n

Feature Article

Orthostetrics: Management of Orthopedic

Conditions in the Pregnant Patient
Leslie J. Matthews, PharmD; David B. McConda, MD; Trapper A. J. Lalli, MD; Scott D. Daffner, MD

abstract
Managing orthopedic conditions in pregnant patients leads to challenges that must
be carefully considered so that the safety of both the mother and the fetus is maintained. Both perioperative and intraoperative considerations must be made based
on physiologic changes during pregnancy, risks of radiation, and recommendations
for monitoring. Operative timing, imaging, and medication selection are also factors that may vary based on trimester and clinical scenario. Pregnancy introduces
unique parameters that can result in undesirable outcomes for both mother and fetus
if not handled appropriately. Ultimately, pregnant patients offer a distinct challenge
to the orthopedic surgeon in that the well-being of 2 patients must be considered in
all aspects of care. In addition, not only does pregnancy affect the management of
orthopedic conditions but the pregnant state also causes physiologic changes that
may actually induce various pathologies. These pregnancy-related orthopedic conditions can interfere with an otherwise healthy pregnancy and should be recognized
as possible complications. Although the management of orthopedic conditions in
pregnancy is often conservative, pregnancy does not necessarily preclude safely
treating pathologies operatively. When surgery is considered, regional anesthesia
provides less overall drug exposure to the fetus and less variability in fetal heart rate.
Intraoperative fluoroscopy can be used when appropriate, with 360 fetal shielding
if possible. Lateral decubitus positioning is ideal to prevent hypotension associated
with compression of the inferior vena cava. [Orthopedics. 2015; 38(10):e874-e880.]

The authors are from West Virginia University School of Medicine (LJM) and the Department of
Orthopaedics (DBM, TAJL, SDD), West Virginia University, Morgantown, West Virginia.
Drs Matthews, McConda, and Lalli have no relevant financial relationships to disclose. Dr Daffner
is on the speakers bureau of DePuy-Synthes and holds stock in Amgen and Pfizer.
Correspondence should be addressed to: David B. McConda, MD, Department of Orthopaedics,
West Virginia University, PO Box 9196, Morgantown, WV 26506 (dmcconda@hsc.wvu.edu).
Received: May 29, 2014; Accepted: February 4, 2015.
doi: 10.3928/01477447-20151002-53

e874

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n Feature Article

he pregnant patient may present

with musculoskeletal aches and
pains, most of which can be managed conservatively. The American College of Obstetricians and Gynecologists
(ACOG) recommends that elective procedures be postponed until after delivery or
at least until the second trimester, when
the risk of spontaneous abortion is lower.
However, the ACOG also recognizes that,
in some cases, surgery cannot be delayed
and is still indicated, regardless of trimester.1 Pregnant patients offer a unique
challenge to the orthopedic surgeon because ultimately there are 2 patients to
consider. Clinical decisions must be made
while keeping the best interests of both
mother and fetus in mind.
The physiologic changes that accompany pregnancy must be considered when
treating pregnant patients with orthopedic
conditions. Some physiologic changes are
even responsible for certain musculoskeletal conditions and symptoms.2 In addition,
recommendations for medication selection
and imaging may also differ from those in
nonpregnant patients.2,3 This review discusses common musculoskeletal changes
associated with pregnancy, the effect of
pregnancy-related physiologic changes on
patient care, and the management of traumatic injuries and nontraumatic orthopedic
conditions in the pregnant patient.

Physiologic Changes of Pregnancy

Normal physiologic changes that occur
during pregnancy can have a significant
effect on patient management. Cardiovascular and renal changes are particularly important because failure to consider
these changes when making treatment
decisions can have life-threatening consequences to both the mother and the fetus.
Fluctuations in heart rate, cardiac output,
and blood flow may result in amplified effects on the fetus and may go unnoticed
if the practitioner is not familiar with the
normal physiology during pregnancy.
When surgery is needed, these changes
also have implications for perioperative

OCTOBER 2015 | Volume 38 Number 10

management and administration of anesthesia.

