Osteoporosis in pregnancy

Effective strategies for pregnancy and lactation-associated osteoporosis: teriparatide use in focus

INTRODUCTION

Pregnancy and lactation-associated osteoporosis (PLO) is a rare condition characterized by fragility fractures occurring during late pregnancy or lactation, primarily affecting the spine and causing significant morbidity and back pain. PLO can lead to mobility impairment and work incapacity, with recovery taking up to several years. Due to the lack of clinical trials, treatment strategies remain poorly defined, historically focusing on calcium supplements, vitamin D, and weaning from breastfeeding. However, recent attention has turned to teriparatide (TPD) as an option due to its anabolic properties and potential suitability for women of childbearing age.

METHODS

This review evaluates TPD's use in PLO treatment, using published systematic reviews and case studies. Over 300 cases with PLO were identified through PubMed, Google Scholar, and Cochrane searches until August 2023.

RESULTS

We identified 175 cases with PLO treated with TPD alone or followed by antiresorptive therapy. Most women (85.7%) were primiparas. The mean ± SD duration of TPD use was 15 ± 6 months. Among the study patients, 91.4% used TPD alone, while 8.6% (15/175) utilized sequential therapy. Approximately 93% of our cohort exhibited potential risk factors for PLO. Despite the increased risk of recurrent fractures in PLO, only 14.7% (20/175) of those treated with TPD sustained new fractures during a 9-month to 9 years' follow-up period. The mean ± SD percent increase in BMD at the LS was 21.14% ± 7.4%, and at the FN it was 12.1% ± 9.3%. The baseline Z-scores at the LS ranged from -3.3 (-3.7 to -2.7), while the baseline Z-scores at the FN ranged from -2.0 (-2.7 to -1.5).

CONCLUSION

This review emphasizes PLO severity, advocating for increased awareness and timely interventions. TPD emerges as a promising therapeutic option in certain cases.

Clinical Features, Incidence and Treatment Outcome in Pregnancy-Associated Osteoporosis: A Single-Centre Experience over Two Decades

Pregnancy-associated osteoporosis (PAO) is a rare syndrome which typically presents with vertebral fractures during pregnancy or lactation. The medical records of sixteen patients with PAO who presented to a specialist clinic at the Western General Hospital in Edinburgh over a 20-year period were reviewed to evaluate the mode of presentation, potential risk factors and response to treatment. The most common presentation was back pain occurring in 13/16 (81.2%) individuals due to multiple vertebral fractures. The diagnosis was usually made postpartum and in 12/16 individuals (75.0%), PAO presented during the woman's first pregnancy. Medicines which could have contributed to the development of PAO included thromboprophylaxis therapies in 8 subjects (50.0%), inhaled or injected corticosteroids in 5 (31.3%), anticonvulsants in 2 (12.5%) and a LHRH agonist in 1 (6.3%). Five individuals reported a family history of osteoporosis, and two pregnancies were complicated by hyperemesis gravidarum. Treatments administered included calcium and vitamin D supplements, bisphosphonates and teriparatide. Bone mineral density increased following the diagnosis in all cases, regardless of treatment given. One patient had further fracture during follow-up, but four patients had subsequent pregnancies without fractures. We estimated that in this locality, the incidence of PAO was 6.8/100,000 pregnancies with a point prevalence of 4.1 per 100,000 women. This case series indicates the importance of family history of osteoporosis and thromboprophylaxis drugs as risk factors for PAO while also demonstrating that the reductions in bone density tend to reverse with time, irrespective of the treatment given.

Pregnancy- and lactation-related osteoporosis: an important topic also for rheumatologists

<b>Objectives</b> <b>Material and methods</b> <b>Results</b> <b>Conclusions</b> <b></b> <b></b>

Response of vertebral fractures to treatment with denosumab in a patient with postpartum osteoporosis: a case report and literature review

Postpartum osteoporosis (PO) is a rare condition characterized by low bone mineral density (BMD) and an increased risk of vertebral fragility fracture. We encountered a 34-year-old woman who developed back pain 1 week after delivery. Magnetic resonance imaging of the lumbar spine revealed three vertebral compression fractures. Pretreatment BMD evaluation by dual-energy X-ray absorptiometry revealed a low T-score and Z-score (-2.0 and -2.0, respectively; BMD, 0.876 g/cm²) in the affected region of the spine. The patient was diagnosed with PO and treated with subcutaneous injection of denosumab 60 mg (Prolia; Amgen, Inc., Thousand Oaks, CA, USA) every 6 months. After two treatments, the BMD had significantly increased and the back pain was improved; the patient therefore decided to terminate the treatment. Two months later, her back pain worsened and BMD decreased as measured by dual-energy X-ray absorptiometry examination of the lumbar spine. Therefore, the patient resumed treatment with denosumab, and the BMD of the lumbar spine increased after another two treatments. Therefore, we consider denosumab to be promising in the management of PO with respect to increased BMD and decreased pain.

Bone metabolism and osteoporosis during pregnancy and lactation

PURPOSE

Osteoporosis in pregnancy is an uncommon disease and there is little information regarding its pathogenesis and its effects on the skeleton. This review aims to describe changes in mineral metabolism during pregnancy and lactation as well as their clinical impact.

METHODS

We performed a narrative review of the literature using the PubMed and Google Scholar databases for articles published from 1955 to 2021.

