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Definitions

Gestation: Entire period from fertilization to birth (Benagiano 2023a)

Pregnancy: Begins after implantation and placental formation and includes maternal changes to support fetal growth and development - including extensive physiological, metabolic and hormonal adaptations (Benagiano 2023b).

Postpartum: Referred to as the '4th Trimester' - defined as the period beginning immediately after delivery and extending to 12 weeks after birth (Paladine 2019)

"Pseudo short-arm syndrome": an increase in the distance between the person and the piano due to the circumference of the abdomen associated with pregnancy. Worz-Bilfinger identified strain on the upper arm / shoulder girdle due to positioning difficulties associated with pregnancy that was addressed by positioning the height of the piano with the patient playing in a standing position ((Worz-Bilfinger 2009) 

Full Presentation (44 min 17 sec)

Focus on brass instrument playing (2 min 59 sec)

Background in General

Work-related problems associated normal physiology generally escape consideration in the context of providing music-related medical advice that more commonly addresses disease processes. Articles in medical journals addressing pregnancy in musicians are scarce and often limited to small series or case reports.  On-line informal sources address the issue more commonly, but generally present information from surveys, personal experience, or opinion.

 Worz-Bilfinger identified female gender specific impediments to performance in three case studies addressing the 'pseudo short--arm syndrome' associated with pregnancy, shoulder girdle pain associated with heavy mammae associated with breast feeding, and 'pseudo breathing-problems' during menstruation (Worz-Bilfinger 2009)

Women in Live Music (WILM) is an online community for women and minorities working within live events and includes musicians, sound engineer, tour managers, stage managers and more (Women in Live Music 2020). They published an on-line survey of women aged 18 to 35+ dividing respondents into 3 categories in the table below. The authors identify from their survey 'the most alarming results to be the 28% of women who have felt the need to hide their pregnancy at work" 

Orchestral performers have adapted to pregnancy through collaboration including use of a "shared lacy black long gown for pregnancy" (Horvath 2019). The capacity to continue performing almost to the point of delivery appears to be greater for violinists who hold their instrument under their chins - and distinguished from cellists - leading Horvath to identify that she performed until the 'cello wobbled, when I was too big to hold or reach around the cello". 

Head and Neck:

Factors affecting (including a useful listing of pharmacologic agents and potential impact on pregnancy) were reviewed by Lawlor et al (2023) identifying

• Gastroesophageal Reflux and Heartburn is common as Broussard et al identified in 45 to 85% of pregnant women (Broussard 1998) and attributed to hormonal effects of estrogenand prgesterone on lower esophagel sphincter function. Additional consideration for increased abdominal pressure, abnormal gastric emptying, and delayed small bowel transit have also been implicated (Thélin 2020).
• Voice -Saltürk et al (2015)identified studies suggesting changes to hormone levels during the menstrual cycle correlated with best voicing during highest estrogen levels (ovulatory phase) and huskier voice with lower pitch and vocal fatigue during the premenstrual period. The evaluated voice changes during each of the three trimesters of pregnancy to identify the only detected difference was decreased maximum phonation time isolated to the third trimester attributed to decreased breathing capacity. Perceived difficulty in their own voice was also limited to those in the third trimester (assessed with Voice Handicap Index).
  • Ghaemi H et al (2018) compared healthy women (93 pregnant / 31 non-pregnant) non-voice professionals without previous voice complaints with voice analysis supplemented by videostroboscopy focussed on vocal fold edema, movmeent and symmetry. No identifiable abnormalities were detected on videostroboscopy with the dominant voice analysis change seen only in the pregnant group during the third trimester identifying a reduction in maximum phonation time, and increase in S:Z ratio, and as self rated decrement in voicing per the VHI (Voice Handicap Index.
  • Cassiraga et al (2012) compared 44 pregnant women in their third trimester with 45 non pregnant controls with an sophisticated vocal assessment identifying significantly greater breathiness and hoarseness in the pregnant group. These researchers suggest that the impact of estrogen and progesterone causes the laryngeal tissue to become hyperemic and edematous with thickening of the vocal folds contributing to the dysphonia. Additional changes in breathing (using upper aspect of the lungs = clavicular breathing) results in worse respiratory support.
• Hearing may be affected during pregnancy most commonly with small fluctuations with eustachian tube dysfunction common - usually with resolution after delivery (Frosolini 2021)
• Nasal congestion - 'rhinitis of pregnancy' has been reported in 20-30% of pregnancies based on the symptoms of nasal congestion and rhinorrhea without other identifiable cause. Gani et al (2003) suggest it may be addressed primarily by saline nasal rinses and generally resolves 2 weeks following delivery.
• Epistaxis (nose bleed) was identified with a matched pair analysis identifying an increased prevalence of 20.3% with pregnancy compared to 6.2% nonpregnant  (Dugan-Kim 2009)
• Excessive salivation during pregnancy  termed 'ptyalism gravidarum' or 'sialorrhea of pregnancy' has been reported in 0.3 to 35% of pregnant patients with symptoms usually abating in second trimester but may continue to delivery (Thaxter 2016). Ptyalism gravidarum has been most commonly found in patients also complaining of nausea and vomiting in pregnancy - and has been associated with eating disorders in pregnancy.

