis BW, Shapiro B, Randolph J, Janney CA, Zhang D, Schork A,
Crutchfield M, Stanczyk F, Russell-Aulet M. Elevated parathyroid hormone-related
peptide associated with lactation and bone density loss. JAMA 276: 549 554, 1996.
864. Sowers MR, Clark MK, Hollis B, Wallace RB, Jannausch M. Radial bone mineral
density in pre- and perimenopausal women: a prospective study of rates and risk
factors for loss. J Bone Miner Res 7: 647 657, 1992.
865. Sowers MR, Wallace RB, Lemke JH. Correlates of mid-radius bone density among
postmenopausal women: a community study. Am J Clin Nutr 41: 10451053, 1985.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
866. Spanos E, Brown DJ, Stevenson JC, MacIntyre I. Stimulation of 1,25-dihydroxychole-
calciferol production by prolactin and related peptides in intact renal cell prepara-
tions in vitro. Biochim Biophys Acta 672: 715, 1981.
867. Spanos E, Colston KW, Evans IM, Galante LS, Macauley SJ, MacIntyre I. Effect of
prolactin on vitamin D metabolism. Mol Cell Endocrinol 5: 163167, 1976.
868. Sparks JW. Human intrauterine growth and nutrient accretion. Semin Perinatol 8:
74 93, 1984.
869. Specker B, Binkley T. High parity is associated with increased bone size and strength.
Osteoporos Int 16: 1969 1974, 2005.
870. Specker BL, Beck A, Kalkwarf H, Ho M. Randomized trial of varying mineral intake
on total body bone mineral accretion during the first year of life. Pediatrics 99: E12,
1997.
871. Specker BL, Tsang RC, Ho ML. Changes in calcium homeostasis over the first year
postpartum: effect of lactation and weaning. Obstet Gynecol 78: 56 62, 1991.
872. Specker BL, Tsang RC, Hollis BW. Effect of race and diet on human-milk vitamin D
and 25-hydroxyvitamin D. Am J Dis Child 139: 1134 1137, 1985.
873. Specker BL, Vieira NE, OBrien KO, Ho ML, Heubi JE, Abrams SA, Yergey AL.
Calcium kinetics in lactating women with low and high calcium intakes. Am J Clin Nutr
59: 593599, 1994.
874. St-Arnaud R, Arabian A, Travers R, Barletta F, Raval-Pandya M, Chapin K, Depovere
J, Mathieu C, Christakos S, Demay MB, Glorieux FH. Deficient mineralization of
intramembranous bone in vitamin D-24-hydroxylase-ablated mice is due to elevated
1,25-dihydroxyvitamin D and not to the absence of 24,25-dihydroxyvitamin D. En-
docrinology 141: 2658 2666, 2000.
875. St-Arnaud R, Naja RP. Vitamin D metabolism, cartilage and bone fracture repair. Mol
Cell Endocrinol 347: 48 54, 2011.
876. Steichen JJ, Tsang RC, Gratton TL, Hamstra A, DeLuca HF. Vitamin D homeostasis
in the perinatal period: 1,25-dihydroxyvitamin D in maternal, cord, and neonatal
blood. N Engl J Med 302: 315319, 1980.
877. Stevenson JC, Abeyasekera G, Hillyard CJ, Phang KG, MacIntyre I, Campbell S,
Townsend PT, Young O, Whitehead MI. Calcitonin and the calcium-regulating
hormones in postmenopausal women: effect of oestrogens. Lancet 1: 693 695,
1981.
878. Stevenson JC, Hillyard CJ, MacIntyre I, Cooper H, Whitehead MI. A physiological
role for calcitonin: protection of the maternal skeleton. Lancet 2: 769 770, 1979.
879. Stevenson JC, Lees B, Devenport M, Cust MP, Ganger KF. Determinants of bone
density in normal women: risk factors for future osteoporosis? Br Med J 298: 924
928, 1989.
880. Stiegler C, Leb G, Kleinert R, Warnkross H, Ramschak-Schwarzer S, Lipp R, Clarici
G, Krejs GJ, Dobnig H. Plasma levels of parathyroid hormone-related peptide are
elevated in hyperprolactinemia and correlated to bone density status. J Bone Miner
Res 10: 751759, 1995.
543
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
881. Streeten EA, Ryan KA, McBride DJ, Pollin TI, Shuldiner AR, Mitchell BD. The rela-
tionship between parity and bone mineral density in women characterized by a
homogeneous lifestyle and high parity. J Clin Endocrinol Metab 90: 4536 4541, 2005.
882. Strewler GJ, Stern PH, Jacobs JW, Eveloff J, Klein RF, Leung SC, Rosenblatt M,
Nissenson RA. Parathyroid hormonelike protein from human renal carcinoma cells.
Structural and functional homology with parathyroid hormone. J Clin Invest 80:
18031807, 1987.
883. Stride PJ, Patel N, Kingston D. The history of osteoporosis: why do Egyptian mum-
mies have porotic bones? J R Coll Physicians Edinburgh 43: 254 261, 2013.
