"Pregnancy and Lactation Associated Osteoporosis"

Prevalence of pregnancy- and lactation-associated osteoporosis in the postpartum period: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to estimate the prevalence of pregnancy- and lactation-associated osteoporosis in postpartum women within 1 year of delivery. We searched MEDLINE via PubMed and Igaku Chuo Zasshi for articles published in English or Japanese from the inception of the database to September 2021. Two researchers independently screened and included observational studies reporting the prevalence of pregnancy- and lactation-associated osteoporosis in postpartum women within 1 year of delivery. Of the 3,425 screened records, 8 articles centered on postpartum women were included in the review. Seven studies used dual-energy X-ray absorptiometry for assessing bone mineral density, while one used a quantitative ultrasound method. In the seven studies that used dual-energy X-ray absorptiometry, the parameters used to define osteoporosis were the T-score (two studies), Z-score (three studies), both T- and Z-scores (one study), and young adult mean (one study). Evaluation timeframes included 1 week (three studies), 1-2 months postpartum (three studies), and 1 week to 12 months postpartum (one study). The estimated prevalence of pregnancy- and lactation-associated osteoporosis defined by dual-energy X-ray absorptiometry was as follows: lumbar spine (six studies), 5% (95% confidence interval [CI], 0-13; heterogeneity [I2] = 99%) and femoral neck (three studies), 12% (95% CI, 0-30; I2 = 99%). Pregnancy and lactation were found to elevate the fracture risk in women, underscoring the necessity for a standardized assessment in diagnosing pregnancy- and lactation-associated osteoporosis. This imperative step aims to enable early detection and treatment of bone mineral loss among postpartum women.

Bone Metabolism, Bone Mass, and Bone Structure During Pregnancy and Lactation: Normal Physiology and Pregnancy and Lactation-Associated Osteoporosis

This article reviews bone metabolism, bone mass, and bone structure changes expected during and after pregnancy and lactation, as well as the condition of pregnancy and lactation-associated osteoporosis (PLO)-a presentation with fragility fracture(s) in the context of these physiologic changes. Clinical implications of physiologic bone changes will be addressed, as will specific management considerations that apply to premenopausal women with PLO.

Predictors associated with night sleep disturbance among breastfeeding women

OBJECTIVE

The aim of this study was to investigate the incidence of somnological disorders among Kazakhstani women who breastfeed and to assess the association of this phenomenon with some medical and social characteristics.

METHODS

The authors used the standardized questionnaire of A.M. Vein and Y.I. Levin to assess nocturnal sleep among 1101 breastfeeding women in the Republic of Kazakhstan, applied Pearson's chi-square test to study the correlation between sleep disturbances and duration of breastfeeding, and multiple logistic regression to assess the influence of various medical and social factors on somnological disorders. Data collection occurred in February 2023.

RESULTS

On average, 80% of breastfeeding women (ranging from 79% to 85.9%) experienced some form of nocturnal sleep disorders, with no significant association found between these disorders and breastfeeding duration (p = 0.234), while urban residence, history of operative delivery, child's health issues, and low satisfaction levels with various aspects were associated with over twofold increased odds of experiencing sleep disorders (p ≤ 0.05).

CONCLUSIONS

The elevated prevalence of nocturnal sleep disorders among breastfeeding Kazakhstani women serves as a risk indicator for adverse health outcomes, with predictors including place of residence, obstetric complications, child health issues, and satisfaction levels with social conditions and personal expression opportunities.

Breastmilk calcium concentrations in Palestinian lactating women

AIM

Breastmilk calcium concentrations can vary between lactating women and over the lactation period. This study assessed breastmilk calcium concentrations among Palestinian lactating women.

METHODS

The demographic and dietary variables of the lactating women were collected using a questionnaire. The women provided a sample of about 5 mL of breastmilk using hand expression. Breastmilk calcium concentrations were quantified using an inductively coupled plasma-mass spectrometric method.

RESULTS

Breastmilk samples were taken from 240 lactating women. The mean breastmilk calcium concentration was 285.4 ± 115.1 mg/L. Lower breastmilk calcium concentrations were associated with age, lactating period, unemployment, dissatisfaction with income and insufficient consumption of vitamins and minerals.

