Author(s): Reina Nakamura, DO, Sara Dykowski, MD
Originally published: December 2, 2013 Last updated: June 1, 2022
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Disease/ Disorder

Definition

Pregnancy-related complications include a multitude of topics from musculoskeletal disorders to potentially life-threatening vascular conditions. The most common issues faced by physiatrists include musculoskeletal, neurologic, endocrine, and cardiovascular issues. The most concerning complications can threaten the health of both the pregnant woman and the fetus.

Etiology

Pregnancy results in hormonal, vascular, and physical changes, all of which have varying effects on the body.  Labor and delivery can also result in musculoskeletal and neurologic injury that are important for physiatrists to consider.

There can be multiple pain generators in pregnancy that result in low back, pelvic girdle, and joint pain. Weight gain and a growing gravid abdomen are examples of increased biomechanical stressors that can contribute to symptoms. Soft-tissue edema can put one at risk for tenosynovitis or nerve entrapment, such as in De Quervain’s tenosynovitis or carpal tunnel syndrome, respectively. Other neurologic concerns include meralgia paresthetica, neuropathy, and plexopathy. Meralgia paresthetica is a result of anatomical changes resulting in compressive forces on the lateral femoral cutaneous nerve.  Median, femoral, obturator, and peroneal neuropathies, as well as lumbosacral plexopathy are a few examples of compressive or traction nerve injuries that may occur during pregnancy or the peri-partum period. 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, gestational diabetes, transient osteoporosis, and sequelae of joint laxity, 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, and perhaps underdiagnosed.1 Transient osteoporosis, in addition to increased relaxin levels, weight gain, and rapid fetal head descent, all may contribute to various musculoskeletal sequelae including hip pain, osteonecrosis, sacroiliac dysfunction, pubic symphysis separation, and pelvic insufficiency fracture. Physiologic ligamentous laxity is a vital antepartum change, however increased laxity can cause excessive joint mobility increasing pain, such as in pubic symphysis dysfunction. There are rare case reports of hormone-mediated tumor growth in pregnancy as a result of hormonal fluctuations in pregnancy.2 Cardiovascular events, including venous thrombosis, embolism and stroke, are the result of hypercoagulability in pregnancy. The etiology of preeclampsia is not known.3

Epidemiology including risk factors and primary prevention

Low back pain occurs in 50% to 90% of pregnant women. Risk factors include higher maternal 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.4

Pelvic girdle pain occurs in approximately 45% pregnant women. Risk factors include history of prior lumbopelvic pain, strenuous work, and previous lumbopelvic pain during pregnancy.5

Hip pain is also common in pregnant women, which may be related to transient osteoporosis or the development of osteonecrosis.

Soft tissue swelling at some point in pregnancy is reported by up to 80% of pregnant women.6 Soft tissue swelling can lead to compressive or traction neuropathies.

Carpal tunnel syndrome (CTS) is common in pregnancy with a prevalence as high as 25%.7

Gestational diabetes is reported in 2% to 10% of pregnant women.8

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.9 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.10

Patho-anatomy/physiology

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, or hyperlordosis. 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.  Relaxin exerts collagenolytic properties increasing ligamentous laxity though there has been evidence refuting the correlation between relaxin levels alone and the incidence of pelvic girdle pain in pregnancy.11

Relaxin has also been further implicated in remodeling of multiple tissues in the musculoskeletal system. It is an osteoclast activating factor which plays an integral role in bone resorption.  As an anti-inflammatory modulator, relaxin downregulates neutrophil function.  In combination with estrogen, relaxin provides anti-inflammatory effects in rheumatoid arthritis patients through downregulation of tumor necrosis factor alpha in animal models and increase IL-10 (anti-inflammatory cytokine in humans), which could potentially explain some of the benefit of pregnancy in autoimmune conditions.12, 13,14  

Compression nerve injuries in pregnancy often occur at superficial locations due to local soft tissue edema. For example, pregnancy-associated carpal tunnel syndrome may be related to hormonal changes and increasing peripheral edema, causing median nerve compression. Fluid retention in upper limbs may also result in stenosing tenosynovitis of the hand and wrist, or De Quervain’s disease.

