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Rahimi M, Daneshvar S, Khabbazi A. Pregnancy-associated osteoporosis following in vitro fertilization: A case report. Clin Case Rep 2024; 12:e8702. [PMID: 38523825 PMCID: PMC10957487 DOI: 10.1002/ccr3.8702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024] Open
Abstract
This case report illustrates that in vitro fertilization (IVF) may be a potential risk factor for pregnancy-associated osteoporosis (PAO), highlighting the need for awareness and monitoring of bone health in women undergoing IVF treatments. PAO is a rare disease resulting from an imbalance of calcium in the body during pregnancy and lactation and presenting with fragility fractures. PAO occurs in late pregnancy or early postpartum period. A 28-year-old woman who conceived through IVF experienced severe back pain 2 days after delivery. Magnetic resonance imaging of the spine showed wedge-shaped fractures of T9-T12 vertebrae. Bone mineral density (BMD) was low on dual-energy x-ray absorptiometry. The laboratory tests were within the normal range. Based on the clinical manifestations, osteoporotic spine fracture, results of BMD, and exclusion of other causes of osteoporosis, the patient was diagnosed with PAO. Considering the deleterious effect of treatment with gonadotropin-releasing hormone and repeated superovulation on bone, we hypothesized that IVF may be an etiological factor for PAO.
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Affiliation(s)
- Mehran Rahimi
- Connective Tissue Diseases Research CenterTabriz University of Medical SciencesTabrizIran
| | - Sara Daneshvar
- Connective Tissue Diseases Research CenterTabriz University of Medical SciencesTabrizIran
| | - Alireza Khabbazi
- Connective Tissue Diseases Research CenterTabriz University of Medical SciencesTabrizIran
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2
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Anagnostis P, Lampropoulou-Adamidou K, Bosdou JK, Trovas G, Galanis P, Chronopoulos E, Goulis DG, Tournis S. Comparative Effectiveness of Therapeutic Interventions in Pregnancy and Lactation-Associated Osteoporosis: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab 2024; 109:879-901. [PMID: 37708365 PMCID: PMC10876413 DOI: 10.1210/clinem/dgad548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/09/2023] [Accepted: 09/12/2023] [Indexed: 09/16/2023]
Abstract
CONTEXT The optimal management of pregnancy and lactation-associated osteoporosis (PLO) has not been designated. OBJECTIVE To systematically review the best available evidence regarding the effect of different therapeutic interventions on bone mineral density (BMD) and risk of fractures in these patients. METHODS A comprehensive search was conducted in PubMed/Scopus databases until December 20, 2022. Data were expressed as weighted mean difference (WMD) with 95% CI. The I2 index was employed for heterogeneity. Studies conducted in women with PLO who received any antiosteoporosis therapy were included. Studies including women with secondary causes of osteoporosis or with transient osteoporosis of the hip were excluded. Data extraction was independently completed by 2 researchers. RESULTS Sixty-six studies were included in the qualitative analysis (n = 451 [follow-up time range 6-264 months; age range 19-42 years]). The increase in lumbar spine (LS) BMD with calcium/vitamin D (CaD), bisphosphonates, and teriparatide was 2.0% to 7.5%, 5.0% to 41.5%, and 8.0% to 24.4% at 12 months, and 11.0% to 12.2%, 10.2% to 171.9%, and 24.1% to 32.9% at 24 months, respectively. Femoral neck (FN) BMD increased by 6.1% with CaD, and by 0.7% to 18% and 8.4% to 18.6% with bisphosphonates and teriparatide (18-24 months), respectively. Meta-analysis was performed for 2 interventional studies only. Teriparatide induced a greater increase in LS and FN BMD than CaD (WMD 11.5%, 95% CI 4.9-18.0%, I2 50.9%, and 5.4%, 95% CI 1.2-9.6%, I2 8.1%, respectively). CONCLUSION Due to high heterogeneity and lack of robust comparative data, no safe conclusions can be made regarding the optimal therapeutic intervention in women with PLO.
