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

Minodronate for severe multiple vertebral fractures due to pregnancy- and lactation-associated osteoporosis: a case report and literature review

Pregnancy- and lactation-associated osteoporosis (PLO) is a rare type of premenopausal osteoporosis, typically occurring during the third trimester of pregnancy and the early postpartum lactation period. This report presents a case involving severe multiple vertebral fractures due to PLO with low bone mineral density (BMD) and heightened bone turnover. A 39-year-old primiparous Japanese woman reported low back pain (LBP) starting at 28 weeks of pregnancy. The pain temporarily improved after delivery, although the LBP recurred and worsened 2 months into breastfeeding. Thereafter, the patient visited the Obstetrics and Orthopedic departments. Plain radiographs of the thoracic and lumbar spine showed loss of vertebral body height at the T4-12 and L1-3,5 vertebrae, leading to a diagnosis of 13 fractured vertebrae. BMD and serum bone turnover markers revealed low bone density and heightened bone turnover. In the absence of any identified alternative cause of secondary osteoporosis, the diagnosis was severe PLO with 13 vertebral fractures related to pregnancy and lactation. After treatment with bisphosphonates and an active vitamin D analog, the patient exhibited an increased BMD and normalization of bone turnover and resumed regular daily activities. Although the optimal PLO treatment strategy remains uncertain, bisphosphonates are an option; however, bisphosphonates can potentially affect the fetus through placental transfer. Therefore, careful consideration is required for patients planning pregnancy. Despite bisphosphonates' widespread use and cost-effectiveness, selecting PLO medications involves multiple factors, necessitating further research.

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.

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.

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.

Severe Bone Microarchitecture Impairment in Women With Pregnancy and Lactation-Associated Osteoporosis

Context

Pregnancy- and lactation-associated osteoporosis (PLO) is a rare condition characterized by fragility fractures, mostly vertebral, during the third trimester of pregnancy or the early postpartum period.

Objective

The aim of this study was to evaluate bone microarchitecture in women with PLO to better understand the pathophysiology of this disease.

Methods

In this retrospective study, we included women with PLO referred to our bone center between November 2007 and July 2012. We assessed bone mineral density (BMD) by dual-energy x-ray absorptiometry, bone turnover markers, and bone microarchitecture by high-resolution peripheral quantitative computed tomography. Results were compared with a control group of healthy lactating women.

Results

Of the 7 primiparous patients with PLO, 6 suffered vertebral fractures and 1 developed a hip fracture during the seventh month of gestation. Fractures occurred within the eighth month of pregnancy and the fourth month post partum; vertebral fractures were multiple in 85.7%. Major or minor risk factors for osteoporosis were present in 86% of our patients. Trabecular density, number, and thickness were 34%, 20% and 22% lower than controls (P < .01, P = .01, and P = .01, respectively). Cortical parameters were also deteriorated but to a lesser extent.

Conclusion

In comparison with healthy lactating women, patients with PLO presented severe deterioration of bone trabecular and cortical microarchitecture. This significant compromise may explain the occurrence of multiple fractures in these otherwise healthy young women. Further prospective studies are needed to determine whether bone microarchitecture might be able to be restored in the future.

Woman with Pregnancy and Lactation-Associated Osteoporosis (PLO)

Osteoporosis is a disease known to reduce bone density and to damage bone microarchitecture leading to increased fracture risk. Osteoporosis is one of the most common diseases among the middle aged and elderly people that impose high costs on the community. So far, despite rare cases of pregnancy and lactation-associated osteoporosis (PLO) reported in Iran, it can be treated with accurate diagnosis. Patient Introduction. A 24-year-old woman was referred to the outpatient rheumatologic clinic after the cesarean section during the first pregnancy with severe back pain. In the thoracolumbar radiographs, a loss of vertebral height in the T11 to L5 vertebra was recognized. Other complaints were abdominal pain and anemia. In order to evaluate the gastrointestinal disease and celiac, the patient underwent gastrointestinal and hematologic workup. Ultimately, secondary causes of the osteoporosis were excluded. Based on the patient's clinical course, imaging finding, and exclusion of other causes of osteoporosis, the patient was diagnosed with PLO. Conclusion. Clinicians should be aware of PLO as rare complication of pregnancy. The situation should be particularly considered in females offering from new onset back pain in the third trimester of pregnancy or breastfeeding period.

Relationship of breastfeeding duration with joint pain and knee osteoarthritis in middle-aged Korean women: a cross-sectional study using the Korea National Health and Nutrition Examination Survey

Background

The effect of joint health on the quality of life of middle-aged and older women is becoming more widely recognized with the aging of the world’s population. However, the association of long-term breastfeeding with joint pain and knee osteoarthritis has not been fully examined. The aim of this study was to determine the association of prior breastfeeding duration with current joint pain and knee osteoarthritis in middle-aged Korean women.

Methods

This cross-sectional study was conducted among 3454 women aged ≥50 years who underwent knee radiography and answered a questionnaire on breastfeeding and joint pain for the 5th Korea National Health and Nutrition Examination Survey (2010–2011). After adjusting for confounding sociodemographic, medical history, and obstetric and gynecologic variables, logistic regression analysis was conducted to analyze the prevalence of joint pain and knee osteoarthritis according to breastfeeding and its duration.

Results

Among the 3454 participants, 298 had not breastfed and 1042, 815, and 1299 had breastfed for 1–24, 25–48, and ≥ 49 months, respectively. Of all participants, 1731 had joint pain and 739 were diagnosed with knee osteoarthritis after radiography.

Using the non-breastfeeding group as a reference, the odds ratio (OR) for joint pain among women who breastfed ≥1 month was 1.49 (95% confidence interval [CI] 1.01–2.21). As the breastfeeding duration increased, the OR of joint pain prevalence also increased (p for trend; p = 0.002). For knee osteoarthritis, the OR was 2.30 in the 25–48 months group (95% CI 1.09–4.86). The OR of knee osteoarthritis in the ≥49 months group was 2.17 (95% CI 1.01–4.64). Sensitivity analysis after selecting only participants aged ≥60 years showed that the prevalence of joint pain and knee osteoarthritis was more positively correlated with extended breastfeeding duration (joint pain, p for trend; p = 0.005) (knee osteoarthritis, p for trend; p = 0.012).

Conclusions

Long-term feeding for more than 25 months was associated with an increased prevalence of joint pain and degenerative arthritis in Korean women aged ≥50 years.

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.

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.

Spinal compression fractures due to pregnancy-associated osteoporosis

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Influence of simvastatin-loaded implants on osseointegration in an ovariectomized animal model

The success of bone implants in the presence of osteoporosis is limited by lack of osseointegration between the implant and the natural bone. This study applied an electrochemical process to deposit simvastatin-nanohydroxyapatite (HA) coatings on porous implant surfaces and investigated the effects of these simvastatin-HA coatings on implant surfaces in an animal model of osteoporosis. In this study, simvastatin-HA coated implants were inserted into the tibia of osteoporotic rats. After 2, 4, and 12 weeks, tissue was retrieved for histomorphometric evaluation. The results indicated that the simvastatin-HA coatings increased bone-implant contact and new bone formation around implant surfaces. In conclusion, implants loaded with simvastatin by an electrochemical process improved implant osseointegration in osteoporotic rats. Furthermore, the increased concentration of simvastatin could affect the osseointegration, but the dose-effects also need further investigation.