General principles

Pregnant females should always consult with their physicians before making any decisions regarding participating in an exercise program. Although this disclaimer is frequently stated, many spine physicians are not well versed in the pregnancy and exercise literature. Women who regularly exercised before pregnancy were found to have a decreased risk of pregnancy-related back pain.⁴ Exercise during pregnancy can have a protective effect and does not appear to be detrimental to the unborn child.¹⁶ Those females who exercise do not have shorter or easier labors but it may enable them to tolerate it better. Exercise may help prevent as well as treat gestational diabetes since the utilization of large muscle groups improves insulin sensitivity.¹⁷

A major concern with exercise is fetal injury, which may potentially occur during the second and third trimester. It is therefore recommended that sports with a high risk of collision and contact sports be avoided. Fetal heart rate may increase during maternal exercise between 10 and 30 beats per minute; however, the clinical significance is unknown. Tachycardia may be due to hypoxia; however, blood flow to the uterus during exercise is maximal at its attachment to the placenta, thereby minimizing any potential hypoxic effects.¹⁸ There is a small decrease in the average birth weight of babies born to women who exercised intensively during pregnancy, yet there are no reported cases of adverse outcome in pregnancy. No cases of premature labor due to maternal exercise have been reported. Hyperthermia is also a concern since it has been shown to possibly cause neural tube defects in animals, though not in humans. Since the neural tube closes approximately 25 days after conception, hyperthermia should be avoided in pregnant females during the first few weeks of pregnancy. Since only minimal increases in core temperatures occur with moderate levels of exercise under normal environmental conditions, this level of activity should be safe in the pregnant female.¹⁹

Risks to the pregnant woman include an increase in musculoskeletal injuries such as low back pain and hypotension, which can occur as a result of lying in the supine position or with prolonged standing. Contraindications for exercise in pregnant females are as listed in Table 124.1.

Table 124.1 Contraindications to exercise in pregnant females

Adapted from American College of Obstetricians and Gynecologists committee opinion, Exercise During Pregnancy and the Postpartum Period.²⁰

If the pregnant woman was exercising before pregnancy, barring any pregnancy-related abnormalities or complications, she can safely continue without increasing complication risks to the unborn fetus. There is, however, a tendency for the mother to gain less weight and deliver smaller babies than sedentary women.²¹ She should be prepared to modify the intensity and duration of her regimen if she experiences severe discomfort and as the pregnancy progresses, usually around the sixth month. Sedentary pregnant women should not initiate high-intensity exercise programs, yet moderate exercise should be encouraged. As pregnancy progresses into the third trimester the adverse effects of supine exercises need to be taken into consideration.²² The Sports Medicine Australia position statement indicates that moderate exercise for pregnant females is safe. It also indicates that studies have shown that it may be possible for trained athletes to exercise at a higher level than is recommended by the American College of Obstetricians and Gynecologist. No adverse effects have been seen with resistance training with moderate weights and submaximal isometric contractions in pregnant women.²³

There are general guidelines published by the American College of Obstetricians and Gynecologists and the American College of Sports Medicine for exercise in pregnancy.^20,24 Some highlights are listed below:

Prevention of back pain

Patients who regularly exercised before pregnancy are less likely to develop low back pain during pregnancy.¹⁶ In a study by Mantle et al.,³ there was no evidence linking backache during pregnancy with height, weight, obesity index, weight gain, or the baby’s weight. There were differences, however, between LBP in pregnancy and ‘mechanical’ LBP in the nonpregnant patient. This finding is consistent with Kristiansson.²⁸ Pregnant patients attending antenatal physical therapy had slightly less LBP reported, but no clear evidence of a protective effect was established. Smoking, however, has been shown not only to be detrimental to fetal growth, but in the nonpregnant population it has been correlated with disc herniation and the severity of low back pain.²⁹ Weight and weight gain were not associated with LBP in pregnancy. Focusing on weight loss or minimizing weight gain is not likely to be beneficial at preventing or treating back pain.^3,30 A prospective study has shown that the functional pattern of back extensors is related and can predict future back pain, including in pregnancy. Dysfunction in the relaxation of the lumbar extensors was directly related to current and future pain levels, and back muscle activity level was inversely related to disability.³⁰