RESULTS

Mineral metabolism in the mother must adapt to the demand created by the fetus and the placenta, which together absorb calcium and other minerals from the mother to mineralize the developing fetal skeleton; analyses of iliac bone biopsies at the beginning and end of pregnancy have shown that pregnancy significantly modifies maternal bone status. The greatest demand for calcium for the maternal skeleton occurs during lactation; women who breastfeed have an even greater loss of calcium to produce milk. However, it is controversial whether breastfeeding can increase the risk of osteoporotic fractures, and the possible mechanism is considerably complicated. Osteoporosis in pregnancy is an uncommon disease characterized by the occurrence of fragility fractures, most commonly in the vertebral column, in the third trimester of pregnancy, or early postpartum. The pathogenesis of PLO remains unclear owing to its rarity; DXA provides a sensitive and specific method for diagnosing osteoporosis by measuring BMD, one of the parameters that allow a better understanding of fracture risk. One limitation is the controversy in using radiation in pregnant women and the risk to the embryo/fetus; a safe alternative can be MRI.

CONCLUSION

Pregnancy and lactation alter the maternal bone status; without a balance in metabolism, this may cause an increased risk of fracture due to changes in BMD. There is little information on BMD during pregnancy; more clinical studies are required to elucidate if this represents a risk factor for osteoporosis.

Modulatory role of genistein on placenta and maternal bone minerals composition: further insight into its influence on pregnancy and foetal development

Pregnancy is a crucial period with an increased need to supply necessary minerals for both the mother and the developing foetus and with a tendency of altering the maternal bone mineral density when there is no balance between demand and supply of these minerals. This study evaluated the influence of genistein on the maternal bone and placenta mineral composition. Pregnant rats were grouped into control, 2 mg/kg and 4 mg/kg genistein groups, dosed accordingly till sacrificed at different gestation days (GD). Body and placenta weights, right femur bone and placenta mineral composition were analysed. A significant decrease in body weight and percentage relative right femur bone weight at GD-20 was recorded in the 2-mg group with the reverse occurring in the 4-mg genistein group. The right femur bone Ca²⁺ and Zn²⁺ was reduced towards GD-20 in both 2-mg and 4-mg genistein groups. Genistein had no influence on placenta selenium and cadmium level, but significantly decreased zinc and lead level concentration as the gestation progressed towards GD-20. Copper level was increased at GD-16 at the doses used. Genistein modulated maternal bone mineral composition and placenta capability in retaining some heavy metals at various stages of pregnancy.

Bone metabolism in pregnancy and lactation

INTRODUCTION

Different hormonal mechanisms regulate bone metabolism during pregnancy and lactation. In both those periods of life, a fine modulation of calcium metabolism is necessary to meet the needs of foetus and newborn.

METHODS

We review scientific literature on the topic "osteoporosis", "pregnancy" and "lactation", evaluating the most relevant data from original articles, reviews and meta-analyses.

EVIDENCE SYNTHESIS

Pregnancy- and lactation-associated bone loss and related fractures rarely occur and, generally, clinicians have to manage it case to case, since there is not a unique guideline. Fortunately, bone mineral density (BMD) usually tends to recover within 12 months after weaning, thus, it could be reasonable waiting of assessing the effective magnitude of bone mass regain before starting any pharmacological treatment.

CONCLUSIONS

Osteoporosis and/or fragility fractures remain uncommon events associated with gestation and/or breastfeeding. The management of bone loss and/or fractures during those periods is generally conservative and a tailored approach is advisable in the absence of any specific recommendation in this field.

Associations of Parity, Breastfeeding, and Fractures in the Women's Health Observational Study

OBJECTIVE

To examine associations of several aspects of parity and history of lactation with incident hip fractures and clinical fractures and, in a subset of women, with bone mineral density.

METHODS

In this observational study, we analyzed data from 93,676 postmenopausal women participating in the Women's Health Initiative Observational Study and all bone density data from the subset of participants who underwent bone density testing at three clinical centers. At baseline, participants were aged 50-79 years. Using Cox proportional hazards regression analysis, we examined associations of fracture incidence and bone density with several aspects of parity (number of pregnancies, age at first pregnancy lasting 6 months or greater, and number of pregnancies lasting 6 months or greater) and breastfeeding (number of episodes of breastfeeding for at least 1 month, number of children breastfed, age when first breastfed, age when last breastfed, total number of months breastfed).

RESULTS

The mean baseline age (standard deviation) of participants was 64 (±7.4) years (mean follow-up 7.9 years). During follow-up, the incident rate of hip fracture was 1.27%. Ten percent of participants were nulligravid. In fully adjusted models, number of pregnancies, parity, age at first birth, number of children breastfed, age at first breastfeeding, age at last breastfeeding, and total duration of breastfeeding were not statistically significantly associated with hip fracture incidence. There were no consistent associations of parity or lactation characteristics with overall clinical fracture risk or bone density. However, compared with never breastfeeding, a history of breastfeeding for at least 1 month was associated with a decreased risk of hip fracture (yes compared with no, hazard ratio 0.84, 95% confidence interval 0.73-0.98).

CONCLUSION

Patterns of parity and history of lactation were largely unrelated to fracture risk or bone density.

Pregnancy-associated osteoporosis: a case-control study

The etiology and underlying mechanisms of pregnancy-associated osteoporosis (PAO) are still unknown, since no systematic analyses exist. Our results indicate that PAO is a heterogeneous, rare but severe disease including a substantial number of fractures with a significant delay from first symptom to diagnose.

INTRODUCTION

Pregnancy-associated osteoporosis (PAO) is a rare but severe type of premenopausal osteoporosis. Most common symptom includes acute lower back pain due to vertebral fracture predominantly occurring in the last trimester of pregnancy or immediately postpartum. The exact underlining mechanisms and risk factors of PAO are still unknown, and up to date, there are no published systematic analyses.

METHODS

We identified 102 PAO patients and matched them with 102 healthy controls according to age, region, and gravidity to evaluate risk factors in a large and homogenous population of women.

