Management of pelvic injuries in pregnancy

Obstetricians are likely to elect for cesarean section in women with retained pelvic implants: a radiographic survey study

PURPOSE

Women with a history of pelvic fracture undergo cesarean section (CS) at a higher rate than the general population. The purpose of our study is to query obstetricians on their preferences.

METHODS

An electronic survey consisting of 22 radiographs of patients who underwent pelvic fixation was sent to obstetricians at 3 academic medical centers. For each radiograph, a hypothetical scenario was given, and the respondents were asked if they would elect for a vaginal delivery or CS.

RESULTS

We collected 58 responses. The overall CS rate was 59%. Respondents were significantly more likely to elect for CS with trans-symphyseal fixation or sacroiliac fixation, independently (p < 0.001).

DISCUSSION

Obstetricians are likely to elect for elective CS in the presence of pelvic implants especially in patients with trans-symphyseal and sacroiliac fixation. Based on there is an opportunity for collaboration between orthopedic trauma surgeons and obstetricians.

Suprapatellar intramedullary nailing of tibial shaft fractures in pregnancy. A report of two cases

Background

Treatment of closed tibial shaft fractures in the 3^rd trimester of pregnancy is controversial. Since there are few case reports published in literature, there is no consensus on the appropriate management of these fractures. This case report proposes intramedullary nailing throught the suprapatellar approach for the treatment of tibial shaft fracture in pregnant women, never described before in literature.

Case presentation

We report 2 cases of a tibial diaphyseal fracture treated by intramedullary nailing in women at the 3^rd trimester of pregnancy.

Conclusion

Surgical treatment of tibial shaft fracture of pregnant women in the 3^rd trimester of pregnancy with intramedullary nailing seems to be safe. The use of the specific suprapatellar approach helps in the intra-operative management of the pregnant patients.

Musculoskeletal Considerations for Exercise and Sport: Before, During, and After Pregnancy

There is little written in the orthopaedic literature regarding common musculoskeletal problems that women encounter in relation to pregnancy and their clinical and surgical management. Exercise and other physical activity are generally recommended for most women before, during, and after pregnancy. Unfortunately, a variety of musculoskeletal issues may keep women from starting, continuing, or resuming a healthy exercise regimen throughout a notable portion of their reproductive years. Untreated and undertreated orthopaedic conditions in female athletes may therefore have further unintended negative effects on maternal and fetal health. This article reviews the existing literature on musculoskeletal health considerations before, during, and after pregnancy to provide practical information to orthopaedic surgeons who treat women of all ages and athletic abilities.

Maxillofacial trauma in a pregnant patient: Contemporary management principles with a case report & review of literature

Trauma during pregnancy deserves special attention because of its management objectives, i.e. well-being of both pregnant woman and foetus. Maxillofacial trauma directly affects the nutrition of foetus by interfering with the normal functions in a pregnant woman such as mouth opening, mastication and breathing. Hence early restitution of form and function of maxillofacial skeleton is essential. However, the gravid status is associated with numerous anatomical and physiological changes which present with clinical dilemma related to imaging and treatment. A careful scrutiny of the patient's systemic and gestational status is absolutely essential before, during and after instituting any interventional procedures. We present a case of bilateral condyle fracture in a 30-year-old pregnant woman in the third trimester (32 weeks). She was treated with inter maxillary fixation using orthodontic brackets & elastics. After successful restitution of occlusion, the patient was advised aggressive physiotherapy which ensured normal mouth opening. Two weeks later, the patient delivered uneventfully. The patient was followed up at one month and 3 month and demonstrated restitution of normal occlusion, mouth opening and lower facial height. This article aims at analyzing the contemporary principles in management of maxillofacial trauma in a pregnant woman and clarifying the common misconceptions.

Lateral Compression-I Pelvic Ring Injury: Not Benign to the Developing Fetus

OBJECTIVE

To determine whether certain patterns of pelvic ring injury are associated with more frequent intrauterine fetal demise (IUFD).

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Of 44 pregnant patients with pelvic and/or acetabular fractures, 40 had complete records that allowed determination of fetal viability. χ2 tests were used for categorical variables (Fisher exact tests when expected cell counts were fewer than 5), and t tests were used for continuous variables.

