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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Second Child After Pregnancy and Lactation-Related Osteoporosis (PLO) Treated With Teriparatide: A Case Report

Pregnancy and lactation-associated osteoporosis (PLO) is one of the rarest and most serious primary osteoporotic conditions that develops during the third trimester of gestation and/or early postpartum period. A history of PLO often causes individuals to hesitate when considering an additional child due to anxiety about recurrence risk. Reported here are details of a 29-year-old patient with PLO given aggressive treatment for osteoporosis with teriparatide who subsequently gave birth to a healthy child at age 33 without PLO recurrence. Further case studies are needed to examine the efficacy and safety of PLO treatment and to provide beneficial results for those who wish to have another pregnancy.

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.

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.

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.

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.

Energy, Waves, and Forces in Bilateral Fracture of the Femoral Necks: Two Case Presentations and Updated Critical Review

Two case reports and an updated critical review on bilateral fractures of the femoral neck are presented. Bilateral fractures of the femoral neck have been investigated for at least 80 years and are treated as rare cases. The primary cause is usually considered an external shock; however, aside from high energy shocks (e.g., falling and impact with hard, rigid surfaces, traffic accidents, etc.) the underlying causes of femoral neck frailty have not yet been fully understood. Although not exhaustive, the review spans cases reported as early as 1944 and compares their conclusions in line with medicine developments at the time of the reports until present. The discussion is perhaps controversial at times; it brings to the fore the energy balance between shock waves and stress waves. The two cases reported here add to the review, one highlighting the biomechanics, and the other supporting more recent findings on metabolic disorders, which ultimately lead to enhanced frailty of the femoral neck. Investigation of the fractures has been performed with X-ray radiographs, MRI, and CT, with a follow up using a Doppler US to check blood flow in the lower zone of the limbs. The second case was investigated both for fractures and metabolic diseases, e.g., type I diabetes and kidney failure (dialysis). In Case 1 the second fracture was not observable at the time of admission, and therefore two surgery operations were performed at seven days interval. Taperloc Complete prostheses (Zimmer Biomet) were applied. Case 2 suffered a second fracture in the right hip in the segment above the knee and required better fixation with cables. Despite this, she returned one month later with a new crack in the femur. Case 1 is a typical case of wear consequences on the biomechanics of the hill pad-tibia-femur-femoral neck system, where tension of the neck occurred due to a stress wave rather than a shock wave. This can be proven by the absence of a second fracture from the images first acquired, the only evidence being pain and walking difficulty. Case 2 shows that metabolic diseases can dramatically enhance the frequency of bilateral femoral neck fractures.

Unusual presentation of atraumatic insufficiency pelvic fractures unmasking pregnancy-related osteoporosis: A case report

We describe the case of a young 27-year-old Caucasian female who presented in the third trimester of her first pregnancy with sudden and severe suprapubic and left-sided hip pain without history of trauma. She was eventually diagnosed with two insufficiency fractures of the pelvis. The underlying diagnosis was pregnancy-related osteoporosis. Her baby was delivered successfully at term, with an elective caesarean section. The diagnosis was eventually made using a magnetic resonance imaging scan. Pregnancy-related osteoporosis is relatively rare, and cases of patients presenting with insufficiency fractures of this condition are rarer still. Our case raises the importance of considering this diagnosis in females in the later stages of pregnancy, with severe sudden hip or pelvis pain. The patient gave informed written consent for the publication of this case.

