Spontaneous sternal fracture in multiparous woman during labor: a case report
Tade Popović1, Vajdana Tomić2,3
, Nikolina Penava2,3, Milena Brkić1, Andrej Galić4
Contributions: (I) Conception and design: T Popović, V Tomić, N Penava, M Brkić; (II) Administrative support: T Popović, V Tomić, N Penava, M Brkić; (III) Provision of study materials or patients: T Popović, V Tomić, A Galić; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: T Popović, V Tomić, N Penava, M Brkić; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Background: Spontaneous sternal fracture is an extremely rare cause of chest pain during or after childbirth. To date, only three cases of sternal fracture during childbirth have been reported. This case report represents the first documented case of spontaneous sternal fracture among multiparous women.
Case Description: A 33-year-old multiparous woman with an uncomplicated medical history is described, who delivered a healthy fourth infant vaginally at 41 weeks of pregnancy. After the previous three deliveries, each child had been breastfed for more than a year, and the third delivery was eight months before conception, and she breastfed until 3 months of pregnancy. During the final stage of labor, while performing the Valsalva maneuver in the lithotomy position, she felt a sharp, severe chest pain. Postpartum work-up included cardioselective enzymes that were within reference values, and radiological work-up confirmed a non-displaced sternal fracture, which was treated conservatively with symptomatic therapy, with complete recovery after 6 weeks.
Conclusions: This case report suggests the need to consider sternal fracture as a differential diagnostic consideration in women who experience chest pain during or immediately after delivery. Changes in metabolism, especially calcium metabolism during pregnancy and lactation, can result in transient osteopenia and, with increased mechanical stress, cause bone fracture. Special attention should be paid to patients who breastfed immediately before conception or who breastfeed during pregnancy, to vitamin and mineral replacement therapy, adequate nutrition, and physical activity. Timely diagnosis of sternal fracture can significantly reduce the need for expensive and invasive diagnostic tests. Further research is needed on osteopenia in pregnant women, especially multiparous women who are breastfeeding immediately before conception or during pregnancy.
Keywords: Chest pain; sternum fracture; multiparous woman; breastfeeding; case report
Received: 06 April 2025; Accepted: 22 August 2025; Published online: 11 October 2025.
doi: 10.21037/acr-2025-106
Highlight box
Key findings
• A 33-year-old quadriparous woman is presented here, who was admitted in the 41st week of pregnancy for a planned induction of labor. Although she had felt strong chest pain during labor, i.e., during the expulsion and simultaneous spine flexion on the Valsalva maneuver and pressing, she complained about this pain to the clinical physician the day after. Spontaneous sternal fracture that had occurred during labor was diagnosed 5 days following the delivery.
What is known and what is new?
• Only three studies of spontaneous sternal fracture during labor have been described in the literature to date.
• In the three papers described, two patients are primiparous, and for the third patient we have no information on the number of births. This paper presents the first case of a multiparous woman with a spontaneous sternal fracture.
What is the implication, and what should change now?
• A sternal fracture is a very rare diagnosis in an obstetric patient, which should be kept in mind when a woman complains of chest pain that started during childbirth.
• In this paper, we also discuss bone density during pregnancy, with special attention to the group of women who have multiple pregnancies.
• This paper indicates the need for further study of osteopenia in multiparous women who are breastfeeding immediately before conception or during pregnancy.
Introduction
The differential diagnosis of chest pain in an obstetric patient is broad. This includes conditions that are specific to pregnancy, such as preeclampsia with consequent pulmonary edema, conditions that worsen in pregnancy, such as gastroesophageal reflux, and conditions that increase in frequency in pregnancy, such as pulmonary embolism (1). Chest pain during labor can be the main symptom of life-threatening conditions such as: pulmonary embolism, aortic dissection, coronary artery dissection, pneumothorax, and myocardial infarction (2). Chest pain during or immediately after labor is usually caused by muscle strain, costochondritis, or gastroesophageal reflux (3). Some of the rare causes of chest pain that occur during or immediately after labor are Hamman’s syndrome and esophageal rupture (4,5). A very rare cause of chest pain is a spontaneous (traumatic) sternum fracture during labor. In this paper, we describe only the fourth case of spontaneous sternum fracture. During an extensive search of PubMed and Google Scholar, we found three papers describing sternum fractures during labor. Three sternum fractures were described, two of them in primiparous women, while the third paper did not indicate whether it was a primiparous or a multiparous woman. Our paper presents the first case of sternum fracture in multiparous women. This paper aims to raise awareness of this extremely rare diagnosis and highlights the importance of a physical examination. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-106/rc).
