DOI: 10.1111/1471-0528.

14237 General obstetrics

www.bjog.org

Maternal creatine in pregnancy: a retrospective

cohort study
H Dickinson,a,b M Davies-Tuck,a,b SJ Ellery,a,b JA Grieger,c EM Wallace,a,b RJ Snow,d DW Walker,a,b
VL Cliftonc,e
a
The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Vic., Australia b Department of Obstetrics and Gynaecology, Monash
University, Melbourne, Vic., Australia c Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, SA, Australia
d
School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition, Deakin University, Burwood, Vic., Australia e Mater
Medical Research Institute and Translational Research Institute, University of Queensland, Brisbane, Qld, Australia
Correspondence: Dr H Dickinson, The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Vic. 3168,
Australia. Email hayley.dickinson@hudson.org.au

Accepted 24 June 2016. Published Online 23 August 2016.

Objective To estimate creatine concentrations in maternal plasma
and urine, and establish relationships with maternal
characteristics, diet and fetal growth.
Design Retrospective cohort study.
Setting Lyell McEwin Hospital, Adelaide, Australia.
Population A biobank of plasma and urine samples collected at 13,
18, 30 and 36 weeks’ gestation from 287 pregnant women from a
prospective cohort of asthmatic and non-asthmatic women.
Methods Creatine was measured by enzymatic analysis. Change in
creatine over pregnancy was assessed using the Friedman test.
Linear mixed models regression was used to determine associations
between maternal factors and diet with creatine across pregnancy
and between creatine with indices of fetal growth at birth.
Main outcome measures Maternal creatine concentrations,
associations between maternal factors and creatine and between
creatine and fetal growth parameters.
Results Maternal smoking, body mass index, asthma and socio-
economic status were positively and parity negatively associated with
maternal plasma and/or urine creatine. Maternal urine creatine
concentration was positively associated with birthweight centile and
birth length. After adjustment, each lmol/l increase in maternal
urinary creatine was associated with a 1.23 (95% CI 0.44–2.02) unit
increase in birthweight centile and a 0.11-cm (95% CI 0.03–0.2)
increase in birth length.
Conclusions Maternal factors and fetal growth measures are
associated with maternal plasma and urine creatine
concentrations.
Keywords Fetal growth, phosphocreatine, placenta.
Tweetable abstract Maternal creatine is altered by pregnancy; fetal
growth measures are associated with maternal creatine
concentrations.

Please cite this paper as: Dickinson H, Davies-Tuck M, Ellery SJ, Grieger JA, Wallace EM, Snow RJ, Walker DW, Clifton VL. Maternal creatine in pregnancy:
a retrospective cohort study. BJOG 2016;123:1830–1838.

Creatine is an amino acid derivative required for replen-

Introduction
Pregnancy is a state of heightened metabolic activity that
places additional demands, both nutritional and oxidative,
on the mother. Maternal metabolic adaptations are there-
fore required to meet these demands and ensure optimal
maternal and perinatal outcomes of pregnancy.1 This is
usually discussed in relation to placental transfer of oxygen,
glucose and essential amino acids2; however, recent preclin-
ical studies and nuclear magnetic resonance (NMR) meta-
bolomics assessments in human pregnancies suggest that
maternal creatine biosynthesis and metabolism may also be
critical to a healthy pregnancy.3,4
ishment of adenosine triphosphate (ATP) via the creatine
kinase reaction.5 Human adults obtain about half of their
daily requirement for creatine from a diet of fresh fish,
meat, and other animal products. The remainder is
acquired by endogenous synthesis from the amino acids
arginine, glycine and methionine, predominantly by the
kidney and liver.5 Circulating creatine is then actively
transported into tissues via the creatine transporter
(SLC6A8) and within cells the majority is phosphorylated
to phosphocreatine, where it is an essential spatio-temporal
metabolite, maintaining ATP availability particularly in tis-
sues with high and fluctuating energy demands5 (Figure 1).

