The most common symptom of osteoporosis is back pain in late pregnancy or postpartum. Other symptoms are hip pain, either unilateral or bilateral, and diiculty in weight bearing until the woman is nearly immobilized (Maliha, 2012). In more than half of women, no apparent reason for osteopenia is found. Some known causes include heparin (unfractionated only), prolonged bed rest, and corticosteroid therapy (Cunningham, 2005; Galambosi, 2016). In a few cases, overt hyperparathyroidism or thyrotoxicosis eventually develops.
Treatment is problematic and includes calcium and vitamin D supplementation and standard pain management. Shown in Figure 58-5 is a hip radiograph from a woman
FIGURE 58-5 Anteroposterior plain hip radiograph of a 25-yearold woman at 26 weeks' gestation. She complained of left hip and knee pain and progressive weakness. Transient osteoporosis of the left femur responded over 3 months to physical therapy combined with vitamin 0 and calcium supplementation.
treated at Parkland Hospital during the third trimester for transient osteoporosis of pregnancy. For women with pregnancy-associated osteopenia, long-term surveillance indicates that although bone density improves, these women and their ofspring may have chronic osteopenia (Carbone, 1995). Related, prenatal supplementation of normal women with cholecalciferol, 1000 IU / d, did not increase ofspring bone mineral content, although it did ensure maternal vitamin D repletion (Cooper, 2016).
Pregnancy has profound efects on adrenal cortical secretion and its control or stimulation. These interrelationships were reviewed by Lekarev and New (2011) and are discussed in detail in Chapter 4 (p. 71).
Pheochromocytomas are chromain tumors that secrete catecholamines and usually are located in the adrenal medulla, although 10 percent are located in sympathetic ganglia. They are called the 10-percent tumor because approximately 10 percent are bilateral, 10 percent are extraadrenal, and 10 percent are malignant. These tumors can be associated with medullary thyroid carcinoma and hyperparathyroidism in some of the autosomally dominant or recessive multiple endocrine neoplasia syndromes, as well as in neurofibromatosis and von HippelLindau disease (Neumann, 2015).
These tumors complicate approximately 1 per 50,000 pregnancies (Quartermaine, 2017). Notably, they are found in 0.1 percent of hypertensive patients (Abdelmannan, 2011). However, they are more commonly found at autopsy but with infrequent clinical recognition. Symptoms are usually paroxysmal and manifest as hypertensive crisis, seizure disorders, or anxiety attacks. Hypertension is sustained in 60 percent of patients, but half of these also have paroxysmal crises. Other symptoms during paroxysmal attacks are headaches, profuse sweating, palpitations, chest pain, nausea and vomiting, and pallor or flushing.
The standard screening test is quantification of metanephrines and catecholamine metabolites in a 24-hour urine specimen (Neumann, 2015). Diagnosis is established by measurement of a 24-hour urine collection with at least two of three assays for free catecholamines, metanephrines, or vanillylmandelic acid (VMA). Determination of plasma catecholamine levels is the most sensitive test. In nonpregnant patients, adrenal localization is usually successful with either computed tomography (CT) or magnetic resonance (MR) imaging. For most cases, preferred treatment is laparoscopic adrenalectomy (Neumann, 2015).