CASE REPORT

Fracture of the neck of the femur and osteomalacia in pregnancy

Amanda Henry, Lucy Bowyer*

Case report

A 24 year old Muslim woman in full purdah, (no skin

exposed in public, including veiling of the face and gloving

of the hands), appeared at the antenatal clinic in a wheel-

chair at term. This was her third pregnancy, having

received no antenatal care until consulting her general

practitioner at 38 weeks of gestation by uncertain dates.

She had had two previous vaginal deliveries, in January

1999 and May 2000, both at term. Her second pregnancy

had been complicated by right-sided ‘sciatica’ in the third

trimester, but her obstetric and medical history was other-

wise unremarkable and she took no medications apart from

iron supplements. Antenatal blood results were normal as

was an ultrasound scan. She had complained to her general

practitioner of severe right-sided leg pain on mobilising.

Doppler ultrasound examination of her legs was normal. No

further examination or investigation of her leg was under-

taken at the antenatal clinic. The pain, which continued to

confine her to a wheelchair, was again thought to be due to

‘sciatica’.

At 42 weeks of gestation by a late ultrasound scan she

was admitted to the delivery suite in early labour. Her

labour progressed slowly over the following 22 hours and

the fetal head failed to engage into the pelvis. The woman

agreed to a caesarean section, resulting in the delivery of a

healthy boy weighing 4285 g. On the fourth day after her

caesarean section, it was noted that the woman walked with

extreme difficulty. On examination, the right quadriceps

and gastrocnemius muscles were wasted and there was

weakness of the muscles of the right hip. Her reflexes were

normal and there was no loss of sensation. She had a

markedly abnormal gait. Plain X-rays of her pelvis and

right hip showed a fracture of the neck of her right femur,

with significant displacement. In addition, there were sub-

acute healing fractures of the left superior and inferior

pubic rami, a sclerotic area of the right ischium suggestive

of an old healing fracture and generally osteopenic bones

with subcortical tunnelling and thinning of the cortex.

The results of bone mineral densitometry were in keep-

ing with established osteoporosis. The results of bone

biochemistry are shown in Table 1. A bone scan showed

abnormal focal uptake throughout the ribs bilaterally, the

intertrochanteric area of the right femur, the neck of the left

femur medially and the distal part of the left femur, in

keeping with multiple fractures. Bone marrow biopsy

performed 16 days postnatally was normal, showing normal

cellularity, a little patchy endosteal fibrosis and some bone

resorption and remodelling with groups of osteoclasts.

Screening for the malabsorption syndrome found a high

IgG gliadin but normal IgA and endomysial antibody.

A diagnosis of osteomalacia secondary to vitamin D

deficiency was made, with superimposed osteoporosis and

possibly a component of malabsorption (the woman pre-

ferred not to undergo further gastrointestinal investi-

gations). Her vitamin D deficiency was thought to be a

combination of lack of exposure to sunlight (she had been

wearing full purdah since arrival in Australia four years

previously), poor nutrition and possible malabsorption. She

denied the possibility of physical abuse when questioned

through a female interpreter by a female doctor without her

husband present, and there were no marks on her body to

suggest this alternative diagnosis.

Closed reduction of the right hip fracture and insertion of

three cannulated screws was performed by the orthopaedic

team. The woman was discharged 23 days postnatally

partially weight-bearing on her left leg (the bone scan

suggested incipient left-sided femoral fracture) and still

non-weight-bearing on her right leg. She was given

600,000 units of vitamin D intramuscularly before her

discharge. She went home taking ergocalciferol 1000 U

twice daily and calcium 600 mg twice daily. Her baby

showed no signs of neonatal hypocalcaemia and had

normal alkaline phosphatase but low vitamin D levels.

Discussion

Although symptomatic osteomalacia in pregnancy has

been reported previously, we believe this is the first case

of fractured neck of femur in pregnancy secondary to

osteomalacia. The fetus at term contains approximately

30 g of calcium and lactating women excrete approxi-

mately 210 mg/day of calcium in breast milk1. Pregnancy

BJOG: an International Journal of Obstetrics and GynaecologyMarch 2003, Vol. 110, pp. 329–330

D RCOG 2003 BJOG: an International Journal of Obstetrics and Gynaecology

doi:10.1016/S1470-0328(02)01642-7 www.bjog-elsevier.com

St George Hospital, Kogarah, Sydney, NSW, Australia

* Correspondence: L. Bowyer, St George Hospital, Kogarah, Sydney,

NSW 2177, Australia.

and lactation, therefore, are a time of increased require-

ments for calcium and vitamin D. Vitamin D may be

obtained in the mother either through the direct action of

sunlight on the skin or in the diet, animal products

(especially eggs and fish) being the richest sources.

Women thought to be particularly at risk of vitamin D

deficiency are dark skinned, vegetarians living at high

latitudes. Studies of pregnant Asian women in England

and Norway have shown rates of vitamin D insufficiency

(25-hydroxycalciferal <10 ng/mL) during pregnancy of

53% of 43 women and 83% of 36 women, respectively2,3.

