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

Low serum lipase levels in mothers of children with stunted growth indicate the possibility of low calcium absorption during pregnancy: A cross-sectional study in North Sumatra, Indonesia

Stunting is caused by various factors, including low nutritional intake in the first two years of life. This study aimed to investigate the differences in sociodemographic factors and mineral, vitamin, and enzyme parameters in mothers associated with the occurrence of stunting in children. We conducted a cross-sectional study from September to November 2020 on North Sumatra Island, Indonesia. The data collected included sociodemographic characteristics, pregnancy history, birth history, food intake, and laboratory examinations, including measurements of calcium, iron, zinc, vitamin D, pancreatic amylase, and serum lipase levels. This study included 50 healthy mothers aged 18-50 years old with children aged 2 to 60 months. There was a significant difference in serum calcium levels between the groups of mothers of children with normal and stunted growth (p = 0.03, mean difference±standard error (SE) = 0.23±0.12, 95% CI: 0.19-0.45). All of the study subjects were categorized as vitamin D deficient. The mean lipase level in the group of mothers of children with stunted growth was significantly lower than that in the group of mothers of children with normal growth (p = 0.02, mean difference±SE = 4.34±1.83, 95% CI: 0.62-8.06). The conclusion was that serum lipase levels were significantly lower in mothers of children with stunted growth compared to mothers of children with normal growth. Serum lipase levels this low are likely to indicate that a mother is unable to meet her child's calcium needs during pregnancy, increasing the child's risk of stunted growth.

Age- and sex-related changes in vertebral trabecular bone architecture in Neolithic and Mediaeval populations from Poland

This paper investigates trabecular bone ontogenetic changes in two different Polish populations, one prehistoric and the other historical. The studied populations are from the Brześć Kujawski region in Kujawy (north-central Poland), one from the Neolithic Period (4500-4000 BC) and one from the Middle Ages (twelfth-sixteenth centuries AD), in total 62 vertebral specimens (32 males, 30 females). Eight morphometric parameters acquired from microCT scan images were analysed. Two-way ANOVA after Box-Cox transformation and multifactorial regression model were calculated. A significant decrease in percentage bone volume fraction (BV/TV; [%]) with age at death was observed in the studied sample; Tb.N (trabecular number) was also significantly decreased with age; trabecular separation (Tb.Sp) increased with advancing age; connectivity density (Conn.D) was negatively correlated with biological age and higher in the Neolithic population. These data are found to be compatible with data from the current biomedical literature, while no loss of horizontal trabeculae was recorded as would be expected based on modern osteoporosis.

Pregnancy and lactation-associated osteoporosis as a major type of premenopausal osteoporosis: a retrospective cohort study based on real-world data

BACKGROUND

Pregnancy and lactation-associated osteoporosis (PLO), as well as premenopausal osteoporosis, might be a predictor of future fracture. This study aimed to describe the clinical features of PLO as a subtype of premenopausal osteoporosis and to evaluate medical interventions for it.

METHODS

From an administrative claims database including 4,224,246 people in Japan, we classified women for whom the date of childbirth had been defined and who had suffered low-trauma fracture between the ages of 18-47 years as the premenopausal osteoporosis group. A fracture site for which the odds ratio for fractures occurring between 5 months before and 12 months after childbirth (around childbirth) was greater than 1 was considered the PLO site. We classified patients with a fracture at the PLO site around childbirth as the PLO group. The control group consisted of 500 women without fragility fractures. We investigated some drugs and diseases to explore fracture-causing factors, as well as medical interventions such as osteoporosis diagnosis, bone densitometry, anti-osteoporosis pharmacotherapy, and lactation inhibitors.

RESULTS

In total, 231 parous women were classified into the premenopausal osteoporosis group. The most common fracture was vertebral fracture and was likely to occur around childbirth, followed by distal radius and sacral fractures, which were rare around childbirth. Considering vertebral, pelvic, and proximal femoral fractures as PLO sites, 56 women with 57 PLO fractures were classified into the PLO group. The incidence of PLO was estimated at 460 per million deliveries. Ovulation disorder and high maternal age were associated with the development of PLO. Vertebral fracture was the most common PLO fracture. It was mainly diagnosed a few months, and possibly up to 1 year, postpartum. PLO patients with vertebral fractures underwent more medical interventions than did those with other fractures, but they were still inadequate.

CONCLUSIONS

PLO with vertebral fracture was one of the major types of premenopausal osteoporosis. The prevalence of PLO is considered to be higher than previously thought, indicating the presence of potentially overlooked patients. More timely interventions for PLO might lead to the improved management of latent patients with premenopausal osteoporosis and reduce future fracture risk.

Comparative Effectiveness of Therapeutic Interventions in Pregnancy and Lactation-Associated Osteoporosis: A Systematic Review and Meta-analysis

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.

The terminologies of transient, migratory, or localized osteoporosis, and bone marrow edema syndrome: a scoping review

There is no formally defined terminology for the related entities transient osteoporosis of the hip (TOH), localized or regional migratory osteoporosis (RMO) and bone marrow edema syndrome (BMES). This study aimed to map the diversity and frequency of diagnostic terms and vocabulary utilized in the literature. A comprehensive search of electronic databases and reference lists was conducted. Publications that reported on patients with TOH, RMO, BMES, or related variants were eligible for inclusion. The terminologies were categorized based on the wording of the titles, abstracts, or texts. We included 561 publications, of which 423 were case reports, involving 2921 patients. Overall, TOH was the most commonly used term, occurring in 257 (45.8%). RMO was used in 34 (6.1%) and BMES in 57 (10.2%). The remaining used various combinations of transient, migratory, and regional in conjunction with either osteoporosis or bone marrow edema. Localized osteoporosis was not used. We identified three different terms related to pregnancy. In 76.3% of the publications, the terminology was related to osteoporosis and in 18.2% to bone marrow edema, although terminology did not correspond to actual findings. Bone marrow edema occurred as often as osteoporosis, and osteoporosis was generally ascertained by visual inspection of radiographs, seldom by bone densitometry. Many publications used osteoporosis-related terms without evidence that osteoporosis had been detected. The terminology of these closely related entities is confusing and unstandardized. The lack of formal definitions impedes accurate diagnosis, research on disease mechanisms, and effective treatment.

Bone fragility and osteoporosis in children and young adults

Osteoporosis is a metabolic bone disorder which increases fragility fracture risk. Elderly individuals, especially postmenopausal women, are particularly susceptible to osteoporosis. Although rare, osteoporosis in children and young adults is becoming increasingly evident, highlighting the need for timely diagnosis, management and follow-up. Early-onset osteoporosis is defined as the presence of a low BMD (Z-score of ≤ -2.0 in individuals aged < 20 years; T-score of ≤ -2.5 in those aged between 20 to 50 years) accompanied by a clinically significant fracture history, or the presence of low-energy vertebral compression fractures even in the absence of osteoporosis. Affected children and young adults should undergo a thorough diagnostic workup, including collection of clinical history, radiography, biochemical investigation and possibly bone biopsy. Once secondary factors and comorbidities are excluded, genetic testing should be considered to determine the possibility of an underlying monogenic cause. Defects in genes related to type I collagen biosynthesis are the commonest contributors of primary osteoporosis, followed by loss-of-function variants in genes encoding key regulatory proteins of canonical WNT signalling (specifically LRP5 and WNT1), the actin-binding plastin-3 protein (encoded by PLS3) resulting in X-linked osteoporosis, and the more recent sphingomyelin synthase 2 (encoded by SGMS2) which is critical for signal transduction affecting sphingomyelin metabolism. Despite these discoveries, genetic causes and underlying mechanisms in early-onset osteoporosis remain largely unknown, and if no causal gene is identified, early-onset osteoporosis is deemed idiopathic. This calls for further research to unravel the molecular mechanisms driving early-onset osteoporosis that consequently will aid in patient management and individualised targeted therapy.