Management

As per Marisa Bloom "'there isn't a lot of advice circulating in cyberspace about playing a show while pregnant" (Bloom 2024). As an 'pretty athletic person, wielding a guitar' Bloom identified the following adjustments that worked for her:

1. Focus on fun   /   2. Scale back as needed   /    3. Hydrate  /   4. Control your environmemnt (such as access to a bathroom) / 5. When it comes to lugging equipment, don't be a hero

References

Wörz-Bilfinger D. Special performing problems of female musicians: three case studies. Work. 2012;41(1):33-6. doi: 10.3233/WOR-2012-1241. PMID: 22246301.

Horvath J: Pregnancy, Motherhood, and Playing Music   Interlude  July 6th, 2019   <accessed 1-14-2025  https://interlude.hk/pregnancy-motherhood-playing-music/>

Bloom MT: Playing a Rock Gig While Pregnant: Advice from Mamas Who've Done it   Rock Mommy  Sept 23, 2024 <accesed 1-14-2025 https://rockmommy.com/2016/09/playing-a-rock-gig-while-pregnant-advice-from-mamas-whove-done-it/ >

Women in Live Music:  Pregnancy and Motherhood in the live Music Industry  June 2020 <accessed 1-14-2025 https://womeninlivemusic.eu/wp-content/uploads/2020/06/Pregnancy-Motherhood-Survey-REPORT_Final.pdf>

Lawlor CM, Graham ME, Owen LC, Tracy LF. Otolaryngology and the Pregnant Patient. JAMA Otolaryngol Head Neck Surg. 2023;149(10):930–937. doi:10.1001/jamaoto.2023.2558

MacDonald LA, Johnson CY, Lu ML, Santiago-Colón A, Adam GP, Kimmel HJ, Napolitano PG, Saldanha IJ. Physical job demands in pregnancy and associated musculoskeletal health and employment outcomes: a systematic review. Am J Obstet Gynecol. 2024 Jun;230(6):583-599.e16. doi: 10.1016/j.ajog.2023.12.014. Epub 2023 Dec 17. PMID: 38109950; PMCID: PMC11139607.

Murphy VE, Jensen ME. Longitudinal Changes in Upper and Lower Airway Function in Pregnancy. Immunol Allergy Clin North Am. 2023 Feb;43(1):17-26. doi: 10.1016/j.iac.2022.07.005. Epub 2022 Oct 28. PMID: 36411003.

Ejikeme C, Nandakumar V, Gotur D. Respiratory physiological changes in pregnancy. Respir Med. 2025 Sep;246:108245. doi: 10.1016/j.rmed.2025.108245. Epub 2025 Jul 3. PMID: 40614834.

