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The Active Pregnant Female: What your OB/GYN doesn’t tell you November 15, 2014 Monica Rho, MD Director of Women’s Sports Medicine Program Spine & Sports.

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Presentation on theme: "The Active Pregnant Female: What your OB/GYN doesn’t tell you November 15, 2014 Monica Rho, MD Director of Women’s Sports Medicine Program Spine & Sports."— Presentation transcript:

1 The Active Pregnant Female: What your OB/GYN doesn’t tell you November 15, 2014 Monica Rho, MD Director of Women’s Sports Medicine Program Spine & Sports Rehabilitation Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine

2 Disclosures National Institute of Health K12HD (Fellow for the Rehabilitation Medicine Scientist Training Program): –The relationship of joint morphology and neuromuscular control in femoroacetabular impingement of the hip Richard Materson ERF New Investigator Award, Foundation for Physical Medicine and Rehabilitation: –Preferential load-bearing during double-leg squat in cam-type femoroacetabular impingement

3 Objectives Understand the physiologic changes in pregnancy Discuss appropriate exercise criteria for peri-partum women Identify and define the common musculoskeletal problems in pregnant women

4 Physiologic Changes of Pregnancy Cardiovascular: –Cardiac output increased by 30-50% –Systemic vascular resistance decreases: fall in BP Hematology: –Plasma volume increases by 50% –Hypercoaguable state Pulmonary –Increased minute ventilation –Decreased total lung capacity by 5% Gastrointestinal: –Prolonged gastric emptying times –Decreased gastroesophageal sphincter tone –Reflux, nausea, constipation Renal: –Kidneys increase in size and ureters dilate –GFR increases by 50%

5 EXERCISE IN PREGNANCY

6 Exercise in Pregnancy Prevalence of physical activity and exercise in pregnant women ranges from % (Evenson 2004, Walsh 2011, Liu 2011, Domingues 2007) –Vastly varying rates can be culturally driven Motivation to make behavioral changes for the baby – it can leave a long-term positive impact

7 History of Exercise and Pregnancy Initial ACOG recommendations were made in 1985 Endorsed the safety of most aerobic exercise –Advised caution with high-impact activities such as running Included restriction for duration, HR, and temperature –No longer than 15 minutes for strenuous physical activity –HR<140bpm –Core body temperature <100.4º F

8 Current ACOG Guidelines for Exercise in Pregnancy New guidelines addresses exercise during pregnancy and postpartum in 2002 All healthy pregnant women without complications should engage in moderate physical exercises 30 minutes or more per day in the majority or preferable all days of the week Wide range of recreational activities are safe ACSM recommendations for non-pregnant women –30 minutes or more of moderate intensity physical activity on most (preferably all) days of the week –Moderate intensity is defined as activity with 3-5METS (approximately a brisk walk at 3-4mph)

9 Intensity of exercise ACSM recommends 60-90% of maximal heart rate in all individuals Variability in maternal heart rate response make it difficult to monitor exercise intensity by HR alone (Artal 2003) Ratings of perceived exertion have been found to be useful during pregnancy (should be on the 6-20 scale)

10 Duration of Exercise Main concerns –Thermoregulation –Energy balance If exercise is self-paced, in an environment that is controlled, where the core temperature rose less than 1.5ºC over 30 minutes the mother and fetus remained safe (Soultanakis, 1996)

11 Benefits of Exercise during Pregnancy Lower maternal weight gain (Clapp 1990, Hui 2012, Nascimento 2011, Haakstad 2011, Phelan 2011, Barakat 2011) Decreases postpartum weight retention (Phelan 2011) Less obstetric intervention and shorter labor (Clapp 1990) Improvement in low back pain (Kluge 2011) Decreased depression (Robledo-Colonia 2012) Improves level of maternal glucose tolerance (Barakat 2012, DeBarros 2010) Decreases urinary incontinence symptoms (Mason 2010)

12 Contraindications to Exercise Absolute Hemodynamically significant heart disease Restricted lung disease Incompetent cervix/cerclage Multiple gestation at risk for premature labor Persistent 2 nd or 3 rd trimester bleeding Placenta previa after 26 weeks Ruptured membranes Pregnancy induced HTN Relative Severe anemia Unevaluated maternal cardiac arrhythmia Chronic bronchitis Poorly controlled type 1 diabetes Extreme morbid obesity Extreme underweight (BMI<12) History of extremely sedentary life- style Intrauterine growth restriction Poorly controlled HTN, Seizure disorder, thyroid disease Heavy smoker (ACOG Committee, 2002)

