妊娠哺乳相关性骨质疏松症的研究进展

妊娠哺乳相关性骨质疏松症(pregnancy and lactation-associated osteoporosis,PLO)是指发生于妊娠和哺乳期,以低骨量和骨组织微结构破坏为特征,骨质脆性增加和易于骨折的全身性骨代谢性疾病。由于PLO发病率低,医师重视程度不够,常常容易被漏诊或误诊。目前PLO的病理生理机制尚未完全明确,研究报道也多以个案或病例报道为主,尚无统一治疗方案。本文就妊娠哺乳相关性骨质疏松症的发病机制和治疗进展等方面作一综述。     

妊娠哺乳相关骨质疏松症的诊治进展

妊娠哺乳相关骨质疏松症(pregnancy and lactation associated osteoporosis,PLO)是一种罕见的疾病,主要发生在妊娠晚期和产后早期妇女,常在第一次妊娠时发病,以胸腰椎多发压缩性骨折最常见,主要表现为腰背疼痛、身高变矮、活动受限。其发病机制目前尚不清楚,可能与妊娠、哺乳状态、遗传因素等相关。在怀孕期间,通过肠道钙吸收的加倍以满足胎儿及母体对钙的需求,但如果母亲摄入的钙不足,不能满足母亲和胎儿的综合需求,母亲的骨骼会通过PTHrP(parathyroid hormone-related peptide,PTHrP)刺激骨骼吸收。哺乳期,在高水平PTHrP的主导作用和低雌激素的共同作用下,促进骨吸收动员骨钙入血。目前PLO尚无统一的诊断标准,防治措施尚无定论。现有研究表明大多数PLO患者在断奶后骨量逐渐增加,因此对PLO患者建议停止哺乳并补充充足钙剂及维生素D。有报道双膦酸盐、迪诺赛麦、特立帕肽等抗骨质疏松药物治疗PLO,但其存在或潜在的不良反应,使用受到限制;椎体成形术和后凸成形术等用于治疗产后椎体骨折整体疗效尚不明确,一般不推荐使用。对PLO患者需充分评估患者情况慎重选择治疗方案。     

妊娠哺乳相关骨质疏松症

目的提高对妊娠哺乳相关骨质疏松症(PLO)的认识。方法回顾分析2例PLO的临床资料,同时对相关文献进行复习。结果 2例PLO患者均表现为妊娠晚期腰背痛,产后加重,活动受限,胸腰椎多椎体骨折,腰椎和骨盆骨质疏松。停止哺乳并予钙剂、活性维生素D和双膦酸盐治疗后随访发现,腰背痛等症状在治疗后半年至9个月消失,无新发骨折,骨密度增加。结论在妊娠晚期或产后出现的腰背痛应考虑PLO。钙剂、活性维生素D的补充及抗骨吸收治疗对PLO可能有效。     

妊娠哺乳相关骨质疏松症1例分析及文献回顾

目的探讨妊娠哺乳相关骨质疏松症(PLO)的临床特点及诊治。方法围绕1例妊娠哺乳相关骨质疏松症的临床资料进行回顾性分析。结果本例患者在妊娠哺乳期出现骨痛、活动受限、胸腰椎多椎体压缩性骨折、骨密度明显降低等骨质疏松症表现。并在确诊前进行了充分的代谢性骨病的鉴别诊断。停止哺乳,予以钙剂、活性维生素D疗效良好。结论 PLO可能具备多种易患因素,在妊娠哺乳期出现的腰背痛应考虑本病可能,需引起临床医生的重视,但充分的鉴别诊断是确诊该病的前提。     

妊娠和哺乳期骨质疏松症并发腰椎骨折：病例报告及文献复习

目的 妊娠和哺乳期骨质疏松症（pregnancy and lactation-associated osteoporosis,PLO）是发于妊娠期和哺乳期的一种特发性的罕见的骨质疏松症,是多种因素影响骨代谢的结果。分析PLO的典型临床特征,以期进行早期的预防干预及诊疗。方法 对在山东省中医院就诊的两名典型PLO患者的临床特点及治疗进行归纳总结,并结合文献对其临床特点、发病机制等方面进行分析。结果 两名PLO患者均是在产后无明显诱因出现腰椎的剧烈腰痛,活动受限,并伴有腰椎的压缩性骨折,明确诊断后建议立即停止哺乳,两名患者均拒绝,予以中药、钙剂、维生素D等药物治疗,治疗后两名患者的症状均有明显改善。结论 在妊娠和哺乳期间,未受明显外力的情况下出现突发性的严重腰痛患者应考虑PLO的可能,在确诊为PLO后,应建议立即停止哺乳,并予以中药、钙剂、维生素D、双膦酸盐类等药物治疗。     