CONCLUSION

Breastmilk calcium concentrations were affected by demographic variables of the lactating women and insufficient consumption of vitamins and minerals. The findings reported in this study are informative to healthcare providers and decision makers who might be interested in improving the health of lactating women and their infants.

Urinary Silicon Excretion in Relation to Lactation and Bone Mineral Density - a Longitudinal Study Post-partum

Silicon (Si) may be a mineral beneficial for bone health. Pregnancy and lactation have major impacts on maternal bone metabolism as bone minerals, including calcium (Ca), are required for growth of the foetus and for milk production. Like urinary Ca excretion, Si excretion has been reported to be high in pregnant women, but there are no data post-partum and during lactation. The aim of the present study was to investigate the urinary excretion of Si (U-Si), from the third trimester of pregnancy until 18 months post-partum, and in relation to the length of lactation, to determine if changes in U-Si are associated with changes in areal bone mineral density (aBMD). This longitudinal study included 81 pregnant women, of whom 56 completed the study. Spot urine samples were collected at the third trimester and at 0.5, 4, 12, and 18 months post-partum and were analysed for Si and Ca by ICP-OES. The aBMD was measured post-partum at lumbar spine and femoral neck by dual-energy x-ray absorptiometry. Women lactating for 4-8.9 and ≥ 9 months had significantly higher U-Si at 4 months post-partum, compared with the third trimester. No significant longitudinal differences in U-Si were found after correcting for creatinine. Changes in U-Si and in aBMD were not correlated, except at the lumbar spine from 0.5 to 12 months post-partum in the women lactating for 4-8.9 months. Taken together, our results suggest that there is a possibility that U-Si increases post-partum in women lactating for 4 months or longer, although it is not related to changes in aBMD.

Pregnancy-associated osteoporosis following in vitro fertilization: A case report

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.

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.

Pregnancy and lactation-related osteoporosis in a 22-year-old-woman

Key Clinical Message

Any pregnant or lactating woman with severe constant back pain, PLO must be kept in mind due to its effect on the quality of life of the mother and her child.

Abstract

A 22-year-old woman, who delivered her first child 5 months ago and is now breastfeeding her baby, presented with mid-back pain. After investigations, including laboratory tests, X-rays, and bone density measurements, the diagnosis was PLO. The patient is being treated with calcium, vitamin D, and alendronate besides discontinuation of lactation.

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.

Drug Delivery and Therapy Strategies for Osteoporosis Intervention

With the advent of the aging society, osteoporosis (OP) risk increases yearly. Currently, the clinical usage of anti-OP drugs is challenged by recurrent side effects and poor patient compliance, regardless of oral, intravenous, or subcutaneous administration. Properly using a drug delivery system or formulation strategy can achieve targeted drug delivery to the bone, diminish side effects, improve bioavailability, and prolong the in vivo residence time, thus effectively curing osteoporosis. This review expounds on the pathogenesis of OP and the clinical medicaments used for OP intervention, proposes the design approach for anti-OP drug delivery, emphatically discusses emerging novel anti-OP drug delivery systems, and enumerates anti-OP preparations under clinical investigation. Our findings may contribute to engineering anti-OP drug delivery and OP-targeting therapy.

Long-term and sequential treatment for osteoporosis

Osteoporosis is a skeletal disorder that causes impairment of bone structure and strength, leading to a progressively increased risk of fragility fractures. The global prevalence of osteoporosis is increasing in the ageing population. Owing to the chronic character of osteoporosis, years or even decades of preventive measures or therapy are required. The long-term use of bone-specific pharmacological treatment options, including antiresorptive and/or osteoanabolic approaches, has raised concerns around adverse effects or potential rebound phenomena after treatment discontinuation. Imaging options, risk scores and the assessment of bone turnover during initiation and monitoring of such therapies could help to inform individualized treatment strategies. Combination therapies are currently used less often than 'sequential' treatments. However, all patients with osteoporosis, including those with secondary and rare causes of osteoporosis, as well as specific patient populations (for example, young adults, men and pregnant women) require new approaches for long-term therapy and disease monitoring. New pathophysiological aspects of bone metabolism might therefore help to inform and revolutionize the diagnosis and treatment of osteoporosis.