1830 ª 2016 Royal College of Obstetricians and Gynaecologists


Dietary
Intake
(via SLC6A8)
Figure 1. Creatine is obtained from a diet of animal products or by de
novo synthesis. This involves the production of guanidinoacetate (GAA)
and ornithine from arginine and glycine in the kidney. This reaction is
catalysed by the enzyme arginine:glycine aminotransferase (AGAT).
GAA is then methylated in the liver via the activity of guanidinoacetate
methyltranserfase (GAMT) to produce creatine. Once synthesised,
creatine is released into the bloodstream and taken up by most tissues
via the creatine transporter (SLC6A8). Here it is phosphorylated (PCr)
via creatine kinase (CK) activity and stored. In the form of PCr, the
primary function of creatine is to donate a phosphate group, allowing
regeneration of ATP from ADP. There is minimal intracellular creatine
consumption; however, there is a spontaneous irreversible non-
enyzmatic conversion of creatine to creatinine (Crn) at a daily rate of
1.7% of total body creatine content.
Animal studies have shown that the fetus relies upon the
placental transfer of maternal creatine until late in preg-
nancy6 and that maternal creatine supplementation in late
pregnancy can improve offspring survival following acute
severe birth asphyxia, preventing multi-organ damage.7–11
More recently we have described marked changes to mater-
nal creatine biosynthesis during pregnancy in the spiny
ª 2016 Royal College of Obstetricians and Gynaecologists
Maternal creatine in pregnancy
mouse, suggesting an increased demand for creatine in
pregnancy.4
However, whether these apparent changes in creatine
across pregnancy are related to pregnancy outcomes
remains largely unknown. In a clinical study published over
a century ago it was shown that increases in newborn
birthweight were roughly proportional to the creatine
excreted in the urine by the mother (indicative of more
than adequate maternal circulating levels of creatine).12
There is a need to obtain more complete data about
whether maternal creatine levels are associated with param-
eters of fetal growth. Therefore, we sought to determine
the creatine concentrations in maternal plasma and urine
across the greater part of gestation in women from various
demographic backgrounds, and determine whether creatine
was associated with clinical indices of fetal growth.
Methods
Population
Data and biobanked biological samples from 287 women
who were part of an existing prospective cohort at the Lyell
McEwin Hospital, Adelaide, Australia, that determined the
effects of asthma during pregnancy on the mother, placenta
and baby, were examined.13 This cohort represented 92%
of the samples bio-banked at the University of Adelaide,
but only 70% of the original cohort study. We did not
introduce additional inclusion/exclusion criteria from the
original study. Thus, the inclusion of these samples/exclu-
sion of the other samples was completely random. Creatine
concentrations were determined in plasma and urine sam-
ples of the 287 women from this biobank, collected
between May 2009 and July 2013. The project was
approved by The Queen Elizabeth Hospital and Lyell McE-
win Hospital Human Research Ethics Committee and The
University of Adelaide Human Research Ethics Committee.
All women gave written informed consent.
Maternal demographics and pregnancy
information
Maternal and neonatal data collection
At the first antenatal clinic visit (median 13 weeks’ gesta-
tion), maternal body weight was measured to the nearest
0.1 kg using calibrated electronic scales (Professional Medi-
cal Scale, ScalesPlus, Australia) and height was measured by
a wall-mounted stadiometer. Body mass index (BMI) was
calculated as weight (kg)/height (m)2. Previous and current
obstetric history, medical, mental and surgical health infor-
mation, and socio-economic status (Socio-Economic Indexes
for Areas, SEIFA) were obtained from medical records.
Smoking history was recorded; women who did not smoke
at any stage during pregnancy or who were former smokers
1831
 Dickinson et al.
(i.e. had quit a median 3 years previously) were classified as
non-smokers, whereas current smokers and those who quit
smoking in pregnancy (median 5.5 weeks’ gestation) were
classified as smokers. To determine asthma status (i.e. asth-
matic versus non-asthmatic), the midwife asked ‘have you
been told by a doctor that you have asthma?’ and ‘have you
used any asthma medications in the last year like salbutamol
or a preventer?’ Asthma was then confirmed by spirometry
and airway reversibility. Neonatal data were collected at
delivery (gestational age, birthweight, birth length, and head
circumference). Fetal birthweight centile was computed
using the most recent Australian birthweight charts.14 Pla-
centa weight was wet weight including membranes and