The Relationship Between Bone and Reproductive Hormones Beyond Estrogens and Androgens

Reproductive hormones play a crucial role in the growth and maintenance of the mammalian skeleton. Indeed, the biological significance for this hormonal regulation of skeletal homeostasis is best illustrated by common clinical reproductive disorders, such as primary ovarian insufficiency, hypothalamic amenorrhea, congenital hypogonadotropic hypogonadism, and early menopause, which contribute to the clinical burden of low bone mineral density and increased risk for fragility fracture. Emerging evidence relating to traditional reproductive hormones and the recent discovery of newer reproductive neuropeptides and hormones has deepened our understanding of the interaction between bone and the reproductive system. In this review, we provide a contemporary summary of the literature examining the relationship between bone biology and reproductive signals that extend beyond estrogens and androgens, and include kisspeptin, gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone, prolactin, progesterone, inhibin, activin, and relaxin. A comprehensive and up-to-date review of the recent basic and clinical research advances is essential given the prevalence of clinical reproductive disorders, the emerging roles of upstream reproductive hormones in bone physiology, as well as the urgent need to develop novel safe and effective therapies for bone fragility in a rapidly aging population.

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.

Post-pregnancy osteoporosis-related multiple vertebral fractures associated with post-partum thyroiditis: A CARE-compliant case report

INTRODUCTION

Osteoporosis is a condition commonly observed in elderly and postmenopausal women. Pregnancy and lactation-induced osteoporosis are rare, and the development of severe vertebral fractures is uncommon. Postpartum thyroiditis (PPT) is a minor cause of osteoporosis. To the best of our knowledge, the development of osteoporosis associated with pregnancy has not yet been reported.

PATIENT CONCERNS

Here, we report a rare case of post-pregnancy osteoporosis-related multiple vertebral fractures associated with PPT. A 25-year-old woman developed lower back pain after her first delivery. She was then admitted to our medical center because of aggravated back pain.

DIAGNOSIS

On radiographic examination, she had multiple compressions of the lumbar spine. Bone mineral density was associated with osteoporosis. Laboratory tests, thyroid scans, and thyroid ultrasonography were performed. The patient was diagnosed with PPT.

INTERVENTIONS

The patient stopped lactating immediately. She was administered bisphosphate at 3 mg/3 months intravenously, elementary calcium at 1000 mg/day, and calcitriol 0.5 μg/day.

OUTCOMES

A month later, her pain was relieved by proper management and she could independently walk indoors.

CONCLUSION

PPT might play a role in aggravating post-pregnancy osteoporosis. It should be considered as a differential diagnosis in patients presenting with postpartum osteoporosis-related multiple spine fractures.

Risk factors, fractures, and management of pregnancy-associated osteoporosis: a retrospective study of 14 Turkish patients

Pregnancy-associated osteoporosis (PAO) is a rare but painful disease. The current study aimed to investigate the demographic and clinical features, risk factors, treatment options, and outcomes of Turkish patients with PAO. In our retrospective, cross-sectional, and descriptive study the time to PAO diagnosis was 3.6 months. Pain and loss of height were detected in 78.6% and 28.6% of patients, respectively. As such, 60.6% of patients reported fractures at the thoracic area, 30.3% at the lumbar area, and 9.1% at the sacral area. While 14.3% of patients had optimal vitamin D status during pregnancy, 64.3% had vitamin D deficiency, and 21.4% had vitamin D insufficiency. Of the patients, 21.4% received anticoagulant therapy during their pregnancy. Dual X-ray absorptiometry scans revealed that osteoporosis was predominantly in the trabecular bone (L1-L4 Z-score -2.9, Femur Z score -2.19). Management options included supplements of calcium with vitamin D (93%), weaning the baby (79%), specific treatments for osteoporosis (64%), use of a supportive corset (50%), and exercise (21%), respectively. In addition, after delivery, 35.7% of patients were administered denosumab, 21.4% bisphosphonate, and 7.1% were given teriparatide. Data of the clinical features, treatments, and outcomes of PAO may contribute to early detection and management.

Pregnancy-related fractures: a retrospective study of a French cohort of 52 patients and review of the literature

A retrospective, multicentre study involving 52 patients was carried out to define the causes and characteristics of pregnancy-related osteoporosis. The mean number of vertebral fractures occurring during the last trimester of pregnancy or at the time of delivery was 3.8. This is often promoted by risk factors before or during pregnancy.

