BRIEF COMMUNICATIONS
257
Fig. 1. Hysteroscopic evacuation of interstitial pregnancy under laparoscopic guidance. A. Imaging of right interstitial pregnancy on 3D ultrasound (white arrow denotes interstitial line sign; black arrow denotes gestational sac). B. Interstitial cavity after dilation and evacuation (black arrows denote residual tissue). C. View of the uterus at laparoscopy (black arrow denotes ipsilateral round ligament; white arrow denotes ipsilateral fallopian tube). D. Removal of residual tissue from the interstitial cavity (black arrows denote residual tissue).
0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.10.002
Knowledge regarding signs and complications of menopause among women in Burkina Faso Adama Faye a,b,⁎, Ousseynou Ka c, Christelle Nickiema a, Mouhamadou M. Leye a, Anta Tal-Dia a a b c
Institute of Health and Development, Cheikh Anta Diop University, Dakar, Senegal University of Montreal, Montreal, Canada Gerontology and Geriatrics Center of Ouakam, Dakar, Senegal
a r t i c l e
i n f o
Article history: Received 9 July 2013 Received in revised form 23 September 2013 Accepted 6 December 2013 Keywords: Burkina Faso Complication Knowledge Menopause Sub-Saharan Africa
⁎ Corresponding author at: Institut de Santé et Développement, BP 16390 UCAD, Dakar, Senegal. Tel.: +221 338249878; fax: +221 338253648. E-mail addresses: [email protected], [email protected] (A. Faye).
The onset of menopause can be accompanied by many signs and functional complications of which women may be ignorant. There are preventive and curative treatments effective against the signs and complications of menopause [1] but the use of such care requires a good knowledge of the signs and complications. In Africa, there is little evidence of the extent of women's knowledge about the signs and complications of menopause [2]. The availability of such information would assist in guiding programs to get the attention of menopausal women. The aim of the present study was to measure the level of knowledge of menopausal women in Burkina Faso regarding the signs and complications of the condition and its determinants. A cross-sectional study was conducted involving women aged 40–80 years living in and around Koudougou, Burkina Faso. The women were selected using cluster sampling. The city of Koudougou is located 100 km west of the capital, Ouagadougou. Each village or neighborhood of Koudougou constituted a sector and, depending on its size, a sector could contain 1 or several clusters. The number of
258
BRIEF COMMUNICATIONS
participants required was calculated to be 600, with a cluster effect of 1.5 and a response rate of 92%. Data were collected from October 22 to 28, 2012, through individual interviews in the homes of women; the interviews were conducted by trained interviewers after informed consent had been obtained. Information collected included personal characteristics, medical history, and knowledge of menopause. Data analysis was performed with R statistical software (R Foundation, Vienna, Austria). Initially, bivariate analyses using χ2 and Student t test were used to identify associations between dependent variables and background factors. All associations for which P b 0.25 [3] were entered into the final model and assessed using multiple logistic regression via stepdown procedure. P b 0.05 was considered to be statistically significant. In total, 600 women were surveyed. Mean age was 56.9 ± 8.6 years. Signs related to menopause were often overlooked and 74.0% of women did not cite any. The signs most frequently cited were joint and muscle pain (17.2%), menstrual irregularities (17.0%), headache (8.2%), and dizziness (6.0%). Overall, 84.2% of women did not recall any complications of menopause (Table 1). Cystitis was the most frequently listed
Table 1 Characteristics of women surveyed (n = 598). No. (%) Characteristics Residence Town Village Other Education None Primary Secondary University Parity 0-3 4–7 ≥8 Contraception Yes No Opportunity for consultation in a public health facility Yes No Occupation Housewife Not housewife Availability of electricity in home Yes No Availability of water in home Yes No Personal transportation Car Motorcycle Bicycle None Marital status Married Not married Knowledge Menopause signs 0 1–3 ≥4 Menopause complications 0 1–3 ≥4 Presence of menopause symptoms Yes No
242 (40.4) 293 (48.8) 63 (10.8) 268 (44.7) 120 (20.0) 187 (31.2) 25 (4.2) 59 (9.8) 331 (55.2) 210 (35.0) 48 (16.0) 552 (84.0)