Strength and resistance training

According to the American College of Sports Medicine’s guidelines, an exercise program for pregnant females is somewhat unique in that stretching is recommended only to relieve muscle soreness and not to lengthen muscle because of concern with overstretching connective tissue.²⁴ Relaxin is a polypeptide hormone secreted by the corpora lutea of mammalian species during pregnancy. It is thought to facilitate the birth process by remodeling pelvic connective tissue via softening and lengthening of the pubic symphysis and cervix during pregnancy. Kristiannson et al. noted that there was an increase in serum relaxin levels that occurred, with peak value at the twelfth week followed by decline until the seventeenth week. Thereafter, it remained stable around 50% of peak value. By 3 months postpartum, serum relaxin was no longer detectable. They noted that there was a strong correlation between mean serum relaxin levels during pregnancy and symphyseal or low back pain during late pregnancy by medical history or pain provocation tests. Although this information is very interesting, it is currently not only impossible to determine the exact role of relaxin, but it is currently unalterable.³¹

Chan et al. found that soft tissue laxity may be more important as a cause of low back pain than disc prolapse or bulge in pregnancy.³² Before the hazards of radiation to the unborn fetus were known, earlier anatomical studies showed an increase in amount of articular fluid within the sacroiliac joint. This was thought to decrease friction and increase stability of the SI joints.^33–35 In 2001, Damen et al. found that SI joint laxity was not associated with pregnancy-related pelvic pain since laxity was found in all pregnant women. The patients who experienced symptoms of PPP had an asymmetric laxity of the SI joints.³⁶ Treatment recommendations including a nonelastic sacroiliac joint belt,^4,37 as well as strengthening the muscles that stabilize the SI joint,³⁸ are discussed in more detail below.

Kristiansson et al. found that a provocative examination may be more useful than history and range of motion testing in identifying back pain in pregnancy. Since low back pain in pregnancy seems to have several pain generators because of the involvement of numerous ligaments forming a functional unit, this may have therapeutic implications.²⁸ Mens et al. showed less LBP and pelvic pain following cesarean section. Other risks with a positive correlation for LBP and PPP include: twin pregnancy, first pregnancy, higher maternal age, and larger weight of the baby, forceps or vacuum extraction, and fundus expression, prolapse, and flexed position of woman during childbirth. They hypothesized that peripartum pelvic pain is caused by strain of ligaments in the pelvis and lower lumbar spine due to combination of new or previous ligamentous injury, hormonal effects, muscle weakness, and weight of the fetus. Of all the predisposing factors, only muscle weakness and parturition position can be adequately addressed.³⁹

Franklin and Conner-Kerr took measurements in 12 pregnant females in the first and third trimesters and showed that there was a significant increase in low back pain and hyperlordotic posture; however, there was no correlation between magnitude of change in posture and low back pain. There was no conclusive evidence that postural changes leads to increased LBP. It may call into question the appropriateness for posture-correcting exercises in pregnancy.⁴⁰ In a study by Foti et al., a gait analysis was done on 15 pregnant women whose gait remained relatively unchanged throughout pregnancy, with no evidence of the ‘waddling gait.’ The maximum anterior pelvic tilt increased a mean of 4 degrees during gait, but there was a wide variability noted in test subjects. Significant increases in hip and ankle gait parameters resulted in increased demands placed on hip abductors, hip extensor, and ankle plantarflexor muscles during pregnancy. Perhaps strengthening these muscle groups should be emphasized. It should be emphasized that this study was not done on pregnant females with low back pain.⁴¹ As well, Ostgaard et al. concluded that biomechanical factors, such as abdominal sagittal diameter, transverse diameter, and depth of lumbar lordosis, could not alone explain back pain in pregnancy.⁴²

When the sacroiliac joint is thought to be the cause of back pain in pregnancy, using an SI joint belt (see below) and addressing the surrounding musculature may be helpful. The strengthening of muscles that create a force that is perpendicular to the SI joint and surrounding muscles, such as the internal and external abdominal obliques, the latissimus dorsi, multifidus (part of the erector spinae) and the gluteus maximus, could stabilize the SI joint via force closure.^43–45 Mens et al. studied persistent pelvic pain after delivery. Although 63.6% of patients noted improvement after 8 weeks of treatment, they found no difference in outcomes between the experimental group and both control groups. Participants in all three groups received an information video describing causes of peripartum pelvic pain, prognosis, and treatments in addition to recommendations on activity modifications and instructions on the use of a pelvic belt. The treatment group received additional nonindividualized training of the external and internal abdominal oblique and gluteus maximus muscles, while one control group was taught strengthening exercises for the rectus abdominus, the longitudinal components of the erector spinae, and the quadratus lumborum. The other control group did no exercises. Twenty-five percent of the treatment group developed increased fatigue and pain when strengthening the hip extensors and had to cease training. The development of pain and the training cessation may have offset any benefit that they might have otherwise appreciated.³⁸

