OB Cough Induced Rib Fracture? YEP. It’s a Thing.

Summary

Podcast Summary: Dr. Chapa’s OBGYN Clinical Pearls

Episode: OB Cough Induced Rib Fracture? YEP. It’s a Thing.
Date: February 2, 2026
Host: Dr. Chapa

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Overview

This engaging episode of Dr. Chapa’s “OBGYN Clinical Pearls” explores an unusual, but clinically relevant, phenomenon: cough-induced rib fractures during pregnancy. Using a real case from his practice, Dr. Chapa delves into the mechanisms, diagnostic challenges, and management strategies for this rare occurrence. Through evidence-based discussion, Dr. Chapa emphasizes the value of considering rare “zebras” in clinical practice—while also reinforcing the importance of careful diagnosis, patient safety, and thoroughness.

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Key Discussion Points & Insights

1. “Horses vs. Zebras”: Thinking Beyond the Common Diagnoses

• Quote (00:09): “When you hear horse hooves, think of horses, not zebras... but sometimes when you hear horse hooves, they're not horses. It's actually a zebra.” – Dr. Chapa
  • Dr. Chapa opens with the well-known medical adage, encouraging clinicians to stay open-minded for rare but possible diagnoses, especially when standard presentations don’t fit.

2. Case Presentation: The Unusual Rib Fracture (01:00 – 04:00)

• Case Details:
  • Healthy, multigravida woman at 34 weeks gestation.
  • Developed sudden, sharp left chest pain after coughing during her lunch break.
  • No trauma, no bruising, no history suggestive of abuse, nor other risk factors.
• Initial Diagnostics:
  • X-ray negative; clinical suspicion remained high.
  • On further review and CT imaging, a small non-displaced rib fracture was found.
• Quote (01:34): “She went out from work... and she coughed and. Oh, immediately... stabbing pain on her left side of her chest.”
• Quote (03:05): “The initial X Ray was read out as negative... So we got a further scan, and the CT scan very clearly saw the fracture.”

3. Mechanisms and Predisposing Factors (06:47 – 09:50)

• Physical Changes in Pregnancy:
  • Third trimester anatomical shifts increase pressure and alter rib cage mechanics.
  • Ligamentous relaxation and changes in abdominal wall dynamics make ribs more vulnerable.
• Literature Review:
  • Case reports date back to 1979 and 1998 documenting cough-induced rib fractures in pregnancy.
  • Largest review cited 35 cases, most in third trimester, with ribs 8-11 being most affected.
• Quote (07:44): “Just based on the exact same transmission of force at the right time. Specifically, the small ribs, AKA the floating ribs, are more prone to injury, especially with their little distal tips.”

4. Differential Diagnosis and Safety Considerations (09:50 – 12:50)

• Rule Out Trauma & Abuse:
  • Importance of checking for bruising, injury mechanism, and abuse.
  • Need to differentiate from metastasis or pathological fractures.
• Bone Remodeling in Pregnancy:
  • Increased bone resorption as a physiological response; bone formation decreases.
  • Bone turnover markers unreliable during pregnancy.
• Quote (11:38): “Pregnancy itself... causes bone resorption in the woman. Now, I know that sounds scary, but we've known this for about, oh, over 20 years... Bone resorption markers are not representative of what's actually going on in the body because they are totally thrown off in pregnancy.”

5. Calcium, Vitamin D, and Bone Health Perspective (12:50 – 15:15)

• Supplementation:
  • Especially important in teens or women with low sun exposure or low weight-bearing activity.
  • Vitamin D deficiency common; reasonable to screen, but guidelines are variable.
• Breastfeeding Considerations:
  • Recommends continued calcium and vitamin D intake postpartum, especially if breastfeeding.
• Quote (14:22): “Especially if they're going to breastfeed, they should take extra vitamin D and calcium along with weight bearing exercise to help protect their bone.”

6. Management Strategies (15:15 – 17:30)

• Conservative Treatment:
  • Non-displaced fractures: focus on multimodal pain control (acetaminophen preferred, NSAIDs limited to before 28 weeks).
  • Encourage pulmonary hygiene to avoid complications (e.g., incentive spirometry to prevent atelectasis).
• Quote (15:55): “As long as it's not displaced, ... the first line for a non displaced rib fracture is as it is for anybody... it's multimodal pain control with limitation of course on opioids.”
• Key Management Takeaways:
  • No need for bone turnover markers.
  • Conservative care is mainstay unless complications arise.

