Ömercan TOPALOĞLU, Bayram ŞAHİN, İbrahim ŞAHİN

Gebelikte ve Laktasyonda Mineral Metabolizması ve Hipoparatiroidizm

Gebelikte kalsiyum, fosfor ve magnezyum ihtiyacı artar, ancak düzeltilmiş kalsiyum, iyonize kalsiyum, fosfor ve magnezyum seviyeleri değişmez. Gebelikte maternal PTHrP artarak böbrek ve plasentada 1-alfa hidroksilaz aktivitesini ve kalsitriol sentezini arttırır. Gebeliğin ilk trimesterinde PTH normalin altına düşebilir, sonraki haftalarda orta-normal aralığa yükselir. Laktasyonda düzeltilmiş kalsiyum ve iyonize kalsiyum seviyesi normal sınırlardadır. Laktasyonda PTHrP seviyesi artarak maternal iskeletten kalsiyum rezorpsiyonunu ve böbreklerden kalsiyum abzorpsiyonunu uyarır, PTH alt sınırda ölçülür. Maternal iskelet yıkımı pahasına, transplasental kalsiyum geçişi devam ettiğinden, ciddi maternal hipokalsemi gelişmedikçe fetal hipokalsemi beklenmez. Bazı gebeler erken dönemde kalsiyum replasmanına daha az ihtiyaç duyarlar. Hipoparatiroidizm tanısı olan kadınlar gebe kaldığında yakın takip gereklidir. Gebelikte maternal hipokalsemiden ve hiperkalsemiden kaçınılmalıdır. Maternal hipoparatiroidizm tedavisinde günlük 1-1,5 gram kalsiyum ve 0,5-3 μg kalsitriol (bölünmüş dozlarda) veya haftalık 50000-150000 IU 25(OH)D vitamini verilmesi önerilir. Gebelikte hipoparatiroidi izleminde obstetrik, endokrinoloji ve pediatri doktorları iş birliği içinde olmalıdır. Düzeltilmiş serum kalsiyum veya iyonize kalsiyum düzeyi gebelik boyunca 3-4 haftada bir, laktasyonda ilk ay haftalık sonra ayda bir ölçülmelidir; gebelikte ve laktasyonda alt-normal referans aralığında tutulmalıdır.

MINERAL METABOLISM AND HYPOPARATHYROIDISM IN PREGNANCY AND LACTATION

Need of calcium, phosphorus and magnesium increases in pregnancy, but corrected calcium, ionized calcium, phosphorus or magnesium levels do not change. Increased maternal PTHrP in pregnancy increases 1-alfa hydroxylase activity in kidney and placenta, and thus increases calcitriol synthesis. PTH may decrease below normal range in the first trimester of pregnancy, but increases up to mid-normal levels in the subsequent weeks. Corrected and ionized calcium levels are in normal limits in lactation. Increasing levels of PTHrP in lactation stimulates calcium resorption from maternal skeleton and calcium reabsorption from kidneys; PTH levels are measured at lower limits of normal. Because transplacental calcium entry continues at the expense of maternal skeletal resorption, fetal hypocalcemia does not occur unless severe maternal hypocalcemia emerges. Some pregnant women need less calcium replacement in the earlier pregnancy. Close follow-up is necessary when the women with hypoparathyroidism become pregnant. Maternal hypo- or hypercalcemia should be avoided in pregnancy. It is recommended that 1-1.5 gr calcium and 0.5-3 μg calcitriol (divided doses) daily or 50000-150000 IU 25(OH) vitamin D (weekly) may be given in the treatment of maternal hypoparathyroidism. In the management of maternal hypoparathyroidism during pregnancy, medical doctors in obstetrics, endocrinology and pediatrics should be collaborated with each other. Corrected serum calcium or ionized calcium levels should be adjusted as to be at lower-normal reference range in pregnancy and lactation, measured at each 3-4 weeks in pregnancy, weekly in first month of lactation, and monthly in later lactation.

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