884. Strozier WE, Bohmfalk JM. Parathyroid deficiency associated with pregnancy. Am J
Obstet Gynecol 85: 541544, 1963.
885. Stumpf UC, Kurth AA, Windolf J, Fassbender WJ. Pregnancy-associated osteoporo-
sis: an underestimated and underdiagnosed severe disease. A review of two cases in
short- and long-term follow-up. Adv Med Sci 52: 94 97, 2007.
886. Sun W, Xie H, Ji J, Zhou X, Goltzman D, Miao D. Defective female reproductive
function in 1,25(OH)2D-deficient mice results from indirect effect mediated by
extracellular calcium and/or phosphorus. Am J Physiol Endocrinol Metab 299: E928
E935, 2010.
887. Sun YP, Lee TJ, Shah GV. Calcitonin expression in rat anterior pituitary gland is
regulated by ovarian steroid hormones. Endocrinology 143: 4056 4064, 2002.
888. Suntornsaratoon P, Wongdee K, Goswami S, Krishnamra N, Charoenphandhu N.
Bone modeling in bromocriptine-treated pregnant and lactating rats: possible osteo-
regulatory role of prolactin in lactation. Am J Physiol Endocrinol Metab 299: E426
E436, 2010.
889. Suva LJ, Winslow GA, Wettenhall RE, Hammonds RG, Moseley JM, Diefenbach-
Jagger H, Rodda CP, Kemp BE, Rodriguez H, Chen EY, Hudson PJ, Martin TJ, Wood
WI. A parathyroid hormone-related protein implicated in malignant hypercalcemia:
cloning and expression. Science 237: 893 896, 1987.
890. Sweeney LL, Malabanan AO, Rosen H. Decreased calcitriol requirement during
pregnancy and lactation with a window of increased requirement immediately post
partum. Endocr Pract 16: 459 462, 2010.
891. Taga M, Minaguchi H. Reduction of bone mineral density by gonadotropin-releasing
hormone agonist, nafarelin, is not completely reversible at 6 months after the ces-
sation of administration. Acta Obstet Gynecol Scand 75: 162165, 1996.
892. Takatori Y, Kokubo T, Ninomiya S, Nakamura T, Okutsu I, Kamogawa M. Transient
osteoporosis of the hip. Magnetic resonance imaging. Clin Orthop Relat Res 271:
190 194, 1991.
893. Takeuchi A, Okano T, Tsugawa N, Tasaka Y, Kobayashi T, Kodama S, Matsuo T.
Effects of ergocalciferol supplementation on the concentration of vitamin D and its
metabolites in human milk. J Nutr 119: 1639 1646, 1989.
894. Takeuchi K, Morikawa H, Ueda Y, Mochizuki M. Studies on the effects of placental
lactogen on calcium metabolism during pregnancy. Nippon Naibunpi Gakkai Zasshi
64: 11751186, 1988.
895. Tamma R, Colaianni G, Zhu LL, DiBenedetto A, Greco G, Montemurro G, Patano N,
Strippoli M, Vergari R, Mancini L, Colucci S, Grano M, Faccio R, Liu X, Li J, Usmani S,
Bachar M, Bab I, Nishimori K, Young LJ, Buettner C, Iqbal J, Sun L, Zaidi M, Zallone
A. Oxytocin is an anabolic bone hormone. Proc Natl Acad Sci USA 106: 7149 7154,
2009.
896. Tanaka Y, Halloran B, Schnoes HK, DeLuca HF. In vitro production of 1,25-dihy-
droxyvitamin D3 by rat placental tissue. Proc Natl Acad Sci USA 76: 50335035, 1979.
897. Tanriover MD, Oz SG, Sozen T, Kilicarslan A, Guven GS. Pregnancy- and lactation-
associated osteoporosis with severe vertebral deformities: can strontium ranelate
be a new alternative for the treatment? Spine J 9: 20 24, 2009.
898. Tarnawa E, Sullivan S, Underwood P, Richardson M, Spruill L. Severe hypercalcemia
associated with uterine leiomyoma in pregnancy. Obstet Gynecol 117: 473 476,
2011.
899. Taylor RN, Badell ML. The endocrinology of pregnancy. In: Greenspans Basic and
Clinical Endocrinology (9th ed.), edited by Gardner DG, Shoback DG. New York:
Lange Medical Books/McGraw-Hill, 2011, p. 553572.
900. Taylor TG, Lewis PE, Balderstone O. Role of calcitonin in protecting the skeleton
during pregnancy and lactation. J Endocrinol 66: 297298, 1975.
544 Physiol Rev VOL 96 APRIL 2016 www.prv.org
901. Teerapornpuntakit J, Klanchui A, Karoonuthaisiri N, Wongdee K, Charoenphandhu
N. Expression of transcripts related to intestinal ion and nutrient absorption in
pregnant and lactating rats as determined by custom-designed cDNA microarray.
Mol Cell Biochem 391: 103116, 2014.
902. Teotia M, Teotia SP. Nutritional and metabolic rickets. Indian J Pediatr 64: 153157,
1997.
903. Teotia M, Teotia SP, Nath M. Metabolic studies in congenital vitamin D deficiency
rickets. Indian J Pediatr 62: 55 61, 1995.