RESULTS

The baseline characteristics and anthropometric data of the two study groups were similar. Eighty-eight percent of the patients with PAO suffered from one or more fractures with a mean of 3.3 fractures per patient. The most common fracture site was the thoracolumbar spine, whereas 29, 37, 48, and 35% of the patients reported fractures at TH11, TH12, L1, and L2, respectively. PAO patients suffered more frequently from excessive dental problems in childhood (p < 0.001). The control group performed significantly more frequently sports both before (p < 0.002) and after puberty (p < 0.01). Compared to the controls, the patients with PAO reported twice as often severe diseases during pregnancy (p < 0.029). Hereby, the frequency of immobilization was twice as often in the PAO group compared to that in the control group (p < 0.005).

CONCLUSIONS

Our results indicate that PAO is a heterogeneous, rare but severe disease including a substantial number of fractures with a significant delay from first symptom to diagnose. Increased awareness is warranted to immediately start effective treatment.

Successful neridronate therapy in pregnancy-associated osteoporosis

Pregnancy-associated osteoporosis is a rare condition. The pathogenesis is probably multifactorial but has not yet been completely clarified. In this case report, a 38-year-old woman was referred to hospital after suffering an acute, non-traumatic back pain one month after delivering her first child. The radiological examination revealed four vertebral fractures. Bone mineral density was reduced, particularly at spine level. Biochemical tests were within normal range, except for increased urinary deoxypyridinoline and a slight reduction of the serum 25-OH vitamin D level. The patient was treated with neridronate, calcium and cholecalciferol. After one month, the patient was free of pain and DXA measurement after six months showed a marked recovery of bone mineral density at the spine and hip level.

Maternal Mineral and Bone Metabolism During Pregnancy, Lactation, and Post-Weaning Recovery

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 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 requirements 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 absorption 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.

Spinal compression fractures due to pregnancy-associated osteoporosis

OBJECTIVES

To report on unique cases of spinal compression fractures due to pregnancy-associated osteoporosis (PAO) and to suggest a satisfactory treatment modality.

MATERIALS AND METHODS

A single-center retrospective study. We reviewed the data of 535 patients with osteoporotic spinal compression fractures over a period of 5-year. Two patients who developed spinal compression fractures due to PAO were identified and treated.

RESULTS

The clinical presentation and blood investigations ruled out other causes of osteoporosis. Dual-energy X-ray absorptiometry was used to confirm the diagnosis. All patients improved with medical management.

CONCLUSION

Vertebral fractures due to PAO should be considered as a differential diagnosis in patients with back pain who are in the third trimester of pregnancy or in postpartum. Early recognition and appropriate conservative management would be necessary to prevent complications such as new vertebral fractures and chronic back pain.

Postpartum sacral fracture in a 30-year-old female

Possible causes of sacral and low back pain in the postpartum patient include sacroiliac joint dysfunction, sacroiliitis, lower lumbar diskitis, and irritation of the sciatic nerve. Postpartum stress fracture is a recognized cause of pain that should be considered in the differential diagnosis of the postpartum patient's low back pain. Several case reports of postpartum stress fracture are now in the literature (1, 2, 3, 4, 5, 6, 7, 8). A 30-year-old female presented postpartum with pain in the coccyx region that was most severe nine weeks after the uneventful spontaneous vaginal delivery of her first child. Imaging with computed tomography (CT) obtained 36 days after delivery demonstrated bilateral sclerosis in the lower sacrum. Plain film radiographs may not demonstrate this finding. Both magnetic resonance imaging (MRI) and CT are sensitive for sacral stress fracture.

Rare causes of osteoporosis

Osteoporosis is a metabolic bone disease characterized by loss of bone mass and strength, resulting in increased risk of fractures. It is classically divided into primary (post-menopausal or senile), secondary and idiopathic forms. There are many rare diseases, that cause directly or indirectly osteoporosis. The identification and classification of most of these rare causes of osteoporosis is crucial for the specialists in endocrinology and not, in order to prevent this bone complication and to provide for an early therapy. Several pathogenic mechanisms are involved, including various aspects of bone metabolism such as: decreased bone formation, increased bone resorption, altered calcium, phosphorus and/or vitamin D homeostasis, and abnormal collagen synthesis. In this review, less common forms of primary and secondary osteoporosis are described, specifying, if applicable: genetic causes, epidemiology, clinical features, and pathogenic mechanisms causing osteoporosis. A greater awareness of all rare causes of osteoporosis could reduce the number of cases classified as idiopathic osteoporosis and allow the introduction of appropriate and timely treatments.

Presentation and management of osteoporosis presenting in association with pregnancy or lactation

In this review, we summarize our current understanding of the pathophysiology of fragility fractures that occur for the first time during pregnancy and lactation, and provide guidance on appropriate investigations and treatment strategies. Most affected women will have had no prior bone density reading, and so the extent of bone loss that may have occurred during pregnancy or lactation is uncertain. During pregnancy, intestinal calcium absorption doubles in order to meet the fetal demand for calcium, but if maternal intake of calcium is insufficient to meet the combined needs of the mother and baby, the maternal skeleton will undergo resorption during the third trimester. During lactation, several hormonal changes, independent of maternal calcium intake, program a 5-10 % loss of trabecular mineral content in order to provide calcium to milk. After weaning the baby, the maternal skeleton is normally restored to its prior mineral content and strength. This physiological bone resorption during reproduction does not normally cause fractures; instead, women who do fracture are more likely to have additional secondary causes of bone loss and fragility. Transient osteoporosis of the hip may affect one or both femoral heads during pregnancy but it involves localized edema and not skeletal resorption. Case reports have described the use of calcitonin, bisphosphonates, strontium ranelate, teriparatide, vertebroplasty, and kyphoplasty to treat post-partum vertebral fractures. However, the need for such treatments is uncertain given that a progressive increase in bone mass subsequently occurs in most women who present with a fracture during pregnancy or lactation.

