FUNCTIONAL AND ANATOMICAL CHANGES IN THE LOWER EXTREMITIES DURING PREGNANCY

Objective. To evaluate the prevalence of functional and anatomical changes in the lower extremities of pregnant women and discuss their possible causes and current therapeutic recommendations.

Patients and methods. To assess changes in the lower extremities, 100 pregnant women at 38.5±1.3 weeks of gestation age were consecutively enrolled in an individual direct questionnaire. Patients’ ages ranged from 19 to 43 years (mean 31.4±5.3). The number of previous pregnancies and labours were 2.4±1.5 and 1.8±1.2 respectively. The demographic part of the questionnaire included information on age, height, body weight and shoe size before pregnancy and antepartum, medical and obstetric history and physical activity. The clinical section of the original questionnaire contained sections related to the assessment of skin, vascular, neurological and musculoskeletal disorders.

Results. During pregnancy, there was an increase in women’s body weight from 66.6±14.8 kg to 78.8±14.6 kg and an increase in casual shoe size by 0.3 cm from 37.9±1.3 to 38.2±1.2 (in 27% of observations). More than half (57%) of study participants described their level of daily physical activity as moderate. The study showed that 85% of pregnant women reported functional or anatomical changes in the lower extremities, which included dermatological changes in 53%, vascular changes in 49%, peripheral nerves changes in 22%, and musculoskeletal changes in 69%.

Conclusion. The gestational period is characterised by significant endocrine, immunological and metabolic changes of the pregnant woman, which provokes a range of both physiological and pathological conditions. Establishing the prevalence of lower limb symptoms and syndromes will provide the basis for developing an effective system of medical prevention and treatment of undesirable lower extremities effects.

1. Ouzounian JG, Elkayam U. Physiologic changes during normal pregnancy and delivery. Cardiol Clin. 2012 Aug;30(3):317-29. https://doi.org/10.1016/j.ccl.2012.05.004.

2. Anselmo DS, Love E, Tango DN, Robinson L. Musculoskeletal effects of pregnancy on the lower extremity (A literature review). J Am Podiatr Med Assoc. 2017 Jan;107(1):60-4. https://doi.org/10.7547/15-061.

3. Dunn J, Dunn C, Habbu R, Bohay D, Anderson J. Effect of pregnancy and obesity on arch of foot. Orthop Surg. 2012 May;4(2):101-4. https://doi.org/10.1111/j.1757-7861.2012.00179.x.

4. Ogamba MI, Loverro KL, Laudicina NM, Gill SV, Lewis CL. Changes in gait with anteriorly added mass: a pregnancy simulation study. J Appl Biomech. 2016 Aug;32(4):379-87. https://doi.org/10.1123/jab.2015-0178.

5. Zhou K, West HM, Zhang J, Xu L, Li W. Interventions for leg cramps in pregnancy. Cochrane Database Syst Rev. 2015 Aug 11;(8):CD010655. https://doi.org/10.1002/14651858.CD010655.pub2.

6. Sikora-Szubert A, Kowalska-Koprek U, KarowiczBilińska A. The analysis of selected biochemical parameters concentration in pregnant women with idiopathic edema of the lower limbs – preliminary report. Ginekol Pol. 2012 Sep;83(9):660-4.

7. Khryshchanovich VYa, Skobeleva NYa. Medical prevention and management of varicose vein disease during pregnancy. Russian Bulletin of Obstetrician-Gynecologist. 2021;21(4):27-34. https://doi.org/10.17116/rosakush20212104127.

8. Erpolat S, Eser A, Kaygusuz I, Balci H, Kosus A, Kosus N. Nail alterations during pregnancy: a clinical study. Int J Dermatol. 2016 Oct;55(10):1172-5. https://doi.org/10.1111/ijd.13316.

9. Saliba OAJ, Rollo HA, Saliba O, Sobreira ML. Compression stocking prevents increased venous retrograde flow time in the lower limbs of pregnant women. Phlebology. 2020 Dec;35(10):784-91. https://doi.org/10.1177/0268355520939371.