Case presentation
This paper will present first case report of spontaneous sternum fracture during labor in multiparous woman.
A 33-year-old quadriparous woman was admitted in the 41st week of pregnancy for a planned induction of labor, given the favorable gynecological findings, gestational age reached, and gestational diabetes. In the family anamnesis, we single out only chronic diseases: hypertension and diabetes mellitus, and from the personal anamnesis, she has not been seriously ill so far, she is a non-smoker, she has not had any bone fractures, she does not take any medications, except for prenatal vitamins enriched with calcium. Before pregnancy, the patient did recreational fitness. She never used oral hormonal contraception, had no period of amenorrhea caused by medication or improper eating habits. The patient had three previous uncomplicated pregnancies. Each child was breastfed for more than a year. The previous child was born eight months before conception. During pregnancy, the patient performed moderate physical activity, which included walking approximately 45 minutes to one hour per day, three to four times a week. She also performed stretching exercises for pregnant women to strengthen the lower back musculature, as well as the pelvis and hip joints, and knees and feet. Body mass index (BMI) at the beginning of pregnancy was 21.3 kg/m2, and during pregnancy she gained 12 kg. During pregnancy, she was diagnosed with gestational diabetes according to HAPO (Hyperglycemia and Adverse Pregnancy Outcome Study) criteria, which she managed with a balanced diet and physical activity. Her first delivery was an elective cesarean section due to breech presentation, and subsequent pregnancies ended in normal vaginal deliveries at term. Given that the woman was 40 weeks and 5 days pregnant, had a history of gestational diabetes, and a favorable gynecological examination, labor was induced with syntocinon infusion. Four hours passed from the start of induction to labor, and the expulsion itself lasted 30 minutes. The pregnant woman did not request any form of analgesia or anesthesia. During the labor, she was in the lithotomy position on a regular delivery bed, as she had been in previous vaginal deliveries. The delivery proceeded without episiotomy and without any pressure on the uterus; a live newborn was delivered with a birth weight of 3,950 grams. After birth, the child was immediately placed on the mother’s chest, and skin-to-skin contact was established. The mother complained of chest pain the day after giving birth. Although she felt strong chest pain at the moment of labor, i.e., during the expulsion and simultaneous spine flexion on the Valsalva maneuver and pressing, she complained about this pain to the clinical physician the day after. Laboratory findings were performed immediately after she complained about the chest pain, including complete blood count, urea, creatinine, minerals, hepatogram, biochemistry, and high-sensitivity troponin (Table 1). The electrocardiogram (ECG) was also normal. She underwent a consultative examination by an internist, who found no clinical signs of pulmonary embolism, and no further treatment was requested. During her 2-day stay in the hospital, she was mobile and only occasionally asked for oral analgesics. Apart from moderate sternal pain, she felt well at discharge from the hospital.