The goal of exercise is not always to strengthen the surrounding musculature around the sacroiliac joint. Mooney et al. found symptomatic patients with SI joint pain had electromyographic evidence of hyperactivity in the ipsilateral gluteus maximus and contralateral latissimus dorsi. When those patients underwent a rotary strengthening exercise program, there was not only improvement in strength and myoelectric activity but also a decrease in pain.⁴³ Vleeming and colleagues reported tension not only in the gluteus maximus but also in the hamstring muscles further decreases the mobility of the SI joint.³⁷

The abdominal muscles are weakened during pregnancy. Fast and colleagues found that 16.6% of pregnant women had difficulty performing a single sit-up whereas all nonpregnant women could do a single sit-up. Although the abdominal muscles become insufficient during pregnancy, there is no statistically significant correlation with abdominal muscle weakness, specifically sit-up performance, and occurrence of LBP.^46,47 In a cross-sectional analysis by Mens et al. performed in patients with posterior pelvic pain after pregnancy (PPPP) it was concluded that hip adduction strength can be used to measure disease severity. The apparent decrease in strength, however, appeared to be caused by the inability to activate the hip muscles rather than by true neurologic weakness.⁴⁸ Therefore, correcting the muscle inhibition would, in theory, decrease PPPP. Another exercise that could potentially decrease back pain is the ‘sitting pelvic tilt exercise.’ In a prospective, randomized, single-blinded study evaluating primigravidas treated during the last trimester, it was found that the ‘sitting pelvic tilt exercise’ could decrease back pain without complications to the mother or unborn child.⁴⁹

Aquatic therapy

Water therapy is used to aid in the treatment of many musculoskeletal disorders. In a prospective, randomized, controlled trial of pregnant women, with 129 patients treated with water gymnastics in the second half of pregnancy and 129 patients in the control group, water gymnastics was found to reduce the intensity of LBP and number of days on sick leave. Back pain invariably increased with pregnancy, but there was no excess risk of LBP, or urinary or vaginal infections in the water gymnastics group, indicating this method of treatment is safe in pregnancy. The water temperature ranged 32–34°C, and the program consisted of exercises recommended by the Swedish Swimming Society performed 17–20 times (once a week during the second half of the pregnancy). The duration of the class was one hour: 30 minutes of physical training and 30 minutes of relaxation.⁵⁰

Self-directed versus formal physical therapy

Should the patient undergo a formal physical therapy treatment program or simply receive instructions and/or perform exercises on an individual basis? Noren et al. compared the effects of an individual-based education and training program to no treatment in pregnant females who had peripartum pelvic pain. They found that the intervention group had a decrease in sick leave in comparison to the no treatment group.¹² In another study, Mantle et al. noted that when back care advice (as used in low back pain schools) was given to primiparous women as early as possible, patients experienced significantly less ‘troublesome and severe backache’ than the control group, who were not advised.⁵¹ In a randomized trial, Ostgaard et al. evaluated 407 pregnant patients.⁴ Sick leave was reduced in patients who had undergone an individualized program that consisted of back school education and training program, whereas the control group participants did not fair as well.

Summary

Stuge et al. performed a systemic review of prospective, controlled clinical trials assessing the effectiveness of physical therapy interventions for the prevention and treatment of pregnancy-related back and pelvic pain. Three high-quality studies were found. Two showed no difference in pain intensity and functional status between the exercise and control groups. The third study found a significant reduction in sick leave in patients participating in water gymnastics compared to the control group. Strong evidence supporting the effectiveness of physical therapy in preventing and treating pregnancy-related back and pelvic pain is lacking.⁵²

