spine and joint disorders in late prenatal maternal care management options
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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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outline
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
outline3
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
slide4
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

physiologic change in musculoskeletal system
Physiologic change in musculoskeletal system
  • Progressive lordosis
    • Compensating for anterior position of the enlarging uterus
  • Increased mobility of sacrococcygeal , sacroiliac and pubic joints
physiologic change in musculoskeletal system6
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

physiologic change in musculoskeletal system7
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
general considerations
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
hormonal considerations
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
hormonal considerations11
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
mechanical explanations for back and pelvic pain in pregnancy
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
mechanical explanations for back and pelvic pain in pregnancy13
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 “
lumbar disc disease
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
vascular congestion and night backache
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
sacroiliac pain
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
risk factors during pregnancy
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
risk factors postpartum pain
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

evaluations
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
evaluations20
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
slide22

Sacrospinous & sacrotuberous ligament tenderness

suggest a pelvic contribution to the pain

slide23

Femoral compression test / posterior shear

-Sacral area or ipsilateral buttock

Iliac compression test

-sacral and buttock

slide24

Patrick test

-sacroiliac area

Pelvic torsion / Gaenslen

evaluations25
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
harmful radiation levels to fetus
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
treatments
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
treatments33
Treatments
  • Analgesic agents
  • Lumbar epidural steroids
  • Transcutaneous electrical nerve stimulation
  • Sacroiliac injection with corticosteroids and local anesthetic in severe care
analgesics
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)
analgsics
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)
slide37
TENS
  • transmission of low-voltage electrical impulses from a

handheld battery-powered generator to the skin via surface electrodes

slide40
Spondylolysis
    • a bony insufficiency at the par interarticularis os the spine
    • Can cause instability and pain
slide41
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
slide42
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
management options
Management options
  • Rest and immobilization
  • Analgesic agent
slide45
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
slide46
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
slide47
Women of childbearing age with curves greater than 30 degrees , radiographs should be done soon after each delivery
pelvic arthropathy
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
pelvic arthropathy50
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

pelvic arthropathy51
Pelvic arthropathy
  • Investigation : Ultrasonography / MRI
  • Management
    • Rest with / without a pelvic band
    • Analgesics
rupture of the pubic symphysis
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
rupture of the pubic symphysis53
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
rupture of the pubic symphysis54
Rupture of the pubic symphysis
  • Management
    • Tight pelvic binding
    • Rest in the lateral decubitus position
    • External fixation
rupture of the pubic symphysis55
Rupture of the pubic symphysis
  • Complication
    • Nonunion
    • Pubic degenerative joint disease
    • Osteitis pubis
    • Hemorrhage
slide57
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
slide60
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
transient osteoporosis of the hip63
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
transient osteoporosis of the hip64
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
avascular necrosis of hip
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
avascular necrosis of hip67
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

slide69
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

slide71
Usually no significant problem encountered nor special

management required

  • Normal birthing position can be used
slide74
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
slide75
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
slide76
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
slide77
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
references
References
  • High risk pregnancy : management options,

third edition , section 5

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