妊娠和哺乳相关的骨质疏松症病例分享

妊娠和哺乳相关的骨质疏松症(pregnancy and lactation-associated osteoporosis, PLO)是一种罕见的临床特殊骨质疏松症,大多数病例出现在初产妇的妊娠晚期或产后早期,但是也会发生于经产妇中。PLO患者主要表现为在妊娠晚期以及产后初期严重的下背部疼痛、身高下降和脆性骨折,尤其是椎骨骨折。迄今为止,全球报道的PLO患者患病率仅有120余例。目前尚缺乏PLO治疗的指南与共识,各报告病例中指出双膦酸盐、钙和维生素D的补充是治疗PLO的一线疗法,此外特立帕肽、雷奈酸锶、地舒单抗也被证明有助于增加骨密度(bone density, BMD)。本文通过回顾分析两例PLO患者的临床资料,并对相关文献进行复习,以提高对PLO疾病的认识。     

妊娠哺乳相关性骨质疏松症1例并文献复习

正妊娠哺乳相关性骨质疏松症(pregnancy and lactationassociated osteoporosis,PLO)是一种特发性骨质疏松症,一般指妊娠晚期至产后18个月内,尤其产后/哺乳早期所诊断的骨质疏松,常因发生椎体脆性骨折而被发现,骨折部位常为下位胸椎及上位腰椎~([1])。PLO临床少见,发病机制尚未明确,1955年由Nordin等报道了第1例~([2])。因PLO发生在妊娠哺乳这一特殊时期,常导致孕产妇脊椎多发骨折,造成孕产妇生活能力下降,还会对胎儿和婴儿产生不良影响。本文报告1例PLO病例并进行文献复习,以引起临床医生的重视。     

妊娠哺乳相关性骨质疏松症的临床应对

目的 妊娠哺乳相关性骨质疏松症(PLO)是一种罕见的明显致残性疾病,通过个案分析和文献回顾以提高对本病的认识和临床应对能力.方法 回顾性分析一例PLO患者的临床特点和诊疗经过并进行相关文献复习.结果 该患者为青年女性,平素月经规律,哺乳早期出现腰痛及活动障碍,生化检查基本正常,影像学检查示椎体多发亚急性压缩性骨折,骨密...     

妊娠和哺乳相关骨质疏松症的研究进展

妊娠和哺乳相关骨质疏松症是一种罕见的继发性骨质疏松症，通常发生在妊娠晚期和哺乳早期，由于发病率较低及发病时间特殊，相对诊断工具有限，并且大多数文献报道也属个案或对疾病状态的一般描述，因此对其管理与诊断尚未形成指南与共识。由于妊娠和哺乳相关骨质疏松症具有自限性，一部分病人在妊娠和哺乳完成后，骨密度会自发改善，因此如何治疗该病的确凿建议也未明确提出。降钙素、双膦酸盐、地舒单抗和特立帕肽均已用于个体患者，但是治疗效果褒贬不一，也没有大量的客观数据反馈长远治疗效果，因此，对于妊娠和哺乳相关骨质疏松症的探索仍然有待继续，有望在未来形成共识并开发出更安全的药物进行治疗。     

中国维吾尔族女性特发性骨质疏松患者临床分析及生活方式相关因素的调查

目的 通过分析中国维吾尔族女性特发性骨质疏松患者临床特点与生活方式的相关性,为药物治疗及生活方式的干预,预防和减少特发性骨质疏松的发生提供依据。方法 回顾性分析中国维吾尔族女性特发性骨质疏松患者36例临床特点,采用统一问卷对生活方式进行调查。结果 女性特发性骨质疏松患者发病基本在孕期及哺乳期,常见临床表现有腰背部酸痛及臀部疼痛。骨密度可有骨量减少,骨质疏松。实验室检查血钙水平低或正常低值,血碱性磷酸酶及甲状旁腺激素水平增高。治疗后血碱性磷酸酶及甲状旁腺激素水平下降明显。发病原因孕期或哺乳期饮食及生活方式相关。结论 妊娠期和哺乳期妇女应保证合理营养,适当户外活动和日光照射,可预防女性特发性骨质疏松的发生。     

Effect of teriparatide on pregnancy and lactation-associated osteoporosis with multiple vertebral fractures

Pregnancy and lactation-associated osteoporosis (PLO) is very rare, but it can cause severe vertebral compression fractures with disabling back pain. PLO patients have commonly been treated with antiresorptive agents against high bone turnover. There are, however, some concerns regarding the use of bisphosphonates: (1) PLO occurs during the first pregnancy with a high possibility of recurrence during the second pregnancy, (2) long-term outcomes of bisphosphonates in PLO are lacking, and (3) there is a possibility of bisphosphonates accumulated in the bones crossing the placenta. Therefore, alternative therapies must be considered. We analyzed the effect of teriparatide (TPTD), the human recombinant parathyroid hormone (1-34), for 18?months in three women with PLO. Multiple vertebral fractures with severe back pain appeared within 6?months after their first childbirth. Two of them had a family history of osteoporosis. Lactation was discontinued immediately after diagnosis of PLO. Calcium carbonate, cholecalciferol, and TPTD were prescribed. The back pain immediately resolved. Bone mineral density (BMD) increased by 14.5-25.0% (mean 19.5%) at the lumbar spine and by 9.5-16.7% (mean 13.1%) at the femoral neck, after 18?months of treatment. The final Z scores in these PLO patients were nearly normalized. Two women had a second baby without any complication. BMD significantly improved after 18 months of treatment with TPTD without further fractures. In conclusion, TPTD should be considered to avoid long-term morbidity in young patients with PLO and is highly encouraged for use in PLO patients with multiple vertebral fractures.     