7. Memorable Moments & Clinical Pearls

• Recurrent Mantra (00:36, 03:02, 03:52, 18:32): “One rib. One rib.” – Dr. Chapa
  • Used throughout as a catchy refrain highlighting the case’s oddity.
• Clinical Pearl:
  • Stay cautious about discarding unusual presentations just because they seem rare—occasionally, they really are “zebras.”
• Quote (18:35): “Sometimes things that we hear are... bizarre and that they truly are zebras. So just because somebody has never heard of it doesn't mean it doesn't exist.”

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Important Timestamps

| Timestamp | Segment Description | |-------------|-----------------------------------------------------| | 00:09 | “Horses, Not Zebras” adage, opening remarks | | 01:00 – 04:00 | Case presentation and diagnostic journey | | 06:47 – 09:50 | Mechanisms, literature history, and evidence | | 09:50 – 12:50 | Differential diagnosis and bone health in pregnancy| | 12:50 – 14:22 | Calcium, Vitamin D, and clinical guidance | | 15:15 – 17:30 | Management, conservative care, follow-up advice | | 18:32 – 18:35 | Closing clinical pearl: sometimes it is a zebra |

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Takeaway

Dr. Chapa highlights the importance of not dismissing rare diagnoses, even in routine clinical scenarios. Cough-induced rib fractures in pregnancy, though rare, are documented and should be considered in the right clinical context. Detailed evaluation, judicious use of imaging, a solid understanding of physiologic changes in pregnancy, and a conservative, safety-first management approach are key. And above all: “When you hear horse hooves… sometimes, it really is a zebra.”

Transcript

[Dr. Chapa]

Foreign.

I'm sure you've heard this during training, whether it was medical school, nursing school, Penn school, whatever. You probably heard this from one of your attendings. When you hear horse hooves, think of horses, not zebras, Right? Meaning common things are common and rare stuff. Well, by definition, are rare, but sometimes when you hear horse hooves, they're not horses. It's actually a zebra.

One rib. One rib.

Sometimes things are so out there, you're like, surely it can't be this thing. But it turns out to be exactly the issue. Stress fractures are common in athletes and military recruits and those who carry heavy weights. We get that because of the physical forces placed on long bones. Remember, the stress fracture is defined as either a partial or a complete fracture of a bone. That's a result from repeated application of stress or forces that lead to weakening of the bone. And then you get the stress fracture. We get that. However, pregnancy is not immune to strange and unusual and new forces on the body. Now, it's okay. The female body is meant for pregnancy. It's an adaptable change. But that doesn't mean the body is free from some kind of injury. So here's where we're going in this case. In this episode, we're gonna present a real case that our team had not long ago on our OB service. Where she was at 34 weeks is so bizarre. 34 weeks, otherwise healthy, no issues. She's a multigravida, by the way. And she went out from work to. To. For her lunch break and she coughed and. Oh, immediately. I mean, at that split moment, she had a stabbing pain on her left side of her chest. Now, I know what you're thinking, oh, my goodness, it's a pe. No, no shortness of breath, just a stabbing pain that was worse with arm movement. Weird. Short of it is. Here it is. Let's just get to the zebra. She had an OB cough induced rib fracture. An OB cough induced rib fracture. So before you go, no, that's probably an abuse issue. Well, we asked. It wasn't. Plus, there was no overlying skin trauma or bruising that would suggest that she took a blow to the area. Bizarre. So here's the question. Is this thing reportable? Is this in the literature? The answer is, yeah, it's actually a thing. And it's a real zebra that we took care of. My point is this. When something is out there, when you hear horse hooves, yes, think of horses. But sometimes it just may be a zebra.

One rib. One rib.

So here's where we're going. The initial X Ray was read out as negative. Remember, it's a small little break in the typical spot where these things happen. I'm gonna explain here in a minute. Bizarre. So we got a further scan, and the CT scan very clearly saw the fracture. All right, so a couple of lessons here. Number one, sometimes it is a zebra. Number two, when something is initially read out as negative, look at it yourself and call the radiologist to say, no, man, we got to go through this again, because something's not making sense here. And very clearly on the reread with us on the phone, like, oh, my gosh, it's a so rib fracture. Classic right here. And it's also classic that we see. Here it is, guys. In pregnancy, one rib.

One rib.

Yep. One little rib had its fracture. So we're going to talk about this. Our bone remodel test necessary for this workup. Do we have to make sure this isn't something else? Trauma being number one, and we're going to get into all of that in this episode. It's. It's odd. So here's the thing, guys. When something out there presents, think broad and then narrow it down. And don't let go of that diagnosis until it is either completely ruled in or ruled out. You see, once the initial X ray came back, this was. We. We adopted this case in the morning. And the initial night team said, well, I don't know. It sure sounded like a rib fracture. It hurts with movement, hurts with deep palpation, but it was negative on the scan. But don't let it go. I mean, I was like, that sounds exactly like a rib fracture. You gotta keep looking. And sure enough, it was found.