Neither of these studies reported osteomalacia, but osteo-

malacia in pregnancy has otherwise been reported in Asian

immigrants to Britain4. There are also case series of

children with symptomatic vitamin D deficiency, a com-

mon association with maternal osteomalacia. These chil-

dren have rickets or hypocalcaemic seizures. In a series of

55 infants with vitamin D deficiency, Nozza and Rodda5

found 25 of the 31 mothers tested (81%) also had vitamin D

deficiency.

Women who do not expose themselves to sunlight for

religious or cultural reasons are at risk of vitamin D

deficiency irrespective of climate. A study of 119 term

pregnant women in Saudi Arabia found vitamin D defi-

ciency in 25%6. A recent study from Israel compared

vitamin D levels in 156 orthodox mothers (who wear

concealing clothing) with 185 non-orthodox mothers, and

found vitamin D deficiency in 37.2% and 13%, respec-

tively7. The woman in our case had a deficiency of sunlight

and deficiency of nutritional vitamin D. This case is a

reminder that a substantial number of pregnant women,

living in high or low latitudes, are at risk of vitamin D

deficiency. In a recent Australian study8, 80% of 82 veiled

or dark-skinned pregnant women were found to have

vitamin D deficiency.

The clinical effects of vitamin D supplementation in

pregnancy are uncertain. Although trials have shown that

supplementation in the third trimester leads to a significant

rise in serum 25-hydrocalciferal9,10, the Cochrane Review

on supplementation with vitamin D found only two trials

involving 232 women fulfilling the inclusion criteria for the

systematic review. The conclusion was that there is insuf-

ficient clinical evidence to justify supplementation with

vitamin D11. We recommend that further randomised trials

should be carried out.

References

1. Power ML, Heaney RP, Kalkwarf HJ, et al. The role of calcium in

health and disease. Am J Obstet Gynecol 1999;181:1560– 1569.

2. Brooke OG, Brown IR, Cleeve HJ, Sood A. Observations on the

vitamin D state of pregnant Asian women in London. Br J Obstet

Gynaecol 1981;88(1):18– 26.

3. Brunvand L, Henriksen C, Haug E. Vitamin D deficiency among

pregnant women from Pakistan. How best to prevent it? Tid Nor

Laegeforen 1996;116(13):1585– 1587.

4. Dandona P, Okonofua F, Clements RV. Osteomalacia presenting as

pathological fractures during pregnancy in Asian women of high

socioeconomic class. BMJ 1995;290(1):837–838.

5. Nozza JM, Rodda CP. Vitamin D deficiency in mothers of infants

with rickets. MJA 2001;175(5):253–255.

6. Serenius F, Elidrissy A, Dandona P. Vitamin D nutrition in pregnant

women at term and in newly born babies in Saudi Arabia. J Clin

Pathol 1984;37:444– 447.

7. Mukamel MN, Weisman Y, Somech R, et al. Vitamin D deficiency

and insufficiency in Orthodox and non-Orthodox Jewish mothers in

Israel. Isr Med Assoc J 2001;3(6):419– 421.

8. Grover SR, Morley R. Vitamin D deficiency in veiled or dark-skinned

pregnant women. MJA 2001;175(5):251– 252.

9. Mallet E, Gugi B, Brunelle P, Henocq A, Basuyau JP, Lemeur H.

Vitamin D supplementation in pregnancy: a controlled trial of two

methods. Obstet Gynecol 1986;68(3):300– 304.

10. Brooke OG, Brown IRF, Bone CDM, et al. Vitamin D supplements in

pregnant Asian women: effects on calcium status and fetal growth.

BMJ 1980;1:751– 754.

11. Mahomed K, Gulmezoglu AM. Vitamin D supplementation in preg-

nancy [Cochrane Review]. The Cochrane Library, Issue 2. Oxford:

Update Software, 2001.

Accepted 3 July 2002

Table 1. Bone biochemistry and bone mineral densitometry results.

Bone biochemistry Normal range Likely significance

ALP (five days postpartum, U/L) 300 38– 126 Uncertain (often high in pregnancy)

Serum calcium (mmol/L) 2.23 2.25– 2.58 Slightly low

Serum phosphate (mmol/L) 0.61 0.8– 1.5 Response to zPTH

25-hydrocalciferal (nmol/L) <10 39– 140 Clear deficiency

Parathyroid hormone (pmol/L) 22.3 1.1– 6.9 Secondary hyperparathyroidism

Osteocalcin (Ag/L) <4.2 6.8– 32.3 Poor laying down of bone matrix

Bone density (g/cm2) % Young adult T Score

Lumbar spine 0.73 61 �3.9

Left femoral neck 0.60 61 �3.2

ALP ¼ alkaline phosphatase.

PTH ¼ parathormone.

CASE REPORT330

D RCOG 2003 Br J Obstet Gynaecol 110, pp. 329–330