Current Topics in Women's Sports Medicine

Evaluation and Treatment of the Female Athlete

Miho J. Tanaka, MD

Disclosures

Curr Orthop Pract. 2019;30(1):11-15. 

In This Article

Evaluation and Management of Injuries in the Pregnant Athlete

Very little information exists on the evaluation and treatment of female athletes in the setting of pregnancy, yet this is a unique area within women's sports medicine that is gaining increasing attention due to the sports participation of several elite female athletes during or after their pregnancies. Despite the understanding of pregnancy-related gait changes and changes in ligamentous laxity that can occur, the prevalence of orthopaedic conditions during pregnancy is not well described because of the multidisciplinary nature of this problem. Orthopaedic surgeons are often unaware of the specific modifications and considerations for maternal and fetal health in the management of sports medicine injuries and can be hesitant to treat this population. Because of this, collaborations with maternal fetal medicine specialists are paramount in the treatment of a pregnant female athlete, as well as to guide future research in this area.

In the case of a pregnant athlete who presents with an injury, radiographs of the extremities can be obtained during routine evaluation. Patients should be counseled about the risks of undergoing versus not undergoing imaging. The estimated threshold of radiation-induced teratogenesis ranges from 50–100 mGy 0–2 wk after fertilization to 250–280 mGy at 16–25 wk.[46] The estimated threshold at various stages of pregnancy for radiation-induced teratogenesis are detailed in Table 2. In general, radiography of the extremity leads to an estimated fetal dose of <0.001 mGy and falls far below this threshold.[47] The fetal radiation dosages per commonly performed imaging modalities in a sports medicine practice are detailed in Table 3. Appropriate modifications at the time of imaging include minimizing the exposure of the fetus to radiation by reducing field size, usage of intensifying screens, limiting exposure times, and reducing absolute dose, as well as shielding the fetus.[48] Pelvic and serial scanning should be performed with caution.

MRI during pregnancy is considered to be relatively safe, and no harmful effects from the use of clinical MRI have been identified to date. According to the American College of Radiology Guidelines from 2013, "no special consideration is recommended for the first, versus any other, trimester in pregnancy."[49] However, it should be confirmed that the information sought from the imaging study cannot be acquired by other nonionizing means such as ultrasonography. Furthermore, despite the relative safety of MRI, as with any study, the imaging should only be obtained if the data should potentially affect the care of the patient during the pregnancy, and that it would not be prudent to wait until after delivery.[49] Contrast agents such as gadolinium have known potential risks to the fetus, and therefore should not be routinely provided to pregnant patients.[49]

In the treatment of the pregnant athlete, nonsteroidal antiinflammatory medications should be avoided because of the reported teratogenic effects. Cortisone injections may be considered when necessary, as systemic steroids are considered safe during pregnancy and lactation, given lack of contraindication due to any systemic disorders. Surgical treatment should be delayed until after delivery if possible. If not, the second trimester has been reported to be the safest time frame for this due to the lowest likelihood for preterm contractions and spontaneous abortion.[50] Any surgical considerations should be performed with an obstetric anesthesiologist and team to ensure proper considerations in medication, fetal monitoring, and positioning.

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