INTRODUCTION

In order to define the causes or predisposing factors of pregnancy-related osteoporosis and its clinical, radiological and bone density characteristics, laboratory findings, course and outcome, we carried out a retrospective multicentre study.

METHODS

The records of 52 women hospitalised over the last 10 years in the rheumatology departments of six French university hospitals and with a diagnosis of pregnancy-related osteoporosis were examined.

RESULTS

The patients' mean age at time of fracture was 32.1 years. In 10 patients, the fractures had occurred during the last trimester of pregnancy, and in 36 at the time of delivery or during the first 2 months post-partum. The mean number of vertebral fractures was 3.8 ± 2.0. Thirty three of the 52 patients had a risk factor of low bone mass before pregnancy. Twelve had disorders or treatments (heparin) that might promote osteoporosis during pregnancy, while 14 had no trigger factors before or during pregnancy. Overall, phosphate and calcium levels were normal, except for hyperphosphoraemia in lactating women (90%). On DXA scan, osteoporosis predominated in the trabecular bone (spinal T-score - 3.4, hip T-score - 2). Only 10 patients had a repeat fracture, and the increase in bone mineral density during follow-up was considerable, and improved by bisphosphonates (annual gain + 10% in the spine) or teriparatide (+ 15%).

CONCLUSIONS

Pregnancy-related osteoporosis gives rise to multiple vertebral fractures. It is often promoted by risk factors before or during pregnancy. Its mechanism is still unknown. Treatment with bisphosphonates or teriparatide appears to improve the recovery of bone mineral density.

Approach to the patient with pregnancy and lactation-associated osteoporosis: A case report and a review of the literature

RATIONALE

Pregnancy and lactation-associated osteoporosis (PLO) is very rare, but it can cause severe vertebral compression fractures with disabling back pain. Although it is a rare, PLO must be kept in mind in the differential diagnosis in patients presenting with low back pain during or after pregnancy.

PATIENT CONCERNS

A 23-year-old woman who suffered from lumbago and fractures in the vertebral column 1 month after delivery.

DIAGNOSIS

Pregnancy and lactation-associated osteoporosis.

INTERVENTIONS

Combination therapy of calcium and vitamin D were used for treatment, as well as regular follow-up.

OUTCOMES

The patient's back pain had decreased significantly, the bone metabolic index, bone mineral density (BMD) had improved and she did not experience any recurrence.

LESSONS

Early diagnosis and treatment of calcium and vitamin D, as well as the efficacy of PLO intervention monitoring and evaluation are critical for the success of treatment.

Pregnancy-related osteoporosis and spinal fractures

Pregnancy-related osteoporosis is a very rare condition characterized by the occurrence of fracture during pregnancy or the puerperium. Despite its relative rarity, it can be a dangerous condition that causes severe back pain, height loss and disability. Normal physiologic changes during pregnancy, genetic or racial difference, obstetrical history and obstetrical disease, such as preterm labor or pregnancy-induced hypertension, are presumed risk factors of pregnancy-related osteooporosis. However, exact etiology and pathogenesis are uncertain. The management and natural history are still poorly defined. Traditional medications for osteoporosis are calcium/vitamin D and bisphosphonate. Concerns with bisphosphonate include accumulation in bone and fetal exposure in subsequent pregnancies. The newly developed medication, teriparatide, has shown good results. We report six cases of pregnancy-related osteoporosis and spinal fracture with literature review.

A study of bone turnover markers in gestational diabetes mellitus

INTRODUCTION

Gestational diabetes is defined as carbohydrate intolerance resulting in hyperglycemia of variable severity with the first recognition during pregnancy. Established risk factors for gestational diabetes mellitus (GDM) are maternal age, obesity, family history of diabetes, etc. Vitamin D, parathyroid hormone (PTH), and various other hormones are known for their function in maintaining calcium and phosphorous homeostatic. Furthermore, Vitamin D, PTH serum ionized calcium, and alkaline phosphatase (ALP) have been reported to be altered with glucose homeostasis. The present study compares the bone markers in pregnant women with and without gestational diabetes.

