Maternal Obstetric Palsy: Difference between revisions
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== Introduction | == Introduction == | ||
Maternal obstetric palsy or obstetric maternal palsy or obstetric maternal lumbosacral plexopathy refers to an injury to the lumbosacral plexus whose signs and symptoms become evident during labor or after childbirth. | Maternal obstetric palsy or obstetric maternal palsy or obstetric maternal lumbosacral plexopathy refers to an injury to the lumbosacral plexus whose signs and symptoms become evident during labor or after childbirth. | ||
== Epidemiology == | == Epidemiology == | ||
The population of women with maternal obstetrical palsy are relatively small, hence the absence of the condition in many | The population of women with maternal obstetrical palsy are relatively small, hence the absence of the condition in many textbooks<ref name=":0">2 | ||
</ref>. Feasby et al. reported two cases in 1992<ref name=":0" />, Katirji et al. had seven (7) women reported in 2002<ref name=":1">4 | |||
</ref>. And some others had nineteen (19) patients in the year 2000. | |||
== Risk factors | == Risk factors<ref name=":0" /> == | ||
Short stature | Short stature | ||
Macrosomia | Macrosomia | ||
Cephalopelvic disproportion | Cephalopelvic disproportion | ||
Delayed/Prolonged labor | Delayed/Prolonged labor | ||
Mid forceps rotation | |||
Mid forceps rotation | |||
Fetal malpositioning | Fetal malpositioning | ||
== Clinically Relevant Anatomy | == Clinically Relevant Anatomy == | ||
The lumbar plexus and sacral plexus, if taken as one entity becomes the lumbosacral plexus, the largest spinal nerve plexus. | The lumbar plexus and sacral plexus, if taken as one entity becomes the lumbosacral plexus, the largest spinal nerve plexus. It consists of nerves originating from spinal segments L1 to S4, lumbar plexus taking its origin from L1 to L4 and sacral plexus from L5 to S4 respectively. Nerves arising from the lumbosacral plexus generally course behind the psoas major, piercing the abdominal wall antero-laterally, then course antero-medially, upon the pelvic rim or iliac crest to enter into the lower limb. | ||
It consists of nerves originating from spinal segments L1 to S4, lumbar plexus taking its origin from L1 to L4 and sacral plexus from L5 to S4 respectively. Nerves arising from the lumbosacral plexus generally course behind the psoas major, piercing the abdominal wall antero-laterally, then course antero-medially, upon the pelvic rim or iliac crest to enter into the lower limb. | |||
== Mechanism of Injury / Pathological Process | == Mechanism of Injury / Pathological Process == | ||
The position of the lumbocsacral plexus predisposes it to compression during prolonged labour, especially in some categories of women e.g. short women. Any trauma, or compression or injury to the trunks of the lumbosacral plexus creates clinical signs and symptoms in the mother. Katirji et al. (2002) concluded that intrapartum foot drop occurs mostly in short women and is caused by lumbosacral trunk compression by the fetal head at the pelvic brim primary pathology being predominantly demyelination and recovery is complete in up to 5 months.<ref name=":1" /> | |||
The peroneal nerve is frequently affected and "Hunerman in 1892 attributed its frequency to its position in the lumbosacral plexus." | The peroneal nerve is frequently affected and "Hunerman in 1892 attributed its frequency to its position in the lumbosacral plexus." | ||
== Types | == Types == | ||
Presentation of signs and symptoms and | Presentation of signs and symptoms and electro diagnostic studies have helped in differentiating lumbosacral plexopathy into sub-groups | ||
Types according to research articles reviewed are | Types according to research articles reviewed are | ||
Electrodiagnostic studies further describes postpartum maternal lumbosacral plexopathy into Upper and Lower Lumbosacral Plexopathy. Upper lumbosacral plexopathy involves the muscles of the lower limb and affectation to motor and sensory functions, while ,lower plexopathy only involves the lower part of the plexus (s2-s4).Lower postpartum lumbosacral plexopathy is evoked when perineal sensory disturbances whether or not associated with urinary or fecal incontinence persist after a history of a difficult vaginal delivery with no associated lower limb sensory or motor deficits noted | 1. Intrapartum maternal lumbosacral plexopathy: it involves the lumbosacral plexopathy easily recognized while the woman is in labour<ref name=":1" /> | ||
2. Postpartum maternal lumbosacral plexopathy: this manifests after childbirth<ref name=":2">4 | |||
</ref> | |||