Circulating blood volume increases
as early as week 6 of gestation and peaks
at approximately week 32, after which it
remains generally constant. During resuscitation, consequentially, it can take up
to 50% more volume to cause changes in
hemodynamic status. In addition to careful
consideration of fluid volume for resuscitation, selection of infusion products is important. When an acute blood transfusion is
required in a pregnant patient whose blood
type is unknown, Rh-negative blood should
be given, along with Rh immunoglobulin,
to prevent a transfusion reaction in the fetus.4
Even before significant plasma volume
expansion occurs, there may be clinically
significant increases in renal blood flow
and the glomerular filtration rate. The
renin-angiotensin system is activated during pregnancy as a result of widespread
vasodilation, causing increases in renal
perfusion and filtration. Consideration of
these changes can affect medication dosing because pharmacokinetic parameters
may also differ. In particular, medications
with a narrow therapeutic window, such
as vancomycin and gentamicin, must be
monitored more closely during pregnancy
because of altered renal clearance and increased volumes of distribution. Additionally, with changes in renal filtration, electrolyte stores are altered during pregnancy,
requiring close monitoring of electrolytes
and fluid status. Serum electrolyte levels
that appear to fall within normal ranges
may actually reflect derangements in true
electrolyte concentrations, putting both the
mother and the fetus at risk.5,6
Respiratory changes also occur during
pregnancy. An increase in oxygen consumption, coupled with a decrease in pulmonary functional residual capacity, can
alter parameters for ventilation. Pregnant
patients have a baseline physiologic decrease in arterial CO2. Therefore, an apparently normal arterial blood gas result may
indicate hypoxia in these patients.4 Oro-

pharyngeal swelling is also often notably

present during the third trimester and can
further complicate airway management.7
Ultimately, in pregnant patients,
hemodynamic and respiratory status should
be monitored very closely, particularly in
the perioperative period, when patients can
become unstable rapidly. A well-organized
team approach that includes the orthopedic
surgeon, obstetrician, and anesthesiologist
is essential for the safe perioperative management of pregnant surgical patients.

Conditions of the Spine

Low back pain is one of the most common symptoms in pregnancy, reported by
nearly half of patients.8 As the uterus expands, the patients center of gravity shifts
anteriorly, applying increased mechanical
stress to the axial skeleton. Increasing lordosis and laxity in the sacroiliac ligaments
contribute to the discomfort, especially in
the lumbar region. Patients with a history
of back pain have a higher prevalence, as
do multiparous women compared with primiparous women. Low back pain can affect women before gestational week 12 and
can interfere with everyday life, making it
a significant source of distress in pregnant
women.8 A study by Stapleton et al9 found
that 61.8% of women reported pregnancyrelated back pain as at least moderately severe and 9% reported complete disability
secondary to the pain. Although in most
cases the pain resolves postpartum and patients have no long-term discomfort, Ostgaard et al8 suggested that many women
who have chronic back pain experienced
their first occurrence during pregnancy.
Management of low back pain in pregnancy should be conservative, with activity
modification and over-the-counter analgesia. Acetaminophen is the recommended
agent in all trimesters because nonsteroidal
anti-inflammatory agents should be avoided in pregnancy.
Although pregnancy does not increase
the risk of herniation, lumbar disk problems in women of childbearing age are
possible and must be considered in women

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increased compared with the general population. Activity modification and simple
analgesia should also be encouraged in
these patients, along with reassurance that
curve progression and delivery are not
problematic. Scoliosis is not necessarily
a contraindication to vaginal delivery, and
the incidence of delivery by cesarean section is no greater in patients with scoliosis
than in patients without it.11
Figure: The patient may be positioned on a wedge
at approximately 15 to unload the vena cava.