Effective treatment of severe pregnancy and lactation-related osteoporosis with teriparatide: case report and review of the literature

Pregnancy or lactation-related osteoporosis (PLO) is a very rare and debilitating condition which is usually diagnosed during the last trimester of the pregnancy or early postpartum period. Herein, we report a case with severe PLO and multiple vertebral compression fractures that were successfully treated with teriparatide. Twenty-three-year-old female patient was admitted to our clinic two months after her first spontaneous vaginal delivery with the complaint of severe back pain. Bone mineral density was measured using dual energy X-ray absorptiometry (DEXA), and low T- and Z-scores were observed in lumbar vertebrae. In vertebral MRI, severe height loss was detected in thoracic (T) 5,7,10,11,12 vertebrae. After exclusion of the other possible causes of OP, she was diagnosed to have PLO and the lactation was stopped. She was treated with calcium 1000 mg/day, cholecalciferol 800 mg/day and teriparatide 20 µg/day. At the 12th and 18th month of therapy, BMD was increased by 8% and 27%, respectively, at the lumbar spine and pain was completely relieved in few months. There are pharmacological therapy modalities that can be used in PLO. Bisphosphonates are effective, but there are some concerns that they accumulate in bone and may expose fetus in subsequent pregnancies. Teriparatide is a strong candidate to be the optimal medical therapy in severe cases since it is effective and safe.

Bone metabolic changes during pregnancy: a period of vulnerability to osteoporosis and fracture

Changes in bone density and bone markers suggest that pregnancy is associated with deterioration of bone mass in the mother. The metabolism of calcium resets to allow for the needs imposed by the building of the fetal skeleton. The fetus contributes to the process through the output of regulators from the placenta. Understanding of the whole process is limited, but some changes are unambiguous. There is an increase in the circulating levels of vitamin D, but its functional impact is unclear. Fetal parathyroid hormone (PTH) and PTH-related peptide (PTHrp) play an indirect role through support of a calcium gradient that creates hypercalcemia in the fetus. Placental GH, which increases up to the end of pregnancy, may exert some anabolic effects, either directly or through the regulation of the IGF1 production. Other key regulators of bone metabolism, such as estrogens or prolactin, are elevated during pregnancy, but their role is uncertain. An increase in the ratio of receptor activator of nuclear factor kappa B ligand (RANKL) to osteoprotegerin (OPG) acts as an additional pro-resorbing factor in bone. The increase in bone resorption may lead to osteoporosis and fragility fracture, which have been diagnosed, although rarely. However, the condition is transitory as long-term studies do not link the number of pregnancies with osteoporosis. Prevention is limited by the lack of identifiable risk factors. When fractures are diagnosed, rest, analgesics, or, when indicated, orthopedic intervention have demonstrated efficacy. Systemic treatment with anti-osteoporotic drugs is effective, but the potential harm to the fetus imposes caution in their use.

Osteoporosis presenting in pregnancy, puerperium, and lactation

PURPOSE OF REVIEW

To describe our current state of knowledge about the pathophysiology, incidence, and treatment of osteoporosis that presents during pregnancy, puerperium, and lactation.

RECENT FINDINGS

When vertebral fractures occur in pregnant or lactating women, it is usually unknown whether the skeleton was normal before pregnancy. Maternal adaptations increase bone resorption modestly during pregnancy but markedly during lactation. The net bone loss may occasionally precipitate fractures, especially in women who have underlying low bone mass or skeletal fragility prior to pregnancy. Bone mass and strength are normally restored postweaning. Transient osteoporosis of the hip is a sporadic disorder localized to one or both femoral heads; it is not due to generalized skeletal resorption. Anecdotal reports have used bisphosphonates, strontium ranelate, teriparatide, or vertebroplasty/kyphoplasty to treat postpartum vertebral fractures, but it is unclear whether these therapies had any added benefit over the spontaneous skeletal recovery that normally occurs after weaning.

SUMMARY

These relatively rare fragility fractures result from multifactorial causes, including skeletal disorders that precede pregnancy, and structural and metabolic stresses that can compromise skeletal strength during pregnancy and lactation. Further study is needed to determine when pharmacological or surgical therapy is warranted instead of conservative or expectant management.

A rare cause of postpartum low back pain: pregnancy- and lactation-associated osteoporosis

Pregnancy- and lactation-associated osteoporosis (PLO) is a rare form of osteoporosis. It results in severe low back pain in the last trimester of pregnancy and in the postpartum period, decreases in height, and fragility fractures, particularly in the vertebra. The current case report presents a 32-year-old patient who presented with back and low back pain that began in the last trimester of the pregnancy and worsened at two months postpartum and who was diagnosed with pregnancy- and lactation-associated osteoporosis after exclusion of other causes; the findings are discussed in view of the current literature. PLO is a rare clinical condition causing significant disability. PLO must be kept in mind in the differential diagnosis in patients presenting with low back pain during or after pregnancy. The patients must be evaluated for the risk factors of PLO, and an appropriate therapy must be initiated.

Pregnancy-associated osteoporosis with a heterozygous deactivating LDL receptor-related protein 5 (LRP5) mutation and a homozygous methylenetetrahydrofolate reductase (MTHFR) polymorphism