complication (6.0%) and osteoporosis the least cited (1.5%). Among the women surveyed, 61.5% had symptoms of menopause. None of the women used hormone replacement therapy. The results in Table 2 show that the level of knowledge regarding signs of menopause was higher among married women (30.3%; odds ratio [OR] 1.76; 95% confidence interval [CI], 1.19–2.59), those with high socioeconomic level (45.9%; OR 2.59; 95% CI, 1.32–5.09), those who had used contraception in the past (43.8%; OR 2.38; 95% CI, 1.31–4.34), and those with opportunities for consultation in a public health facility (OR 2.94; 95% CI, 1.51–5.55). Furthermore, it increased with level of education. Knowledge was not related to the presence of symptoms. Knowledge of signs of menopause was related to complications, which were reported in 30.1% of women experiencing signs compared with 10.8% of those who did not know. The level of knowledge regarding the signs of menopause was low among the women surveyed in the present study. This differs from findings in high-resource countries, where women have a good knowledge of menopause [4], and may be explained by the low level of education in Burkina Faso [5]. Education allows women better access to information and promotes improved levels of knowledge. In the present study, women using a modern contraceptive method had a better understanding of menopause. This is probably a consequence of contact with a health center, and a similar process applied to women who had the opportunity to attend public health facilities. Particular emphasis should be placed on educating and encouraging contact between women and health facilities. The presence of clinical signs was not associated with improved knowledge about menopause. Women may not establish a link between the presence of these signs and menopause; often, they may not be aware of the changes caused by menopause [6], which might explain the fact that none of the interviewed women used hormone therapy. The level of knowledge regarding the signs and complications of menopause was low in the present study. It is vital to develop specific programs for menopausal women, similar to those available for women of reproductive age. Providers should consider appropriate means of Table 2 Factors related to knowledge regarding signs of menopause.a
508 (84.7) 92 (15.3) 195 (32.5) 405 (67.5) 410 (68.3) 190 (31.7) 346 (57.7) 254 (42.3) 38 (6.3) 281 (46.8) 154 (25.7) 127 (21.2) 353 (58.8) 247 (41.2)
444 (74.0) 94 (15.7) 62 (10.3) 505 (84.2) 91 (15.1) 4 (0.7) 299 (49.8) 301 (50.2)
Socioeconomic level Low High Education None Primary Secondary or higher Employment Housewife Elementary occupation Salaried employee Marital status Unmarried Married Parity 0–3 4–7 ≥8 Contraception No Yes Opportunity for consultation in a public health facility No Yes Presence of menopause symptoms Yes No a
Knowledge of signs
P value
Adjusted odds ratio (95% confidence interval)
563 (24.7) 37 (45.9)
0.007
1 2.59 (1.32–5.09)
0.001 268 (17.2) 120 (30.8) 212 (34.4)
1 2.15 (1.30–3.55) 2.53 (1.65–3.87) 0.007
195 (18.5) 59 (23.7) 346 (30.6)
1 1.37 (0.68–2.76) 1.95 (1.27–2.99) 0.005
49 (19.8) 107 (30.3)
1 1.76 (1.19–2.59) 0.0002
59 (23.7) 331 (32.3) 210 (16.7)
1 1.53 (0.80–2.91) 0.64 (0.31–1.29) 0.004
552 (24.5) 48 (43.8)
1 2.38 (1.31–4.34) 0.001
92 (12.0) 508 (28.5)
1 2.94 (1.51–5.55) 0.24
301 (28.2) 299 (23.7)
1 0.79 (0.55–1.14)
Values are given as number (percentage) unless otherwise indicated.
BRIEF COMMUNICATIONS
communication because of the low level of education among women in Burkina Faso. Conflict of interest The authors have no conflicts of interest. References [1] Nelson HD, Walker M, Zakher B, Mitchell J. Menopausal hormone therapy for the primary prevention of chronic conditions: a systematic review to update the U.S. Preventive Services Task Force recommendations. Ann Intern Med 2012;157(2):104–13.
259
[2] Cisse CT, Diouf AA, Dieng T, Gueye Dieye A, Moreau JC. Menopausal African environment: epidemiology, experience and support to Dakar. La Lettre du Gynécologue 2008;335:6–10. [3] Hosmer Jr DW, Lemeshow S. Applied Logistic Regression. 2nd ed. New York, NY: John Wiley & Sons; 2004. [4] Velasco-Murillo V, Fernández-Gárate IH, Ojeda-Mijares RI, Padilla-Vallejo I, de la Cruz-Mejía L. Knowledge, experience and behavior at climacteric and menopause stages among family medicine female users at IMSS. Rev Med Inst Mex Seguro Soc 2007;45(6):549–56. [5] Jassim GA, Al-Shboul QM. Knowledge of Bahraini women about the menopause and hormone therapy: implications for health-care policy. Climacteric 2009;12(1):38–48. [6] Chedraui P, Blümel JE, Baron G, Belzares E, Bencosme A, Calle A, et al. Impaired quality of life among middle aged women: a multicentre Latin American study. Maturitas 2008;61(4):323–9.