Electrodiagnostic studies further describes postpartum maternal lumbosacral plexopathy into Upper and Lower Lumbosacral Plexopathy. Upper lumbosacral plexopathy involves the muscles of the lower limb and affectation to motor and sensory functions, while ,lower plexopathy only involves the lower part of the plexus (s2-s4).Lower postpartum lumbosacral plexopathy is evoked when perineal sensory disturbances whether or not associated with urinary or fecal incontinence persist after a history of a difficult vaginal delivery with no associated lower limb sensory or motor deficits noted<ref name=":2" /> "The first, second and third sacral roots entering into the formation of the sacral plexus lie on the piriformis muscle and are thus unprotected against pressure on the bone"<ref name=":3">2 | |||
</ref> | |||
== Clinical Presentation == | == Clinical Presentation == | ||
| Line 41: | Line 53: | ||
For the lower palsy:2 | For the lower palsy<ref name=":2" /> | ||
Perineal sensori-neuropathy | Perineal sensori-neuropathy | ||
Urinary incontinence | Urinary incontinence | ||
Fecal incontinence | Fecal incontinence | ||
Sexual dysfunction | Sexual dysfunction | ||
== Diagnostic Procedures == | == Diagnostic Procedures == | ||
Subjective history taking form the patient. Intrapartum palsy would have been observed during parturition. | Subjective history taking form the patient. Intrapartum palsy would have been observed during parturition. | ||
Objective diagnostic procedures include the use of | |||
Objective diagnostic procedures include the use of Electrodiagnostic devices vis a vis: EMG in determining the level of affectation. Compound Muscle Action Potential (CMAP), Sensory Nerve Action Potential (SNAP) are recorded to know the exact site of injury. | |||
== Outcome Measures == | == Outcome Measures == | ||
| Line 56: | Line 72: | ||
add links to outcome measures here (see [[Outcome Measures|Outcome Measures Database]]) | add links to outcome measures here (see [[Outcome Measures|Outcome Measures Database]]) | ||
== Physiotherapy Management / Interventions | == Physiotherapy Management / Interventions == | ||
Electrical Muscle Stimulation | Electrical Muscle Stimulation | ||
Tactile Stimulation | Tactile Stimulation | ||
== Differential Diagnosis | Proprioceptive Neuromuscular Facilitation | ||
Prescription of ankle foot orthoses | |||
== Differential Diagnosis == | |||
Spinal Cord Injury | Spinal Cord Injury | ||
Guillain-Barre Syndrome | Guillain-Barre Syndrome | ||
Injection Neuritis | Injection Neuritis | ||
== Resources | == Resources == | ||
Feasby TE, Burton SR, Hahn AF. Obstetrical lumbosacral plexus injury. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 1992 Aug;15(8):937-40. | Feasby TE, Burton SR, Hahn AF. Obstetrical lumbosacral plexus injury. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 1992 Aug;15(8):937-40. | ||
| Line 75: | Line 97: | ||
== References == | == References == | ||
<ref name=":0" />Feasby TE, Burton SR, Hahn AF. Obstetrical lumbosacral plexus injury. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 1992 Aug;15(8):937-40. | |||
Katirji B, Wilbourn AJ, Scarberry SL, Preston DC. Intrapartum maternal lumbosacral plexopathy. Muscle & nerve. 2002 Sep;26(3):340-7. | <ref name=":1" />Katirji B, Wilbourn AJ, Scarberry SL, Preston DC. Intrapartum maternal lumbosacral plexopathy. Muscle & nerve. 2002 Sep;26(3):340-7. | ||
Ismael SS, Amarenco G, Bayle B, Kerdraon J. Postpartum lumbosacral plexopathy limited to autonomic and perineal manifestations: clinical and electrophysiological study of 19 patients. Journal of Neurology, Neurosurgery & Psychiatry. 2000 Jun 1;68(6):771-3. | <ref name=":2" />Ismael SS, Amarenco G, Bayle B, Kerdraon J. Postpartum lumbosacral plexopathy limited to autonomic and perineal manifestations: clinical and electrophysiological study of 19 patients. Journal of Neurology, Neurosurgery & Psychiatry. 2000 Jun 1;68(6):771-3. | ||
Tillman AJ. Traumatic neuritis in the puerperium. American Journal of Obstetrics and Gynecology. 1935 May 1;29(5):660-6 | <ref name=":3" />Tillman AJ. Traumatic neuritis in the puerperium. American Journal of Obstetrics and Gynecology. 1935 May 1;29(5):660-6. | ||
Revision as of 16:41, 8 March 2019
Original Editor - Onigbinde Omotola Adam
Lead Editors
Introduction[edit | edit source]
Maternal obstetric palsy or obstetric maternal palsy or obstetric maternal lumbosacral plexopathy refers to an injury to the lumbosacral plexus whose signs and symptoms become evident during labor or after childbirth.
Epidemiology[edit | edit source]
The population of women with maternal obstetrical palsy are relatively small, hence the absence of the condition in many textbooks[1]. Feasby et al. reported two cases in 1992[1], Katirji et al. had seven (7) women reported in 2002[2]. And some others had nineteen (19) patients in the year 2000.
