Arch Gynecol Obstet (2007) 276:175–177 DOI 10.1007/s00404-007-0321-9 123 CASE REPORT The eVect of pregnancy on pre-existing osteopenia: a case report Shobana Athimulam · Patricia Chan · Michelle Baker · Maud Nauta · Wai Yoong Received: 23 September 2006 / Accepted: 2 January 2007 / Published online: 8 February 2007  Springer-Verlag 2007 Case report A 34-year-old Greek Cypriot lady (Mrs. AMC) P 2+0 booked at 10 weeks gestation with spontaneously con- ceived dizygotic twins. Her two previous uncompli- cated pregnancies resulted in normal vaginal deliveries of male infants weighing 3.2 and 3.4 kg, respectively. Immediately following her second delivery, she under- went a manual removal of placenta (MRP) under gen- eral anaesthesia and sustained a fracture of the triquetral bone of her left wrist while being lifted oV the operating table. Although she had complained of pain and restricted movement in her left hand after the MRP, the fracture remained undiagnosed for several weeks until an X-ray of her left wrist showed signs of delayed fracture healing of the triquetral bone. The pathological fracture was suggestive of osteoporosis during pregnancy but this was not investigated further at this stage. In 2004, she was referred to an orthopaedic surgeon with concern over a height loss of 3 cm in the preceding 6 months, as well as with generalised bony tenderness over her hips and lower back. Dual Energy X ray Absorptiometry (DEXA) to measure bone mineral density (BMD) revealed a T score of –1.6 SD (which is the WHO deWnition of osteopenia) in her right hip, which subsequently deteriorated to –1.8 SD (Table 1) the following year despite treatment with alendronate and calcium supplementation. There was no family his- tory of osteoporosis and metabolic/endocrine causes of secondary osteoporosis such as thyrotoxicosis and hyperprolactaemia had been excluded by her family physician. She was a well-controlled asthmatic with no recent history of acute attacks. She had been treated with three courses of high dose short duration oral prednis- olone in her late teenage years for acute exacerbation of asthma, although this is unlikely to contribute to her reduced BMD. At booking, all her haematological (including electrophoresis) and biochemical parame- ters were normal and she had a normal BMI of 22.7. She smoked Wve cigarettes a day. Alendronic acid and calcium supplement were dis- continued when she became pregnant. Serial ultra- sound scans revealed satisfactory growth of the twins with the head and abdominal circumferences being on the 20th and 25th centiles, respectively. She subsequently complained of bilateral hip pain with weight bearing, associated with limited abduction. In view of the pathological triquestral fracture during her last pregnancy and the documented osteopenia of her hip when not pregnant, she was anxious that the hip pain may indicate osteoporosis of her hip. Discus- sion with her obstetrician conWrmed that pregnancy itself may lead to further reduction of hip BMD and that vaginal delivery may increase the risk of hip frac- ture although this risk is diYcult to quantify. It was estimated that there was a three- to fourfold increase in the risk of hip fracture in this pregnancy irrespective of the mode of delivery and following counselling, the patient decided to have an elective Caesarean Section (CS) at 38 weeks gestation. S. Athimulam · P. Chan · M. Baker UCL and RFH Medical School, London, UK M. Nauta · W. Yoong (&) Department of Obstetrics and Gynaecology, North Middlesex Hospital, London N18 1QX, UK e-mail: wai.yoong@nmh.nhs.uk