Pregnancy-related complications include a multitude of topics from musculoskeletal disorders to potentially life-threatening vascular conditions. The most common and concerning issues faced by physiatrists include musculoskeletal, endocrine, and cardiovascular issues. These complications can threaten the health of both the pregnant woman and the fetus.
Pregnancy results in hormonal and vascular changes in addition to the physical effects of weight gain focused around the abdomen. This may result in low back pain and pelvic girdle pain. The etiology of carpal tunnel syndrome is multifactorial, including hormonal changes and edema. The etiology of leg cramps in pregnancy is not fully known, but hypothesized to be the result of the accumulation of lactic and other acids.
Endocrine complications, including hyperemesis gravidarum, transient osteoporosis, and gestational diabetes, are the result of hormonal changes. Hyperemesis, and the more severe hyperemesis gravidarum, are related to hormonal changes with gastrointestinal dysmotility. The origin of transient osteoporosis related to pregnancy is unknown.
Cardiovascular events, including venous thrombosis, embolism and stroke, are the result of hypercoagulability in pregnancy. The etiology of preeclampsia is not known.1
Epidemiology including risk factors and primary prevention
Low back pain occurs in 50% to 90% of pregnant women. Risk factors include age, history of non-gestational back pain, race, parity, occupation, and weight, but these risk factors have shown no correlation with gestational back pain in some studies.2
Carpal tunnel syndrome (CTS) is common in pregnancy with a prevalence as high as 25%.3
Gestational diabetes is reported in 2% to 10% of pregnant women.4
Hypercoagulability results in an increased risk of arterial and venous events. Risk factors for thromboembolic events are age older than 35 years, thrombophilia, history of thrombosis, and medical conditions that place the non-pregnant population at risk for similar events.5 Certain populations may require anticoagulation during pregnancy and the postpartum period as a method of primary prevention.
The risk of preeclampsia is increased in patients with a history of hypertension, prior preeclampsia, family history, obesity and some systemic diseases. Certain risk factors may lead to obstetricians recommending delivery prior to 40 weeks.6
Pregnancy-related low back and pelvic pain may be the result of postural changes with abdominal weight gain. This results in shifting of the center of gravity and increased lumbar lordosis. Abdominal wall stretching and separation further strains the lumbar spine. Hormonal changes cause ligaments to relax in the pelvis, resulting in increased mobility in the sacroiliac joints, pubic symphysis, and lumbar spine. This is in preparation for delivery, but this laxity may result in both low back and pelvic pain. Hormonal changes possibly responsible for the increased laxity and pain are relaxin, estradiol, and progesterone. There has been evidence refuting the correlation between relaxin levels alone and the incidence of pelvic girdle pain in pregnancy.7
Pregnancy-associated carpal tunnel syndrome may be related to hormonal changes and increasing peripheral edema, causing median nerve compression.
Leg cramps are frequent in the late second and third trimesters, in the evening or night. This may be due to vascular changes and increased weight.
Gestational diabetes is the result of decreased insulin sensitivity. The exact mechanism of this is not known.
Cardiovascular events, such as venous thromboembolism (VTE) and stroke, are the result of hypercoagulability, a state in which there is an increase in clotting factors and fibrinogen. It is thought that this is a protective mechanism against excessive bleeding in childbirth or miscarriage. The risk of VTE is 4 to 5 times greater in pregnant women than nonpregnant women.5 The etiology of preeclampsia is unknown, but this and hypercoaguability increase the risk of stroke.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
In most cases, low back pain, pelvic girdle pain, and CTS resolve spontaneously within the postpartum period.
Insulin resistance typically increases as pregnancy progresses. In 90% to 95% of women, diabetes resolves after delivery. Women with gestational diabetes have an increased risk of developing diabetes in the future. There is concern for miscarriage, birth defects, and excessive fetal growth with poorly controlled blood sugar. Both babies and mothers with gestational diabetes have an increased risk of diabetes later in life.
