10a - Pregnancy Pelvic Girdle Pain

Question 1

Ovary role

Answer 1

• Main role is egg maturation and
hormonal secretion during a standard
menstrual cycle
– Oestrogen
– Progesterone

Question 2

Uterus role

Answer 2

• Purpose:
– Mechanical protection, nutritional support & waste removal for the developing embryo / fetus.
– Muscular wall creates the contractions necessary to “eject” the fetus at the time of birth.

• Pear-shaped (upside down) muscular organ.
• Normally the size of an adult fist

Question 3

Changes in Pregnancy - Heart

Answer 3

– Increase in size by ~12%

– Cardiac volume increases by ~70-80mls

Question 4

Changes in Pregnancy - BP

Answer 4

– Slight overall decrease
• Systolic decreases slightly
• Diastolic decreases by 10-15mmHg in 2nd trimester
• Therefore common to be 110/70

Question 5

Changes in Pregnancy - cardiac output

Answer 5

Increases by 40%, or as much as 1.5L/min
– Reaches maximum by 20-24/40
– Is very sensitive to chance in mother’s posture / position
• Impingement of inferior vena cava if supine
• Left side-lying produces least impingement

Question 6

Cardiopulmonary Changes in Pregnancy

Answer 6

– Decreased venous tone due to progesterone and ?? oestrogen
\+
– Decreased blood pressure
\+
– Increased pressure / compression of inferior vena cava and common
iliac vein
=
Lower limb oedema from 2nd trimester

Question 7

What occurs during 1st trimester

Answer 7

• 0-12 weeks, baby is called an ‘embryo’
• High risk of miscarriage
• Many women experience morning sickness

Question 8

What occurs during 2nd trimester

Answer 8

• 12-26 weeks, baby now called a ‘foetus’
• Less chance of miscarriage
• Scans: Nuchal Translucency Scan at 12-14/40
General Morphology scan at 18-20/40
• Foetus becomes “viable” from 24/40 (~10% survival)

Question 9

What occurs during 3rd trimester

Answer 9

• Foetus increasingly viable
• At 26-28/40 may have Glucose Tolerance Test for GDM
• At 34-36/40 may have repeat Ultrasound if placenta was low
in uterus at 18-40

Question 10

How common is back pain in pregnant women

Answer 10

• Back Pain affects 48-90% of pregnant women

Question 11

Most common sites of back pain in pregnancy

Answer 11

Pelvis – “Pelvic Girdle Pain”
• Anterior Pelvic Pain – Pubic Symphysis
• Posterior Pelvic Pain – Sacroiliac Joints
– Lumbar Spine – “Low Back Pain”
– Thoracic Spine – “Upper Back Pain”

Question 12

What are the kinds of back pain in pregnancy

Answer 12

Prior onset back pain

New onset back pain (very likely due to pregnancy related changes)

Question 13

Most likely cause of back pain prior to pregnancy and since pregnancy

Answer 13

• Prior to Pregnancy are more likely to be thoraco-lumbar, with the same causal
factor that was causing pain prior to pregnancy
• Since Pregnancy are more likely to have a pelvic component

Question 14

Stability of the pelvis is maintained by 3 main systems

Answer 14

1. Osteoarticularligamentus System “Form Closure”
   • Passive stabilisation as a result of interaction between joint
   surfaces, ligaments, capsule etc
2. Myofascial System: “Force closure”
   • Allows active stabilisation through contraction of muscles
   surrounding the joint
3. Neural Feedback System “Co-ordination of Form & Force Closure”

Question 15

Factors Contributing to Form Closure of SIJ

Answer 15

• Triangular shape of sacrum
• Varying orientation of joint surface at S1,2,3
• Sacrum wedged anteroposteriorly
• Complimentary ridges/grooves in hyaline
cartilage in mature SIJ
• Strong ligamentous attachments

Question 16

Sacroiliac Ligaments

Answer 16

• Sacrotuberous Ligament
• Long Dorsal Ligament
• Interrosseus & Posterior Ligs

Question 17

Force Closure of SIJ

Stabilisation via Muscular activation of:

Answer 17

– erector spinae
– glut max/med,
– latissimus dorsi,
– piriformis
– transversus abdominus
– multifidus
– pelvic floor

Question 18

WHAT CAUSES PELVIC INSTABILITY &

PELVIC PAIN DURING PREGNANCY??

Answer 18

Theory: ??Decreased Form Closure
Hormonal changes Increased laxity of pelvic ligaments in pregnancy (MAYBE relaxin)

1. Increased demand on muscles
2. Increased movement of joint surfaces against one another
3. Possible movement of one component of pelvis out of alignment

Question 19

Aggravating factor PGP pregnancy

Answer 19

assymetric movement - torsioning of joints, eg stairs, rolling in bed

Question 20

Relieves PGP pregnancy

Answer 20

– Pain often improved by
• application of pelvic belt to stabilise pelvis
• Advice aimed at preventing movement at SIJ and PS

Question 21

Pain Map for the SIJ
Sensory distribution of the SIJ grouped into 3
categories:

Answer 21

1. Medial Buttock
2. From Medial Buttock extending to lateral
   buttock and trochanteric area
3. From medial buttock to superior aspect of
   posterolateral thigh
   Nil altered sensation beyond knee (unless piriformis syndrome)

Question 22

Tests for SIJ

Answer 22

Posterior pelvic pain provocation test

Palpation of Long Dorsal Sacroiliac Lig (>5 seconds after hand removed)

Question 23

Test for pumbic symphysis

Answer 23

Palpation

Modified trendelenberg

Question 24

Test for PG instability

Answer 24

Active straight leg raise

Question 25

Prognosis during pregnancy -Old onset Lumbar and mixed pain

Answer 25

Old onset Lumbar and mixed pain tends
to improve or remain constant during a
subsequent pregnancy

Question 26

Prognosis during pregnancy -Pelvic Pain with initial onset during
pregnancy tends to:

Answer 26

– Not spontaneously resolve
during pregnancy
– Gradually increase in intensity
as pregnancy progresses

Question 27

Pelvic pain postpartum

Answer 27

– Be more likely to become chronic the more pelvic joints involved.

– Pubic symphysis pain alone is the least likely to become chronic

Question 28

Prognosis with Assymetric Joint Laxity

Answer 28

– Have a 3-fold higher chance of persistent pelvic pain

– 77% had persistent pelvic pain 8/52 postpartum