10. Ismail L, Normahani P, Standfield NJ, Jaffer U. A systematic review and meta-analysis of the risk for development of varicose veins in women with a history of pregnancy. J Vasc Surg Venous Lymphat Disord. 2016 Oct;4(4):518-24. https://doi.org/10.1016/j.jvsv.2016.06.003.

11. Skudder PA, Farrington DT. Venous conditions associated with pregnancy. Semin Dermatol. 1993 Jun;12(2):72-7.

12. Tsakiridis I, Bakaloudi DR, Oikonomidou AC, Dagklis T, Chourdakis M. Exercise during pregnancy: a comparative review of guidelines. J Perinat Med. 2020 Jul 28;48(6):519-25. https://doi.org/10.1515/jpm-2019-0419.

13. Schardt C, Adams MB, Owens T, Keitz S, Fontelo P. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak. 2007;7(1):16. http://dx.doi.org/10.1186/1472-6947-7-16. PMid:17573961

14. Rathore SP, Gupta S, Gupta V. Pattern and prevalence of physiological cutaneous changes in pregnancy: A study of 2000 antenatal women. Indian J Dermatol Venereol Leprol. 2011 May-Jun;77(3):402. https://doi.org/10.4103/0378-6323.79741.

15. Tyler KH. Physiological skin changes during pregnancy. Clin Obstet Gynecol. 2015 Mar;58(1):119-24. https://doi.org/10.1097/GRF.0000000000000077.

16. Khunger N, Kandhari R. Ingrown toenails. Indian J Dermatol Venereol Leprol. 2012 May-Jun;78(3):279-89. https://doi.org/10.4103/0378-6323.95442.

17. Ponnapula P, Boberg JS. Lower extremity changes experienced during pregnancy. J Foot Ankle Surg. 2010 Sep-Oct;49(5):452-8. https://doi.org/10.1053/j.jfas.2010.06.018.

18. Panicker VV, Riyaz N, Balachandran PK. A clinical study of cutaneous changes in pregnancy. J Epidemiol Glob Health. 2017 Mar;7(1):63-70. https://doi.org/10.1016/j.jegh.2016.10.002.

19. Sehgal VN, Verma P, Srivastava G, Aggarwal AK, Verma S. Melasma: treatment strategy. J Cosmet Laser Ther. 2011 Dec;13(6):265-79. https://doi.org/10.3109/14764172.2011.630088.

20. Zieleniewski Ł, Schwartz RA, Goldberg DJ, Handler MZ. Voigt-Futcher pigmentary demarcation lines. J Cosmet Dermatol. 2019 Jun;18(3):700-2. https://doi.org/10.1111/jocd.12884.

21. Bieber AK, Martires KJ, Stein JA, Grant-Kels JM, Driscoll MS, Pomeranz MK. Pigmentation and pregnancy: knowing what is normal. Obstet Gynecol. 2017 Jan;129(1):168-73. https://doi.org/10.1097/AOG.0000000000001806.

22. Mehta N, Chen KK, Kroumpouzos G. Skin disease in pregnancy: The approach of the obstetric medicine physician. Clin Dermatol. 2016 May-Jun;34(3):320-6. https://doi.org/10.1016/j.clindermatol.2016.02.003.

23. Bergman H, Melamed N, Koren G. Pruritus in pregnancy: treatment of dermatoses unique to pregnancy. Can Fam Physician. 2013 Dec;59(12):1290-4.

24. Bechtel MA. Pruritus in pregnancy and its management. Dermatol Clin. 2018 Jul;36(3):259-65. https://doi.org/10.1016/j.det.2018.02.012.

25. Hay RJ. Mycetoma, mycoses and pregnancy. Acta Derm Venereol. 2015 Mar;95(3):259-60. https://doi.org/10.2340/00015555-2037.

26. Diagnostics and treatment of chronic venous disease: guidelines of Russian Phlebological Association. Flebologiya. 2018;12(3):146-240. (In Russ.). https://doi.org/10.17116/flebo20187031146.