13 Stop Exercising Vaginal bleeding Dyspnea before exertion Dizziness Headache Chest pain Muscle weakness Calf pain or swelling Pre-term labor Decreased fetal movement Amniotic fluid leakage

14 MSK Changes of Pregnancy Musculoskeletal: –Growing gravid uterus  Shift of center of gravity anteriorly  20% weight gain increases the force on a joint by as much as 100% (Ritchie 2003) –Musculature  Abdominal and pelvic floor muscles stretched –Endocrine (Blecher 1998, Weiss 1979)  RELAXIN - the major contributor to joint laxity –Soft Tissue Edema (Ritchie 2003)  80% of pregnant women  Last 8 weeks of pregnancy –Bones  Widening of symphysis pubis  Increased mobility of SI joints

15 Low Back Pain and Pregnancy Incidence: 50% (Mantle 1977, Carlson 2003) Approximately 30% of temporarily disabling symptoms (Wang 2004) No consistent relationship with height, weight or weight gain of the mother or baby (Heckman 1994) 30-45% of women report LBP in post-partum period (Wong 2003) –Main risk factors: previous episode of LBP, severe pain early during gestation and inability to reduce weight to pre-pregnancy level (Wong 2003, Wong 2004) Previous physical activity decrease the risk of lumbopelvic pain during pregnancy (Mogren 2005)

16 The Name Game Low back pain Lumbopelvic pain Posterior pelvic pain Pelvic girdle pain Radiculopathy Facet Joint Lasègue, 18 th century Mooney V, Clin Orthop 1976 Fortin J, Am J Orthopedics, 1999 SIJ Lesher JM, Pain Med 2008 Hip Joint

17 Differential Diagnosis of LBP in Pregnancy Discogenic pain –Disc herniations –Annular tears Sacroiliac joint pain Spondylolisthesis/Spondylolysis Z joint-mediated pain Altered biomechanics (Ritchie 2003, Owens 2002, Carlson 2003) –Mechanical strain of muscles due to poor posture –Hyperlordosis Hip pathology Transient Osteoporosis of Pregnancy (TOP) causing sacral insufficiency fracture Vascular compression (Fast 1992) Visceral pain Neoplasm

18 History Onset, duration, frequency, mechanism of injury, relieving and aggravating factors Prior history of LBP Prior pregnancies and history of LBP during those pregnancies Birth history –Nulliparous vs multiparous –Baby weight, height and head circumference –Time of labor –Time of pushing –Vaginal tearing or episiotomy – C-section

19 Red Flags Disabling Pain – pain that limits your patient’s life, work, ability to care for themselves or their family Neurologic symptoms – weakness, numbness or tingling, bladder or bowel loss of control

20 Sacroiliac Joint Dysfunction Pain in the gluteal region Sacral motion in relation to the ilium Ilial motion in relation to the sacrum Lumbar motion in relation to pelvis Hip motion in relation to pelvis Really a lumbo-pelvic-hip problem

21 Making the Diagnosis History and single PE test for SIJ pain has not been validated by SIJ intraarticular injection If you have >3 positive SIJ tests the sensitivity for diagnosis is 93% and specificity is 78% (Laslett 2001) Diagnostic Criteria for SI joint dysfunction –No neurological deficit –No dural tension –No objective testing indicating medical causes –No evidence of lumbar pain –75% relief with intra-articular SIJ injection

22 SIJ Pain In Review Biomechanics are complex Differential crosses multiple joints No gold standard for evaluation or treatment Treatment must be directed at the entire lumbo-pelvic-hip complex

23 Pubic Symphyseal Pain Widening begins during 10 th - 12 th weeks of pregnancy driving by relaxin (Young 1940) Normal antepartum widening < 10mm (Young 1940) Incidence 20-28% (Albert 2002, Mousavi 2007) Osteitis pubis –Bony resorption followed by reossification Pubis symphysis separation –Ususally occurs during labor – especially with epidural –Disc extrusion