with severe low back pain, particularly

those with focal neurologic deficits. The
incidence of lumbar herniated disk in
pregnancy is just 1 in 10,000 patients,
but distinguishing simple low back pain
from disk disruption is essential. Without
intervention, neurologic symptoms can
progress, resulting in long-term discomfort and sensory deficits.10
The only absolute indication for surgical treatment of back pain in pregnancy is cauda equina syndrome. A
complete history, including a history of
saddle anesthesia, bowel incontinence,
and urinary retention, is crucial in pregnant patients because operative management would be deferred otherwise. Surgical treatment of disk herniation may
be considered in patients with severe
neurologic symptoms or disabling pain,
but management should be conservative
whenever possible. Epidural injections
can be used in the second or third trimester.9 Definitive recommendations for
vaginal delivery vs cesarean section in
patients with lumbar disk herniation have
not been established and should be determined on a case-by-case basis.
The increased axial load of the spine
in pregnancy does not worsen curve
progression in women with a history of
scoliosis. In patients with mild to moderate scoliosis, no significant pregnancyassociated changes or complications have
been shown. However, both the incidence
and the severity of general back pain are

e876

Pelvic Pain
Pelvic girdle pain is another condition that is exacerbated by physiologic
changes during pregnancy. Up to 20% of
women have pain at the pubic symphysis
and/or sacroiliac joint at some point during pregnancy.12 Around the tenth week of
gestation, the overall width of the pubic
symphysis increases. In a nonpregnant
woman, the pubic symphysis consists of a
4- to 5-mm separation. In pregnancy, this
space can widen by at least 2 to 3 mm.13
The increased mobility and mechanical
strain in the pelvis can lead to pain and
discomfort for most of a womans pregnancy. Pubic symphysis diastasis is an uncommon but highly painful result of the
altered mechanical stress on the pelvis.
Symptoms include suprapubic pain and
tenderness, with pain occasionally radiating to the legs or back.14 The reported
incidence of isolated pubic symphysis diastasis is highly variable, from 1 in 300
pregnancies to 1 in 30,000 pregnancies.
Bed rest in the lateral decubitus position
with a pelvic brace or girdle for support is
recommended until delivery.15 Although
some case reports have been published of
open reduction and internal fixation in patients with a dramatic increase in gap size,
surgical repair is not routinely recommended except in cases with diastasis of
25 mm or more.16,17 Symphysis widening
does not immediately resolve postpartum
because women can have pelvic girdle
pain well after delivery. Symptoms usually resolve within 6 months of delivery,
when the symphysis reverts to its normal
physiologic width.17

Trauma in Pregnancy and Pelvic

Fractures
Trauma is the primary cause of nonobstetric maternal death. Up to 8% of
pregnancies are affected by trauma, and
motor vehicle crashes and falls are the
most common mechanisms of injury.18
Special consideration of the physiologic
changes that occur in pregnancy is necessary to improve outcomes in a pregnant
trauma patient. Cardiovascular changes
of pregnancy must be taken into account when resuscitating trauma victims,
particularly if surgical intervention is
planned. During pregnancy, cardiac output and blood volume can increase by up
to 50%. The erythrocyte mass does not
increase by the same factor, causing a
state of dilutional anemia. These parameters increase the risk that blood loss will
be masked in trauma patients because
a drastic loss of blood may not result
in predictable changes in mean arterial
pressure.19
Inferior vena cava compression can also
have a drastic effect on a hemodynamically
unstable trauma patient. A gravid uterus can
increase pressure on the inferior vena cava,
especially when the patient is in the supine
position. Reduction in preload caused by
compression of the inferior vena cava can
lead to further hemodynamic instability
and complicate trauma resuscitation. Once
the initial skeletal survey is complete and
spinal cord injury is excluded, the patient
should be positioned to avoid compression
of the inferior vena cava. If possible, the
patient should be placed in the left lateral
decubitus position. A patient who has an
unstable spine injury or other contraindications to left lateral decubitus positioning
may remain supine and tilted approximately 15 with a wedge under the right side
to displace the uterus laterally (Figure). In
the case of a left posterior wall acetabulum
fracture, typically approached from a right
lateral decubitus position, positioning the
patient prone is also an acceptable alternative, with ample padding of the abdomen to
protect the gravid uterus.2