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Affiliation(s)
- Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 56403, Greece
| | - Kalliopi Lampropoulou-Adamidou
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
| | - Julia K Bosdou
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki 11527, Greece
| | - Georgios Trovas
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
| | - Petros Galanis
- Clinical Epidemiology Laboratory, Faculty of Nursing, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Efstathios Chronopoulos
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 56403, Greece
| | - Symeon Tournis
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
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Pregnancy-Associated Osteoporosis: A Literature Review. Clin Rev Bone Miner Metab 2023. [DOI: 10.1007/s12018-023-09287-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Qian Y, Wang L, Yu L, Huang W. Pregnancy- and lactation-associated osteoporosis with vertebral fractures: a systematic review. BMC Musculoskelet Disord 2021; 22:926. [PMID: 34732196 PMCID: PMC8567545 DOI: 10.1186/s12891-021-04776-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 10/06/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND To review, analyze and characterize the pregnancy and lactation-related osteoporosis (PLO) with vertebral fractures based on the extraction data in the previous studies. METHODS A comprehensive literature search of electronic databases including the PubMed, Embase and Web of Science was conducted from January 1st,1990 to December 1st, 2020. The enrolled data were pooled to analyze the baseline characteristics, clinical features, risk factors and treatment options. RESULTS A total of 65 articles with 338 cases were enrolled for data extraction. The enrolled cases aged from 19 to 47 years, with a mean value of 35.7 years old. The average body mass index (BMI) was 22.2 kg/m2 ranged from 16.0 to 39.0 kg/m2. Of the 173 cases, 149 cases with vertebral fractures occurred in the first pregnancy, 19 cases in the second pregnancy, four cases in the third pregnancy and one case in the fourth pregnancy. Up to 91.5% of the back pain occurred within the last 3 months of pregnancy and the first 3 months after delivery. The most involved vertebral levels were L2, L1 and T12 accounting for 32.6% of all the fractures. The average fracture numbers were 4.4 levels per patient. The lumbar Z-scores were mostly recorded with a mean value of - 3.2 ranged from - 7.8 to 0. CONCLUSIONS PLO with vertebral fractures is a rare clinical entity, which is more likely to occur in older and thinner pregnant women. Back pain is the clinical complaint and mostly occurs in the late pregnancy and early lactation periods. Most vertebral fractures appear in the first pregnancy but it can occur in any time of pregnancy. Thoracolumbar region is the mostly involved region. As compared with postmenopausal osteoporotic fractures, PLO usually has multiple levels fractures. Bisphosphonates are the most widely used treatment so far, however, many factors need to be taken into account to decide which drug to choose in PLO and further studies are necessary for clear recommendation in the future.
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Affiliation(s)
- Ying Qian
- Endocrinology Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
| | - Lei Wang
- Orthopaedic Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
| | - Lili Yu
- Medical Information Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
| | - Weimin Huang
- Orthopaedic Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
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Stumpf U, Kraus M, Hadji P. Influence of denosumab on bone mineral density in a severe case of pregnancy-associated osteoporosis. Osteoporos Int 2021; 32:2383-2387. [PMID: 34041561 PMCID: PMC8563672 DOI: 10.1007/s00198-021-06008-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/12/2021] [Indexed: 11/28/2022]
Abstract
Pregnancy and lactation-associated osteoporosis (PLO) with predominantly subsequent vertebral fracture is a rare but severe disease with an estimated incidence of 0.4 in 100,000. In the past, patients with PLO have been predominantly treated with oral and i.v. bisphosphonates to reduce subsequent fracture risk. Hereby, the use of bisphosphonates in premenopausal women is controversial, as bisphosphonates know to persist in bone for many years and can be exposed and circulate in maternal serum and subsequently pass the placenta barrier and may have a detrimental effect on fetal bone health. Here we report the effects of denosumab on the bone mineral density (BMD) and subsequent fracture risk in PLO. In this case presentation, denosumab was administered postpartum with 3000 IE vitamin D and 1000 mg of calcium daily in a patient with PLO and vertebral fracture of L1 and L4. After 18 months of treatment with denosumab, we could demonstrate a clinical significant increase of BMD at the lumbar spine, femoral neck, and total hip of 32.2%, 13.0%, and 11.5% respectively with no further subsequent fractures. As the patient had regular menstrual cycles and considered a further pregnancy, denosumab treatment was terminated and soon a second pregnancy occurred. After the second pregnancy, BMD decreased at the lumbar spine, femur neck, and total hip by -8.8%, -6.9%, and -7.0% respectively compared to the maximum values during treatment with denosumab, but was still significantly higher compared to baseline levels with no further fractures.