904. Teti A, Zallone A. Do osteocytes contribute to bone mineral homeostasis? Osteo-
cytic osteolysis revisited. Bone 44: 1116, 2009.
905. Thibaud D, Janisch S, Koelbl H, Hanzal E, Jacquet AF, Leodolter S, Burckhardt P,
Pecherstorfer M. Direct evidence of a parathyroid related protein gradient between
the mother and the newborn in humans. Bone Miner 23: 213221, 1993.
906. Thiede MA. The mRNA encoding a parathyroid hormone-like peptide is produced in
mammary tissue in response to elevations in serum prolactin. Mol Endocrinol 3:
14431447, 1989.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
907. Thiede MA. Parathyroid hormone-related protein: a regulated calcium-mobilizing
product of the mammary gland. J Dairy Sci 77: 19521963, 1994.
908. Thiede MA, Grasser WA, Petersen DN. Regulated expression of parathyroid hor-
mone-related protein in mammary blood supply supports a role in mammary blood
flow. In: Calcium Regulating Hormones and Bone Metabolism: Basic and Clinical As-
pects, edited by Cohn DV, Gennari C, Tashjian AHJr. Amsterdam: Excerpta Medica,
1992, p. 62 66.
909. Thiede MA, Harm SC, Hasson DM, Gardner RM. In vivo regulation of parathyroid
hormone-related peptide messenger ribonucleic acid in the rat uterus by 17 beta-
estradiol. Endocrinology 128: 23172323, 1991.
910. Thiede MA, Rodan GA. Expression of a calcium-mobilizing parathyroid hormone-
like peptide in lactating mammary tissue. Science 242: 278 280, 1988.
911. Thiede MA, Yoon K, Golub EE, Noda M, Rodan GA. Structure and expression of rat
osteosarcoma (ROS 17/2.8) alkaline phosphatase: product of a single copy gene. Proc
Natl Acad Sci USA 85: 319 323, 1988.
912. Thomas AK, McVie R, Levine SN. Disorders of maternal calcium metabolism impli-
cated by abnormal calcium metabolism in the neonate. Am J Perinatol 16: 515520,
1999.
913. Thomas BR, Bennett JD. Late-onset neonatal hypocalcemia as an unusual presenta-
tion in an offspring of a mother with familial hypocalciuric hypercalcemia. Clin Pediatr
36: 547550, 1997.
914. Thomas BR, Bennett JD. Symptomatic hypocalcemia and hypoparathyroidism in two
infants of mothers with hyperparathyroidism and familial benign hypercalcemia. J
Perinatol 15: 2326, 1995.
915. Thomas ML, Forte LR. Serum calcium and parathyroid hormone during the repro-
ductive cycle in normal and vitamin D-deficient rats. Endocrinology 110: 703707,
1982.
916. Thompson GE, Ratcliffe WA, Hughes S, Abbas SK, Care AD. Local control of para-
thyroid hormone-related protein secretion by the mammary gland of the goat. Comp
Biochem Physiol A 108: 485 490, 1994.
917. To WW, Wong MW. Changes in bone mineral density of the os calcis as measured by
quantitative ultrasound during pregnancy and 24 months after delivery. Aust N Z J
Obstet Gynaecol 51: 166 171, 2011.
918. To WW, Wong MW, Leung TW. Relationship between bone mineral density changes
in pregnancy and maternal and pregnancy characteristics: a longitudinal study. Acta
Obstet Gynecol Scand 82: 820 827, 2003.
919. Tohei A, VandeGarde B, Arbogast LA, Voogt JL. Calcitonin inhibition of prolactin
secretion in lactating rats: mechanism of action. Neuroendocrinology 71: 327332,
2000.
920. Tojo Y, Kurabayashi T, Honda A, Yamamoto Y, Yahata T, Takakuwa K, Tanaka K.
Bone structural and metabolic changes at the end of pregnancy and lactation in rats.
Am J Obstet Gynecol 178: 180 185, 1998.
 CHRISTOPHER S. KOVACS
921. Tolstykh EI, Degteva MO, Kozheurov VP, Burmistrov DS. Strontium transfer from
maternal skeleton to the fetus estimated on the basis of the Techa river data. Radiat
Prot Dosimetry 79: 307310, 1998.
922. Tolstykh EI, Degteva MO, Vorobiova MI, Kozheurov VP. Fetal dose assessment for
the offspring of the Techa Riverside residents. Radiat Environ Biophys 40: 279 286,
2001.
923. 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. Radiat Environ Biophys 53: 551557, 2014.
924. Tolstykh EI, Shagina NB, Peremyslova LM, Degteva MO, Phipps AW, Harrison JD,
Fell TP. Reconstruction of (90)Sr intake for breast-fed infants in the Techa riverside
settlements. Radiat Environ Biophys 47: 349 357, 2008.
925. Tov AB, Mandel D, Weissman Y, Dollberg S, Taxir T, Lubetzky R. Changes in serum
parathyroid hormone-related protein in breastfed preterm infants. Breastfeed Med
7: 50 53, 2012.
