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Aug22
ORTHOPEDIC MANIFESTATIONS DURING PREGNANCY
ORTHOPEDIC MANIFESTATIONS DURING PREGNANCY

Almost all pregnant women experience musculoskeletal discomfort during pregnancy,
with a good portion of them suffering from severe disability. The enlarging gravid uterus alters
the maternal body's center of gravity, mechanically stressing the axial and pelvic systems, and compounds the stresses that hormone level fluctuations and fluid retention exert. While the pregnant woman
is prone to many musculoskeletal injuries, most can be controlled conservatively, but some require emergent surgical intervention.

Often, the source of these musculoskeletal problems can be traced to an endocrine disorder.
For example, carpal tunnel syndrome is not uncommon in patients who are pregnant or
have diabetes, hypothyroidism, or acromegaly. Joint problems and arthritis
are other common findings in diabetes, pregnancy, and hyperparathyroidism. Muscle weakness or stiffness is seen in both hypothyroidism and hyperthyroidism, and muscle wasting is a characteristic of adrenocorticoid insufficiency. Bone disorders are common with glucocorticoid excess, acromegaly, and hyperparathyroidism. Some presentations are a classic picture of a specific endocrine condition and are readily recognized if the index of suspicion is appropriately high.

During pregnancy, certain anatomical and hormonal changes occur that produce
increased stress on the pelvic
articulations resulting in the development of pelvic girdle relaxation. Pelvic girdle relaxation during pregnancy is physiological and is caused by hormonal and biomechanical factors. When a pregnant woman presents as
a patient with low back or pelvic pain, walking dysfunction and with reproduction
of pain with sacroiliac provocation, the diagnosis of symptomatic pelvic girdle relaxation can be madeThe gravid uterus
and the compensatory lordosis that it
causes create a tremendous mechanical
burden on the lower back. Joint laxity increases during pregnancy. The hormone relaxin has been identified as a major contributor to joint laxity during pregnancy. It decreases the intrinsic strength of the connective tissue allowing it to expand and lose its rigidity, resulting in increased widening and sliding mobility of the joints, thus causing potential instability. This occurs especially in the ligaments of the sacroiliac and pubic symphysis joints,
but may also occur in peripheral joint.
This may result in pubic symphysis pain,
low back pain or hip pain.

Pubic Symphysis Pain

Pathology: Separation of the pubic symphysis joint (diastasis or symphysiolysis), as a result of pelvic girdle relaxation, is thought to be the main cause of pubic symphysis pain. Relaxin levels were found
to be significantly higher in pregnant
women with pelvic pain and joint laxity.
The highest level was found in those women with the most severe clinical symptoms, who also took a longer time to recover after pregnancy. Swelling within the joint, ligament disruption and hemorrhage have
also been suggested to cause pubic symphysis pain. The severity of these conditions varies from mild self-limiting pain to a severe disabling condition. Lack of awareness and failure of recognition of these complications by obstetricians not only results in women feeling very lonely and misunderstood, but may also result in long-term morbidity.

Presentation: Patients may present during pregnancy (usually in the second or third trimester), during labour or 24-48 hours postpartum, with a sudden or insidious
onset of pain of variable severity in the pubic area or groin which may radiate to
the medial aspect of the thigh and increases on weight-bearing. Pain may occur also in the hips, suprapubic area or the lower back and be aggravated by walking, standing, stairs climbing, parting of the legs or turning in bed.

Clinically, a waddling gait or limp may be noticed. The woman may not be able to stand comfortably on one leg. Abduction of the thigh is usually painful. Point tenderness in the region of the pubic symphysis and pain on compression of the pelvis by simultaneous pressure on both trochanters are usually present. Care must be taken as exquisite pain may occur on palpation of
the pubic symphysis, which may also reveal
a gaping pubic defect and edema.

The symptoms (and their severity) experienced vary, but include:

. Present swelling and/or inflammation over joint.

. Difficulty lifting leg.
. Pain pulling legs apart.
. Unable to stand on one leg.
. Unable to transfer weight through pelvis and legs.

. Pain in hips and/or restriction of hip movement.

. Transferred nerve pain down leg.
. Can be associated with bladder and/or bowel dysfunction.

. A feeling of symphysis pubis giving way.
. Stand with a stooped over back.
. Mal-alignment of pelvic and/or back joints.

. Struggle to sit or stand.
. Pain may also radiate down the inner thighs.

. You may waddle or shuffle.
. Aware of an audible ‘clicking’ sound coming from the pelvis.

