Osteomalacia presenting as pathological fractures during pregnancy in Asian women of high socioeconomic class.

Osteomalacia is widely prevalent in the Asian immigrant population at clinical' and subclinical2l levels, especially in those who are vegetarians. Pregnancy is associated with increased demands for vitamin D and hence may be responsible for the induction ofclinical osteomalacia4 among women who may otherwise have only biochemical , subclinical abnormalities. We describe two vegetarian Asian women who presented with pathological fractures during the third trimester ofpregnancy, having been completely asymptomatic before pregnancy. So far as we know this is the first report showing the occurrence of such fractures in pregnant women who were asymptomatic before pregnancy. Case 1 A vegetarian primigravid Asian chartered accountant aged 28 developed pain in her foot during the seventh month of pregnancy. The pain gradually increased and she was referred for an orthopaedic consultation. She had tenderness and swelling over the metatarsal bones and a radiograph confirmed fractures of the metatarsals. She also stated that she had aches and pains in her chest and pelvis and weakness, with difficulty in climbing stairs. She had proximal myopathy. Plasma biochemical studies confirmed osteomalacia-calcium concentration 2-0 mmol/l (8-0 mg/100 ml); phosphate 0-7 mmol/l (2-1 mg/100 ml); alkaline phosphatase activity 222 IU/l (normal 30-120 IU/1); albumin concentration 38 g/l. 25 Hydroxyvitamin D was not detectable and serum parathyroid hormone concentration (N terminal assay) was 320 ng/l (upper Osteomalacic fractures may occur in pregnancy in Asian women irrespective of socioeconomic state limit of normal 120 ng/l). She was treated with calciferol, 600 000 IU by intramuscular injection, and with one tablet of calcium and vitamin D daily. Over the next four weeks the pain in her foot subsided, the aches and pains disappeared, and the proximal myopathy resolved. Plasma calcium and phosphate concentrations became normal. At term she delivered a normal baby who had no neonatal complications. After delivery she stopped taking vitamin D tablets and did not attend for follow up. She breast fed her baby. Six months after delivery she presented with diffuse aches and pains and inability to carry her baby in her arms. She had diffuse bony tenderness and severe proximal myopathy. Plasma calcium and phosphate concentrations had fallen, while alkaline phosphatase activity had increased. She was treated with calciferol and calcium+vitamin D tablets. She again lost her symptoms within four weeks and continued to take vitamin D supplements thereafter. A 25 year old Asian vegetarian primigravid biochemist (the wife of a pharmacist) presented with severe …