Pelvic girdle pain during pregnancy and puerperium

Transient osteoporosis of the hip in pregnancy - a case series

OBJECTIVE

Transient Osteoporosis of the Hip is a self-limiting disorder of severe hip joint pain presenting in pregnancy or postpartum, of which magnetic resonance imaging (MRI) is the modality of choice for diagnosis. Clinical data regarding transient osteoporosis of the hip is limited, precluding evidence-based decision-making such as recommended mode of delivery. In this case-series retrospective study, we aim to describe the natural course of transient osteoporosis of the hip during pregnancy and the postpartum period including implications of the mode of delivery.

METHODS

All women diagnosed with unilateral/bilateral transient osteoporosis of the hip by MRI during pregnancy or postpartum between 2010 and 2019 at a single tertiary medical center were retrospectively studied. All MRI scans were reviewed by an experienced radiologist at the same single tertiary medical center. Data obtained from patients' electronic medical records and telephone questionnaires included maternal baseline characteristics, obstetric history, and current pregnancy obstetric and clinical outcome characteristics. Outcomes of normal vaginal delivery (NVD) and cesarean delivery (CD) were compared and analyzed.

RESULTS

Thirty-four women were diagnosed with unilateral or bilateral transient osteoporosis of the hip during pregnancy (17 women) and postpartum (17 women). The mean maternal age was 34.18 ± 4.75 years. A family history of osteoporosis was reported in a rate of 29.4%. The rate of smokers was 47.1%, 32.4% of pregnancies were conceived by in-vitro fertilization (IVF), pre-pregnancy and term body mass index (BMI) were 22.03 and 27.6, respectively. No significant differences were found between NVD and CD in all parameters evaluated. Of 15 women with a sequential pregnancy, two were diagnosed with transient osteoporosis of the hip (13.3%).

CONCLUSION

Women diagnosed with transient osteoporosis of the hip had advanced maternal age, low BMI, family history of osteoporosis, prevalent smoking and IVF pregnancies. Transient osteoporosis of the hip was bilateral in 25% and presented postpartum in 50% of cases. There was no significant difference in maternal outcomes between NVD and CD. Higher awareness of this potential diagnosis during pregnancy and postpartum may improve patient management and outcomes.

Childbearing with Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders: A Large International Survey of Outcomes and Complications

One in 20 births could be affected by hypermobile Ehlers-Danlos syndrome or Hypermobility Spectrum Disorders (hEDS/HSD); however, these are under-diagnosed and lacking research. This study aimed to examine outcomes and complications in people childbearing with hEDS/HSD. A large online international survey was completed by women with experience in childbearing and a diagnosis of hEDS/HSD (N = 947, total pregnancies = 1338). Data were collected on demographics, pregnancy and birth outcomes and complications. Participants reported pregnancies in the UK (N = 771), USA (N = 364), Australia (N = 106), Canada (N = 60), New Zealand (N = 23) and Ireland (N = 14). Incidences were higher in people with hEDS/HSD than typically found in the general population for pre-eclampsia, eclampsia, pre-term rupture of membranes, pre-term birth, antepartum haemorrhage, postpartum haemorrhage, hyperemesis gravidarum, shoulder dystocia, caesarean wound infection, postpartum psychosis, post-traumatic stress disorder, precipitate labour and being born before arrival at place of birth. This potential for increased risk related to maternal and neonatal outcomes and complications highlights the importance of diagnosis and appropriate care considerations for childbearing people with hEDS/HSD. Recommendations include updating healthcare guidance to include awareness of these possible complications and outcomes and including hEDS/HSD in initial screening questionnaires of perinatal care to ensure appropriate consultation and monitoring can take place from the start.

