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
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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 increase load 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) lt 2.2 RADS
• 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 lt8 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 spondylolithesis
  than 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