Lumbosacral binder

Maternal weight gain and an enlarging uterus changes the center of gravity for the pregnant woman, causing subtle changes in posture and gait that can lead to muscle fatigue and strain on weight-bearing joints.⁴¹ The use of maternity support binders could offer a safe, low-cost, and accessible comfort measure for the many women affected by back pain during pregnancy. Carr studied the acceptability and effectiveness of a maternity support binder for the relief of LBP in women in the second and third trimesters of pregnancy.⁵⁷ The study included 40 women with self-reported LBP of at least a ‘medium’ level and no history of prior back pain or disc disease. The orthosis used was the Loving Comfort® lumbosacral orthosis, which is a wide belt that supports the low back and lower abdomen. It fastens under the abdomen with hook and loop fastener straps, and an optional narrow, stabilizing belt used across the top of the uterus. The binder is advertised to provide low back support, stabilize the pelvis, and support the lower abdomen. It is approved by the Food and Drug Administration and covered by some insurance companies. Over a 2-week period, the intervention group had significantly fewer days of pain and significantly fewer hours of pain than the control group. Interview data revealed a high level of acceptance of the back support. The woman’s size, weight, or obesity did not affect the fit of the binder, but height appeared to be a challenge. Short women (under 62 inches) and women with short torsos complained that the belt rolled in the back and buckled with sitting. The sample group’s size was small, and more studies need to be performed with randomized and diverse populations. However, the modest price, its ease of fitting, and lack of side effects holds promise for the lumbosacral binder’s use in pregnancy.

Sacroiliac belt

Ostgaard et al. studied the efficacy of nonelastic sacroiliac belts.⁴ The belts were found to reduce PPP during ambulation in a large majority of women studied. Posterior pelvic pain is differentiated from low back pain in its distribution and etiology as defined earlier in the chapter. Most of the 59 women studied wore the belt daily and found that they were able to increase their walking distance. None of the women experienced pain reduction at work or at rest, and visual analog scales were unchanged. Physical fitness alleviates symptomatic patients with low back pain, but has less of a demonstrable beneficial effect for those with PPP. Nonetheless, the use of a low nonelastic SI belt is a cost-effective and safe tool for alleviation of posterior pelvic pain in many women during ambulation. The mechanism of action of the SI belt is still unclear. It may have an effect on muscle forces or muscular insertions on the posterior pelvis. Lowering vertical load transmission to the SI joints is unlikely but not entirely unreasonable.

Pelvic and lumbar belts

Pelvic belts are another type of supportive device that have been studied in pregnant women. They appear to be effective in the treatment of peripartum pelvic pain (PPPP),³⁹ defined as pain in the pelvic region that started during pregnancy or within the first 3 weeks after delivery and for which no clear diagnosis is available to explain the symptoms. PPPP is prominent around the sacroiliac joints and symphysis. There is a striking incidence of increased PPPP during pregnancy which parallels the increase of movement of the sacroiliac joints during pregnancy observed in anatomic and radiographic studies.^58,59 The belts have been beneficial in patients during pregnancy, and even more so following delivery. According to Mens et al., the beneficial influence of a pelvic belt supports the notion that PPPP results from strain of the muscular and osteoligamentous complex in the pelvis and lower parts of the spine.³⁹

To further evaluate the biomechanical effect of a pelvic belt, 12 cadaveric sacroiliac joints of six human pelvis–spine preparations were sagittally rotated via bidirectional forces at the level of the acetabula.³⁷ The sacroiliac joints were tested without the belt, with a nonelastic pelvic belt of 50 N tension, and with a nonelastic belt of 100 N tension. In seven out of 12 joints, application of the 50 N loaded pelvic belt caused a significant decrease in sagittal rotation. The average reduction in rotation was 29.3%. A comparable result was obtained with the 100 N belt, and the differences between the 50 N and 100 N belts were not statistically significant. Larger tensile forces on the belt did not yield better results. These results are concordant with a previous biomechanical study, in which the efficacy of a pelvic belt was determined by the site of application and not by the amount of tension.⁶⁰ Wearing the belt just above the greater trochanter braced the pelvis and improved pain. The exact position must be adjusted according to the patient’s demands and comfort. In addition, the authors do not advise use of the pelvic belts as a monotherapy. Simultaneous muscle training, especially the internal pelvic musculature and gluteus maximus, has been recommended.

