Orthopedics as It Relates to Pregnancy and the Parturient Charlotte Orr MD† †UNM Department of Orthopaedics and Rehabilitation

Introduction Occurrence of PRPPP in one pregnancy is predictive of future postpartum posterior pelvic . It is treated with a Pregnancy has diverse effects on the musculoskeletal nonelastic sacroiliac or pelvic belt, which is applied properly system, and the effects of orthopedic or trauma if it covers the greater trochanters. on pregnancy merit consideration as well. This article will summarize a variety of conditions in which orthopedics Lumbar Disk Herniation and pregnancy collide. Herniation of a lumbar disk occurs in 1/10,000 pregnant Conditions women. Risk increases with increasing maternal age, not necessarily the state of being pregnant. Average age of the Low Back Pain (LBP) mother was 33 years in a case series of 6 patients reported in 1995. There has been one case report of cauda equina This occurs in 72% of pregnant women, and is defined as syndrome from a disk herniation in a pregnant woman. pain in the lumbar region of the spine, above the . Symptoms include acute onset of radicular pain and The enlarging uterus causes an anterior shift in the center numbness in the lower extremity, positive straight leg raise of gravity, which means the fulcrum of the is further test, leg pain greater than back pain, and hypoactive reflexes. away from the spine, causing strain on the lumbar spine. Treatment is conservative if neurologic symptoms remain LBP is treated with acetaminophen and exercise, especially constant. If muscle relaxers are required, cyclobenzaprine aquatic exercise. is category B for pregnant women. If neurologic deficits are progressive or severe, an MRI is indicated to plan for surgery. Pregnancy Related Posterior Pelvic Pain (PRPPP) In Spine in 2001, a case report of 3 pregnant patients with This occurs in 20% of pregnant women, and is defined as herniated disks who underwent surgery was reported. The patients positioned themselves on the operating table (such pain in the sacroiliac joints of the pelvis and in the buttocks as an OSI table) in order to ensure that their abdomens with or without radiation down the posterior thigh to the were hanging free and that there was no pressure on the knee. Pain occurs with weight bearing, and can also be fetus. Two of the patients had L5-S1 disk herniations with elicited with the posterior pelvic pain provocation test lower extremity radiculopathy and had a neurologic exam (PPPPT). To perform the PPPT, the pregnant patient lies that was back to baseline at 1 year postoperatively. The supine with one lower extremity extended and the other other patient had cauda equina syndrome and still had flexed to 90 degrees at the hip and knee. The examiner diminished sacral sensation at 1 year postoperatively. In exerts a force from anterior to posterior along the femur Archives of Physical Medicine and Rehabilitation, 5 patients of the flexed lower extremity, which should elicit pain in with disk herniations were treated nonoperatively until they the sacroiliac joints similar to what the patient experiences delivered, and then they were treated with laminectomy with weight bearing. PRPPP results more from asymmetry and diskectomy. Two of the five patients had a permanent of SI joint laxity, not simply the degree of laxity. Serum residual drop. The article didn’t specify the trimester of levels of relaxin were thought to be associated with joint disk herniation onset in relation to the patients who had a laxity, but this has become more controversial lately as permanent neurologic deficit. more recent evidence implies that levels of relaxin are not related to joint laxity. Relaxin seems to have more hemodynamic effects such as increased cardiac output and renal blood flow, as well as increased arterial compliance.

