Management of women with pregnancy-related pelvic girdle pain: an international Delphi study

Management of childbearing with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders: A scoping review and expert co-creation of evidence-based clinical guidelines

OBJECTIVE

To co-create expert guidelines for the management of pregnancy, birth, and postpartum recovery in the context of hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD).

DESIGN

Scoping Review and Expert Co-creation.

SETTING

United Kingdom, United States of America, Canada, France, Sweden, Luxembourg, Germany, Italy, and the Netherlands.

SAMPLE

Co-creators (n = 15) included expertise from patients and clinicians from the International Consortium on the Ehlers-Danlos syndromes and Hypermobility Spectrum Disorders, facilitated by the Ehlers-Danlos Society.

METHODS

A scoping review using Embase, Medline, the Cochrane Central Register of Controlled Trials and CINHAL was conducted from May 2022 to September 2023. Articles were included if they reported primary research findings in relation to childbearing with hEDS/HSD, including case reports. No language limitations were placed on our search, and our team had the ability to translate and screen articles retrieved in English, French, Spanish, Italian, Russian, Swedish, Norwegian, Dutch, Danish, German, and Portuguese. The Mixed Methods Appraisal Tool was used to assess bias and quality appraise articles selected. The co-creation of guidelines was based on descriptive evidence synthesis along with practical and clinical experience supported by patient and public involvement activities.

RESULTS

Primary research studies (n = 14) and case studies (n = 21) including a total of 1,260,317 participants informed the co-creation of guidelines in four overarching categories: 1) Preconceptual: conception and screening, 2) Antenatal: risk assessment, management of miscarriage and termination of pregnancy, gastrointestinal issues and mobility, 3) Intrapartum: risk assessment, birth choices (mode of birth and intended place of birth), mobility in labor and anesthesia, and 4) Postpartum: wound healing, pelvic health, care of the newborn and infant feeding. Guidelines were also included in relation to pain management, mental health, nutrition and the common co-morbidities of postural orthostatic tachycardia syndrome, other forms of dysautonomia, and mast cell diseases.

CONCLUSIONS

There is limited high quality evidence available. Individualized strategies are proposed for the management of childbearing people with hEDS/HSD throughout pregnancy, birth, and the postpartum period. A multidisciplinary approach is advised to address frequently seen issues in this population such as tissue fragility, joint hypermobility, and pain, as well as common comorbidities, including dysautonomia and mast cell diseases.

Knowledge Mapping Analysis of Research on Pregnancy-Related Pelvic Girdle Pain (PPGP) from 2002 to 2022 Using Bibliometrics

Background

Pregnancy-related Pelvic Girdle Pain (PPGP) is a prevalent condition characterized by various physiological and pathological processes in the female body. The objective of this study is to offer a comprehensive understanding of the current research landscape, key areas of interest, and potential future directions in the field of PPGP.

Methods

Using Web of Science, we explored PPGP literature from 2002 to 2022. VOSviewer and CiteSpace facilitated a quantitative analysis, revealing co-authorship patterns, co-occurring themes, citations, and co-citations.

Results

We identified, peaking at 99 publications in 2021. The United States led with 138 publications and the highest citation count (3160). The Karolinska Institute boasted the highest tally of publications (n = 21). Regarding the volume of publications, the esteemed journal of BMC Pregnancy and Childbirth attained the foremost position. Notably, Gutke, Annelie emerged as the most prolific and highly cited author. The analysis of keyword co-occurrence and co-citation clustering unveiled an intricate tapestry of PPGP studies, spanning various domains including risk factors, mechanistic intricacies, diagnostic benchmark, treatment modalities, and far-reaching ramifications on one's quality of life.

Conclusion

Research endeavors exploring PPGP have unveiled an enduring trajectory of growth in contemporary times. The existing body of research primarily focuses on delving into the intricate interplay of epidemiological factors and the profound implications of interventions encompassing physical therapy, exercise protocols, and diverse modes of pain management within the domain of PPGP. Multidisciplinary integration encapsulates a prevailing trajectory of progress within this domain, while the focal point of future inquiries into PPGP may revolve around subjects pertaining to standardized outcome reporting.

The Influence of Physical Activity during Pregnancy on Maternal Pain and Discomfort: A Meta-Analysis

Pregnant women may experience pain and discomfort during pregnancy, especially in areas such as the lower back and pelvic girdle. Pain in pregnancy is associated with poor quality of life, and because it is a common occurrence, pregnant women may be offered several resources to prevent discomforts throughout pregnancy, such as engaging in physical activity. This study was a meta-analysis of randomised controlled trials (prospectively registered in Prospero, registration number: CRD42023451320) aimed to assess the effects of physical activity during pregnancy on maternal pain and discomfort. We analysed 16 randomised clinical trials. The results of these analyses indicate that women who performed physical activity had significantly less intensity of pain (z = <2.69, p = <0.007; SMD = -0.66, 95% CI = -1.13, -0.18, I2 = <91%, Pheterogeneity = <0.001) and a reduction observed in the disability questionnaire (z = <2.37, p = <0.02; SMD = -0.80, 95% CI = -1.47, -0.14, I2 = <91%, Pheterogeneity = <0.001), and overall reduced general pain (z = <3.87, p = <0.001; SMD = -0.56, 95% CI = -0.84, -0.27, I2 = <86%, Pheterogeneity = <0.001) than women who did not practice physical activity during pregnancy. In conclusion, physical activity during pregnancy could effectively help to diminish pain intensity, reduce disability due to pain, and generally reduce pain.