Lumbar spine bone mineral density in women breastfeeding for a period of 4 to 6 months: systematic review and meta-analysis

BACKGROUND

During the breastfeeding period, important transient changes in calcium homeostasis are verified in the maternal skeleton, to meet the demand for calcium for breastmilk production. The literature is inconclusive regarding the causes and percentages of involvement of bone densitometry resulting from exclusive breastfeeding (4 to 6 months).

METHODS

This article aims to systematically review the literature, to determine the occurrence, intensity, and factors involved in alterations in maternal bone mineral density (BMD), during a period of 4 to 6 months of exclusive breastfeeding. The search descriptors "woman", "breastfeeding", "human milk", and "bone mineral density" were used in the electronic databases of the Virtual Health Library, Scielo (Scientific Electronic Library Online), CAPES Periodicals Portal, LILACS, Embase, PubMed/Medline, Cochrane, Scopus, and Web of Science in June 2023. Inclusion criteria for breastfeedingmothers were; aged to 40 years, primigravida, exclusively breastfeeding, with BMD assessments using dual-energy X-ray absorptiometry (DXA), with values expressed at baseline and from 4 to 6 months postpartum. The Jadad scale, Newcastle-Ottawa Scale, and Oxford Centre for Evidence-based Medicine - levels of evidence were adopted to assess the quality of the studies. For the meta-analytical study, statistical calculations were performed.

RESULTS

Initially, 381 articles were found using the search strategy and 26 were read in full. After risk of bias analysis, 16 articles remained in the systematic review and four were included in the meta-analysis. The studies showed a reduction in bone mass in the lumbar spine in the first months postpartum (4 - 6 months), when compared with a longer period of breastfeeding (12-18 months). The breastfeeding group presented a greater impact in the meta-analysis than the control group (non-breastfeeding, pregnant, or immediate postpartum), with a reduction in BMD in the lumbar spine of -0.18 g/cm2 (-0.36, -0.01 g/cm2); 95% Confidence Interval, on a scale from 0 to 10.

CONCLUSIONS

Our results demonstrated a transitory reduction in bone densitometry of the lumbar spine during exclusive breastfeeding for 4 to 6 months, which was gradually restored later in the postpartum period. More prospective studies are needed to better understand the topic.

TRIAL REGISTRATION

PROSPERO platform (nº CRD42021279199), November 12th, 2021.

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.

Transient osteoporosis of the hip in pregnancy - a case series

OBJECTIVE

Transient Osteoporosis of the Hip is a self-limiting disorder of severe hip joint pain presenting in pregnancy or postpartum, of which magnetic resonance imaging (MRI) is the modality of choice for diagnosis. Clinical data regarding transient osteoporosis of the hip is limited, precluding evidence-based decision-making such as recommended mode of delivery. In this case-series retrospective study, we aim to describe the natural course of transient osteoporosis of the hip during pregnancy and the postpartum period including implications of the mode of delivery.

METHODS

All women diagnosed with unilateral/bilateral transient osteoporosis of the hip by MRI during pregnancy or postpartum between 2010 and 2019 at a single tertiary medical center were retrospectively studied. All MRI scans were reviewed by an experienced radiologist at the same single tertiary medical center. Data obtained from patients' electronic medical records and telephone questionnaires included maternal baseline characteristics, obstetric history, and current pregnancy obstetric and clinical outcome characteristics. Outcomes of normal vaginal delivery (NVD) and cesarean delivery (CD) were compared and analyzed.

RESULTS

Thirty-four women were diagnosed with unilateral or bilateral transient osteoporosis of the hip during pregnancy (17 women) and postpartum (17 women). The mean maternal age was 34.18 ± 4.75 years. A family history of osteoporosis was reported in a rate of 29.4%. The rate of smokers was 47.1%, 32.4% of pregnancies were conceived by in-vitro fertilization (IVF), pre-pregnancy and term body mass index (BMI) were 22.03 and 27.6, respectively. No significant differences were found between NVD and CD in all parameters evaluated. Of 15 women with a sequential pregnancy, two were diagnosed with transient osteoporosis of the hip (13.3%).

CONCLUSION

Women diagnosed with transient osteoporosis of the hip had advanced maternal age, low BMI, family history of osteoporosis, prevalent smoking and IVF pregnancies. Transient osteoporosis of the hip was bilateral in 25% and presented postpartum in 50% of cases. There was no significant difference in maternal outcomes between NVD and CD. Higher awareness of this potential diagnosis during pregnancy and postpartum may improve patient management and outcomes.

Metabolomics insights into the effects of pre-pregnancy lead exposure on bone metabolism in pregnant rats

Today's women of childbearing age with a history of high lead (Pb) exposure in childhood have large Pb body burdens, which increases Pb release during pregnancy by promoting bone Pb mobilisation. The purpose of this study was to investigate the metabolic mechanisms underlying bone Pb mobilisation and explore the bone metabolism-related pathways during pregnancy. Drinking water containing 0.05% sodium acetate or Pb acetate was provided to weaned female rats for 4 weeks followed by a 4-week washout period, and then rats were co-caged with healthy males of the same age until pregnancy. Blood and bone tissues of the female rats were collected at gestational day (GD) 3 (early pregnancy), GD 10 (middle pregnancy), and GD 17 (late pregnancy), respectively. Pb and calcium concentrations, biomarkers for bone turnover, bone microstructure, serum metabolomics, and metabolic indicators were intensively analyzed. The results demonstrated that pre-pregnancy Pb exposure elevated blood lead levels (BLLs) at GD17, accompanied by a negative correlation between BLLs and trabecular bone Pb levels. Meanwhile, Pb-exposed rats had low bone mass and aberrant bone architecture with a larger number of mature osteoclasts (OCs) compared to the control group. Moreover, the metabolomics uncovered that Pb exposure caused mitochondrial dysfunction, such as enhanced oxidative stress and inflammatory response, and suppressed energy metabolism. Additionally, the levels of ROS, MDA, IL-1β, and IL-18 involved in redox and inflammatory pathways of bone tissues were significantly increased in the Pb-exposed group, while antioxidant SOD and energy metabolism-related indicators including ATP levels, Na+-K+-ATPase, and Ca2+-Mg2+-ATPase activities were significantly decreased. In conclusion, pre-pregnancy Pb exposure promotes bone Pb mobilisation and affects bone microstructure in the third trimester of pregnancy, which may be attributed to OC activation and mitochondrial dysfunction.