18 UNM Orthopaedics Journal 2014 Scoliosis interlaminar space is wider on the convexity of the curve Idiopathic scoliosis is present in 2% of the population. as well. 80% of nonoperatively treated scoliosis patients in a Incidence is 3% for curves measuring 10-20 degrees, and 2009 review article had successful spinal anesthetic; failure 0.3% for curves greater than 30 degrees in magnitude. was due to failed placement, multiple attempts, patchy pain Scoliosis involves a lateral curve of the spine in the coronal relief, asymmetric pain relief, and unilateral blockade. In plane, as well as a rotational abnormality in the axial plane. patients who had undergone posterior spinal fusion, 69% 30% of people with scoliosis will have a family history had a successful spinal anesthetic. Reasons for failure were positive for scoliosis. similar for the nonoperative patients, except there was a An article in JBJS in 1987 discusses scoliosis as it relates to 4% incidence of dural puncture in the operative group. The pregnancy. Group A consisted of 175 patients who became lower success rate in the fused patients was attributed to pregnant one or more times, and Group B consisted of 180 scar tissue and bone graft hindering entrance of the needle, patients who never became pregnant. Both Group A and as well as postoperative adhesions and obliteration of the Group B patients were treated nonoperatively, either with epidural space. However, the article noted that anesthesia observation or bracing. Both groups sustained an average providers incorrectly identify the lumbar interspaces by 2.2 degree progression in their curves, and 2/3 of patients in palpation 71% of the time. Some strategies to overcome both groups had curves that did not progress over time. The unilateral blockade include positioning the patient in braced Group B patients had a decreased risk of >10 degree the lateral decubitus position with the less affected side progression (2%) than braced Group A patients (11%). dependent, or using a high volume low concentration There was no difference in curve progression between solution. As an alternative to standard spinal anesthetic Groups A and B with regards to curve pattern. The highest placement in the lumbar region, a caudal block could be risk of having >10 degree progression of a curve occurred in used. mothers (Group A) who had their first pregnancy after age Carpal Tunnel Syndrome 24 years. There was no difference in the amount of curve progression with one pregnancy versus three pregnancies CTS is a compression or entrapment mononeuropathy in the Group A patients. More severe curves are at greater of the median nerve at the wrist. Its true incidence in risk of progression. For the group of 165 patients who had pregnancy is unknown. It is a clinical diagnosis in 31- undergone posterior spinal fusion, there were 63 patients 62% of pregnant patients, and an electrodiagnostic who became pregnant (Group A) and 42 patients who did diagnosis in 7-43%. In nonpregnant women, the incidence not become pregnant (Group B). In these nonoperative ranges 0.7-9.2%. It is second only to low back pain as a Group A patients, there was no progression of the curve musculoskeletal complaint in pregnancy. It can be related at any pseudoarthroses and no coronal imbalance after to the generalized of pregnancy, as pregnant women pregnancy. 67% of fused Group A patients developed tend to have fluid retention, increased blood volume by back pain during pregnancy compared with 77% of the 30-50%, and progesterone-induced hyperemia. It can nonoperative Group A patients. Two of the 159 deliveries also be associated with altered glucose metabolism, as it in the Group A patients (fused and nonoperative) had is in diabetes, because of the increased metabolic needs unsuccessful spinal anesthesia, one in the fused group and of the mother and fetus. There is a higher risk of CTS in one in the nonoperative group. Two of the 79 deliveries patients with gestational hypertension and preeclampsia, for the fused Group A patients were by caesarean section, and in patients with enough swelling to prevent compared with 10/159 deliveries for the nonoperative wearing of rings. It usually occurs starting in the third Group A patients. None of the caesarean sections were due trimester, but earlier onset can have a more rapid course. to scoliosis; rather, they were for common delivery issues Compared to age-matched female controls, pregnant such