The use of large lumbar belts may be difficult due to the growing size of the abdomen. The belts may fit poorly and many women worry about pressure on the fetus from the belt. In considering the safety of lumbar supports on the hemodynamics of a mother and fetus, a study was conducted by Beaty et al. that included 25 healthy women between 24 and 36 weeks’ gestation.⁶¹ No significant changes were seen in the fetal heart rate baseline or variability during use of the support. The maternal mean arterial blood pressures were unaffected, as were the right- and left-sided cardiac outputs. They found that the women studied reported improvement in back discomfort with the use of a lumbar support while sitting and standing. Therefore, this option should not be entirely excluded when considering orthotic devices that are available to the patient and are potentially beneficial in treating low back pain.

Bracing for scoliosis

Danielsson and Nachemson looked at the progression of scoliotic curvature during pregnancy and childbirth, as well as the incidence of LBP in women with scoliosis, as part of their study published in 2001.⁶² The frequency of low back pain during pregnancy was 36% for patients surgically treated for adolescent idiopathic scoliosis with Harrington rods and 43% for patients who had been treated with Milwaukee or Boston braces. These numbers are similar to the incidence of pain in the nonscoliotic pregnant control group whose prevalence was 49% for back pain.⁷ As well, the curve type did not appear to influence back pain during pregnancy. The rate of complications in women with scoliosis during pregnancy, including back pain and number of cesarean sections, was no higher than in the general population. The severity of the scoliotic curve did not seem to be affected by the number of pregnancies or the age at first pregnancy. This suggests that corrective interventions during pregnancy are not necessary other than for cosmesis.

Ozzlo pillow

The Ozzlo pillow is a hollowed out, nest-shaped pillow which appears to provide better pain relief than a standard pillow in pregnant women. It is probably most helpful to women who suffer back pain at night. A review article by Young and Jewell⁸⁷ describes results of a study by Thomas utilizing the Ozzlo pillow for relief of back pain in pregnancy. A crossover randomized trial⁶⁴ included 109 women comparing the efficacy of a specially designed pillow (Ozzlo pillow) for supporting the pregnant abdomen to a standard hospital (Tontine) pillow. Of the 92 women who completed the 2-week study, 63 women obtained moderate or better improvement in sleep using the Ozzlo pillow and 47 women rated it as at least moderately useful for back pain as compared to only 31 who reported decreased low back pain using a standard pillow versus no pillow. Although there is a plethora of articles specifically citing and evaluating the Ozzlo pillow, it is no longer being manufactured. Women can attempt to form their own version of the Ozzlo pillow until orthotic companies consider remanufacturing this product.

Acetominophen (Tylenol)

Acetaminophen seems to be a safe and effective first-choice drug in the pregnant patient. It provides similar analgesia without the antiinflammatory effects of the nonsteroidal antiinflammatory drugs (NSAIDs). It has no known teratogenic properties, and does not inhibit prostaglandin synthesis or platelet function.⁶⁶ If persistent pain demands use of a mild analgesic, acetaminophen is a safe choice.

Nonsteroidal antiinflammatories

The results of the Collaborative Perinatal Project suggest that first-trimester exposure to aspirin does not pose appreciable teratogenic risk.⁶⁷ However, aspirin-induced inhibition of prostaglandin synthesis may result in prolonged gestation and protracted labor.⁶⁸ Low-dose aspirin therapy (60–80 mg/day) has not been associated with maternal or neonatal complications, but larger doses seem to increase the risk of neonatal intracranial hemorrhage before 35 weeks of gestation.⁶⁶ Even in a full-term newborn, platelet function can be inhibited for up to 5 days after birth.⁶⁹ Furthermore, aspirin’s platelet-inhibiting properties may increase the risk of peripartum hemorrhage, placing both the mother and child at risk. NSAIDs have been known to delay onset of labor as well as increasing neonatal risk for pulmonary hypertension. The use of the NSAID, indometacin, has been linked to premature antenatal closure of the fetal ductus arteriosus.⁶⁸ Ibuprofen and naproxen have not been linked to congenital defects; however, their use during pregnancy may result in a reversible and mild constriction of the fetal ductus arteriosus.⁷⁰