MAIN OUTCOME MEASUREMENTS

Fetal or maternal death.

RESULTS

Sixteen patients had isolated acetabular fractures, 25 had isolated pelvic ring injuries, and 3 had acetabular fractures with concomitant pelvic ring injuries. Maternal and fetal mortality were 2% and 40%, respectively. No patients with isolated acetabular fractures experienced IUFD, compared with 68% (15/22) of those with isolated pelvic ring injuries (P < 0.0001). Eight (53%) of 15 IUFDs were associated with lateral compression (LC)-I pelvic ring injuries (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 61-B2). Of the 13 LC-I pelvic ring injuries, 8 (62%) resulted in IUFD. Pelvic ring stability, Young-Burgess classification, and operative treatment were not associated with IUFD. Maternal Glasgow Coma Scale (average 13.2) and Injury Severity Score (average 18.2) at admission were predictive of IUFD.

CONCLUSIONS

The most frequent pelvic fractures in gravid trauma patients are LC-I. Although the rate of maternal mortality was low, the risk of IUFD was quite high (40%). LC-I pelvic ring injuries often had catastrophic outcomes, with IUFD in 62% of cases.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Musculoskeletal Approach to Pelvic Pain

Visceral and somatic causes of pelvic pain are often inter-related, and a musculoskeletal examination should always be considered for the successful diagnosis and treatment of pelvic pain. For the diverse etiologies of hip pain, there are many unique considerations for the diagnosis and treatment of these various disorders. Pelvic pain is often multidimensional due to the overlap between lumbo-hip-pelvic diagnoses and may require a multidisciplinary approach to evaluation and management.

Treatment of Pregnant Patients With Orthopaedic Trauma

Fracture management in pregnant patients is challenging. Anatomic and physiologic changes in pregnancy increase the complexity of treatment. Maternal trauma increases the risk of fetal loss, preterm birth, placental abruption, cesarean delivery, and maternal death. Initial resuscitation and treatment in a facility equipped to handle the orthopaedic injury and preterm births are paramount. Pelvic and acetabular injuries are potentially life threatening. The benefits and risks of surgical treatment must be carefully considered. The risks posed by anesthetic agents, antibiotic agents, anticoagulant agents, and radiation exposure must be understood. Positioning of the patient can affect the viability of the fetus. If surgery is necessary, the left lateral decubitus position decreases fetal hypotension. A specialized team including an obstetrician, perinatologist, orthopaedic surgeon, general trauma surgeon, critical care specialist, emergency medicine specialist, anesthesiologist, radiologist, and nurse must collaborate to improve maternal and fetal outcomes.

Pelvic trauma: WSES classification and guidelines

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

Definitive use of external fixation for pelvic ring injuries (open book/APC2) in pregnancy

Pelvic fractures in pregnancy are rare, resulting in a paucity of evidence-based management. We describe a case of open book pelvic injury in a 32-year-old woman in her third trimester of pregnancy. She was successfully managed with a supra-acetabular external fixator, which allowed the safe delivery of a healthy baby boy at 34 weeks, via caesarean section. The external fixator was removed postpartum, when the pelvis was deemed stable, and mother and baby both continue to do well. This is the only case in the literature that demonstrates the successful use of external fixation for pelvic injuries in pregnancy.

Orthostetrics: Management of Orthopedic Conditions in the Pregnant Patient

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.

Low Back Pain and Pelvic Girdle Pain in Pregnancy

Pregnancy has a profound effect on the human body, particularly the musculoskeletal system. Hormonal changes cause ligamentous joint laxity, weight gain, and a shift in the center of gravity that leads to lumbar spine hyperlordosis and anterior tilting of the pelvis. In addition, vascular changes may lead to compromised metabolic supply in the low back. The most common musculoskeletal complaints in pregnancy are low back pain and/or pelvic girdle pain. They can be diagnosed and differentiated from each other by history taking, clinical examination, provocative test maneuvers, and imaging. Management ranges from conservative and pharmacologic measures to surgical treatment. Depending on the situation, and given the unique challenges pregnancy places on the human body and the special consideration that must be given to the fetus, an orthopaedic surgeon and the obstetrician may have to develop a plan of care together regarding labor and delivery or when surgical interventions are indicated.