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 wheelchair 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 otherwise 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 undertaken 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 subacute 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 keeping 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.
|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 ↑PTH|
|25-hydrocalciferal (nmol/L)||<10||39–140||Clear deficiency|
|Parathyroid hormone (pmol/L)||22.3||1.1–6.9||Secondary hyperparathyroidism|
|Osteocalcin (μg/L)||<4.2||6.8–32.3||Poor laying down of bone matrix|
|Bone density (g/cm2)||% Young adult||T Score|
|Left femoral neck||0.60||61||−3.2|
A diagnosis of osteomalacia secondary to vitamin D deficiency was made, with superimposed osteoporosis and possibly a component of malabsorption (the woman preferred not to undergo further gastrointestinal investigations). 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.