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Affiliation(s)
- U Stumpf
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Campus Innenstadt, Nussbaumstrasse, 20 80336, Munich, Germany.
| | - M Kraus
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Campus Innenstadt, Nussbaumstrasse, 20 80336, Munich, Germany
| | - P Hadji
- Frankfurt Center of Bone Health, Frankfurt, Germany and Philipps-University of Marburg, Marburg, Germany
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Cerit ET, Cerit M. A case of pregnancy and lactation associated osteoporosis in the third pregnancy; robust response to teriparatide despite delayed administration. Bone Rep 2020; 13:100706. [PMID: 32884982 PMCID: PMC7451846 DOI: 10.1016/j.bonr.2020.100706] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/08/2020] [Accepted: 07/30/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pregnancy and lactation associated osteoporosis (PLO) is a rare condition that may present with fragility fractures occurring for the first time in pregnancy or postpartum period while breastfeeding. Here, we report a rare case of PLO in the 3rd pregnancy treated with teriparatide. CASE REPORT A 35-year-old woman who presented with back pain (visual analogue scale; VAS = 10/10) two months after her third delivery. PLO was diagnosed from multiple vertebral fragility fractures and low bone mineral density (BMD). She was treated with teriparatide and her pain significantly reduced in the second month. After 12 months of teriparatide treatment, her BMD increased 18.1% from the baseline. CONCLUSION PLO should be considered in patients who complain with back pain during late pregnancy and postpartum period. Weaning off breastfeeding and supplementation of calcium/vitamin D should be the first recommendation as conventional treatment after the diagnosis of PLO. Teriparatide may be an effective option to improve the recovery of BMD If there is not enough improvement with conventional treatment.
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Affiliation(s)
- Ethem Turgay Cerit
- Ankara Memorial Hospital, Endocrinology and Metabolism Department, Ankara, Turkey
| | - Mahinur Cerit
- Gazi University Faculty of Medicine, Radiology Department, Ankara, Turkey
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Vassalou EE, Klontzas ME, Tsifountoudis IP, Spanakis K, Karantanas AH. Spectrum of skeletal disorders during the peripartum period: MRI patterns. ACTA ACUST UNITED AC 2020; 25:245-250. [PMID: 31063145 DOI: 10.5152/dir.2019.18354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pregnancy is a normal condition in which a combination of biomechanical and hormonal changes may result in a wide spectrum of skeletal disorders. Skeletal overloading due to postural and weight changes, combined with increased ligamentous laxity stemming from the action of relaxing and the risk of pregnancy-related osteoporosis during childbearing, childbirth, and postpartum, have been associated with various pathologies. Owing to the heterogeneity of proposed contributing factors, skeletal lesions in the peripartum period may be related to different pathogenesis depending on the metabolic status of the patient and the degree of biomechanical stress; thus, a fatigue or insufficiency discrimination is not always easy to make. When combined with clinical data, magnetic resonance imaging (MRI) is a powerful tool in clarifying the cause of skeletal pain in the majority of patients or alerting clinicians to proceed to further investigations. Early detection and tailored treatment are important in order to avoid disease progression and long-term restriction of daily activities which may have an adverse impact on the relationship between the mother and the newborn. This pictorial essay provides an overview of the MRI characteristics and pattern of involvement of skeletal lesions presenting during the peripartum period, combined with demographic data and dual-energy X-ray absorptiometry (DEXA) measurements.
