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Spine and joint disorders in late prenatal – maternal care management options Outline Introduction Low back and pelvic pain in general General considerations and Hormonal considerations Mechanical explanations for back and pelvic pain in pregnancy Lumbar disc disease

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Spine and joint disorders in late prenatal – maternal care management options

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Spine and joint disorders in late prenatal – maternal caremanagement options


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Outline

  • Introduction

  • Low back and pelvic pain in general

    • General considerations and Hormonal considerations

    • Mechanical explanations for back and pelvic pain in

      pregnancy

    • Lumbar disc disease

    • Vascular congestion and night backache

    • Sacroiliac pain, osteitis condensans illii, and an

      associated with the inflammatory processes

    • Risk factors

    • Evaluations

    • Treatment


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Outline

Specific conditions – risks and management options

  • Spondylolysis and spondylolithesis

  • Scoliosis

  • Pelvic arthropathy and pubic symphysis rupture

  • Postpartum osteitis pubis

  • Stress fractures of the pubic bone

  • Transient osteoporosis of the hip

  • Avascular necrosis of the hip

  • Hip arthroplasty


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  • Complaints of musculoskeletal discomfort during

    pregnancy are common and may be temporarily

    disabling

  • Problems usually resolve spontaneously with

    completion of pregnancy

  • Some conditions that exist prior to pregnancy

    may effect the course of the pregnancy


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Physiologic change in musculoskeletal system

  • Progressive lordosis

    • Compensating for anterior position of the enlarging uterus

  • Increased mobility of sacrococcygeal , sacroiliac and pubic joints


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Physiologic change inmusculoskeletal system

  • Aching, numbness and weakness of upper extremities

    mark lordosis with anterior neck flexion and

    slumping of the shoulder girdle

    traction of ulnar and median nerve


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Physiologic change inmusculoskeletal system

  • Most relaxation of symphysis pubis occur in first half of pregnancy and retrogression begins immediately following delivery, usually complete within 3 – 5 months


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Low back and pelvic pain


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General considerations

  • Back and pelvic pain occur in 48 – 90 % of

    pregnancy

  • Lumbar pain may be more common during pregnancy in women who noted back pain before pregnancy

  • Onset during pregnancy is more commonly described as sacral pain


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Hormonal considerations

  • Relaxin

    • A polypeptide hormone

    • Produced by corpus luteum , deciduas and chorion

    • Receptor sites / target organs ; pubic symphysis , myometrium , cervix , placenta , breasts and skin fibroblast


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Hormonal considerations

  • Relaxin

    • Thought to relax connective tissue and relax myometrium

    • Peak in first trimester , decreasing toward the end of gestation, increase again in early labor and undetectable by the third day postpartum

  • However , the relationship between hormone levels and joint pain in pregnancy is unclear


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Mechanical Explanations for back and pelvic pain in pregnancy

  • General weight gain and the weight of the uterus, fetus and breast increaseload on spine

  • Response in increasing lumbar lordosis ; more anterior center of mass & producing shear stress across the motion segments of lumbar spine

  • The contribution of abdominal musculature to support the spine may be diminished


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Mechanical Explanations for back and pelvic pain in pregnancy

  • Radicular symptoms are common , caused by direct pressure of the uterus on nerve roots and lumbar and sacral plexus

  • Mechanical pressure on nerve roots by ligamentous structures of increasingly lordotic spine “ parietal neuralgia of pregnancy “


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Lumbar disc disease

  • Relaxin may weaken the annulus of the intervertebral discs

  • Less studies related lumbar disc disease to pregnancy

  • Potential for disc herniation and lumbar nerve root compression, with radicular pain and definite neurologic loss should be considered

  • EMG , MRI may helpful in diagnosis


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Vascular congestion and night backache

  • Increased venous flow through lumbar veins, the vertebral plexus , and paraspinal and azygous vein

  • Mechanical vena cava compression in supine position


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Sacroiliac pain

  • Inflammatory changes in the sacroiliac joint

  • Osteitis condensans illii

    • Fairly uniform area of increased density in the lower iliac bone, adjacent to the sacroiliac joint ,unilateral or bilateral

    • Most common in women, particularly in pregnancy


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Risk factors: during pregnancy

  • Increasing parity

  • Younger age

  • Back pain before pregnancy

  • Increased lordosis before pregnancy

  • Smoking

  • Physically strenuous work

    • Physical heaviness of work

    • Sitting work posture

    • Frequency of twisting and forward bending


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Risk factors : postpartum pain

  • Twin pregnancy

  • First pregnancy

  • Higher age at first pregnancy

  • Increased weight of the baby

  • Forceps or vacuum extraction

  • Flexed position of the women at childbirth

  • Cesarean section is negatively associated

    with postpartum pain


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Evaluations

  • Consider extraskeletal causes for backache

  • Atypical presentations or pain refractory to the usual care may indicate more significant, although rare , pathology