Opioid analgesics

There is no evidence to suggest a relationship exists between exposure to opioid agonists or agonist–antagonists during pregnancy and major or minor malformations. The Collaborative Perinatal Project monitored over 50 000 mother–child pairs, 563 of which had first-trimester exposure to codeine and 686 of which had first-trimester exposure to propoxyphene.⁶⁷ No evidence was found to link either drug to large categories of malformations. Codeine was associated weakly with respiratory defects, genitourinary defects, Down syndrome, tumors, and umbilical and inguinal hernias in a total of 35 cases. Only the association with respiratory malformation was found to be statistically significant. The possible associations with individual defects following propoxyphene exposure included microcephaly, persistent ductus arteriosus, benign tumors, and clubfoot in a total of 41 cases. None of these associations reached statistical significance. Thus, data from large surveillance studies have pointed to possible associations with individual defects, but the incidence is not statistically greater than that in the general population with the exception of respiratory malformations and codeine. Both codeine and propoxyphene are labeled Risk Category C by the FDA.

Caution is advised with administration of fentanyl to the mother immediately before delivery, as this drug may lead to respiratory depression in the newborn.⁷¹ Maternal administration of fentanyl or other opioids has been shown to depress the normal variability in fetal heart rate, which signals fetal hypoxemia. Hydrocodone, meperidine, methadone, morphine, oxycodone, fentanyl, hydromorphone, oxymorphone, butorphanol, and nalbuphine are all labeled Risk Category B by the FDA.

Muscle relaxants

Benzodiazepines are frequently prescribed as skeletal muscle relaxants in patients with chronic pain.⁷² First-trimester exposure to benzodiazepines may be associated with an increased risk of congenital malformations. Diazepam may be associated with cleft lip and palate, as well as congenital inguinal hernia.⁷³ This is mentioned as a possible risk even though the incidence of cleft lip and palate remained stable after the introduction and widespread use of diazepam.⁷³ Benzodiazepine use immediately prior to delivery carries the risk of fetal hypothermia, hyperbilirubinemia, and respiratory depression.⁷⁴ There have been no extensive studies determining the risks associated with other commonly prescribed muscle relaxants such as tizanidine, cyclobenzaprine, and methocarbamol.

Anticonvulsants

Women who were receiving phenytoin, carbamazepine, or valproic acid for epileptic seizures were found to have twice the risk of bearing a child with a congenital defect than the general population.⁷⁵ While inadequate maternal folate absorption associated with anticonvulsant use during pregnancy may contribute to neural tube defects, epilepsy itself may be partially responsible for fetal malformations.⁷⁶ It is plausible that pregnant women taking anticonvulsants for chronic pain may have a lower risk of fetal malformations than those taking the same medications for seizure control. Nonetheless, women taking anticonvulsants for neuropathic pain should strongly consider discontinuation of anticonvulsants during pregnancy, particularly during the first trimester.

A prospective and retrospective study by Montouris⁷⁷ collected data involving 51 fetuses from 39 women with epilepsy and other disorders exposed to gabapentin during pregnancy. The results of this study showed that the rates of maternal complication, cesarean section, miscarriage, low birth weight, and malformation were less than or similar to those seen in the general population or among women with epilepsy. Gabapentin exposure during pregnancy did not lead to an increased risk for adverse maternal and fetal events in this study. Animal studies have shown gabapentin to be toxic to fetuses in rodents and to be associated with increased postimplantation fetal loss in rabbits. These adverse effects occurred at varying doses, some of which were equivalent to human doses. Because of the small number of patients examined in the Montouris study, additional data from more pregnancies and outcomes are needed.

In summary, acetaminophen (Tylenol) is the safest medication for pain control during all three trimesters of pregnancy. Other drug treatments for the control of pain must be closely evaluated, with risks and benefits to the patient and unborn child considered carefully.

Breastfeeding considerations while taking medications

The typical neonatal dose of most medications obtained through breastfeeding is 1–2% of the maternal dose.⁷⁵ Even with minimal exposure via breast milk, neonatal drug allergy and slower infant drug metabolism must be considered. The American Academy of Pediatrics has classified recommendations for maternal medication use during lactation (Table 124.3).

