Pishnamaz et al. Journal of Medical Case Reports 2012, 6:98 http://www.jmedicalcasereports.com/content/6/1/98 should be examined for injuries after a bone density measurement. The first step in the pain management of sacral stress fractures is usually rest and activity modification [2]. This is difficult in pregnant patients in whom the stress on the fracture is exerted by the fetus. There is some contro- versy with those supporting early mobilization because weight bearing appears to be necessary to stimulate osteoblastic activity [6,11]. In our case of an intrapartum sacral fracture, pain control was the greater challenge because of the limited therapy options. In such cases, we endorse early immobilization until sufficient pain control is achieved. Subsequent partial weight bearing is essential to accelerate bone healing and to reduce other complica- tions of immobility. The following points should be considered for the application of analgesics during pregnancy: effects on the fetus, stage of the pregnancy, influence on the pregnancy course, influence on the mother, risk of pre-eclampsia and analgesia. In principle, especially early in pregnancy, there should be strict indications, low dosages and a short duration of drug administration. Oral paracetamol is the primary analgesic choice during all phases of preg- nancy. Ibuprofen can also be used under a strict maxi- mum daily dose of 1,600 mg. In certain situations, intravenous Perfalgan (paracetamol), morphine or pethi- dine can be administered. Because of its less systemic side effects, epidural anesthesia is recommended in cases of severe pain of the lower extremity and sacrum that is refractory to other therapies. The cases currently described in the literature demon- strate that most patients regain their activities of daily living within six weeks. Surgical treatment was never necessary. The heterogeneity of the risk groups (preg- nant women, endurance athletes or older patients) and the differences between stress and insufficiency fractures mean that treatment options must be adapted. Never- theless, in all cases, a prompt diagnosis and sufficient pain management must be achieved. Conclusions During pregnancy, fractures of the sacrum must be included in the differential diagnosis of patients with low back pain. The injury should be diagnosed early, and treatment should be tailored accordingly. Even in the complicated setting of pregnancy, insufficient treat- ment of severe pain should be avoided. Consent Written informed consent was obtained from the patient for publication of this manuscript and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal Page 3 of 3 Authors’ contributions MP analyzed and interpreted the patient data and wrote a major part of the manuscript. 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Clin Calcium 2010, 20:672-681. doi:10.1186/1752-1947-6-98 Cite this article as: Pishnamaz et al.: Low back pain during pregnancy caused by a sacral stress fracture: a case report. Journal of Medical Case Reports 2012 6:98.