1
|
Yiangou A, Weaver SRC, Thaller M, Mitchell JL, Lyons HS, Tsermoulas G, Mollan SP, Lucas SJE, Sinclair AJ. The Impact of Valsalva Manoeuvres and Exercise on Intracranial Pressure and Cerebrovascular Dynamics in Idiopathic Intracranial Hypertension. Neuroophthalmology 2023; 48:122-133. [PMID: 38487358 PMCID: PMC10936629 DOI: 10.1080/01658107.2023.2281433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/30/2023] [Indexed: 03/17/2024] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a disease characterised by elevated intracranial pressure (ICP). The impact of straining and exercise on ICP regulation is poorly understood yet clinically relevant to IIH patient care. We sought to investigate the impact of Valsalva manoeuvres (VMs) and exercise on ICP and cerebrovascular haemodynamics in IIH. People with IIH were prospectively enrolled and had an intraparenchymal telemetric ICP sensor inserted. Three participants (age [mean ± standard deviation]: 40.3 ± 13.9 years) underwent continuous real-time ICP monitoring coupled with cerebrovascular haemodynamic assessments during VMs and moderate exercise. Participants had IIH with supine ICP measuring 15.3 ± 8.7 mmHg (20.8 ± 11.8 cm cerebrospinal fluid (CSF)) and sitting ICP measuring -4.2 ± 7.9 mmHg (-5.7 ± 10.7 cmCSF). During phase I of a VM ICP increased by 29.4 ± 13.5 mmHg (40.0 ± 18.4 cmCSF) but returned to baseline within 16 seconds from VM onset. The pattern of ICP changes during the VM phases was associated to that of changes in blood pressure, the middle cerebral artery blood velocity and prefrontal cortex haemodynamics. Exercise led to minimal effects on ICP. In conclusion, VM-induced changes in ICP were coupled to cerebrovascular haemodynamics and showed no sustained impact on ICP. Exercise did not lead to prolonged elevation of ICP. Those with IIH experiencing VMs (for example, during exercise and labour) may be reassured at the brief nature of the changes. Future research must look to corroborate the findings in a larger IIH cohort.
Collapse
Affiliation(s)
- Andreas Yiangou
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Samuel R. C. Weaver
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- Centre for Human Brain Health, University of Birmingham, Birmingham, UK
| | - Mark Thaller
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James L. Mitchell
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Academic Department of Military Rehabilitation, Defense Medical Rehabilitation Centre, Stanford Hall, UK
| | - Hannah S. Lyons
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Georgios Tsermoulas
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P. Mollan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Samuel J. E. Lucas
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- Centre for Human Brain Health, University of Birmingham, Birmingham, UK
| | - Alexandra J. Sinclair
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
2
|
LoMauro A, Aliverti A. Respiratory physiology in pregnancy and assessment of pulmonary function. Best Pract Res Clin Obstet Gynaecol 2022; 85:3-16. [PMID: 35868980 DOI: 10.1016/j.bpobgyn.2022.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/18/2022] [Accepted: 05/31/2022] [Indexed: 12/14/2022]
Abstract
A progressive chest wall adaptation occurs during pregnancy driven by the hormones and the expanding uterus. The effect of the former is more prevalent in the first weeks of pregnancy, while the latter is more evident in the last trimester. The combination of the hormonal-induced joint loosening together with the progressively enlarging uterus produces changes in the whole chest wall geometry, with the thoracic alterations being the most fundamental. The ribcage changes in size, but not in volume, secondary to an upward bucket handle shift centred in the xiphoidal process so that the lung is not restricted. A virtuous cycle of stretching and muscle conditioning seems to be established between the enlarging uterus, the diaphragm, and the abdominal muscles to prepare these muscles for the expulsive phase. From the respiratory point of view, the supine position seems to hinder the action of the abdominal muscles during forced expiration at the end of pregnancy.
Collapse
Affiliation(s)
- Antonella LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy.
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| |
Collapse
|
3
|
LoMauro A, Aliverti A, Frykholm P, Alberico D, Persico N, Boschetti G, DeBellis M, Briganti F, Nosotti M, Righi I. Adaptation of lung, chest wall, and respiratory muscles during pregnancy: preparing for birth. J Appl Physiol (1985) 2019; 127:1640-1650. [PMID: 31697596 DOI: 10.1152/japplphysiol.00035.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
A plethora of physiological and biochemical changes occur during normal pregnancy. The changes in the respiratory system have not been as well elucidated, in part because radioimaging is usually avoided during pregnancy. We aimed to use several noninvasive methods to characterize the adaptation of the respiratory system during the full course of pregnancy in preparation for childbirth. Eighteen otherwise healthy women (32.3 ± 2.8 yr) were recruited during early pregnancy. Spirometry, optoelectronic plethysmography, and ultrasonography were used to study changes in chest wall geometry, breathing pattern, lung and thoraco-abdominal volume variations, and diaphragmatic thickness in the first, second, and third trimesters. A group of nonpregnant women were used as control subjects. During the course of pregnancy, we observed a reorganization of rib cage geometry, in shape but not in volume. Despite the growing uterus, there was no lung restriction (forced vital capacity: 101 ± 15% predicted), but we did observe reduced rib cage expansion. Breathing frequency and diaphragmatic contribution to tidal volume and inspiratory capacity increased. Diaphragm thickness was maintained (1st trimester: 2.7 ± 0.8 mm, 3rd trimester: 2.5 ± 0.9 mm; P = 0.187), possibly indicating a conditioning effect to compensate for the effects of the growing uterus. We conclude that pregnancy preserved lung volumes, abdominal muscles, and the diaphragm at the expense of rib cage muscles.NEW & NOTEWORTHY Noninvasive analysis of the kinematics of the chest wall and the diaphragm during resting conditions in pregnant women revealed significant changes in the pattern of thoracoabdominal breathing across the trimesters. That is, concomitant with the progressive changes of chest wall shape, the diaphragm increased its contribution to both spontaneous and maximal breathing, maintaining its thickness despite its lengthening due to the growing uterus. These results suggest that during pregnancy the diaphragm is conditioned to optimize its active role provided during parturition.