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Ultimately, maternal resuscitation and

stabilization is the priority in the management of pregnant trauma patients.
Pregnant patients should be managed
according to standard Advanced Trauma
Life Support algorithms, and management of fetal status should not precede
maternal care.20 Orthopedic emergencies
should be treated as such, regardless of
pregnancy status. Any patient beyond 20
weeks gestation should have cardiotocographic monitoring. Emergent cesarean
section may be considered in critically
ill trauma patients with life-threatening
injuries after 24 weeks gestation if the
fetus shows nonreassuring heart tones.21
Previous or acute pelvic fractures do
not automatically necessitate delivery
by cesarean section. In many patients
with a history of pelvic fracture, vaginal delivery may still be safe. Although
patient-specific factors must be considered, it is important to inform the patient
that a history of pelvic fracture does not
preclude successful vaginal delivery.22
On the other hand, acute pelvic or acetabular injury during pregnancy can put
both mother and fetus at increased risk
of mortality.23 Management includes bed
rest, traction, and a pelvic sling in most
patients. When indicated, external fixation or open reduction and internal fixation should be performed within 3 weeks
of injury.2
Closed extremity fractures can be managed nonoperatively, or treatment can be
delayed until postpartum when appropriate. Sorbi et al24 reported a 40-year-old
woman with a displaced midshaft tibia
fracture at 36 weeks gestation. The patient
was treated conservatively initially with
a short leg cast and underwent successful
open reduction and internal fixation after
delivery. This case showed that nonoperative modalities can be used effectively
when indicated until the postpartum period.
Frequent monitoring for thromboembolism
and pharmacologic prophylaxis should be
considered in immobilized patients undergoing nonoperative management.

OCTOBER 2015 | Volume 38 Number 10

Table 1

Categorization of Pharmacologic Agents in Pregnancya

Pregnancy Category

Explanation

Adequate studies in pregnant women have been performed and

have not shown fetal risk in any trimester.

Animal studies have not shown a risk to the fetus. Human studies
are insufficient.

Animal studies have shown a risk to the fetus. No human studies

have been performed or there are neither animal nor human
studies.

Human studies have shown risk to the fetus, but the potential
benefits to the pregnant woman may outweigh the risks.

Medication is contraindicated. Studies in animals and humans

show clear evidence of risk to the fetus. The risk of use in pregnant women outweighs the potential benefit.

Data from Lee et al.34

Other Pregnancy-Related
Conditions
Certain other orthopedic conditions
are related to pregnancy and are therefore
important considerations when symptoms
arise in pregnant patients. Carpal tunnel
syndrome is the most common mononeuropathy in pregnant patients and is likely
caused by retained fluid in the carpal tunnel as a result of increased fluid volume
during pregnancy. Nerve hypersensitivity and progesterone hyperemia may also
contribute to the condition. In up to 85%
of cases, symptoms of carpal tunnel syndrome resolve within 2 to 4 weeks after
delivery. Conservative management, with
splinting and simple analgesia, is recommended for most patients during pregnancy. Corticosteroid injections can be
considered for more painful symptoms.
Carpal tunnel release surgery is indicated
only for the most severe cases and can be
performed under local anesthesia with a
tourniquet.25
Meralgia paresthetica is another neuropathy associated with the physiology
of pregnancy. Increased abdominal girth
causes compression of the lateral femoral
cutaneous nerve as it passes beneath the inguinal ligament. Symptoms include burning and tingling pain of the lateral thigh. In

