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%

• Gastrointestinal:– Prolonged gastric emptying times– Decreased gastroesophageal sphincter tone– Reflux, nausea, constipation

• 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)

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)

Contraindications to Exercise

Absolute• Hemodynamically significant heart

disease• Restricted lung disease• Incompetent cervix/cerclage• Multiple gestation at risk for

premature labor• Persistent 2nd or 3rd 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)

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

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

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)

The Name Game

• Low back pain• Lumbopelvic pain• Posterior pelvic pain• Pelvic girdle pain

RadiculopathyFacet Joint

Lasègue,18th century

Mooney V,Clin Orthop 1976

Fortin J,Am J Orthopedics, 1999

SIJ

Lesher JM, Pain Med 2008

Hip Joint

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

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

with epidural– Disc extrusion

Osteitis Pubis

• 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

Transient Osteoporosis of Pregnancy

• Sudden-onset, self-resolving osteoporosis that is transient• Transient osteoporosis is seen in men ages 40-60 twice as often

as in pregnant women• Typically 3rd 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)

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

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• 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.

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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

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References

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