The correlation between transient osteoporosis of the hip and pregnancy: A review

Transient osteoporosis of the hip is indubitably a comparatively infrequent entity affecting both men and women worldwide. Its occurrence in the course of pregnancy, specifically in the third trimester, and lactation are of paramount concernment. The exact association between transient hip osteoporosis and pregnancy is precarious. Etiology and potential pathophysiological mechanisms behind this correlation are still to be utterly defined. Magnetic resonance imaging is highly regarded as the gold standard imaging method for assiduous assessment of this disorder. Physicians of copious medical specialties should practice scrupulous techniques for early and pertinent diagnosis when pregnant women are presented with persistent hip pain, as differential diagnosis with femoral head avascular necrosis can be exceedingly arduous. Treatment is predominantly conservative with protected weight-bearing and analgesic medication in the first line of management. In terms of prognosis, the disease ordinarily resolves spontaneously after a few months. Further research is required in order to elucidate the ambiguity surrounding the establishment of globally approved diagnosis and treatment guidelines for pregnancy-associated transient hip osteoporosis. This paper aims to accentuate the significance of this particular disorder by providing a succinct review of the existing literature, augmenting clinicians' knowledge about the features of pregnancy-related transient proximal femur osteoporosis.

Proceedings of the 2023 Santa Fe Bone Symposium: Progress and Controversies in the Management of Patients with Skeletal Diseases

The Santa Fe Bone Symposium (SFBS) held its 23rd annual event on August 5-6, 2023, in Santa Fe, New Mexico, USA. Attendees participated in-person and remotely, representing many states and countries. The program included plenary presentations, panel discussions, satellite symposia, a Project ECHO workshop, and a session on healthcare policy and reimbursement for fracture liaison programs. A broad range of topics were addressed, including transitions of osteoporosis treatments over a lifetime; controversies in vitamin D; update on Official Positions of the International Society for Clinical Densitometry; spine surgery and bone health; clinical applications of bone turnover markers; basic bone biology for clinicians; premenopausal-, pregnancy-, and lactation-associated osteoporosis; cancer treatment induced bone loss in patients with breast cancer and prostate cancer; genetic testing for skeletal diseases; and an update on nutrition and bone health. There were also sessions on rare bone diseases, including managing patients with hypophosphatasia; treatment of X-linked hypophosphatemia; and assessment and treatment of patients with hypoparathyroidism. There were oral presentations of abstracts by endocrinology fellows selected from those who participated in the Santa Fe Fellows Workshop on Metabolic Bone Diseases, held the 2 days prior to the SFBS. These proceedings of the 2023 SFBS present the clinical highlights and insights generated from many formal and informal discussions in Santa Fe.

Mathematical modeling of calcium homeostasis in female rats: An analysis of sex differences and maternal adaptations

Calcium plays a vital role in various biological processes, including muscle contractions, blood clotting, skeletal mineralization, and cell signaling. While extracellular calcium makes up less than 1% of total body calcium, it is tightly regulated since too high or too low extracellular calcium concentration can have dangerous effects on the body. Mathematical modeling is a well-suited approach to investigate the complex physiological processes involved in calcium regulation. While mathematical models have been developed to study calcium homeostasis in male rats, none have been used to investigate known sex differences in hormone levels nor the unique physiological states of pregnancy and lactation. Calcitriol, the active form of vitamin D, plays a key role in intestinal calcium absorption, renal calcium reabsorption, and bone remodeling. It has been shown that, when compared to age-matched male rats, females have significantly lower calcitriol levels. In this study we first seek to investigate the impact of this difference as well as other known sex differences on calcium homeostasis using mathematical modeling. Female bodies differ from male bodies in that during their lifetime they may undergo massive adaptations during pregnancy and lactation. Indeed, maternal adaptations impact calcium regulation in all mammals. In pregnant rodents, intestinal absorption of calcium is massively increased in the mother's body to meet the needs of the developing fetus. In a lactating rodent, much of the calcium needs of milk are met by bone resorption, intestinal absorption, and renal calcium reabsorption. Given these observations, the goal of this project is to develop multi-scale whole-body models of calcium homeostasis that represents (1) how sex differences impact calcium homeostasis in female vs. male rats and (2) how a female body adapts to support the excess demands brought on by pregnancy and lactation. We used these models to quantify the impact of individual sex differences as well as maternal adaptations during pregnancy and lactation. Additionally, we conducted "what if" simulations to test whether sex differences in calcium regulation may enable females to better undergo maternal adaptations required in pregnancy and lactation than males.

Isolated quadrilateral plate fracture with central hip dislocation after epileptic seizure in a postpartum patient: A case report

Isolated quadrilateral plate fractures are extremely rare and their treatment is complex. The postpartum period and recent caesarean section additionally increase already significant risks of surgical treatment. Modified Stoppa approach and the use of infrapectineal plate represent the optimal surgical treatment method. One case of central hip dislocation and isolated quadrilateral plate fracture was reported during an epileptic seizure 1 day postpartum, which was treated with open reduction and internal fixation. A 25-year-old female patient had given birth via cesarean section. One day postpartum, she had multiple generalized tonic clonic seizures. Arteriovenous malformation was identified as the cause of seizures by MRI. The patient complained of left hip pain and inability to move the left leg which prompted clinical and radiological examination. A pelvic CT scan verified multifragmentary fracture of the quadrilateral plate without fracture of the acetabular columns. The central hip dislocation was verified. Due to the rarity of the fracture, the clinical decision-making process was difficult. The patient, being in the postpartum period, was also at a greater risk of infection. The patient was treated surgically, and osteosynthesis was performed with an infrapectineal plate for the acetabulum using the modified Stoppa approach. The initial incision was done through the same Pfannenstiel incision from caesarean section. The patient's postoperative recovery was good at 1 year follow-up.

Recent Insights into Pregnancy and Lactation-Associated Osteoporosis (PLO)

During pregnancy and lactation, female physiology adapts to fulfill the fetal and neonatal calcium and phosphorus requirements. The physiological changes that take place during these periods do not affect maternal skeleton resistance to fracture in most of the cases. However, there is a small percentage of women that do experience fragility fractures during these times of life. Pregnancy and lactation-associated osteoporosis (PLO) is an infrequent condition defined by the occurrence of non-traumatic fractures - most frequently vertebral - during the third trimester of gestation and/or the first months of postpartum. Its physiopathology has not yet been completely elucidated. Several authors have reported that risk factors for secondary osteoporosis might be present in up to 80% of the cases of PLO patients. According to recent studies, genetic factors might also play a relevant role in PLO. Given its rarity, the available literature on this condition is limited. Most of the published data consist on case reports and case series articles. There are not any randomized controlled trials regarding this disorder. Although there is consensus about discontinuation of lactation and calcium and vitamin D supplementation as the first steps in the treatment of these patients, there is still controversy regarding the long-term and/or pharmacological management of this condition. Recent data on the use of teriparatide in this population looks promising. In this review, we aimed to revise and summarize current knowledge about the physiopathology and management of PLO.

Pathological femoral neck fracture in a male patient due to non-simultaneous bilateral transient hip osteoporosis: A case report: Statements and Declarations

We report a case of a 31-year-old man who developed a non-simultaneous bilateral transient hip osteoporosis (THO) complicated with an atraumatic undisplaced pathological femoral neck fracture (FNF) of his left hip. He was successfully treated with internal fixation on the left hip, and a follow-up Magnetic Resonance Imaging evidenced satisfactory resolution on the right side. Diagnosis and management of THO are usually challenging as symptoms before pathological FNFs might be misdiagnosed. This case highlights the importance of suspecting pathological FNFs when pain persists despite conservative treatment. Finally, surgical treatment is strongly recommended if a pathological FNF is confirmed.

Level of evidence

Level IV.

Pregnancy- and lactation-induced osteoporosis: a social-media-based survey

BACKGROUND

Pregnancy- and lactation-induced osteoporosis (PLO) presenting as spinal fractures is rare, and the spectrum of clinical presentation, risk factors and pathophysiology are incompletely understood. The aim of this study was to delineate clinical parameters, risk factors and osteoporosis-related quality of life (QOL) of women with PLO.