24 Inflammatory condition Cumulative overuse of the adductors Pubic symphysis or groin pain that can radiate into the thigh Can cause popping in the pubic region Pain will be produced on resisted adduction Pain with one-legged hopping X-ray and/or CT may show periosteal thickening

25 Transient Osteoporosis of Pregnancy Sudden-onset, self-resolving osteoporosis that is transient Transient osteoporosis is seen in men ages twice as often as in pregnant women Typically 3 rd trimester of pregnancy –Hip, sacrum, knee, foot, ankle, lumbosacral spine, shoulder, elbow, wrist, hand Worse with WB, better with rest Pain out of proportion with exam Limit weight-bearing to avoid pathologic fracture Walker/crutches (Maliha 2012)

26 Imaging in Pregnancy 1997 National Council on Radiation Protection and Measurements evaluated all types of radiation on reproduction Debate over amount of radiation that can cause birth defects High risk to developing fetus with x-ray / CT –X-rays are used - must be after 1st trimester; if benefit outweighs risk Ultrasound poses no fetal harm Non-contrast MRI can be used safely during pregnancy (LaBan 1995)

27 MR Imaging in Pregnancy Used to evaluate severe lumbopelvic pain – stress fractures, disc herniations Gadolinium not recommended b/c of its ability to cross the placental barrier Should be postponed until after the first trimester and limited to cases where diagnostic imaging can be useful (Amin,1999)

28 Diastasis Rectus Abdominus Rectus abdominus muscle separates at the linea alba Palpated while supine and made more apparent with lifting head and shoulders off the table A separation of >2 finger breadths is considered significant  Further disruption of the core This can jeopardize the role of the abdominal wall in posture, trunk stability, mobility May contribute to low back and PGP

29 Summary Exercise is safe for mother and fetus and should be indicated to all pregnant women in the absence of absolute contraindications Exercise in pregnancy is associated with controlling gestational weight gain, gestational diabetes, prevention of urinary incontinence, postpartum depression and low back pain Aerobic and strength training at moderate intensity at least 3 times a week for 30 minutes or more Staying active during pregnancy is possible and will improve overall health and outcomes

30 References Evenson KR, Savitz DA, Huston SL. Lesure-time physical activity among pregnant women in the US. Paediatr Perinat Epidemiol 2004; 18:400–407 Walsh JM, McGowan C, Byrne J, McAuliffe FM. Prevalence of physical activity among healthy pregnant women in Ireland. Int J Gynaecol Obstet 2011; 114:154–155. Liu J, Blair SN, Teng Y, et al. Physical activity during pregnancy in a prospective cohort of British women: results from the Avon longitudinal study of parents and children. Eur J Epidemiol 2011; 26:237–247. Domingues MR, Barros AJD. Leisure-time physical activity during pregnancy in the 2004 Pelotas Birth Cohort Study. Rev Saude Publica 2007; 41:173–180. ACOG Committee. Opinion no. 267: exercise during pregnancy and the postpartum period. Obstet Gynecol 2002;99:171–3. Artal R, O’Tolle M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med 2003; 37:6–12. Soultanakis HN, Artal R, Wiswell RA. Prolonged exercise in pregnancy: glucose homeostasis, ventilatory and cardiovascular responses. Semin Perinatol 1996;20:315–27. Hui A, Back L, Ludwig S, et al. Lifestyle intervention on diet and exercise reduced excessive gestational weight gain in pregnant women under a randomised controlled trial. BJOG 2012; 119:70–77. Nascimento SL, Surita FG, Parpinelli MA, et al. The effect of an antenatal physical exercise programme on maternal/perinatal outcomes and quality of life in overweight and obese pregnant women: a randomized clinical trial. BJOG 2011; 118:1455–1463. Haakstad LA, Bø K. Effect of regular exercise on prevention of excessive weight gain in pregnancy: a randomised controlled trial. Eur J Contracept Reprod Healthcare 2011; 16:116–125. Phelan S, Phipps MG, Abrams B, et al. Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the Fit for Delivery Study. Am J Clin Nutr 2011; 93:772–779. Barakat R, Cordero Y, Coteron J, et al. Exercise during pregnancy improves maternal glucose screen at 24–28 weeks: a randomised controlled trial. Br J Sports Med 2012; 46:656–661. Kluge J, Hall D, Louw Q, et al. Specific exercises to treat pregnancy-related low back pain in a South African population. Int J Gynecol Obstet 2011; 113:187–191.