Bisphosphonates in pregnancy and lactation-associated osteoporosis

Introduction Pregnancy and lactation-associated osteoporosis (PLO) is an uncommon condition characterized by the occurrence of fracture(s) during late pregnancy or the puerperium. The aetiology is uncertain, and its management and natural history poorly defined. Methods We report a series of 11 women with PLO seen at our institution over the past 20 years, with follow-up ranging from 1 to 19 years. Results Ten women presented with painful low-trauma vertebral fractures, at a median of 1 month postpartum. In nine cases the fractures were multiple (median: 3, range: 2–5). At least one recognised risk factor for osteoporosis (low body weight, smoking history, family history of osteoporosis/fracture, vitamin D insufficiency) was present in nine patients. Bone density was in the osteoporotic range at the spine (mean T score: −2.8), with less marked reduction at the proximal femur (mean T score: −1.9). Nine patients received bisphosphonate treatment, for a median duration of 24 months. In the five women who received a bisphosphonate within 1 year of presentation, spinal bone density increased by 23% over baseline values after 2 years of treatment (p=0.0014). Of the 5 women who had subsequent pregnancies, one, who had declined bisphosphonate therapy after the initial presentation, sustained a fracture in the postpartum period. Two patients (both of whom were followed for at least 10 years) sustained fractures outside of pregnancy. Conclusions PLO is therefore associated with significant morbidity, a high prevalence of recognized risk factors for osteoporosis and a risk of recurrence in subsequent pregnancies. Bisphosphonate therapy administered soon after presentation substantially increases spinal bone density in patients with PLO.     

Women With Pregnancy and Lactation–Associated Osteoporosis (PLO) Have Low Bone Remodeling Rates at the Tissue Level

Pregnancy and lactation–associated osteoporosis (PLO) is a rare, severe, early form of osteoporosis in which young women present with fractures, usually multiple vertebral fractures, during late pregnancy or lactation. In studies of idiopathic osteoporosis (IOP) in premenopausal women, we enrolled 78 women with low-trauma fractures and 40 healthy controls, all with normal menses and no secondary cause of bone loss. In 15 of the affected women, the PLO subgroup, fractures had occurred during late pregnancy or lactation. We hypothesized that clinical, bone structural, and metabolic characteristics would differ between women with PLO and those with (non-PLO) IOP and controls. All were evaluated > 12 months postpartum, when structural and remodeling characteristics would be expected to reflect baseline premenopausal status rather than transient postpartum changes. As previously reported, affected subjects (PLO and IOP) had BMD and microarchitectural deficiencies compared to controls. Women with PLO did not differ from those with IOP in terms of age, BMI, body fat, menarcheal age, parity, or age at first pregnancy. However, women with PLO had a more severe clinical presentation than those with IOP: more fractures (5.5 ± 3.3 versus 2.6 ± 2.1; p = 0.005); more vertebral fractures (80% versus 17%; p < 0.001); and higher prevalence of multiple fractures. BMD deficits were more profound and cortical width tended to be lower in PLO. PLO subjects also had significantly lower tissue-level mineral apposition rate and bone formation rates (0.005 ± 0.005 versus 0.011 ± 0.010 mm²/mm/year; p = 0.006), as well as lower serum P1NP (33 ± 12 versus 44 ± 18 µg/L; p = 0.02) and CTX (257 ± 102 versus 355 ± 193 pg/mL; p = 0.01) than IOP. The finding that women with PLO have a low bone remodeling state assessed more than a year postpartum increases our understanding of the pathogenic mechanism of PLO. We conclude that women with PLO may have underlying osteoblast functional deficits which could affect their therapeutic response to osteoanabolic medications. © 2019 American Society for Bone and Mineral Research.     

Use of highly potent bisphosphonates in the treatment of osteoporosis

Bisphosphonates are effective inhibitors of bone remodeling. In the clinical setting, these agents prevent bone loss, preserve bone architecture, and improve bone strength. Clinically significant reduction in the risk of spine and nonspine fractures is observed in patients known to be at risk for fracture. When administered appropriately, these drugs are well tolerated and have an excellent safety profile. Potent bisphosphonates are now the preferred treatment option to reduce the fracture risk in men and women with involutional and glucocorticoid-induced osteoporosis.