Risk factors[1][edit | edit source]
Short stature
Macrosomia
Cephalopelvic disproportion
Delayed/Prolonged labor
Mid forceps rotation
Fetal malpositioning
Clinically Relevant Anatomy[edit | edit source]
The lumbar plexus and sacral plexus, if taken as one entity becomes the lumbosacral plexus, the largest spinal nerve plexus. It consists of nerves originating from spinal segments L1 to S4, lumbar plexus taking its origin from L1 to L4 and sacral plexus from L5 to S4 respectively. Nerves arising from the lumbosacral plexus generally course behind the psoas major, piercing the abdominal wall antero-laterally, then course antero-medially, upon the pelvic rim or iliac crest to enter into the lower limb.
Mechanism of Injury / Pathological Process[edit | edit source]
The position of the lumbocsacral plexus predisposes it to compression during prolonged labour, especially in some categories of women e.g. short women. Any trauma, or compression or injury to the trunks of the lumbosacral plexus creates clinical signs and symptoms in the mother. Katirji et al. (2002) concluded that intrapartum foot drop occurs mostly in short women and is caused by lumbosacral trunk compression by the fetal head at the pelvic brim primary pathology being predominantly demyelination and recovery is complete in up to 5 months.[2]
The peroneal nerve is frequently affected and "Hunerman in 1892 attributed its frequency to its position in the lumbosacral plexus."
Types[edit | edit source]
Presentation of signs and symptoms and electro diagnostic studies have helped in differentiating lumbosacral plexopathy into sub-groups
Types according to research articles reviewed are
1. Intrapartum maternal lumbosacral plexopathy: it involves the lumbosacral plexopathy easily recognized while the woman is in labour[2]
2. Postpartum maternal lumbosacral plexopathy: this manifests after childbirth[3]
Electrodiagnostic studies further describes postpartum maternal lumbosacral plexopathy into Upper and Lower Lumbosacral Plexopathy. Upper lumbosacral plexopathy involves the muscles of the lower limb and affectation to motor and sensory functions, while ,lower plexopathy only involves the lower part of the plexus (s2-s4).Lower postpartum lumbosacral plexopathy is evoked when perineal sensory disturbances whether or not associated with urinary or fecal incontinence persist after a history of a difficult vaginal delivery with no associated lower limb sensory or motor deficits noted[3] "The first, second and third sacral roots entering into the formation of the sacral plexus lie on the piriformis muscle and are thus unprotected against pressure on the bone"[4]
Clinical Presentation[edit | edit source]
For the upper palsy: pain, paraesthesia, weakness of ankle dorsiflexion, eversion, and inversion, and sensory loss in the L‐5 dermatome, foot drop.
For the lower palsy[3]
Perineal sensori-neuropathy
Urinary incontinence
Fecal incontinence
Sexual dysfunction
Diagnostic Procedures[edit | edit source]
Subjective history taking form the patient. Intrapartum palsy would have been observed during parturition.
Objective diagnostic procedures include the use of Electrodiagnostic devices vis a vis: EMG in determining the level of affectation. Compound Muscle Action Potential (CMAP), Sensory Nerve Action Potential (SNAP) are recorded to know the exact site of injury.
Outcome Measures[edit | edit source]
add links to outcome measures here (see Outcome Measures Database)
Physiotherapy Management / Interventions[edit | edit source]
Electrical Muscle Stimulation
Tactile Stimulation
Proprioceptive Neuromuscular Facilitation
Prescription of ankle foot orthoses
Differential Diagnosis[edit | edit source]
Spinal Cord Injury
Guillain-Barre Syndrome
Injection Neuritis
Resources[edit | edit source]
Feasby TE, Burton SR, Hahn AF. Obstetrical lumbosacral plexus injury. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 1992 Aug;15(8):937-40.
Ismael SS, Amarenco G, Bayle B, Kerdraon J. Postpartum lumbosacral plexopathy limited to autonomic and perineal manifestations: clinical and electrophysiological study of 19 patients. Journal of Neurology, Neurosurgery & Psychiatry. 2000 Jun 1;68(6):771-3.
References[edit | edit source]
[1]Feasby TE, Burton SR, Hahn AF. Obstetrical lumbosacral plexus injury. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 1992 Aug;15(8):937-40.
[2]Katirji B, Wilbourn AJ, Scarberry SL, Preston DC. Intrapartum maternal lumbosacral plexopathy. Muscle & nerve. 2002 Sep;26(3):340-7.
[3]Ismael SS, Amarenco G, Bayle B, Kerdraon J. Postpartum lumbosacral plexopathy limited to autonomic and perineal manifestations: clinical and electrophysiological study of 19 patients. Journal of Neurology, Neurosurgery & Psychiatry. 2000 Jun 1;68(6):771-3.
[4]Tillman AJ. Traumatic neuritis in the puerperium. American Journal of Obstetrics and Gynecology. 1935 May 1;29(5):660-6.
