European Journal of Obstetrics & Gynecology and Reproductive Biology, 36 (1990) 167-173 Elsevier
167
EUROBS 00942
Aseptic necrosis of the femoral head associated with pregnancy; a case report.
Igna Van den Veyver I, Jozef Vanderheyden ‘, Eric Krauss ’ and Saskia Jankie ’
’ Department of Obstetrics and Gynecology and 2 Department of Physical Medicine and Rehabilitation, Saint Augustinushospital, Wilrijk Belgium
Accepted for publication 20 September 1989
A documented case of beginning aseptic necrosis of the femoral head associated with pregnancy together with a review of the literature about this rare complication of pregnancy is presented. The patient complained of increasing pain in the right hip and limitation of movement of the affected joint. After delivery, the diagnosis of beginning avascular necrosis of the right femoral head was confirmed on X-ray, technetium-99 bone scan and CT-scan of the hips. Three weeks after delivery the patient was treated with drilling of the femoral head. Recovery was complete.
Pregnancy; Femoral head; Aseptic necrosis
Inlroduction
Until now, only 16 cases [l-5] of aseptic necrosis of the femoral head in association with pregnancy have been described. The first report was made by Pfeiffer in 1957 [8]. Only nine of the patients described did not have any other interfering disease, trauma or medical treatment (e.g., corticosteroids) known as possible causes of bone necrosis. In our patient, all other predisposing factors but pregnancy have been excluded.
Because until now few cases have been described, little is known about the evolution and treatment of this disease in association with pregnancy.
Correspondence: Dr. Igna Van den Veyver, Department of Obstetrics and Gynecology, Saint Augustinushospital, 24, Oosterveldlaan, 2610 Wilrijk, Belgium.
0028-2243/90/$03.50 0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
168 Case
A 36-year-old women, G2 Pl AO, experienced increasing pain in her right hip radiating to the knee during the third trimester of her pregnancy. The pain was most severe when the leg bore weight and when the affected joint was moved, and disappeared completely at rest. The pain was not radicularly distributed. For the further course of the pregnancy rest was prescribed and also advice not to bear any weight on the leg.
At 40 weeks of amenorrhea, she delivered uneventfully of a girl weighing 3200 g.
More extensive examinations were done immediately postpartum. X-rays with tomography showed diminished density of the right femoral head and acetabulum (Fig. 1). A CT-scan confirmed the findings and also showed increased intra-articular fluid (Figs. 2 and 3). A technetium-99 bone scan demonstrated increased uptake of the label at the affected joint (Fig. 4).
Extensive blood analysis only revealed an increased sedimentation rate and a slightly elevated white blood cell count which were attributed to the recent delivery.
The diagnosis of early aseptic necrosis of the right femoral head was withheld.
Intra-osseus pressure measurements at the time of a drilling procedure 3 weeks after her delivery demonstrated elevated values in the right femoral head.
Six months after this treatment, the X-rays are completely normal and the patient is without symptoms.
Fig. 1. X-ray showing hypodensity of the right femoral head when compared to left side.
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Discussion
The first complaint is mostly unilateral, sudden or gradually increasing pain deep in the groin and radiating to the knee, thigh or back. It usually starts during the third trimester of pregnancy or shortly after a difficult delivery, typically in an elderly primigravida [l-4,6,7].
Sometimes the pain is so severe that a crutch is needed for walking [2]. This was also the case with our patient.
Physical examination shows a painful limitation of active and passive movement of the joint, especially with rotation and less pronounced with abduction and flexion [1,2,6,7]. Some swelling and stiffness may be present [2].
The patient sometimes presents with a Trendelenburg or Musculus Gluteus gait, to be differentiated from the typical gait of an instable pelvis during pregnancy [4].
In the early stages, sacro-iliac strain, is&as and pain due to compression of pelvic structures or secondary to relaxation of the pelvic ligaments have to be ruled out [2,4]. Specific X-rays as well as laboratory findings will allow the differential diagnosis With joint tuberculosis in developing countries [5].
Figs. 2 and 3. CT-scan showing marked hypodensity of the right femoral head with cortical thinning.
Fig. 3.
Pain due to nerve compression will be partly relieved at rest; however, contrary to the pain of aseptic necrosis there is an obvious exacerbation of the neuralgic pain during the night.