as fetal distress and cephalopelvic disproportion. The women have a shorter duration of symptoms, are more rate of caesarean section in this study was 7.4%, which as likely to have bilateral symptoms, exhibit lower severity of less than half the national average at the time of 16%. nerve compression on electrodiagnostic studies, and have Scoliosis also has bearing on the effectiveness of neuraxial 3-4 times higher change of improvement. Diagnosis is by anesthetic, or epidural analgesia. Because of the rotational physical exam, and electrodiagnostic studies are obtained component of scoliosis, the spinous process projects towards if surgery is being considered. Night splints provide relief in the concavity of the curve while the epidural space deviates 82%. Corticosteroid injections may be tried, though they’ve to the convexity of the curve. Consequently, when starting not been studied in pregnant patients, as steroids aid in below the spinous process, anesthesia providers must angle surfactant production in premature babies. Resolution of the needle approximately 35 degrees towards the convexity CTS symptoms is variable in the literature, but about 85% of the curve in order to enter the epidural space. The of patients experience resolution of symptoms within 2-4

Chief Review Article 19 weeks of delivery. Up to 50% of the remaining 15% have vessels, as suggested by a case report from Japan, where residual symptoms 3 years postpartum. the condition resolved within 3 weeks of terminating a pregnancy in one patient. Parathyroid hormone does Femoral Head Osteonecrosis of Pregnancy mobilize calcium from bone, and was previously thought to be high in pregnant women, but the radioimmunoassays This was first described in 1957. It is rare in pregnancy used in those studies measured multiple fragments of PTH, without coexistent risk factors such as corticosteroids, many of which are inactive. Parathyroid hormone levels are trauma/dislocation, or alcohol. There are only about 40 case actually low to normal in all trimesters. TOH presents in reports of femoral head osteonecrosis in pregnancy. The third trimester, and the fetus acquires 80% of its calcium femoral head can be thought of as an “end-organ system” during that time. TOH is usually unilateral. Patients have with regards to perfusion, and is in a confined space. It then pain with weight bearing, walking, and extremes in range sustains a temporary or permanent loss of blood supply, of motion. In the early stages, radiographs are normal, resulting in necrosis. Multiple factors in pregnancy have and MRI is recommended. Ultrasound would only show been proposed: higher levels of estrogen and progesterone hip effusion, a bone density scan involves radiation, and can lead to fat embolism, there is an increasing amount of labs such as Vitamin D and alkaline phosphatase are not unbound plasma cortisol in the third trimester, pregnancy helpful. Labs could be used to rule out infection. MRI will is a hypercoagulable state, there is some venous congestion show diminished signal on T1 sequences over a diffuse area in pregnancy, and there is mechanical stress from the (as opposed to a focal lesion for osteonecrosis) and high weight gain during pregnancy. Osteonecrosis of the femoral intensity signal on T2 sequences (as opposed to moderately head in pregnancy occurs in the late second trimester or increased signal only in the subchondral region for third trimester. Groin or buttock pain is worse with weight osteonecrosis). Bisphosphonates may be used for treatment bearing and walking, though not completely relieved by postpartum, but TOH tends to resolve within 2-4 months rest. Patients will have an antalgic or Trendelenburg gait, postpartum anyway. Protected weight bearing is advised, and some limited internal rotation at the hip. Radiographs and surgery may become necessary if osteoporotic fracture are not helpful in the early stages of the disease, but MRI has occurs. Multiple case reviews of TOH in pregnancy describe 99% sensitivity and specificity. MRI can also differentiate subcapital femoral neck fractures. femoral head osteonecrosis from transient of the femoral head. Treatment is surgical. In a metaanalysis of Pregnancy Outcomes after Pelvic Ring Injury 819 nonpregnant patients with early stage osteonecrosis of the femoral head, observation with limited weight bearing An article out of Journal of Orthopaedic Trauma in 2012 led to treatment failure with femoral head collapse by 3 described delivery outcomes for 31 women who became pregnant one or more times after pelvic ring injury. 