umbilical cord. Gestational age was determined from the
date of the last menstrual period and confirmed by ultra-
sound at 18 weeks.
Dietary intakes and food group consumption
At the first antenatal visit the validated Cancer Council of
Victoria’s Dietary Questionnaire for Epidemiological Stud-
ies was used to obtain dietary intake data covering the
12 months prior to pregnancy.15 Daily nutrient intakes
were estimated by multiplying frequency responses by the
nutrient compositions of the specified portion size of each
food item according to Australian food composition tables.
For the purposes of this study, only maternal carbohydrate,
fat and protein intake were examined.
Blood and urine sampling
Maternal venous blood was collected at antenatal visits at
13, 18, 30 and 36 weeks gestation in lithium/heparin tubes,
centrifuged at 1000 g for 15 minutes and plasma collected,
aliquoted and stored at 20°C until assay. A midstream
urine sample was collected at the same time, aliquoted and
stored at 20°C.
Creatine determination
Stored samples ( 20°C) from the prospective study biobank
were analysed for creatine. Plasma samples (100 ll) were
extracted with 1.5 mol/l perchloric acid (45 ll acid/100 ll
sample) before neutralisation with 2.1 mol/l potassium
hydrogen carbonate. Creatine was measured in extracted
plasma and urine (not extracted) by enzymatic analysis, as
previously described.8,16,17 These data were generated over
five assays conducted during a 1-week period. Intra-assay
coefficients of variation are 12.10, 14.58, 20.23, 13.65 and
4.33%. Inter-assay coefficient of variation for this set of
assays is 12.98%. Creatinine concentrations for urine samples
were determined by Monash Pathology (Clayton, Vic., Aus-
tralia) according to standard diagnostic practices. The limit
of detection of our creatine assay was 0.167 lmol/l. Samples
below the detection range were assigned the value 0.12. This
was calculated as level of detection/square root (2).
1832
Statistical analysis
Continuous data were assessed for normality and are
expressed as means and standard deviations or median and
interquartile range. Categorical data are expressed as counts
and proportions. Characteristics of the population were
tabulated. Differences in maternal factors between women
with biological samples and those without were assessed
using a chi-square test, t-test or Wilcoxon rank test. The
creatine/creatinine values for each sample were used to
determine the creatine:creatinine ratio. Change in plasma
and urinary creatine over the course of pregnancy was
assessed using the Friedman test. The association between
maternal factors [age (years), BMI (kg/m2), ethnicity (Cau-
casian versus not Caucasian), smoking status (non-smokers
versus smokers), asthma status (asthmatic versus non-asth-
matic), SEIFA centile, parity (0 versus ≥1), hypertensive
conditions of pregnancy (gestational hypertension and
preeclampsia), gestational diabetes mellitus (GDM), intake
in grams per day of protein, fat and carbohydrates, baby
sex and maternal creatine (plasma and urine) over preg-
nancy (13, 18, 30 and 36 weeks)] was assessed. Correlations
between variables were assessed using the Spearman corre-
lation coefficient. Potential co-linearity between predictor
variables was assessed by computing tolerance for each
model (1 r2), where tolerance of <0.2 warrants caution.
All combinations of variables were within acceptable toler-
ance limits. Stepwise mixed models multivariate regression
(forward and backward) with variables P < 0.1 in univari-
ate analysis was performed to determine final multivariate
models. We used the likelihood ratio test to determine the
final model. Multivariate linear mixed models was also
used to determine the associations between creatine over
pregnancy and the growth parameters birthweight centile,
placental weight, birth length and head circumference,
adjusting for the potential confounders maternal BMI, baby
sex, gestation (not included for centile analysis), smoking,
asthma, parity, country of birth, hypertensive conditions
and GDM. All statistical analyses were undertaken using
STATA (I/C) version 12 (StataCorp, College Station, TX,
USA). A P-value <0.05 (two-tailed) was considered statisti-
cally significant.
Results
The characteristics of the cohort of women included in this
study are presented in Table 1. Of the original 409 women
in the study, 287 had biological samples stored. Compared
with those women who did not have stored samples, those
with samples were not significantly different with regards
to maternal factors. However, their babies weighed slightly
more (P = 0.04), were of moderately later gestation
(P = 0.004) and had a heavier birthweight (P = 0.005).
Median maternal plasma and urine creatine concentrations
ª 2016 Royal College of Obstetricians and Gynaecologists
 Maternal creatine in pregnancy