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Affiliation(s)
- Evangelia E Vassalou
- Department of Medical Imaging, University Hospital, Heraklion, Greece; Department of Medical Imaging, General Hospital of Sitia, Lasithi, Greece
| | - Michail E Klontzas
- Department of Medical Imaging University Hospital, Heraklion, Greece; Imperial College London, London, United Kingdom
| | | | - Konstantinos Spanakis
- Department of Medical Imaging, University Hospital, Heraklion, Greece; Department of Medical Imaging, General Hospital of Sitia, Lasithi, Greece
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Lewiecki EM, Bilezikian JP, Kagan R, Krakow D, McClung MR, Miller PD, Rush ET, Shuhart CR, Watts NB, Yu EW. Proceedings of the 2019 Santa Fe Bone Symposium: New Concepts in the Care of Osteoporosis and Rare Bone Diseases. J Clin Densitom 2020; 23:1-20. [PMID: 31685420 DOI: 10.1016/j.jocd.2019.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 09/24/2019] [Indexed: 02/08/2023]
Abstract
The 20th annual Santa Fe Bone Symposium was held August 9-10, 2019, in Santa Fe, New Mexico, USA. This is an annual meeting devoted to clinical applications of recent advances in skeletal research that impact the care of patients with osteoporosis, metabolic bone diseases, and inherited bone diseases. Participants included practicing and academic physicians, fellows, advanced practice providers, fracture liaison service (FLS) coordinators, clinical researchers, and bone density technologists. The symposium consisted of lectures, case presentations, and panel discussions, with an emphasis on learning through interaction of all attendees. Topics included new approaches in the use of anabolic agents for the treatment osteoporosis, a review of important events in skeletal health over the past year, new and emerging treatments for rare bone diseases, the use of genetic testing for bone diseases in clinical practice, medication-associated causes of osteoporosis, new concepts in the use of estrogen therapy for osteoporosis, new Official Positions of the International Society for Clinical Densitometry, skeletal consequences of bariatric surgery, and update on the progress and potential of Bone Health TeleECHO, a virtual community of practice using videoconferencing technology to link healthcare professionals for advancing the care of osteoporosis worldwide. Sessions on rare bone diseases were developed in collaboration with the Rare Bone Disease Alliance. Symposium premeetings included an FLS workshop by the National Osteoporosis Foundation and others devoted to the use of new therapeutic agents for the care of osteoporosis and related disorders.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA.
| | - John P Bilezikian
- Columbia University College of Physicians and Surgeons, NYC, NY, USA
| | - Risa Kagan
- UCSF and Sutter East Bay Medical Foundation, Berkeley, CA, USA
| | - Deborah Krakow
- University of California Los Angeles, Los Angeles, CA, USA
| | - Michael R McClung
- Oregon Osteoporosis Center, Portland, OR, USA; Mary MacKillop Center for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Paul D Miller
- University of Colorado Health Sciences Center, Denver, CO, USA
| | - Eric T Rush
- University of Kansas Medical Center, Kansas City, MO, USA; Children's Mercy Hospital, Kansas City, MO, USA; University of Missouri - Kansas City, Kansas City, MO, USA
| | | | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Elaine W Yu
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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9
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Cohen A, Kamanda-Kosseh M, Dempster DW, Zhou H, Müller R, Goff E, Colon I, Bucovsky M, Stubby J, Nickolas TL, Stein EM, Recker RR, Lappe JM, Shane E. Women With Pregnancy and Lactation-Associated Osteoporosis (PLO) Have Low Bone Remodeling Rates at the Tissue Level. J Bone Miner Res 2019; 34:1552-1561. [PMID: 31348548 PMCID: PMC6744311 DOI: 10.1002/jbmr.3750] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/19/2019] [Accepted: 04/21/2019] [Indexed: 01/19/2023]
Abstract
