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
33
Embed
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.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
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
Disclosures
• National Institute of Health K12HD001097-16 (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
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
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%
• Renal:– Kidneys increase in size and ureters dilate – GFR increases by 50%
EXERCISE IN PREGNANCY
Exercise in Pregnancy
• Prevalence of physical activity and exercise in pregnant women ranges from 4.7-48.8% (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
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
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)
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 12-14 on the 6-20 scale)
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)
– 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
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
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
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
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
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
Pubic Symphyseal Pain
• Widening begins during 10th- 12th 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
• Worse with WB, better with rest• Pain out of proportion with exam• Limit weight-bearing to avoid pathologic fracture• Walker/crutches
(Maliha 2012)
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)
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)
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
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
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.
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: 408-10• 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
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;
27:2831-4• 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): 1167-1171, 2001.• Vleeming, A. et al. Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain. Acta Obstet Gynecol
Scand. 81: 430-436, 2002. • 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 , 2008.• Maliha G, Morgan J, Vrahas M. Transient Osteoporosis of Pregnancy. Injury, Int J Care Injured 43(2012) 1237-1241• Vleeming. Spine 1990; 15: 133-135