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.

Dynamics of Skeletal Status under Optimized Management during Subsequent Pregnancy in Three Women with a History of Pregnancy- and Lactation-Associated Osteoporosis Carrying pathogenic Variants in WNT1 and LRP5

Pregnancy- and lactation-associated osteoporosis (PLO) is a rare but clinically highly relevant condition, characterized by reduced bone mineral density (BMD) and acute onset of severe pain due to symptomatic bone marrow edema of the hip or vertebral and/or insufficiency fractures, among others. Previous reports showed a high frequency of hereditary bone disorders unmasked by PLO, predisposing for more severe forms. To date, no data on the risk for additional fractures during subsequent pregnancy in women with PLO and genetic bone disorder have been available. To address this question, we retrospectively analyzed the clinical, biochemical, and densitometric course of three women with a history of PLO and detected variants in WNT1 or LRP5 and subsequent pregnancies. Calcium homeostasis and bone turnover were optimized by basic treatment, and timely initiation of weaning was recommended. Teriparatide treatment for 12 months under strict contraception was initiated in one woman after the diagnosis of PLO. In none of the women did additional fractures or symptomatic bone marrow edemas occur, and BMD by dual-energy X-ray absorptiometry as bone microarchitecture by high-resolution peripheral quantitative computed tomography remained stable. In conclusion, this report expands the understanding of this rare but severe condition and helps to improve clinical counseling and management. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Clinical characteristics of pregnancy and lactation associated osteoporosis: An online survey study

Pregnancy and lactation associated osteoporosis is a rare and often severe osteoporosis presentation. Little information is available about etiology, clinical characteristics, risk factors and predictors of severity. Using an anonymized questionnaire, we defined clinical characteristics and potential risk factors for disease severity in PLO including primiparity, heparin exposure and celiac disease.

PURPOSE

Pregnancy and lactation associated osteoporosis (PLO) is a rare form of early-onset osteoporosis in which young women present with fractures, usually multiple vertebral fractures, during late pregnancy or lactation. Little information is available about etiology, clinical characteristics, risk factors and predictors of disease severity.

METHODS

PLO patients were recruited to complete an anonymized online questionnaire. Disease severity was defined as total number of fractures during or after the first pregnancy associated with a fracture(s). Analyses related disease severity to potential predictors including diseases/conditions or medication exposures.

RESULTS

177 completed surveys were received between 5/29/2018 and 1/12/2022. Average age at initial PLO fracture event was 32 ± 5 years. The majority were primiparous with singleton pregnancy and 79% fractured during lactation. Subjects reported 4.7 ± 2.7 total PLO fractures, with 48% reporting ≥ 5 fractures. Vertebral fractures, reported by 164/177 responders (93%), were the most common fracture type. Conditions and medications most commonly reported included vitamin D deficiency, amenorrhea unrelated to pregnancy, nephrolithiasis, celiac disease (CD), oral steroid use, heparin products during pregnancy and progestin only contraceptive after pregnancy. CD and heparins exposure during pregnancy were significantly related to disease severity.

CONCLUSION

This is the largest study characterizing clinical features of PLO to date. The large number of participants and broad range of clinical and fracture characteristics queried has yielded novel information on the characteristics of PLO and potential risk factors for its severity, including primiparity, exposure to heparin and CD. These findings provide important preliminary data that can help target future mechanistic investigations.

Pregnancy- and lactation-associated osteoporosis in the mother after the first and second children: A case report

INTRODUCTION

This study reports an unusual experience of a mother who may have developed birth-related osteoporosis after each of the births of her two children.

PRESENTATION OF CASE

A 31-year-old woman presented with lumbar back pain. She had given birth to her first child through vaginal delivery 4 months prior and was breastfeeding. Magnetic resonance imaging showed multiple fresh vertebral fractures, but continued breastfeeding resulted in further loss of bone density. The bone mineral density recovered after weaning. The patient gave birth to a second child three years after the first child's birth. She opted to discontinue breastfeeding after the detection of repeated instances of significant bone loss. No new vertebral fractures have occurred in the 9 years since the patient's initial visit to our clinic.