METHODS

Participants of a social-media (WhatsApp) PLO group and mothers of a parents' WhatsApp group (control group) were offered to fill a questionnaire, including an osteoporosis-related QOL section. The groups were compared using the independent Students t test for numerical variables, and the Chi-square test or Fisher's exact test for categorical variables.

RESULTS

Twenty-seven women with PLO and 43 in the control group (aged 36.2 ± 4.7 and 38.8 ± 4.3 years, respectively, p = 0.04) participated. Among women with PLO, more than 5 vertebrae were involved in 13 (48%), 4 vertebrae in 6 (22%), and 3 or fewer vertebrae in 8 (30%). Among the 24 women with relevant data, 21 (88%) had nontraumatic fractures; 3 (13%) women had fractures during pregnancy, and the remaining during the early postpartum period. Diagnosis was delayed for over 16 weeks for 11 (41%) women; 16 (67%) received teriparatide. Significantly lower proportions of women in the PLO group engaged in physical activity over 2 hours/week, before and during pregnancy (37 vs. 67%, p < 0.015 and 11 vs. 44%, p < 0.003, respectively). A lower proportion of the PLO than the control group reported calcium supplementation during pregnancy (7% vs. 30%, p = 0.03) and a higher proportion reported treatment with low-molecular-weight-heparin during pregnancy (p = 0.03). Eighteen (67%) of the PLO group expressed fear of fractures and 15 (56%) fear of falls, compared to none and 2%, respectively, of the control group (p < 0.00001 for both).

CONCLUSIONS

Most of the women with PLO who responded to our survey reported spinal fractures involving multiple vertebrae, delayed diagnosis, and treatment with teriparatide. Compared to a control group, they reported less physical activity and impaired QOL. For this uncommon yet severe condition, a multidisciplinary effort should be exerted for early identification and treatment, to alleviate back pain, prevent subsequent fractures and improve QOL.

Dietary macrominerals: Updated review of their role and orchestration in human nutrition throughout the life cycle with sex differences

Macrominerals play vital roles in a multitude of physiologic systems. A myriad of biochemical reactions are dependent on or affected by these electrolytes. The current review attempts to identify the role of macrominerals as calcium, phosphorus, magnesium, sodium, potassium and sulfur in human health, in addition to their absorption and homeostasis inside the body. We also focused on their amount in major food sources and the recommended daily intake of each macromineral. In addition, a deep insight into the orchestration of the 6 different macrominerals' requirements is presented across the human life cycle, beginning from fertility and pregnancy, and reaching adulthood and senility, with insight on interactions among them and underlying action mechanisms. The effect of sex is also presented for each mineral at each life stage to highlight the different daily requirements and/ or effects. The current review identified the role of macrominerals in human health, in addition to their absorption and homeostasis in the body. Based on the in-depth understanding of the factors influencing the metabolism of macrominerals, we could better explore their safety and possible therapeutic potential in specific disorders. There is still a need to precisely demonstrate the bioavailability of macrominerals from various types of functional food.

Gebelik Dönemindeki Potansiyel Kas-İskelet Sistemi Sorunları

Gebelik sırasında kadınlarda çeşitli fizyolojik ve anatomik değişiklikler meydana gelmektedir. Bu biyomekanik, hormonal ve vasküler değişiklikler gebelik ilerledikçe belirginleşmektedir. Kas-iskelet sistemi bu değişimlerden en çok etkilenen sistemlerden biridir. Gebelikle ilişkili kas-iskelet sistemi problemlerinin başında bel ağrısı gelmekte ve bunu sırt ağrısı, el-el bilek ağrısı ve kalça ağrısı takip etmektedir. Gebelikle ilişkili bu problemlerin çoğu gebelikten sonraki aylarda düzelmektedir. Ancak bazı gebelerde ciddi ağrı ve dizabiliteye neden olmaktadır. Bu nedenle, gebelik döneminde görülen kas-iskelet sistemi problemlerinin erken tanınması, koruyucu önlemlerin alınması ve bireysel tedavinin planlanması önemlidir. Bu yazıda, gebelik döneminde görülen kas-iskelet sistemi değişiklikleri, sık görülen patolojiler ve bu problemlerin tedavisi ile ilgili güncel literatürün gözden geçirilmesi amaçlanmaktadır.

Pregnancy and Lactation-Associated Osteoporosis Successfully Treated with Romosozumab: A Case Report

Pregnancy- and lactation-associated osteoporosis (PLO) is a rare type of premenopausal osteoporosis that occurs mainly in the third trimester or immediately after delivery; one of its most common symptoms is back pain caused by a vertebral fracture. The pathogenesis of PLO is unclear, and there is no accepted consensus regarding the treatment of PLO. Although treatments with drugs such as bisphosphonate, strontium ranelate, denosumab, and teriparatide were reported, there is no report of a patient with PLO treated with romosozumab. We present the first case of a patient with PLO treated with romosozumab following 4-month teriparatide treatment. A 34-year-old primiparous and breastfeeding Japanese woman experienced severe low back pain 1 month postdelivery. She was diagnosed with PLO on the basis of low bone marrow density (BMD) and multiple vertebral fractures with no identified cause of secondary osteoporosis. She was treated with teriparatide injection for 4 months, but the treatment was discontinued because of the patient feeling severe nausea after every teriparatide injection and the appearance of new vertebral fractures. Thereafter, we used romosozumab for 12 months. After the romosozumab treatment, her BMD was increased from the baseline by 23.6% at L1-L4, 6.2% at the femoral neck, and 11.2% at the total hip. Treating PLO with 12-month romosozumab after 4 months of teriparatide injection remarkably increased the BMD of the lumbar spine, femoral neck, and total hip without subsequent fracture. Romosozumab has potential as a therapeutic option to improve the BMD and reduce the subsequent fracture risk of patients with PLO.

Fractures within 2 years of an obstetric hospitalization: analysis of nationwide administrative data in Japan

INTRODUCTION

Pregnancy- and lactation-associated osteoporosis (PLO) is a condition in which young women develop fractures during pregnancy or breastfeeding. Though PLO is a severely debilitating disease, its pathophysiology and epidemiology have not been clarified and its treatment has not been established. We aimed to identify the incidence and factors associated with fractures occurring within 2 years following an obstetric hospitalization.

MATERIALS AND METHODS

We extracted data on fractures occurring within 2 years of an obstetric hospitalization from the Japanese Diagnosis Procedure Combination database. We analyzed the implementation of bone mineral density and bone metabolism marker tests, prescription status, and factors associated with fractures occurring within 2 years of an obstetric hospitalization.

RESULTS

Among 837,347 patients with a history of obstetric hospitalization from 2010 to 2014, 379 patients had a history of hospitalization due to a fracture occurring within 2 years (4.5/10,000 pregnancies). Among the patients with fractures occurring within 2 years of an obstetric hospitalization, 6.7% underwent bone mineral quantification or a bone metabolism marker test, and 7.5% were prescribed a lactation inhibitor or osteoporosis treatment. Factors associated with fractures occurring within 2 years following an obstetric hospitalization identified included Cushing syndrome, Charlson Comorbidity Index score ≥ 1, age ≥ 40 years old at pregnancy, smoking history, and steroid administration.