Table 124.3 American Academy of Pediatrics classification of maternal medication use during lactation

Salicylate transport into breast milk is limited, in part due to its high degree of protein binding and its highly ionized state. It would be prudent, however, to limit long-term or frequent aspirin use, as neonates tend to eliminate salicylates very slowly.⁷⁸ Both ibuprofen and naproxen are also minimally transported into breast milk and are considered compatible with breastfeeding.⁷⁵

Indomethacin should be avoided during lactation, based on case reports of neonatal seizures and nephrotoxicity.⁷⁹ Acetaminophen does enter breast milk, although maximal neonatal ingestion is considered less than 2% of a maternal dose.⁸⁰ Acetaminophen is considered compatible with breastfeeding.⁶⁷

Opioids are excreted into breast milk. Breast milk concentrations of codeine and morphine tend to be equal to or greater than maternal plasma concentrations.⁸¹ Fortunately, morphine undergoes glucoronidation via first-pass metabolism, converting the drug to its inactive metabolites. The American Academy of Pediatrics considers morphine, and other opioid analgesics including codeine, fentanyl, methadone, and propoxyphene, compatible with breastfeeding. Meperidine, on the other hand, undergoes N-demethylation to normeperidine, an active metabolite, whose prolonged half-life and subsequent accumulation results in risks of neurobehavioral depression and seizures in the newborn.⁶⁶

Diazepam and its metabolite desmethyldiazepam can be detected in infant serum for up to 10 days after a single maternal dose due to the slower metabolism in neonates.⁸² Clinically, infants who are nursing from mothers receiving diazepam may show sedation and poor feeding.⁸² It seems prudent to avoid any use of benzodiazepines during lactation.

In summary, ibuprofen, naproxen, acetaminophen, and some opioids are considered compatible with breastfeeding. Colostrum production and secretion is minimal for the first few days postpartum, so medications received during the delivery period pose little risk to the newborn via breast milk. All other medications should be discontinued or used with caution.

Acupuncture

Properly performed acupuncture appears to be a safe procedure. As used in pregnancy, it is theorized to activate endogenous opioid mechanisms. Functional magnetic resonance imaging has suggested region-specific and quantifiable effects of acupuncture on relevant brain structures. Acupuncture may also stimulate gene expression of neuropeptides. It has been shown to be effective for pregnancy-associated nausea, yet there has been equivocal and contradictory results for chronic pain, back pain, and headache.⁸³ In an unblinded, controlled study done by Kvorning et al., acupuncture was found to relieve pelvic and LBP in pregnancy. It was safe with no serious adverse effects in treatment group (n=37) to either mother or infant. The treatment sessions occurred 1–2 times a week until delivery or recovery of LBP. Pain on visual analog score (VAS) decreased in 60% of the acupuncture group versus 14% in control group, and 43% of the treated group noted improvement with activities compared to only 9% of the controls.⁸⁴ Forrester documented a case report of a 24-year-old primigravida at 24 weeks of gestation who was incapacitated by severe low back pain. After serious organic causes were excluded, acupuncture was performed to control her pain and improve function, with good success.⁸⁵

Wedenberg et al. compared the efficacy of acupuncture to physical therapy. There were 60 patients involved in the study. In comparing the mean morning and evening VAS, the acupuncture group scores were statistically significantly lower in comparison to the physical therapy group. The values of the Disability Rating Index had also significantly decreased in the acupuncture group in 11 out of 12 activities whereas in the physical therapy group there was little change.⁸⁶ These differences, however, could be explained by the fact that the acupuncture group received individual attention.⁸⁷

Manipulation

Low back pain in the general population is often treated with chiropractic or osteopathic manipulations. Daly et al. diagnosed 11 out of 23 pregnant women with ‘sacroiliac subluxations.’ Of those 11, 10 had relief of pain after rotatory manipulations to the SI joint with no adverse clinical side effects.⁸⁸ A similar study by McIntyre and Broadhurst found that low back pain in pregnancy from clinically diagnosed SI joint dysfunction can be successfully treated with SI joint manipulation and home exercises. Of 20 pregnant women with back pain, they identified pain emanating from the SI joint in 17. After these patients were treated for three visits, 15 had no pain, and the other two had more than 50% improvement.⁸⁹

Osteopathic treatments are also often used in pregnancy; however, their role, especially the cranial–sacral techniques, is somewhat unknown.⁶³ Their role will hopefully be better delineated as new research becomes available.