926. Toverud SU, Cooper CW, Munson PL. Calcium metabolism during lactation: ele-
vated blood levels of calcitonin. Endocrinology 103: 472 479, 1978.
927. Toverud SU, Harper C, Munson PL. Calcium metabolism during lactation: enhanced
effects of thyrocalcitonin. Endocrinology 99: 371378, 1976.
928. Tran HA, Petrovsky N. Pregnancy-associated osteoporosis with hypercalcaemia.
Intern Med J 32: 481 485, 2002.
929. Tremollieres FA, Pouilles JM, Drewniak N, Laparra J, Ribot CA, Dargent-Molina P.
Fracture risk prediction using BMD and clinical risk factors in early postmenopausal
women: sensitivity of the WHO FRAX tool. J Bone Miner Res 25: 10021009, 2010.
930. Trotter M, Hixon BB. Sequential changes in weight, density, and percentage ash
weight of human skeletons from an early fetal period through old age. Anat Rec 179:
118, 1974.
931. Tsuchida T, Ishimura E, Hirowatari K, Matsumoto N, Imanishi Y, Jono S, Miki T,
Inaba M, Nishizawa Y. Serum levels of 1 84 and 7 84 parathyroid hormone in
predialysis patients with chronic renal failure measured by the intact and bio-PTH
assay. Nephron Clin Pract 102: &#X2013;c108 114, 2006.
932. Tu Q, Pi M, Karsenty G, Simpson L, Liu S, Quarles LD. Rescue of the skeletal
phenotype in CasR-deficient mice by transfer onto the Gcm2 null background. J Clin
Invest 111: 1029 1037, 2003.
933. Tulchinsky D, Hobel CJ. Plasma human chorionic gonadotropin, estrone, estradiol,
estriol, progesterone, and 17 alpha-hydroxyprogesterone in human pregnancy. 3.
Early normal pregnancy. Am J Obstet Gynecol 117: 884 893, 1973.
934. Tuppurainen M, Kroger H, Saarikoski S, Honkanen R, Alhava E. The effect of gyne-
cological risk factors on lumbar and femoral bone mineral density in peri- and post-
menopausal women. Maturitas 21: 137145, 1995.
935. Turan V. Grand-grand multiparity (more than 10 deliveries) does not convey a risk
for osteoporosis. Acta Obstet Gynecol Scand 90: 1440 1442, 2011.
936. Turner E, Freier A. Hypoparathyroidism and pregnancy. Am J Obstet Gynecol 85:
133134, 1963.
937. Turner M, Barre PE, Benjamin A, Goltzman D, Gascon-Barre M. Does the maternal
kidney contribute to the increased circulating 1,25-dihydroxyvitamin D concentra-
tions during pregnancy? Miner Electrolyte Metab 14: 246 252, 1988.
938. Tverberg LA, Gustafson MF, Scott TL, Arzumanova IV, Provost ER, Yan AW, Rawie
SA. Induction of calcitonin and calcitonin receptor expression in rat mammary tissue
during pregnancy. Endocrinology 141: 3696 3702, 2000.
939. US Department of Agriculture. USDA National Nutrient Database for Standard
Reference Release 22. NBD no. 01107. Milk, human, mature, fluid. Available online:
http://www.ars.usda.gov/main/site_main.htm?modecode1235-45-00 Accessed
August 2, 2010. 2009.
940. Uemura H, Yasui T, Umino Y, Yamada M, Kuwahara A, Matsuzaki T, Maegawa M,
Irahara M. Regulatory factors on parathyroid hormone-related peptide production
by primary culture of lactating rat mammary gland. Horm Metab Res 37: 463 467,
2005.
941. Uemura H, Yasui T, Yoneda N, Irahara M, Aono T. Measurement of N- and C-ter-
minal-region fragments of parathyroid hormone-related peptide in milk from lactat-
Physiol Rev VOL 96 APRIL 2016 www.prv.org
ing women and investigation of the relationship of their concentrations to calcium in
milk. J Endocrinol 153: 445 451, 1997.
942. Uemura T, Mohri J, Osada H, Suzuki N, Katagiri N, Minaguchi H. Effect of gonado-
tropin-releasing hormone agonist on the bone mineral density of patients with en-
dometriosis. Fertil Steril 62: 246 250, 1994.
943. Ulrich U, Miller PB, Eyre DR, Chesnut CHr Schlebusch H, Soules MR. Bone remod-
eling and bone mineral density during pregnancy. Arch Gynecol Obstet 268: 309 316,
2003.
944. Unni J, Garg R, Pawar R. Bone mineral density in women above 40 years. J Midlife
Health 1: 19 22, 2010.
945. Usta IM, Chammas M, Khalil AM. Renal cell carcinoma with hypercalcemia compli-
cating a pregnancy: case report and review of the literature. Eur J Gynaecol Oncol 19:
584 587, 1998.
946. Uusi-Rasi K, Sievanen H, Pasanen M, Oja P, Vuori I. Association of physical activity
and calcium intake with the maintenance of bone mass in premenopausal women.