0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.09.020
Fractures due to transient osteoporosis of pregnancy Helen Vester a,⁎, Vanadin Seifert-Klauss b, Martijn van Griensven a, Markus Neumaier a a b
Department of Trauma Surgery, Technical University of Munich, Munich, Germany Department of Gynaecology, Technical University of Munich, Munich, Germany
a r t i c l e
i n f o
Article history: Received 13 August 2013 Received in revised form 22 September 2013 Accepted 9 December 2013 Keywords: Pregnancy complications Third trimester Transient osteoporosis of pregnancy
In the third trimester, pain in the hips or the lower back is often attributed to normal physiology of pregnancy. Transient osteoporosis of pregnancy (TOP) is a rare and often misdiagnosed condition. Pain associated with TOP can become excruciating, immobilizing the patient and putting normal delivery at risk. Bone mass may be reduced, with Tscores indicating osteopenia. The present article describes 3 cases of TOP at the Department of Trauma Surgery and the Department of Gynaecology, Technical University of Munich, Munich, Germany. Patient 1 (33 years of age) fell on her right hip shortly after delivery and presented with immobilizing pain. Radiology revealed a femoral neck fracture without dislocation (Garden type 1) (Fig. 1A). To prevent femoral head necrosis, the fracture was fixed surgically (Fig. 1B). Postoperative limited weight bearing and vitamin D supplementation were recommended. A dual-energy X-ray absorptiometry (DXA) scan 4 years later, after a second pregnancy, revealed mild osteopenia. The patient’s vitamin D level was 9 ng/mL (normal range, 30–100 ng/mL), warranting supplementation before a third pregnancy. Patient 2 (33 years of age), who was 34 + 4 weeks pregnant, presented with a displaced femoral neck fracture (Garden type 3) after a fall. She had reported diffuse hip and back pain in the preceding ⁎ Corresponding author at: Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany. Tel.: + 49 894140 2126; fax: + 49 894140 4815. E-mail address: [email protected] (H. Vester).
weeks. Osteosynthesis was performed with screws (Fig. 1C), and the postoperative course was uncomplicated but slow. Patient 3 (38 years of age) presented 11 days after cesarean delivery with bilateral os sacral insufficiency fractures (Fig. 1D), which were treated conservatively. Her DXA measurements were normal but her serum vitamin D level was 6 ng/mL. None of the patients received anticoagulant therapy during pregnancy. The pathophysiology of TOP remains unclear and diagnosis is difficult. Three stages can be identified. Stage 1 is characterized by progressive discomfort over several weeks until near immobilization. Other conditions (e.g. osteonecrosis, infection, stress fractures) must be excluded. Magnetic resonance imaging—although used cautiously in pregnancy—may detect edema [1]. In stage 2, significant calcium demineralization is found and bone density scans may indicate osteoporosis [2]. During the third trimester, 80% of the fetal skeleton is mineralized, which requires massive maternal calcium transfer. Systemic upregulation of placental 1-α-hydroxylase and increased serum levels of parathyroid hormone-related peptide may also have a role [3]. Symptoms of TOP usually disappear after delivery (stage 3). However, breastfeeding promotes further calcium loss, which can prolong recovery time. Calcium/vitamin D supplementation is encouraged. Weight bearing is limited postpartum in order to reduce secondary fractures. The etiology of TOP is unclear but seems to involve neurologic and bone metabolism malfunctions [2]. Vitamin D deficiency seems to be relevant (as in the first and third cases) but it does not explain the localized bone demineralization and is not a universal finding [4]. Patients with TOP are treated conservatively, and fractures necessitate close interdisciplinary cooperation. Pregnancy should not be terminated in such cases but surgery may be indicated to prevent femoral head necrosis. Pain during pregnancy should be taken seriously and may require imaging. More research concerning prevention and early detection of TOP may help to avoid invasive modes of management.
Conflict of interest The authors have no conflicts of interest.