Table 1
| Parameters | Day 1 | Day 5 | Reference range |
|---|---|---|---|
| WBC (×109 /L) | 10.2 | 9.7 | 3.4–9.7 |
| CRP (mg/L) | 5 | 4 | 0.0–5.0 |
| RBC (×1012 /L) | 3.90 | 4.42 | 3.86–5.08 |
| HGB (g/L) | 118 | 122 | 119–157 |
| HCT (L/L) | 0.365 | 0.387 | 0.356–0.470 |
| MCV (fL) | 87.1 | 87.6 | 83.0–97.2 |
| PLT (×109 /L) | 380 | 406 | 158–425 |
| Glucose (mmol/L) | 5.1 | 4.9 | 4.4–6.4 |
| Sodium (mmol/L) | 141 | 139 | 137–146 |
| Potassium (mmol/L) | 4.9 | 4.6 | 3.9–5.1 |
| Chloride (mmol/L) | 101 | 104 | 97–108 |
| Aspartate aminotransferase (IU/L) | 21 | 27 | 8–30 |
| Alanine aminotransferase (IU/L) | 19 | 26 | 10–36 |
| Alkaline phosphatase (IU/L) | 58 | 60 | 54–119 |
| γ-glutamyltransferase (IU/L) | 9 | 18 | 9–35 |
| Lactate dehydrogenase (IU/L) | 241 | 140 | 124–241 |
| Creatine kinase (IU/L) | 150 | 85 | 0–153 |
| Creatine kinase-MB (IU/L) | 17.5 | 9.8 | 0–24 |
| High-sensitivity troponin (pg/mL) | 1 | 0.1 | 0–34.2 |
CRP, C-reactive protein; HCT, hematocrit; HGB, hemoglobin; MB, muscle-brain type; MCV, mean corpuscular volume; PLT, platelet; RBC, red blood cell; WBC, white blood cell.
Five days after delivery, the patient came to our clinic because of persistent chest pain localized on the front of the chest, in the sternum area. The pain did not radiate to the shoulder or neck. In the anamnesis, it is also noted that the pain was minimal during shallow breathing and at rest, while the pain increased during deep breathing and movement. In the physical examination, painful sensitivity was distinguished during palpation of the middle third of the sternum. Vital parameters (blood pressure 120/80 mmHg, pulse 75/min, oxygen saturation 98%) and laboratory findings were normal (Table 1), as was the ECG. X-ray of the sternum showed an irregular and partially concave anterior contour of the sternum body in the cranial part—fracture of the sternum without displacement (Figure 1).
A thoracic surgeon was consulted and conservative treatment was decided. Analgesic therapy consisted of paracetamol 1 g, 3 per day, breathing exercises included 10 deep breaths every hour, and she was advised not to expose herself to any hard physical activity for the following 4 to 6 weeks, and not to perform any other activities that could amplify the pain. The first follow-up examination by the thoracic surgeon was performed 7 days after the sternum fracture diagnosis. At the follow-ups after 6 weeks, the patient reported that she no longer felt pain in her chest, and the follow-up X-ray image showed proper bone healing (Figure 2). The treatment was not accompanied by complications.
All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Discussion
Only three studies of spontaneous sternum fractures during labor have been described in the literature to date (3,6,7).
Aserlind and Burnweit described a healthy primiparous woman who delivered at 39 weeks and 1 day of pregnancy. Before delivery, she had a history of celiac disease and 6 years of amenorrhea. The establishment of menstrual cycle occurred 4 months before conception. At the time of conception, the BMI was 19.5 kg/m2. During labor, she was put under spinal anesthesia and there was no need for oxytocin. During labor, she was in the lithotomy position with her chin resting on the chest. She gave birth to a healthy child weighing 2,800 grams. After the diagnosis of a sternum fracture, additional workup was performed, where normal calcium and vitamin D values were determined. DXA (bone density scans) identified lumbar T-score of −1.8 and Z-score of −1.6 (3).
Edwards and Ward described a healthy 24-year-old female patient who was admitted to the hospital with chest pain, that had begun 4 days earlier, during the final stages of labor. Then she gave birth to a healthy child. The paper does not describe the data on whether it is a primiparous or multiparous woman, nor are the patient’s anthropometric measurements described, nor do we have data on the delivery itself (6).
Stubert J. and Gerber B. decribed a sternum fracture during labor in a healthy 31-year-old primiparous woman who gave birth naturally at 39-week gestation. She felt chest pain in the final stage of labor. She gave birth to a child of 3,300 g. No anthropometric measurements were provided, and no further investigations were performed (7).
In the three papers described (3,6,7), two patients are primiparous, and for the third patient we have no information on the number of births. This paper presents the first case of a multiparous woman with a spontaneous sternum fracture. In the final stage of labor, during expulsion, there is significant strain when performing the Valsalva maneuver in the lithotomy position with the chin resting on the chest, which, along with transient osteopenia, can lead to a sternum fracture.
