|Year : 2013 | Volume
| Issue : 2 | Page : 108-110
Transient osteoporosis of pregnancy: A case report and review of anesthetic implications
Victor Eduardo Anillo Lombana1, Estibaliz Alsina Marcos2, Emilia Guasch Arévalo3, Fernando Gilsanz Rodríguez4
1 Department of Obstetrics Anesthesia and Critical Care, Third year resident of Anesthesiology. Hospital Universitario La Paz. Madrid, Spain
2 Department of Obstetrics Anesthesia and Critical Care. Hospital Universitario La Paz. Madrid, Spain
3 Section Chief of Anesthesiology and Critical Care. Hospital Universitario La Paz. Madrid, Spain
4 Profesor, Chief, Department of Anesthesiology, Hospital Universitario La Paz. Madrid, Spain
|Date of Web Publication||19-Dec-2013|
Victor Eduardo Anillo Lombana
Santuario de Valverde. Numero 18. Portal E. Piso 1. Puerta A, 28049 Madrid
Source of Support: None, Conflict of Interest: None
Transient osteoporosis of pregnancy (TOP) is a rare and self-limited disease with an unknown etiology. A 29-year-old woman complained at her 39 th week of pregnancy of focalized pain in the right hip with functional disability and instability. Pain increased during the early puerperium after removal of the epidural catheter. The X-ray and magnetic resonance imaging (MRI) showed a displaced intracapsular fracture in the right femur, which needed surgical correction. The patient underwent urgent orthopedic surgery.
We reviewed the anesthetic implications of this rare disease, particularly the use of a regional technique that removes the restrictive effect of the hip pain, and therefore increases the risk of a fracture.
Keywords: Anesthetic implications, hip fracture, osteoporosis of pregnancy, pregnancy
|How to cite this article:|
Lombana VE, Marcos EA, Arévalo EG, Rodríguez FG. Transient osteoporosis of pregnancy: A case report and review of anesthetic implications. J Obstet Anaesth Crit Care 2013;3:108-10
|How to cite this URL:|
Lombana VE, Marcos EA, Arévalo EG, Rodríguez FG. Transient osteoporosis of pregnancy: A case report and review of anesthetic implications. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2019 Dec 13];3:108-10. Available from: http://www.joacc.com/text.asp?2013/3/2/108/123311
| Introduction|| |
Transient osteoporosis of pregnancy (TOP) is a rare and self-limited disease with an unknown etiology. During pregnancy, osteoporosis presents with gradual onset of groin pain and antalgic gait not preceded by trauma. Pathological fractures are the most serious complication of this condition. Considerations relevant to anesthesia management are discussed.
| Case Report|| |
A 29-year-old woman primigravida with 39 weeks' gestation and no significant medical history or allergies presented to our emergency department (ED), with severe pain unrelated to trauma or infection in the right hip and lower back that had initially occurred 5 weeks before admission. At the examination, the hip was considerably tender to palpation and passive motion reproduced the pain. There was no leg-length discrepancy. No plain radiographs were performed.
The patient had no history of steroid therapy, osteoporosis, or alcohol abuse. Her body temperature and serological parameters were normal, including white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and basic inflammatory serology. There were no problems during antenatal check-ups.
Labor was induced and a lumbar epidural catheter was placed via mid-line approach, confirmed by loss of resistance technique with the patient in sitting position, and was threaded up to a length of 4 cm at the interspace between the third and fourth lumbar vertebrae. A test dose of 3 ml of 0.25% bupivacaine with epinephrine 5 μμg/ml was administered without appreciable evidence of either intravascular or intrathecal placement of the catheter. A bolus of 10 ml of 0.2% ropivacaine was administered over 5 min followed by an epidural infusion of 0.125% levobupivacaine. The fetal heart rate was within normal limits. Pain from the uterine contraction and hip disappeared. The patient was placed in lithotomy position, and she delivered a full-term healthy infant by normal vaginal delivery.
After delivery and removal of the epidural catheter her right groin pain worsened. At this time internal and external rotation of the right hip was impossible. Plain radiographs of the hip were made showing a displaced intracapsular fracture of the right femur. A magnetic resonance imaging (MRI) was performed demonstrating a hypointensity T1 signal with mild hyperintensity in T2 at the subcortical level of both femoral heads compatible with the diagnosis of bone marrow edema or transient osteoporosis of the hip.