Table 1. Characteristics of the population

Demographics Whole population Plasma/urine samples Missing plasma urine P-value

n = 409 available sample
n = 287 n = 122

Maternal age (years) 26.2 (5.3)* 26.5 (5.4) 25.5 (4.9) 0.10
Maternal BMI (kg/h2) 28.3 (7.5)* 28.1 (7.1) 28.9 (8.7) 0.33
Ethnicity
Caucasian 358 (92)** 262 (91.3) 96 (92.3) 0.75
Not Caucasian 51 (8)** 25 (8.7) 8 (7.7)
Smoker 130 (34)** 90 (31.7) 40 (40.8) 0.10
Asthma 212 (54.2)** 153 (53.3) 59 (56.7) 0.55
Socio-economic status (quintile)
1 Lowest 214 (55.9)** 154 (54.2) 60 (61)
2 113 (29.5)** 87 (30.6) 26 (26.3) 0.87
3 13 (3.4)** 10 (3.5) 3 (3)
4 25 (6.5)** 19 (6.7) 6 (6.0)
5 Highest 18 (4.7)** 14 (4.9) 4 (4)
Nulliparous 174 (44.6)** 133 (56.5) 41 (39.4) 0.21
Gestational Hypertension/pre-eclampsia 25 (6.4)** 18 (6.3) 7 (6.8) 0.86
Gestational diabetes Mellitus (GDM) 16 (4.0)** 9 (3.2) 7 (6.2) 0.11
Baby sex (female) 194 (48.6) 49 (43.4) 145 (50.7) 0.73
Preconception dietary intake
Protein (g/day) 82 (63–102)***
Carbohydrate (g/day) 178 (143–225)***
Fat (g/day) 74.4 (57–92)***
Baby outcomes
Birthweight centile 47 (30) 48 (29.4) 45 (32.6) 0.38
Birthweight 3405 (2985–3754)*** 3432 (3060–3790)*** 3350 (2780–3675)*** 0.04
Gestation 39 (2.0) 39.2 (1.98) 38.5 (2.3) 0.004
Placental weight (g) 635 (160)* 629 (160) 653 (160) 0.31
Birth length (cm) 49.7 (3.0)* 49.8 (2.7) 49.6 (2.7) 0.63
Head circumference (cm) 32.7 (8.8)* 33.5 (7.3) 30.8 (11.5) 0.005
APGAR<7 at 10 minutes 3 (0.75%) 2 (0.7) 1 (0.9) 0.85

*Mean (standard deviation). Difference between detectable and non-detectable plasma creatine assessed by independent t-test.
**Number (%). Difference assessed by chi-square test.
***Median (interquartile range). Difference between detectable and non-detectable plasma creatine assessed by Wilcoxon rank sum test.
Bold values indicate statistical significance was reached.

Figure 2. Median ( interquartile range) maternal plasma and urine creatine levels across gestation in all women.

across gestation are shown in Figure 2. Plasma creatine and plasma creatine concentrations were only weakly corre-
concentration did not change significantly with increasing lated at two time points (q = 0.0.5, P = 0.54 at 12 weeks;
gestation (P = 0.42), whereas urine creatine concentration q = 0.14, P = 0.04 at 18 weeks; q = 0.14, P = 0.04 at
decreased significantly over pregnancy (P = 0.01). Urinary 30 weeks and q = 0.02, P = 0.77 at 36 weeks).

ª 2016 Royal College of Obstetricians and Gynaecologists 1833

 Dickinson et al.