MATERIALS AND METHODS

This cross-sectional study was conducted at outpatient antenatal check-up clinic and outpatient diabetic clinics at J. N. Medical College and Hospital, Aligarh. One hundred pregnant females, of which fifty with GDM and fifty without GDM, were included in the study from January 2014 to November 2015. Detailed history, physical examination, and anthropometric measurement were done. Bone turnover markers in the form of Vitamin D, parathyroid hormone, serum ionized calcium, and serum ALP were measured in pregnant women who had gestational diabetes which was compared with normal pregnant women.

RESULTS

In our study, the mean age of participate of GDM group was 28.2 ± 3 years, while the mean age group in non-GDM group was 25.44 ± 2.78 years. Ionized calcium in GDM was found to be 4.606 ± 0.354 mEq/L, while in non-GDM, it was 4.548 ± 0.384 mEq/L, P = 0.430. Vitamin D came out to be 21.80 ± 9.48 ng/ml, while it was 32.346 ± 8.37 ng/ml in non-GDM group. Serum PTH in GDM group was 71.436 ± 36.189 pg/ml and 37.168 ± 8.128 pg/ml in nondiabetic gestational group. Serum ALP in GDM group was 9.1 ± 4.56 KA U/dl and 6.98 ± 2.2 KA U/dl in nondiabetic gestational group, P - 0.0038. In GDM group, there was a significant negative linear correlation between PTH and 25-hydroxyvitamin D with research correlation coefficient r = -0.9073, P = 0; there was a significant positive linear correlation coefficient between PTH and ALP with Persian correlation coefficient r = 0.6597, P = 0; there was no statistically significant correlation between PTH and ionized calcium r = 0.1416, P = 0.3267.

CONCLUSION

All GDM subjects should ideally be screened for serum calcium, vitamin D, PTH, ALP. If found impaired should immediately be corrected in order to prevent its adverse effects on maternal and fetal outcome. Vitamin D supplementation should ideally be initiated in all GDM females even if the above parameters are not investigated in Indian setup.

Successful neridronate therapy in pregnancy-associated osteoporosis

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

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

During pregnancy and lactation, female physiology adapts to meet the added nutritional demands of fetuses and neonates. An average full-term fetus contains ∼30 g calcium, 20 g phosphorus, and 0.8 g magnesium. About 80% of mineral is accreted during the third trimester; calcium transfers at 300-350 mg/day during the final 6 wk. The neonate requires 200 mg calcium daily from milk during the first 6 mo, and 120 mg calcium from milk during the second 6 mo (additional calcium comes from solid foods). Calcium transfers can be more than double and triple these values, respectively, in women who nurse twins and triplets. About 25% of dietary calcium is normally absorbed in healthy adults. Average maternal calcium intakes in American and Canadian women are insufficient to meet the fetal and neonatal calcium requirements if normal efficiency of intestinal calcium absorption is relied upon. However, several adaptations are invoked to meet the fetal and neonatal demands for mineral without requiring increased intakes by the mother. During pregnancy the efficiency of intestinal calcium absorption doubles, whereas during lactation the maternal skeleton is resorbed to provide calcium for milk. This review addresses our current knowledge regarding maternal adaptations in mineral and skeletal homeostasis that occur during pregnancy, lactation, and post-weaning recovery. Also considered are the impacts that these adaptations have on biochemical and hormonal parameters of mineral homeostasis, the consequences for long-term skeletal health, and the presentation and management of disorders of mineral and bone metabolism.

