Fractures and Orthopaedic Disorders During Pregnancy and the Following Recovery Period : An epidemiologic nationwide register study

Raskauden aikaiset fysiologiset muutokset ovat moninaisia ja altistavat äidin luuston, sidekudoksen ja hormonaalisen aineenvaihdunnan muutosten vuoksi useille ortopedisille ongelmille sekä raskauden aikana että sitä seuraavan toipumisjakson aikana. Ortopediset ongelmat raskauden aikana ovat myös hoidollisesti haasteellisia, koska ne vaikuttavat sekä äitiin että kehittyvään sikiöön. Vaikka aiheesta on julkaistu lukuisia tapausselostuksia sekä potilassarjoja, ei laajamittaisia epidemiologisia tutkimuksia aiheesta ole tähän mennessä julkaistu. Suoritimme retrospektiivisen rekisteripohjaisen kohorttitutkimuksen yleisimpien ortopedisten ongelmien esiintyvyyden analysoimiseksi sekä raskauden aikana että ensimmäisen vuoden aikana synnytyksen jälkeen. Aineisto kerättiin yhdistämällä tiedot terveydenhuollon hoitoilmoitusrekisteristä ja lääketieteellisestä synnytysrekisteristä 1. tammikuuta 1998 ja 31. joulukuuta 2018 väliseltä ajalta. Kaikki tieto 15–49- vuotiaiden naisten ortopedisistä traumoista ja leikkauksista sekä kaikista raskauksista kerättiin ja tieto yhdistettiin muodostaen ikävakioidut kohortit ortopedisistä ongelmista raskauden aikana tai ensimmäisen synnytyksen jälkeisen vuoden aikana sekä niistä, jotka tapahtuivat näiden ajanjaksojen ulkopuolella. Tilastollisissa analyyseissa käytettiin logistisia regressiomalleja ja Kaplan-Meierin selviytymisanalyysiä. Äidin tupakoinnin vaikutus riskitekijänä tapahtumille analysoitiin. Osatyössä I analysoimme murtumien sairaalahoito- ja murtumaleikkausilmaantuvuutta raskauden aikana. Vastaava ilmaantuvuus ensimmäisen synnytyksen jälkeisen vuoden aikana tapahtuvista murtumista analysoitiin osatyössä II. Alatiesynnytyksen jälkeisten symfyysirepeämien ilmaantuvuutta tutkittiin erikseen osatyössä III. Osatyössä IV analysoimme lannerangan välilevykirurgian ilmaantuvuutta raskauden aikana ja ensimmäisen synnytyksen jälkeen. Vastaavaa ilmaantuvuutta koskien ääreishermojen dekompressioleikkauksia analysoitiin erikseen osatyössä V. Tutkimuksemme tärkeimmät löydökset olivat seuraavat. Murtumien ilmaantuvuus raskauden aikana (osatyö I) oli alhaisempi kuin saman ikäisillä normaaliväestöön kuuluvilla naisilla (IRR 0.34, lv 0.33-0.34). Sairaalahoitoisten murtumien kokonaisilmaantuvuus oli 247 murtumaa 100 000 raskausvuotta kohti (lv 237-259). Näistä noin viidesosa vaati leikkaushoitoa ilmaantuvuudella 61 leikkausta 100 000 raskausvuotta kohti (lv 56-67). Ensimmäisen synnytyksen jälkeisen vuoden (tutkimus II) sairaalahoitoisten murtumien kokonaisilmaantuvuus oli 280 murtumaa 100 000 henkilövuotta kohti (lv 270-290), joista neljännes vaati leikkaushoitoa. Lantion murtumien esiintyvyys ensimmäisen 4 kuukauden aikana synnytyksen jälkeen oli vastaava kuin normaaliväestössä, mutta muutoin ilmaantuvuudet läpi linjan pysyivät normaaliväestöä matalampina. Alatiesynnytyksen jälkeisten symfyysirepeämien (tutkimus III) ilmaantuvuus oli 0,8 repeämää 100 000 synnytystä kohti (lv 0,4-1,5). Lannerangan välilevyleikkausten kokonaisilmaantuvuus raskauden aikana oli 11 leikkausta 100 000 henkilövuotta kohden ja ensimmäisen synnytyksen jälkeisenä vuonna 47 leikkausta 100 000 henkilövuotta kohden (tutkimus IV). Raskaana olevilla naisilla oli pienempi välittömän uusintaleikkauksen riski kuin normaaliväestöllä (IRR 0,5, lv 0.1-3.5), mutta suurempi ensimmäisen synnytyksenjälkeisen vuoden aikana (IRR 1,7, lv 1.1- 2.7). Äidin tupakointi ennen raskautta lisäsi lannerangan välilevyleikkauksen riskiä raskauden aikana. Perifeeristen hermojen dekompressioleikkausten joukossa (tutkimus V) yleisin toimenpide oli rannekanavan vapautus. Muita vapautusleikkauksia havaittiin vain yksittäistapauksina. Rannekanavan vapautusten kokonaisilmaantuvuus raskauden aikana oli 38 leikattua naista 100 000 henkilövuotta kohden, jääden normaaliväestöä matalammaksi (IRR 0.5, lv 0.4-0.6). Synnytyksen jälkeen ilmaantuvuus nousi 63 leikattuun naiseen 100 000 henkilövuotta kohden ensimmäisenä synnytyksen jälkeisenä vuonna (IRR 0.8, lv 0.7-1.0). Rannekanavan leikkauksen riski raskauden aikana ja sen jälkeen oli korkeampi naisilla, jotka tupakoivat aktiivisesti ennen raskautta. Tutkimustuloksemme osoittavat äitien saavan väestötasolla vähemmän murtumia muuhun saman ikäiseen naisväestöön verrattuna vielä jopa vuoden ajan synnytyksen jälkeen. Siitä huolimatta leikkaushoidon kriteerit vaikuttavat olevan yhteneväiset, sillä toimenpiteiden osuus oli vastaava kuin normaaliväestöllä. Lannerangan välilevyleikkausten ja rannekanavan vapautusten osalta äitejä leikataan päinvastoin harvemmin, erityisesti raskauden