CONCLUSION

We investigated fracture cases occurring within 2 years of an obstetrics hospitalization. This finding may be useful in selecting preventative measures for patients at risk of fractures within 2 years after obstetric hospitalization, including PLO.

Incidence of Fracture Hospitalization and Surgery in Women Increases Steadily During the Puerperal and Lactation Period: A Retrospective Register-Based Cohort Study in Finland From 1999 to 2018

This retrospective cohort study assesses the incidences of major fractures and surgery in women during the puerperium and the lactation period in Finland between January 1, 1999, and December 31, 2018. Using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register, all women aged between 15 and 49 years with a fracture hospitalization within 12 months of delivery between 1999 and 2018 were included. During the study period, a total of 3140 fractures after delivery and 152,800 fractures of the female normal population of similar age were hospitalized. The incidence rate after delivery increased from 219/100,000 person-years during the first 4 months to 310 fractures/100,000 person-years during the latter 8 months of the first year after delivery. Altogether, 29% (n = 904/3140) of these fractures were treated operatively. The most common fractures were ankle and distal radius fractures, which made up one-third of all fractures. The incidence of pelvic fracture hospitalization was 15/100,000 person-years at 4 months after delivery, with an operation rate of 22%. Over half of all fractures occurred between 6 and 12 months after delivery (mean 6.6 months). The incidence of fracture hospitalization after delivery increased steadily during the puerperium and the lactation periods but remained lower than in the general population (age-adjusted incidence 554/100,000 person-years) with an incidence rate ratio of 0.51. However, a higher proportion of pelvic fractures were observed in the first months after delivery. Surgical rates were in line with the general population. Fractures of the wrist and ankle made up most of the fractures. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Effect of Teriparatide on Subsequent Fracture and Bone Mineral Density in 47 Women with Pregnancy- and Lactation-associated Osteoporosis and Vertebral Fractures

Introduction Pregnancy- and lactation-associated osteoporosis (PLO) with predominantly vertebral fractures is a rare but severe disease which can occur in the last trimester of pregnancy or postpartum. The aim of the present study was to assess the impact of teriparatide on subsequent fractures and bone mineral density (BMD) in patients with PLO.

Materials and Methods A total of 47 patients with PLO and postpartum spinal fractures (mean: 4 fractures) undergoing treatment with teriparatide were investigated. The data collection period was set between 2006 and 2018. All patients received a subcutaneous injection of 20 µg teriparatide once a day for 24 months as well as individually adapted vitamin D supplementation. After 24 months of treatment, all women received no further treatment and either had regular menstrual cycles or took oral contraceptives. Fractures were confirmed by X-ray or MRI. Changes in BMD from baseline were examined using serial DXA measurements.

Results After 24 months of teriparatide treatment, we could demonstrate an increase in BMD at the lumbar spine, femoral neck and total hip of + 30.1%, + 11.7% and + 12.2% respectively (p < 0.001 for all). At 12 months after cessation of treatment, BMD remained stable compared to the 24-month measurements at the lumbar spine, femoral neck and total hip which showed non-significant changes of + 1.4%, + 2.6% and + 4.1% respectively. Out of the 47 patients with PLO with a mean of 4 existing fractures, 4 patients (7.8%) sustained a subsequent fracture, two after 3 – 5 months of treatment and two at > 6 months of treatment.

Conclusion 24 months of treatment with teriparatide in women with PLO and multiple vertebral fractures significantly increased BMD, predominantly BMD of the spine. As patients were premenopausal, there was no significant decrease in BMD in the following 12 months after cessation of treatment.

No effect of maternal calcium intake and bone resorption during pregnancy on offspring bone mineral density at age 5 years

Maternal nutrition during pregnancy plays a role in offspring bone health. In a prospective cohort study, offspring bone mineral density at 5 years was not associated with maternal calcium intake or maternal bone resorption during pregnancy.

PURPOSE

Suboptimal bone mineral density in childhood can result in osteoporosis later in life. We reported previously that lower calcium intake during pregnancy was associated with higher maternal bone resorption during pregnancy and that lower maternal dietary calcium and higher maternal bone resorption in pregnancy were associated with lower maternal bone mineral density (BMD) 5 years later. The current study sought to investigate the effect of both maternal dietary calcium intake and maternal bone resorption during pregnancy on offspring BMD at 5 years.

METHODS

Data collected as part of the ROLO longitudinal cohort study (n = 103, mother-child dyads) were used in the current analysis. ROLO started as a randomised controlled trial of a low glycemic index diet during second pregnancy in women with macrosomia in first pregnancy in order to prevent recurrence of macrosomia. Maternal dietary intakes were assessed using 3-day food diaries completed during each trimester of pregnancy. Bone resorption in early and late pregnancy was calculated through urinary excretion of cross-linked N-telopeptides (uNTX). Offspring whole-body BMD at 5 years was measured using dual-energy X-ray absorptiometry.

RESULTS

Offspring BMD at 5 years correlated with offspring body mass index (r = .385; p < .001) and offspring BMD was higher in boys than girls (t = 2.91; p = .004). Offspring BMD at 5 years was not associated with either maternal calcium intake or uNTX during pregnancy, after controlling for offspring body mass index and offspring sex.

CONCLUSION

Offspring BMD at 5 years is not associated with either maternal calcium intake or maternal bone resorption during pregnancy.

"Pregnancy and Lactation Associated Osteoporosis"

Pregnancy-associated osteoporosis (PAO) is a rare condition of skeletal fragility affecting women in pregnancy or the postpartum period. During normal pregnancy and lactation, substantial changes in calcium metabolism and skeletal physiology occur in order to meet the demands of the developing foetus. Whilst these adaptations are reversible and generally of no clinical consequence for the mother, a small number of women will develop osteoporosis and suffer fragility fractures. Vertebral fractures occur most commonly in PAO and are often multiple. Due to the rarity of PAO, systematic study to date has been limited. Aetiology is poorly understood, but traditional osteoporosis risk factors and genetic factors are likely to play a role. A small number of cases may be due to an underlying metabolic bone disorder or monogenic condition. Management of PAO is challenging, due both to a poor evidence base and the fact that spontaneous improvement in BMD is known to occur once pregnancy and lactation are complete. Bisphosphonates, denosumab and teriparatide have all been used in individual patients, but the data supporting their use are currently limited.

Low pre-pregnant body mass index is a risk factor for the decrease of postpartum bone mineral density in systemic lupus erythematosus patients received glucocorticoid therapy

OBJECTIVES

This study investigated postpartum bone mineral density (BMD) in patients with systemic lupus erythematosus (SLE) receiving long-term glucocorticoid (GC) therapy, assessed risk factors for decreased postpartum BMD, and evaluated change of BMD after postpartum initiation or restarting of osteoporosis drugs.

METHODS

We retrospectively examined 30 SLE patients who gave birth and 31 non-pregnant SLE patients. In the postpartum SLE patients, BMD was measured after delivery and 1 year later. Multivariate analyses were performed to assess risk factors for decreased BMD in postpartum SLE patients.

RESULTS

Patient age at pregnancy was 34.5 ± 4.5 years, and SLE duration was 9.7 ± 6.0 years. The mean prednisolone dose was 9.7 ± 3.2 mg/day. Body mass index (BMI) was 21.6 ± 2.2 kg/m², with 13 women (43%) experiencing their first delivery. Postpartum BMD was 1.080 ± 0.120 g/cm² in the lumbar spine and 0.834 ± 0.109 g/cm² in the total hip. Bone loss occurred in six patients (21%) in the lumbar spine and 11 patients (37%) in the total hip. Postpartum lumbar spine BMD was significantly reduced compared to that in the non-pregnant group (1.143 ± 0.120 g/cm², p = 0.048). Multivariate analysis identified gestational age and low BMI before pregnancy as risk factors for hip bone loss.