Massage

Field et al. noted that pregnant women benefited from massage and had less anxiety, improved mood, better sleep, and less back pain by the last day of treatment in comparison to the relaxation therapy group. The level of norepinephrine, considered a urinary stress hormone, was less in the massage group, and they had fewer complications during labor and less prematurity. Both groups underwent 20-minute sessions twice a week and reported less anxiety and leg pain.⁹⁰

Psychosocial treatment

Well-being can be defined as adequate physical and mental functioning.⁹¹ During pregnancy, shifts occur in a couple’s interactions, as well as relationships among friends and colleagues. Moreover, ability to perform daily and occupational tasks may be challenged. Until recently, little attention has been paid in the literature to the genuine pregnancy-related complaints, such as fatigue, nausea, and back pain. Nevertheless, it can be deduced that pregnancy-related complaints may reflect some aspect of an individual’s psychosocial well-being. The aim of the study by Paarlberg et al. was to examine the potential of psychosocial variables as predictors of well-being and of pregnancy-related complaints.⁹¹ Over 400 pregnant, nulliparous women were used in this study, none of whom had psychological or psychiatric illnesses requiring hospitalization. Correlations were found in all trimesters between depression and the independent variables age, work satisfaction, and degree of satisfaction with received support. A high correlation was found between depression and number of daily stressors. Incidence of back pain showed a consistent correlation with age and professional and educational level. As to the predictive value of psychosocial factors with regards to pregnancy-related complaints, back pain complaints were predicted by lower educational level, younger age, increased number of daily stressors, and with depression. Of note, the mean physical workload was calculated for women with low, middle, and high education levels. The observed higher mean physical workload reported by women with a low educational level was significant.

Another study which correlated with the above findings was conducted by Orvieto et al.¹³ It was conducted to assess the frequency, manifestation, and the contribution of various factors to the development of LBP during pregnancy. One factor found to be significantly associated with an increased risk of developing LBP during pregnancy was low socioeconomic class, apparently because these women are exposed to more strenuous physical work, including repetitive lifting and bending. This is consistent with previous reports.⁹² In contrast, another report shows a much higher incidence of LBP among Caucasian women of a higher socioeconomic class and an ‘easier life.’⁹³

Several studies show a connection between high back pain intensity, decreased functional ability, and an increased number of days on sick leave.^7,94 Pregnant women with back pain were found to rate significantly higher on the Disability Rating Index (DRI), and on The Nottingham Health Profile (NHP) for assessing health-related quality of life.⁹³

Several investigators^7,93 found that work factors, younger maternal age, and low educational level were the most important predictors of back pain. Work factors that increase risk include twisting, forward bending, standing work posture, and inability to change posture or take breaks. Twisting or bending many times per hour emerged as significant in the regression analyses for low back pain performed by Endresen.⁹² The correlation matrix showed that working hours were inversely correlated with LBP. This agrees with other studies that show that, on the whole, women who work ‘short part-time’ suffer most. Short part-time work is often associated with occupations that are physically demanding, such as sales work, nursing assistants, service work, etc.⁹⁵ A significant positive correlation was found between back pain and physical workload, and an inverse correlation was found between work satisfaction and back pain.

In a study performed in Sweden, 135 working pregnant women were divided into an intervention group and a control group, with evaluation of the effects of individual education as well as individualized therapy on pain and number of sick days. Five visits were offered at physical therapy centers. After back pain assessment, an individually designed program was started. Patients were taught anatomy, body posture, vocational ergonomics, gymnastics, pelvic floor training, and relaxation training. An individual exercise program, including back muscle strengthening exercises, was designed according to pain type and intensity. With this intervention, pain intensity was significantly reduced, and sick days were reduced from an average of 53.6 days for the control group to 30.4 days for the intervention group. Furthermore, the economical gain was considerable in the intervention group despite the cost of physical therapy, as determined by The Social Insurance Office in Boras, Sweden.¹²

A controlled trial by Ostgaard et al. was aimed at reducing back pain during pregnancy by determining whether particular preventive measures can impact occupational exposures.⁴ It was found that individual instruction, not classes, reduced sick leave during pregnancy. In the study by Orvieto et al., back care advice early in pregnancy, such as appropriate posture and lifting technique, was subjectively reported to significantly reduce LBP occurrence and intensity.¹³ Public health nurses, family physicians, and obstetricians advised these women on how to prevent LBP.

Pregnancy health, including LBP, was found to improve with increasing power to control work pace, in both manual and nonmanual work.⁹⁶ This suggests increased individual control over work pace as a prime target for job adjustment during pregnancy.