most cases, symptoms resolve after delivery, when the abdomen returns to prepregnancy size and compression of the nerve
is relieved. For persistent or severe cases,
local anesthetic injections or transdermal
lidocaine patches may be considered; they
are pregnancy category B (Table 1).26
Transient osteoporosis of pregnancy is
a multifactorial condition that can present
suddenly during the third trimester and
can cause great discomfort. Patients may
have excruciating pain in the hips, with
increased pain during walking and standing. Patients may also have limited range
of motion at the hip joint. Imaging shows
drastic loss of bone mass, along with bone
marrow edema, most commonly in the
femoral neck, with preserved joint space.
Symptoms may be unilateral or bilateral.27
The etiology of the condition is not clearly described, but defects in fibrinolysis
or vitamin and mineral deficiencies may
increase risk. Compression of the obturator nerve may also contribute to painful
symptoms.28 The recommended treatment
of transient osteoporosis of pregnancy includes bed rest and restriction of mobility
to allow the joints to rest.29 Bisphosphonates and calcitonin sometimes speed recovery, but both are category C drugs and
the risk vs benefit must be considered.30

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Imaging and Radiation Exposure

Table 2

Pregnancy Categories of
Common Medications in
Orthopedics
Therapeutic Class
and Medication

Pregnancy
Category

Analgesics
Acetaminophen

Codeine

Hydrocodone

Hydromorphone

Ibuprofen

C (1st and 2nd

trimesters); D
(3rd trimester)

Ketorolac

C (1st and 2nd

trimesters); D
(3rd trimester)

Morphine

Naproxen

Oxycodone

Antibiotics
Cefazolin

Ceftazidime

Cephalexin

Clindamycin

Daptomycin

Gentamicin

Linezolid

Sulfamethoxazoletrimethoprim

Tetracycline

Tobramycin

Vancomycin

Anticoagulants/antiplatelet agents
Aspirin

Enoxaparin

Fondaparinux

Heparin

Warfarin

Miscellaneous perioperative medications

Docusate

Ondansetron

Promethazine

Senna

e878

When diagnosing orthopedic conditions in pregnant patients, it is important to choose imaging judiciously to
minimize radiation exposure to the fetus. Major organogenesis occurs during
gestational weeks 3 through 8. The central nervous system is the most sensitive
system to ionizing radiation. Because the
risk to the fetus is based on both radiation dose and gestational age, the American College of Radiology (ACR) established guidelines for the management of
pregnant patients. At less than 2 weeks
gestation, the threshold for spontaneous
abortion is exposure of 50 to 100 mGy.
Most diagnostic examinations provide
less than 50 mGy radiation to the uterus.
Plain radiographs of the abdomen or pelvis deliver less than 10 mGy, and computed tomography (CT) scans of the pelvis
deliver approximately 25 mGy. However,
procedures such as fluoroscopy of the
pelvis may exceed the teratogenic threshold. The amount of radiation exposure
from fluoroscopy is highly variable and
depends on the complexity of the procedure as well as the duration of exposure
and the number of images obtained. At
10 to 18 weeks gestation, there may be
an increased risk of spontaneous abortion
or developmental delay with exposure of
greater than 100 mGy. At radiation doses
of 50 to 100 mGy, the effects on a fetus at this gestational age are less clear,
although some risk is likely. After 27
weeks gestation, even radiation exposure
beyond 100 mGy has not been shown to
put a fetus at high risk.3
According to the overall recommendations of the ACR and ACOG, when
possible, ultrasound and magnetic resonance imaging (MRI) are the imaging
techniques of choice because they do not
deliver ionizing radiation to the patient
or fetus. However, as with trauma management, the well-being of the mother is
a priority, and imaging required for lifethreatening injuries should be performed,
regardless of gestational age.31

