Corticosteroid Injection for an Orthopedic Complaint in a Female with Gestational Diabetes
Myrex et al. Sports Medicine - Open
Corticosteroid Injection for an Orthopedic Complaint in a Female with Gestational Diabetes
Palee Myrex 0
Lorie Harper 0
Sara Gould 0
0 Birmingham , USA
A female with gestational diabetes presented with hip pain characteristic of meralgia paresthetica and trochanteric bursitis. She had similar episodes prior to pregnancy that were treated successfully with non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections. However, NSAID use during pregnancy poses risks to the fetus and corticosteroids carry a risk of hyperglycemia, especially in those with diabetes. Unfortunately, all attempts made to treat her conservatively failed to improve her symptoms. The use of antenatal corticosteroids as an intervention for preterm labor has been documented, but to our knowledge, there are no published reports of corticosteroid injections for orthopedic complaints in someone with gestational diabetes. Review of her glucose log showed well-controlled levels, and subsequently, a corticosteroid injection was administered. Blood glucose levels were monitored for the next 48 h, and all measurements were within normal limits. The patient's symptoms resolved, and she went on to vaginally deliver a healthy term infant without complications, suggesting that gestational diabetes should not be used as absolute criteria to withhold corticosteroid injections for orthopedic complaints.
Gestational diabetes mellitus; Blood glucose; Corticosteroid injection
Orthopedic complaints in pregnant patients can be
difficult to treat as providers may be hesitant to
employ certain traditional therapies in the gravid
Corticosteroid injections are often used to help
fetal lung maturity during preterm labor, but
corticosteroids have not been studied for their use
to treat orthopedic complaints in the mother.
Although corticosteroids carry the risk of
hyperglycemia, gestational diabetes should not be
used as absolute criteria to withhold corticosteroid
injections for orthopedic complaints.
A 32-year-old female recently diagnosed with gestational
diabetes after an abnormal glucose challenge test (blood
glucose level of 206 mg/dL at 1 h) presented to the
sports medicine clinic at 30 weeks pregnant with lateral
hip pain. She described the pain as a “burning that
started in the lateral aspect of the left hip and radiated
down the lateral aspect of the thigh.” The patient also
reported lateral hip pain which was worse when rising
from a seated position, climbing stairs, and lying on her
left side. The pain was rated as a 2/10 in severity and
was similar to the pain she had prior to pregnancy that
was treated successfully with NSAIDs and a
corticosteroid injection into the trochanteric bursa. Physical exam
was notable for the absence of skin changes and absence
of tenderness to palpation in the left groin but positive
for tenderness to palpation in the lateral aspect of the
thigh as well as directly over the greater trochanter.
Range of motion testing was limited by her gravid
habitus, but there was normal external and internal rotation
of the left hip. Complete patient history and physical
exam were indicative of meralgia paresthetica as well as
Although her previous episodes had been treated
successfully with NSAIDs and corticosteroid injections,
NSAIDS are contraindicated in the third trimester of
pregnancy and her gestational diabetes placed her at an
increased risk of hyperglycemia from corticosteroid
injections. Conservative measures such as physical
therapy, education about weight loss, and instructions to
wear loose clothing were recommended; however, the
patient returned around 2 weeks later with no
improvement in her symptoms. The patient’s daily blood glucose
log was reviewed, and it showed an average fasting blood
glucose level of 92 mg/dL and an average postprandial
blood glucose level of 119 mg/dL. She was controlling
her blood glucose by diet and exercise alone. Clearance
was obtained by her OB/GYN to receive the
corticosteroid injection, and subsequently, the patient received an
ultrasound-guided injection of a sterile mixture
containing 4 cc 0.5% marcaine and 40 mg methylprednisolone
acetate into the left greater trochanteric bursa (Fig. 1).
Blood glucose levels were closely monitored for the next
48 h, and all readings were within normal limits. At a
1month follow-up, the patient reported that the pain was
significantly improved, now rated as 0/10, and therefore,
she had returned to her normal exercise routine.
Approximately 6 weeks after the steroid injection, the
patient vaginally delivered a 3000-g male at 38 weeks and
1-day gestation. There were no complications, and the
baby tolerated delivery well, recording APGAR scores of
7 at 1 min and 9 at 5 min.
Our patient was experiencing meralgia paresthetica and
trochanteric bursitis, both orthopedic conditions that
can be related to the physiologic and anatomic changes
of pregnancy [
]. Glucocorticoids are potent
immunosuppressive and anti-inflammatory drugs indicated for
various orthopedic complaints including refractory
meralgia paresthetica and trochanteric bursitis. However,
a potentially serious complication of corticosteroid use,
especially in a patient with gestational diabetes, is their
propensity to cause hyperglycemia and possibly diabetic
]. Diabetic ketoacidosis during
pregnancy poses significant risk to the fetus as a single
episode of diabetic ketoacidosis is associated with a 10–25%
fetal loss rate [
]. Despite the risks associated with these
drugs, they can still be used safely in pregnancy. A prime
example is the use of antenatal corticosteroids to
accelerate lung maturity in the fetus of a threatened preterm
]. The benefits of improved fetal survival are so
great that the National Institute of Health and Care
Excellence (NICE) state in their clinical guidelines that
“diabetes should not be considered a contraindication to
antenatal steroids for fetal lung maturation .” NICE
provides general guidelines for managing this subset of
patients, yet they emphasize that each individual should
be managed on a case-by-case basis.
Although the guidelines for administration of
antenatal corticosteroids in threatened preterm labor are
documented, there is little data about corticosteroid
injections for orthopedic complaints in pregnant women,
especially those with gestational diabetes . As the
prevalence of gestational diabetes is increasing, clinical
scenarios such as the one with our patient are also likely
to increase. Therefore, we felt it was necessary to share
this report to draw attention to an important clinical
complication and demonstrate the safety of an
intervention that might otherwise be withheld during pregnancy
due to concerns of the possible complications. Despite
having gestational diabetes, our patient’s daily blood
glucose levels were controlled and she tolerated the
corticosteroid injection well. Her symptoms improved
markedly, and there were no significant adverse effects
on her blood glucose or subsequent impact on the baby.
This absence of adverse effects may be due to
nonfluorinated glucocorticoids, such as methylprednisolone,
having minimal placental transfer . In summary, all
cases should be handled on an individual basis but
gestational diabetes should not be an absolute contraindication
for corticosteroid injections used to treat orthopedic
NICE: National Institute of Health and Care Excellence; NSAIDs: Non-steroidal
There was no funding received for this research.
Availability of Data and Materials
PM was involved in designing, collecting, and analyzing the information, as
well as drafting of the manuscript. SG was involved in the conception and
design, collection, and analysis of the information as well as revision of the
manuscript. LH was involved in the analysis as well as revision of the
manuscript. All authors read and approved the final version to be published.
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Palee Myrex, Sara Gould, and Lorie Harper declare that they have no conflict
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