Collapse
Affiliation(s)
- Antonella LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy.,Section of Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Peter Frykholm
- Section of Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniela Alberico
- Department of Obstetrics and Gynecology "L. Mangiagalli," Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Nicola Persico
- Department of Obstetrics and Gynecology "L. Mangiagalli," Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Giulia Boschetti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Michela DeBellis
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Federica Briganti
- Pneumology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Ilaria Righi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| |
Collapse
|
4
|
Elvander C, Ahlberg M, Thies-Lagergren L, Cnattingius S, Stephansson O. Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births. BMC Pregnancy Childbirth 2015; 15:252. [PMID: 26453177 PMCID: PMC4600206 DOI: 10.1186/s12884-015-0689-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 10/05/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The association between birth position and obstetric anal sphincter injury (OASIS) in spontaneous vaginal deliveries is unclear. METHODS The study was based on the Stockholm-Gotland Obstetric Database (Sweden) from Jan 1(st) 2008 to Oct 22(nd) 2014 and included 113 279 singleton spontaneous vaginal births with no episiotomy. We studied risk of OASIS with respect to the following birth positions: a) sitting, b) lithotomy, c) lateral, d) standing on knees, e) birth seat, f) supine, g) squatting, h) standing and i) all fours. All analyses were stratified for parity. General linear models were used to calculate risk ratios (RR) adjusted for maternal, pregnancy and fetal characteristics. RESULTS The rates of OASIS among nulliparous women, parous women and women undergoing vaginal birth after a caesarean (VBAC) were 5.7%, 1.3% and 10.6%, respectively. The rates varied by birth position: from 3.7 to 7.1% in nulliparous women, 0.6% to 2.6% in parous women and 5.6% to 18.2% in women undergoing VBAC. Regardless of parity, the lowest rates were found among women giving birth in standing position and the highest rates among women birthing in the lithotomy position. Compared with sitting position, the lithotomy position involved an increased risk of OASIS among nulliparous (adjusted RR 1.17, 95% CI 1.06-1.29) and parous women (adjusted RR 1.66, 95% CI 1.35-2.05). Birth seat and squatting position involved an increased risk of OASIS among parous women (adjusted RR [95% CI] 1.36 [1.03-1.80] and 2.16 [1.15-4.07], respectively). Independent risk factors for OASIS were maternal age, head circumference ≥35 cm, birth weight ≥4000 g, length of gestation ≥ 40 weeks, prolonged second stage of labour, non-occiput anterior presentation and oxytocin augmentation. CONCLUSIONS Compared with sitting position, lateral position has a slightly protective effect in nulliparous women whilst an increased risk is noted among women in the lithotomy position, irrespective of parity. Squatting and birth seat position involve an increase in risk among parous women.
Collapse
Affiliation(s)
- Charlotte Elvander
- Department of Medicine, Division of Clinical Epidemiology, T2, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Mia Ahlberg
- Department of Medicine, Division of Clinical Epidemiology, T2, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Li Thies-Lagergren
- The Department of Health Sciences, Faculty of Medicine, Lund University, Box 117, 221 00, Lund, Sweden.
| | - Sven Cnattingius
- Department of Medicine, Division of Clinical Epidemiology, T2, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Olof Stephansson
- Department of Medicine, Division of Clinical Epidemiology, T2, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| |
Collapse
|
5
|
Jansen L, Gibson M, Bowles BC, Leach J. First do no harm: interventions during childbirth. J Perinat Educ 2013; 22:83-92. [PMID: 24421601 PMCID: PMC3647734 DOI: 10.1891/1058-1243.22.2.83] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Although medical and technological advances in maternity care have drastically reduced maternal and infant mortality, these interventions have become commonplace if not routine. Used appropriately, they can be life-saving procedures. Routine use, without valid indications, can transform childbirth from a normal physiologic process and family life event into a medical or surgical procedure. Every intervention presents the possibility of untoward effects and additional risks that engender the need for more interventions with their own inherent risks. Unintended consequences to intrapartum interventions make it imperative that nurse educators work with other professionals to promote natural childbirth processes and advocate for policies that focus on ensuring informed consent and alternative choices. Interdisciplinary collaboration can ensure that intrapartum caregivers "first do no harm."
Collapse
|