Co-Created Solutions for Perinatal Professionals and Childbearing Needs for People with Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders

Individuals living with hypermobile Ehlers-Danlos syndrome (hEDS) and Hypermobility Spectrum Disorders (HSD) have reported feeling discredited and unsupported by healthcare professionals. However, the level of knowledge about hEDS/HSD among maternity staff remains unknown. Informed by patient and public involvement, this research aimed to investigate maternity staff's knowledge and confidence in supporting people with hEDS/HSD, examine people with hEDS/HSD's experiences of perinatal care, and co-create tools to help maternity staff support people childbearing with hEDS/HSD. Two online mixed-methods international surveys were completed by childbearing people with hEDS/HSD (N = 955) and maternity staff (N = 307). This was followed by the co-creation of three tools with 17 co-creators and a design team. Two main qualitative themes were identified through thematic analysis: (1) a need for recognition of hEDS/HSD in perinatal care and (2) the delivery of appropriate individualised perinatal care. Quantitatively, people with hEDS/HSD perceived maternity professionals to have a low level of knowledge about the conditions. Respectively, maternity staff reported low levels of confidence in supporting people with hEDS/HSD. The co-created tools provide applicable outputs for both education and practice and include an i-learn module hosted by the Royal College of Midwives, a tool for perinatal records, and infomercials.

Pelvic Girdle Pain in Pregnancy: A Review

Importance

Pelvic girdle pain is often thought to be a recent phenomenon, but this condition was described as early as 400 BC by Hippocrates. Despite being identified for years, confusion continues about the definition and management of this ailment affecting many pregnancies.

Objective

The purpose of the review is to assess the incidence, etiology, pathophysiology, risk factors, diagnosis, management, and pregnancy outcomes/recovery of current pregnancies, and outcomes of future pregnancies complicated by pelvic girdle pain.

Evidence Acquisition

Electronic databases (PubMed and Embase) were searched from 1980 to 2021 with the only limitation being that the articles were in English. Studies were selected that examined associations between pelvic pain/pelvic girdle pain and pregnancy.

Results

There were 343 articles identified. After reviewing the abstracts, 88 were used in this review. Pelvic girdle pain is a common condition of pregnancy, affecting a reported 20% of pregnant women. The pathophysiology is poorly understood and likely multifactorial, involving both hormonal and biomechanical changes that occur during pregnancy. Several risk factors have been identified. This diagnosis is most commonly made based on symptoms related to pelvic pain during pregnancy. Treatment should be multimodal, including pelvic girdle support, stabilizing exercises, analgesia, and potentially complementary therapies. The effects on future pregnancies are uncertain, although some limited information suggests an increased risk of recurrent PGP in subsequent pregnancies.

Conclusions

Pelvic girdle pain in pregnancy is a common condition that is often overlooked as a normal part of pregnancy but has a significant impact on quality of life during, after, and in subsequent pregnancies. Multimodal therapies are available and are largely low cost and noninvasive.

Relevance

Our aim is to increase the awareness of pelvic girdle pain in pregnancy as a common but often underdiagnosed and undertreated condition.

The Main Changes in Pregnancy—Therapeutic Approach to Musculoskeletal Pain

Background and Objectives: During pregnancy, women undergo various physiological and anatomical changes that are accentuated as the pregnancy progresses, but return to their previous state a few weeks/months after the pregnancy. However, a targeted therapeutic approach is needed. Most of the time, during this period, these changes precipitate the appearance of pain, musculoskeletal pain being the most common. Pregnant women should avoid treating musculoskeletal pain with medication and should choose alternative and complementary methods. Exercise along with rest is the basis for treating chronic musculoskeletal pain. Side effects of physical therapy are rare and, in addition, it is not contraindicated in pregnant women. The benefits of this type of treatment in combating pain far outweigh the risks, being an easy way to improve quality of life. The objective of this article is to discuss the management of musculoskeletal pain during pregnancy, to identify the main musculoskeletal pain encountered in pregnant women along with drug treatment, and to expose the beneficial effects of alternative and complementary methods in combating pain. Materials and Methods: A literature search was conducted using medical databases, including PubMed, Google Scholar, and ScienceDirect, using the keywords “changes of pregnancy”, “musculoskeletal pain”, “pregnancy pain”, “pain management”, “pharmacological approach”, “alternative and complementary treatment” and specific sites. Information was collected from studies whose target population included pregnant women who complained of musculoskeletal pain during the 9 months of pregnancy; pregnant women with other pathologies that could increase their pain were not included in this review. Results: The articles related to the most common non-obstetric musculoskeletal pain in pregnancy along with pharmacological treatment options and alternative and complementary methods for musculoskeletal pain management during pregnancy were selected. Conclusions: The results were used to guide information towards the safest methods of therapy but also to raise awareness of the treatment criteria in order to compare the effectiveness of existing methods. Treatment must consider the implications for the mother and fetus, optimizing non-pharmacological therapeutic options.