Osteoporos Int 13: 211217, 2002.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
947. Vajda EG, Bowman BM, Miller SC. Cancellous and cortical bone mechanical prop-
erties and tissue dynamics during pregnancy, lactation, and postlactation in the rat.
Biol Reprod 65: 689 695, 2001.
948. Van Cromphaut SJ, Dewerchin M, Hoenderop JG, Stockmans I, Van Herck E, Kato S,
Bindels RJ, Collen D, Carmeliet P, Bouillon R, Carmeliet G. Duodenal calcium ab-
sorption in vitamin D receptor-knockout mice: functional and molecular aspects.
Proc Natl Acad Sci USA 98: 13324 13329, 2001.
949. Van Cromphaut SJ, Rummens K, Stockmans I, Van Herck E, Dijcks FA, Ederveen AG,
Carmeliet P, Verhaeghe J, Bouillon R, Carmeliet G. Intestinal calcium transporter
genes are upregulated by estrogens and the reproductive cycle through vitamin D
receptor-independent mechanisms. J Bone Miner Res 18: 17251736, 2003.
950. Van Heerden JA, Gharib H, Jackson IT. Pseudohyperparathyroidism secondary to
gigantic mammary hypertrophy. Arch Surg 123: 80 82, 1988.
951. Van Hemert AM, Vandenbroucke JP, Birkenhager JC, Valkenburg HA. Prediction of
osteoporotic fractures in the general population by a fracture risk score. A 9-year
follow-up among middle-aged women. Am J Epidemiol 132: 123135, 1990.
952. VanHouten J, Dann P, McGeoch G, Brown EM, Krapcho K, Neville M, Wysolmerski
JJ. The calcium-sensing receptor regulates mammary gland parathyroid hormone-
related protein production and calcium transport. J Clin Invest 113: 598 608, 2004.
953. VanHouten JN, Dann P, Stewart AF, Watson CJ, Pollak M, Karaplis AC, Wysolmerski
JJ. Mammary-specific deletion of parathyroid hormone-related protein preserves
bone mass during lactation. J Clin Invest 112: 1429 1436, 2003.
954. VanHouten JN, Neville MC, Wysolmerski JJ. The calcium-sensing receptor regulates
plasma membrane calcium adenosine triphosphatase isoform 2 activity in mammary
epithelial cells: a mechanism for calcium-regulated calcium transport into milk. En-
docrinology 148: 59435954, 2007.
955. Vanhouten JN, Wysolmerski JJ. The calcium-sensing receptor in the breast. Best
Pract Res Clin Endocrinol Metab 27: 403 414, 2013.
956. VanHouten JN, Wysolmerski JJ. Low estrogen and high parathyroid hormone-re-
lated peptide levels contribute to accelerated bone resorption and bone loss in
lactating mice. Endocrinology 144: 55215529, 2003.
957. Vaughan LA, Weber CW, Kemberling SR. Longitudinal changes in the mineral con-
tent of human milk. Am J Clin Nutr 32: 23012306, 1979.
958. Verhaeghe J, Allewaert K, Van Herck E, Van Bree R, Van Assche FA, Bouillon R.
1,25-Dihydroxyvitamin D3 and osteocalcin in maternal and fetal guinea pigs. Bone
Miner 26: 261273, 1994.
959. Verhaeghe J, Bouillon R. Calciotropic hormones during reproduction. J Steroid
Biochem Mol Biol 41: 469 477, 1992.
960. Verhaeghe J, Thomasset M, Brehier A, Van Assche FA, Bouillon R. 1,25(OH)2D3 and
Ca-binding protein in fetal rats: relationship to the maternal vitamin D status. Am J
Physiol Endocrinol Metab 254: E505E512, 1988.
961. Verhaeghe J, Van Herck E, Van Bree R, Van Assche FA, Bouillon R. Osteocalcin
during the reproductive cycle in normal and diabetic rats. J Endocrinol 120: 143151,
1989.
545
 MINERAL METABOLISM DURING PREGNANCY AND LACTATION
962. Von Recklinghausen F. Untersuchungen ber Rachitis und Osteomalacie. Jena, Ger-
many: Verlag von Gustav Fischer, 1910.
963. Wagner CL. Vitamin D Supplementation during Pregnancy: impact on Maternal
Outcomes. In: Centers for Disease Control and Prevention Conference on Vitamin D
Physiology in Pregnancy: Implications for Preterm Birth and Preeclampsia. Atlanta, Geor-
gia: Centers for Disease Control and Prevention, 2011.
964. Wagner CL, Baggerly C, McDonnell SL, Baggerly L, Hamilton SA, Winkler J, Warner
G, Rodriguez C, Shary JR, Smith PG, Hollis BW. Post-hoc comparison of vitamin D
status at three timepoints during pregnancy demonstrates lower risk of preterm
birth with higher vitamin D closer to delivery. J Steroid Biochem Mol Biol 148: 256
260, 2015.
965. Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. High-dose vitamin D3
supplementation in a cohort of breastfeeding mothers and their infants: a 6-month
follow-up pilot study. Breastfeed Med 1: 59 70, 2006.
