Abstract
Pregnancy associated osteoporosis (PAO) is a rare clinical condition that may affect women during third trimester of pregnancy or after delivery. Little is known about the prevalence, cause, risk factors and prognosis of PAO. It can cause severe, prolonged back pain with one or more vertebral fractures and height loss. Herein we report a case of PAO in a 32 year-old female who presented with severe back pain with multiple vertebral fractures started 1 month after delivery. There were delayed menarche and low dietary calcium intake in history. The radiological examinations have shown compression fracture of 8th thoracic vertebra and wedging of 11th and 12th thoracic vertebras and whole lumbar spine. In the bone mineral density (BMD) testing, total lumbar spine T-score and Z-score were -2,8 and femoral neck T-score and Z-score were -1,2 and -1,1 respectively. There were no abnormalities in laboratory findings except mild alkaline phosphatase elevation and low 25-hydroxy vitamin D level. Three months after delivery for pain reduction T8 kyphoplasty was applied. Along 5-year follow up vitamin D3, calcium, calcitonin, bisphosphonate, GABA anologs, analgesics, physical agents, dry needling were used for treatment. Back pain improved with all kinds of treatments significantly (On the 10-point visual analog scale (VAS) pain scores decreased from 10 to 3). The patient had continued pain in the operated area with decreased intensity (VAS score of 3) along 5-year follow up. There were no new fractures and marked recovery of spine BMD was observed during the same period. Activities of daily living improved permenantly. When back pain occurs in a patient at last trimester of pregnancy or early postpartum period, PAO should be considered in differential diagnosis and long term support should be planned for patient’s well being. (Turkish Journal of Osteoporosis 2014;20: 36-40)
Keywords: Pregnancy associated osteoporosis, vertebral fracture, management
Giris
Kadinlarda sikça rastlanilan osteoporozun (OP) aksine gebelik ile iliskili osteoporoz (GIO) nadir görülen bir klinik tablodur. GIO’nun etiyolojisi ve patofizyolojisi tam olarak bilinmemektedir (1). Gebeligin bir sonucu olarak mi gelistigi yoksa gebelikle rastlantisal olarak mi birlikte görüldügü halen aydinlatilamamistir. Fetal iskeletin mineralizasyonu ve maternal plazmanin genislemesi maternal kalsiyum ihtiyacini arttirmaktadir. Kalsiyum ihtiyaci kalsiyumun barsaktan emiliminin arttirilmasi, böbrekten atiliminin azaltilmasi ve maternal kemikten kalsiyum mobilizasyonu ile saglanmaktadir. Hormonal degisiklikler, kilo artisi, aktivite kisitlanmasina neden olabilen gebelik komplikasyonlari, ilaç kullanimi maternal kemik sagligini etkilemektedir (2). Gebelik ve laktasyon döneminde kemik ve mineral metabolizmasindaki degisiklikler fetüse yeterli kalsiyum geçisine izin vermektedir. Dolayisiyla gebelik ve emzirme döneminde görülen %3-%6’lik kemik kaybinin ve omurga kiriklarinin GIO’dan kaynaklanabilecegi varsayilmaktadir (1). Gebelik ile iliskili OP siklikla ilk gebelikte görülür ve genellikle tekrarlayici degildir. Tani konulurken gebelik sirasinda agri ve kiriklara neden olabilen ikincil osteoporoz nedenleri, geçici osteoporoz, osteonekroz, simfiz pubis disfonksiyonu dislanmalidir (3,4). Su ana kadar GIO tedavisi ile ilgili herhangi bir kilavuz bulunmadigi gibi herhangi bir ortak görüs de saglanabilmis degildir. Bu nedenle tedavi planinin hastaya göre belirlenmesi gerekmektedir. Gebeligin son 3 ayinda veya erken postpartum dönemde sirt, bel agrisi yakinmasi ile basvuran kadinlarda ayirici tanida GIO düsünülmelidir (1).