You're breaking the ribs.

So something broke the ribs. And in this case, it was one rib, and it was her own cough. Fascinating. I think I've set it up enough. We'll be right back.

Foreign.

This is Dr. Chapa's ob gyn no spin podcast.

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[Dr. Chapa]

Yeah, a cough related rib fracture in pregnancy. Now, if you're not pregnant and you cough really hard, the chance of you breaking a rib is negligible. Unless you have some other really bad issue, maybe a metastasis. We'll get into that in a little bit. And this wasn't the case here. Potentially something like osteogenesis imperfecta, where just the right amount of force in theory could do it. So there's other things that could be involved here that the patient did not meet either history criteria for or other physical exam findings for. She had no past history of a fracture. This was timed specifically to a cough on her lunch break. Boom. Broken ribbon. Yes, it actually is very well published, even though, of course, there's no large scale studies that have looked at this because it's kind of a zebra. There are some recent publications on this, mainly as case reports, small case series that have explained this phenomenon. This is, this is a very true issue. And watch this, guys. Nothing new as of now. It's not like, oh my gosh, it was just discovered, you know, two years ago. Because one of the earliest findings, one of the earliest publications I found on this was back in 1979. 1979 in international surgery. That was one. And then again, there was a really nice review in 1998. This one was published in the International Journal of Obstetrics and Anesthesia. Go figure. The short of it is they give good reviews as to why rib fractures in pregnancy are much more likely. Obviously there's physical changes to the dynamics and the dimensions of the chest put together with changes in the ligamentous structure and forces of a cough. And they say, sure enough, just based on the exact same transmission of force at the right time. Specifically, the small ribs, AKA the floating ribs, are more prone to injury, especially with their little distal tips. And that's exactly what happened here. All right, so these changes to the rib cage and their effects on the mechanics, very well described. That was back in 1979. And another very nice review in 1998, that one published in the International Journal of Obstetrics. Anesthesia really explain the dynamics here. So, yes, it absolutely is a thing. Now there actually is a relatively large review, large meaning an end of the 35 cases. And that's the one of the biggest we're going to get because again, it is pretty much a zebra. But Long et Al described 35 cases, I'm actually pretty impressed by that. Of patients with a rib fracture due to coughing. And here it is guys, in the third trimester, just like this patient. Because that's where the rib cage gets most of its stress in terms of the anatomical changes and the dimensions that change from the third trimester. Pregnancy crazy. Now, most of these patients had fractures. Fractures of rib 8 to 11 of those are again, fractures of ribs 8 to 11. And here's what's interesting. While in non pregnant women, the ones that are most likely affected are six through seven. All right, so again, there are different dynamics and it's the lower part of the rib cage that's most prone to injury by the normal mechanics of the abdominal wall during pregnancy. But if the woman is non pregnant, those ribs tend to be a little bit higher up, meaning six through seven. All right, now here's a weird part. So cough induced rib fractures, look how the body works. Amazing. Fractures of the ribs by a cough, by a normal anatomical change. Yes, that's reported in pregnancy, though again, still kind of rare. However, here's what's crazy with an OB trauma. Oddly enough, rib fractures are actually less common than fractures of other things like the pelvis or the long bones. So if somebody asks you, what's the bone more likely to break in pregnancy? What which one? I mean the rare stuff is like the ribs because of the changes in the dimensions and the size of the rib cage. But actually trauma related rib fractures in pregnant women actually occur at lower rates than in non pregnant women. Strange. Is that weird or what? So once again, while rib fractures can happen in pregnancy with a cough, trauma related rib fractures in pregnant women actually occur at lower rates than in non pregnant women. So it's a weird kind of dynamic here. You would think if they are more prone to have a break with a cough, surely you can have a trauma related rib fracture in pregnant. But trauma related rib fractures in pregnancy actually occur at lower rates than in non pregnant women. The most common kind of bone injury that happens in the trauma of course is long bones or the pelvis or a spine, based on how it's hit. But if you're talking about specifically of the ribs, trauma related rib fractures in pregnant women actually occur at lower rates than in non pregnant women. Just a very strange, very strange and kind of ironic little fact. There's. All right, so very quickly, because we're going to do this quick, I just wanted to call attention to this really strange occurrence what do we do with this thing? Well, first, of course, for patient safety, if you have a patient with a rib fracture in pregnancy or not. But in this case, we're focusing on pregnancy, obviously, look for trauma, ask of abuse, and in order for there to be a rib fracture in general, there's going to be some kind of ecchymosis or bruising on the chest wall, which this patient did not have. Not that every bruising on the chest wall is abuse. She very well could have fallen. We've had that where a patient's had a rib