April 1, 2012

E. ANCUTA, MUSCULO-SKELETAL PAIN AND PREGNANCY

Musculoskeletal pain and pregnancy

Eugen Ancuta MD, PhD, MSC Research Department Cuza-Voda Obstetrics and Gynecology Hospital Iasi, Romania
I. Musculoskeletal conditions during pregnancy

As many women gain weight during the third trimester of pregnancy there is an increase in force on joints and soft tissues resulting in musculoskeletal pain. It has been suggested that this pains will continue and may be aggravated by prolonged postures or even daily activities. Repetitive injury to the disc can compromises spinal integrity. A conglomerate of anatomical changes including hyperlordosis, hyperextension of the knees and a hyperkyphosis can be noted. Estrogen, progesterone and relaxin cause global relaxation to the ligaments and muscles in the pregnant women. Many times the increase in ligament mobility and loss of muscle tone that creates hypermobility in the spinal segment can irritate an existing condition or develop a injury to the ligaments muscles. Causes of musculoskeletal pain include: auto accidents, fractures, sprains, dislocations or postural strain, repetitive movements, prolonged immobilization etc. Pregnancy is a time of changes in the musculoskeletal system. These changes can develop a variety of problems including: low back pain, pelvic pain, leg cramps, carpal tunnel syndrome, de Quervain tenosynovitis or transient osteoporosis. Therefore, preexisting musculoskeletal problems such as rheumatoid arthritis or previous low back pain also contribute to the musculoskeletal symptoms of pregnancy but with greater frequency. The reported incidence of these conditions is less than 70 % of pregnant women. Low back pain is not correlated with maternal weight or fetal size. Changes in sacroiliac joints and pubic symphysis width less than 1 cm have been considered normal in pregnant women. Rupture of the pubic symphysis (diastasis) can be associated with severe pain. Treatment includes acetaminophen 0.5 to 1 gram orally, 6-hourly as necessary, up to maximum dose of 4 grams daily. Also pelvic pain can occur up to several years and the treatment of posterior pelvic pain, diastasis or persistence of sacroiliac joint is predominantly conservative. Surgical fixation in diastasis greater than 3 cm can be used.

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E. ANCUTA, MUSCULO-SKELETAL PAIN AND PREGNANCY

Leg cramps is often exacerbated in the second and third trimester and occur in up to 30% of pregnant women. Pre-pregnancy fitness and maintaining adequate hydration may be beneficial. Treatment options include calcium carbonate 1.5 grams (elemental calcium 600 mg) orally, daily. Also magnesium supplements can be used with no significant benefit. Carpal tunnel syndrome has been reported in up to 20% cases of pregnant women. It occurs more commonly later in life, especially around menopause. Injections of corticosteroid may provide symptomatic relief in pregnancy but can be used only if the symptoms are severe during breastfeeding. Decompressive surgery during pregnancy should be avoided if possible. De Quervain tenosynovitis mostly occurs in postpartum than in pregnancy and usually affect the tendons of abductor pollicis longus and extensor pollicis. Local infiltration of 1 ml of lignocaine (1%) premixed with corticosteroid (methylprednisolone or betamethasone) can be used during breastfeeding. Resting the thumb is effective to reduce pain but is difficult at this time. Moreover, the use of NSAID drugs may be effective temporary. Transient osteoporosis of pregnancy can occur in the third trimester and usually affects the hip. The reported incidence of this condition is reduced than the asymptomatic physiological loss of bone mass that occurs during pregnancy and lactation. Pregnant women with significant hip pain should be referred for rheumatologist assessment. Bisphosphonates should be avoided in pregnancy.

II.

Postpartum depression and fatigue

Mother with postpartum depression may be at an increased risk of spinal injury. Those who had a career find that they may lose touch with collegues and social calendar events. Therefore clinicians can suggest them to stay active in their health. Women with downward head tilt, a flexed cervical spine and rounded shoulders can give way to recognize a potentially depressed subject. Patients who are primiparid may find that after cesarean delivery they have had to resume their regular activities. Postpartum depression can also be associated with issues of weight. Clinicians can guide them to join healthy weight loss program that will restore health and aid in weight management. As a support for weight control they should be referred to their physician for full blood chemistry to include a thyroid panel and cancer. The most important aspect to recovery is the assistance of family and friends.

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E. ANCUTA, MUSCULO-SKELETAL PAIN AND PREGNANCY

Moms should be advised to supplement their diet with multivitamins and essential fatty acids vitamins because nutritional compromise can cause fatigue or exacerbate an existing condition of fatigue. Other nutritional support may be indicated to prevent fatigue (anemia or thyroid dysfunction): B-Complex vitamin, Co Q10 supplements and Iron supplements. Patients should be advised to acquire as much sleep as possible. As the re-setting of hormones to a non-gravid state for new mothers, the patient may experience low back and sacral pain, but the most profound affect can be to the thoracic spine. There are factors that contribute to postpartum musculoskeletal pain including: engorged breast tissue, rounded shoulder position and ergonomic compromises seen with lifting or carrying newborn. Also phone use while carrying the newborn causes excessive contraction of the muscles of the cervical spine. These postural changes cause cervical pain. Patients should be educated to switch arms or can use many devices available at stores that are designed to support proper ergonomics to mothers.