aikana. Leikkaushoitoa harkittaessa komplikaatioriskit saattavatkin korostua niiden vaikutusten kohdistuessa myös sikiöön.Mothers experience various physiological changes both during pregnancy analyse the incidence of common orthopaedic disorders during pregnancy and the first year after delivery. We collected data on orthopaedic trauma and operations for all women aged 15 to 49 years as well as on all pregnancies in Finland over a 21-year period from 1 January 1998 to 31 December 2018. We created age-adjusted cohorts of orthopaedic disorders mortality were studied separately. Similar data for fractures occurring and the postpartum period that make them more vulnerable to the orthopaedic disorders caused by altered bone, connective tissue and hormonal metabolism. Since these conditions have significant effects on both the mother and the developing foetus, they require special attention. Although there have been several case reports and series on the epidemiology of orthopaedic disorders during pregnancy, no large-scale studies have been conducted thus far. To fill this knowledge gap, we carried out a retrospective cohort study based on data from two Finnish national registries. The study aimed to occurring during pregnancy or the first postpartum year, and outside of these periods. We used logistic regression models and Kaplan-Meier survival analysis for statistical analysis and included data on maternal smoking as a risk factor for events. In study I, we analysed the incidence of fracture hospitalisation and fracture surgery during pregnancy. Pelvic trauma and rates of perinatal during the first postpartum year were analysed in study II. Traumatic ruptures of the pubic symphysis occurring after vaginal delivery were analysed separately in study III. In study IV, we analysed the incidence of lumbar discectomy during pregnancy and the first postpartum year. Similar incidences regarding peripheral nerve decompression surgery were analysed separately in study V. The main findings of our study were that the incidence of fractures during pregnancy (study I) was lower than in the normal female population of the same age (IRR 0.34, CI 0.33 to 0.34). The total fracture incidence was 247 fractures per 100 000 pregnancy-years (95% CI 237 to 259) leading to hospitalisation during pregnancy. Of these, about one fifth required operative treatment resulting in an incidence of 61 operations per 100 000 pregnancy-years (CI 56 to 67). After delivery (study II), the total incidence of fractures leading to hospitalisation during the first 12 months after delivery was 280 fractures per 100 000 person-years (95% CI 270 to 290) with one fourth of these fractures requiring operative treatment. Incidences of pelvic fractures during the first 4 months postpartum were similar to those in the normal population, but otherwise all rates remained lower. Traumatic ruptures of the pubic symphysis following vaginal birth (study III) occurred at a rate of 0.8 ruptures per 100 000 deliveries (CI 0.4 to 1.5). For lumbar discectomy (study IV), the cumulative incidence during pregnancy was 11 operations per 100 000 person-years and 47 operations per 100 000 person-years during the first postpartum year. For pregnant women, the immediate reoperation rate was lower than the normal population with an IRR of 0.5 (CI 0.1 to 3.5), but higher during the first 12 months after pregnancy with an IRR of 1.7 (CI 1.1 to 2.7). Maternal smoking before pregnancy increased the risk of lumbar discectomy during pregnancy. For peripheral nerve decompression surgery (study V) the most common procedure was carpal tunnel release (CTR), as only isolated cases of other operations were performed. The total incidence of CTR during pregnancy was lower than in the normal population with 38 operated women per 100 000 person-years (IRR 0.5, CI 0.4 to 0.6). After delivery, the incidence rose to 63 operated women per 100 000 person-years in the first postpartum year (IRR 0.8, CI 0.7 to 1.0). The risk of CTR during and after pregnancy was higher for women who actively smoked before pregnancy. According to the results of our study, pregnant women sustain fewer fractures on a nationwide level when compared to similar aged women in the normal population. This phenomenon continues until at least the end of the first postpartum year. Despite this, the share of operative treatment for fractures is similar to that of the normal population. Interestingly, women are less likely to undergo lumbar discectomy and CTR, especially during pregnancy. One possible explanation for this is that surgeons may be more hesitant to perform operations during pregnancy due to concerns about the safety of the foetus

