Scandinavian Journal of Rheumatology

ISSN: 0300-9742 (Print) 1502-7732 (Online) Journal homepage: http://www.tandfonline.com/loi/irhe20

Osteoporosis during pregnancy and its

management

R. Smith & A.J. Phillips

To cite this article: R. Smith & A.J. Phillips (1998) Osteoporosis during pregnancy
and its management, Scandinavian Journal of Rheumatology, 27:sup107, 66-67, DOI:
10.1080/03009742.1998.11720768

To link to this article: http://dx.doi.org/10.1080/03009742.1998.11720768

Published online: 13 Apr 2016.

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 Scand J Rheumatol 1998;27 Suppl 107:66-7

Osteoporosis during pregnancy and its management

R. Smith and A.J. Phillips

Departments of Metabolism & Radiology, Nuffield Orthopaedic Centre, Headington, Oxford, UK

Osteoporosis leading to fracture can occur during pregnancy. Bone density may be low before pregnancy due to recognised
causes such as coeliac disease, osteogenesis imperfecta and previous anorexia nervosa (secondary osteoporosis). In
some patients there is no identifiable cause. This condition is referred to as "pregnancy associated or pregnancy related
osteoporosis"; it is not known whether pregnancy causes the osteoporosis or merely coincides with it. Typically the loss
of bone leads to vertebral fracture with loss of height or pain in the hips also sometimes with fracture. Symptoms most
often begin in the third trimester of the first pregnancy and improve after delivery; they do not usually recur in subsequent
pregnancies. The cause is unknown and there is no specific treatment; follow up bone density measurements show that the
osteoporosis slowly improves post partum. Recent research in non osteoporotic women shows that breast feeding maintains
a low bone density; it is therefore contraindicated in pregnancy associated osteoporosis.

Osteoporosis associated with pregnancy is rare and delivery. The symptoms were sufficiently severe to
has no identified cause. For this reason it is difficult distinguish them from the discomfort occurring in
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to know whether pregnancy causes excessive bone
loss or whether the two conditions are coinciden-
tally associated. Recent relevant work deals with
its clinical presentation and outcome ( 1); with the
changes in bone density after an affected pregnancy
(2); and with the effects of pregnancy and lactation
on the bone density of the normal skeleton (3 ).
Clinical Features
Typically osteoporosis associated with pregnancy
presents in the third trimester of the first pregnancy,
with pain in the back and loss of height due to
vertebral collapse ( 1,4 ). The first symptoms may
also occur in the hip with pain on weight bearing
sufficient to confine the subject to bed; in severe
cases of the femoral neck fracture can occur. Post
partum densitometry shows a significant reduction
at both hip and vertebral sites, irrespective of the
site of the first symptom (2). Because of this and
because the symptoms improve after delivery the
two conditions are probably related. However, pain
and osteoporosis in the hip may occur as a specific
syndrome of "transient idiopathic osteoporosis" not
limited to pregnancy (5). For the present purposes
osteoporosis of the spine and hip in pregnancy are
considered as part of the same syndrome.
A recent review described the clinical features
and outcome in 24 patients with this syndrome
studied for up to 24 years ( 1). Symptoms occurred
most often in the first pregnancy (17 patients) at
a mean age of 27 years (range 21-36 years); back
pain in late pregnancy or post partum occurred in 18
and hip pain in 5; in most symptoms improved after
Correspondence: R. Smith. Metabolic Unit, Nuffield Orthopaedic
Centre Windmill Road, Headington, Oxford OX3 7LD, UK
a non osteoporotic pregnancy. Significant loss of
vertebral height was common.
Investigations
The number of investigations which can be done
during pregnancy are limited. Routine biochem-
ical measurements are normal, although changes
have been described in the calciotropic hormones
(6; below). During pregnancy radiographic mea-
surements are limited to magnetic resonance imag-
ing; (MRI) and to ultrasound; MRI of the hip is
useful to differentiate pregnancy associated osteo-
porosis from aseptic necrosis; a particular feature
of the former is extensive oedema (I).
Measurements of bone density are necessarily
done after delivery and the bone density before
pregnancy is rarely known. Radial bone density can
be within the normal range but DXA measurements
of the spine are invariably very low (I). Some
reports describe bone histology. However biopsies
have been taken at very different times after the
effects of pregnancy and the appearances have been
variably interpreted (6); they are compatible with
osteoblast failure.
Outcome
In general the prognosis for a particular pregnancy
is good and the symptoms rapidly improve after
delivery. It is unusual for the symptoms to recur in
subsequent pregnancies. Thus I 0 women who had
osteoporosis with fracture in the first pregnancy had
no recurrence in 10 out of 14 subsequent pregnan-
cies with mild symptoms only in the remainder (I).

