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Osteoporosis
increase reported with calcium and vitamin D alone.
20
Of course, even The treatment of TOH is mainly based on bed rest and limited
when bisphosphonates are used, adequate calcium and vitamin D are physical activity, using walkers or crutches to avoid weight-bearing,
absolutely necessary. Unfortunately, the small number of cases and appropriate hip mobilisation to prevent muscular contractures and
different treatment approaches do not allow a clear evaluation of use of non-steroidal anti-inflammatory drugs and analgesics for
treatment efficacy, so a rational strategy is still impossible. pain. Different surgical approaches after delivery have been
described in patients with hip fracture.
30
In cases with bilateral hip
Transient Osteoporosis of the Hip pain, elective Caesarean section has been proposed.
37
Regarding the
This disorder has been given several different names: TOH, use of bone-specific drugs, a study on three women with TOH used
algodystrophy of the hip and idiopathic osteoporosis in pregnancy. sodium fluoride and calcium: two women had some improvement
It is a focal, transient osteoporosis primarily affecting the hip. It and the third remained stable.
38
Bisphosphonates also seem to be
generally occurs in the third trimester of pregnancy, without previous effective.
39
In a case of severe, persistent hip pain without
trauma or evident diseases. It starts with pain and limited hip mobility improvement after delivery, alendronate treatment effectively
and is frequently complicated by a fracture, the highest risk being relieved pain and other symptoms.
40
towards the end of pregnancy.
29–31
In another study on 13 pregnant and lactating women with TOH, eight
Affected women have unilateral or bilateral hip pain and limping. patients were treated with salmon calcitonin (100IU every other day)
They can sustain femoral neck fractures. A recent report described plus calcium supplements. The other five women were treated with
the first case of non-traumatic, bilateral, acetabular and femoral neck rest and mild analgesics only. The eight calcitonin-treated women had
fractures in a 23-year-old breastfeeding woman six days after her a faster resolution of pain and limping and a greater increase in hip
first delivery. The condition was so severe that it required bilateral BMD with respect to the other five. This study is also important
total hip arthroplasty.
32
because it showed the recurrence of TOH in two of the eight women
who had a subsequent pregnancy.
41
Reduced BMD of the affected hip has been observed in some
studies. With magnetic resonance imaging (MRI), joint effusion in Osteoporosis Associated with Heparin
the affected hip and diffuse signal abnormalities on the marrow of The risk of thromboembolic complications is increased during
the femoral head have been shown.
33
Radionuclide bone imaging pregnancy and immediately after delivery due to hypercoagulability,
performed a few days after the onset of symptoms is the best stasis of the venous circulation and delivery-related trauma. Women
with a previous history of thrombosis have a 5–12% probability of
recurrence. For this reason, prophylactic antithrombotic therapy is
The main forms of pregnancy-related
normally prescribed for a relatively long time.
osteoporosis are post-pregnancy spinal
Heparin used to be the choice treatment, as it does not cross the
osteoporosis, transient osteoporosis of
placenta. However, the use of heparin in pregnancy can lead to
osteoporosis in up to 30% of cases and to vertebral fractures in 2%.
42,43
the hip and osteoporosis associated
According to one of these studies,
42
the proximal hip BMD was
with heparin.
decreased by 10% or more from the baseline value in four of 14
women examined immediately after delivery.
technique for the diagnosis of pregnancy TOH. In fact, TOH is In one of the first reports of heparin-induced osteoporosis during
characterised by increased radionuclide uptake in the femoral pregnancy, a significant reduction of the bone cortex of the phalanges
head, whereas reduced uptake occurs in hip osteonecrosis. In was observed in women who received heparin for 25 weeks with
addition, the uptake is within the bone in TOH, while it is respect to those who received it for only seven weeks.
44
In a large
characteristically synovial in infection or inflammatory arthritis, so retrospective study on 184 women, 17% of those treated with heparin
that a differential diagnosis seems easy.
34
Laboratory tests are showed osteopenia at X-ray examination of the spine or hip
usually as expected in any pregnant woman, but in some cases a immediately after delivery. After six to 12 months, the majority of
slightly increased erythrocyte sedimentation rate and low 1,25(OH)
2
cases recovered.
45
D levels have been reported.
35
The aetiology of heparin-induced osteoporosis is not clear: decreased
Various aetiological factors have been proposed to explain this collagen synthesis, increased osteoclast activity, secondary hyper-
localised osteoporosis: femoral venous stasis caused by the pregnant parathyroidism due to chelation of calcium ions and inhibition of
uterus, local ischaemia, viral infection, marrow hypertrophy and foetal calcification due to the high affinity of heparin for calcium have all
pressure on the obturator nerve. Regarding the possible metabolic been proposed. In rats, only increased osteoclast activity and bone
alterations involved in TOH, negative calcium balance, increased resorption have been demonstrated.
46
demand for protein and minerals and increased activity of the adrenal
cortex have been considered.
29,36
Although there is no evidence of dose dependence, the prevention of
heparin-associated osteoporosis is based on the use of the lowest
An improvement in pain occurs rapidly after the end of pregnancy. possible doses of heparin, plus calcium supplements (1,000mg/day)
Both symptoms and radiological alterations usually disappear and vitamin D; however, the effectiveness of this approach is still
within two to nine months of delivery. In some cases, persistent hip unproven.
47
In some cases, bisphosphonates have been given after
pain has been reported for six months or longer. delivery, but their effect could not be clearly evaluated.
32 EUROPEAN MUSCULOSKELETAL REVIEW
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