Incidence of vaginal birth–related rupture of the pubic symphysis : A nationwide register study in Finland from 1998 to 2018

Background and purpose: To assess the incidence of vaginal birth -related rupture of the pubic symphysis in Finland from 1998 to 2018. Methods: A retrospective cohort study using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register. As participants we included all ≥ 22-week pregnancies of women aged between 15 and 49 years from January 1, 1998 to December 31, 2017. Pubic symphysis rupture was classified based on the ICD-10 code S33.4 and operations were gathered with pelvis-specific operation codes of the Nordic NOMESCO-classification. Incidence per 100 000 deliveries with 95% confidence intervals (CI) was calculated for symphysis rupture and surgery using Poisson’s exact test. Results: For a total 1 175 326 deliveries, a total of 9 pubic symphysis ruptures occurred during the intrapartum and puerperal periods. All ruptures occurred after vaginal delivery. Of these, 4 ruptures were treated operatively. The incidence of rupture for vaginal delivery was 0.9 per 100 000 deliveries (CI 0.1 to 1.0). No perinatal mortality was observed. Conclusions: Birth -related ruptures of the pubic symphysis are rate events and are mostly associated with vaginal delivery with most ruptures being treated conservatively.publishedVersionNon peer reviewe

Incidence of fracture hospitalization and surgery during pregnancy in Finland—1998–2017 : a retrospective register-based cohort study