CONCLUSION

Postpartum BMD significantly decrease in SLE patients receiving long-term GC, and low BMI before pregnancy was a risk factor for the decrease. Preconception care to prevent osteoporosis and that regularly monitors BMD after delivery are needed.

Whole exome sequencing reveals potentially pathogenic variants in a small subset of premenopausal women with idiopathic osteoporosis

Osteoporosis in premenopausal women with intact gonadal function and no known secondary cause of bone loss is termed idiopathic osteoporosis (IOP). Women with IOP diagnosed in adulthood have profound bone structural deficits and often report adult and childhood fractures, and family history of osteoporosis. Some have very low bone formation rates (BFR/BS) suggesting osteoblast dysfunction. These features led us to investigate potential genetic etiologies of bone fragility. In 75 IOP women (aged 20-49) with low trauma fractures and/or very low BMD who had undergone transiliac bone biopsies, we performed Whole Exome Sequencing (WES) using our variant analysis pipeline to select candidate rare and novel variants likely to affect known disease genes. We ran rare-variant burden analyses on all genes individually and on phenotypically-relevant gene sets. For particular genes implicated in osteoporosis, we also assessed the frequency of all (including common) variants in subjects versus 6540 non-comorbid female controls. The variant analysis pipeline identified 4 women with 4 heterozygous variants in LRP5 and PLS3 that were considered to contribute to osteoporosis. All 4 women had adult fractures, and 3 women also had multiple fractures, childhood fractures and a family history of osteoporosis. Two women presented during pregnancy/lactation. In an additional 4 subjects, 4 different relevant Variants of Uncertain Significance (VUS) were detected in the genes FKBP10, SLC34A3, and HGD. Of the subjects with VUS, 2 had multiple adult fractures, childhood fractures, and presented during pregnancy/lactation, and 2 had nephrolithiasis. BFR/BS varied among the 8 subjects with identified variants; BFR/BS was quite low in those with variants that are likely to have adverse effects on bone formation. The analysis pipeline did not discover candidate variants in COL1A1, COL1A2, WNT, or ALPL. Although we found several novel and rare variants in LRP5, cases did not have an increased burden of common LRP5 variants compared to controls. Cohort-wide collapsing analysis did not reveal any novel disease genes with genome-wide significance for qualifying variants between controls and our 75 cases. In summary, WES revealed likely pathogenic variants or relevant VUS in 8 (11%) of 75 women with IOP. Notably, the genetic variants identified were consistent with the affected women's diagnostic evaluations that revealed histological evidence of low BFR/BS or biochemical evidence of increased bone resorption and urinary calcium excretion. These results, and the fact that the majority of the women had no identifiable genetic etiology, also suggest that the pathogenesis of and mechanisms leading to osteoporosis in this cohort are heterogeneous. Future research is necessary to identify both new genetic and non-genetic etiologies of early-onset osteoporosis.

Case report: Early-onset osteoporosis in a patient carrying a novel heterozygous variant of the WNT1 gene

The WNT1 gene is crucial for bone development and homeostasis. Homozygous mutations in WNT1 cause severe bone fragility known as osteogenesis imperfecta type XV. Moreover, heterozygous WNT1 mutations have been found in adults with early-onset osteoporosis. We identified a 35 year-old Caucasian woman who experienced multiple vertebral fractures two months after her second pregnancy. There was no history of risk factors for secondary osteoporosis or family history of osteoporosis. Dual-energy X-ray absorptiometry confirmed a marked reduction of bone mineral density (BMD) at the lumbar spine (0.734 g/cm², Z-score -2.8), femoral neck (0.48 g/cm², Z-score -3.5), and total hip (0.589 g/cm², Z-score -3.0). Blood tests excluded secondary causes of bone fragility. Genetic analysis revealed a heterozygous missense mutation (p.Leu370Val) in the WNT1 gene. Varsome classified it as a variant of uncertain significance. However, the fact that the Leucine residue at position 370 is highly conserved among vertebrate species and the variant has a very low allelic frequency in the general population would exclude the possibility of a polymorphism. The patient was treated for two years with teriparatide therapy associated with calcium and vitamin D supplements. During the follow-up period she did not report further clinical fractures. After 24 months of teriparatide, BMD increased at lumbar spine (+14.6%), femoral neck (+8.3%) and total hip (+4.9%) compared to baseline. We confirm that the heterozygous WNT1 mutation could cause a variable bone fragility and low turnover osteoporosis. We suggest that teriparatide is one of the most appropriate available therapies for this case.

Transient alendronate administration to pregnant or lactating mothers prevents bone loss in mice without adverse effects on offspring

Changes in bone metabolism occur in mothers during pregnancy or lactation that may decrease bone mass and result in fragility fractures after partum. However, use of drugs during pregnancy or lactation to counteract these effects is often prohibited or strongly discouraged. Therefore, approaches to protect mothers from fragility fractures have not been established. Here we show that bone mineral density was significantly lower in female mice after partum than in age-matched female mice without partum. We also show that temporary administration of the bisphosphonate alendronate, either just before or just after pregnancy, to female mice was protective against bone loss due to pregnancy or lactation and had no adverse effects on offspring, such as growth retardation. Furthermore, we show that alendronate administration to female mice during lactation was effective in increasing bone mass in mothers without promoting bone abnormalities or growth retardation in offspring. Calcium levels in milk from female mice administered alendronate during lactation were equivalent to those in milk from mothers not treated with alendronate. Overall, we propose that alendronate administration to mothers could prevent bone loss and fragility fractures during pregnancy and lactation.

Phosphate, Calcium, and Vitamin D: Key Regulators of Fetal and Placental Development in Mammals

Normal calcium and bone homeostasis in the adult is virtually fully explained by the interactions of several key regulatory hormones, including parathyroid hormone, 1,25 dihydroxy vitamin D3, fibroblast growth factor-23, calcitonin, and sex steroids (estradiol and testosterone). In utero, bone and mineral metabolism is regulated differently from the adult. During development, it is the placenta and not the fetal kidneys, intestines, or skeleton that is the primary source of minerals for the fetus. The placenta is able to meet the almost inexhaustible needs of the fetus for minerals by actively driving the transport of calcium and phosphorus from the maternal circulation to the growing fetus. These fundamentally important minerals are maintained in the fetal circulation at higher concentrations than those in maternal blood. Maintenance of these inordinately higher fetal levels is necessary for the developing skeleton to accrue sufficient minerals by term. Importantly, in livestock species, prenatal mineralization of the skeleton is crucial for the high levels of offspring activity soon after birth. Calcium is required for mineralization, as well as a plethora of other physiological functions. Placental calcium and phosphate transport are regulated by several mechanisms that are discussed in this review. It is clear that phosphate and calcium metabolism is intimately interrelated and, therefore, placental transport of these minerals cannot be considered in isolation.