Pregnancy-associated osteoporosis (PAO) is a rare, idiopathic disorder that usually presents with vertebral compression fractures (VCFs) within 6 months of a first pregnancy and delivery. Spontaneous improvement is typical. There is no known genetic basis for PAO. A 26-year-old primagravida with a neonatal history of unilateral blindness attributable to hyperplastic primary vitreous sustained postpartum VCFs consistent with PAO. Her low bone mineral density (BMD) seemed to respond to vitamin D and calcium therapy, with no fractures after her next successful pregnancy. Investigation of subsequent fetal losses revealed homozygosity for the methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism associated both with fetal loss and with osteoporosis (OP). Because her neonatal unilateral blindness and OP were suggestive of loss-of-function mutation(s) in the gene that encodes LDL receptor-related protein 5 (LRP5), LRP5 exon and splice site sequencing was also performed. This revealed a unique heterozygous 12-bp deletion in exon 21 (c.4454_4465del, p.1485_1488del SSSS) in the patient, her mother and sons, but not her father or brother. Her mother had a normal BMD, no history of fractures, PAO, ophthalmopathy, or fetal loss. Her two sons had no ophthalmopathy and no skeletal issues. Her osteoporotic father (with a family history of blindness) and brother had low BMDs first documented at ages ∼40 and 32 years, respectively. Serum biochemical and bone turnover studies were unremarkable in all subjects. We postulate that our patient's heterozygous LRP5 mutation together with her homozygous MTHFR polymorphism likely predisposed her to low peak BMD. However, OP did not cosegregate in her family with the LRP5 mutation, the homozygous MTHFR polymorphism, or even the combination of the two, implicating additional genetic or nongenetic factors in her PAO. Nevertheless, exploration for potential genetic contributions to PAO may explain part of the pathogenesis of this enigmatic disorder and identify some at-risk women.

Pregnancy-associated osteoporosis with eight fractures in the vertebral column treated with kyphoplasty and bracing: a case report

Pregnancy-associated osteoporosis is a rare condition, which imposes multiple symptoms in the musculoskeletal system. Common complaints announced by patients are severe pain in the lower back, hips and the joints of the lower extremities with a reduced and less mobility status in general. Most of the patients' problems occur in the last trimester of pregnancy or postpartum and are often not diagnosed as side effects of osteoporosis but as problems associated with pregnancy. Although vertebral fractures are rare complications of pregnancy-associated osteoporosis, they should be always considered in women presenting with an acute pain syndrome in peripregnancy period. This case presents a 40-year-old primagravid woman who developed pain in hips and severe pain in the lower back causing an immobilization diagnosed with a pregnancy-associated osteoporosis with eight compression fractures in the thoracic and lumbar spine. Because of sagittal imbalance of the spine, she was treated with kyphoplasty at the four lumbar fractures and with bracing for the upper, thoracic ones, additional to the conservative anti-osteoporotic therapy. The authors discuss pregnancy-associated osteoporosis and its clinical presentation, as well as the indications of kyphoplasty, spinal alignment and the risk of single conservative treatment.

Osteoporosis in young adults: pathophysiology, diagnosis, and management

Postmenopausal osteoporosis is mainly caused by increased bone remodeling resulting from estrogen deficiency. Indications for treatment are based on low areal bone mineral density (aBMD, T-score  ≤ -2.5), typical fragility fractures (spine or hip), and more recently, an elevated 10-year fracture probability (by FRAX®). In contrast, there is no clear definition of osteoporosis nor intervention thresholds in younger individuals. Low aBMD in a young adult may reflect a physiologically low peak bone mass, such as in lean but otherwise healthy persons, whereas fractures commonly occur with high-impact trauma, i.e., without bone fragility. Furthermore, low aBMD associated with vitamin D deficiency may be highly prevalent in some regions of the world. Nevertheless, true osteoporosis in the young can occur, which we define as a T-score below -2.5 at spine or hip in association with a chronic disease known to affect bone metabolism. In the absence of secondary causes, the presence of fragility fractures, such as in vertebrae, may point towards genetic or idiopathic osteoporosis. In turn, treatment of the underlying condition may improve bone mass as well. In rare cases, a bone-specific treatment may be indicated, although evidence is scarce for a true benefit on fracture risk. The International Osteoporosis Foundation (IOF) convened a working group to review pathophysiology, diagnosis, and management of osteoporosis in the young, excluding children and adolescents, and provide a screening strategy including laboratory exams for a systematic approach of this condition.

Effect of teriparatide on pregnancy and lactation-associated osteoporosis with multiple vertebral fractures

Pregnancy and lactation-associated osteoporosis (PLO) is very rare, but it can cause severe vertebral compression fractures with disabling back pain. PLO patients have commonly been treated with antiresorptive agents against high bone turnover. There are, however, some concerns regarding the use of bisphosphonates: (1) PLO occurs during the first pregnancy with a high possibility of recurrence during the second pregnancy, (2) long-term outcomes of bisphosphonates in PLO are lacking, and (3) there is a possibility of bisphosphonates accumulated in the bones crossing the placenta. Therefore, alternative therapies must be considered. We analyzed the effect of teriparatide (TPTD), the human recombinant parathyroid hormone (1-34), for 18 months in three women with PLO. Multiple vertebral fractures with severe back pain appeared within 6 months after their first childbirth. Two of them had a family history of osteoporosis. Lactation was discontinued immediately after diagnosis of PLO. Calcium carbonate, cholecalciferol, and TPTD were prescribed. The back pain immediately resolved. Bone mineral density (BMD) increased by 14.5-25.0% (mean 19.5%) at the lumbar spine and by 9.5-16.7% (mean 13.1%) at the femoral neck, after 18 months of treatment. The final Z scores in these PLO patients were nearly normalized. Two women had a second baby without any complication. BMD significantly improved after 18 months of treatment with TPTD without further fractures. In conclusion, TPTD should be considered to avoid long-term morbidity in young patients with PLO and is highly encouraged for use in PLO patients with multiple vertebral fractures.

Bilateral subcapital femoral neck fractures secondary to transient osteoporosis during pregnancy: a case report

Transient osteoporosis during pregnancy is a rare, self-limiting disease. We report on a 36-year-old woman who had bilateral subcapital femoral neck fractures during the 6th month of pregnancy. The diagnosis was made 4 days after delivery, because radiography was declined by the patient for fear of radiation. Fixation was not feasible owing to bone resorption, and 2-stage bipolar hemiarthroplasty was therefore performed. Magnetic resonance imaging is the best non-invasive investigative tool for pregnant women with hip pain. Early detection can prevent complications and resorting to major surgeries.