DISCUSSION

We describe a case where a mother experienced multiple episodes of rapid bone loss following childbirth. Bone health evaluation at an early stage following childbirth may be effective for preventing future bone fractures.

CONCLUSION

It is desirable to develop a team and guidelines for treating osteoporosis associated with pregnancy and lactation and for the next pregnancy and delivery.

Determinant of Osteoporosis Preventive Behaviors among Perimenopausal Women: A Cross-Sectional Study to Explore the Role of Knowledge and Health Beliefs

Osteoporosis is a silent chronic disease, and many people did not discover it until they were diagnosed with a fracture. Therefore, regular scanning and appropriate Osteoporosis Preventive Behaviors (OPB) are the management cornerstone. OPB is strongly affected by personal knowledge and health beliefs. This study explores the role of knowledge and health beliefs as determinants of OPB among perimenopausal women. This cross-sectional study was performed on 1075 perimenopausal women in Najran City, Saudi Arabia, from January 2023 to March 2023. The data collection instrument is a self-reported questionnaire consisting of basic data, the OPB scale, an osteoporosis knowledge assessment tool, and the osteoporosis health belief scale. The current study results showed that approximately one-quarter (27.8%) of the study participants had high OPB with an overall mean of 20.83 ± 5.08 grade. The group practicing high OPB demonstrated a higher knowledge mean (11.37 ± 2.99) than the low OPB group (9.93 ± 3.51). In addition, all health beliefs constructs significantly differed among the low and high OPB groups (p ˂ 0.05). The participant's age, occupational status, educational level, attendance of training courses, and history of bone fractures were significantly associated with high OPB. Osteoporosis knowledge, perceived susceptibility, perceived seriousness, exercises' perceived benefits, and health motivations are positive predictors of high OPB (p ˂ 0.05). The study concluded that osteoporosis-related knowledge and health beliefs-especially perceived susceptibility, perceived seriousness, exercises' perceived benefits, and health motivations-are positive predictors of high OPB. The health belief model can be an effective tool used to determine high-risk groups who practice low OPB and build need-based educational interventions.

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

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

Bridging the Gap: Pregnancy-And Lactation-Associated Osteoporosis

Early diagnosis of pregnancy- and lactation-associated osteoporosis (PLO) is mandatory for a good outcome. Standard care is not a matter of conventional guidelines, rather it requires an individualized strategy while true overall incidence and pathogeny remain open issues. This is a narrative review based on full-length English articles, published between January 2021 and March 2023 and accessed via PubMed (no traumatic fractures or secondary osteoporosis are included). Our case-sample-based analysis included 836 females with PLO (the largest cohort based on published cases so far) through 12 studies and 24 single case reports. Except for one survey, these involved retrospective cohorts of small size (6-10 females/study) to medium size (23-47 women/study), and large cohorts with >50 subjects per study (a maximum of 379). Age of diagnosis: from 24 to 40 years for case reports (most subjects being over 30 and primigravida), while original studies indicated an average age between 31 and 34.18 years. Type of fractures underlined a most frequent vertebral phenotype (a mean of 2 to 5.8 vertebral fractures per patient) versus a most severe non-vertebral phenotype (hip and femoral neck fractures mostly requiring surgery). Potential contributors varied: smoking (1/3-1/2 of subjects), family history of osteoporosis (1/3), heparin and glucocorticoid use in pregnancy, low body mass index (majority of cases), hypovitaminosis D; and (with a low level of statistical significance) anti-psychotic medication, gestational diabetes, lupus, thrombophilia, anemia, in vitro fertilization (1/3 in one study), twin pregnancy, tocolysis with MgSO4, and postpartum thyroiditis. Most remarkably, up to 50% of PLO patients harbor mutations of LRP5, WNT1, and COL1A1/A2 (more damaged form with potential benefits from osteoanabolic drugs); gene testing might become the new norm in PLO. The low index of clinical suspicion should be supported by performing magnetic resonance imaging (gold standard in pregnancy) with DXA (in lactation). Low bone mineral density is expected (Z-score varying from -2.2 SD to -4 SD, unless normal which does not exclude PLO). Bone turnover markers might be useful in individuals with normal DXA, in pregnancy when DXA cannot be performed, and in following the response to anti-osteoporosis drugs. Alternatively, microarchitecture damage might be reflected by DXA-trabecular bone score and high-resolution peripheral quantitative computed tomography. Specific medical interventions are currently focused on teriparatide (TPT) use (3 studies; n = 99 females treated with TPT and an additional subgroup of 18 patients from the gene-analysis-based study, thus a total of 117 females) which seems to be the therapy of choice as reflected by these new data: 6-24 months, 20 µg/day, no sequential therapy needed; case selection based on high fracture risk is necessary). The first case using romosozumab was reported in 2022. PAO/LAO remains a challenging condition which is a battle for the wellbeing of two individuals, on one hand, considering maternal-fetal outcomes and taking care of the offspring, but it is a battle for a multidisciplinary team, on the other hand, since a standardized approach is lacking.