Pregnancy and lactation-associated osteoporosis (PLO) is a rare, severe, early form of osteoporosis in which young women present with fractures, usually multiple vertebral fractures, during late pregnancy or lactation. In studies of idiopathic osteoporosis (IOP) in premenopausal women, we enrolled 78 women with low-trauma fractures and 40 healthy controls, all with normal menses and no secondary cause of bone loss. In 15 of the affected women, the PLO subgroup, fractures had occurred during late pregnancy or lactation. We hypothesized that clinical, bone structural, and metabolic characteristics would differ between women with PLO and those with (non-PLO) IOP and controls. All were evaluated > 12 months postpartum, when structural and remodeling characteristics would be expected to reflect baseline premenopausal status rather than transient postpartum changes. As previously reported, affected subjects (PLO and IOP) had BMD and microarchitectural deficiencies compared to controls. Women with PLO did not differ from those with IOP in terms of age, BMI, body fat, menarcheal age, parity, or age at first pregnancy. However, women with PLO had a more severe clinical presentation than those with IOP: more fractures (5.5 ± 3.3 versus 2.6 ± 2.1; p = 0.005); more vertebral fractures (80% versus 17%; p < 0.001); and higher prevalence of multiple fractures. BMD deficits were more profound and cortical width tended to be lower in PLO. PLO subjects also had significantly lower tissue-level mineral apposition rate and bone formation rates (0.005 ± 0.005 versus 0.011 ± 0.010 mm2 /mm/year; p = 0.006), as well as lower serum P1NP (33 ± 12 versus 44 ± 18 µg/L; p = 0.02) and CTX (257 ± 102 versus 355 ± 193 pg/mL; p = 0.01) than IOP. The finding that women with PLO have a low bone remodeling state assessed more than a year postpartum increases our understanding of the pathogenic mechanism of PLO. We conclude that women with PLO may have underlying osteoblast functional deficits which could affect their therapeutic response to osteoanabolic medications. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Adi Cohen
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mafo Kamanda-Kosseh
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - David W Dempster
- Department of Clinical Pathology and Cell Biology, Columbia University, New York, NY, USA.,Regional Bone Center, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - Hua Zhou
- Regional Bone Center, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - Ralph Müller
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Elliott Goff
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Ivelisse Colon
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mariana Bucovsky
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - Julie Stubby
- Department of Clinical Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Thomas L Nickolas
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Emily M Stein
- Division of Endocrinology, Hospital for Special Surgery, New York, NY, USA
| | - Robert R Recker
- Department of Medicine, Division of Endocrinology, Creighton University school of Medicine, Omaha, NE, USA
| | - Joan M Lappe
- Department of Medicine and College of Nursing, Creighton University school of Medicine, Omaha, NE, USA
| | - Elizabeth Shane
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
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10
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Hardcastle SA, Yahya F, Bhalla AK. Pregnancy-associated osteoporosis: a UK case series and literature review. Osteoporos Int 2019; 30:939-948. [PMID: 30671611 DOI: 10.1007/s00198-019-04842-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/03/2019] [Indexed: 11/26/2022]
Abstract
Mini Abstract: Pregnancy-associated osteoporosis (PAO) is a rare syndrome affecting women during late pregnancy and the early postpartum period. We set out to review the clinical features of ten cases of PAO from a single UK centre. Patients had attended the Royal National Hospital for Rheumatic Diseases, Bath (RNHRD) between January 2000 and June 2016. The principal criterion for inclusion was the occurrence of low trauma fractures either during pregnancy or the immediate post-partum period. Data were obtained from retrospective review of medical notes. Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (Hologic ®Discovery system) at the lumbar spine and hip. Data pertaining to the pregnancy, as well as type and duration of treatment received, were reviewed. All ten cases presented with vertebral fractures. In four patients, no risk factors for fracture other than pregnancy or breastfeeding could be identified. Four patients were found to have vitamin D insufficiency at the time of diagnosis, and a further two patients had received treatment with low molecular weight heparin (LMWH). In one case, further investigation led to a diagnosis of osteogenesis imperfecta (OI) confirmed on genetic testing. In terms of treatment, eight out of the ten patients in this series received a bisphosphonate, most commonly risedronate due to its relatively short skeletal retention time. Clinicians should be aware of PAO, a rare but recognised complication of pregnancy. The condition should be especially considered in women presenting with new onset back pain in pregnancy or the postpartum period.
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Affiliation(s)
- S A Hardcastle
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK.
