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DOI: 10.1055/s-2003-45172
Osteonekrose und HELLP-Syndrom
Osteonecrosis and HELLP-SyndromePublication History
Eingereicht: 14.8.2003
Angenommen nach Überarbeitung: 14.10.2003
Publication Date:
19 December 2003 (online)
Zusammenfassung
Hintergrund/Fragestellung: Das im Rahmen einer Schwangerschaftsgestose in etwa 25 % der Fälle auftretende Hemolysis-Elevated-Liver-enzymes-and Low-Platelet-count-Syndrom (HELLP-Syndrom) ist pathogenetisch eng mit Gerinnungsaktivierungsmechanismen verbunden, welche zu Knochenmarkveränderungen führen können. Diese sind zusammen mit den therapeutisch häufig eingesetzten Steroiden und einem hohen Gebäralter bei Erstgebärenden für ein hohes Osteonekroserisiko mitverantwortlich. Aus anatomischen und biomechanischen Gründen sind die subchondralen Areale des Hüftkopfes häufigster Manifestationsort einer schwangerschaftsassoziierten Osteonekrose.
Patienten/Methodik: Es wird über den zweijährigen Verlauf einer 37-jährigen Patientin mit bilateralen Osteonekrosen beider Hüftköpfe nach HELLP-Syndrom berichtet, die sich nach einer operativen Markraumdekompression bei einem Begatelltrauma eine proximale Femurfraktur zuzog. Anschließend werden aktuelle Daten zur Pathogenese, Diagnostik und Therapie der HELLP-assoziierten Osteonekrosen aufgeführt und diskutiert.
Ergebnisse/Schlussfolgerung: Bei schwangerschaftsassoziierten Knochen-/Gelenkbeschwerden wird ein frühzeitiges MRT-Screening zum Ausschluss einer Osteonekrose empfohlen, um frühzeitig therapieren zu können und irreversible Spätschäden zu vermeiden. Es existieren Hinweise, dass auch ohne den Einsatz von Steroiden zur Behandlung des HELLP-Syndroms das Osteonekroserisiko erhöht ist.
Diskussion: Bisher können nur Frühstadien der Osteonekrose kurativ therapiert werden. Differenzialdiagnostische Schwierigkeiten bestehen in der Abgrenzung einer sich entwickelnden Osteonekrose zum Knochenmarködemsyndrom (KMÖ) und zur transienten Osteoporose.
Abstract
Background: In 25 % of patients who develope gestosis a Hemolysis-Elevated-Liver-enzymes-and-Low-Platelet-count-Syndrome (HELLP-Syndrome) may occur, which is characterized by activation of the coagulation mechanism and bone marrow alterations. Besides this therapeutical steroid application and an elevated age of primigravidity are responsible for an increased osteonecrosis risk in women, too. Because of anatomical and biomechanical reasons the highest incidence of pregnancy-associated osteonecrosis are the subchondral areas of the femoral epiphysial head.
Patients/Methods: In this investigation data of pathogenesis, diagnostic work up and therapy in HELLP-associated osteonecrosis are reviewed and discussed based on a case report. We report of a 37-year old HELLP-patient showing bilateral femoral head osteonecrosis, who sustained a proximal femur fracture after bone marrow core decompression surgery.
Results/Conclusions: In pregnant patients with joint or bone associated pain an early MRI screening is recommended to detect osteonecrosis at early stages. This allows for therapeutic procedures which may be successful at early stages. If steroids are applicated for HELLP-treatment, the risk of osteonecrosis is elevated.
Discussion: Only early stages of osteonecrosis can be treated curatively. Sometimes it can be difficult to differentiate between early osteonecrosis stages, a bone marrow edema syndrome and a transient osteoporosis.
Schlüsselwörter
HELLP-Syndrom - Osteonekrose - Schwangerschaft
Key words
HELLP-syndrome - Osteonecrosis - pregnancy
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Dr. med. Marcus Jäger
Orthopädische Universitätsklinik
Heinrich-Heine Universität Düsseldorf
Moorenstraße 5
40225 Düsseldorf
Germany (FRG)
Phone: 0211-81-17960
Fax: 0202-9422622
Email: Jaeger@med.uni-duesseldorf.de