During pregnancy, intestinal absorption of calcium doubles to meet fetal calcium needs. An increase in calcitriol, estradiol from the ovaries, placental lactogen and prolactin stimulates intestinal absorption. Under normal circumstances, little skeletal resorption occurs, but if the mother’s calcium intake is insufficient, then skeletal resorption must follow to meet the needs of the fetus. During lactation, high prolactin suppresses the hypothalamic-pituitary-ovarian axis causing very low estradiol; these three factors combine to stimulate the production of parathyroid hormone-related protein (PTHrP) from the breast, which increases in the mother’s circulation and passes into the milk. The combination of low estradiol and high PTHrP, and possibly other factors, promotes bone resorption. After the cessation of breastfeeding, the bone mineral density (BMD) of the mother’s skeleton is usually completely restored during the next 12 months (8).
This explains why transient skeletal fragility may occur during pregnancy and breastfeeding. However, fractures are also caused by increased mechanical stress due to increased body weight associated with pregnancy, excessive lumbar lordosis.
Given the lack of controlled trials and the fact that spontaneous recovery should occur, a wait-and-see approach seems prudent with dual-energy X-ray absorptiometry (DXA) performed 12–18 months after cessation of breastfeeding (postpartum in non-breastfeeding women), to optimize skeletal strength before triggering it again with the second reproductive cycle (8).
Conservative treatment including optimized nutrition [including 1,200 mg calcium per day and vitamin D intake to achieve 25-hydroxyvitamin D (25OHD) levels >75 nmol/L], correction of any malabsorption disorders, avoiding activities with significant lifting or risk of falling, physiotherapy to maintain mobility and improve core muscle strength are preferred.
Women may be reassured that fractures may not recur during subsequent pregnancies. However, recurrences have been documented in 20–25% of cases, particularly with genetic causes of skeletal fragility or where nutritional deficiencies are not corrected (9).
Our patient gave birth to four children in a period of 7 years. She gave birth to a previous child eight months before conception. She breastfed all three children for more than a year. Also, despite breastfeeding, the patient had a regular menstrual cycle for a period of 6 weeks to 5 months after each birth. After the last delivery, the first menstrual cycle followed after seven weeks.
Our patient expressed her desire to become pregnant again. Twelve months after cessation of breastfeeding, a DXA scan was performed, which showed a lumbar T-score of –1.4 and a Z-score of –1.6, consistent with normal BMD.
Despite numerous studies and case reports of BMD changes during pregnancy, postpartum, and breastfeeding, there is controversy regarding the time course of BMD changes and recovery to baseline levels. The extent to which pregnancy affects BMD in the long term remains unclear. Several influencing factors, including breastfeeding, duration of amenorrhea after pregnancy, and parity, have been studied with respect to changes in BMD in healthy women (10).
Recent meta-analyses suggest that lactation is associated with a transient loss of trabecular and cortical bone in the axial and peripheral skeletal regions and it is dependent on the period of resumption of menstruation and cessation of breastfeeding. Most women recover after stopping breastfeeding (11).
After the return of menstruation, there is a tendency for recovery of bone loss in the first months of lactation, particularly in relation to estrogen status, which is similar, but not analogous, to its effect during puberty and opposite to its role after menopause (11).
There appears to be good evidence that calcium is mobilized from the maternal skeleton into the developing fetal skeleton during pregnancy (10). Calcium mobilization from the maternal skeleton is possible only through significant hormonal adjustments during pregnancy. The placenta actively transports minerals, extracting adequate amounts even if concentrations in the maternal circulation are low. The total net calcium accumulation in the delivered fetus is approximately 30 g (12). However, the eventual return of BMD to pre-pregnancy values suggests that maternal bone loss is not permanent. Results of a systematic review of literature by Ensom et al., Effect of Pregnancy on Bone Mineral Density in Healthy Women, which specifically assessed the effect of lactation on BMD, were mixed, ranging from a decrease in BMD to no change. Among the studies that assessed the effect of parity on BMD, none found an association linking higher number of pregnancies with higher decreases in BMD. Pregnancy-related osteoporosis appears to be uncommon, based on limited published reports. Overall, no long-term adverse clinical effects have been observed in healthy women who have had at least one pregnancy, despite evidence that bone loss occurs soon after delivery (10).