257
Fig. 1. Hysteroscopic evacuation of interstitial pregnancy under laparoscopic guidance. A. Imaging of right interstitial pregnancy on 3D ultrasound (white arrow denotes interstitial line sign; black arrow denotes gestational sac). B. Interstitial cavity after dilation and evacuation (black arrows denote residual tissue). C. View of the uterus at laparoscopy (black arrow denotes ipsilateral round ligament; white arrow denotes ipsilateral fallopian tube). D. Removal of residual tissue from the interstitial cavity (black arrows denote residual tissue).
0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.10.002
Knowledge regarding signs and complications of menopause among women in Burkina Faso Adama Faye a,b,⁎, Ousseynou Ka c, Christelle Nickiema a, Mouhamadou M. Leye a, Anta Tal-Dia a a b c
Institute of Health and Development, Cheikh Anta Diop University, Dakar, Senegal University of Montreal, Montreal, Canada Gerontology and Geriatrics Center of Ouakam, Dakar, Senegal
a r t i c l e
i n f o
Article history: Received 9 July 2013 Received in revised form 23 September 2013 Accepted 6 December 2013 Keywords: Burkina Faso Complication Knowledge Menopause Sub-Saharan Africa
⁎ Corresponding author at: Institut de Santé et Développement, BP 16390 UCAD, Dakar, Senegal. Tel.: +221 338249878; fax: +221 338253648. E-mail addresses: [email protected], [email protected] (A. Faye).
The onset of menopause can be accompanied by many signs and functional complications of which women may be ignorant. There are preventive and curative treatments effective against the signs and complications of menopause [1] but the use of such care requires a good knowledge of the signs and complications. In Africa, there is little evidence of the extent of women's knowledge about the signs and complications of menopause [2]. The availability of such information would assist in guiding programs to get the attention of menopausal women. The aim of the present study was to measure the level of knowledge of menopausal women in Burkina Faso regarding the signs and complications of the condition and its determinants. A cross-sectional study was conducted involving women aged 40–80 years living in and around Koudougou, Burkina Faso. The women were selected using cluster sampling. The city of Koudougou is located 100 km west of the capital, Ouagadougou. Each village or neighborhood of Koudougou constituted a sector and, depending on its size, a sector could contain 1 or several clusters. The number of
258
BRIEF COMMUNICATIONS
participants required was calculated to be 600, with a cluster effect of 1.5 and a response rate of 92%. Data were collected from October 22 to 28, 2012, through individual interviews in the homes of women; the interviews were conducted by trained interviewers after informed consent had been obtained. Information collected included personal characteristics, medical history, and knowledge of menopause. Data analysis was performed with R statistical software (R Foundation, Vienna, Austria). Initially, bivariate analyses using χ2 and Student t test were used to identify associations between dependent variables and background factors. All associations for which P b 0.25 [3] were entered into the final model and assessed using multiple logistic regression via stepdown procedure. P b 0.05 was considered to be statistically significant. In total, 600 women were surveyed. Mean age was 56.9 ± 8.6 years. Signs related to menopause were often overlooked and 74.0% of women did not cite any. The signs most frequently cited were joint and muscle pain (17.2%), menstrual irregularities (17.0%), headache (8.2%), and dizziness (6.0%). Overall, 84.2% of women did not recall any complications of menopause (Table 1). Cystitis was the most frequently listed
Table 1 Characteristics of women surveyed (n = 598). No. (%) Characteristics Residence Town Village Other Education None Primary Secondary University Parity 0-3 4–7 ≥8 Contraception Yes No Opportunity for consultation in a public health facility Yes No Occupation Housewife Not housewife Availability of electricity in home Yes No Availability of water in home Yes No Personal transportation Car Motorcycle Bicycle None Marital status Married Not married Knowledge Menopause signs 0 1–3 ≥4 Menopause complications 0 1–3 ≥4 Presence of menopause symptoms Yes No
242 (40.4) 293 (48.8) 63 (10.8) 268 (44.7) 120 (20.0) 187 (31.2) 25 (4.2) 59 (9.8) 331 (55.2) 210 (35.0) 48 (16.0) 552 (84.0)