27. Smyth RM, Aflaifel N, Bamigboye AA. Interventions for varicose veins and leg oedema in pregnancy. Cochrane Database Syst Rev. 2015 Oct 19;2015(10):CD001066. https://doi.org/10.1002/14651858.CD001066.pub3

28. Saliba OAJ, Rollo HA, Saliba O, Sobreira ML. Compression stocking prevents increased venous retrograde flow time in the lower limbs of pregnant women. Phlebology. 2020 Dec;35(10):784-91. https://doi.org/10.1177/0268355520939371.

29. Tsukanov YuT, Kropmayer KP, Tsukanov AYu, Beznoshchenko GB. Chronic venous diseases of the lower extremities and small pelvis in pregnant women and blood flow in the maternal-fetoplacental system. Flebologiya. 2012;1:20-7. (In Russ.).

30. Segiet OA, Brzozowa M, Piecuch A, Dudek D, Reichman-Warmusz E, Wojnicz R. Biomolecular mechanisms in varicose veins development. Ann Vasc Surg. 2015 Feb;29(2):377-84. https://doi.org/10.1016/j.avsg.2014.10.009.

31. Taylor J, Hicks CW, Heller JA. The hemodynamic effects of pregnancy on the lower extremity venous system. J Vasc Surg Venous Lymphat Disord. 2018 Mar;6(2):246-55. https://doi.org/10.1016/j.jvsv.2017.08.001.

32. Beznoshchenko GB, Kravchenko EN, Tsukanov YuT, Kropmayer KP, Tsygankova OYu. Varicose veins in pregnant women: Specific features of a gestational period, phlebohemodynamics of the small pelvis and lower limbs. Rossiyskiy vestnik akushera-ginekologa. 2016;3:4-8. (In Russ.). https://doi.org/10.17116/rosakush20161634-8

33. Bolz M, Körber S, Reimer T, Buchmann J, Schober HC, Briese V. The Treatment of Illnesses Arising in Pregnancy. Dtsch Arztebl Int. 2017 Sep 15;114(37):616-26. https:// doi.org/10.3238/arztebl.2017.0616.

34. Marques NR, Martinello C, Kramer GC, Costantine MM, Vadhera RB, Saade GR, et al. Passive leg raising during pregnancy. Am J Perinatol. 2015 Mar;32(4):393-8. https://doi.org/10.1055/s-0034-1389089.

35. Coban A, Sirin A. Effect of foot massage to decrease physiological lower leg oedema in late pregnancy: a randomized controlled trial in Turkey. Int J Nurs Pract. 2010 Oct;16(5):454-60. https://doi.org/10.1111/j.1440-172X.2010.01869.x.

36. Mozheyko LF, Tikhonovich EV, Perepelitsa SI. Aspects of pregnancy and labor in patients suffering from chronic venous insufficiency. Reproduktivnoye zdorovye. Vostochnaya Evropa. 2016;6(4):519-25. (In Russ.).

37. Benninger B, Delamarter T. Anatomical factors causing oedema of the lower limb during pregnancy. Folia Morphol (Warsz). 2013 Feb;72(1):67-71. https://doi.org/10.5603/fm.2013.0011.

38. Gardenghi LA, Dezotti NR, Dalio MB, Joviliano EE, Piccinato CE. Gestational lower limb edema and venous reflux in healthy primigravidae. Int Angiol. 2017 Dec;36(6):569-73. https://doi.org/10.23736/S0392-9590.17.03865-2.

39. Ochalek K. Three-year follow-up of the compression use in lower limb edema during pregnancy: a case report. J Vasc Nurs. 2021 Jun;39(2):43-6. https://doi.org/10.1016/j.jvn.2021.04.002.

40. Ochalek K, Pacyga K, Curyło M, Frydrych-Szymonik A, Szygula Z. Risk factors related to lower limb edema, compression, and physical activity during pregnancy: a retrospective study. Lymphat Res Biol. 2017 Jun;15(2):166-71. https://doi.org/10.1089/lrb.2016.0038.