Unilateral Atraumatic Femoral Neck Fracture in the Peripartum Period: Case Report and Literature Review

Transient osteoporosis of the hip (TOH) refers to a temporary, focal reduction in bone mineral density that selectively affects bones in weight-bearing joints of young pregnant females. Due to inherent difficulties in diagnosing this pathology, it is difficult to estimate the incidence and it is conceivable that TOH is vastly underreported. In a rare subset of patients, TOH may progress to pathological fractures. We report a case of a 38-year-old pregnant woman who developed an atraumatic, displaced femoral neck fracture during her last trimester. Diagnosis and adequate management of TOH represents a clinical challenge as symptoms that precede the fracture are often non-specific, while the timing of the surgical treatment (i.e. before or after delivery) is debatable.

Pregnancy- and lactation-associated osteoporosis with vertebral fractures: a systematic review

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.

Bone Density After Teriparatide Discontinuation With or Without Antiresorptive Therapy in Pregnancy- and Lactation-Associated Osteoporosis

Pregnancy- and lactation-associated osteoporosis (PLO) is a rare and severe disorder that causes low-trauma or spontaneous fractures, most commonly multiple vertebral fractures, in the late pregnancy or lactation period [1]. In severe PLO, teriparatide (TPTD) might aid in bone mineral density (BMD) recovery and subsequent fracture risk reduction. However, it is unclear whether TPTD can be discontinued without sequential antiresorptive therapy (ART) in premenopausal women with PLO. In this retrospective cohort study, we investigated the changes in BMD in premenopausal women with PLO treated with TPTD 20 mcg daily with or without sequential ART. Data for 67 patients diagnosed with PLO from 2007 through 2017 were reviewed. Among 43 women with annual follow-up dual-energy X-ray absorptiometry data for 3 years, 33 were treated with TPTD (median 12 months) with (TPTD-ART, n = 13; median, 18 months) or without (TPTD-no ART, n = 20) sequential ART. The two groups showed no differences in the mean age (31 vs. 31 years), body mass index (BMI, 20.5 vs. 21.0 kg/m²), and baseline lumbar spine (LS) BMD (0.666 vs. 0.707 g/cm²; p > 0.05 for all). LSBMD increased at 1, 2, and 3 years from baseline in both the TPTD-ART (14.1%, 21.8%, and 24.0%, respectively) and TPTD-no ART (17.3%, 24.1%, and 23.4%, respectively) groups, without significant between-group differences. Similar results were observed for the total hip BMD. LSBMD gain at 3 years did not differ by ART use (adjusted β, 0.40; p = 0.874) in univariable and multivariable models adjusted for age, BMI, and baseline LSBMD. In summary, BMD gain by TPTD administration in premenopausal women with PLO can be well maintained without sequential ART treatment.

Influence of denosumab on bone mineral density in a severe case of pregnancy-associated osteoporosis

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.

Teriparatide Treatment in Patients with Pregnancy- and Lactation-Associated Osteoporosis

Pregnancy- and lactation-associated osteoporosis (PLO) is a rare disease, presenting in most cases with severe back pain due to low energy vertebral fractures (VFs). Our purpose was to assess the effect of teriparatide (TPTD) vs. conventional management on areal bone mineral density (aBMD) and trabecular bone score (TBS) in patients with PLO. A multicenter retrospective cohort study concerning premenopausal women with PLO. Nineteen women were treated with TPTD (20 μg/day) (group A) plus calcium and vitamin D and eight women with calcium and vitamin D only (group B) for up to 24 months. The primary end-point was between group differences in lumbar spine (LS) and total hip (TH) aBMD, and TBS at 12 and 24 months. Patients in group A had sustained a median of 4.0 VFs (3-9) vs. 2.5 VFs (1-10) in group B (p = 0.02). At 12 months, patients on TPTD vs. controls achieved a mean aBMD increase of 20.9  ±  11.9% vs. 6.2  ±  4.8% at the LS (p < 0.001), 10.0  ±  11.6% vs. 5.8  ±  2.8% at the TH (p = 0.43), and 6.7  ±  6.9% vs. 0.9  ±  3.7% in TBS (p = 0.09), respectively. At 24 months, seven patients on TPTD and six controls achieved a mean LS aBMD increase of 32.9  ±  13.4% vs. 12.2  ±  4.2% (p = 0.001). P1NP levels during the first month of TPTD treatment were positively correlated with the 1-year LS aBMD change (r = 0.68, p = 0.03). No new clinical fractures occurred while on-treatment. In patients with PLO, TPTD treatment resulted in significantly greater increases in LS aBMD compared with calcium and vitamin D supplementation at 12 and 24 months.

Femoral µCT Analysis, Mechanical Testing and Immunolocalization of Bone Proteins in β-Hydroxy β-Methylbutyrate (HMB) Supplemented Spiny Mouse in a Model of Pregnancy and Lactation-Associated Osteoporosis

A metabolite of leucine, ß-hydroxy-ß-methylbutyrate (HMB), used as a dietary supplement effects muscle tissue gain and bone tissue quality. Since there are no studies on the effects of HMB during pregnancy yet, the aim of the current study was to determine the effects of HMB supplementation during pregnancy on osteoporotic bone quality postpartum and post-lactation using spiny mice (Acomys cahirinus) as the animal models. The six-month-old dams were divided into four groups: pregnant and lactating controls, and pregnant and lactating HMB-treated (during the second trimester of pregnancy) females. The intensity of the immunoreaction of osteocalcin (OC), osteoprotegerin (OPG), bone morphogenetic protein 2 (BMP-2), tissue inhibitor of metalloproteinases 2 (TIMP-2), matrix metalloproteinase 8 and 13 (MMP-8 and MMP-13) and proteins involved in bone turnover, was measured in femoral trabecular and compact bone, as well as in the hyaline and epiphyseal cartilage of the femora. The analysis of the trabecular bone microarchitecture showed that the administration of HMB to pregnant females, by influencing the proteins responsible for bone cell activity and collagen remodeling, can provide protection from bone loss. Based on the results of the current study it can be assumed that HMB administration to pregnant females has a more positive impact on trabecular than compact bone.

Analysis of Fracture Incidence in 135 Patients With Pregnancy and Lactation Osteoporosis (PLO)

Pregnancy and lactation-related osteoporosis (PLO) is the development of osteoporosis in a premenopausal woman, usually in the third trimester of pregnancy or puerperium. The hormonal changes that allow for the maternal-fetal calcium gradient may be the underlying cause for bone loss, but it is not currently known why some women are affected so severely. Because osteoporosis does not cause symptoms until the condition is advanced, diagnosis is usually made upon the development of an osteoporotic fracture or incidentally when imaging is performed for other reasons. Spontaneous recovery is common once lactation is discontinued, as the underlying hormonal factors that caused the osteoporosis revert to the pre-pregnancy state. We used the research database TriNetX (TriNetX, LLC, Cambridge, MA) to perform a query selecting women between the ages of 10 and 50 years old who experienced an osteoporotic fracture within 12 months of pregnancy. We analyzed the cohort of patients to determine the incidence of fractures at different skeletal locations and evaluated the medications that were utilized in the patients who received treatment.