complication (6.0%) and osteoporosis the least cited (1.5%). Among the women surveyed, 61.5% had symptoms of menopause. None of the women used hormone replacement therapy. The results in Table 2 show that the level of knowledge regarding signs of menopause was higher among married women (30.3%; odds ratio [OR] 1.76; 95% confidence interval [CI], 1.19–2.59), those with high socioeconomic level (45.9%; OR 2.59; 95% CI, 1.32–5.09), those who had used contraception in the past (43.8%; OR 2.38; 95% CI, 1.31–4.34), and those with opportunities for consultation in a public health facility (OR 2.94; 95% CI, 1.51–5.55). Furthermore, it increased with level of education. Knowledge was not related to the presence of symptoms. Knowledge of signs of menopause was related to complications, which were reported in 30.1% of women experiencing signs compared with 10.8% of those who did not know. The level of knowledge regarding the signs of menopause was low among the women surveyed in the present study. This differs from findings in high-resource countries, where women have a good knowledge of menopause [4], and may be explained by the low level of education in Burkina Faso [5]. Education allows women better access to information and promotes improved levels of knowledge. In the present study, women using a modern contraceptive method had a better understanding of menopause. This is probably a consequence of contact with a health center, and a similar process applied to women who had the opportunity to attend public health facilities. Particular emphasis should be placed on educating and encouraging contact between women and health facilities. The presence of clinical signs was not associated with improved knowledge about menopause. Women may not establish a link between the presence of these signs and menopause; often, they may not be aware of the changes caused by menopause [6], which might explain the fact that none of the interviewed women used hormone therapy. The level of knowledge regarding the signs and complications of menopause was low in the present study. It is vital to develop specific programs for menopausal women, similar to those available for women of reproductive age. Providers should consider appropriate means of Table 2 Factors related to knowledge regarding signs of menopause.a
508 (84.7) 92 (15.3) 195 (32.5) 405 (67.5) 410 (68.3) 190 (31.7) 346 (57.7) 254 (42.3) 38 (6.3) 281 (46.8) 154 (25.7) 127 (21.2) 353 (58.8) 247 (41.2)
444 (74.0) 94 (15.7) 62 (10.3) 505 (84.2) 91 (15.1) 4 (0.7) 299 (49.8) 301 (50.2)
Socioeconomic level Low High Education None Primary Secondary or higher Employment Housewife Elementary occupation Salaried employee Marital status Unmarried Married Parity 0–3 4–7 ≥8 Contraception No Yes Opportunity for consultation in a public health facility No Yes Presence of menopause symptoms Yes No a
Knowledge of signs
P value
Adjusted odds ratio (95% confidence interval)
563 (24.7) 37 (45.9)
0.007
1 2.59 (1.32–5.09)
0.001 268 (17.2) 120 (30.8) 212 (34.4)
1 2.15 (1.30–3.55) 2.53 (1.65–3.87) 0.007
195 (18.5) 59 (23.7) 346 (30.6)
1 1.37 (0.68–2.76) 1.95 (1.27–2.99) 0.005
49 (19.8) 107 (30.3)
1 1.76 (1.19–2.59) 0.0002
59 (23.7) 331 (32.3) 210 (16.7)
1 1.53 (0.80–2.91) 0.64 (0.31–1.29) 0.004
552 (24.5) 48 (43.8)
1 2.38 (1.31–4.34) 0.001
92 (12.0) 508 (28.5)
1 2.94 (1.51–5.55) 0.24
301 (28.2) 299 (23.7)
1 0.79 (0.55–1.14)
Values are given as number (percentage) unless otherwise indicated.
BRIEF COMMUNICATIONS
communication because of the low level of education among women in Burkina Faso. Conflict of interest The authors have no conflicts of interest. References [1] Nelson HD, Walker M, Zakher B, Mitchell J. Menopausal hormone therapy for the primary prevention of chronic conditions: a systematic review to update the U.S. Preventive Services Task Force recommendations. Ann Intern Med 2012;157(2):104–13.
259
[2] Cisse CT, Diouf AA, Dieng T, Gueye Dieye A, Moreau JC. Menopausal African environment: epidemiology, experience and support to Dakar. La Lettre du Gynécologue 2008;335:6–10. [3] Hosmer Jr DW, Lemeshow S. Applied Logistic Regression. 2nd ed. New York, NY: John Wiley & Sons; 2004. [4] Velasco-Murillo V, Fernández-Gárate IH, Ojeda-Mijares RI, Padilla-Vallejo I, de la Cruz-Mejía L. Knowledge, experience and behavior at climacteric and menopause stages among family medicine female users at IMSS. Rev Med Inst Mex Seguro Soc 2007;45(6):549–56. [5] Jassim GA, Al-Shboul QM. Knowledge of Bahraini women about the menopause and hormone therapy: implications for health-care policy. Climacteric 2009;12(1):38–48. [6] Chedraui P, Blümel JE, Baron G, Belzares E, Bencosme A, Calle A, et al. Impaired quality of life among middle aged women: a multicentre Latin American study. Maturitas 2008;61(4):323–9.