VTE and pulmonary embolism risk is elevated throughout pregnancy and greatest in the first 3 months after delivery.8
Preeclampsia results in hypertension, proteinuria, and lower limb edema. If untreated, it may progress to life-threatening eclampsia and other syndromes.
Specific secondary or associated conditions and complications
Autonomic dysreflexia is a potentially life-threatening complication in pregnant women with spinal cord injuries at the T6 level or higher. Triggering events include labor, pelvic exams, bowel or bladder irritation, decubitus ulcers, and sexual activity. Spasticity may also be increased in pregnancy and trigger autonomic dysreflexia, but other causes should be considered.
Women treated for hydrocephalus with a ventriculoperitoneal shunt have a higher risk for shunt malfunction during pregnancy, possibly because of increasing intraperitoneal pressure.
2. Essentials of Assessment
Patients complain of low back pain with or without leg pain, which worsens with activity and is typically relieved with rest. Patients with pelvic pain may describe pain in the suprapubic or sacroiliac regions.
Patients with CTS may complain of tingling, numbness, pain, or weakness in the hand and wrist, primarily in the thumb, index, and middle fingers, which may involve the forearm.
Patients with possible deep vein thrombosis may complain of pain and swelling in a lower limb. Patients with pulmonary embolism (PE) may complain of shortness of breath and chest pain.
Patients developing stroke may complain of difficulties with speech, motor deficits, and sensory deficits similar to a nonpregnant patient. Patients may complain of headaches, visual changes, edema, excessive weight gain, vomiting, and decreased urine output.
Vital signs, including blood pressure and pulse, should be checked.
There may be tenderness to palpation in the lumbar spine, sacroiliac joints, paraspinals, or suprapubic area. Provocative sacroiliac joint maneuvers have a 60% positive predictive value in identifying sacroiliac joint-mediated pain.9 A complete neurologic exam with manual muscle testing, sensory testing, reflex testing, and provocative maneuvers should be completed to assess for any neurologic compromise, indicating possibilities of lumbosacral plexus, or nerve root impingement. Additionally, the patient should have an abdominal and gynecologic exam by her obstetrician.
On exam, the lower limbs should be examined for tenderness, edema, and erythema and should be checked for distal pulses. If there is concern for a PE, the patient should be evaluated immediately in the emergency department.
A complete neurologic exam should be completed for concerns of stroke or preeclampsia.
Depression and anxiety before, during, and in the postpartum period are serious issues needing assessment by the treating clinician because they can be debilitating and result in poor self-care and detrimental behavior for the patient and fetus. Antidepressants and anxiolytic medication adjustments may be necessary in relation to pregnancy. Pain thresholds may also be affected by depression and anxiety.
Electromyogram and nerve conduction testing may be done to delineate CTS, but they are not absolutely necessary.
A glucose tolerance test is done to assess for gestational diabetes.
Diagnostic imaging is typically not needed. If x-ray imaging of the lumbar spine or pelvis is required, it should be discussed with the obstetrician. Radiographs are contraindicated. In certain circumstances, in the third trimester, an obstetrician may allow a medically necessary radiograph. Magnetic resonance imaging (MRI) may be performed if advanced treatments, such as epidural steroid injection or surgery, are being considered.
A lower limb compression ultrasound can be completed to assess for DVT. Computed tomography angiography may be done to assess for PE.
MRI of the brain may be done for a clinical suspicion of stroke.
Early predictions of outcomes
Opioid-dependent pregnant patients with anxiety will benefit from additional support. In a randomized controlled trial, extra clinical resources were found to prevent early discontinuation of substance abuse treatments.10 Further studies will be helpful to predict outcomes in these patients.
Social role and social support system
A strong support system helps patients with gestational diabetes adhere to dietary and activity modifications. A good support system also provides aid in activities such as lifting large objects, carrying children or acting as a primary caregiver in a physically demanding way. This support with strenuous activities may help reduce exacerbations of low back or pelvic pain.