966. Wagner CL, McNeil R, Hamilton SA, Winkler J, Rodriguez Cook C, Warner G, Bivens
B, Davis DJ, Smith PG, Murphy M, Shary JR, Hollis BW. A randomized trial of vitamin
D supplementation in 2 community health center networks in South Carolina. Am J
Obstet Gynecol 208: 137.e13159 113, 2013.
967. Wagner CL, McNeil RB, Johnson DD, Hulsey TC, Ebeling M, Robinson C, Hamilton
SA, Hollis BW. Health characteristics and outcomes of two randomized vitamin D
supplementation trials during pregnancy: a combined analysis. J Steroid Biochem Mol
Biol 136: 313320, 2013.
968. Walker A, Fraile JJ, Hubbard JG. Parathyroidectomy in pregnancy-a single centre
experience with review of evidence and proposal for treatment algorithim. Gland
Surg 3: 158 164, 2014.
969. Walker AR, Richardson B, Walker F. The influence of numerous pregnancies and
lactations on bone dimensions in South African Bantu and Caucasian mothers. Clin Sci
42: 189 196, 1972.
970. Wallace LR. The growth of lambs before and after birth in relation to the level of
nutrition. J Agric Sci 38: 93153, 1948.
971. Wardlaw GM, Pike AM. The effect of lactation on peak adult shaft and ultra-distal
forearm bone mass in women. Am J Clin Nutr 44: 283286, 1986.
972. Warnock GM, Duckworth J. Changes in the skeleton during gestation and lactation
in the rat. Biochem J 38: 220 224, 1944.
973. Wasnich R, Yano K, Vogel J. Postmenopausal bone loss at multiple skeletal sites:
relationship to estrogen use. J Chronic Dis 36: 781790, 1983.
974. Wasserman RH, Comar CL, Nold MM, Lengemann FW. Placental transfer of calcium
and strontium in the rat and rabbit. Am J Physiol 189: 9197, 1957.
975. Watney PJ, Rudd BT. Calcium metabolism in pregnancy and in the newborn. J Obstet
Gynaecol Br Commonw 81: 210 219, 1974.
976. Weaver CM. Age related calcium requirements due to changes in absorption and
utilization. J Nutr 124: 1418S1425S, 1994.
977. Weisman Y, Sapir R, Harell A, Edelstein S. Maternal-perinatal interrelationships of
vitamin D metabolism in rats. Biochim Biophys Acta 428: 388 395, 1976.
978. Weisman Y, Vargas A, Duckett G, Reiter E, Root AW. Synthesis of 1,25-dihydroxyvi-
tamin D in the nephrectomized pregnant rat. Endocrinology 103: 19921996, 1978.
979. Weisz J, Ward IL. Plasma testosterone and progesterone titers of pregnant rats, their
male and female fetuses, and neonatal offspring. Endocrinology 106: 306 316, 1980.
980. Wermers RA, Khosla S, Atkinson EJ, Hodgson SF, OFallon WM, Melton L Jr. The rise
and fall of primary hyperparathyroidism: a population-based study in Rochester,
Minnesota, 19651992. Ann Intern Med 126: 433 440, 1997.
981. Whitehead M, Lane G, Young O, Campbell S, Abeyasekera G, Hillyard CJ, MacIntyre
I, Phang KG, Stevenson JC. Interrelations of calcium-regulating hormones during
normal pregnancy. Br Med J 283: 10 12, 1981.
982. Widdowson EM. Metabolic relationship of calcium, magnesium and phosphorus in
the foetus and newly born. Voeding 23: 6271, 1962.
983. Widdowson EM, Dickerson JW. Chemical composition of the body. In: Mineral
Metabolism: An Advanced Treatise. The Elements, edited by Comar CL, Bronner F.
New York: Academic, 1964, vol. II, pt. A, p. 1247.
546 Physiol Rev VOL 96 APRIL 2016 www.prv.org
984. Widdowson EM, McCance RA. The metabolism of phosphorus, calcium, magnesium
and strontium. Pediatr Clin North Am 12: 595 614, 1965.
985. Wieland P, Fischer JA, Trechsel U, Roth HR, Vetter K, Schneider H, Huch A. Peri-
natal parathyroid hormone, vitamin D metabolites, and calcitonin in man. Am J Physiol
Endocrinol Metab 239: E385E390, 1980.
986. Wiklund PK, Xu L, Wang Q, Mikkola T, Lyytikainen A, Volgyi E, Munukka E, Cheng
SM, Alen M, Keinanen-Kiukaanniemi S, Cheng S. Lactation is associated with greater
maternal bone size and bone strength later in life. Osteoporos Int 23: 1939 1945,
2012.
987. Wilson SG, Retallack RW, Kent JC, Worth GK, Gutteridge DH. Serum free 1,25-
dihydroxyvitamin D and the free 1,25-dihydroxyvitamin D index during a longitudi-
nal study of human pregnancy and lactation. Clin Endocrinol 32: 613 622, 1990.
988. Wittelsberger A, Rosenblatt M. Parathyroid hormone-receptor interactions. In: Prin-
ciples of Bone Biology (3rd ed.), edited by Bilezikian JP, Raisz LG, Martin TJ. New
York: Academic, 2008, p. 595 637.
