What is the best practice for calcium management in medical termination of pregnancy (MTP)?

Best Practice for Calcium Management in Medical Termination of Pregnancy (MTP)

Calcium carbonate supplementation at a dose of 1.0-1.5g elemental calcium daily, administered in divided doses of ≤500mg per dose, is recommended during medical termination of pregnancy to prevent preeclampsia and related complications. 1

Rationale for Calcium Supplementation

• Calcium supplementation during pregnancy reduces the risk of preeclampsia by approximately 50%, particularly in populations with low calcium intake 1
• The WHO strongly recommends calcium supplementation for pregnant women to prevent preeclampsia, which is a leading cause of maternal mortality globally 1
• Calcium supplementation is associated with reduced risk of preterm delivery and low birth weight, which are significant concerns in pregnancy management 2

Optimal Formulation

• Calcium carbonate is the preferred formulation for supplementation during pregnancy due to:
  • Higher cost-effectiveness compared to other calcium salts 1
  • Better bioavailability compared to calcium gluconate 1
  • More calcium by weight compared to calcium citrate (which contains almost 50% less calcium) 1

Dosage Recommendations

• The WHO recommends 1.5-2.0g elemental calcium daily during pregnancy 1
• However, a lower dose of 1.0-1.5g elemental calcium daily is likely sufficient and offers better adherence 1
• Calcium should be administered in divided doses of ≤500mg per administration to maximize absorption 1
• Higher single doses reduce fractional absorption of calcium 1

Timing of Administration

• Calcium supplementation should be initiated at the earliest contact in pregnancy and continued until delivery 1
• While the WHO recommends starting at 20 weeks gestation, earlier initiation aligns better with other antenatal care practices 1
• For MTPs specifically, calcium should be administered throughout the procedure to maintain maternal calcium homeostasis 1

Co-administration with Other Supplements

• Iron and folic acid (IFA) supplementation is commonly recommended during pregnancy 1
• While calcium can theoretically interfere with iron absorption in short-term studies, the clinical effect over longer periods is minimal 1
• To simplify the regimen and facilitate adherence:
  • Calcium and IFA pills can be taken together rather than separately 1
  • One calcium dose can be administered with IFA, either in the morning or evening 1

Special Considerations for MTP

• During medical termination of pregnancy, calcium supplementation should continue as it may help reduce the risk of complications 1
• For prostaglandin-induced terminations, calcium supplementation may be particularly important as prostaglandin E compounds can lower systemic vascular resistance and blood pressure 1
• Monitoring of systemic arterial oxygen saturation is recommended when prostaglandin E compounds are used 1

Potential Side Effects and Precautions

• Calcium supplementation is generally safe but has been associated with rare side effects:
  • Increased risk of HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), though absolute numbers are low 1
  • Postnatal bone resorption that may persist through lactation 1
• These side effects should not impede implementation of calcium supplementation as the benefits outweigh the risks 1

Implementation Considerations

• Dietary counseling should complement calcium supplementation, though dietary approaches alone are unlikely to meet requirements in low-resource settings 1
• Adherence can be improved by:
  • Using a lower total daily dose (1.0g vs. 2.0g) 1
  • Reducing the number of daily pill-taking events 1
  • Providing clear instructions on administration 1