Pregnancy and osteoporosis

Research has shown that bone density decreases in the later part of pregnancy but returns to normal in the months after birth. This drop in bone density is different to PAO. In a standard pregnancy, the change in bone density doesn’t cause bones to break.

Bone density can drop while a woman breast-feeds but returns to normal when the baby is weaned. This change in bone density doesn’t cause bones to break.

You may have heard that a drug called heparin may be linked to PAO. Heparin is sometimes used during pregnancy to thin the blood. For example, if you have a condition such as anti-phospholipid antibody syndrome that can cause blood clots. Heparin is an important drug treatment to reduce the chance of clots and keep the baby safe and well. But the evidence isn’t clear on whether heparin increases the chance of osteoporosis and fractures. Some research has shown a link. But other research hasn’t. It’s unlikely the drug causes PAO. 

"I suffered 9 spinal fractures over the first 11 weeks of my baby’s life. Some were caused by very minor things such as lifting the pram into the car or putting the baby in the cot. The incidents caused horrific spasms across my back. The pain was so bad it took my breath away, then made me scream. Each episode left me in a state of shock, not being able to stop shaking for hours at a time.

I tried to continue with activities, but after the third incident, I realised I couldn’t lift the baby anymore. I was unable to lift him from when he was 3 to 6 months.

It never crossed my mind that these incidents could have been fractures as I had no history of fractures or osteoporosis and had never heard of PAO. I was diagnosed 11 months after giving birth.

I continue to recover slowly with help from physiotherapy and my baby is now over 2 and a half. I can do most things that I would need to do in everyday life including walking, driving and lifting my child.

Keep going! It does get better. Give yourself credit for everything that you’ve managed to do with a fractured spine.

Don’t worry about whether it will affect your relationship with the baby, because it really won’t. The baby doesn’t know it’s normal for a mother to be able to walk and hold her baby. The baby will love all the things you can do - like talking and singing. Your relationship will be stronger for this experience not weaker. And one day when your child goes through something difficult you will be an amazing support to them because of your experiences."

Some specialist doctors recommend taking a bone-strengthening drug such as a bisphosphonate or teriparatide if you have PAO. Bisphosphonates are the usual choice. Some bisphosphonates stay in the bones for a number of years. But risedronate stays in bones for less time. This may be offered as a better option if you want another child. This is because these drugs have not been tested in pregnancy. 

Others take an ‘active monitoring’ approach, where you won’t be given a drug treatment. Instead, they will monitor your bones over a few years. This is because most women don’t keep breaking bones and their bones seem to naturally recover over time.

As with any treatment, there are reasons to take and not take a drug treatment. You should think about these when deciding whether to take a drug treatment, and about what’s important to you.

Here are some of the main things to consider.

Reasons to take a drug treatment

• They can help to reduce your risk of broken bones.
• They are prescribed by experts who have the knowledge and experience to help you make the best decision for you.
• They are safe and effective to treat osteoporosis.
• There are different types of osteoporosis drug treatments to suit your situation.

Reasons not to take a drug treatment

• PAO seems to get better over time, without a drug treatment. Bone density improves and fractures don’t keep happening.
• They don’t make broken bones heal more quickly or take away the pain.
• As with all drug treatments, some people get side effects.
• They haven’t been tested in younger women so we don’t know if they are helpful in PAO.

After breaking a bone in pregnancy it’s good to have a well-balanced, calcium-rich diet and gradually increase gentle and regular exercise. This helps to reduce the chance of breaking another bone.

You should try and eat 700mg of calcium every day. Most people can get enough calcium from their diet.

Vitamin D helps to keep bones strong by helping the body to absorb calcium. You can get Vitamin D from sunlight.

There’s no clear evidence that women with PAO need extra supplements of calcium and vitamin D. But many women will decide to take them because PAO is so poorly understood. Taking supplements isn’t going to be harmful.

Exercise can help with pain after a spinal fracture and help reduce the chance of breaking a bone.

We have a selection of videos and fact sheets to guide you through the exercises.

These exercises are not for pregnant women. They are suitable for people with spinal fractures after the baby is born.

There are also breathing and relaxation exercises that can help you to cope with pain. Read our daily living after fractures fact sheet.

I was 27 when I had my first baby and began to have back pains when I was breastfeeding. One day, five weeks after the birth, I collapsed on the floor with knife-like pains down the length of my spine. It was extremely frightening and painful. I was soon in hospital diagnosed with osteoporosis of the spine. I had two impacted vertebrae at the bottom of my spine. The worst part was if I moved quickly, or even laughed, my back muscles went into violent spasms. I had bad backache at night for four years but for me, learning yoga completely stopped the pain. During my third pregnancy, I slipped in the snow three weeks before the baby was due and fractured my hip. It was a difficult fracture and took a long time to heal. It was six months before the crutches became redundant but there were no after effects at all so I feel extremely lucky. I now live a normal life. I walk briskly, cycle, horse-ride and am still working full time in a plant nursery. Marjorie

You’ll probably need to take strong pain-relieving drugs if the pain is severe. Many women feel anxious about taking tablets if they are breast-feeding. Talk to your doctor about which drugs are suitable. Getting the pain under control can help you feel able to manage. 