Psychosocial impact - interferes with participation in society and activities of daily life; the average sick leave due to posterior pelvic pain during pregnancy is 7 to 12 weeks. In some cases patient may also experience emotional problems such as anxiety over the cause of pain, resentment, anger, lack of self-esteem, frustration and depression; she is three times more likely to suffer postpartum depressive symptoms. Other psychosocial risk factors associated with woman experiencing PGP include higher level of stress, low job satisfaction and poorer relationship with spouse.

Diagnosis of pubic symphysis separation is based on the clinical presentation and the response to therapy. Imaging (X-ray, ultrasound o r magnetic resonance [MRI])
may be useful in confirming the diagnosis. Ultrasound examination using a 7.5 MHz or 5 MHz linear array transducer may demonstrate widening of the interpubic gap in excess of 10 mm. Ultrasound has many advantages over conventional X-ray, as it can be done during pregnancy and can be repeated safely for follow-up. However, the amount of symphyseal separation does not always correlate with the severity of the symptoms, or the degree of disability, nor does it appear to
predict outcome.

Severity - The severity and instability of the pelvis can be measured on a three level scale.

Pelvic type 1: The pelvic ligaments support the pelvis sufficiently. Even when the muscles are used incorrectly, no complaints will occur when performing everyday activities. This is the most common situation in persons who have never been pregnant, who have never been in an accident, and who are not hyperactive.
Pelvic type 2: The ligaments alone do not support the joint sufficiently. A coordinated use of muscles around the joint will compensate for ligament weakness. In case the muscles around the joint do not function, the patient will experience pain and weakness when performing everyday activities. This kind of pelvic often occurs after giving birth to a child weighing 3000 grams or more, in case of hyperactivity,
and sometimes after an accident involving the pelvis. Type 2 is the most common form of pelvic instability. Treatment is based on learning how to use the muscles around the pelvis more efficiently.

Pelvic type 3: The ligaments do not support the joint sufficiently. This is a serious situation whereby the muscles around the joint are unable to compensate for ligament weakness. This type of pelvic instability usually only occurs after an accident, or occasionally after a (small) accident in combination with giving birth. Sometimes a small accident occurring long before giving birth is forgotten so that the pelvic instability is attributed only to the childbirth. Although the difference between Type 2 and 3 is often difficult to establish, in case of doubt an exercise program may help the patient. However, if Pelvic Type 3 has been diagnosed then invasive treatment is the only option: in this case parts of the pelvic are screwed together.

Treatment: One of the main factors in helping women cope with the condition is with education, information and support. Other coping strategies include physical medicine and rehabilitation, physiotherapy, osteopathy, chiropractic, psychologist, prolo therapy or platelet-rich plasma therapy, massage therapy, acupuncture and alternative medicine. Mobility aids such
as a wheelchair, walker, elbow crutches
and walking stick can be very useful. Medication dispensed by a qualified health care provider can also be used to manage:

• Chronic pain
• Anxiety
• Depression
• Post Traumatic Stress Disorder (resulting from birth trauma/ pregnancy)
• Musculo-skeletal disorders.

Conservative treatment is effective in most cases, including those women with the most severe symptoms at presentati0n. A clear explanation of the condition and its management, to both the woman and her partner, is vital. The aim is to avoid abduction of the hip joint and encourage immobilization of the pubic symphysis joint. In cases presenting during pregnancy or after birth, women should be advised to rest as much as possible in the lateral decubitus position: avoid prolonged weight bearing and stairs and keep her legs together in activities such as turning in bed or getting into a car. Since immobilization is a primary risk factor for deep vein thrombosis, isometric exercises should be encouraged. Anti-embolism stockings and heparin may be required. Analgesics can be given on demand. If the above measures fail to improve the
symptoms, referral to an obstetric physiotherapist should be arranged. Pelvic support by a tight binder or tubular
bandage and the use of a walker or elbow crutches may be required. The maximum hip abduction possible without pain (pain-free gap) should be measured before labour, to avoid over-abduction of thighs in labour, especially when regional anesthesia is
used. Some pelvic joint trauma will not respond to conservative type treatments
and orthopedic surgery might become the
only option to stabilize the joints.

Surgery is rarely indicated, but may be considered for those who have inadequate reduction, recurrent diastases or
persistent symptoms. External skeletal fixation is the treatment of choice. The symphysis is compressed using a frame
which can be removed once stability has returned. Prognosis is uniformly good.
Mild cases typically resolve within 2 days to eight weeks of delivery with no lasting sequelae. However, some women require as much as eight months before they are free
of pain when walking. During this time the pain may be worse during the secretory phase of the menstrual cycle. In a recent survey of Norwegian women registered as having pregnancy-initiated pelvic joint pain, it was found that pelvic pain worsened with subsequent pregnancy in 81.4% of the responding. However, in the absence of specific obstetric indications, prior pubic symphysis separation should not be considered a strong indication for subsequent operative delivery.