During surgical procedures, steps

should be taken to minimize radiation exposure to mother and fetus. For example,
the use of a mini-C-arm fluoroscopy unit
for certain extremity fractures can provide
acceptable intraoperative imaging with
less radiation than a full-sized C-arm.32
To further reduce fetal radiation exposure,
careful shielding of the patient, including
all sides of the abdomen and pelvis, is recommended for nonpelvic procedures.33
It can be difficult to shield the fetus in
cases of pelvic fractures. In these cases,
preoperative imaging should be limited
to radiographs or MRI scans to limit radiation exposure. When needed, CT scans
can be modified to limit the slice width
and number of cuts. Intraoperative fluoroscopy should be minimized. Using a
more extensile exposure to adequately
visualize fracture reduction is a way to accomplish this goal. Careful preoperative
planning with templating can also limit
the need for intraoperative C-arm fluoroscopy and thus reduce unnecessary radiation exposure to the mother and fetus.4

Pharmacotherapy and
Anticoagulation
Pregnancy status must also affect medication selection. Typical first-line medications routinely used for orthopedic patients
may not be the safest options during pregnancy. Perioperative antibiotics, such as
first- or second-generation cephalosporins,
are category B agents and are considered
relatively safe in all trimesters. Category C
antibiotics, such as aminoglycosides and
vancomycin, may induce risk to the fetus;
therefore, risk vs benefit must be considered and use should be reserved for cases
when other agents are not acceptable, such
as in patients with methicillin-resistant
Staphylococcus aureus infections.2 Category D agents, such as tetracyclines and
sulfamethoxazole-trimethoprim, should be
avoided if possible because they can put
the fetus at risk (Table 2).35
Pregnancy is a known hypercoagulable
state and, combined with the decreased

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mobility associated with many orthopedic

injuries, anticoagulation is often necessary. As a category X drug, warfarin is
absolutely contraindicated and should
never be used during pregnancy. The drug
readily crosses the placenta and can lead
to fetal hemorrhaging and spontaneous
abortion. Fetuses that survive exposure to
warfarin are often delivered preterm and
frequently have skeletal abnormalities
and developmental disabilities. For these
reasons, unfractionated heparin or low
molecular-weight heparins at prophylactic doses are the recommended agents for
anticoagulation during pregnancy. Compression stockings are also an appropriate
method of mechanical prophylaxis that
can further prevent thrombotic events during pregnancy.2

compensation of the fetus.1 In managing

obstetric patients, it is important to use a
team approach and to establish a plan of
care before surgery.

Anesthesia in the Pregnant

Orthopedic Patient

References

As stated earlier, elective surgical procedures in the pregnant patient should be

postponed until after delivery. There is no
conclusive evidence that the type of anesthesia, regional or general, has an effect on
pregnancy outcome or that either technique
is safer than the other. However, in lowerextremity procedures, regional anesthesia
(spinal or epidural) is associated with lower overall drug exposure and less variability in fetal heart rate. It has the added benefit of providing better postoperative pain
control and mobilization. When general
anesthesia is necessary, patients should be
given prophylaxis against aspiration. This
precautionary measure is especially beneficial in pregnancy because gastric emptying
is slowed. In addition, H2 receptor blockers, such as famotidine and ranitidine, are
pregnancy category B and are safe to use
preoperatively to prevent reflux.7
The ACOG recommends intraoperative fetal monitoring of all viable fetuses
whenever possible. Additional recommendations include having an obstetrician
available and obtaining patient consent
for emergency cesarean delivery before
nonobstetric surgery in case of acute de-

OCTOBER 2015 | Volume 38 Number 10

Conclusion
Many nonemergent orthopedic conditions can be managed conservatively in
pregnant patients, and delaying surgical
treatment until after delivery is often a
safe option. In some cases, however, when
intervention is necessary, the orthopedic
surgeon must consider the physiologic
changes that accompany pregnancy and
the potential risks to the fetus. Surgical
positioning, medication administration,
and diagnostic imaging are crucial considerations to ensure the best outcomes for
both mother and child.

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