55% years in 80% of those patients. There was a case report in were treated surgically for their injuries. 16 patients had 1988 of 2 pregnant patients who developed osteonecrosis of spontaneous vaginal deliveries, 3 of which had retained the femoral head 4 weeks before delivery, treated with hip transsymphyseal plating. 13 patients underwent caesarean joint aspiration and limited weight bearing, with resolution section, 46% of which had retained implants. 2 of the 13 of symptoms in 2 months and normal radiographs after patients had a pre-injury caesarean section, 4 patients several months. This would contribute to the theory of experienced preeclampsia, breech, or arrest of labor, 3 increased pressure causing osteonecrosis. Bisphosphonates patients elected caesarean section, and 4 were advised by have been proposed to prevent collapse of the femoral head their obstetric physician to have a caesarean section. In total, after osteonecrosis, but are not FDA approved for necrosis the rate of caesarean section was 44% post-injury, and over of the femoral head in pregnancy and they are category C half of these were due to patient or physician preference. for pregnant patients. Surgical options are the same as for 1 of the 4 patients advised to have a caesarean section by nonpregnant patients, and are typically delayed until after her OB had 1.8cm of narrowing of the pelvic ring due to a delivery. lateral compression injury, but 3 of the patients who had an SVD had pelvic ring narrowing of 1.2-2.2cm. Transient Osteoporosis of the Hip in Pregnancy Pregnancy Outcomes after Orthopedic Trauma: In The TOH of pregnancy was first reported in 1959. It is more Journal of Trauma: Injury, Infection, and Critical Care in common than femoral head osteonecrosis of pregnancy, 2010, a retrospective review of pregnant patients presenting with 500 case reports. TOH also affects men aged 40-60 to a Level 1 trauma center over 12 years was analyzed. They years. Etiology is uncertain. It is a localized phenomenon, compared patients with orthopedic injuries (65 patients) to so metabolic, hematologic, and systemic causes are unlikely. patients with nonorthopedic injuries (990 patients). Motor It is possible that the fetus impinges on local nerves or blood vehicle collisions and falls were 80% of the mechanisms

20 UNM Orthopaedics Journal 2014 of injury in both groups. Orthopedic injuries included Pubic Symphysis Diastasis fractures, complex hand injuries such as tendon lacerations, This occurs in 1/2,000 to 1/30,000 pregnant patients during and soft tissue injuries extending down to bone. Patients delivery. As opposed to high energy trauma, the force with orthopedic injuries were more likely to have an injury (baby’s head) is applied from posterior to the symphysis. severity score of greater than or equal to 17 (12%) compared 40% of pelvic stability comes from the symphysis, where a to patients with nonorthopedic injuries (0%). 34% of patients tensile force is applied with weight bearing. Diastasis can with orthopedic injuries delivered at the time of trauma occur due to multiparity, fetal macrosomia, precipitous admission, compared to 13% of patients with nonorthopedic labor, cephalopelvic disproportion, and hyperabduction of injuries. 31% of patients with orthopedic injuries delivered the hips during delivery. When it occurs, there is often a at less than 37 weeks gestation, compared to 3% of patients palpable or audible crack; subsequently, the patient has pain with nonorthopedic injuries. Multiple orthopedic injuries with weight bearing and lifting, and sometimes bladder resulted in 50% of patients having a preterm delivery, dysfunction. Diastasis >2.5cm implies that the anterior whereas a single orthopedic injury resulted in 25% of sacroiliac ligaments have been damaged. Diastasis <4cm patients having a preterm delivery. Adverse pregnancy can be treated with a binder and bedrest. Surgery is required outcomes were similar for patients with operative and with diastasis more than 4cm, typically an external fixator nonoperative orthopedic injuries. The number of surgical acutely with possible internal fixation later. procedures for orthopedic injuries did not affect pregnancy outcomes. Pelvic fractures were associated with fetal death Pelvic Dislocation in 30%, and placental abruption in 30%. In