MSK

Question 1

Discuss pelvic girdle pain
-Definition
-Incidence
-Clinical features (4)
-Aetiology (4)
-Risk factors (5)

Answer 1

1. Definition
   -Pain in the pelvic girdle commonly affecting the sacroilliac joints or the symphsis pubis
2. Incidence
   -1:5 pregnant women
3. Clinical features
   -Onset 14-20 weeks
   -Pain in pelvic area with radiation to thighs, lower back, groin and knees
   -Pain worse with movement and resolves with rest
   -Grinding or clicking sensation on movement
4. Aetiology
   -Relaxin and progesterone increase ligamentous laxitiy and pelvic instability
   -Shift from maternal centre of gravity with compensatory lumbar lordosis
   -Genetics
   -Previous pelvic trauma
5. Risk factors
   -Previous back or pelvic pain
   -History of back or pelvic trauma
   -Multiparity
   -High BMI
   -Physically demanding job

Question 2

Discuss the diagnosis of pelvic girdle pain
-Role of imaging
-Pain provocation tests (5)

Answer 2

1. Diagnosis is based mainly of history
2. Imaging with MRI of the pelvis adds nothing unless other causes for pain are suspected
3. Pain provocation tests include
   -Patrick’s flexion - hip flexed and external rotation
   Menell’s test - straight leg with 30 abduction and pushing and pull leg away from pelvis
   -Posterior pain pelvic provocation test - flex hip and knee and apply force along axis of femur
   -Palpate SP and if pain continues = positive
   -Modified Trendelenburg test - stand on one leg with hip and knee flexed
   -Straight leg raise - give idea of degree of disability associated with pelvic girdle pain

Question 3

How should pelvic girdle pain be managed (11 points)

Answer 3

1. MDT with PT, MW, Obstetrician
2. Review for red flags and consider imaging +/- ref to ortho
3. Manage pain
   -Simple analgesia - paracetamol +/- codeine
   -Heat or ice packs
   -Rest +/- LMWH or TEDS
4. Advice about movement/modification of activties
5. Pelvic girdle support braces
6. Hydrotherapy
7. Exercises to increase gluteal, adductor abdo and pelvic muscles
8. Walking frames or crutches may be required
9. Reassurance
10. No contra-indication to vaginal birth but consider positioning and avoid over abduction of hips
11. IOL or CS not indicated for PGP

Question 4

What is the prognosis of pelvic girdle pain (3)

Answer 4

1. Resolution varies from instantly to months
2. 95% of women have resolution by 3 months
3. Recurrence of symptoms in subsequent pregnancies 65-85%

Question 5

Discuss scoliosis in pregnancy
-Effect of scoliosis on pregnancy (3)
-Effect of pregnancy on scoliosis (5)
-Management (4)

Answer 5

1. Effect of scoliosis on pregnancy
   -Increased pelvic girdle pain
   -IUGR
   -PTD
2. Effect of pregnancy on scoliosis
   -In untreated scoliosis 1-2 pregnancies do not increase curve progression
   -If unstable curvature can worsen in pregnancy
   -Worsening of cardiorespiratory function
   -Maternal mortality and morbidity are directly linked to level of respiratory compromise
   -Worsening of breathlessness
3. Management - MDT based
   -Ref for anaesthetic review
   -Ref for respiratory function
   -Ref for cardiac function
   -Aim for vaginal delivery. CS only for obstetric grounds