Chapter 30 – Musculoskeletal Considerations in Pregnancy




Abstract




Cauda Equina Syndrom





Chapter 30 Musculoskeletal Considerations in Pregnancy



Hiran Amarasekera




Key Facts


Pregnancy causes several changes to the musculoskeletal system that should be remembered when treating sports injuries during pregnancy. The main changes are a shift in the centre of gravity, increase in body weight and increase in ligament laxity caused mainly by increased relaxing release during pregnancy.


As a result of these changes in pregnancy women are more prone to develop certain musculoskeletal conditions. Some of the common conditions (Table 30.1) are [1]




  • Low back pain



  • Hip problems:




    • Transient osteoporosis avascular necrosis of hip leading to hip pain and even femoral neck fractures [2]




  • Compression neuropathies and tendonopathies, for example, carpal tunnel syndrome, De Quervain’s tenosynovitis



  • Leg cramps/deep vein thrombosis



  • The following bed-side clinical tests may be useful in delineating the site of nerve injury:



  • Tinel’s test: Light tapping of the median nerve over carpal tunnel causes pain and tingling sensation radiating to lateral three and a half fingers.



  • Phalen’s test: Hyperflexion of the wrist and holding for about 30 seconds causes numbness over the medial nerve distribution (lateral three and a half fingers).



  • Finkelstein’s test: Flex the thumb and grasp inside a closed fist, and ulna deviate the hand. This stretches the extensor pollicis brevis and abductor pollicis longus tendon, causing sharp pain along the radial side.



  • Faber/Patrick’s test: The affected side knee is flexed to 90 degrees and the foot is rested on the opposite knee. The pelvis is firmly held against the table and the affected side knee is pushed towards the examination table; if this causes pain it is more likely to originate from sacro-iliac joint.




Table 30.1 Common musculoskeletal conditions in pregnancy



































Key implications Key pointers Key diagnostic signs Key actions Key pearls
Low back pain Caused by lumbar lordosis; shift in centre of gravity and ligament laxity Previous low back pain; previous pregnancy conditions causing large abdomen Low posterior pelvic pain, relieved by lying or sitting Early education; early training
Transient osteoporosis (TO) and avascular necrosis of the hip (AVN) Rare conditions; aetiology unknown Hip pain at rest; pain on movement; pain on weight-bearing; sometimes night pain Limited movement of hip; MRI, pelvic ultrasound and radiograph TO – No action required, self-limiting AVN – need early orthopaedic referral
Compression neuro/ tendinopathies


  • Carpal tunnel syndrome (CTS)



  • Dequavain’s tenosynovitis (DT)

Both caused by increased fluid retention

CTS – Pain, numbness tingling


over lateral three and a half fingers


DT – pain on


radial side of hand


CTS – Tinel’s test, Phalen’s test ultrasound DT – tenderness near radial


Styloid; Finkelstein’s test


Mild


conditions do not require any intervention


Identifying the condition, observing the progression and reassurance are important initially



Cauda Equina Syndrome



Key Facts




  • Rare complication; seen 1 in 10 000 pregnancies [3].



  • However, when diagnosed it is an emergency that requires an acute surgical intervention.



  • This is caused by lumbar disc herniation compressing the cauda equina.



Key Implications




  • It is important to differentiate normal back pain from cauda equina syndrome.



  • If not treated early could result in permanent neurological deficit such as incontinence, foot drop.



Key Pointers




  • Pre-existing lumbar disc disease



  • Pregnancy-related changes (see earlier)



  • Increased maternal age [4]



Key Diagnostic Signs




  • Acute onset or progressively increasing back ache



  • Pain spreading down the legs



  • Motor involvement; muscle weakness mainly at L4, L5, S1 roots



  • Lower limb motor weakness (L4, L5, S1)



  • Foot drop



  • Bladder sphincter involvement causing either urinary retention or incontinence



  • Bowel involvement; mainly loss of anal sphincter tone



  • Saddle anaesthesia around the perianal area



Key Actions




  • Once clinical diagnosis is made.



  • If cauda equina is suspected it should be referred to the spinal team urgently (prthopaedic or neurosurgery depending on the hospital), as early surgery gives the best results.



  • In pregnancy clinical features can be easily missed; therefore a high index of suspicion is needed make a diagnosis.



  • Early diagnosis.



  • Early referral.



Management in a Low-Resource Setting


MRI scans can be omitted, as the diagnosis is mainly clinical. However, when surgery is indicated an MRI scan is taken, as it allows localisation of the lesion and act as a road map for the surgeon. If MRI is not available a CT scan is an option. However, it is worth noting that CT exposes the patient to radiation and has a limited value in showing soft tissues.



Key Actions/Management


Lower back pain and lumber disc herniation do not need an acute surgical intervention, as they are self =-limiting and likely to resolve after delivery.



Surgical Options




  • Open surgery: laminectomy, partial hemilaminectomy [4]



  • Microdisectomy



Symphysis Pubis Diastasis



Key Facts




  • Pubic symphysis separation is a recognised complication of pregnancy, with incidence estimates ranging from 1 in 600 to 1 in 3400 among obstetrics patients [5].



  • Most cases are self-limiting and resolve spontaneously during the postpartum period and do not require any acute intervention.



  • Most patients respond to conservative management (Figure 30.1). However, severe disruptions, persistent symptoms and unstable symphysis pubis diastasis will require surgical intervention.





Figure 30.1 Supporting the pelvic girdle in pregnancy.



Key Implications


Symphysis pubis diastasis itself in most cases is self-limiting and does not require surgical intervention. With conservative management most patients recover fully. However, it is important to identify patients who may need surgery, those with the following conditions:




  • Skeletal: associated damage to rest of pelvis ring sacra-iliac joints



  • Soft tissue:




    1. 1. Bladder injuries, bladder herniation [6]



    2. 2. Vaginal injuries (rare)



    3. 3. Rectal injuries (rare)




Key Pointers




  • Instrumentations such as forceps delivery



  • Large head



  • Forceful separation of legs (forced flexion abduction)



  • Prolonged labour and/or rapid descent during second stage [7]



  • This is an under-diagnosed, under-reported condition and without a high index of suspicion can be easily missed [7].



Key Diagnostic Signs




  • Intrapartum history, for example, difficult labour, instrumentation, external cephalic version



  • Postpartum pain around pubis symphysis



  • Urinary incontinence with change of position



  • Pain when walking



  • Gait changes



  • On examination palpable gap between the symphyses

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May 9, 2021 | Posted by in OBSTETRICS | Comments Off on Chapter 30 – Musculoskeletal Considerations in Pregnancy

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