Find out about other ways to help relieve pain. These methods are not for pregnant women. If you’re pregnant, talk to your doctor about pain relief. 

Some women with PAO have a change in their appearance. They may have a change in posture or a loss of height. Women often say they have lost their ‘waistline’. This change is due to spinal fractures. These types of fractures cause the bones in the spine to change shape, becoming compressed or wedge-shaped. Even when healed, spinal bones don’t go back to their previous shape. Women say that the impact this loss of height and curved spine has on body image can be very difficult.

Spinal fractures will heal and get better without an operation. The pain normally gets better as they heal.  

Find out more about recovering from spinal fractures.

Broken bones normally take about six weeks or longer to heal. But it will probably be a number of months before things seem to get better. Some people report a loss of confidence, frustration and not feeling like themselves.

Be patient with yourself. Experiences are very varied and the outcome for most women is positive. With good pain control, physiotherapy and lots of support you should make a good recovery.

Some women do have pain which can last for months or years. They may also have changes to their posture. But most women can still do the things they want to do, it may just need some adjustments.

Living with PAO can also have an impact on your emotional health. But you're not alone and we're here to support you. There's information and support available to help you and your family and friends.

You will feel like yourself again.

As a district nurse I knew something was wrong when I started to suffer hip pain in the 30th week of my pregnancy and found it difficult to walk or bend. When I gave birth I actually fractured my left hip during delivery. I was in severe pain, which was dismissed by everyone at first. Then a day later it was obvious that something was wrong. It was decided that I needed an x-ray and the fracture was diagnosed. I was on crutches for 18 months but with lots of physiotherapy and, because I suppose I was so determined, I got back to nursing again. I am now still affected by a slight limp but otherwise my life is back to normal. Kate 

All new mothers need to have some time to themselves. But for mothers with broken bones, time to rest from caring for your child is very important. Often, people don’t have family living close by who are able to help. And finding other support is essential.

Most of the women we spoke to found a trustworthy, practical person with experience looking after children is more helpful and less expensive than a qualified maternity nurse. Talking to friends and neighbours and setting up a rota of people who can help is how some women have managed.

Women who have been through the same experience of osteoporotic fractures can often give practical tips. One woman found having a mobile phone close to hand gave her confidence if she was left alone. Another found having a trolley with everything she needed made life easier.

Breast-feeding is a very personal decision. The body has an excellent inbuilt way of regulating itself during breast-feeding to make sure both mother and baby have enough vitamins and minerals.

Doctors may advise women with PAO not to breast-feed because bone density does drop when breast-feeding and stays low until you stop. But there’s no research to suggest that breast-feeding stops bones healing or causes more bones to break. 

Some women take certain precautions while breast-feeding. These include

• taking calcium and vitamin D supplements
• limiting breast-feeding for a few weeks rather than a number of months or years.

Your midwife, health visitor and doctors will be able to help and support you with these decisions. If you decide to breast-feed, even for a short time, make sure you are comfortably supported with pillows. If possible, ask someone to pass the baby to you to avoid lifting.

For some women, the decision not to breast-feed is made because of back pain or because they don’t feel strong enough. It's most important you look after yourself so you can recover and look after your baby more easily.

Breast-feeding doesn’t seem to increase the risk of osteoporosis in the long term. Studies of women who have breastfed their babies show they’re not at an increased risk of breaking a hip in later life. One study showed a decreased risk of having a broken hip in women who breastfed. The reasons for this were unclear.

You can find out more about breast-feeding and support on the UK’s NHS breast-feeding website.

Partners, family and friends often want to help but this can be a difficult time for everyone. Some partners will feel the pressure to go back to work while wanting to help at home. In addition, being a parent for the first time brings its own challenges. It’s important for partners to support each other by discussing all the options regarding child and homecare and make a joint decision, which they will both be able to cope with.

As with any other activity there are no rules! Many women and their partners are anxious about returning to a physical relationship. There's often a fear of getting more pain or further fractures, or of causing either of these. Being honest and sensitive and talking about these fears will help as well as being imaginative about trying different positions – and keeping a sense of humour!

It's very much a personal choice as to whether you decide to have another baby. It's rare to have fractures in future pregnancies although sometimes they do happen. If your bone density has improved since you gave birth, this is a good sign you won’t break a bone again. But having lower bone density doesn’t mean you will definitely break a bone. Some women decide not to have another baby, while others do.

As PAO is rare, there's no guidance on how best to manage future pregnancies.

Some doctors are very cautious and recommend a caesarean delivery. Others would avoid the lithotomy position (which puts a strain on the hip). But there are also others who simply ensure women are looked after as any woman with a back pain problem would be.

It's unclear whether having fractures associated with pregnancy means you’re likely to have broken bones, due to osteoporosis, in later life. The research hasn’t proved this either way.

As a result of this uncertainty, most women who have had this condition would be advised to discuss their overall risk of osteoporosis and fractures with their doctor when they reach the menopause. There is a tool called the fracture risk assessment that can assess the health of your bones. As part of this, you may be offered a bone density scan. The fracture risk assessment will help to decide if an osteoporosis drug treatment would be useful.

This article is aimed at researchers and clinicians.

Clinical Features, Incidence and Treatment Outcome in Pregnancy-Associated Osteoporosis: A Single-Centre Experience over Two Decades