31 References Robledo-Colonia AF, Sandoval-Restrepo N, Mosquera-Valderrama YF, et al. Aerobic exercise training during pregnancy reduces depressive symptoms in nulliparous women: a randomized clinical trial. J Physiother 2012; 58:9–15. de Barros MC, Lopes MA, Francisco RP, et al. Resistance exercise and glycemic control in women with gestational diabetes mellitus. Am J Obstet Gynecol 2010; 203:556.e1–e6. Mason L, Roe B, Wong H, et al. The role of antenatal pelvic floor muscle exercises in prevention of postpartum stress incontinence: a randomised controlled trial. J Clin Nurs 2010; 19:2777–2786. Ritchie JR: Orthopedic considerations during pregnancy. Clin Obstet Gynecol 2003;46:456–66 Blecher AM, Richmond JC. Transietn laxity of an anterior cruciate ligament-reconstructed knee related to pregnancy. Arthroscopy 1998; 14:77-9 Weiss M, Nagelschmidt M, Struck H. Relaxin and collagen metabolism. Horm Metab Res 1979; 11: Mantle MJ, Greenwood RM, Currey HL: Backache in pregnancy. Rheumatol Rehabil 1977;16:95–101 Carlson HL, Carlson NL, Pasternak BA, et al: Understanding and managing the back pain of pregnancy. Curr Womens Health Rep 2003;3:65–71 Wang SM, Dezinno P, Maranets I, et al: Low back pain during pregnancy: Prevalence, risk factors, and outcomes. Obstet Gynecol 2004;104:65–70 Heckman JD, Sassard R: Current concepts review: Musculoskeletal considerations in pregnancy. J Bone Joint Surg Am 1994;76:1720–30 Wong CA, Scavone BM, Dugan S, et al: Incidence of postpartum lumbosacral spine and lower extremity nerve injuries. Obstet Gynecol 2003;101:279–88 Mogren IM. Previous physical activity decreases the risk of low back pain and pelvic pain during pregnancy. Scand J Public Health 2005;33:300-6 Owens K, Pearson A, Mason G: Symphysis pubis dysfunction: A cause of significant obstetric morbidity. Eur J Obstet Gynecol Reprod Biol 2002;105:143–6

32 References LaBan MM, Rapp NS, von Oeyen P, et al: The lumbar herniated disk of pregnancy: A report of six cases identified by magnetic resonance imaging. Arch Phys Med Rehabil 1995;76:476–9 Young J. Relaxation of the pelvic joints in pregnancy: pelvic arthropathy of pregnancy. J Obstet Gynaecol Br Emp 1940;47:493 Albert HB, Godskesen M, Westergaard JG. Incidence of four syndromes of pregnancy-related plevic joint pain. Spine 2002; 27: Mousavi SJ, Parnianpour M, Vleeming A. Pregnancy related pelvic girdle pain and low back pain in an Iranian population. Spine 2007; 32:E100-4 Stolp-Smith KA, Pascoe MK, Ogburn PL: Carpal tunnel syndrome in pregnancy: Frequency, severity and prognosis. Arch Phys Med Rehabil 1998;79:1285–7 Ekman-Ordeberg G, Salgeback S, Ordeberg G: Carpal tunnel syndrome in pregnancy: A prospective study. Acta Obstet Gynecol Scand 1987;66:233–5 Voitk AJ, Mueller JC, Farlinger DE, et al: Carpal tunnel syndrome in pregnancy. Can Med Assoc J 1983;128:277–81 Wand JS: The natural history of carpal tunnel syndrome in lactation. J R Soc Med 1989;82:349–50 Mens, JM., Vleeming, A. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine. 26(10): , Vleeming, A. et al. Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain. Acta Obstet Gynecol Scand. 81: , Vleeming A, Albert HB, Ostgaard HC, et al : European guidelines for the diagnosis and treatment of pelvic girdle pain, Eur Spine J 17 : 794 – 819, Maliha G, Morgan J, Vrahas M. Transient Osteoporosis of Pregnancy. Injury, Int J Care Injured 43(2012) Vleeming. Spine 1990; 15:

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