Pregnancy in patients with systemic lupus erythematosus: a systematic review

Systemic lupus erythematosus (SLE)-a most common disorder in women of reproductive age-has been described to be associated with adverse pregnancy outcomes. Despite the increased health risks for the mother (preeclampsia, lupus flare, arterial hypertension, gestational diabetes mellitus and thrombotic risk when antiphospholipid antibodies are present) and fetus (miscarriage, stillbirth, premature birth, intrauterine growth restriction and neonatal lupus), the majority of patients can deliver healthy neonates. With appropriate management by a multidisciplinary team, composing rheumatologists, obstetricians and neonatologists, women with SLE can achieve better pregnancy outcomes by monitoring associated predictive indicators, raising major concern for severe complications and somewhat early delivery if necessary. In this review, we summarize the latest advances in secondary infertility and pregnancy-related risk perception for lupus patients, with an emphasis on the safety of biological agents (mainly belimumab and rituximab) and traditional therapeutic regimens.

A Systematic Review of Elective Laser Therapy during Pregnancy

Introduction: Currently, lasers are used to treat many diseases and their complications. However, the use of lasers in pregnant patients is still controversial. Methods: In this review, the application of lasers in the fields of urology, surgery, obstetrics, dermatology, and musculoskeletal disorders is evaluated. The following keywords were used to search through PubMed, Google Scholar, and Scopus: pregnancy, laser, urolithiasis, endovenous laser ablation (EVLA) or treatment, leg edema, varicose vein, venous insufficiencies, hair removal, pigmentation, telangiectasia, vascular lesions, Q switch laser, diode laser, holmium, holmium-YAG laser, erbium laser and Pulsed dye laser, low-level laser therapy, high-intensity laser therapy, pain, musculoskeletal disorders, twin to twin transfusion syndrome (TTTS), amnioreduction, and safety. Results: Totally, 147 articles were found, and their abstracts were evaluated; out of 53 articles extracted, 14 articles were about dermatology, 24 articles were about urology, 12 articles were about obstetrics and gynecology, 10 articles were about musculoskeletal disorders and three articles were related to surgery. Conclusion: Laser therapy can be used as a safe treatment for urolithiasis, skin diseases, TTTS and varicose veins of the lower extremities. However, the use of laser therapy for musculoskeletal disorders during pregnancy is not recommended due to lack of evidence, and also we cannot recommend endovenous ablation.

Pubic Symphysis Separation and Regression in Vaginal versus Cesarean Delivery

OBJECTIVE

To quantify the association of pubic symphysis separation with mode of delivery and follow the resolution of this physiologic separation in the postpartum period.

METHODS

Prospective observational cohort study that recruited two cohorts of primiparous women: those undergoing vaginal and cesarean delivery (45 and 46 patients, respectively). Chart review collected intrapartum factors. Patients were followed with serial anterior-posterior radiographs within 48 hours of delivery and at 6, 12, and 24 weeks postpartum, to evaluate the extent of pubic symphysis separation. Differences between the two cohorts in intrapartum factors were assesses as was pubic symphysis separation at each time point.