Calcium and bone disorders in pregnancy

Significant transplacental calcium transfer occurs during pregnancy, especially during the last trimester, to meet the demands of the rapidly mineralizing fetal skeleton. Similarly, there is an obligate loss of calcium in the breast milk during lactation. Both these result in considerable stress on the bone mineral homeostasis in the mother. The maternal adaptive mechanisms to conserve calcium are different in pregnancy and lactation. During pregnancy, increased intestinal absorption of calcium from the gut mainly due to higher generation of calcitriol (1,25 dihydroxy vitamin D) helps in maintaining maternal calcium levels. On the other hand, during lactation, the main compensatory mechanism is skeletal resorption due to increased generation of parathormone related peptide (PTHrP) from the breast. Previous studies suggest that in spite of considerable changes in bone mineral metabolism during pregnancy, parity and lactation are not significantly associated with future risk for osteoporosis. However, in India, the situation may not be the same as a significant proportion of pregnancies occur in the early twenties when peak bone mass is not yet achieved. Further, malnutrition, anemia and vitamin D deficiency are commonly encountered in this age group. This may have an impact on future bone health of the mother. It may also probably provide an opportunity for health care providers for prevention. Other metabolic bone diseases like hypoparathyroidism, hyperparathyroidism and pseudohypoparathyroidism are rarely encountered in pregnancy. Their clinical implications and management are also discussed.

Five-year follow-up of a woman with pregnancy and lactation-associated osteoporosis and vertebral fractures

We report the 5-year follow-up of a young woman who developed vertebral fractures after pregnancy and lactation and was treated with active vitamin D hormone. A 32-year-old Japanese woman consulted us because of acute lower back pain caused by L2 and L5 vertebral fractures after pregnancy and lactation. Following cessation of breast-feeding, analgesia, bed rest, and wearing of a hard brace, her lower back pain disappeared within 2 months. After 5 years of treatment with alfacalcidol 1 μg daily, the lumbar spine (L1, L3, L4) bone mineral density increased by 21.4% following vigorous reductions in bone turnover markers. No osteoporotic fractures occurred, and the vertebral fractures healed. The patient experienced no side effects, including hypercalcemia. Thus, the present case report shows long-term changes in bone turnover markers and lumbar spine bone mineral density, as well as long-term safety of alfacalcidol treatment in a young woman with pregnancy and lactation-associated osteoporosis and vertebral fractures.

Calcium and bone metabolism disorders during pregnancy and lactation

Pregnancy and lactation cause a substantial increase in demand for calcium that is met by different maternal adaptations within each period. Intestinal calcium absorption more than doubles during pregnancy, whereas the maternal skeleton resorbs to provide most of the calcium content of breast milk during lactation. These maternal adaptations also affect the presentation, diagnosis, and management of disorders of calcium and bone metabolism. Although some women may experience fragility fractures as a consequence of pregnancy or lactation, for most women, parity and lactation do not affect the long-term risks of low bone density, osteoporosis, or fracture.

Severe postpartum osteoporosis with increased PTHrP during lactation in a patient after total thyroidectomy and parathyroidectomy

We present a 27-year-old woman with hypoparathyroidism following total thyroidectomy for papillary carcinoma, who presented postpartum during lactation with several vertebral osteoporotic fractures, increase in bone turnover markers, and measurable parathyroid hormone-related protein (PTHrP) levels. Cessations of lactation led to gradual decrease in bone turnover markers and PTHrP and improvement in bone mineral density. Pregnancy- and postpartum-associated osteoporosis is an uncommon condition characterized by the occurrence of fractures during late pregnancy or the puerperium. The patient presented postpartum with severe back pain and multiple vertebral fractures. Metabolic evaluation performed at presentation revealed hypercalcemia, hypercalciuria, increased alkaline phosphatase, vitamin D insufficiency, normal serum protein immunoelectrophoresis, and a detectable level of PTHrP. Serum levels of bone turnover markers were markedly increased. Bone mineral density at the lumbar spine was severely reduced. After cessation of lactation, the PTHrP level became undetectable. Bone turnover markers gradually decreased to normal and bone mineral density improved. Several factors contributed to the reduced bone mass in this patient, including amenorrhea treated with oral contraceptives, suppressive levothyroxine treatment, and lactation of twins with increased PTHrP. Patients with severely reduced bone mass need surveillance during pregnancy and lactation and should possibly consider avoiding breastfeeding. Patients with hypoparathyroidism should temporarily reduce their alphacalcidiol dose while lactating.

An unusual presentation of osteogenesis imperfecta type I

Osteogenesis imperfecta (OI) is a rare inherited disorder with a broad spectrum of clinical and genetic variability. The genetic diversity involves, in the majority of the cases, mutations in one of the genes that encodes the type 1 collagen protein (COL1 A1 and COL1 A2), but it is not a requirement for the diagnosis. The most benign form is OI type I. The authors present a case report of a 25-year-old woman who had severe low back pain associated with incapacity to walk and breast-feed post-partum. Symptoms developed 2 weeks after delivery. The radiological examination revealed severe osteoporosis with no abnormalities in the laboratory findings. The clinical signs and a positive personal and family history of multiple fractures in childhood suggested OI type I, although other diagnosis, such as pregnancy-associated osteoporosis, was also considered. The atypical presentation of this rare disorder in adulthood calls attention to the need for early diagnosis for prompt treatment. Treatment of OI is never curative, but it improves the quality of the patient’s life.

Maternal circulating osteoprotegerin and soluble RANKL in pre-eclamptic women

OBJECTIVE

To evaluate alterations in the concentrations of osteoprotegerin (OPG), RANKL and the OPG/RANKL ratio in pre-eclamptic women during the puerperium.