| | - F Yahya
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - A K Bhalla
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK
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11
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Che H, Breuil V, Cortet B, Paccou J, Thomas T, Chapuis L, Debiais F, Mehsen-Cetre N, Javier RM, Loiseau Peres S, Roux C, Briot K. Vertebral fractures cascade: potential causes and risk factors. Osteoporos Int 2019; 30:555-563. [PMID: 30519756 DOI: 10.1007/s00198-018-4793-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 11/29/2018] [Indexed: 12/11/2022]
Abstract
UNLABELLED We performed a study to identify potential causes and risk factors of vertebral fracture cascade. Vertebral fracture cascade is a severe clinical event in patients with bone fragility. Only half of patients have an identified cause of secondary osteoporosis. INTRODUCTION Vertebral fracture (VF) is the most common osteoporotic fracture, and a strong risk factor of subsequent VFs leading to VF cascade (VFC). We prompted a study to identify potential causes and risk factors of VFC. METHODS VFC observations were collected retrospectively between January 2016 and April 2017. VFC was defined as an occurrence of at least three VFs within 1 year. RESULTS We included in 10 centers a total of 113 patients with VFC (79.6% of women, median age 73, median number of VFs in the cascade, 5). We observed 40.5% and 30.9% of patients with previous major fractures and a previous VF, respectively, and 68.6% with densitometric osteoporosis; 18.9% of patients were currently receiving oral glucocorticoids and 37.1% in the past. VFC was attributed by the physician to postmenopausal osteoporosis in 54% of patients. A secondary osteoporosis associated with the VFC was diagnosed in 52 patients: glucocorticoid-induced osteoporosis (25.7%), non-malignant hemopathies (6.2%), alcoholism (4.4%), use of aromatase inhibitors (3.6%), primary hyperparathyroidism (2.7%), hypercorticism (2.7%), anorexia nervosa (2.7%), and pregnancy and lactation-associated osteoporosis (1.8%). A total of 11.8% of cases were reported following a vertebroplasty procedure. A total of 31.5% patients previously received an anti-osteoporotic treatment. In six patients, VFC occurred early after discontinuation of an anti-osteoporotic treatment, in the year after the last dose effect was depleted: five after denosumab and one after odanacatib. CONCLUSION The results of this retrospective study showed that only half of VFC occurred in patients with a secondary cause of osteoporosis. Prospective studies are needed to further explore the determinants of this severe complication of osteoporosis.
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Affiliation(s)
- H Che
- Rheumatology Department, CHU Lapeyronie Montpellier, 371 avenue du Gaston Giraud, 34090, Montpellier, France.
| | - V Breuil
- Department of Rheumatology, BIAM - UMR E 4320 TIRO-MATOs CEA/UNS, Université Côte D'Azur, Centre Hospitalier Universitaire Nice, Nice, France
| | - B Cortet
- Service de rhumatologie, CHRU France et Université de Lille, Université Littoral Côte d'Opale, 59000 Lille, PMOI EA 4490 faculté de chirurgie dentaire, place de Verdun, 59000, Lille, France
| | - J Paccou
- Service de rhumatologie, CHRU France et Université de Lille, Université Littoral Côte d'Opale, 59000 Lille, PMOI EA 4490 faculté de chirurgie dentaire, place de Verdun, 59000, Lille, France
| | - T Thomas
- Rheumatology Department, CHU de Saint Etienne, INSERM U1059, Lab Biologie Intégrée du Tissu Osseux, Université de Lyon, 42055, Saint-Etienne Cedex 2, France
| | - L Chapuis
- Rheumatology Department, CH Simone Veil du Vitre, 30 route de Rennes, 35500, Vitre, France
| | - F Debiais
- Rheumatology Department, CHU La Miletrie Poitiers, 2 rue de la Miletrie, 86021, Poitiers Cedex, France
| | - N Mehsen-Cetre
- Rheumatology Department, CHU Pellegrin Bordeaux, Rue de la pelouse de Douet, 33000, Bordeaux, France
| | - R M Javier
- Rheumatology Department, Hôpitaux Universitaires de Strasbourg, 1 avenue Moliere, 67098, Strasbourg, France
| | - S Loiseau Peres
- Rheumatology Department, CHR Orléans, 14 avenue de l'Hopital, 45000, Orleans, France
| | - C Roux
- Rheumatology Department, INSERM 1153, CHU Paris Cochin, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - K Briot
- Rheumatology Department, INSERM 1153, CHU Paris Cochin, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
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12
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Abstract
A 33-year-old woman in the 6th month postpartum and breast-feeding period suffered from acute thoracolumbar pain for 1 month. She presented with slightly decreased serum calcium level. Other laboratory assessments were unremarkable. Considering the worsening symptom and her strong demand to exclude potential malignancy, F-FDG PET/CT was performed. Multiple FDG-avid foci in the thoracic and lumbar vertebra were detected on FDG PET, corresponding to vertebral compression fractures on CT, and diffuse FDG uptake was seen within bilateral breast, and dual-X ray absorptiometry showed markedly decreased bone mineral density, all of which supported the diagnosis of pregnancy and lactation-associated osteoporosis.