RESULTS

Mean age of women was 25.8 (SD 5.1) years, and 56% were White. Mean birth weight was 3.5 (SD 0.52) kg. Mean immediate postpartum pubic symphysis separation was 7.6 (SD 2.2) mm and did not differ between groups, at 7.18 mm for vaginal delivery versus 8.04 mm for cesarean delivery (CD; P = 0.08). Pubic symphysis separation was not significantly different for CD with and without labour. Black race and obesity were associated with increased pubic symphysis separation. No intrapartum events were related to extent of separation. Normalization of pregnancy pubic symphysis separation to 4-5 mm occurred by 6 weeks postpartum. Separation of >10mm and <15mm occurred in 10 of the 91 women and occurred after vaginal and cesarean delivery. The widest pubic symphysis separation was observed in 3 patients after vaginal delivery.

CONCLUSION

Physiological pubic symphysis separation occurs during pregnancy and regresses postpartum with minimal effects from labour and delivery. Cesarean delivery does not prevent physiological pubic symphysis separation.

Women's Experience of Pelvic Girdle Pain After Childbirth: A Meta-Synthesis

INTRODUCTION

Persistent pelvic girdle pain (PGP) and the resulting consequences may occur for more than 10 years after birth. The purpose of this meta-synthesis is to provide a new interpretation and deeper understanding of women's experience of living with PGP postpartum.

METHODS

A literature review of CINAHL, PsycINFO, PubMed, Scopus, and ProQuest dissertations was conducted for any qualitative study addressing PGP after birth and published in English from 2000 to 2019. A meta-synthesis using Noblit and Hare's meta-ethnography approach was performed.

RESULTS

Seven studies were found describing the experiences of women living with PGP from birth to 13 years after birth. Six themes emerged that represented women's experience: invisible pain, life being restrained, failure to perform the maternal role, experiencing downward emotional spiral, need for active social support, and adaptation to a new conditional life.

DISCUSSION

The experiences of women living with PGP after birth highlight the need for holistic care. Interventions by health care providers should support the ability of women to perform daily functions and adapt to their new reality instead of a disease-focused intervention. In addition, women with PGP emphasize the importance of active social support from family members and health care providers. Future research that examines the differences between PGP during the first 3 months postpartum versus that which persists later is needed to develop targeted interventions.

A multivariate model for predicting PPGP considering postural adjustment parameters

BACKGROUND

Prospective studies have described evidence about the risk of developing pregnancy-related pelvic girdle pain (PPGP) such as, parity, previous history of low back and pelvic girdle pain. No previous studies have prospectively associated PPGP with postural control.

AIM

This study aimed to identify postural control predictors of PPGP during pregnancy.

METHODS

Forty-six pregnant women were surveyed throughout their pregnancy for the presence of PPGP. At baseline, participants were evaluated for muscle latencies, mediolateral centre-of-pressure (COP) displacement and velocity during single-leg lift performed with eyes open and closed. PPGP was considered if they presented with one positive clinical assessment as well as pain within the pelvic area.

RESULTS

Eighteen (45%) of the participants developed PPGP. This group presented with PPGP around a mean 29th week (SD = 5.7), with mean pelvic pain intensity of 4 mm VAS (SD = 2) on a (0-10 cm VAS) and mean PPGP questionnaire score of 21.5 points (SD = 10.6) out of a possible 100 points with 0 indicating no functional disability. The two factors that were significantly associated with PPGP were the right and left biceps femoris (BF) muscle. For every 50 ms of difference of BF muscles latency between eyes open and closed, the risk of PPGP increases by 20% (right BF) and 30% (left BF) to develop PPGP.

CONCLUSION(S)

This study shows that BF muscle delay during single-leg lift presented at baseline was a significant predictor for the development of PPGP in late pregnancy.

Sickness absence in pregnancy and sedentary behavior: a population-based cohort study from Norway

Background

Sickness absence in pregnancy accounts for a large part of sickness-related absenteeism among women. Exercise in pregnancy is associated with a lower level of sickness absence, however little is known about how sedentary behaviour is related to sickness absence in pregnancy. In the current study, we hypothesize a positive association between sedentary hours/day and the risk of long-term sickness absence.