III.

Prevention and enhanced care

Mothers/Caregivers who engage in the repetition of removing the entire car seat with child is exposed to biomechanical stress to the spine. Educate patients to remove the infant within the car seat. At this time they should pull the seat as close as possible to their body. Removing the newborn from the baby bathtub can create postural compromises that can insult the integrity of the lumbar and thoracic spine. To avoid musculoskeletal pain the newborn should be held close to the body. Employ mothers to take the time to do rehabilitative exercises. These can assist in the reduction of the disc, zygapohyseal joint and muscular injury. Patients can also use play pens when them needs to be hand -free. Outward stretched arms can compromise the thoracic spine. To accommodate the extra weight the child is place down into the play pens while the mother is in a flexed position. To avoid back injuries, the adult caregiver can lowering one of the side bars. This create a repetitive strain on the upper and middle trapezious muscle rhomboids and levator scapular muscles. Viable alternatives exist for caregivers in order to maintain joint mobility and spinal integrity. To accommodate the extra weight check for leg inequality, hypertonic erector spinae muscles trigger points in the quadratus lumborum muscles, myofascial trigger points and hypertonic rhomboids, levator scapulae and cervical muscles. Chronic shortening of the lumbar muscles with an increase in the lumbar lordosis in pregnancy should be receiving as much attention.

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E. ANCUTA, MUSCULO-SKELETAL PAIN AND PREGNANCY

Talking wireless phone while carrying a child, parents are free to move about and accomplish tasks around the house. In addition, focused history can turn into an educational consult. Advise patients to opt for the carrier that maximizes spinal integrity and to look for a stroller with handles that are high enough in order to avoid hunching.

IV.

Women physiology and its concern to physical exercise

Recreational physical fitness such as running and varied aerobics help to facilitate the goal of muscle tone. There are some differences between men and women: they have a comparably smaller sized thorax, cardiac muscle and the total red cells, hemoglobin and hematocrite concentration average are approximately 6%, 10% respectively and peak bone density is less than the bone density seen in men of the same age. All these factors may hinder exercise performance. Therefore, weight equipment has been designed to accommodate a male physique.

V.

Knees, shoulders and foots injuries

Imbalance between quadriceps and hamstring muscles, altered biomechanics from an increased quadriceps angle and pronation or improper shoes are the foundation to these injuries. Clinically, mothers can present limb and spinal mal-alignment. Restoration of kinesiology should include orthotics, strengthening of the quadriceps, stretching and strengthening the hamstrings and correction of foot alignment. Ligament laxity affect female during pregnancy and has been suggested as predisposing them to injury. Injury rates to the knees have been found to be greater in women with wide pelvis, increased femoral anteversion and increased valgus of the knees. Footwear with high heels can accentuate pressure on the metatarsal heads and intersegmental spinal dysfunctions can appear. Clinically these patients should complain of low back pain, neck or hip pain. Orthotic foot wear would be recommended. Pregnant women involved in excessive exercise can developed shoulder injuries. These exercise may be accomplish by upward and anterior migration of the humeral head in the fossa with not enough space in forward flexion. Simple remedies to these habits would be to encourage women to join a rehabilitative program that includes gleno-humoral joint and cervical spine.

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April 1, 2012

E. ANCUTA, MUSCULO-SKELETAL PAIN AND PREGNANCY

As well as female change physiologically and anatomically during pregnancy, clinicians should encourage them to maintain proper posture as often as possible. Educating pregnant women regarding posture may prevent myofascial pain and spinal joint dysfunction. Women should pay attention to bend their knees or hold the child close to the body when lifting weights. Researchers also noted a direct relationship between excessive foot pronation and injury of the anterior cruciate ligament.

IV.