Predisposing factors, other than pregnancy, found in association with femoral head necrosis should be looked for and ruled out (Table I). Some pregnancy-associ- ated diseases, e.g., pregnancy-induced hypertension or the lupus anticoagulant syndrome are to be excluded [2]. The laboratory tests used for this purpose are listed in Table II. Their use should be adapted to the individual case.
At present six stages (Stage O-5) of aseptic necrosis are defined, with typical clinical and histological signs in each stage [lo]. X-rays and conventional tomogra- phy become pathological only in stage 2, often several months after the onset of clinical symptoms, showing arc-like subchondral radiolucent areas, patchy lucent areas, sclerosis, a ‘crescent’ sign and osseus collapse [lo].
In our patient, a CT scan of both hips was performed, showing the radiological characteristics of ostenecrosis more clearly.
Because early diagnosis is important for the success of treatment, other tech- niques have to be used for this purpose. Bone scintigraphy shows a cold lesion in the
Fig. 4. The 99Te bone scan shows an increased uptake at the right femoral head.
initial stage of devascularisation and a hot lesion after weeks or months, when reparative processes are taking place [lo].
Recently, magnetic resonance imaging is used more frequently for early diagno- sis, showing a persisting decrease in normal signal intensity of the affected bone as early as 12-48 hours after the onset of the disease.
When it is available, it represents now the noninvasive technique of choice for early diagnosis [lo]. It is also an apparently safe procedure during pregnancy.
A core bone biopsy can finally give histologic confirmation of the diagnosis when necessary [6,10].
The exact cause of osteonecrosis of the femoral head in the pregnant patient is not known and many possible mechanisms have been postulated to explain its occurence. The high estrogen and progesterone production by the placenta can contribute to the development of osteonecrosis by fatty embolism [14]. The elevated non-protein bound cortisol and glucocorticoid activity of progesterone can be responsible [1,2]. The pregnancy-related maternal parathyroid gland hyperplasia with high levels of parathyroid hormone may also contribute [1,2]. Direct injury to the femoral joint or the artery in the round ligament by compression of the growing uterus or during a difficult delivery have been mentioned [1,2].
172 TABLE I
Other possible predisposing factors described in association with aseptic necrosis of the femoral head [l-3,5-7]
Gaucher disease
Sickle cell disease or other hemoglobinopathies Irradation
Major trauma
Exposure to dysbaric conditions (Caisson disease) Administration of glucocorticoids
Traumatic dislocation and fractures Neck and subtrochanteric osteotomies Cushing disease
Alcoholism Gout
Legg-Calve-Perthes disease Obesity
Renal transplantation Sustemic lupus erythematosis Rheumatoid arthritis Pheochromocytoma
Hemolytic and aplastic anaemia Pancreatitis
Serious infections Fabry’s disease Hemophylia Hyperlipidemia Fatty embolism
TABLE II
Laboratory tests [1,2,4-61 Erythrocyte sedimentation rate Red blood cell count
White blood cell count with formula
Coagulation parameters (PT, APTT, antithrombin-III) Platelet count
Blood glucose Liver function tests Renal function tests Uric acid
Total protein with protein electrophoresis Blood lipids
Rheumatoid arthritis
Anti-nuclear antibodies (with ENA and ds-DNA) Calcium, phosphor, alcalic phosphatase
Blood cortisol Amylase (lipase)
(Antiphospholipid antibodies) (Blood smears)
(Hemoglobin electrophoresis) (Tuberculin test)
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We presume that all factors can act together, causing an insufficiency of the blood supply to the femoral head at a certain point. Very little is known about the best way to treat the pregnant patient, but it seems that early diagnosis, rest and advice not to bear any weight on the leg are very important.
The prognosis after this conservative therapy seems very good, although sec- ondary degenerative or arthrotic changes eventually require surgical treatment at a later age [6]. The drilling procedure as was first described by Kleinberg (1939) and Bozsman (1941) and later by Phemister (1949) is done to replace dead necrotic bone by channels through which revascularisation can take place. It also causes pain relief by decompressing the elevated intra-osseus pressure [ll].
Conclusion
The diagnosis of this rare condition of avascular necrosis of the femoral head during pregnancy is often missed initially because the pains are easily taken for pelvic relaxation symptoms, round ligament pains and pains due to hyperlordosis of the lumbar spine. In a less pronounced form, namely algodystrophia of the hip (sometimes associated with the same lesions of the shoulder) it is probably more common than was initially thought [12].
The patients should be treated early and adequatly to prevent secondary degener- ative changes in the hip joints in these young women.
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