STUDY DESIGN

This cross-sectional study was performed in the maternity ward of Aretaieio Hospital in Athens, Greece. Fifteen pregnant women with severe pre-eclampsia and 15 matched controls with premature rupture of the membranes were recruited. Fasting blood samples were obtained antepartum, immediately after diagnosing pre-eclampsia (median: 32nd gestational week), and during the 3rd-6th day postpartum, to estimate levels of circulating OPG and RANKL as well as the OPG/RANKL ratio. The anthropometric parameters evaluated included body mass index and blood pressure.

RESULTS

Mean circulating OPG levels decreased significantly in both groups in the postpartum period (controls: 43.7 ± 19.1 ng/ml vs 22.9 ± 9.1 ng/ml, p = 0.008; pre-eclamptic group: 72.3 ± 49.9 vs 49.7 ± 40.9 ng/ml, p = 0.002). The antepartum OPG/RANKL ratio was elevated in hypertensive pregnancies (2.41 ± 1.72) compared to normotensive pregnancies (1.45 ± 0.63), but the difference did not reach statistical significance (p = 0.1). The OPG/RANKL ratio decreased in the control group (0.76 ± 0.30, NS) following delivery, while it remained unchanged in the pre-eclamptic women (1.63 ± 1.40, p = 0.13). Consequently, the postpartum OPG/RANKL ratio was significantly higher in the pre-eclamptic women compared to control women (1.63 ± 1.40 vs 0.76 ± 0.30, p = 0.01). Levels of RANKL demonstrated no significant alterations during puerperium in both cases.

CONCLUSION

Pregnancies complicated with pre-eclampsia exhibit higher OPG levels and OPG/RANKL ratios, compared to control pregnancies, which might be compatible with lower bone turnover. The significance of this finding with respect to bone metabolism remains to be elucidated in larger studies.

Treatment with teriparatide in a patient with pregnancy-associated osteoporosis

INTRODUCTION

The decrease of BMD during a physiological pregnancy can in rare cases be intensified and lead to dramatic microarchitectural changes, which causes an increase incidence of fractures, preferably at the spine. This dramatic clinical picture is called pregnancy-associated osteoporosis.

CASE HISTORY

We present the case of a 40-year-old woman (gravida IV, para II) with acute back pain right after delivery due to four fractures of the spine. The diagnosis was confirmed by dual-energy X-ray absorptiometry measurement result (T-score -4.1 SD (0.598 g/cm(2)) at the lumbar spine (L1-L4), T-score -1.5 SD (0.759 g/cm(2)) at the total hip). Due to the severity of symptoms, a therapy with teriparatide (20 mg daily) was started for a period of 18 months.

RESULTS

After end of therapy, the T-score had significantly increased at the lumbar spine as well as at the hip (T-score of -2.1 (0.813 g/cm(2)) and -0.6 (0.864 g/cm(2)), respectively. The relative increase of BMD at the spine and total hip was 36% and 13.8%, respectively.

DISCUSSION

Our report demonstrates the successful use of teriparatide underlined by the increase of bone mineral density and the improvement of clinical symptoms in a case of severe pregnancy-associated osteoporosis for the first time.

[Pregnancy-associated osteoporosis. Differential diagnosis of "common" musculoskeletal pain during pregnancy and lactation]

Musculoskeletal pain during pregnancy and lactation is a common finding. Differential diagnoses range from"normal" findings to disturbances in bone metabolism and pregnancy-associated osteoporosis (PAO). Imaging options are limited due to pregnancy, and laboratory diagnostics are time-consuming. Treatment of PAO with physiotherapy, pain killers and substitution of vitamin D and calcium leads to a rapid recovery from symptoms.

Pregnancy- and lactation-associated osteoporosis with severe vertebral deformities: can strontium ranelate be a new alternative for the treatment?

BACKGROUND CONTEXT

Pregnancy- and lactation-associated osteoporosis is an uncommon condition that may be a consequence of preexisting low bone density, loss of bone mineral content during pregnancy, and increased bone turnover.

PURPOSE

To present a case of severe osteoporosis associated with pregnancy and lactation and its treatment protocol.

STUDY DESIGN/SETTING

A tertiary care hospital.

PATIENT SAMPLE

A young female after twin pregnancy presenting with severe osteoporosis.

METHODS

The diagnosis was done on the basis of bone mineral density (BMD) measurement. The patient was treated with first alendronate and then strontium ranelate. She was considered as a candidate for kyphoplasty.

RESULTS

A dramatic increase in the BMD and palliation of back pain were observed.

CONCLUSIONS

Strontium ranelate may be a new alternative in the treatment of pregnancy- and lactation-associated osteoporosis.

Heparin-induced osteoporosis and pregnancy

PURPOSE OF REVIEW

Osteoporosis is the most common serious side effect of long-term unfractionated heparin use. Until recently, it was unknown whether long-term low-molecular-weight heparin was associated with any change in bone mineral density. With increasing long-term low-molecular-weight heparin use, for a variety of indications, this was an important knowledge gap.

RECENT FINDINGS

We recently completed an a-priori planned substudy to assess the effect of low-molecular-weight heparin on bone mineral density in an ongoing multicenter multinational randomized trial designed to compare the effect of low-molecular-weight heparin prophylaxis on pregnancy outcomes in thrombophilic pregnant women. The results revealed that there is no significant difference in mean bone mineral density between a low-molecular-weight heparin prophylaxis group and a no prophylaxis group. The study was not adequately powered to detect differences in absolute fracture risk.

SUMMARY

Recent results suggest that the use of long-term prophylactic low-molecular-weight heparin in pregnancy is not associated with a significant decrease in bone mineral density. Whether higher doses might be a risk factor for osteoporosis is still an unanswered question. It is also possible that subgroups are more susceptible. Overall, women should be reassured regarding the risk of osteoporosis associated with the use of prophylactic dose of low-molecular-weight heparin during their pregnancy.