  • Differentiation from similar symptoms from direct fetal pressure on nerve roots is necessary

  • Routine examination and specific tests


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Evaluations

  • Specific test

    • Straight-leg raising test

    • PSIS pressure in the standing

    • Sacrospinous and sacrotuberous ligament pressure

    • Pubic symphysis pressure

    • Femoral compression test ( thigh thrust test )

    • Iliac or ventral gapping test, dorsal gapping test

    • Patrick test

    • Pelvic torsion ( Gaenslen test )

    • Fortin finger test


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Straight leg raising test


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Sacrospinous & sacrotuberous ligament tenderness

suggest a pelvic contribution to the pain


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Femoral compression test / posterior shear

-Sacral area or ipsilateral buttock

Iliac compression test

-sacral and buttock


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Patrick test

-sacroiliac area

Pelvic torsion / Gaenslen


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Evaluations

  • Radiographic evaluation

    • Plain film

      • Lumbar spine x-ray 0.031 to 4.0 RADS

      • Pelvis XRAy (AP) < 2.2RADS

    • Ultrasound

    • MRI

    • Electromyography and nerve conduction study


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Harmful Radiation Levels to fetus

  • RADS : 5 -10

    • Fetal Exposure in first 47 days: Spontaneous Abortion

    • Fetal Exposure after 47 days: Live fetus

      • Risk of congenital malformation increased 1 to 3%

      • Mental retardation and other CNS effects

      • Microcephaly

      • Intrauterine Growth restriction

    • First trimester exposure (especially <8 weeks)

      • Risk of childhood cancer

  • RADs: 200

    • Infertility Risk

    • Higher risk to fetus in early pregnancy


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Treatments

  • Rest

  • Daily low back exercise

  • Pelvic tilt exercise

  • Simple measure taught in back care programs;

    placing one foot on afoot stool when standing

  • Maternity cushion

  • Elastic compression stocking

  • Trochanteric belt for posterior pelvic pain


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Low back exercise


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Maternity cushion


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Elastic compression stocking and belt


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Treatments

  • Analgesic agents

  • Lumbar epidural steroids

  • Transcutaneous electrical nerve stimulation

  • Sacroiliac injection with corticosteroids and local anesthetic in severe care


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Analgesics

  • Class B: No risk in controlled animal studies

  • Acetaminophen (Tylenol)

    • Analgesic of choice in pregnancy

  • Narcotics (Class D if prolonged use or high dose)

    • Fentanyl (Duragesic)

    • Morphine Sulfate

  • NSAIDs (first or second trimester only)

    • Ibuprofen (Motrin)

    • Indomethacin (Indocin)

    • Naproxen (Naprosyn)

    • Piroxicam (Feldene)


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Analgsics

  • Class C: Small risk in controlled animal studies

  • Narcotics (Class D if prolonged use or high dose)

    • Codeine (Tylenol with codeine

    • Tramadol (Ultram)

  • NSAIDs (first or second trimester only)

    • Aspirin

  • Class D: Strong evidence of risk to the human fetus

  • Aspirin

    • Used only with specific indications in pregnancy

    • Risk of neonatal hemorrhage, IUGR, perinatal death

    • Low dose Aspirin may be safer

  • All NSAIDs (Third Trimester)


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Lumbar epidural steroids


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TENS

  • transmission of low-voltage electrical impulses from a

    handheld battery-powered generator to the skin via surface electrodes


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Sacroiliac injection


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Spondylolysis and spondylolithesis


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  • Spondylolysis

    • a bony insufficiency at the par interarticularis os the spine

    • Can cause instability and pain


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  • Spondylolithesis

    • The slipping forward of one vertebra on another

    • Can result from a spondylolytic defect or from degenerative change in the facet joints

    • Common in males than females , but higher chance of progression in female

    • Common occur at the L5-S1


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  • No significant differences in symptomatology , impairment, degree of slip , or progression of slip in men , nulliparous and parous wome

  • Spondylolysis ,with or without spondylolithesis, was not a risk factor for pregnancy complications

  • Women who had borne children had a significantly higher incidence of degenerative spondylolithesisthan those who was not


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Management options

  • Rest and immobilization

  • Analgesic agent


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Scoliosis


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  • Scoliosis

    • A three – dimensional deformity of the spine most prominently manifested by curvature in the coronal plane

    • Usually idiopathic , commonly familial

    • Common in females than in males


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  • No significant increase in the rate and incidence of curve progression during pregnancy

  • Somes have severe back pain during pregnancy

  • Spinal anesthesia may not be possible

  • The incidence of complications or deformity in the newborn was not increased

  • Postpartum back pain not greater than general population


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  • Women of childbearing age with curves greater than 30 degrees , radiographs should be done soon after each delivery


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Pelvic arthropathy and pubic symphysis rupture


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Pelvic arthropathy

  • Occur in two recognizable syndromes

    • Abnormal mobility of the pelvic joints may lead to pain and waddling gait

    • After difficult delivery, there may be a ruptue of the symphysis


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Pelvic arthropathy

  • Clinical pain with walking, turning to bed , or other exertion,unilateral or bilateral waddling gait

  • Asymmetrical SI laxity is much more associated with pelvic pain than absolute laxity

  • Diagnosis : history of pregnancy , pain at the pubic symphysis or SI joints, tender, laxity of

    ligaments


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Pelvic arthropathy

  • Investigation : Ultrasonography / MRI

  • Management

    • Rest with / without a pelvic band

    • Analgesics


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Rupture of the pubic symphysis

  • Slight widening of the symphysis occur during a normal pregnancy, but not more than 8-9 mm.

