Musculoskeletal Pain and Pregnancy

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April 1, 2012 E. ANCUTA, MUSCULO-SKELETAL PAIN AND PREGNANCY

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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 orpostural 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 considerednormal 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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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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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 stretchedarms 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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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 inter-

segmental 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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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, anti-

SSB/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-beta2-

glycoprotein1 (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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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 duringpregnancy 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 thrombosisor Apl.




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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.

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