Pregnancy-related low back/pelvic girdle pain: Prevalence, severity, and risk factors in Zhengzhou, China

BACKGROUND

Pregnancy-related low back pain (LBP) and pelvic girdle pain (PGP) significantly affect the quality of life of pregnant women. Understanding their severity and risk factors may help prevent and alleviate such pain and their resulting dysfunction.

OBJECTIVE

This study investigated the prevalence, severity, and biopsychosocial risk factors of pregnancy-related LBP and PGP in Zhengzhou, China.

METHODS

The Numeric Pain Rating Scale (NPRS), Chinese version of the Roland-Morris Disability Questionnaire (RMDQ), and other questionnaires were self-administered by 1020 pregnant women undergoing treatment at a tertiary hospital between July and December 2019. Binary logistic regression was used to identify factors associated with pregnancy-related LBP and/or PGP.

RESULTS

The prevalence of LBP and/or PGP during pregnancy was 63.0%, and most participants (80.4%) had both. The mean NPRS and RMDQ disability scores were 2.44 ± 2.10 and 6.66 ± 4.65, respectively. A higher gestational body mass index, LBP and/or PGP during menstruation, history of pregnancy-related LBP and/or PGP, and constant pressure were significantly associated with pregnancy-related LBP and/or PGP. Subjective support was a protective factor against LBP and/or PGP.

CONCLUSION

The prevalence of LBP and/or PGP was high. The risk factors should be included in routine prenatal care to identify patients at risk of LBP and/or PGP.

Lumbopelvic pain and sick leave during pregnancy: A comparison of Italy and Norway

BACKGROUND

Pregnancy-related lumbopelvic pain is a frequently reported musculoskeletal disorder, but few studies have compared data between countries.

OBJECTIVES

Examine prevalence, severity, and sick leave and explore potential risk factors associated with pregnancy-related lumbopelvic pain in Italian women and compare the results to a similar study in Norway, utilizing the same questionnaire.

DESIGN

Cross-sectional.

METHODS

Italian (n = 481) and Norwegian women (n = 435) were allocated from two public hospitals in Rome (Fatebenefratelli San Giovanni Calibita-Isola Tiberina) and Oslo (Oslo University Hospital), as well as four antenatal clinics in Modena (Italy). The questionnaire was completed between gestation weeks 32 and 36, addressing women's experiences of pregnancy-related lumbopelvic pain and sick leave in current week, and retrospectively for prepregnancy, first and second trimesters.

RESULTS

In Italy and Norway, 39% and 57% of pregnant women reported pregnancy-related lumbopelvic pain, respectively, with 11% and 25% experiencing severe pregnancy-related lumbopelvic pain. Pregnancy-related lumbopelvic pain was associated with sick leave in Norway (p < 0.01), but not in Italy (p = 0.66) at late gestation. In both countries, women with pregnancy-related lumbopelvic pain versus those with no pregnancy-related lumbopelvic pain were more likely to be multiparous (Italy: 40% versus 31%, p = 0.06 and Norway: 53% versus 38%, p < 0.01), and have gestational weight gain above guidelines (Italy: 21% versus 13%, p = 0.02% and Norway: 27% versus 14%, p < 0.01) and previous experience of pregnancy-related lumbopelvic pain (Italy: 15% versus 2%, p < 0.01 and Norway: 31% versus 4%, p < 0.01). Maternal exercise (⩾2 times weekly) was associated with less pregnancy-related lumbopelvic pain (Italy: odds ratio = 0.33, 95% confidence interval = 0.11-1.0, p = 0.05 and Norway: odds ratio = 0.55, 95% confidence interval = 0.29-1.0, p = 0.06).

CONCLUSION

We observed high rates of pregnancy-related lumbopelvic pain in Italy and Norway, with Norwegian women reporting the highest prevalence and severity level. While both countries had similar rates of sick leave in late gestation, an association between pregnancy-related lumbopelvic pain and sick leave was observed among Norwegian women only. Health care providers should be proactive in addressing pregnancy-related lumbopelvic pain through open communication and seeking input from pregnant individuals. However, it is essential to acknowledge that the current evidence on effective treatments remains limited and inconclusive, highlighting the need for further research in this field.

The Association between Postpartum Pelvic Girdle Pain and Pelvic Floor Muscle Function, Diastasis Recti and Psychological Factors-A Matched Case-Control Study

There is uncertainty regarding the association between abdominal morphology, pelvic floor function, and psychological factors in women with postpartum pelvic girdle pain (PGP). The aim of this case-control study was to evaluate the differences between women with and without persistent PGP regarding pelvic floor function, diastasis recti, and psychological factors 6−24 weeks postpartum. Pelvic floor manometry, palpation examination of abdominal muscles, the International Consultation on Incontinence Questionnaire Short Form, The Depression, Anxiety and Stress Scale—21, and the Pain Catastrophizing Scale were used. The PGP group presented with lower vaginal resting pressure (p < 0.001), more tenderness (p = 0.018) and impaired voluntary activation of pelvic floor muscles (p ≤ 0.001). Women with pain also had more distortion on the level of the anterior abdominal wall (p = 0.001) and more severe diastasis recti (p = 0.046) when compared to pain-free controls. Lower vaginal resting pressure was the strongest factor explaining PGP (OR 0.702, 95%CI 0.502−0.981). There were no differences in terms of the pelvic floor strength, endurance, severity of urinary incontinence and reported distress between the groups. Women with PGP 6−24 weeks postpartum differ in pelvic floor and abdominal muscle function from the pain-free controls. Vaginal resting pressure may be an important factor in pelvic girdle pain shortly postpartum. Further studies are needed to see a trend in changes over time.