Glucocorticoid-induced osteoporosis in premenopausal women: management for the rheumatologist

PURPOSE OF REVIEW

This review seeks to summarize the literature relevant to the treatment of glucocorticoid-induced osteoporosis in premenopausal women; an issue commonly encountered by rheumatologists and yet lacking good clinical practice guidelines.

RECENT FINDINGS

Although most of the relevant literature on osteoporosis includes postmenopausal women only, data from both randomized controlled trials and case reports suggest bisphosphonates can be an effective and well tolerated treatment for premenopausal patients. Data for other medications to treat premenopausal osteoporosis is less robust.

SUMMARY

The use of bisphosphonates in young women may be safer than initially thought and should likely be used for the treatment of glucocorticoid-induced osteoporosis in rheumatology clinics. Further research is needed to continue to understand long-term risk.

Postoperative Osteoporosis in Subjects with Morbid Obesity Undergoing Bariatric Surgery with Gastric Bypass or Sleeve Gastrectomy

Obesity has become a worldwide epidemic accompanied by adverse health effects. The limited efficiency of traditional weight reduction regimens has led to a substantial increase in the use of bariatric surgery. Today, sleeve gastrectomy (SG) and Roux-en-Y-gastric bypass (RYGB) are the most used procedures. The present narrative review focuses on the risk of developing postoperative osteoporosis and summarizes some of the most relevant micronutrient deficiencies associated with RYGB and SG. Preoperatively, the dietary habits of obese individuals might lead to precipitated deficiencies in vitamin D and other nutrients affecting bone mineral metabolism. Bariatric surgery with SG or RYGB can aggravate these deficiencies. The various surgical procedures appear to affect nutrient absorption differently. Being purely restrictive, SG may particularly affect the absorption of vitamin B12 and also vitamin D. In contrast, RYGB has a more profound impact on the absorption of fat-soluble vitamins and other nutrients, although both surgical methods induce only a mild protein deficiency. Despite adequate supplementation of calcium and vitamin D, osteoporosis may still occur after the surgery. This might be due to deficiencies in other micronutrients, e.g., vitamin K and zinc. Regular follow-ups with individual assessments and nutritional advice are indispensable to prevent osteoporosis and other adverse postoperative issues.

Dietary Diversity, Micronutrient Adequacy and Bone Status during Pregnancy: A Study in Urban China from 2019 to 2020

Diet quality during reproduction is crucial to maternal and infant health. However, the association between dietary diversity and bone health of pregnant women remains unclear. We aimed to evaluate the dietary quality of Chinese urban gravidas using the dietary diversity score (DDS), and to explore the relationship of the DDS with micronutrient adequacy and bone health. In this cross-sectional study, we analyzed data from 775 pregnant women aged 18 years or older in urban China. Dietary diversity was assessed using the Minimum Dietary Diversity for Women (MDD-W) indicator. A 24-h dietary recall was used to collect diet data and to calculate the MDD-W and the nutrient intake. Bone health was measured using quantitative ultrasound and assessed by the speed of sound (SOS). Pearson's correlation coefficients between the DDS and the nutrient adequacy ratio (NAR) were calculated. A multivariable linear regression model was used to estimate the effect size of the DDS on the SOS. The mean DDS was 6.61 ± 1.53 points and 91.0% of participants reported the consumption of five or more food groups. Women in the diverse diet subgroup (DDS ≥ 7 points) were more likely to consume all kinds of food except starchy staples and had higher NARs. Pearson's correlation coefficients between the DDS and the NAR ranged from 0.161 to 0.484. For participants in the second trimester, those with a diverse diet had a higher SOS. A multivariable linear regression analysis showed that the DDS was positively and significantly associated with the SOS (β = 17.18, 95% CI = 5.97-28.39, p = 0.003), but this was not the case for women in the first and third trimesters. Urban Chinese women had good dietary diversity during pregnancy. A higher dietary diversity was associated with a higher NAR. From the point of view of bone, a diverse diet was positively correlated with better bone status, suggesting the importance of improving diet diversity for pregnant women, especially from mid-pregnancy.