summary, if a patient sustains trauma with enough energy to impart an The incidence of pelvic dislocation is limited to case reports. orthopedic injury, she is at much higher risk of having It is defined by pubic symphysis diastasis >6cm combined adverse outcomes for her pregnancy compared to a patient with sacroiliac joint disruption. Pelvic dislocation can with nonorthopedic injuries. result in sacral fractures, lumbosacral plexus injury, and Consequently, pregnant women require much closer even death. In the Journal of Trauma in 1997, a case series attention after injury. Pregnant women have a dilutional of 4 patients was reported. Pelvic dislocation was diagnosed anemia at baseline, with an increase in plasma volume by in the peripartum period in 3 patients and at 25 months 50% and a lesser increase in amount of red blood cells. With postpartum in the 4th patient. All patients were in the 30% blood volume loss, the mother’s mean arterial pressure lithotomy position with epidural analgesia. The average can remain unchanged, but the blood flow to the placenta weight of the babies was 8.8 pounds. ¾ had hyperabduction is already decreased 10-20%. Fetal monitoring is required and flexion of the hips during delivery. For ¾, it was the at more than 20 weeks gestation as fetal distress may be first attempt at a vaginal delivery. The average pubic the first indicator of maternal hemodynamic compromise. symphysis diastasis recorded was 6.4cm. One patient If the mother is stable, ultrasound can be used to evaluate required exploratory laparotomy and transfusion of 10 fetal motion, fetal heart rate, and placental integrity. Avoid units of blood. All patients were treated nonoperatively placing the mother supine, as this can cause hypotension with closed reduction, a binder, and lying in the lateral due to compression of the great vessels; 15 degrees of left decubitus position until they were able to walk. One patient lateral decubitus is enough. If radiographs are required, the had pressure necrosis over her hips from the binder, the maximum radiation dose allowed is 5 rads. For example, an patient diagnosed at 25 months had a permanent lumbar AP pelvis is 0.040 rads but a CT of the abdomen is 2.6 rads. neuropraxia, and the patient who underwent exploratory The fetal central nervous system is relatively radioresistant laparotomy had a unilateral femoral neuropraxia. All after 25 weeks. If surgery is required for orthopedic injuries, patients had permanent residual sacroiliac joint discomfort open plating techniques are recommended versus more with sclerosis on radiographs, plus a residual pubic percutaneous techniques that utilize more fluoroscopy. symphysis diastasis of 1.7cm. Again, surgery is typically Local anesthetics are not teratogenic, but general anesthetics indicated for diastasis >4cm. have the potential to increase the risks of spontaneous abortion, low birth weight, and premature delivery. Fracture Additionally, pregnant women are more hypercoagulable There are case reports of coccyx fracture sustained during than nonpregnant patients, so lovenox is recommended if delivery. It most often occurs with delivery on a hard surface, they are immobilized. which limits the normal 2.5cm posterior excursion of the coccyx that occurs with delivery in order to increase the anterior to posterior diameter of the birth canal. The patient

Chief Review Article 21 will note pain and crepitus with sitting, pain with bowel a patient who developed anterior compartment syndrome movements, pain with hip extension, and tension myalgias after “difficult labor” in the lithotomy position for only 45 of the pelvic floor. Diagnosis is typically by palpation, minutes. as lateral radiographs of the sacrum can be difficult to Pregnancy and after Total Hip Arthroplasty interpret and an MRI would not change the treatment plan. Treatment is with analgesics and having the patient sit on More than 5000 total hip arthroplasties are performed a doughnut-shaped cushion. It is important to distinguish in women less than age 45 years every year. Reasons for a coccyx fracture from sacroiliac joint injury, as SI joint this include developmental hip dysplasia, osteonecrosis injury can cause pain to be referred to the pelvic floor. of the femoral head such as Legg Calve Perthes, juvenile inflammatory arthritis, and trauma such as hip dislocation. Sacral Stress Fracture In an article in JBJS in 2005, the Mayo clinic analyzed 47 