Introduction: The aim of this study was to assess the incidence of all major fractures and surgery during pregnancy and the outcomes of pregnancy in Finland between 1998 and 2017. Materials and methods: A retrospective cohort study using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register. As participants we included all women aged between 15 and 49 years from January 1, 1998 to December 31, 2017 and their ≥ 22-week pregnancies. Results: Of a total 629,911 pregnancies, 1813 pregnant women were hospitalized with a fracture diagnosis, yielding an incidence of 247 fractures/100,000 pregnancy-years. Of these, 24% (n = 513/2098) were treated operatively. The most common fractures were fractures of the tibia, ankle, and the forearm, which made up half of all fractures. The incidence of pelvic fractures was 6.8/100,000 pregnancy-years, with an operation rate of 14%. The stillbirth rate of all fracture patients was low at 0.6% (n = 10/1813), although this was 1.5-fold the overall stillbirth rate in Finland. Lumbosacral and comminuted spinopelvic fractures resulted in preterm delivery in 25% (n = 5/20) of parturients, with a stillbirth rate of 10% (n = 2/20). Conclusion: The incidence of fracture hospitalization during pregnancy is lower than in the general population, and fractures in this population are more often treated conservatively. A higher proportion of preterm deliveries and stillbirths occurred in women with lumbosacral and comminuted spinopelvic fractures. Maternal mortality and stillbirth rates remain low among women with fractures leading to hospitalization or surgery during pregnancy.Peer reviewe

Pregnancy and delivery after pelvic fracture in fertile-aged women : A nationwide population-based cohort study in Finland

Objective: Only a few small studies have assessed the effects of pelvic fractures on pregnancies, deliveries, and rates of cesarean sections. We aimed to evaluate the effect of pelvic fractures on subsequent pregnancy and delivery in Finland. Study design: In this retrospective register-based nationwide cohort study, data on all fertile-aged (aged 15–49) women with a pelvic fracture during our study period (1998–2018) were retrieved from the Care Register for Health Care. The data were subsequently combined with data from the National Medical Birth Register. Women with pelvic fracture before pregnancy were compared with a no-fracture group consisting of 621 141 women who had had 1 156 723 singleton deliveries without a preceding pelvic fracture. We used logistic regression to analyze preterm deliveries, cesarean sections, and neonatal health. Results are reported as adjusted odds ratios (AOR) with 95% confidence intervals (CI). Results: A total of 2 878 women with a previous pelvic fracture were identified. Of these, 596 women had 1 024 singleton deliveries after pelvic fracture. In the no-fracture group, 621 141 women had 1 156 378 singleton deliveries. Compared to the no-fracture group, women with a previous pelvic fracture had higher rates of cesarean sections (22.6% vs 15.9%) (AOR 1.55 CI 1.32–1.80), higher rate of preterm deliveries (6.2% vs 4.6%) (1.32 CI 1.01–1.69), and a higher rate of neonates requiring intensive care unit treatment (13.5% vs 10.0%) (AOR 1.35 CI 1.13–1.62). Conclusion: Vaginal delivery was the primary mode of delivery despite the higher rate of cesarean section among women with a previous fracture of the pelvis. The rate for preterm deliveries and need for neonatal intensive care was also higher, but the clinical importance of these findings is unclear. Our results suggest that vaginal delivery after fractures of the pelvic circle is generally safe for both mother and neonate.publishedVersionPeer reviewe

Incidence of lumbar discectomy during pregnancy and within 12 months post-partum in Finland between 1999 and 2017 : a retrospective register-based cohort study