Osteogenesis Imperfecta: characterization of fractures during pregnancy and post-partum

Background

Pregnancy and breastfeeding are associated with bone density loss. Fracture occurrence during pregnancy and post-partum, and its determinants, remain poorly known in Osteogenesis Imperfecta (OI). The aim of this study was to characterize fractures that occurred during pregnancy and post-partum in OI patients.

Results

We conducted a retrospective multicentric study including a total of 50 previously pregnant OI women from 10 Bone Centers in France. Among these patients, 12 (24%) patients experienced fractures during pregnancy or in the 6 months following delivery, and 38 (76%) did not experience any fracture. The most frequent localizations were: proximal femur (25%), spine (25%), distal femur (12.5%), and pelvis (12.5%). Fractures during pregnancy occurred during the third trimester and post-partum fractures occurred with a mean delay of 2 months following delivery. No fractures occurred during childbirth.

We next compared the 12 patients with pregnancy or post-partum fractures with the 38 patients without fractures. Mean age at pregnancy was 32.7 ± 3.1 years-old in the fractured group, vs 29.3 ± 5.0 years-old in the non-fractured group (p = 0.002). Breastfeeding was reported in 85.7% of patients in the fractured group, vs 47.1% in the non-fractured group (p = 0.03). All patients with post-partum fractures were breastfeeding. Bone mineral density was significantly lower in patients with pregnancy-related fractures compared with other patients: spine Z-score − 2.9 ± 1.6DS vs − 1.5 ± 1.7DS (p = 0.03), and total hip Z-score − 2.0 ± 0.7DS vs − 0.5 ± 1.4DS (p = 0.04). At least one osteoporosis-inducing risk factor or disease other than OI was identified in 81.8% vs 58.6% of fractured vs non-fractured patients (not significant). Fracture during pregnancy or post-partum was not associated with the severity of OI. Bisphosphonates before pregnancy were reported in 16.7% and 21.1% of patients with pregnancy-related fractures and non-fractured patients, respectively (not significant).

Conclusions

OI management during pregnancy and post-partum should aim for optimal control of modifiable osteoporosis risk factors, particularly in patients with low BMD. Breastfeeding should be avoided.

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.

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.

Osteoanabolic therapy for osteoporosis in women

Therapy to activate bone formation is required to reverse and restore the damaged bone architecture found in women with postmenopausal osteoporosis. The osteoanabolic drugs include teriparatide, which has been available for several years, and abaloparatide and romosozumab, novel osteoanabolic drugs that have become available more recently. By stimulating bone formation, these drugs produce greater increases in bone mass and bone strength, and they do so more quickly compared to the commonly used anti-remodeling (also called antiresorptive) drugs such as bisphosphonates. In head-to-head trials, teriparatide and romosozumab reduce fracture risk more effectively than do oral bisphosphonates in women with osteoporosis and high fracture risk. Osteoanabolic drugs have little role in the prevention of bone loss during early menopause, but they have an important place in the treatment of women at very high risk of fracture or who remain at high fracture risk after a course of bisphosphonate therapy. Primarily because of the high cost of the drugs, these therapies are initiated by specialists rather than primary-care physicians in most countries. This review will present the evidence for efficacy and safety of these drugs so that clinicians may discern their appropriate use when caring for postmenopausal women with osteoporosis.

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.