Methods

Population-based cohort study of pregnant women attending three Child Health Clinics in Groruddalen, Oslo, 823 Women (74% of those eligible) were included between 2008 and 2010. Questionnaire data were collected at gestational weeks 10–20 (visit 1) and 28 (visit 2). Sedentary time and physical activity were objectively recorded at visit 1 with the multi-sensor SenseWear™ Pro3 Armband (SWA). Long-term sickness absence was self-reported at visit 2. We explored the association between sedentary time and long-term sickness absence in pregnancy using multiple logistic regression analysis.

Results

The odds of long-term sickness absence was significantly increased per one-hour increase in daily sedentary time (odds ratio 1.45 [95% confidence interval 1.13–1.84]), providing support for our hypothesis that sedentary time is positively associated with long-term sickness absence.

Conclusions

Pregnant women with a sedentary lifestyle have a higher risk of long-term sickness absence from work. Reducing sedentary time in pregnancy may improve health, and may, in turn reduce sickness absence in pregnancy.

Chiropractic Management of Pregnancy-Related Lumbopelvic Pain: A Case Study

OBJECTIVE

The purpose of this case report is to describe chiropractic management of a patient with pregnancy-related lumbopelvic pain.

CLINICAL FEATURES

A pregnant 35-year-old woman experienced insidious moderate to severe pregnancy-related lumbopelvic pain and leg pain at 32 weeks' gestation. Pain limited her endurance capacity for walking and sitting. Clinical testing revealed a left sacroiliac joint functional disturbance and myofascial trigger points reproducing back and leg pain.

INTERVENTION AND OUTCOME

A diagnosis of pregnancy-related low back pain and pregnancy-related pelvic girdle pain was made. The patient was treated with chiropractic spinal manipulation, soft tissue therapy, exercises, and ergonomic advice in 13 visits over 6 weeks. She consulted her obstetrician for her weekly obstetric visits. At the end of treatment, her low back pain reduced from 7 to 2 on a 0-10 numeric pain scale rating. Functional activities reported such as walking, sitting, and traveling comfortably in a car had improved.

CONCLUSION

This patient with pregnancy-related lumbopelvic pain improved in pain and function after chiropractic treatment and usual obstetric management.

The effect of factors other than age upon skeletal age indicators in the adult

CONTEXT

Estimation of adult age from skeletal remains is problematic due to the weak and variable relationship between age indicators and age.

OBJECTIVES

To assess the proportion of variation in age indicators that is associated with factors other than age and to attempt to identify what those factors might be.

METHODS

The paper focuses on frequently used adult bony age markers. A literature search (principally using Web of Science) is conducted to assess the proportion of variation in age indicators associated with factors other than age. The biology of these age markers is discussed, as are factors other than age that might affect their expression.

RESULTS

Typically, ∼60% of variation in bony age indicators is associated with factors other than age. Factors including inherent metabolic propensity to form bone in soft tissue, vitamin D status, hormonal and reproductive factors, energy balance, biomechanical variables and genetic factors may be responsible for this variation, but empirical studies are few.

CONCLUSION

Most variation in adult skeletal age markers is due to factors other than age; dry bone study of historic documented skeletal collections and high resolution CT scanning in modern cadavers or living individuals is needed to identify these factors.

Determinants of use of care provided by complementary and alternative health care practitioners to pregnant women in primary midwifery care: a prospective cohort study

BACKGROUND

Pregnant women visit complementary/alternative health care practitioners in addition to regular maternal health care practitioners. A wide variation has been reported with regard to rates and determinants of use of complementary/alternative medicine (CAM), which may be due to heterogeneous populations. The aim of this study was to examine the prevalence and determinants of use of CAM practitioners by a homogeneous population of low-risk pregnant women in the Netherlands.

METHODS

Data from the population-based DELIVER study was used, concerning 1500 clients from twenty midwifery practices across the Netherlands in 2009 and 2010. CAM use was measured based on patient reports. Potential determinants were derived from Andersen's behavioural model of health care utilization.