Table 2. Factors associated with plasma and urinary creatine in pregnancy

Univariate b-coefficient (95% CI)* P-value Multivariate b-coefficient (95% CI) P-value

Plasma creatine
Maternal age (years) 2.0 ( 3.1, 0.9) <0.001 NI
Maternal BMI (kg/h2) 0.79 ( 1.6, 0.07) 0.07 NI –
Ethnicity (Caucasian) 11.6 ( 11, 34.1) 0.32 NI –
Smoking status 21.4 (8.2, 34.7) 0.002 22.9 (9.77–36.2)** 0.001
Asthma status 7.9 ( 20.1, 4.2) 0.20 NI –
Socio-economic quintile
1 Lowest 1 –
2 6.8 ( 20.7,7.1) 0.34 NI
3 7.04 ( 39.4, 25.3) 0.67 NI –
4 14.1 ( 38.5, 10.2) 0.26 NI –
5 Highest 14 ( 41.5, 13.6) 0.32 NI
Parous 17.9 ( 30.0, 5.8) 0.004 19.7 ( 32, 7.6)** 0.001
Gestational Hypertension/pre-eclampsia 5.3 ( 30.5,19.9) 0.68 NI –
Gestational diabetes Mellitus (GDM) 6.92 ( 25.8,39.7) 0.68 NI –
Baby sex (female) 5.52 ( 6.6,17.6) 0.37 NI –
Protein consumption (g/day) 0.005 ( 0.14,0.15) 0.95 NI –
Total fat consumption (g/day) 0.11 ( 0.06,0.28) 0.21 NI –
CHO consumption (g/day) 0.02 ( 0.07,0.11) 0.71 NI –

Urinary creatine
Maternal age (years) 2.34 ( 0.80,5.48) 0.14 NI –
Maternal BMI (kg/h2) 4.46 (2.13,6.78) <0.001 4.0 (1.70,6.4)*** 0.001
Ethnicity (Caucasian) 31.1 ( 92.2,29.9) 0.32 NI –
Smoking 5.56 ( 30.9,42) 0.77 NI –
Asthma 80.7 (47.4.1, 114) <0.001 78.6 (44.9,112.4)*** <0.001
Socio-economic quintile
1 Lowest 1 – 1 –
2 7.6 ( 46.3,31.2) 0.70 15.1 ( 53.6,23.3)*** 0.44
3 90.8 ( 7.4, 189.1) 0.07 110 (13.6,206)*** 0.03
4 16.0 ( 48.4,80.4) 0.63 24 ( 38.7,87.6)*** 0.45
5 Highest 32.0 ( 41.4,105.4) 0.39 36.9 ( 35.4, 109)*** 0.32
Parous parity ≥1 25.2 ( 8.4,58.8) 0.14 NI –
Gestational hypertension/pre-eclampsia 7.6 ( 60.4,75.6) 0.83 NI –
Gestational diabetes Mellitus (GDM) 19.9 ( 115.3,75.5) 0.68 NI –
Baby sex (female) 17.8 ( 15.8,51.5) 0.30 NI –
Protein consumption (g/day) 0.0004 ( 0.36,0.35) 0.99 NI –
Total fat consumption (g/day) 0.10 ( 0.54,0.34) 0.65 NI –
CHO consumption (g/day) 0.04 ( 0.27,0.19) 0.75 NI –

*Univariate regression coefficient for plasma or urinary creatine per unit increase in each respective variable.
**Multivariate regression coefficient for plasma creatine per unit increase in each respective variable adjusting for maternal smoking and parity.
***Multivariate regression coefficient for urine creatine per unit increase in each respective variable adjusting for maternal BMI, asthma and SES
quintile.
NI, not included.
Bold values indicate statistical significance was reached.

Factors associated with maternal plasma and
urinary creatine concentration in pregnancy
The associations between maternal factors and diet and
maternal plasma creatine concentration in pregnancy are
presented in Table 2. Plasma creatine concentration was
negatively associated with maternal age and parity and pos-
itively associated with smoking in univariate analyses. After
multivariate analysis factors, maternal smoking status
remained positively and parity negatively associated with
plasma creatine. The maternal and dietary factors signifi-
cantly associated with urinary creatine in pregnancy dif-
fered from those associated with plasma creatine (Table 2).
In both univariate and multivariate analyses, maternal BMI
and asthma status were positively associated with urine