women ages 18-45 years old who underwent total hip There are 11 case reports of postpartum sacral stress arthroplasty prior to pregnancy and delivery. During fracture. It is unclear whether it is a stress fracture due pregnancy, 60% of the patients had pain in the replaced to fatigue, where normal bone fractures under abnormal hip, but 57% of those patients actually had pain in both stress, or whether the stress fracture is due to osteoporosis, hips. 36% of the patients had a caesarean section: 2 which can be associated with pregnancy. Risk factors patients because of OB preference, 1 patient because of include excessive load caused by the weight gain and the Orthopedist’s preference, 1 patient due to fetal breech lumbar hyperlordosis, jogging before or soon after delivery, positioning, 3 patients due to hypertension or preeclampsia, vaginal delivery of a large infant, and precipitous delivery. 7 patients due to delay or arrest of labor, and 3 patients for Patients can experience radicular pain with these sacral unknown reasons. 64% of the 47 patients had spontaneous stress fractures. The FABER (hip flexion, abduction, vaginal deliveries. There was no difference in rate of SVD external rotation) test can be positive, and patients will versus caesarean between patients with unilateral or have a negative straight leg raise test with no neurologic bilateral hip arthroplasties. There were no instances of deficits, hopefully differentiating the radicular pain from prosthesis dislocation, loosening, or fracture during SVD. a herniated disk. Radiographs are difficult to interpret due With persistent groin pain after delivery, the orthopedist to overlying bowel, so a CT scan performed postpartum is should evaluate for acetabular loosening. 5 of 7 patients advised for diagnosis. MRI is an alternative to CT scan, the with persistent groin pain postpartum were revised 5 years gold standard. Treatment is with protected weight bearing later; 3 patients had a loose acetabular component, 1 patient until symptoms resolve. had only fibrous ingrowth onto the acetabular cup, and 1 patient had a loose acetabular component with catastrophic Compartment Syndrome of the Leg polyethylene wear and osteolysis. Age at the time of total Reports are rare in the obstetric literature, and most instances hip arthroplasty, not the occurrence of childbirth, is the of this are actually described in the urology literature. most important risk factor for requiring revision of the Incidence is 1/3,500 for procedures in the lithotomy arthroplasty. However, there was a 1.7 times higher risk for position. Multiple factors relating to the lithotomy position requiring arthroplasty revision after childbirth. can predispose to developing compartment syndrome of Pelvic Osteotomy and Childbirth the leg: there is decreased hydrostatic perfusion pressure of the leg, there is a reduced arteriovenous gradient, hip and 10/1,000 children are born with hip dysplasia; 1/1,000 knee flexion impedes arterial flow and venous return, the have a dislocated hip. Hip dysplasia is more common in weight of the limb in the stirrups, and forced dorsiflexion females (80% of babies with developmental hip dysplasia). of the foot. Additionally, patients can become hypotensive, In some instances, this disorder requires corrective pelvic are sometimes administered vasoconstricting drugs, and osteotomy. Pelvic osteotomy can alter the dimensions can sustain a reperfusion injury after release from the of the bony pelvis. The most important pelvic diameter lithotomy position. Compartment syndrome is a clinical is the “midpelvis” measurement; on the lateral, this is diagnosis established by the patient’s pain: pain out of measured from the inferior aspect of the pubic symphysis proportion, pain not responsive to pain medications, and to the sacrum. On an AP view of the pelvis, the midpelvis pain with passive stretch. Additionally, the examiner can dimension is measured from ischial spine to ischial spine. often palpate tense, swollen compartments. If the patient Ideally, the patient has a minimum midpelvis measurement is obtunded, measure the pressures in the compartments. of 9.5cm, as the average biparietal diameter of the fetus is Treatment is fasciotomies of all compartments of the leg. 9.3cm. The mothers will have lower midpelvis dimensions There was a case report in Orthopedics in 2007 regarding if they were older at the time of pelvic osteotomy, due to the