Management of the rheumatic illnesses during pregnancy

The clinical management of pregnancy complicated by rheumatic illnesses as systemic lupus erythematosus, antiphospholipid syndrome, rheumatoid arthritis, scleroderma, juvenile idiopathic arthritis or spondyloarthropathy depends on both fetal and maternal factors. Clinicians have suggested that assessment of anti-DNA, antiphospholipid, anti-SSA/Ro, antiSSB/La, RNP antibodies and ESR level can be used. Also, in antiphospholipid syndrome measurements of anticardiolipin antibodies (high titer >40 IU of IgM or IgG), anti-beta2glycoprotein1 (present for at least 12 weeks), lupus anticoagulant test, proteinuria and thrombocytopenia may be usefull. A diagnosis of rheumatoid arthritis, scleroderma or juvenile arthritis depends on clinical grounds alone. Systemic lupus erythematosus during pregnancy can include musculoskeletal manifestations as arthralgia or myalgia and vascular, hematological, renal or myocardial disorders. The injuries sites are located in proximal interphalangeal joints, metacarpal phalangeal joints and the knees. Patients can often suffer from cramping, diarrhea or vomiting resultant mostly from vasculitis of the intestines. Also can suffer from sudden death, arrhythmias or cardiac failure from pericarditis. Other clinical signs may include pleurisy or pleural effusion. The re-setting of hormones to a non-gravid state can reduce musculoskeletal pain, fatigue and other signs. When diagnosing SLE, there are certain criteria that must be met. Most important to the pregnant women is to adopt a multidisciplinary approach. Patients should be referred to their gynecologist and rheumatologist for evaluation. Monitoring of SLE consists of ultrasound evaluation of the fetal growth rate and placental volume. Establishing a diagnosis of SLE flare requires a new or increasing of anti-dsDNA antibody. A diagnosis of neonatal lupus syndrome include a high-titer anti-Ro/SSA or anti-La/SSB antibodies in neonates. Mothers may develop severe preeclampsia or HELLP syndrome.
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April 1, 2012

E. ANCUTA, MUSCULO-SKELETAL PAIN AND PREGNANCY

Diagnosing congenital complete heart block requires ultrasonography between 18 and 24 weeks of gestation. Monitoring fetal heart rate show spontaneous bradycardia, reduced placental volume, decreased amniotic fluid or fetal death. V. Treatment options in SLE during pregnancy

Corticosteroids may increase risk of pregnancy-induced diabetes, hypertension or premature rupture of membranes as maternal complications and slight increase in cleft palate or fetal growth restriction as fetal complications. Hydroxycholoquine discontinuation during pregnancy can result in a flare of SLE. ACE inhibitors and angiotensin receptor blockers may increased risk of oligohydramnios, fetal growth restriction or fetal renal dysfunction in second and third trimester. Also there is a direct relatioship between teratogenesis and ACE inhibitors or angiotensin receptor blockers. Evidence indicates that pregnant women with SLE are better treated with anticoagulants in stead of anti-inflammatory drugs. Heparin or aspirin lower doses may be protective against fetal death in SLE(antiphospholipid syndrome). Anticoagulant therapy during pregnancy is successful and can ameliorate the discomfort associated with SLE. Low dose aspirin has been used in order to improve pregnancy outcome by preventing preeclampsia, hypertension, preterm birth, intrauterine growth restriction or perinatal death (women with historical risk factors). The administration of low dose aspirin during pregnancy is significantly related to fetal survival in patients with renal lupus. Also low dose aspirine in the first trimester does not increase the risk of congenital malformations and in the second and third trimester do not increase fetal side effects. Management SLE during pregnancy include: no increase more than 25% in serum creatinin; normal arterial blood pressure; no increase in proteinuria (more than 1g/24h); no symptoms/signs of active SLE; normal C3 and C4 and negative anti-DNA; normal uterine and ombelical artery doppler ultrasound at 24 weeks of gestation. Stop low dose aspirin at the end of the 36 weeks, continue LMWH until delivery and resume warfarin after delivery, if no obstetrical contraindications. There is no contraindication to vaginal delivery related to SLE or treatment. Women who took low dose aspirin during pregnancy have a lower risk of preterm delivery than did those treated with placebo.
VI. Options for female contraception in women with SLE

Contraception includes intrauterine device, oral pill, depot medroxyprogesterone, subcutaneous implants. Combined hormonal contraception should be avoided in female with previous thrombosis or Apl. Page | 6

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E. ANCUTA, MUSCULO-SKELETAL PAIN AND PREGNANCY

The need for contraception should be periodically assessed with the counselling of a dedicated team of rheumatologists and obstetricians. The team gives the patient the opportunity to adequately modify her treatment and to achieve a good pregnancy outcome.

VII.

Cancers during pregnancy

On very rare situation, metastatic disease (breast, thyroid, cervical, kidney cancer) can also affect the pregnant women. Patients may present musculoskeletal dysfunction. If the musculoskeletal pain is not abated by treatment be sure to refer to an oncologist.

Selective references
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E. ANCUTA, MUSCULO-SKELETAL PAIN AND PREGNANCY

14. Ranzi, A., Use of Complementary Medicines and Therapies Among Obstetric Patients, Obstetrics and Gynecology 2001, April 1997 (4 suppl ): s4 15. Carli G, Suman A, Biasi G, Marcolongo R, Reactivity to Superficial and Deep Stimuli in Patients with Chronic Musculoskeletal Pain, International Association of the Study of Pain Management, 2002 Dec; 100 (3): 259-69 16. Diakow, P., D.C., et al, Back Pain During Pregnancy and Labor, Journal of Manipulative and Physiological Therapeutics, Vol. 14, Number 2, February 1991 17. Cohen K Chiropractic Treatment of the Musculoskeletal System During Pregnancy, Journal of the American Chiropractic Association/May 1997 18. Seidel H., Ball J., Dains J., Benedict G. Mosbys Guide to Physical Examination Third Ed. 1995; pp. 444-466

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