BACKGROUND CONTEXT: Both lumbar disc herniation in the general population and lower back pain in the pregnant population are known to be common conditions. The physiological and anatomical of the mother predispose to increased strain of the lumbar disc, while pregnancy may promote caution in physicians contemplating surgical care. PURPOSE: We aimed to report the incidence of lumbar discectomy during pregnancy and 12 months post-partum in Finland between 1999 and 2017. STUDY DESIGN: Retrospective register-based cohort study. PATIENT SAMPLE: Using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register, all women aged 15 to 49 years with a lumbar discectomy or pregnancy ending in delivery from 1st January, 1999 to 31st December, 2017 were included. OUTCOME MEASURES: Incidence rates and their 95% confidence intervals were calculated for lumbar discectomy. Incidence rate ratios (IRR) were calculated between the study population and the control population. The effect of smoking on surgery risk was reported using odds ratios. METHODS: A retrospective statistical analysis was performed to identify patients undergoing lumbar discectomy during pregnancy or the first 12 months after delivery. Incidence rates were compared to the age-adjusted values of the age-matched female general population. The effect of smoking on the risk of lumbar discectomy was analysed using age-adjusted odds ratios. RESULTS: In total, 91 discectomies were performed during pregnancy and 508 within 12 months post-partum. The total incidence of lumbar discectomy during pregnancy was 11 operations per 100 000 person-years with an incidence rate ratio (IRR) of 0.2 (95% CI 0.1 to 0.2) when compared to the age-adjusted female general population. Women with active smoking before pregnancy were at a higher risk for lumbar discectomy during pregnancy (OR 2.0, 95% CI 1.2 to 3.2). Caesarean section was more common after lumbar discectomy (22%). No perinatal mortality was observed. During the first year post-partum the rate of lumbar discectomy increased to 47 per 100 000 person-years with an IRR of 0.7 (95% CI 0.6 to 0.8). 90-day reoperation rates were higher than in the general population with an IRR of 1.7 (95% CI 1.1 to 2.7). CONCLUSIONS: Lumbar discectomy during pregnancy is rare, but smoking increases the risk. Lumbar discectomy during pregnancy seems to be safe for the neonate. Post-partum incidences increased towards the end of the first year, but remained below the rates in the general population with a higher risk for short-term reoperation.publishedVersionPeer reviewe

Pregnancy and delivery after traumatic brain injury : a nationwide population-based cohort study in Finland

Objectives: Few studies have assessed pregnancies and deliveries after traumatic brain injury (TBI). We report the incidence of TBIs and TBI-related surgeries in fertile-aged females and investigate subsequent pregnancy outcomes. Methods: All fertile-aged (15–49) women with TBI diagnosis during our study period (1998–2018) were retrieved from the Care Register for Health Care and combined with data from the National Medical Birth Register. TBIs were categorized into three subgroups based on the length of the hospitalization period and the need for neurosurgery. Logistic regression was used to analyze preterm deliveries, cesarean sections (CS) and neonatal health. Results are reported as adjusted odds ratios (AOR) with 95% confidence intervals (CI). Results: The incidence of TBIs increased from 103 per 100 000 person-years in 1998 to 257 per 100 000 (149.5%) in 2018. The incidence of TBI-related surgeries remained stable during our study period. The rate of preterm deliveries was 5.6% in the TBI group and 3.0% in the control group (AOR 1.23, CI 1.17–1.28). The CS rate in the TBI group was 19.2% and 15.9% in the control group (AOR 1.23, CI 1.18–1.29). The use of labor analgesia was higher among women with previous TBI. The rate of neonates requiring intensive care in the TBI group was 13.1% and 9.9% in the control group (AOR 1.30, CI 1.24–1.37). Conclusion: The incidence of TBI hospitalizations increased during our study period, whereas the number of surgically treated TBI remained stable. Preterm deliveries, CS, instrumental vaginal deliveries and labor analgesia were more prevalent in women with previous TBI. Furthermore, more neonates required intensive care in this group. Therefore, a history of TBI should be acknowledged as a possible factor affecting the delivery and health of the neonate.publishedVersionPeer reviewe

Pregnancy and delivery after spine fracture or surgery : A nationwide population-based register study in Finland

BACKGROUND: The incidences of spine fractures and fusion surgeries have increased. A few studies have reported an increased rate of caesarean sections (CS) in women who have undergone spine surgery but have not reported on the health of neonates. OBJECTIVE: We report the incidence of spine fractures, spine fracture surgeries and fusion surgery for other reasons and the effect of these injuries and procedures on later pregnancy outcomes in Finland. METHODS: Data on all fertile-aged women (1998-2018) who had undergone spine fracture or spine fusion surgery were retrieved from the Care Register for Healthcare and combined with data from the National Medical Birth Register. Women with spine fracture or spine surgery before pregnancy were compared with women without previous spine fracture or surgery. We calculated incidences of spine fracture, spine fracture surgery and fusion surgery for other reasons with 95% confidence intervals (CI). We used multivariable logistic regression to evaluate CS and neonatal health. Results are reported as adjusted odds ratios (AOR). RESULTS: The main finding of our study was the increasing incidence (156%) of spine fusion surgeries for other reasons in fertile-aged women. A total CS rate (including elective and unplanned CS) in the spine fracture group was 19.7% (AOR 1.26, CI 1.17-1.34), in fusion surgery for other reasons group 25.3% (AOR 1.37, CI 1.30-1.49) and 15.9% in the control group. The rate for neonates requiring intensive care in the spine fracture group was 12.2% (AOR 1.18, CI 1.08-1.29), in fusion surgery for other reasons group 13.6% (AOR 1.12, CI 1.02-1.23) and 10.0% in the control group. CONCLUSIONS: The incidence of fusion surgery for other reasons increased during our study period. The rate of CS was higher in women with preceding spine fracture or fusion surgery. Our results suggest that vaginal delivery after fractures of the spine is both possible and safe for mother and neonate.publishedVersionPeer reviewe