Bone Mineral Density Changes Associated With Pregnancy, Lactation, and Medical Treatments in Premenopausal Women and Effects Later in Life

Bone mineral density (BMD) changes during the life span, increasing rapidly during adolescence, plateauing in the third decade of life, and subsequently entering a phase of age-related decline. In women, menopause leads to accelerated bone loss and an increase in fracture risk. Between peak bone mass attainment and menopause, BMD is generally stable and the risk of fracture is typically low. This time period is marked by life events such as pregnancy and lactation, which transiently decrease BMD, yet their long-term effects on fracture risk are less certain. BMD may also be altered by exposure to medications that affect bone metabolism (e.g., contraceptives, glucocorticoids, antidiabetic medications, antiepileptic drugs). Although oral contraceptives are often believed to be neutral with regard to bone health, depot medroxyprogesterone acetate (DMPA) and gonadotropin-releasing hormone (GnRH) agonists have been associated with decreases in BMD. Development of newer medical therapies, principally GnRH antagonists (e.g., ASP1707, elagolix, linzagolix, relugolix), for treatment of endometriosis-associated pelvic pain and heavy menstrual bleeding due to uterine fibroids has renewed interest in the short- and long-term impacts of changes in BMD experienced by premenopausal women. It is important to understand how these drugs influence BMD and put the findings into context with regard to measurement variability and naturally occurring factors that influence bone health. This review summarizes what is known about the effects on bone health pregnancy, lactation, and use of DMPA, GnRH agonists, and GnRH antagonists in premenopausal women and potential consequences later in life. ClinicalTrials.gov identifier: NCT03213457.

Musculoskeletal Considerations for Exercise and Sport: Before, During, and After Pregnancy

There is little written in the orthopaedic literature regarding common musculoskeletal problems that women encounter in relation to pregnancy and their clinical and surgical management. Exercise and other physical activity are generally recommended for most women before, during, and after pregnancy. Unfortunately, a variety of musculoskeletal issues may keep women from starting, continuing, or resuming a healthy exercise regimen throughout a notable portion of their reproductive years. Untreated and undertreated orthopaedic conditions in female athletes may therefore have further unintended negative effects on maternal and fetal health. This article reviews the existing literature on musculoskeletal health considerations before, during, and after pregnancy to provide practical information to orthopaedic surgeons who treat women of all ages and athletic abilities.

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.

Relevant genetic variants are common in women with pregnancy and lactation-associated osteoporosis (PLO) and predispose to more severe clinical manifestations

Pregnancy and lactation-associated osteoporosis (PLO) is a rare skeletal disorder characterized by early-onset osteoporosis typically manifestating with vertebral compression fractures or transient osteoporosis of the hip. We hypothesized that genetic variants may play a role in the development of PLO. This study aimed to analyze the presence of genetic variants and a potential association with the clinical presentation in PLO. 42 women with PLO were included from 2013 to 2019 in a multicenter study in Germany. All cases underwent comprehensive genetic analysis based on a custom-designed gene panel including genes relevant for skeletal disorders. The skeletal status was assessed using dual-energy X-ray absorptiometry (DXA). Subgroups were further analyzed by serum bone turnover markers (n = 31) and high-resolution peripheral computed tomography (HR-pQCT; n = 23). We detected relevant genetic variants in 21 women (50%), with LRP5, WNT1 and COL1A1/A2 being the most commonly involved genes. The mean number of vertebral compression fractures was 3.3 ± 3.4 per case with a significantly higher occurrence in the subgroup with genetic variants (4.8 ± 3.7 vs. 1.8 ± 2.3, p = 0.02). Among the total cohort, DXA Z-scores were significantly lower at the lumbar spine compared to the femoral neck (p = 0.002). HR-pQCT revealed a pronounced reduction of trabecular and cortical thickness, while trabecular number was within the reference range. Eighteen women (43%) received a bone-specific therapy (primarily teriparatide). Overall, a steep increase in bone mass (+37.7%) was observed after 3 years. In conclusion, pregnancy and lactation represent skeletal risk factors, which may unmask hereditary bone disorders leading to PLO. These cases were affected more severely. Nevertheless, a timely diagnosis and adequate treatment can ensure a substantial recovery potential even without specific therapy. Patients with genetically induced low bone turnover (e.g.; LRP5, WNT1) may especially benefit from osteo-anabolic medication.

Pregnancy associated transient osteoporosis of the hip (PR-TOH): A non-obstetric indication to caesarean section. A case report with literature review

Pregnancy related transient osteoporosis of the hip (PR-TOH) is a rare condition that manifests with sudden pain located in the groin region, anterior thigh and buttocks. It is a benign and in the majority of cases self-limiting disease, related to bone marrow oedema. It occurs during the third trimester of pregnancy or less frequently during the post-partum period. Hip movements are usually restricted by pain and it often becomes a non-obstetric indication for Caesarean delivery. Here, we report a case of unilateral PR-TOH diagnosed by magnetic resonance imaging (MRI) and a literature review.

Hormonal regulation of biomineralization

Biomineralization is the process by which organisms produce mineralized tissues. This crucial process makes possible the rigidity and flexibility that the skeleton needs for ambulation and protection of vital organs, and the hardness that teeth require to tear and grind food. The skeleton also serves as a source of mineral in times of short supply, and the intestines absorb and the kidneys reclaim or excrete minerals as needed. This Review focuses on physiological and pathological aspects of the hormonal regulation of biomineralization. We discuss the roles of calcium and inorganic phosphate, dietary intake of minerals and the delicate balance between activators and inhibitors of mineralization. We also highlight the importance of tight regulation of serum concentrations of calcium and phosphate, and the major regulators of biomineralization: parathyroid hormone (PTH), the vitamin D system, vitamin K, fibroblast growth factor 23 (FGF23) and phosphatase enzymes. Finally, we summarize how developmental stresses in the fetus and neonate, and in the mother during pregnancy and lactation, invoke alternative hormonal regulatory pathways to control mineral delivery, skeletal metabolism and biomineralization.

Review of Current Real-World Experience with Teriparatide as Treatment of Osteoporosis in Different Patient Groups

Teriparatide has proven effective in reducing both vertebral and non-vertebral fractures in clinical trials of post-menopausal and glucocorticoid-induced osteoporosis. Widespread adoption of Teriparatide over the last two decades means that there is now substantial experience of its use in routine clinical practice, which is summarized in this paper. Extensive real-world experience of Teriparatide in post-menopausal osteoporosis confirms the fracture and bone density benefits seen in clinical trials, with similar outcomes identified also in male and glucocorticoid-induced osteoporosis. Conversely, very limited experience has been reported in pre-menopausal osteoporosis or in the use of Teriparatide in combination with other therapies. Surveillance studies have identified no safety signals relating to the possible association of Teriparatide with osteosarcoma. We also review the evidence for predicting response to Teriparatide in order to inform the debate on where best to use Teriparatide in an increasingly crowded therapeutic landscape.

Maternal and fetal vitamin D and their roles in mineral homeostasis and fetal bone development

During pregnancy, female physiology adapts to meet the additional mineral demands of the developing fetus. Meanwhile, the fetus actively transports minerals across the placenta and maintains high circulating levels to mineralize the rapidly developing skeleton. Most of this mineral is accreted during the last trimester, including 30 g of calcium, 20 g of phosphate and 0.8 g of magnesium. Given the dependence of calcium homeostasis on vitamin D and calcitriol in the adult and child, it may be expected that vitamin D sufficiency would be even more critical during pregnancy and fetal development. However, the pregnant mother and fetus appear to meet their mineral needs independent of vitamin D. Adaptations in maternal mineral and bone metabolism during pregnancy appear to be invoked independent of maternal vitamin D, while fetal mineral metabolism and skeletal development appear to be protected from vitamin D deficiency and genetic disorders of vitamin D physiology. This review discusses key data from both animal models and human studies to address our current knowledge on the role of vitamin D and calcitriol during pregnancy and fetal development.