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

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

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

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

Osteoporosis presenting in pregnancy, puerperium, and lactation

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

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

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

Osteoporosis with vertebral fractures associated with pregnancy: two case reports

Pregnancy and lactation-associated osteoporosis (PAO) is a rare condition characterized by the occurrence of fragility fractures, most commonly vertebral, in late pregnancy or the early postpartum period. The prevalence, etiology and pathogenesis of this osteoporosis are unknown, although there are several hypotheses attempting to explain the etiopathogenesis of pregnancy associated osteoporosis. In this paper we present two cases of young women who developed severe PAO with vertebral fractures: a 42-year-old woman with a family history of osteoporosis, and a 21-year-old woman affected with myasthenia gravis. The case 1 presented fragility fracture of D12, L2, and L3. She did not have any disease causing osteoporosis. However, she had a positive familial history for osteoporosis and during pregnancy (12th week) she had a detached placenta, so bed rest was prescribed for two months. The case 2 presented multiple vertebral fracture. She was affected by myasthenia gravis, which was diagnosed two years before pregnancy, and treated with corticosteroid. In summary, pregnancy and lactation-induced osteoporosis, although it is a rare disorder, should be kept in mind when pregnant women or women in postpartum period develop persistent back pain and it is important to monitor the patients with risk factors or secondary causes of osteoporosis.

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

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

Pre-suckling calcium supplementation effectively prevents lactation-induced osteopenia in rats

During lactation, osteoclast-mediated bone resorption and intestinal calcium hyperabsorption help provide extra calcium for lactogenesis. Since the suckling-induced surge of pituitary prolactin (PRL) rapidly stimulates calcium absorption in lactating rats, it is hypothesized that pre-suckling oral calcium supplementation should be an efficient regimen to shift the calcium source from bone to diet, thereby slowing lactation-induced osteopenia. Our results showed that 30-min suckling markedly stimulated maternal duodenal calcium transport, which returned to the baseline at 45 min. Lactating rats given 4 mg/kg per dose calcium via a gavage tube at 90 min pre-suckling 4 doses a day for 14 days prevented a decrease in bone mineral density (BMD) of long bones and vertebrae. On the other hand, a single-dose supplementation, despite the same amount of calcium per day, appeared less effective. Because glucose and galactose further stimulated duodenal calcium transport in lactating rats, pre-suckling calcium supplement containing both sugars successfully normalized plasma ionized calcium and led to better bone gain than that with calcium alone. A histomorphometric study revealed that lactating rats given pre-suckling calcium plus monosaccharide supplement manifested greater trabecular bone volume and thickness and exhibited less eroded surface than in vehicle-treated lactating rats. Beneficial effects of the 14-day calcium supplementation persisted until 6 mo postweaning in dams and also elevated the baseline BMD of the offspring. In conclusion, our proof-of-concept study has corroborated that pre-suckling calcium supplements, especially regimens containing monosaccharides, are efficient in preventing osteopenia in lactating rats and could increase bone density in both breastfeeding mothers and neonates.

Influence of number of deliveries and total breast-feeding time on bone mineral density in premenopausal and young postmenopausal women

OBJECTIVES

Pregnancy and lactation have been associated with decline in bone mineral density (BMD). It is not clear if there is a full recovery of BMD to baseline. This study sought to determine if pregnancy or breast-feeding or both have a cumulative effect on BMD in premenopausal and early postmenopausal women.

STUDY DESIGN

We performed single-center cohort analysis. Five hundred women aged 35-55 years underwent routine BMD screening from February to July 2011 at a tertiary medical center. Patients were questioned about number of total full-term deliveries and duration of breast-feeding and completed a background questionnaire on menarche and menopause, smoking, dairy product consumption, and weekly physical exercise. Weight and height were measured. Dual-energy X-ray absorptiometry was used to measure spinal, dual femoral neck, and total hip BMD.

MAIN OUTCOME MEASURES

Associations between background characteristics and BMD values were analyzed.

RESULTS

Sixty percent of the women were premenopausal. Mean number of deliveries was 2.5 and mean duration of breast-feeding was 9.12 months. On univariate analysis, BMD values were negatively correlated with patient age (p=0.006) and number of births (p=0.013), and positively correlated with body mass index (p<0.001). On multiple (adjusted) logistic regression analysis, prolonged breast-feeding duration, but not number of deliveries, was significantly correlated to a low BMD (p=0.008). An effect was noted only in postmenopausal women. The spine was the most common site of BMD decrease.

