A 25-year-old woman presented to our outpatient department with a complaint of having developed a severe pain in her hips (left more than right), which she noticed for the first time when she was pregnant 2 years previously. She continued to have pain from the sixth month of her pregnancy which progressed in severity, limiting her ability to walk and squat or even sit cross legged. Six months earlier she had also noticed shortening of her left limb (fig 1). An x ray pelvis revealed the diagnosis (fig 2).
Figure 1.
Shortening of the left limb.
Figure 2.
Pelvic x ray.
Clinicians evaluating pregnant patients with pain around the hip joint may encounter a diagnostic dilemma. Pain in the hip joint during the later stages of pregnancy and postpartum is common in some pregnant women and is usually attributed to sciatica, lumbosacral strain, or compression of pelvic structures. In our patient the pelvic x ray pelvis revealed irregular and deformed contours of both femur heads, more on the left side. Subchondral sclerosis was also noted in the femoral head on both sides, with increased severity on the left side. This was associated with loss of joint space. The margins of the acetabular roof were also blurred and irregular. These findings suggest bilateral avascular necrosis (AVN) grade II–III of both femoral heads.
There are around 40 cases of avascular necrosis of the femoral head associated with pregnancy reported in the literature up to February 2008.1 It is possible that this association may be coincidental.2 High levels of adrenocortical activity, elevated maternal parathyroid hormone and its adverse effects on bone, and mechanical stress (especially due to excessive weight gain during the last trimester of pregnancy in women with a small body frame) have all been postulated to explain this association.3 However, further reports and studies are needed to establish a causal association.
Acknowledgments
All staff of People’s College of Medical Sciences who were involved in caring for this patient.
Footnotes
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication
References
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