The mechanics of labor and delivery can result in traction and compressive neuropathies. The femoral nerve may be injured by direct compression under the inguinal ligament, stretching, or ischemia. One study found nulliparity and prolonged pushing risk factors for femoral nerve injury.15 As the obturator nerve crosses the pelvic brim, it is susceptible to compressive injury from obstetrical instrumentation and the fetus. The fetal head may also directly compress the lumbosacral plexus resulting in plexopathy. Additional studies have shown focal peroneal nerve compression at the fibular head related to hand positioning, squatting, and improper foot rest placement during labor.7The pathophysiology of transient osteoporosis in pregnancy is not well understood. Bony resorption at the pubic symphysis can put pregnant and postpartum women at risk for osteitis pubis. Osteoarthritic joints also put patients at risk for pregnancy-related musculoskeletal pain.

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 hypercoagulability, 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, meralgia paresthetica, and CTS resolve spontaneously within the postpartum period. Traction neuropathy and plexopathies can take up to several months to recover.

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.16

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.

Cerebral arteriovenous malformation (AVM) is a complicated co-morbidity in pregnancy without a risk and treatment consensus. Some studies have shown equal bleeding risk in the pregnant population compared to the general population, while others have shown an odds ratio of 7.91 in pregnancy with 28% mortality.17

Essentials of Assessment

History

Patients complain of low back pain with or without leg pain, which worsens with weight-bearing and activity, and is typically relieved with rest. Patients with pelvic pain may describe pain in the suprapubic, groin, inner thighs, or lumbosacral spine.

Patients with hip pain typically present with acute onset of pain, worsened by weight-bearing and relieved with rest, and functional disability.

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 meralgia paresthesia may experience burning, pain, or numbness along the anterolateral thigh.

Patients with lumbosacral plexopathy typically present with lower extremity pain, paresthesias and/or weakness.

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.

Physical examination

Vital signs, including blood pressure and pulse, should be checked.

There may be tenderness to palpation in the lumbosacral spine, sacroiliac joints, paraspinals, or suprapubic area.  Provocative sacroiliac joint maneuvers have a 60% positive predictive value in identifying sacroiliac joint-mediated pain.18 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. Gait assessment is an instrumental part of the neuromuscular examination. Additionally, the patient should have an abdominal and gynecologic exam by her obstetrician.

On exam, the upper limbs and 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.

Functional assessment

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.

Laboratory studies

Electromyogram and nerve conduction testing may be done to delineate mononeuropathies or plexopathies, but they are not absolutely necessary.  A glucose tolerance test is done to assess for gestational diabetes.

Imaging

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.

Diagnostic ultrasound is an attractive imaging modality due to its relative safety during pregnancy.  Ultrasound can be useful in diagnosing musculoskeletal conditions such as tenosynovitis as well as mononeuropathies such as CTS with known diagnostic criteria by ultrasound.

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, distinguishing osteoporosis versus osteonecrosis, AVM or aneurysm assessment.

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.19 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.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Treatment of pregnancy-related low back and pelvic girdle pain includes lifestyle modifications, physical therapy, aqua therapy, support binders and 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.20 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. Massage, relaxation, yoga, and chiropractic care are additional alternative therapies prenatal health care and pregnant women utilize for low back pain.7 Lumbar and pelvic surgery is avoided, if possible, during pregnancy. In rare instances, surgical intervention for pubic symphysis rupture or diastasis may be warranted if symptoms persist post-partum.

Exercise prescriptions for obese patients may require special considerations and assessment of their pre-pregnancy activity levels.21

Treatment for CTS and De Quervain’s tenosynovitis is similar to that in nonpregnant patients, with lifestyle modification, splinting, therapy, medications, injections, and surgical considerations.

Meralgia paresthesia typically resolves in the postpartum period. Avoiding tight clothing along the pelvis and carrying younger children along the affected hip can help prevent exacerbating symptoms further. Consideration of prolonged hip flexion and shortening pushing time during labor and deliver may also help the patient.

Individuals who sustain a neuropathy in labor and delivery should undergo physical therapy evaluation and assistive-device training prior to discharge.

Treatment of transient osteoporosis is conservative with symptom management as the condition typically regresses spontaneously over 6-8 months.22 Using assistive device to offload the painful joint and reduce risk for pathologic fracture is important if not done. Analgesics may be as needed. Consultation with orthopedics surgery for management of osteonecrosis is warranted.