Female Athlete Issues for the Team Physician: A Consensus Statement—2017 Update. Medicine & Science in Sports & Exercise 50(5):p 1113-1122, May 2018. | DOI: 10.1249/MSS.0000000000001603 

Paladine HL, Blenning CE, Strangas Y. Postpartum Care: An Approach to the Fourth Trimester. Am Fam Physician. 2019 Oct 15;100(8):485-491. PMID: 31613576.

ACOG Committee Opinion No. 736 Summary: Optimizing Postpartum Care. Obstet Gynecol. 2018 May;131(5):949-951. doi: 10.1097/AOG.0000000000002628. PMID: 29683906.

Frosolini A, Marioni G, Gallo C, de Filippis C, Lovato A. Audio-vestibular disorders and pregnancy: a systematic review. Am J Otolaryngol. 2021;42(5):103136. doi:10.1016/j.amjoto.2021. 103136

Thaxter Nesbeth KA, Samuels LA, Nicholson Daley C, Gossell-Williams M, Nesbeth DA. Ptyalism in pregnancy—a review of epidemiology and practices. Eur J Obstet Gynecol Reprod Biol. 2016;198:47-49. doi:10.1016/j.ejogrb.2015.12.022

Gani F, Braida A, Lombardi C, Del Giudice A, Senna GE, Passalacqua G. Rhinitis in pregnancy. Eur Ann Allergy Clin Immunol. 2003;35(8):306-3

Saltürk Z, Kumral TL, Bekiten G, Atar Y, Ataç E, Aydoğdu İ, Yıldırım G, Kılıç A, Uyar Y. Objective and Subjective Aspects of Voice in Pregnancy. J Voice. 2016 Jan;30(1):70-3. doi: 10.1016/j.jvoice.2015.02.013. Epub 2015 Apr 23. PMID: 25913751.

Broussard CN, Richter JE. Treating gastro-oesophageal reflux disease during pregnancy and lactation: what are the safest therapy options? Drug Saf. 1998;19(4):325-337. doi:10.2165/00002018-199819040-00007

Thélin CS, Richter JE. Review article: the management of heartburn during pregnancy and lactation. Aliment Pharmacol Ther. 2020 Feb;51(4):421-434. doi: 10.1111/apt.15611. Epub 2020 Jan 17. PMID: 31950535.

Cornthwaite K, Varadharajan K, Oyarzabal M, Watson H. Management of prolonged epistaxis in pregnancy: case report.J Laryngol Otol. 2013;127 (8):811-813. doi:10.1017/S0022215113001576

Dugan-Kim, M. , Connell, S. , Stika, C. , Wong, C. A. & Gossett, D. R. (2009). Epistaxis of Pregnancy and Association With Postpartum Hemorrhage. Obstetrics & Gynecology, 114 (6), 1322-1325. doi: 10.1097/AOG.0b013e3181bea830.

Abitbol J, Abitbol P, Abitbol B. Sex Hormones and the Female Voice. J Voice. 1999;13:424–446

Cassiraga VL, Castellano AV, Abasolo J, Abin EN, Izbizky GH. Pregnancy and voice: changes during the third trimester. J Voice. 2012 Sep;26(5):584-6. doi: 10.1016/j.jvoice.2011.10.004. Epub 2012 May 11. PMID: 22578433.

Ghaemi H, Dehqan A, Mahmoodi-Bakhtiari B, Scherer RC. Voice Changes During Pregnancy Trimesters in Iranian Pregnant Women. J Voice. 2020 May;34(3):358-363. doi: 10.1016/j.jvoice.2018.09.016. Epub 2018 Nov 2. PMID: 30393048.

Nessel E. The problem of voice changes during pregnancy. Munch Med Wochenschr. 1959;5:1007–1009. 

Flach M, Schwickardi H, Simon R. What effect does menstruation and pregnancy have on the trained singing voice. Folia Phoniatr (Basel). 1969;21:199–210

Benagiano, Giuseppe; Salvatore Mancuso, MD, PhD; Luca Gianaroli, MD, PhD; Gian Carlo Di Renzo, MD, PhD Gestation vs pregnancy American Journal of Obstetrics & Gynecology, Volume 229, Issue 2, 91 - 92 August 2023 (a)

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