0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.09.020
Fractures due to transient osteoporosis of pregnancy Helen Vester a,⁎, Vanadin Seifert-Klauss b, Martijn van Griensven a, Markus Neumaier a a b
Department of Trauma Surgery, Technical University of Munich, Munich, Germany Department of Gynaecology, Technical University of Munich, Munich, Germany
a r t i c l e
i n f o
Article history: Received 13 August 2013 Received in revised form 22 September 2013 Accepted 9 December 2013 Keywords: Pregnancy complications Third trimester Transient osteoporosis of pregnancy
In the third trimester, pain in the hips or the lower back is often attributed to normal physiology of pregnancy. Transient osteoporosis of pregnancy (TOP) is a rare and often misdiagnosed condition. Pain associated with TOP can become excruciating, immobilizing the patient and putting normal delivery at risk. Bone mass may be reduced, with Tscores indicating osteopenia. The present article describes 3 cases of TOP at the Department of Trauma Surgery and the Department of Gynaecology, Technical University of Munich, Munich, Germany. Patient 1 (33 years of age) fell on her right hip shortly after delivery and presented with immobilizing pain. Radiology revealed a femoral neck fracture without dislocation (Garden type 1) (Fig. 1A). To prevent femoral head necrosis, the fracture was fixed surgically (Fig. 1B). Postoperative limited weight bearing and vitamin D supplementation were recommended. A dual-energy X-ray absorptiometry (DXA) scan 4 years later, after a second pregnancy, revealed mild osteopenia. The patient’s vitamin D level was 9 ng/mL (normal range, 30–100 ng/mL), warranting supplementation before a third pregnancy. Patient 2 (33 years of age), who was 34 + 4 weeks pregnant, presented with a displaced femoral neck fracture (Garden type 3) after a fall. She had reported diffuse hip and back pain in the preceding ⁎ Corresponding author at: Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany. Tel.: + 49 894140 2126; fax: + 49 894140 4815. E-mail address: [email protected] (H. Vester).
weeks. Osteosynthesis was performed with screws (Fig. 1C), and the postoperative course was uncomplicated but slow. Patient 3 (38 years of age) presented 11 days after cesarean delivery with bilateral os sacral insufficiency fractures (Fig. 1D), which were treated conservatively. Her DXA measurements were normal but her serum vitamin D level was 6 ng/mL. None of the patients received anticoagulant therapy during pregnancy. The pathophysiology of TOP remains unclear and diagnosis is difficult. Three stages can be identified. Stage 1 is characterized by progressive discomfort over several weeks until near immobilization. Other conditions (e.g. osteonecrosis, infection, stress fractures) must be excluded. Magnetic resonance imaging—although used cautiously in pregnancy—may detect edema [1]. In stage 2, significant calcium demineralization is found and bone density scans may indicate osteoporosis [2]. During the third trimester, 80% of the fetal skeleton is mineralized, which requires massive maternal calcium transfer. Systemic upregulation of placental 1-α-hydroxylase and increased serum levels of parathyroid hormone-related peptide may also have a role [3]. Symptoms of TOP usually disappear after delivery (stage 3). However, breastfeeding promotes further calcium loss, which can prolong recovery time. Calcium/vitamin D supplementation is encouraged. Weight bearing is limited postpartum in order to reduce secondary fractures. The etiology of TOP is unclear but seems to involve neurologic and bone metabolism malfunctions [2]. Vitamin D deficiency seems to be relevant (as in the first and third cases) but it does not explain the localized bone demineralization and is not a universal finding [4]. Patients with TOP are treated conservatively, and fractures necessitate close interdisciplinary cooperation. Pregnancy should not be terminated in such cases but surgery may be indicated to prevent femoral head necrosis. Pain during pregnancy should be taken seriously and may require imaging. More research concerning prevention and early detection of TOP may help to avoid invasive modes of management.
Conflict of interest The authors have no conflicts of interest.