RESULTS

The prevalence of CAM practitioner use by low-risk pregnant women was 9.4 %. Women were more likely to use CAM if they had supplementary health care insurance (OR 3.11; CI 1.41-6.85), rated their health as 'bad/fair' (OR 2.63; CI 1.65-4.21), reported a chronic illness or handicap (OR 1.93; CI 1.14-3.27), smoked during pregnancy (OR 1.88; CI 1.06-3.33), or used alcohol during pregnancy (OR 2.30; CI 1.46-3.63).

CONCLUSIONS

CAM is relatively frequently used by low-risk pregnant women. Determinants revealed in this study diverge from other studies using heterogeneous populations. Maternal health care practitioners must be aware of CAM use by low-risk pregnant women and incorporate this knowledge into daily practice by actively discussing this subject with pregnant women.

Outcomes of pregnant patients with low back pain undergoing chiropractic treatment: a prospective cohort study with short term, medium term and 1 year follow-up

Background

Low back pain in pregnancy is common and research evidence on the response to chiropractic treatment is limited. The purposes of this study are 1) to report outcomes in pregnant patients receiving chiropractic treatment; 2) to compare outcomes from subgroups; 3) to assess predictors of outcome.

Methods

Pregnant patients with low back or pelvic pain, no contraindications to manipulative therapy and no manual therapy in the prior 3 months were recruited.

Baseline numerical rating scale (NRS) and Oswestry questionnaire data were collected. Duration of complaint, number of previous LBP episodes, LBP during a previous pregnancy, and category of pain location were recorded.

The patient’s global impression of change (PGIC) (primary outcome), NRS, and Oswestry data (secondary outcomes) were collected at 1 week, 1 and 3 months after the first treatment. At 6 months and 1 year the PGIC and NRS scores were collected. PGIC responses of ‘better’ or ‘much better’ were categorized as ‘improved’.

The proportion of patients ‘improved’ at each time point was calculated. Chi-squared test compared subgroups with ‘improvement’. Baseline and follow-up NRS and Oswestry scores were compared using the paired t-test. The unpaired t-test compared NRS and Oswestry scores in patients with and without a history of LBP and with and without LBP during a previous pregnancy. Anova compared baseline and follow-up NRS and Oswestry scores by pain location category and category of number of previous LBP episodes. Logistic regression analysis also was also performed.

Results

52% of 115 recruited patients ‘improved’ at 1 week, 70% at 1 month, 85% at 3 months, 90% at 6 months and 88% at 1 year. There were significant reductions in NRS and Oswestry scores (p < 0.0005). Category of previous LBP episodes number at one year (p = 0.02) was related to ,improvement’ when analyzed alone, but was not strongly predictive in logistic regression. Patients with more prior LBP episodes had higher 1 year NRS scores (p = 0.013).

Conclusions

Most pregnant patients undergoing chiropractic treatment reported clinically relevant improvement at all time points. No single variable was strongly predictive of, improvement’ in the logistic regression model.

Is pregnancy related pelvic girdle pain associated with altered kinematic, kinetic and motor control of the pelvis? A systematic review

PURPOSE

To determine the level of evidence for altered mechanical and motor control of the pelvis being associated with pregnancy-related pelvic girdle pain (PPGP).

METHODS

This systematic review was undertaken by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Six different databases were used for the electronic search. Observational cohorts, cross sectional or case-control studies focused on the association between altered kinematic/kinetic and motor control of the pelvis and PPGP during pregnancy were included. Study selection was conducted by two reviewers who firstly screened for titles, then for abstracts and finally for full articles. The Newcastle-Ottawa scale and the guidelines proposed by the Cochrane back review group were used to assess risk of bias and quality of evidence, respectively.

RESULTS

354 references were identified, and after excluding unwanted articles, 10 studies met the final inclusion criteria. Studies not related to motor control or pelvic mobility were the main reason for exclusion. Seven studies were case-control and three were prospective cohort studies. Seven studies were ranked as high while three were ranked as low quality. Among the high quality studies, six found association between PPGP and altered motor control and mobility of the pelvis.

CONCLUSIONS

The level of evidence for an association between PPGP and altered motor control and kinematic or kinetic parameters of the pelvis was found to be moderate.