1834 ª 2016 Royal College of Obstetricians and Gynaecologists

 Maternal creatine in pregnancy

creatine. After adjustment maternal, SES was also associ-
ated with urinary creatine. Maternal BMI and SES were
also significantly associated with creatine corrected for crea-
tinine (Table S1).
Association between creatine and fetal growth
outcomes
The associations between plasma creatine, urinary creatine
and creatine adjusted for creatinine over pregnancy and
birthweight centile, placental weight, birth length and head
circumference are presented in Table 3. Plasma creatine
and urinary creatine adjusted for creatinine were not signif-
icantly associated with growth parameters. Urine creatine
was significantly associated with birthweight centile and
birth length. Each lmol/l increase in urinary creatine was
associated with a 1.23 (95% CI 0.44–2.02) unit increase in
birthweight centile and a 0.11 cm (95% CI 0.03–0.2)
increase in birth length. Urine creatine was not associated
with placental weight or head circumference.
Discussion
Main findings
Here we report for the first time the relationship between
maternal plasma and urinary creatine concentration and
some features of maternal health and fetal growth. Mater-
nal factors that were associated with plasma creatine
included maternal smoking and parity; separately, urine
creatine was associated with maternal BMI, asthma and
maternal SEIFA. Urinary creatine was positively associated
with birthweight centile and birth length.
We observed that plasma creatine concentrations did not
change significantly during gestation, whereas urine cre-
atine concentration decreased. Our findings are consistent
with a recent NMR metabolomics study of maternal plasma
and urine during pregnancy that also observed no changes
in plasma creatine levels between 2nd and 3rd trimester.3
Our findings also confirm in humans, the changes that we
have previously reported in our animal studies.4 In the
pregnant spiny mouse, a precocial rodent that gives birth
to highly developed young, we have previously shown that
maternal creatine synthesis, excretion, transport and storage
were all altered by pregnancy.4 These changes include
decreased renal excretion of creatine between mid and late
gestation, increased renal AGAT expression, decreased hep-
atic GAMT expression and increased expression of the cre-
atine transporter in skeletal muscle just prior to
parturition. Interestingly, we observed only a weak correla-
tion between plasma and urinary creatine at 18 and
30 weeks and Pinot et al.3 report no correlations between
plasma and urinary creatine values within their cohort.
These findings suggest that alterations to maternal creatine
homeostasis might be a necessary maternal adaptation to
pregnancy. This may include changes in the synthesis of
creatine, and its distribution between plasma and tissues in
pregnancy. Further work is needed to confirm this.
We identified for the first time a number of maternal
factors associated with plasma and urinary creatine.

Table 3. Creatine and outcomes

Outcomes Univariate coefficient (95% CI) P-value Multivariate coefficient (95% CI) P-value

Birthweight centile
Plasma creatine 1.70 ( 3.65, 0.26) 0.09 0.65 ( 2.52, 1.24) 0.50
Urine creatine 1.6 (0.75, 2.4) <0.001 1.23 (0.44, 2.02) 0.002
Urine creatine/creatinine 3.1 ( 9, 97, 3.9) 0.39 1.95 ( 4.70, 8.59) 0.57
Placental weight (g)
Plasma creatine 10.3 ( 23.0, 2.36) 0.11 5.92 ( 17.9, 6.1) 0.33
Urine creatine 2.17 ( 3.54, 7.88) 0.46 2.76 ( 2.56, 8.1) 0.31
Urine creatine/creatinine 20.9 ( 75.2, 21.4) 0.33 3.56 ( 43.6, 36.5) 0.86
Birth length (cm)
Plasma creatine 0.06 ( 0.27, 0.15) 0.55 0.02 ( 0.17, 0.22) 0.80
Urine creatine 0.08 ( 0.11, 0.17) 0.08 0.11 (0.03, 0.20) 0.007
Urine creatine/creatinine 0.10 ( 0.65, 0.85) 0.80 0.43 ( 0.25, 1.11) 0.22
Head circumference (cm)
Plasma creatine 0.12 ( 0.38, 0.62) 0.63 0.36 ( 0.12, 0.83) 0.14
Urine creatine 0.08 ( 0.27, 0.12) 0.44 0.08 ( 0.28, 0.12) 0.44
Urine creatine/creatinine 0.29 ( 1.87, 1.28) 0.72 0.003 ( 1.57, 1.58) 0.99

Unit increase in birthweight centile/placental weight/birth length/head circumference for each lmol/l increase in creatine at each time point.
Multivariate analysis adjusted for maternal BMI, baby sex, gestation (all but centile), smoking, asthma, parity, hypertensive conditions, GDM and
country of birth.
Bold values indicate statistical significance was reached.