Conclusions
A sternum fracture is a very rare diagnosis in an obstetric patient, which should be kept in mind when a pregnant woman complains of chest pain that started during labor. This case report highlights the importance of recognizing spontaneous thoracic fracture as a possible, although extremely rare, cause of chest pain during labor and immediately after it. This phenomenon can occur due to a combination of mechanical pressure on the sternum during labor, when the patient is in the lithotomy position with her chin resting on her chest and promotes the expulsion of the child with the Valsalva maneuver, and metabolic changes in calcium metabolism during pregnancy and breastfeeding. This case report particularly emphasizes the increased possibility of bone fracture during labor, when a woman is exposed to extreme strain during vaginal delivery, particularly in women who breastfed immediately before conception or during pregnancy. Although by all accounts the loss of bone mass is not permanent, it is recommended that women, especially those who have multiple consecutive pregnancies and who breastfeed until conception or during pregnancy, pay special attention to bone density, diet, physical activity, and replacement therapy with vitamins and minerals in order to potentially prevent labor complications and preserve the health of the pregnant woman. Early recognition of a spontaneous sternum fracture can significantly reduce the need for expensive and aggressive diagnostic methods and ensure faster recovery. This paper points to the need for further study of osteopenia in multiparous women who have multiple consecutive pregnancies, particularly if they breastfeed until conception or during pregnancy. This group of patients deserves special attention in order to prevent obstetric and health complications.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-106/rc
Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-106/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-106/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Firoz T, Magee LA. Acute myocardial infarction in the obstetric patient. Obstet Med 2012;5:50-7. [Crossref] [PubMed]
- Tatham K, Hughes-Roberts Y, Davies S, et al. Peripartum cardiac chest pain and troponin rise. Int J Obstet Anesth 2010;19:453-5. [Crossref] [PubMed]
- Aserlind AB, Burnweit CA. Spontaneous sternal fracture during labor in a healthy primigravida with female athlete triad: A case report. Case Rep Womens Health 2020;27:e00213. [Crossref] [PubMed]
- Khurram D, Patel B, Farra MW. Hamman's Syndrome: A Rare Cause of Chest Pain in a Postpartum Patient. Case Rep Pulmonol 2015;2015:201051. [Crossref] [PubMed]
- Whelan S, Kelly M. Pneumomediastinum following a prolonged second stage of labor - an emphasis on early diagnosis and conservative management: a case report. J Med Case Rep 2017;11:313. [Crossref] [PubMed]
- Edwards D, Ward N. Sternal fracture as a complication of normal vaginal delivery labour. Injury Extra 2007;38:239-40.
- Stubert J, Gerber B. Fracture of maternal sternum during spontaneous delivery. Arch Gynecol Obstet 2009;280:1007-9. [Crossref] [PubMed]
- Kovacs CS. Maternal Mineral and Bone Metabolism During Pregnancy, Lactation, and Post-Weaning Recovery. Physiol Rev 2016;96:449-547. [Crossref] [PubMed]
- Phillips AJ, Ostlere SJ, Smith R. Pregnancy-associated osteoporosis: does the skeleton recover? Osteoporos Int 2000;11:449-54. [Crossref] [PubMed]
- Ensom MH, Liu PY, Stephenson MD. Effect of pregnancy on bone mineral density in healthy women. Obstet Gynecol Surv 2002;57:99-111. [Crossref] [PubMed]
- Grizzo FMF, Alarcão ACJ. How does women's bone health recover after lactation? A systematic review and meta-analysis. Osteoporos Int 2020;31:413-27. [Crossref] [PubMed]
- Salles JP. Bone metabolism during pregnancy. Ann Endocrinol (Paris) 2016;77:163-8. [Crossref] [PubMed]
Cite this article as: Popović T, Tomić V, Penava N, Brkić M, Galić A. Spontaneous sternal fracture in multiparous woman during labor: a case report. AME Case Rep 2025;9:109.