Incidence of Fracture Hospitalization and Surgery in Women Increases Steadily During the Puerperal and Lactation Period : A Retrospective Register-Based Cohort Study in Finland From 1999 to 2018

This retrospective cohort study assesses the incidences of major fractures and surgery in women during the puerperium and the lactation period in Finland between January 1, 1999, and December 31, 2018. Using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register, all women aged between 15 and 49 years with a fracture hospitalization within 12 months of delivery between 1999 and 2018 were included. During the study period, a total of 3140 fractures after delivery and 152,800 fractures of the female normal population of similar age were hospitalized. The incidence rate after delivery increased from 219/100,000 person-years during the first 4 months to 310 fractures/100,000 person-years during the latter 8 months of the first year after delivery. Altogether, 29% (n = 904/3140) of these fractures were treated operatively. The most common fractures were ankle and distal radius fractures, which made up one-third of all fractures. The incidence of pelvic fracture hospitalization was 15/100,000 person-years at 4 months after delivery, with an operation rate of 22%. Over half of all fractures occurred between 6 and 12 months after delivery (mean 6.6 months). The incidence of fracture hospitalization after delivery increased steadily during the puerperium and the lactation periods but remained lower than in the general population (age-adjusted incidence 554/100,000 person-years) with an incidence rate ratio of 0.51. However, a higher proportion of pelvic fractures were observed in the first months after delivery. Surgical rates were in line with the general population. Fractures of the wrist and ankle made up most of the fractures.publishedVersionPeer reviewe

Smoking is associated with an increased risk of fractures in women after childbirth : a nationwide population-based cohort study in Finland

Background and purpose — Smoking weakens bone health and increases the risk of fractures. We investigated the incidence of fractures in smoking, fertile-aged women and compared it with that of non-smoking, fertile-aged women using data from nationwide registers. Patients and methods — We conducted a retrospective register-based nationwide cohort study from 1998 to 2018. We identified all women smoking during pregnancy from the Medical Birth Register and compared these with non-smok-ers. We gathered fractures for both groups from the Care Register for Health Care. Pregnancies with missing smoking or socioeconomic status were excluded. A Cox regression model was used to analyze adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for fractures during the 5-year follow-up starting from delivery. The model was adjusted for the age of the mother at the time of delivery and socioeconomic status. Results — The smoking group included 110,675 pregnancies and the non-smoking group 628,085 pregnancies. The overall fracture rate was higher in smokers after 1-year follow-up (aHR 1.7, CI 1.5–2.0) and 5-year follow-up (aHR 1.7, CI 1.6–1.8). After 5-year follow-up, the fracture rates for polytraumas (aHR 2.3, CI 1.4–3.7), inpatient admitted fractures (aHR 2.0, CI 1.7–2.4), and non-admitted fractures (aHR 1.8, CI 1.7–1.9) were all higher among smoking women. Conclusion — Smoking in fertile-aged women was associated with a higher risk of fractures during the 1-year and 5-year follow-up after giving birth, also after adjusting for age and socioeconomic status. Whether the increased fracture risk is caused by direct effects of smoking on bone health or riskier behavior remains uncertain.publishedVersionPeer reviewe