CONCLUSIONS

Prolonged breast-feeding may have a deleterious long-term effect on BMD and may contribute to increased risk of osteoporosis later in life.

A case of teriparatide on pregnancy-induced osteoporosis

Pregnancy-induced osteoporosis is a rare disorder characterized by fragility fracture and low bone mineral density (BMD) during or shortly after pregnancy, and its etiology is still unclear. We experienced a case of a 39-year-old woman who suffered from lumbago 3 months after delivery. Biochemical evidence of increased bone resorption is observed without secondary causes of osteoporosis. Radiologic examination showed multiple compression fractures on her lumbar vertebrae. We report a case of patient with pregnancy-induced osteoporosis improved her clinical symptom, BMD and bone turnover marker after teriparatide therapy.

Compression fracture in postpartum osteoporosis

Osteoporosis is mainly a problem in postmenopausal women. However, we had a case of postpartum compression fracture associated with osteoporosis. A 42-year-old multiparous woman had undergone tertiary cesarean section without complications 1 month before. She was breast-feeding her baby and had no other bone-related complication history. She did not exercise on a regular basis. She experienced back pain abruptly and was diagnosed with a recent compression fracture of T12, L1, and L3. We evaluated this rare case of postpartum osteoporosis and compression fracture.

Duodenal villous hypertrophy and upregulation of claudin-15 protein expression in lactating rats

In lactation, the intestinal absorption of nutrients and minerals, especially calcium, is markedly enhanced to supply precursors for milk production. Little is known regarding the mechanism of this lactation-induced intestinal hyperabsorption. However, it has been postulated to result from villous hypertrophy with enlarged absorptive area and the upregulation of the cation-selective tight junction protein claudin-15, which could form calcium-permeable paracellular pores, thereby enhancing the paracellular calcium absorption. Here, we demonstrated in the duodenum of 21-day lactating rats that there were increases in the villous height, villous width and crypt depth, which together led to expansion of absorptive surface area. Quantitative real-time PCR further showed that the mRNA levels of claudin-10 and -15 were increased in the duodenal mucosal cells of lactating rats as compared to age-matched unmated control rats. However, immunohistochemical analysis revealed the lactation-induced upregulation of claudin-15, but not claudin-10 protein expression in the duodenal villous cells. The present results, therefore, corroborated the previous hypothesis that lactation induced intestinal absorption of calcium and perhaps other cation minerals, in part, by increasing villous absorptive area and claudin-15 protein expression.

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

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

Calcium and bone metabolism disorders during pregnancy and lactation

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

Osteoporosis in diabetes mellitus: Possible cellular and molecular mechanisms

Osteoporosis, a global age-related health problem in both male and female elderly, insidiously deteriorates the microstructure of bone, particularly at trabecular sites, such as vertebrae, ribs and hips, culminating in fragility fractures, pain and disability. Although osteoporosis is normally associated with senescence and estrogen deficiency, diabetes mellitus (DM), especially type 1 DM, also contributes to and/or aggravates bone loss in osteoporotic patients. This topic highlight article focuses on DM-induced osteoporosis and DM/osteoporosis comorbidity, covering alterations in bone metabolism as well as factors regulating bone growth under diabetic conditions including, insulin, insulin-like growth factor-1 and angiogenesis. Cellular and molecular mechanisms of DM-related bone loss are also discussed. This information provides a foundation for the better understanding of diabetic complications and for development of early screening and prevention of osteoporosis in diabetic patients.

Persistence of back pain symptoms after pregnancy and bone mineral density changes as measured by quantitative ultrasound--a two year longitudinal follow up study

BACKGROUND

Previous research has shown a loss of bone mineral density (BMD) during pregnancy. This loss has been correlated to the occurrence of back pain symptoms during pregnancy. The objective of this study was to evaluate whether persistence of back pain symptoms 2 years after pregnancy could be associated with BMD changes as measured by quantitative USG of the os calcis.