41. Alcahuz-Griñan M, Nieto-Gil P, Perez-Soriano P, Gijon-Nogueron G. Morphological and postural changes in the foot during pregnancy and puerperium: a longitudinal study. Int J Environ Res Public Health. 2021 Mar 2;18(5):2423. https://doi.org/10.3390/ijerph18052423.

42. Gijon-Nogueron GA, Gavilan-Diaz M, Valle-Funes V, Jimenez-Cebrian AM, Cervera-Marin JA, Morales-Asencio JM. Anthropometric foot changes during pregnancy: a pilot study. J Am Podiatr Med Assoc. 2013 JulAug;103(4):314-21. https://doi.org/10.7547/1030314.

43. Segal NA, Boyer ER, Teran-Yengle P, Glass NA, Hillstrom HJ, Yack HJ. Pregnancy leads to lasting changes in foot structure. Am J Phys Med Rehabil. 2013 Mar;92(3):232-40. https://doi.org/10.1097/PHM.0b013e31827443a9.

44. Klein A. Peripheral nerve disease in pregnancy. Clin Obstet Gynecol. 2013 Jun;56(2):382-8. https://doi.org/10.1097/GRF.0b013e31828f260e.

45. Poděbradská R, Šarmírová M, Janura M, Elfmark M, Procházka M. The effect of physiotherapy intervention on the load of the foot and low back pain in pregnancy. Ceska Gynekol. 2019 Winter;84(6):450-7.

46. Wang Y, Li YQ, Tian MR, Wang N, Zheng ZC. Role of relaxin in diastasis of the pubic symphysis peripartum. World J Clin Cases. 2021 Jan 6;9(1):91-101. https://doi.org/10.12998/wjcc.v9.i1.91.

47. Karadag-Saygi E, Unlu-Ozkan F, Basgul A. Plantar pressure and foot pain in the last trimester of pregnancy. Foot Ankle Int. 2010 Feb;31(2):153-7. https://doi.org/10.3113/FAI.2010.0153.

48. Vico Pardo FJ, López Del Amo A, Pardo Rios M, Gijon-Nogueron G, Yuste CC. Changes in foot posture during pregnancy and their relation with musculoskeletal pain: a longitudinal cohort study. Women Birth. 2018 Apr; 31(2):e84-e88. https://doi.org/10.1016/j.wombi.2017.08.114.

49. Ojukwu CP, Anyanwu EG, Nwafor GG. Correlation between foot arch index and the intensity of foot, knee, and lower back pain among pregnant women in a South-Eastern Nigerian Community. Med Princ Pract. 2017;26(5):480-4. https://doi.org/10.1159/000481622.

50. Pires R, Labronici PJ, Giordano V, Kojima KE, Kfuri M, Barbisan M, et al. Intrapartum Pubic Symphysis Disruption. Ann Med Health Sci Res. 2015 Nov-Dec;5(6):476-9. https://doi.org/10.4103/2141-9248.177980.

51. Mei Q, Gu Y, Fernandez J. Alterations of pregnant gait during pregnancy and post-partum. Sci Rep. 2018 Feb 2;8(1):2217. https://doi.org/10.1038/s41598-01820648-y.

52. Ribeiro AP, João SM, Sacco IC. Static and dynamic biomechanical adaptations of the lower limbs and gait pattern changes during pregnancy. Womens Health (Lond). 2013 Jan;9(1):99-108. https://doi.org/10.2217/whe.12.59.

53. Liu J, Song G, Zhao G, Meng T. Effect of oral magnesium supplementation for relieving leg cramps during pregnancy: A meta-analysis of randomized controlled trials. Taiwan J Obstet Gynecol. 2021 Jul;60(4):609-14. https://doi.org/10.1016/j.tjog.2021.05.006.

54. Supakatisant C, Phupong V. Oral magnesium for relief in pregnancy-induced leg cramps: a randomised controlled trial. Matern Child Nutr. 2015 Apr; 11(2):139-45. https://doi.org/10.1111/j.1740-8709.2012.00440.x.