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Treatment of pregnancy-related low back and pelvic girdle pain includes lifestyle modifications, physical therapy, support belts, medications, injections, and alternative treatments. Lifestyle modifications include discontinuing activities that aggravate the pain, if possible. This may require wearing proper footwear, bending with knees instead of the back, avoiding lifting heavy objects, and other similar strategies for proper body biomechanics and ergonomics. Walking and exercise, similar to the pre-pregnancy level, should be encouraged. Physical therapy may include massage, heat, or ice with development of a home stretching program and use of a transcutaneous electrical nerve stimulator, if cleared by the obstetrician. Therapist-assisted exercises may not improve pelvic pain, but a consult may be valuable.11 A sacroiliac belt or maternity support belt may be helpful for pelvic girdle and low back pain. Acetaminophen may be used as an analgesic. With clearance from the obstetrician, if there is tenderness on exam, topical treatments, such as lidocaine ointments or patches, and trigger point injections may be considered. Acupuncture has been shown to be effective in decreasing pregnancy-related pain. Lumbar and pelvic surgery is avoided, if possible, during pregnancy.
Exercise prescriptions for obese patients may require special considerations and assessment of their pre-pregnancy activity levels.12
Treatment for CTS is similar to that in nonpregnant patients, with lifestyle modification, splinting, therapy, medications, injections, and surgical considerations.
Leg cramps may be treated with hydration, movement, and magnesium.13
Treatment for gestational diabetes includes dietary modifications with nutritional counseling, exercise, and insulin or oral medications. Blood sugars must be checked and reviewed on a regular basis by a physician who will adjust medication based on blood sugar control. There may be additional fetal monitoring as well. Exercise, a healthy diet, and breastfeeding can reduce the incidence of type 2 diabetes for the mother and child.14
Treatment for VTE is typically with anticoagulation medications, such as heparin. Warfarin is contraindicated in pregnancy. Other treatments for this and for a stroke, such as physical and/or occupational therapy, are similar to non-pregnant patients.
The ultimate treatment for preeclampsia is delivery.
At different disease stages
Opioid-dependent pregnant patients ideally are weaned off, or rotated to a potentially better-tolerated opioid for the fetus. Patients are often switched to methadone, though this is a category C medication, through a supervised methadone program coordinated with the obstetrician. Oxycodone and buprenorphine may be considered.
Neonatal abstinence syndrome must be treated. Some conditions that may require periodic or chronic opioids, such as multiple sclerosis, are known to be better controlled during pregnancy with fewer exacerbations. Muscular dystrophies include a variety of conditions with unique potential challenges during pregnancy, including worsening of weakness and cardiac and respiratory difficulties.
Patients with rheumatoid arthritis and autoimmune disorders often have less severe symptoms during pregnancy and may not require immunosuppressive or opioid medications during this period. Immunosuppressive medications can cause birth defects, and coordination between rheumatology and obstetrics is required to care for these patients and to develop an appropriate treatment plan.
Meralgia paresthetica, can be related to increasing abdominal girth and resulting compression of the lateral femoral cutaneous nerve. Other compression neuropathies and inflammatory syndromes, such as De Quervain tenosynovitis, may also occur as a result of hormonal changes and edema, as described with CTS.
Pelvic girdle pain postpartum may benefit from stabilizing exercises and physical therapy. 15 There are clinical guidelines for physical therapists to use with varying degrees of evidence based on the International Classification of Functioning, Disability and Health.16
Coordination of care
Care for the pregnant patient should be coordinated between the physiatrist, obstetrician, and therapist, if involved. In cases of VTE and gestational diabetes, coordination with maternal fetal medicine for high-risk pregnancies is recommended.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
If cleared by the patient’s obstetrician, topical treatments, support belts/braces, acetaminophen and physical therapy may be used in combination to treat most musculoskeletal issues.