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13
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Ozturk G, Akpinar P, Karamanlioglu AD, Ozkan FU, Aktas I. Pregnancy-related osteoporotic vertebral compression fractures in two patients treated with low-molecular-weight heparin during pregnancy: case reports. Gynecol Endocrinol 2018; 34:378-380. [PMID: 29069943 DOI: 10.1080/09513590.2017.1393064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Pregnancy-related osteoporosis (PRO) is an uncommon metabolic bone disease that can result in vertebral fragility fractures. Here we report two cases of young women who had been previously treated with LMWH-enoxaparin and were diagnosed with PRO with vertebral fragility fractures after delivery. In first case report, a 33-year-old primigravid woman who was treated with 40 mg/day of enoxaparin for eight months to prevent venous thromboembolism was presented. After delivery, Dual energy X ray absorptiometry (DEXA) revealed osteoporosis in lumbar and femoral neck region. In magnetic resonance imaging (MRI), T4-T7 thoracic vertebral height losses were detected. In second case report, a 28-year-old primigravid woman which was treated with 40 mg/day enoxparin from the second month to the birth was presented. Osteoporosis in lumbar region was detected by DEXA. MRI revealed T12-L1 and L5 vertebral height losses. In conclusion, PRO can cause severe low back pain and should be considered in differential diagnosis. A detailed medical history should be essential to detect relationship between LMWH and PRO.
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Affiliation(s)
- Gulcan Ozturk
- a Fatih Sultan Mehmet Training and Research Hospital , Istanbul , Turkey
| | - Pinar Akpinar
- a Fatih Sultan Mehmet Training and Research Hospital , Istanbul , Turkey
| | | | - Feyza Unlu Ozkan
- a Fatih Sultan Mehmet Training and Research Hospital , Istanbul , Turkey
| | - Ilknur Aktas
- a Fatih Sultan Mehmet Training and Research Hospital , Istanbul , Turkey
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14
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Laroche M, Talibart M, Cormier C, Roux C, Guggenbuhl P, Degboe Y. Pregnancy-related fractures: a retrospective study of a French cohort of 52 patients and review of the literature. Osteoporos Int 2017; 28:3135-3142. [PMID: 28879474 DOI: 10.1007/s00198-017-4165-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 07/17/2017] [Indexed: 12/14/2022]
Abstract
UNLABELLED A retrospective, multicentre study involving 52 patients was carried out to define the causes and characteristics of pregnancy-related osteoporosis. The mean number of vertebral fractures occurring during the last trimester of pregnancy or at the time of delivery was 3.8. This is often promoted by risk factors before or during pregnancy. INTRODUCTION In order to define the causes or predisposing factors of pregnancy-related osteoporosis and its clinical, radiological and bone density characteristics, laboratory findings, course and outcome, we carried out a retrospective multicentre study. METHODS The records of 52 women hospitalised over the last 10 years in the rheumatology departments of six French university hospitals and with a diagnosis of pregnancy-related osteoporosis were examined. RESULTS The patients' mean age at time of fracture was 32.1 years. In 10 patients, the fractures had occurred during the last trimester of pregnancy, and in 36 at the time of delivery or during the first 2 months post-partum. The mean number of vertebral fractures was 3.8 ± 2.0. Thirty three of the 52 patients had a risk factor of low bone mass before pregnancy. Twelve had disorders or treatments (heparin) that might promote osteoporosis during pregnancy, while 14 had no trigger factors before or during pregnancy. Overall, phosphate and calcium levels were normal, except for hyperphosphoraemia in lactating women (90%). On DXA scan, osteoporosis predominated in the trabecular bone (spinal T-score - 3.4, hip T-score - 2). Only 10 patients had a repeat fracture, and the increase in bone mineral density during follow-up was considerable, and improved by bisphosphonates (annual gain + 10% in the spine) or teriparatide (+ 15%). CONCLUSIONS Pregnancy-related osteoporosis gives rise to multiple vertebral fractures. It is often promoted by risk factors before or during pregnancy. Its mechanism is still unknown. Treatment with bisphosphonates or teriparatide appears to improve the recovery of bone mineral density.
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Affiliation(s)
- M Laroche
- Department of Rheumatology, Toulouse University Hospital, Toulouse, France.