22 UNM Orthopaedics Journal 2014 decreased time for remodeling. Patients should be offered • Fingeroth RJ. Successful operative treatment of a displaced a trial of labor with spontaneous vaginal delivery, but they subcapital fracture of the hip in transient osteoporosis need to discuss their history of pelvic osteotomy with their of pregnancy A case report and review of the literature. J obstetrician. Bone Joint Surg Am. 1995 Jan;77(1):127-31. PubMed PMID: 7822345. Hip Arthrodesis • Flik K, Kloen P, Toro JB, Urmey W, Nijhuis JG, Helfet There is one article in the orthopedic literature regarding DL. Orthopaedic trauma in the pregnant patient. J Am hip fusion and its effect on conception and childbirth. 5 Acad Orthop Surg. 2006 Mar;14(3):175-82. PubMed PMID: patients had previous hip arthrodesis; they all described 16520368. difficulty with abducting the hips during intercourse. 2 of • Hagen R. Pelvic girdle relaxation from an orthopaedic the 5 patients conceived, and both of these patients had 2 point of view. Acta Orthop Scand. 1974;45(4):550-63. spontaneous vaginal deliveries each without complication. PubMed PMID: 4451061. Achilles Tendinopathy • Kaushal R, Bhanot A, Luthra S, Gupta PN, Sharma RB. Intrapartum coccygeal fracture, a cause for postpartum The Achilles reflex is typically delayed in the same coccydynia: a case report. J Surg Orthop Adv. 2005 patients when they are pregnant compared to when they Fall;14(3):136-7. PubMed PMID: 16216182. are nonpregnant; this may be related to altered thyroid activity during pregnancy. There is a case report of Achilles • Kharrazi FD, Rodgers WB, Kennedy JG, Lhowe DW. tendinopathy improving during pregnancy in one patient, Parturition-induced pelvic dislocation: a report of four likely due to immune or hormonal factors. The higher cases. J Orthop Trauma. 1997 May;11(4):277-81; discussion levels of cortisol in pregnancy are immunosuppressive. 281-2. PubMed PMID: 9258826. Estrogen and progesterone can shift the immune system • Kirkos JM, Papavasiliou KA, Kyrkos MJ, Sayegh FE, towards production of anti-inflammatory cytokines such Kapetanos GA. The long-term effects of hip fusion on the as interleukins 4 and 10. chorionic gonadotropin is adjacent joints. Acta Orthop Belg. 2008 Dec;74(6):779-87. also anti-inflammatory and immunosuppressive. PubMed PMID: 19205325. Bibliography • Ko JY, Leffert LR. Clinical implications of neuraxial anesthesia in the parturient with scoliosis. Anesth Analg. • Bayar A, Keser S, Hosnuter M, Tanriverdi HA, Ege A. 2009 Dec;109(6):1930-4. PubMed PMID: 19923523. Lower limb compartment syndrome after an uncomplicated labor. Orthopedics. 2007 Nov;30(11):972-3. PubMed PMID: • Kovacs CS, Kronenberg HM. Maternal-fetal calcium 18019995. and bone metabolism during pregnancy, puerperium, and lactation. Endocr Rev. 1997 Dec;18(6):832-72. PubMed • Betz RR, Bunnell WP, Lambrecht-Mulier E, MacEwen PMID: 9408745. GD. Scoliosis and pregnancy. J Bone Joint Surg Am. 1987 Jan;69(1):90-6. PubMed PMID: 2948962. • Loder RT. The long-term effect of pelvic osteotomy on birth canal size. Arch Orthop Trauma Surg. 2002 Feb;122(1):29-34. • Brown MD, Levi AD. Surgery for lumbar disc herniation PubMed PMID: 11995877. during pregnancy. Spine (Phila Pa 1976). 2001 Feb 15;26(4):440-3. PubMed PMID: 11224893. • Maliha G, Morgan J, Vrahas M. Transient osteoporosis of pregnancy. Injury. 2012 Aug;43(8):1237-41. PubMed PMID: • Cannada LK, Pan P, Casey BM, McIntire DD, Shafi S, 22464203. Leveno KJ. Pregnancy outcomes after orthopedic trauma. J Trauma. 2010 Sep;69(3):694-8; discussion 698. PubMed • Mumtaz FH, Chew H, Gelister JS. Lower limb PMID: 20838141. compartment syndrome associated with the lithotomy position: concepts and perspectives for the urologist. BJU • Chang JL, Wu V. External fixation of pubic symphysis Int. 2002 Nov;90(8):792-9. PubMed PMID: 12406113. diastasis from postpartum trauma. Orthopedics. 2008 May;31(5):493. PubMed PMID: 19292310. • Myllynen P, Mäkelä A, Kontula K. Aseptic necrosis of the femoral head during pregnancy. Obstet Gynecol. 1988 • Dunivan GC, Hickman AM, Connolly A. Severe Mar;71(3 Pt 2):495-8. PubMed PMID: 3347443. separation of the pubic symphysis and prompt orthopedic surgical intervention. Obstet Gynecol. 2009 Aug;114(2 Pt • Nuttall FQ, Windschitl HE. Achilles reflex speed during 2):473-5. PubMed PMID: 19622966. pregnancy. Obstet Gynecol. 1971 Jun;37(6):886-91. PubMed PMID: 4143758.

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