Low Back Pain

Pathology: Symptomatic back pain in pregnancy is caused by the mechanical
burden created on the lower back by the pregnant uterus and compensatory lordosis. Relaxation of the sacroiliac joint and
pubic symphysis plays an important part.
The highest levels of relaxin during pregnancy have been found in women with incapacitating low back pain. Very occasionally, low back pain may be attributable to a herniated vertebral disc.
Presentation: The usual presentation is
that of low back pain or posterior pelvic pain that is aggravated by activity and relieved by lying down, sitting and the use of supportive pillow. The pain may radiate to the posterior aspects of the thighs. Examination reveals accentuation of the lumbar lordosis and the cephalad part of
the spine thrown backwards to compensate
for the increased size of the abdomen. Tenderness is usually greatest over the sacroiliac joints. Indirect bimanual compression over the iliac crest also produces discomfort in the sacroiliac
joints.

Management: Each patient should be questioned carefully about neurological compromise as very occasionally radicular signs or even a cauda equina syndrome may
be identified. Most patients with classic symptoms and signs limited to low back strain or sacroiliac instability can be managed without radiographic evaluation. Radiographic evaluation of patients with unusual or severe symptoms may be carried out after the first trimester and can include a three view spine series. However, MRI appears to be a safe way to image the pelvic regions during pregnancy and will give direct information about any disc prolapse without irradiation. This should now be the investigation of choice if indicated.

Treatment: Relief of symptoms of low back pain in pregnancy can be achieved by the patient limiting her physical activity, wearing low-heeled shoes, resting in bed with pillows under the knees and applying heat. Lying on the back with the feet propped approximately two feet above the hips for about 20 minutes four times a day usually relieves muscle spasm, decreases lumbar lordosis and relieves acute pain.
In addition, the pain can be partially relieved if the patient keeps the pelvis
in a flexed position, thereby improving spinal alignment. Exercise to increase the tone of the back and abdominal muscles should be commenced as soon as the pain decreases. A sacroiliac corset or trochanteric belt can relieve symptoms. Surgical treatment of low back pain is contraindicated in pregnancy, except when
a herniated disc is producing bowel or bladder incontinence. Pain relief can be achieved with simple analgesics but anti-prostaglandins are relatively contraindicated in pregnancy.

Hip Pain

Two relatively rare conditions, osteonecrosis of the femoral head and transient osteoporosis of the hip, both
seem to occur with somewhat greater frequency during pregnancy and present with pain in the hip or groin. The diagnosis of these conditions is often missed initially because pain is easily taken for pelvic girdle relaxation or round ligament pain. Early diagnosis and treatment are the keys for a successful outcome and prevention of secondary degenerative changes or fracture in the joints of these young women.

1) Osteonecrosis of the femoral head
Presentation: Symptoms usually begin in the third trimester or shortly after a difficult delivery, with sudden or gradually increasing pain of variable severity, usually unilateral and deep in the groin. The pain may radiate to the knee, thigh or back. Elderly primigravida are most at risk. On examination, painful limitation of
active or passive movements of the hip joint, especially with movement, can be noticed. The exact aetiology is not known. But it has been speculated that the rise in unbound cortisol, oestrogen and
progesterone in late pregnancy, the increased interosseous pressure and a
direct injury to the femoral joint by the compression of the growing uterus or during a difficult delivery may all act together
to produce insufficiency of blood supply
to the fernoral head at some point.

Management: Plain radiography may demonstrate arc-like subchondral
radiolucent areas and other pathological changes in the femoral head, but MRI has been used recently for earlier diagnosis with apparent safety during pregnancy.
Early diagnosis, rest and avoiding weigh-bearing are very important. Aspiration of the hip joint may occasionally be
required. The prognosis after early diagnosis and conservative treatment
seems to be good, although secondary degenerative or osteoarthritic changes
may develop and require surgical treatment at a later age.

Figure: Subchondral separation Figure: Osteonecrosis of femoral head on plain X-ray

2) Transient osteoporosis of the hip
Presentation: This is a poorly understood and frequently undiagnosed syndrome of unknown aetiology. It occurs in the third trimester and presents with pain in the
hip, anterior thigh or groin, which progressively increases and is made worse
by weight-bearing. The left hip is more frequently involved but bilateral involvement can also occur. On examination, pain and limitation of range of mobility on passive abduction and rotation of the affected joint is usually noticed.