Twenty-four hours after the delivery, the patient underwent surgery for the fracture of the femur. A combined spinal epidural technique was used for pinning the three cannulated screws for fixation; the anesthetic was uneventful. Eight months after medical discharge, a control radiography and MRI were performed which showed radiographic lesion resolution.
| Discussion|| |
TOP in the hip most frequently occurs at the third trimester and is characterized by gradual onset of pain in the groin. Pathological fractures are the most serious complication of the condition. The disease is usually self-limiting and protected weight bearing, pain control, and prevention of pathological fractures is the only treatment until resolution occurs, typically within 8 weeks postpartum. Laboratory studies are unrevealing. Radiographs may be normal at the onset, but varying degrees of osteopenia become eventually apparent and usually involve the femoral head and neck as well as the proximal metaphysic. MRI findings reveal low signal intensity of the bone marrow on T1-weighted spin echo images and high signal intensity on T2-weighted images. The clinical course has always been that of a spontaneous resolution of the symptoms within a period of 3-6 months. 
The anesthetic implications of this disease include management of pain which can coexist with labor pain and administration of anesthesia to the parturient if orthopedic intervention is required. In the present patient anesthesia was only required after delivery. An obstetric anesthesiologist should consider the possibility of TOP in all parturients who complain of groin pain or antalgic gait not associated with trauma, especially before instituting any neuraxial blocks.
A differential diagnosis has to be made with other common musculoskeletal pains occurring in pregnancy such as osteoarthritis, avascular bone necrosis, lysis of symphysis pubis, fibromyalgia, rheumatic arthropathies, and finally tumor and pseudotumoral pathologies.  If there is high suspicion of this disease an X-ray or MRI of the hip has to be done in order to make an early diagnosis and initiate appropriate treatment.
Patients with this condition may require for analgesia during labor or anesthesia for a cesarean section. Nevertheless, it is important to remember that pain in this patients has a protective function by limiting the patient's mobility, the stresses upon the fragile bone are reduced. A regional technique allows the mother to have a painless labor, but it will also remove the restrictive effect of the hip pain and may therefore increase the risk of fracture. In order to reduce the risk of inadvertent fractures, a high level of clinical suspicion and extra care during moving and positioning the patient during administration of regional anesthesia is of prime importance.
In the case of our patient, we did not know if the hip fracture was before or after placing the epidural catheter. It is likely that the lithotomy position may have caused the fracture.
These patients may be more comfortable sitting for the central neural blockade techniques rather than lying on one side. 
The fractures in TOP are not only limited to the hip; Ofluoglu  has reported a case of pregnancy-induced severe osteoporosis with eight vertebral fractures. In such a scenario even the placement of a neuraxial block could lead to catastrophic complications. If a cesarean section is necessary, the technique of choice should be a carefully placed neuraxial block; but in case a general anesthetic is required, extra caution needs to be taken to avoid cervical spine injury in patients with severe osteoporosis of the spine. 
The treatment of hip fracture whenever present should be managed as every other femoral neck fracture in non-pregnant patients.  The specific type of operative treatment depends on the age of the patient and the characteristics of the fracture. In young patients (as our patient) it is necessary to obtain a reduction of the femoral neck fracture as soon as possible to decrease the risk of avascular necrosis.  Case series and observational studies suggest that in general population early surgical repair (within 24-48 h) can decrease 1-year mortality in addition to decreasing postoperative pain, length of hospital stay, and major complications.  Nevertheless we found two publications where pregnant patients with hip fracture underwent surgery between the first 6 and 12 h after hospitalization. ,
The anesthetic management of a parturient with hip fracture would depend on the gestational age of the fetus, comorbid conditions and the medications that the parturient is taking - specially anticoagulants.
An anesthesiologist may be required to manage such a parturient under the following three situations.
First, a parturient with hip fracture without any contraindication of regional anesthesia and with no indication of fetal extraction. As in other pregnant patients, regional anesthesia, either spinal or epidural, or even combined spinal-epidural anesthesia are the best choices.
Second, a parturient with hip fracture awaiting surgery with a preterm labor requiring cesarean section, or term pregnancy without contraindication for regional anesthesia and without fetal distress.
In such patients, a combined spinal-epidural or a continuous epidural technique is likely to be the best option. This could enable the surgeons to perform both the cesarean section and the osteosynthesis of the hip. ,
This would also provide postoperative epidural analgesia.
If intraoperative need of an image intensifier arises in a parturient, the total radiation exposure should not exceed the permitted dose 50-100 mGy. As reference during a radiograph of the chest a patient is exposed to 0.001 mGy. 
Lastly in parturients with preterm or term pregnancy with contraindication for regional block a general anesthetic would be the best option.
| Conclusions|| |
A high index of suspicion and early diagnosis are the key to diagnose TOP and prevent inadeverent fractures. A combined spinal and epidural, or epidural anesthesia might be a good option; in such cases, allowing both, first a cesarean section and then the surgery for the fracture as soon as possible.
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