METHODS

A cohort of patients who reported significant back pain symptoms during pregnancy were surveyed for persistent back pain symptoms 24 to 28 months after the index pregnancy. Os calcis BMD was measured by quantitative ultrasound and compared with the BMD values during pregnancy.

RESULTS

A cohort of 60 women who had reported significant back pain symptoms in their index pregnancy completed a 24-28 months follow-up survey and BMD reassessment. Persistence of significant back pain symptoms was seen in 24 (40%) of this cohort. These women had higher BMD loss during pregnancy compared to those without further pain (0.047 Vs 0.030 g/cm2; p = 0.03). Those that remained pain free after pregnancy appeared to have completely recovered their BMD loss in pregnancy, while those with persistent pain had lower BMD values (ΔBMD - 0.007 Vs - 0.025 g/cm2; p = 0.023) compared to their early pregnancy values.

CONCLUSION

Persistence of back pain symptoms after pregnancy could be related to an inability to recover fully from BMD loss during the index pregnancy.

Bone modeling in bromocriptine-treated pregnant and lactating rats: possible osteoregulatory role of prolactin in lactation

The lactogenic hormone prolactin (PRL) directly regulates osteoblast functions in vitro and modulates bone remodeling in nulliparous rats, but its osteoregulatory roles in pregnant and lactating rats with physiological hyperprolactinemia remained unclear. Herein, bone changes were investigated in rats treated with bromocriptine (Bromo), an inhibitor of pituitary PRL release, or Bromo+PRL at different reproductive phases, from mid-pregnancy to late lactation. PRL receptors were strongly expressed in osteoblasts lining bone trabeculae, indicating bone as a target of PRL actions. By using dual energy X-ray absorptiometry, we found a significant increase in bone mineral density in the femora and vertebrae of pregnant rats. Such pregnancy-induced bone gain was, however, PRL independent and may have resulted from the increased cortical thickness. Bone trabeculae were modestly changed during pregnancy as evaluated by bone histomorphometry. On the other hand, lactating rats, especially in late lactation, showed massive bone loss in bone trabeculae but not in cortical shells. Further study in Bromo- and Bromo+PRL-treated rats suggested that PRL contributed to decreases in trabecular bone volume and number and increases in trabecular separation and eroded surface, as well as a paradoxical increase in bone formation rate in late lactation. Uncoupling of trabecular bone formation and resorption was evident in lactating rats, with the latter being predominant. In conclusion, pregnancy mainly induced cortical bone gain, whereas lactation led to trabecular bone loss in both long bones and vertebrae. Although PRL was not responsible for the pregnancy-induced bone gain, it was an important regulator of bone modeling during lactation.

Is prolactin the cardinal calciotropic maternal hormone?

To produce offspring, mothers require a large amount of calcium for fetal growth and milk production. Increased calcium demand leads to enhanced intestinal calcium absorption and stockpiling of bone calcium in pregnancy prior to demineralization in lactation. These coordinated events must be carefully organized by calciotropic hormone(s), but the classical hormones, namely 1,25-dihydroxyvitamin D(3), parathyroid hormone and calcitonin, do not appear to be responsible. Plasma prolactin (PRL) levels are elevated during pregnancy and, in view of the presence of PRL receptors in gut, bone and mammary glands, as well as recent evidence of the stimulatory effects of PRL on intestinal calcium transport, bone resorption and mammary calcium secretion, we postulate that PRL is the cardinal calciotropic hormone during pregnancy and lactation.

Postpartum Spinal Osteoporosis: An Unusual Cause of Low Back Pain

Postpartum spinal osteoporosis (PPSO) is a rare condition characterized by osteoporosis associated with pregnancy. The most common symptoms are low back pain and loss of height due to vertebral compression fractures. It is observed in the last trimester of pregnancy or subsequent to delivery. Herein; we report 2 cases of PPSO who presented with low back pain in the postpartum period, aiming to draw attention to this unusual cause of low back pain. (Turk J Rheumatol 2010; 25: 47-9)