Management: X-rays of the hip show advanced osteoporosis of the femoral head and neck and, occasionally, the acetabulum, but
with preservation of the joint space. These changes are present three to eight weeks after the onset of symptoms. MRI can be
use for early diagnosis. Bone mineral density (BMD) of the femoral neck of symptomatic women has been shown to be 20% lower than the average of age-matched controls. The great concern with regard
to this disorder is that continued unprotected weight-bearing can result in
a fracture of the femoral neck. The aim
of treatment is to avoid unprotected
weight bearing by the use of crutches until the symptoms resolve completely and radiography shows reconstitution of bone
in the proximal part of the femur. Given
the decrease in BMD that occurs during pregnancy and lactation, it might appear prudent to recommend cessation of lactation in these patients.

During pregnancy, circulating total calcium concentration drop slowly but consistently and parallel with decreasing albumin concentration. Reaching a nadir in the middle third of the third trimester. An early hypothesis was that pregnancy is a state of maternal physiologic hyperparathyroidism. According to this theory, transfer of calcium to the fetus induces secondary hyperparathyroidism
in the mother, which leads consequently
to increased 1,25-dihydroxyvitamin D production. Another theory says the
increase in circulating levels of 1, 25-dihydroxyvitamin D is the primary
event in calcium metabolism alterations during pregnancy, subsequently stimulating intestinal calcium absorption and possible additional effects on other target tissues. With these alterations in calcium metabolism, pregnancy may exacerbate or simply coexist with the number of
conditions that may result in maternal hypercalcemia. These conditions include primary hyperparathyroidism, vitamin A or
D intoxication, systemic sarcoid, hyperthyroidism, milk-alkali syndrome, familial hypocalciuric hyoercalcemia, immobilization, malignancy with or without bone metastasis or ectopic PTH secretion.
On the other hand, alterations in calcium and parathyroid hormone metabolism may
also results in hypoparathyroidism and hypocalcemia. Hypoparathyroidism results from inadequate secretions of PTH or defective production of biologically active PTH. Pseudohypoparathyroidism results from end-organ insensitivity to the hormone.
The diminished PTH activity in the kidney and bone leads to hypocalcemia and hyperphosphatemia. Patient with mild hypoparathyroidism may be asymptomatic or may experience only subtle manifestation
of the disease. In more severe forms of the disorder, symptoms and signs related to decreased serum ionized calcium concentrations may occur. Increased neuromuscular excitability, which can be elicited on physical examination by a positive result for Chovstek's sign
(tapping along facial nerve including contractions of the eye, mouth and nose)
or Trousseau's sign (inflating a blood pressure cuff above systolic pressure causing spasm of the hands within minutes), can uncommonly progress from weakness and paresthesia to the development of seizures, tetany, or laryngospasm. Papilloedema, elevated cerebrospinal fluid pressure and neurologic sign that mimic a cerebral
tumor may be found. A spectrum of mental status changes, from irritation to psychosis, can occur. Abnormalities in the cardiac conduction, particularly prolongation of
QT interval and T wave changes, may be present. Radiographs of the skull may demonstrate intracranial calcifications, which are sometimes associated with a parkinsonian-like syndrome. Additionally,
if the disease has been long standing, physical examination may reveal dental abnormalities or cataracts.
Untreated maternal hypoparathyroidism with its associated hypocalcemia leads to a high incidence of maternal, fetal and neonatal complications. Generalized skeletal demineralization, osteitis fibrosa cystica and fetal or neonatal death can occur. Although the secondary hyperparathyroidism is transient and generally resolves in the neonatal period, the infant may not
achieve normal bone mineralization until
6 months of age.

Deficiency of vitamin D and disorders of vitamin D absorption or metabolism can
lead to hypocalcemia and also to
subsequent disorders of bone
mineralization, such as osteomalacia and tetany. Derangements in vitamin D
metabolism may also explain the osteopenia associated with heparin treatment during pregnancy.

References:

1. Medical Complications During Pregnancy by Burrow and Duffy 5th edition

2. http://en.wikipedia.org

3. http://www.maitrise-orthop.com /corpusmaitri/orthopaedic/mo72_hernigou/index.shtml

4. http://www.ncbi.nlm.nih.gov/pubmed/18199383?dopt=AbstractPlus

5. http://www.ncbi.nlm.nih.gov/pubmed/1946104?ordinalpos=1&
itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_ SingleItemSupl.Pubmed_ Discovery_RA&linkpos=4&log$=relatedreviews &logdbfrom=pubmed

N.B. This article was contributed by Medical Student Ms Azreena Baizura bt Ariffin from Melaka Manipal Medical College , Malaysia as an E learning Exercise.


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