ª 2016 Royal College of Obstetricians and Gynaecologists 1835

 Dickinson et al.
Maternal plasma creatine levels were lower in parous
women and higher in women who smoked. There is a
well-recognised association between increased parity and
reductions in maternal levels of some essential micronutri-
ents, such as calcium and fatty acids.18 The fetal require-
ment for these nutrients can result in depletion of these
nutrients from maternal stores. Whether this is the case for
creatine is unknown, although the findings from our study
would suggest this is so. The mechanism underlying the
association between maternal smoking and plasma creatine
is not clear and warrants further research.
We found that urinary creatine levels were higher in
women with a high BMI and also in those who had
asthma. Although the mechanism underlying the associa-
tion with BMI is not known, it is possible that it reflects
differences in food intake or muscle mass. We did not find
a significant association between maternal diet and creatine.
Dietary intakes were determined at time of recruitment,
and were representative of preconception (i.e. 12 months
prior to pregnancy) diet; thus they may not completely
reflect the current diet of the women at each of the time
points in our study. Furthermore, the blood tests were
non-fasting and therefore recent intake of foods containing
creatine may have increased creatine concentrations, which
may in part explain our findings. Skeletal muscle contains
the largest store of creatine in the body and changes in
muscle mass have been shown to influence urinary creatine
levels.19 Whether this is true for our population is not
known and warrants further investigation.
We found that maternal urinary creatine excretion over
pregnancy was positively associated with birthweight centile
and birth length. To our knowledge only one previous
study in 1913 has assessed creatine and baby growth. In that
study of lactating women, newborn birthweight increases
were roughly proportional to the creatine excreted in the
urine by the mother (indicative of more than adequate
maternal circulating levels of creatine).12 We report here,
over 100 years later, that maternal creatine concentrations
in pregnancy are associated with fetal growth. These varia-
tions may be associated with placental metabolism. The pla-
centa is an organ with high metabolic activity, but its
requirement for creatine to meet the energy demands asso-
ciated with glucose, amino acid, and fatty acid transfer, and
other metabolic activities20 intrinsic to placental function is
not known. For the creatine/phosphocreatine/creatine
kinase circuit to operate as an effective shuttle of ATP from
the site of synthesis at the mitochondria to areas of demand
in the cytosol, there needs to be coordinated expression of
two isoforms of creatine kinase [mitochondrial CK (mtCK)
and ubiquitous CK (uCK)]. Placental gene expression of
these CK isoforms is low in the first and second trimesters
of pregnancy, before a substantial increase in expression in
the third trimester. This temporal change in gene
1836
expression parallels the increased metabolic activity of the
placenta, and suggests that the CK pathway contributes to
placental metabolism.21 Whether a reduced capacity of the
placenta to synthesise creatine, or to transfer it from a
maternal or intra-placental store, is associated with fetal
growth is unknown, but warrants further investigation.
Strengths and limitations
Our study has a number of limitations. Although precon-
ception dietary information was available for the women in
the study, the nature of diet at the time that each blood
and urine sample was obtained is not known. Nevertheless,
the few studies available indicate that diet does not change
significantly or in major composition from before preg-
nancy to after conception.22 Only 70% of the original
cohort provided biological samples, thus potentially intro-
ducing selection bias. However, maternal characteristics
and pregnancy complication rates were similar between the
two groups and where there were differences in baby char-
acteristics they were in regard to larger/older babies. The
urine samples are not timed 24-hour collections and there-
fore we are only able to report urine concentrations. Sup-
plementary data included in this study report creatine
values corrected with the gold standard marker of renal
function creatinine. However, we caution against over-
interpretation of these corrected results. It is well docu-
mented that urinary creatinine clearance is increased in the
3rd trimester of pregnancy, as a consequence of increased
glomerular filtration rate. Thus, changes in creatinine and
not creatine may be driving the change in the creatine:crea-
tinine ratio.3,23,24 This retrospective cohort was originally
collected as a longitudinal prospective study to assess the
effects of asthma on pregnancy outcomes; therefore ~50%
of the population has asthma. These results may therefore
not be generalisable to the wider pregnancy population;
however, we have identified a relationship between mater-
nal creatine status and asthma that would otherwise have
gone undetected, and which may be important. The parent
study was powered to detect differences in placental out-
comes between asthmatic and non-asthmatic women, not
differences in creatine concentrations across gestation as
examined here, and thus caution should be applied in the
interpretation of these results.
Interpretation
The exact mechanism by which creatine affects fetal growth
is not known. Findings from our animal work show that
adaptations to maternal creatine homeostasis occur during
healthy pregnancy. The mRNA for the creatine transporter
is first detected from 13 weeks’ gestation in the human pla-
centa.25 If the maternal and/or fetal requirement for cre-
atine is increased early in pregnancy, the possibility should
be considered that the placenta is a site of creatine
ª 2016 Royal College of Obstetricians and Gynaecologists