  • Abrupt onset of pain , may be accompany by audible “ crack “

  • Associated factors

    • Hard lobor

    • Preciptous labor

    • Difficult forcep delivery

    • Abnormal presentation

    • Forceful abduction of the thighs

    • Previous pelvic trauma


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Rupture of the pubic symphysis

  • Associated factors

    • Hard lobor

    • Preciptous labor

    • Mutiparity

    • Difficult forcep delivery

    • Abnormal presentation

    • Forceful abduction of the thighs

    • Previous pelvic trauma


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Rupture of the pubic symphysis

  • Management

    • Tight pelvic binding

    • Rest in the lateral decubitus position

    • External fixation


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Rupture of the pubic symphysis

  • Complication

    • Nonunion

    • Pubic degenerative joint disease

    • Osteitis pubis

    • Hemorrhage


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Postpartum osteitis pubis


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  • Non-infective osteonecrosis that begin at the pubic symphysis and extend into pubic bone

  • Pain and pubic tenderness like pelvic arthropathy

  • Investigate film rarefaction of the pubic bone without symphyseal widening

  • Self – limited

  • Management ; Steroids and NSAIDs


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Stress fractures of the pubic bone


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  • Rare condition during pregnancy

  • Cause due to ligament laxity , muscle imbalance and increase load

  • Clinical insidious pain, tender at fracture

  • Investigate film , MRI

  • Management symtomatic


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Transient osteoporosis of the hip


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Transient osteoporosis of the hip

  • Gradually developing pain in hip with weight bearing, predominate in anterior thigh and groin

  • Pain relieved by rest

  • Symptoms begin in the third trimester

  • Unknown cause

  • No history of trauma

  • Normal musculoskeletal exam ,except for discomfort at the extreme hip motion


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Transient osteoporosis of the hip

  • X-ray : osteopenia , preserved joint space

  • MRI : joint effusion and diffuse signal abnormality in the marrow

  • The condition is self- limited

  • Management : conservative

    • Protection from weight-bearing

    • Maintenance of joint motion

    • Analgesic medications


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Avascular necrosis of the hip


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Avascular necrosis of hip

  • Symptoms begin in the third trimester

  • Clinical

    • hip pain with weight bearing , relieved by rest

    • No associated history of trauma or illness

    • Normal musculoskeletal examination , except for discomfort at the extremes of hip motion


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Avascular necrosis of hip

  • X-ray : differ from transient osteoporosis

    “crescent sign” with subchondral lucency

    or subchondral callapse of weight-

    bearing dome of femoral head


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Hip Arthroplasty


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  • There are few rare indications for hip joint replacement

    in the young

    • Avascular necrosis of the hip

    • Severe rheumatoid disease

    • Certain aggressive tumorous conditions

  • Dislocation during positioning is a theoretical concern

  • Dangerous positions ; hip flexion with internal rotation

    and, to a lesser extent, hip extension with external

    rotation


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  • Usually no significant problem encountered nor special

    management required

  • Normal birthing position can be used


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  • Avoid flexion to more than 90 degrees and internal rotation or adduction of the hips


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Conclusions


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  • Back and pelvic pain are common complaints in pregnancy

  • Risk factors for back pain during pregnancy include

    • Increasing age

    • Increasing parity

    • Younger age

    • Back pain before pregnancy

    • Increased lumbar lordosis before pregnancy

    • Smoking

    • Physically strenuous work


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  • Risk factors for persistent postpartum pain include

    • Twin pregnancy

    • First pregnancy

    • Higher age at first pregnancy

    • Increased weight of the baby

    • Forceps or vacuum extraction

    • Fundus expression

    • A flexed position of the women at childbirth


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  • Cesarean section is negatively associated with persistent postpartum pain

  • Extraskeletal causes should always be remembered in the initial evaluation

  • Atypical presentations, or pain refractory to the usual care, may indicate more significant, although rare, pathology


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  • Radiographic evaluation, although undesirable during pregnancy, may be warranted if insidious causes for pain are suspected

  • MRI may be helpful in the diagnosis of tumor and infection

  • Lesions compressing nerve roots, such as disc herniations, can be initially evaluated with EMG and nerve conduction studies, without exposure to radiation


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THANK YOU


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References

  • High risk pregnancy : management options,

    third edition , section 5


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