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Alireza Mirzaei, Solmaz Piri, Kaveh Gharanizadeh, Mozhdeh Zabihiyeganeh,
Volume 16, Issue 3 (March 2018)

Background: Postpartum bilateral femoral neck fracture (BFNF) is a rare condition. We here report a case of BFNF due to excessive corticosteroid consumption, twin pregnancy, immobility, and vitamin D deficiency.
Case: This is a report of a 32-yr-old woman with bilateral femoral insufficiency fracture five days after emergency cesarean section due to preterm labor, twin pregnancy, and the history of a previous cesarean section at 33 wk. Antenatal repeated courses of betamethasone injections for fetal lung maturity, daily oral use of prednisolone for the history of miscarriage, immobilization, and vitamin D deficiency were the important contributing factors in her past medical history and lab investigations. The bone mineral density examination showed low bone density for the expected age.
Conclusion: Clinicians, who deal with pregnant women, should consider the diagnosis of bilateral femoral insufficiency fracture in any pregnant women with pelvic pain. Awareness of risk factors of BFNF might help to reduce the rate of this complication.

Kaveh Gharanizadeh, Alireza Mirzaei, Solmaz Piri, Mozhdeh Zabihiyeganeh,
Volume 16, Issue 10 (October 2018)

Transient osteoporosis of pregnancy (TOP) is a rare, yet under-reported condition that threatens pregnant women in the third trimester of a usually uneventful pregnancy. It is known to be the consequence of drastic loss of bone mass and elevated rates of bone turnover caused by fetal consumption of calcium and vitamin D from the maternal skeleton (1, 2). Meanwhile, the transient nature of osteoporosis cannot generally be determined at the time of the event, mainly due to the lack of bone mineral density (BMD) history.
With respect to our published article “Undesired effect of excessive betamethasone administration during pregnancy: A rare case” in volume 16, issue 3 of your journal (3), we were highly concerned about TOP based on the characteristics of the fracture. However, due to lack of adequate information of previous BMD, this concern could not be supported at that time and postpartum bilateral femoral neck fracture was the reported diagnosis instead. Therefore, we prescribed teriparatide in addition to calcium and vitamin D supplementation for the management of low BMD of the patient, which was discontinued after three months due to the high cost of the drug for her.
In order to rule out the main cause of bilateral femoral neck fracture in our patient, we followed the patient for 30 months after the surgery, when her ability to walk was completely returned to normal and she had no other complaint as well. We repeated the BMD of the patients to find out if she needs any osteoporosis medication. An 11% improvement was observed in the last lumbar spine BMD of the patient when compared with the earlier BMD performed at the time of bilateral femoral neck fracture diagnosis (BMD=0.906 g/cm2, T score=-1.3 versus BMD=0.816 g/cm2, T score=-2.1, respectively).
According to the provided evidence, especially improvement of follow-up BMD, we are convinced that this case could be truly considered as TOP, which was resolved after pregnancy and elimination of its concomitant risk factors (vitamin D deficiency, immobility, and excess steroid consumption).
Although we prescribed teriparatide for the management of low BMD of the patient, our evaluations revealed that osteoporosis will spontaneously resolve in such cases. Hence, the clinical message of these findings could be to avoid unnecessary osteoporosis treatment in premenopausal pregnant women through the definitive diagnosis of TOP.

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