Exercise appropriate for the patient may help with blood sugar control and minimize excessive weight gain and related complications.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
Sacroiliac joint and other injections to treat local painful syndromes are more frequently being performed under ultrasound guidance because the contraindicated radiation exposure with fluoroscopically guided injections. Ultrasound-guided lumbar or sacroiliac joint injections may be performed with anesthetic and corticosteroid only if cleared by the obstetrician. Even with clearance, the risk-benefit ratio must be considered because corticosteroids are classified as category C in pregnancy.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
There are many knowledge gaps in the etiology of musculoskeletal complications and gestational diabetes. They are the result of a complex combination of several hormonal changes and shifts in multiple endocrine axes. A single hormone, such as relaxin, has not been found to independently cause specific complications, such as pelvic girdle pain. Further research is needed to clarify etiologies of complications to develop targeted treatments.
- Dekkar GA, Sibai BM. Etiology and pathogenesis of preeclampsia: current concepts. Am J Obstet Gynecol. 1998;179:1359-1375.
- Braddom RL. Physical Medicine & Rehabilitation. 2nd ed. Philadelphia, PA: Saunders; 2000.
- Borg-Stein J, Dugan SA. Musculoskeletal disorders of pregnancy, delivery and postpartum. Phys Med Rehabil Clin N Am. 2007;18:459-476.
- U.S. Department of Health and Human Services. National diabetes statistics, 2011. 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/#Gestational. Accessed September 26, 2013.
- James AH. Pregnancy-associated thrombosis. Hematology Am Soc Hematol Educ Program. 2009:277-285.
- Harper LM, Alan TN, Tita JR. Biggio et al. Timing of delivery in pregnancies complicated by diabetes. American Journal of Obstetrics & Gynecology. 2016;214:S90.
- Aldabe D, Ribeiro DC, Milosavljevic S, Dawn Bussey M. Pregnancy-related pelvic girdle pain and its relationship with relaxin levels during pregnancy: a systematic review. Eur Spine J. 2012;21:1769-1776.
- Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ 3rd. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med. 2005;143:697-706.
- Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E. The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome. Arch Phys Med Rehabil. 1998;79:288-292.
- Benningfield MM, Dietrich MS, Jones HE, et al. Opioid dependence during pregnancy: relationships of anxiety and depression symptoms to treatment outcomes. Addiction. 2012;107 Suppl 1:74-82.
- Gupta A, Ceprnja D, Crosbie J. Does therapist-assisted exercise improve pregnancy related pelvic girdle pain? A randomised, cross-over, blinded, sham-controlled trial. Physiotherapy. 2015; 101: e497.
- Seneviratne SN, Lesley ME, McCowan WS, et al. Exercise in pregnancies complicated by obesity: achieving benefits and overcoming barriers. American Journal of Obstetrics & Gynecology. 2014; 212: 442-449.
- Dahle LO, Berg G, Hammar M, Hurtig M, Larsson L. The effect of oral magnesium substitution on pregnancy-induced leg cramps. Am J Obstet Gynecol. 1995;173:175-180.
- Gunderson EP. Breastfeeding after gestational diabetes pregnancy: subsequent obesity and type 2 diabetes in women and their offspring. Diabetes Care. 2007;30 Suppl 2:S161-168.
- Bhardwaj A, Nagandla K. Musculoskeletal symptoms and orthopaedic complications in pregnancy: pathophysiology, diagnostic approaches and modern management. Postgraduate Medical Journal. 2014.
- Clinton SC, Newell A, Downey PA, et al. Pelvic Girdle Pain in the Antepartum Population: Physical Therapy Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Section on Women’s Health and the Orthopaedic Section of the American Physical Therapy Association. Journal of Women’s Health Physical Therapy. 2017; 41:102-125.
Original Version of the Topic
Saloni Sharma, MD. Pregnancy related complications. 12/02/2013.
Saloni Sharma, MD
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