Leg cramps may be treated with hydration, movement, and magnesium.23

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.24

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, a category C medication, through a supervised methadone program coordinated with the obstetrician. Oxycodone and buprenorphine may also 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’s 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. 25 The use of sacral iliac joint belt can also improve pain and function after 4 weeks of therapy.26 There are clinical guidelines for physical therapists to use with varying degrees of evidence based on the International Classification of Functioning, Disability and Health.27

Coordination of care

Care for the pregnant patient should be coordinated between the physiatrist, obstetrician, and physical 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.

Cutting Edge/ Emerging and Unique 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.

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.

References

  1. ReferencesFunk JL, Shoback DM, Genant HK. Transient osteoporosis of the hip in pregnancy: natural history of changes in bone mineral density. Clin Endocrinol (Oxf). 1995;43(3):373-82. 
  2. Tumor growth: Valarezo Chuchuca A, Wong-Achi X, Ullauri Torres L. Medulloblastoma during pregnancy: Hormone-mediated association? Report of 2 cases. Neurochirurgie. 2021 Apr;67(2):140-144.
  3. Dekkar GA, Sibai BM. Etiology and pathogenesis of preeclampsia: current concepts. Am J Obstet Gynecol. 1998;179:1359-1375. (WAS 1)
  4. Braddom RL. Physical Medicine & Rehabilitation. 2nd ed. Philadelphia, PA: Saunders; 2000.
  5. Wu WH, Meijer OG, Uegaki K, et al. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. Eur Spine J. 2004;13(7):575-589.
  6. Ritchie JR. Orthopedic considerations during pregnancy. Clin Obstet Gynecol 2003;46:456–66.
  7. Borg-Stein J, Dugan SA. Musculoskeletal disorders of pregnancy, delivery and postpartum. Phys Med Rehabil Clin N Am. 2007;18:459-476.
  8. 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.
  9. James AH. Pregnancy-associated thrombosis. Hematology Am Soc Hematol Educ Program. 2009:277-285.
  10. 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.
  11. 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.
  12. Dehghan F, Haerian BS, Muniandy S, Yusof A, Dragoo JL, Salleh N. The effect of relaxin on the musculoskeletal system. Scand J Med Sci Sports. 2014 Aug;24(4):e220-9. 
  13. Bani D, Masini E, Bello MG, Bigazzi M, Sacchi TB. Relaxin protects against myocardial injury caused by ischemia and reperfusion in rat heart. Am J Pathol. 1998 May;152(5):1367-76. 
  14. Figueiredo KA, Mui AL, Nelson CC, Cox ME. Relaxin stimulates leukocyte adhesion and migration through a relaxin receptor LGR7-dependent mechanism. J Biol Chem. 2006;281(6):3030–3039. 
  15. To WW, Wong MW. Factors associated with back pain symptoms in pregnancy and the persistence of pain 2 years after pregnancy. Acta Obstet Gynecol Scand 2003;82:1086–91.
  16. 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.
  17. Lv X, Liu P, Li Y. The clinical characteristics and treatment of cerebral AVM in pregnancy. Neuroradiol J. 2015;28(3):234-237.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. Smith MW, Marcus PS, Wurtz LD. Orthopedic issues in pregnancy. Obstet Gynecol Surv. 2008 Feb;63(2):103-11.
  23. 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.
  24. 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.
  25. Bhardwaj A, Nagandla K. Musculoskeletal symptoms and orthopaedic complications in pregnancy: pathophysiology, diagnostic approaches and modern management. Postgraduate Medical Journal. 2014.
  26. Fitzgerald CM, Bennis S, Marcotte ML, Shannon MB, Iqbal S, Adams WH. The impact of a sacroiliac joint belt on function and pain using the active straight leg raise in pregnancy-related pelvic girdle pain. PM R. 2022 Jan;14(1):19-29.
  27. 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. 12/2/2013

Previous Revision(s) of the Topic

Saloni Sharma, MD. Pregnancy related complications. 3/13/2018

Author Disclosure

Reina Nakamura, DO
Nothing to Disclose

Sara Dykowski, MD
Nothing to Disclose