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ORTHOPEDIC PROBLEMS DURING PREGNANCYBY MAGDY ABDELRAHMAN
MOHAMED2015
Trauma.Pregnancy-related pelvic girdle pain.Carpal tunnel
Syndrome.Plantar Fasciitis.
TRAUMA
Trauma is most common non-obstetric cause of maternal
death.Incidence5-10% of pregnancies ( minor & not seen in
hospital)0.2% of all pregnant women ( major)
Types:Motor car accidentFallsAssault
Pregnant women need to wear seat belts properly:
One strap under uterus, the other between breasts.
Many women dont wear them for fear of hurting the baby.
Improper placement can injure fetus.
Most maternal deaths are due to head trauma or hemorrhagic
shock.Fetal deaths usually due to maternal death or due to
placental abruption.
Obstetric complications of traumaTrauma appears to affect the
fetus only in the short-term.Abruption.Pre-term labor.Ruptured
membrane.Uterine rupture.Direct fetal injury (usually penetrating
trauma).Rare: amniotic fluid embolus.
Fetal heart rate monitoring (for hypoxia) after traumaWorry is
abruption.Usually combined with contraction monitoring. 4 hours is
routine.>4 hours if:Abruption suspectedFrequent uterine
activityRupture of membranesFHR abnormalities presentMother is in
critical condition
Predisposing factors to DIC / ARDS after trauma in
pregnancy:Abruption.Dead fetus.ShockSepsisAmniotic fluid embolus
(rare).
Trauma management in pregnancy
Best way to take care of baby is to take care of mother.Common
worries: radiation, drugs, abruption, anesthesia.
Diagnostic radiology in pregnancyShould be done for critical
diagnosesShield uterus when possible.Consult the radiologist for
minimizing exposure.An exposure less than 5 rad is not associated
with increased fetal anomalies or pregnancy loss.
Chest x ray gives 0.02 to 0.07 rad.CT of abdomen & pelvis
gives 2.5-3.2 rad.MRI has no harmful effects. Gadolinium contrast
is associated with IUGR & congenital anomalies in animal
testing.
Hematologic changes at term:Blood volume increased by
45%Pregnant woman may tolerate hemorrhage better than non-pregnant
woman, before showing fall in BP.Increase in coagulation factors,
immobilization and aorto-caval compression . Increase risk of
DVT
Avoid aorto-caval compression: useleft uterine displacement
(LUD)
LUD helps venous return as a part of resuscitation?LUD decreases
chance of DVT.LUD increases O2 delivery to fetus.
Perimortem Cesarean Delivery
To be considered only if:No response to advanced cardiac life
support. Presence of fetal heart rate. Gestational age >24 weeks
gestation.
Delivery of fetus optimize outcome of mother and fetus: By
providing fluid bolus. Decrease IVC compression.
PREGNANCY-RELATED PELVIC GIRDLE PAIN (PGP)
Pain localised at the pelvic girdle during and after pregnancy
has been identified and recorded as an entity since the 4th century
BC by Hippocrates.
Other terminologypelvic joint arthropathy, relaxation,
insufficiency or instability.pelvic pain, and/or low-back pain or
pelvic joint pain.posterior pelvic pain, osteitis pubis or
symphyseal pelvic dysfunction.
DefinitionPain is experienced between the posterior iliac crest
and the gluteal fold, particularly in the area of the SIJ. The pain
may radiate in the posterior thigh and can also occur in
conjunction with/or separately in the symphysis.The endurance
capacity for standing, walking, and sitting is diminished.The
diagnosis of PGP can be reached after exclusion of lumbar
causes.
Aetiology
Uncertain.Multifactorial.Effect of relaxin &
progesterone.
Risk factors
Strenuous work.Prev. history of low back pain.Prev. trauma to
bony pelvis.
PresentationPain (stabbing, dull, shooting, burning) located at
the general area of pelvic girdle, either posteriorly close to the
sacroiliac joints and extending to the gluteal area or anteriorly
to the area of the symphysis pubis.It may radiate to the groin,
perineum or posterior thigh, lacking a typical nerve root
distribution. A precise localisation of the pain is often
impossible and may also change during the course of the
pregnancy.
InvestigationsRadiologicalMRI preferredTherapeutic testlocal
anaesthetic injections to the sacroiliac or symphysis pubis
joint.
TreatmentBed rest.pelvic tilt
exercises.Acupunctures.NSAID.guided injections of local anesthetics
with corticosteroids.
Radiofrequency denervation of the pain receptors of the
sacroiliac joints or transcutaneous electrical nerve
stimulation.Pelvic fusion surgery. ( last option)
CARPAL TUNNEL SYNDROME
Common in pregnancyWt gain & oedema can compress the median
nerve.Pain & numbness or tingling in the thumb, index finger,
middle finger, and radial side of the ring finger on the palmar
aspect.
It occurs frequently in primigravida over age of 30 during 3rd
trimester & usually resolves within 2 weeks after delivery.
Anatomy of the Carpal Tunnel
FCRFPL
FDS ----- FDP
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Non-operative Treatment
Splinting (nocturnal, neutral).Oral agentsNSAIDs, Vitamin B6
(?), Gabapentin.Steroid injection.
PLANTAR FASCIITIS
Plantar fasciitis is inflammation of the thick tissue on the
bottom of the foot which connects the heel bone to the toes and
creates the arch of the foot. More common in pregnant women.
TreatmentRest.Paracetamol & NSAID.Night splints .Apply ice
to the painful area.