989. Wlodek ME, Westcott KT, Serruto A, ODowd R, Wassef L, Ho PW, Moseley JM.
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
Impaired mammary function and parathyroid hormone-related protein during lac-
tation in growth-restricted spontaneously hypertensive rats. J Endocrinol 178: 233
245, 2003.
990. Woloszczuk W, Kovarik J, Pavelka P. Calcitonin in pregnant women and in cord
blood. Gynecol Obstet Invest 12: 272276, 1981.
991. Wong KM, Singer L, Ophaug RH. Metabolic aspects of bone resorption in calcium-
deficient lactating rats. Calcif Tissue Int 32: 213219, 1980.
992. Woodrow JP. Calcitonin modulates skeletal mineral loss during lactation through
interactions in mammary tissue and directly though osteoclasts in bone (PhD thesis).
In: Biomedical Sciences, Faculty of Medicine. St. Johns, Newfoundland: Memorial
University of Newfoundland, 2009.
993. Woodrow JP, Noseworthy CS, Fudge NJ, Hoff AO, Gagel RF, Kovacs CS. Calcitonin/
calcitonin gene-related peptide protect the maternal skeleton from excessive re-
sorption during lactation (Abstract). J Bone Miner Res 18 Suppl 1: S35, 2003.
994. Woodrow JP, Sharpe CJ, Fudge NJ, Hoff AO, Gagel RF, Kovacs CS. Calcitonin plays
a critical role in regulating skeletal mineral metabolism during lactation. Endocrinology
147: 4010 4021, 2006.
995. Wright AD, Joplin GF, Dixon HG. Post-partum hypercalcaemia in treated hypopara-
thyroidism. Br Med J 1: 2325, 1969.
996. Wu TL, Vasavada RC, Yang K, Massfelder T, Ganz M, Abbas SK, Care AD, Stewart
AF. Structural and physiologic characterization of the mid-region secretory species
of parathyroid hormone-related protein. J Biol Chem 271: 2437124381, 1996.
997. Wyshak G. Hip fracture in elderly women and reproductive history. J Gerontol 36:
424 427, 1981.
998. Wysolmerski JJ. Osteocytes remove and replace perilacunar mineral during repro-
ductive cycles. Bone 54: 230 236, 2013.
999. Wysolmerski JJ, Philbrick WM, Dunbar ME, Lanske B, Kronenberg H, Broadus AE.
Rescue of the parathyroid hormone-related protein knockout mouse demonstrates
that parathyroid hormone-related protein is essential for mammary gland develop-
ment. Development 125: 12851294, 1998.
1000. Xue Y, Fleet JC. Intestinal vitamin D receptor is required for normal calcium and
bone metabolism in mice. Gastroenterology 136: 13171327, 2009.
1001. Yadav S, Yadav YS, Goel MM, Singh U, Natu SM, Negi MP. Calcitonin gene- and
parathyroid hormone-related peptides in normotensive and preeclamptic pregnan-
cies: a nested case-control study. Arch Gynecol Obstet 290: 897903, 2014.
1002. Yamaga A, Taga M, Minaguchi H, Sato K. Changes in bone mass as determined by
ultrasound and biochemical markers of bone turnover during pregnancy and puer-
perium: a longitudinal study. J Clin Endocrinol Metab 81: 752756, 1996.
1003. Yamamoto M, Duong LT, Fisher JE, Thiede MA, Caulfield MP, Rosenblatt M. Suck-
ling-mediated increases in urinary phosphate and 3,5-cyclic adenosine monophos-
phate excretion in lactating rats: possible systemic effects of parathyroid hormone-
related protein. Endocrinology 129: 2614 2622, 1991.
1004. Yamamoto M, Fisher JE, Thiede MA, Caulfield MP, Rosenblatt M, Duong LT. Con-
centrations of parathyroid hormone-related protein in rat milk change with duration
 CHRISTOPHER S. KOVACS
of lactation and interval from previous suckling, but not with milk calcium. Endocri-
nology 130: 741747, 1992.
1005. Yamamoto N, Takahashi HE, Tanizawa T, Kawashima T, Endo N. Bone mineral
density and bone histomorphometric assessments of postpregnancy osteoporosis: a
report of five patients. Calcif Tissue Int 54: 20 25, 1994.
1006. Yamamoto Y, Yoshizawa T, Fukuda T, Shirode-Fukuda Y, Yu T, Sekine K, Sato T,
Kawano H, Aihara K, Nakamichi Y, Watanabe T, Shindo M, Inoue K, Inoue E, Tsuji N,
Hoshino M, Karsenty G, Metzger D, Chambon P, Kato S, Imai Y. Vitamin D receptor in
osteoblasts is a negative regulator of bone mass control. Endocrinology 154: 10081020, 2013.
1007. Yang KH, dePapp AE, Soifer NE, Dreyer BE, Wu TL, Porter SE, Bellantoni M, Burtis WJ,
Insogna KL, Broadus AE. Parathyroid hormone-related protein: evidence for isoform-
and tissue-specific posttranslational processing. Biochemistry 33: 7460 7469, 1994.