- Centre de Rhumatologie, Hôpital Pierre Paul Riquet, CHU Purpan, 1 place du Dr Baylac, 31059, Toulouse Cedex, France.
| | - M Talibart
- Department of Rheumatology, Toulouse University Hospital, Toulouse, France
| | - C Cormier
- Department of Rheumatology, Cochin University Hospital, Paris, France
| | - C Roux
- Department of Rheumatology, Cochin University Hospital, Paris, France
| | - P Guggenbuhl
- Department of Rheumatology, Rennes University Hospital, Amiens, France
| | - Y Degboe
- Department of Rheumatology, Toulouse University Hospital, Toulouse, France
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15
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Watts NB. Adverse bone effects of medications used to treat non-skeletal disorders. Osteoporos Int 2017; 28:2741-2746. [PMID: 28752332 DOI: 10.1007/s00198-017-4171-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 07/20/2017] [Indexed: 12/11/2022]
Abstract
There is a growing list of medications used to treat non-skeletal disorders that cause bone loss and/or increase fracture risk. This review discusses glucocorticoids, drugs that reduce sex steroids, antidiabetic agents, acid-reducing drugs, selective serotonin reuptake inhibitors, and heparin. A number of drugs are known to cause bone loss, increase fracture risk, or both. These drugs should be used in the lowest dose necessary to achieve the desired benefit and for the shortest time necessary, but in many cases, long-term treatment is required. Effective countermeasures are available for some.
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Affiliation(s)
- N B Watts
- Mercy Health Osteoporosis and Bone Health Services, 4760 E. Galbraith Rd., Suite 212, Cincinnati, OH, 45236, USA.
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Niculescu DA, Pintoiu D, Dusceac R, Barbu CG, Poiana C. Rapid Response To Teriparatide In A Postpartum Osteoporosis Case Associated With Nardroparine Treatment During Pregnancy. AACE Clin Case Rep 2017. [DOI: 10.4158/ep151178.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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17
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Galambosi P, Hiilesmaa V, Ulander VM, Laitinen L, Tiitinen A, Kaaja R. Prolonged low-molecular-weight heparin use during pregnancy and subsequent bone mineral density. Thromb Res 2016; 143:122-6. [DOI: 10.1016/j.thromres.2016.05.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 04/29/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
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18
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Joseph L, Bartholomew JR. Managing Extended Oral Anticoagulation After Unprovoked Venous Thromboembolism. J Cardiovasc Pharmacol Ther 2016; 22:28-39. [PMID: 27250719 DOI: 10.1177/1074248416652236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, is a major public health problem associated with increased morbidity and mortality. Despite the high recurrence risk associated with unprovoked VTE, extended anticoagulation remains controversial. Oral antithrombotic agents for extended VTE treatment comprise the vitamin K antagonists, aspirin, and the direct oral anticoagulants (also known as target-specific oral anticoagulants and formerly known as the new or novel oral anticoagulants) including rivaroxaban, dabigatran, apixaban, and edoxaban. The efficacy of these anticoagulants in reducing the risk of VTE recurrence (>80%-90% relative risk reduction) is offset by the risk of major bleeding that approaches 3% per year. Stratifying risks of recurrence and bleeding to identify patients at low, intermediate, or high risk and carefully considering the pharmacologic profile of the antithrombotic agents will help clinicians in choosing the optimal anticoagulant and duration and/or surveillance strategy. This review will discuss the current guidelines for extended VTE treatment, review the clinical trials involving the direct oral anticoagulants, and present the clinical considerations and concerns involving extended therapy.
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Affiliation(s)
- Lee Joseph
- 1 Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - John R Bartholomew
- 2 Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA.,3 Section Head of Vascular Medicine, Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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19
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Polat SB, Evranos B, Aydin C, Cuhaci N, Ersoy R, Cakir B. Effective treatment of severe pregnancy and lactation-related osteoporosis with teriparatide: case report and review of the literature. Gynecol Endocrinol 2015; 31:522-5. [PMID: 25893268 DOI: 10.3109/09513590.2015.1014787] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
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.
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Affiliation(s)
- Sefika Burcak Polat
- a Department of Endocrinology and Metabolism, Faculty of Medicine, Ankara , Yildrim Beyazit University , Turkey
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