66

The loss of height persists, as one would expect in
vertebral fracture; and in those who have hip pain
as a major symptom this may continue or recur in
the opposite hip. An important point is what hap-
pens to the bone mineral density (BMD) after an
affected pregnancy (2). This has been recently ex-
amined in 13 women with low spine (Z-score mean
-3.49) and hip (mean -1.97) BMD who had mea-
surements at variable times for up to eight years
after an affected pregnancy. Significant increases
with time in the mean age related BMD (Z-score)
were found, particularly in the spine. These data
show that the skeleton slowly recovers from the ef-
fects of pregnancy and also suggest that the bone
density was not reduced before pregnancy. How-
ever, since there are considerable changes in bone
density with consecutive pregnancies in non osteo-
porotic skeletons, especially when breast feeding
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is prolonged (3), it is difficult to be certain of the
significance of these preliminary results in women
with pregnancy associated osteoporosis.
Management
There are no reports of specific treatment in groups
of patients with pregnancy associated osteoporo-
sis. Most agents which have been used, such as
calcitonin or bisphosphonates have been given be-
cause of their anti-resorptive effects (7). Since im-
provement - in symptoms at least - often oc-
curs spontaneously, it will be difficult to estab-
lish the efficacy of any form of treatment. Some
simple measures are important; first, the diagnosis
must be thought of and established; second, spe-
cific stresses on bone which might lead to fracture
must be avoided, such as forceful delivery leading
to femoral neck fracture. Thirdly, breast feeding,
which is a major cause of maternal calcium loss,
should be suppressed (3).
Cause
There are still opposing views on the cause of preg-
nancy associated osteoporosis. Some regard this as
structural failure of a skeleton of previously low
bone density brought about by the minor changes
in calcium homeostasis and the increased mechan-
ical forces associated with pregnancy (8,9), whilst
Osteoporosis during pregnancy and its management
others (including ourselves 10) consider this a sep-
arate syndrome. Since it is largely confined to
a specific pregnancy, usually the first, it may be
related to a particular foetus. Early studies sug-
gested a failure of the usual compensatory mecha-
nisms in calciotropic hormones, but did not include
measurements of parathyroid hormone related pro-
tein, PTHrP, important in the physiology of preg-
nancy (6). Measurements of bone density in nor-
mal women during consecutive pregnancies show
that the most marked bone loss occurs during breast
feeding (3). Interestingly this loss is unaffected by
calcium supplementation but bone density increases
when breast feeding is stopped (3,11,12).
References
I. Smith R, Athanasou N, Ostlere SJ, Vi pond SE. Pregnancy
associated osteoporosis Quarterly Journal of Medicine
1995; 88:865-78.
2. Phillips AJ, Ostlere SJ, Smith R. Pregnancy associated
osteoporosis : follow up of bone mineral density Journal
of Bone and Mineral Research 1998; 13:521 (Abstract).
3. Laskey MA, Prentice A. Effect of successive lactations
and pregnancy on spine bone status Journal of Bone and
Mineral Research 1997; 12:1527 (Abstract).
4. Dunne F, Waiters B, Marshall T, Heath DA. Pregnancy
associated osteoporosis. Clinical Endocrinology 1993:
39:487-90.
5. Guerra JJ, Steinberg ME. Distinguishing transient osteo-
porosis from avascular necrosis of the hip. Journal of
Bone and Joint Surgery 1995; 77A:616-24.
6. Smith R, Stevenson JC, Winearls CG, Woods CG.
Wordsworth BP. Osteoporosis of pregnancy. Lancet
1985; 1:1178-80.
7. Khovidhunki W, Epstein S. Osteoporosis in pregnancy
Osteoporosis International 1996; 6:345-54.
8. Rizzoli R, Bonjour JP. Pregnancy-associated osteoporosis
Lancet 1996; 347:1274-6 (Letter).
9. Khastgir G, Studd J. Pregnancy associated osteoporo-
sis British Journal of Obstetrics and Gynaecology 1994:
101:836-8.
10. Smith R, Ostlere S, Athanasou N. Vipond S. Pregnancy
associated osteoporosis Lancet 1996; 348:402-3 (Letter).
11. Kalkwarf HJ, Specker BL. Bone mineral loss during lac-
tation and recovery after weaning Obstetrics and Gynae-
cology 1995: 86:26-32.
12. Prentice A. Calcium supplementation during breast feed-
ing. New England Journal of Medicine 1997; 337:558-9.
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