1008. Yasumatsu R, Nakashima T, Kuratomi Y, Komiyama S. Postpartum hypercalcemia in
a patient with previous thyroid carcinoma: a report of 2 cases. Nihon Jibiinkoka
Gakkai Kaiho 105: 897900, 2002.
1009. Yasumizu T, Nakamura Y, Hoshi K, Iijima S, Asaka A. Bone metabolism after human
parturition and the effect of lactation: longitudinal analysis of serum bone-related
proteins and bone mineral content of the lumbar spine. Endocr J 45: 679 686, 1998.
1010. Yoshida T, Suzuki H, Hattori Y, Noda K. Hormonal changes around the parturition
in rats. Tohoku J Exp Med 135: 8791, 1981.
1011. Yoshizawa T, Handa Y, Uematsu Y, Takeda S, Sekine K, Yoshihara Y, Kawakami T,
Arioka K, Sato H, Uchiyama Y, Masushige S, Fukamizu A, Matsumoto T, Kato S. Mice
lacking the vitamin D receptor exhibit impaired bone formation, uterine hypoplasia
and growth retardation after weaning. Nat Genet 16: 391396, 1997.
1012. Yu B, Wu H, Li F, Gong J, Zhou D, Zhang Z, Yang X, Huang Z. Change of BMD after
weaning or resumption of menstruation in Chinese women with different FokI
VDR-genotypes: a randomized, placebo-controlled, calcium supplementation trial.
Biomed Environ Sci 24: 243248, 2011.
1013. Yu CK, Sykes L, Sethi M, Teoh TG, Robinson S. Vitamin D deficiency and supple-
mentation during pregnancy. Clin Endocrinol 70: 685 690, 2009.
1014. Yuan R, Kulkarni T, Wei F, Shah GV. Targeted overexpression of calcitonin in go-
nadotrophs of transgenic mice leads to chronic hypoprolactinemia. Mol Cell Endocri-
nol 229: 193203, 2005.
1015. Yumusakhuylu Y, Turgut ST, Icagasioglu A, Baklacioglu HS, Atlig RS, Murat S, Suer N.
Bone mineral changes during pregnancy and lactation. Gynecol Endocrinol 29: 763
766, 2013.
Physiol Rev VOL 96 APRIL 2016 www.prv.org
1016. Zarattini G, Buffoli P, Isabelli G, Marchese M. Pregnancy-associated osteoporosis
with seven vertebral compression fractures, a case treated with strontium ranelate.
Clin Cases Miner Bone Metab 11: 139 141, 2014.
1017. Zerwekh JE, Breslau NA. Human placental production of 1a,25-dihydroxyvita-
min D3: biochemical characterization and production in normal subjects and
patients with pseudohypoparathyroidism. J Clin Endocrinol Metab 62: 192196,
1986.
1018. Zhang J, Feldblum PJ, Fortney JA. Moderate physical activity and bone density among
perimenopausal women. Am J Public Health 82: 736 738, 1992.
1019. Zhang JY, Lucey AJ, Horgan R, Kenny LC, Kiely M. Impact of pregnancy on vitamin D
status: a longitudinal study. Br J Nutr 112: 10811087, 2014.
1020. Zhang YY, Liu PY, Deng HW. The impact of reproductive and menstrual history on
bone mineral density in Chinese women. J Clin Densitom 6: 289 296, 2003.
1021. Zhu Y, Goff JP, Reinhardt TA, Horst RL. Pregnancy and lactation increase vitamin
D-dependent intestinal membrane calcium adenosine triphosphatase and calcium
binding protein messenger ribonucleic acid expression. Endocrinology 139: 3520
Downloaded from http://physrev.physiology.org/ by 10.220.33.2 on October 10, 2017
3524, 1998.
1022. Ziegler EE, ODonnell AM, Nelson SE, Fomon SJ. Body composition of the reference
fetus. Growth 40: 329 341, 1976.
1023. Zierold C, Mings JA, DeLuca HF. Parathyroid hormone regulates 25-hydroxyvitamin
D3-24-hydroxylase mRNA by altering its stability. Proc Natl Acad Sci USA 98: 13572
13576, 2001.
1024. Zierold C, Reinholz GG, Mings JA, Prahl JM, DeLuca HF. Regulation of the procine
1,25-dihydroxyvitamin D3-24-hydroxylase (CYP24) by 1,25-dihydroxyvitamin D3
and parathyroid hormone in AOK-B50 cells. Arch Biochem Biophys 381: 323327,
2000.
1025. Zinaman MJ, Hickey M, Tomai TP, Albertson BD, Simon JA. Calcium metabolism
in postpartum lactation: the effect of estrogen status. Fertil Steril 54: 465 469,
1990.
1026. Zinser GM, Welsh J. Accelerated mammary gland development during pregnancy
and delayed postlactational involution in vitamin D3 receptor null mice. Mol Endocri-
nol 18: 2208 2223, 2004.
1027. Zwahlen M, Gerber S, Bersinger NA. First trimester markers for pre-eclampsia:
placental vs. non-placental protein serum levels. Gynecol Obstet Invest 63: 1521,
2007.
547