synthesis during pregnancy, and that effective placentation
and placental growth is a determinant of creatine status in
the woman and her fetus from early in gestation. Indeed,
the presence of the creatine synthesising enzymes AGAT
and GAMT in the term human placenta, and the finding
that explants of term placenta can produce creatine de
novo (H. Dickinson, unpubl. obs.), raise this as a plausible
explanation for the associations of maternal creatine con-
centrations with fetal and placenta size at birth. Further
work is therefore warranted.
Conclusion
This is the first study to report maternal circulating and
excreted concentrations of creatine in relation to popula-
tion demographics and pregnancy outcomes. Maternal fac-
tors such as smoking, asthma, parity, BMI and SEIFA are
associated with creatine concentrations. Urinary concentra-
tion of creatine over pregnancy was positively associated
with birthweight centile. We believe that these data offer
the possibility that creatine may be useful as a simple and
cheap nutritional supplement to support better fetoplacen-
tal health. Certainly, studies of creatine supplementation in
compromised pregnancies are worth exploring.
Disclosure of interests
None declared. Completed disclosure of interests form
available to view online as supporting information.
Contribution to authorship
Completion of prospective study and access to biobanked
samples (VC); conception of the retrospective study (HD
with MDT, EW, DW); secured research funding for the
study (HD); assayed the samples for creatine (HD, SE, RS);
provision and interpretation of database of maternal and
pregnancy outcome data (JG, MDT); analysis of results and
preparation of results tables (MDT, HD); interpretation of
results (HD, MDT, JG, EW, DW and VC); intellectual
input (EW, RS, DW); writing of first and final draft of the
manuscript (HD, MDT). All authors contributed to draft-
ing of the manuscript and have approved the final version.
Details of ethics approval
The project was approved by The Queen Elizabeth Hospital
and Lyell McEwin Hospital Human Research Ethics Com-
mittee and The University of Adelaide Human Research
Ethics Committee on 4 May 2009 and still has approval.
All women gave written informed consent.
Funding
This work was supported by the University of Adelaide
(original prospective study design and data collection), the
Victorian Government’s Operational Infrastructure Support
ª 2016 Royal College of Obstetricians and Gynaecologists
Maternal creatine in pregnancy
Program to Hudson Institute of Medical Research and
funding from Cerebral Palsy Alliance (Career Development
Award) and Stillbirth Foundation Australia to Dickinson
for creatine studies and NHMRC, Career Development Fel-
lowship to Dickinson; Early Career Fellowship to Davies-
Tuck; Senior Research Fellowship to Clifton.
Acknowledgements
The authors acknowledge Ms Lobna Ghattas and Ms
Meghan Boomgardt for technical assistance in running the
creatine assay; and Luke Grzeskowiak, Karen Rogers, Nico-
lette Hodyl, Kate Roberts-Thomson, Annette Osei-Kumah
and Sarah Riley for their valuable contributions towards
the collection and recording of population data and sam-
ples from the parent study, utilised in this study.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Factors associated with urine creatine adjusted
for creatinine in pregnancy. &
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