Intravenous Pamidronate for Treatment of Reflex Sympathetic Dystrophy During Breast Feeding

Abstract

A 39-year-old woman presented in the first month of pregnancy with reflex sympathetic dystrophy involving both lower legs. Symptoms became so severe that she could not walk unassisted, and the pain worsened after delivery. Radiographs showed patchy reduction in apparent density in the tarsal bones and around the ankles and knees. Uptake was increased in these areas on technetium methylene diphosphonate bone scan. Bone density (dual-energy X-ray absorptiometry) was reduced in the spine, hip, and radius. Biochemical tests were normal except for an increase in urinary excretion of the N-telopeptide cross-linking region of type I collagen (NTx). Because the patient wanted to continue breast-feeding, intravenous pamidronate was administered at monthly intervals. Breast milk was collected for 48 h after the infusion. The pain began to decrease soon after drug administration was initiated, and it was virtually gone by 6 months. NTx excretion fell by 78% and bone density increased by as much as 18.9% over the 6-month treatment interval. The baby was healthy and grew normally. Milk expressed after the first treatment was assayed for pamidronate content by high-performance liquid chromatography with fluorescence detection. None was detected (limit of quantitation, 0.4 mol/liter).

The following abstracts were presented at the Annual Congress of the Association of Anaesthetists of Great Britain and Ireland in Edinburgh, September 2011

“…Painful traumatic rib fractures commonly cause chest morbidity; non-steroidal anti-inflammatory and opioid drugs form the mainstay of treatment but may cause toxicity. The British Thoracic Society recommends using ultrasound to localise interpleural procedure insertion points [3] and National Institute for Health and Clinical Excellence suggests ultrasound improves efficacy and safety in regional nerve blockade [4]. Our use of real-time in-plane ultrasound guidance complies with both and improves the safety of this analgesic technique.…”

“…Approximately 30 g calcium is transferred from mother to fetus during pregnancy [3]. Compensatory mechanisms restore calcium deficit with reductions in bone mineral density [3,4] and support advice to stop breastfeeding in clinically apparent osteoporosis [3]. Acute pain services have a small presence on obstetric wards but early referrals are recommended with escalating opioid use.…”

The use of bisphosphonates in women prior to or during pregnancy and lactation

“…The baby remained healthy and presented normal growth. 23 In addition, in the case of the patient suffering from Gaucher's disease mentioned above, breastfeeding for 1 year was not accompanied by adverse effects to the infant's health and developmental rate. 17 In the report of 4 cases by Chan et al, also described above, women received intravenous pamidronate for 19-46 months before conception and all of them breastfed their babies for 6 weeks to 18 months.…”

Recurrent Transient Osteoporosis during Pregnancy and Treatment with Oral Bisphosphonates: A Case Report

“…Although bisphosphonates are known to cross the placental barrier and may have an effect on fetal serum calcium levels and growth there have been no reports of congenital abnormalities associated with use of bisphosphonates in animal teratology studies [13]. Concerning bisphosphonates therapy during breastfeeding, a study showed that pamidronate is undetectable in breast milk of nursing mothers in the first 48 h after a 30 mg infusion [14]. In our case, we decided to postpone the bisphosphonate therapy after the C-section and, in accordance with the patient, to suspend breastfeeding in order to avoid further bone demineralization.…”