A case report: pregnancy-induced severe osteoporosis with eight vertebral fractures

Osteoporosis associated with pregnancy and lactation is a rare condition. The prevalence, etiology and its pathogenesis is unknown. It causes one or more vertebral fractures with severe, prolonged back pain and height loss in affected women. Majority of the cases are seen in the third trimester or just after delivery in primagravid women. In this case report, a 30-year-old woman who had severe pregnancy-induced osteoporosis with 8 vertebral fractures was presented. During last month of her first pregnancy she had moderate back pain. After delivery, the back pain has gotten worse. The radiological examinations have shown that there was 50% in T6, T8 and T10; 30% in L2; 20% in L1 height loss and biconcave vertebral images in L3-5. In the bone mineral density, L2-4 T score was -4.7 and total femoral T score was -3.1. There was no abnormality in the laboratory findings except mild elevation in alkaline phosphates. Although pregnancy-associated osteoporosis is a rare condition, when pain occurs in the last trimester or early postpartum period, it should be considered in differential diagnosis.

Bilateral non-traumatic acetabular and femoral neck fractures due to pregnancy-associated osteoporosis

Pregnancy-associated osteoporosis is a rare disorder and its pathophysiology remains unknown. We report a case of pregnancy-associated osteoporosis in a 27-year-old primiparous patient who revealed bilateral hip pain during early postnatal period. The plain radiographs and computerized tomography showed bilateral femoral neck and acetabular fractures. The diagnosis of osteoporosis was established by bone mineral density. Diagnostic work-up excluded a secondary osteoporosis. The case was treated successfully by bilateral cementless total hip arthroplasty. Bone mineral density increased after 2 years of treatment with calcium-vitamin D, calcitriol and alendronate. Diagnosis of pregnancy-associated osteoporosis should be suspected when hip pain occurs during pregnancy or in the post-partum period as it can lead to acetabular and femoral neck fractures.

Pregnancy-related hip diseases: incidence and diagnoses

BACKGROUND

Pregnancy-related hip diseases epidemiology has been poorly evaluated. We report our experience of gestational and postpartum hip diseases and evaluate their incidence.

METHODS

(1) Prospective survey: all pregnant or early postpartum women suspected to have hip involvement during their follow-up in an Obstetric unit were referred to a rheumatologist. If clinically confirmed, magnetic resonance imaging (MRI) and additional investigations as needed were performed. This survey had 2 years duration. (2) Retrospective study: all cases of definite (with MRI confirmation) pregnancy-related hip disease referred to our Rheumatology unit during the past 15 years were analyzed.

RESULTS

During the 2-year prospective survey, 3 patients (4 hips) of pregnancy-related hip disease were observed over 4900 pregnancies (1 case of transient osteoporosis of the hip (TOH) and 2 cases of occult fracture of the femoral head). During the 15-year retrospective study, 12 patients (17 hips) with hip diseases during pregnancy or early postpartum were identified. There were 6 patients (9 hips) with TOH, 4 patients (6 hips) with occult fracture of the femoral head, 1 patient with osteonecrosis of the femoral head, and 1 coxitis in a patient with ankylosing spondylitis. Differentiating diagnosis between TOH and occult fractures could only be made by MRI. Five of the 6 women with TOH had osteopenia at the lumbar spine at dual energy X-ray absorptiometry (DEXA). The 4 women with occult fractures had either osteopenia or osteoporosis at the lumbar spine.

CONCLUSION

Hip diseases are infrequent during pregnancy and early postpartum. Transient osteoporosis of the hip and occult stress fractures of the femoral head appear the main causes and those diagnoses justify evaluation for an underlying bone fragility. Osteonecrosis is very rare in this setting.

Sciatica in the female patient: anatomical considerations, aetiology and review of the literature

The principal author was confronted few years ago with the case of a 38-year-old woman with a 5-month history of ill-defined L5 sciatic pain that was referred to an orthopaedic department for investigation and eventual surgical treatment for what was suspected to be herniated disc-related sciatica. Removal of her enlarged uterus found unexpectedly close to the sacroiliac joint upon lumbar MRI abolished her symptoms. Review of the literature showed that the lumbosacral trunk is vulnerable to pressure from any abdominal mass originating from the uterus and the ovaries. Physiological processes in the female patient and gynaecological diseases may be the source of sciatica, often not readily searched for, leading to fruitless investigations and surgical treatments. The aim of the paper is to highlight gynaecological and obstetrical causes of sciatica and sciatica-like symptoms. To prevent unproductive expenses and morbidity, a thorough gynaecological examination should be done even though neurological examination may be suggestive of a herniated intervertebral disc, and the cyclic pattern of pain related to menses should be routinely asked for.

Orthopaedic trauma in the pregnant patient

Trauma affects up to 8% of pregnancies and is the leading cause of death among pregnant women in the United States. A pregnancy test is mandated for all females of childbearing age who are involved in trauma. Orthopaedic trauma in the pregnant patient is managed similarly to that for all trauma patients. Initial resuscitation efforts should focus on the pregnant patient because stable patient vital signs provide the best chance for fetal survival. In the stable patient, fetal assessment and a pelvic examination are mandatory. Radiographs as well as abdominal ultrasound of the patient and fetal ultrasound are useful. No known biologic risks are associated with magnetic resonance imaging, and no specific fetal abnormalities have been linked with standard low-intensity magnetic resonance imaging. Emergency surgery can be safely performed in most pregnant patients. Avoiding patient hypotension and using left lateral decubitus positioning increase the likelihood of success for the patient and fetus. An experienced multidisciplinary team consisting of an obstetrician, perinatologist, orthopaedic surgeon, anesthesiologist, radiologist, and nursing staff will optimize the treatment of both the pregnant patient and her fetus.