fracture because she fell on the side of the tub. That's a thing. But we gotta make sure that the history and the exam doesn't support abuse. And in this case, it did not. Second, we had to look at all the bones, take a look at the bones on the other film and tell the radiologist, is there any kind of lytic lesion here that we need to be aware of? Because pathological fractures can happen as a result of bony metastases. That was not the case here. So this brings up a question that our team discussed. Should we get markers of bone turnover while she's pregnant to look to see if there's some kind of weird parathyroid issue? Is there some kind of bone resorption going on? To which I rose my hand and said, oh, she totally has a bone resorptive issue. Of course, the intern found that fascinating. They're like, oh my gosh, what kind of deficiency does she have? I said, no deficiency. It's actually something that's additive the child because pregnancy itself. Guys, remember, here's a clinical pearl. Pregnancy itself causes bone resorption in the woman. Now, I know that sounds scary, but we've known this for about, oh, over 20 years, actually like 30 years. Bone resorption markers are not representative of what's actually going on in the body because they are totally thrown off in pregnancy. So the good news is, is that the changes that happen during pregnancy and during lactation do not seem to have any long term fracture risk. Those are all temporary and they all, you know, recoup that bone mass after lactation. But yes, pregnancy itself definitely changes bone resorption markers. So they're not able to be used in pregnancy. There's a lot of changes there. Bone resorption actually kicks in, whereas bone formation kind of drops a little bit and it's progressive throughout the trimesters. I know it sounds scary and, but trust me, this is a normal part of the body's adaptation to pregnancy, ensuring that there's adequate calcium for the child. Amazing. That's why even though there's no real formal guideline for calcium, I think especially in teenagers or those who don't do a lot of weight bearing, yeah, supplemental calcium and even vitamin D in that context can be helpful. We've covered vitamin T supplementation, vitamin D supplementation in pregnancy before. Before. There's really no set guidance of that. You should check a level unless you live in very weather prone areas where there's not a lot of sunlight. And that's controversial because others say we're all vitamin D deficient. And vitamin D is very necessary for a lot of different mechanical and enzymatic processes in the body. And I'm in that line. I think it's very reasonable to check vitamin D since most people just aren't going outside anymore as we used to and vitamin D deficiency is an issue. So calcium and vitamin D, especially in adolescence can have some hindering effects on this bone resorption, although obviously it doesn't completely eliminate that process. So bone resorption markers are just not useful at all during pregnancy because yeah, she's actually in a bone resorptive state that does not seem to have any long term fracture risk issues. That's why if you're going to have someone who's going to breastfeed, and I'm all for breastfeeding, I mean, I think it's phenomenal and they should, but obviously not feel guilty. You know, don't make them feel guilty. They can't or don't want to. That's a personal choice. But especially if they're going to breastfeed, they should take extra vitamin D and calcium along with weight bearing exercise to help protect their bone. But yes, she is absolutely. Pregnancy is a bone resorptive state. But you don't need bone markers to show that because C peptide and antelopeptide, you know, collagen one and collagen two, all those little urinary and serum markers are fine to check, maybe in menopause, but in pregnancy they mean very little. Okay, all right, fine. So that's a little bit about diagnosis. What do we do here in terms of management? Well, the good news is that as long as it's not displaced, as long as it didn't pop a lung, which it did not in this case, you just ride it out. Okay, so the first line for a non displaced rib fracture is as it is for anybody, including men, it's multimodal pain control with limitation of course on opioids. You want Tylenol and NSAIDs first and then. And NSAIDs only if you're able. Remember, no NSAIDs after 28 weeks. So she couldn't do it in this case. And then maybe some cold or warm compresses, maybe the use of some muscle relaxers that if they're not contraindicated in pregnancy, and it will heal. So the short of it is, it's all conservative care. Now, some have published opinions, like maybe a regional anesthetic block can help with arm movement. That's fine. A little bit more invasive, obviously, but for the most part, it's just acetaminophen and NSAIDs as long as it's not prohibited by the EGA and it will heal by themselves. It just takes time. But as long as it's not displaced, it will get better. So. Oh, and another thing is they got to be able to take deep breaths. You got to tell them, look, it hurts to take a deep breath. You got to still do it. So maybe incentive spirometry so they don't have airway plugging and door, maybe a little bit of aspiration. That's also been been documented. They've got to have good pulmonary hygiene in these patients so that they don't get a secondary pulmonary issue. So, podcast family, in this episode, we just. It's just very quick, a quick awareness that sometimes things that we hear are. Are bizarre and that they truly are zebras. So just because somebody has never heard of it doesn't mean it doesn't exist. There's weird stuff out there. And in this case, yeah, the weird rib fracture. It really is a thing.

One rib. One rib.

And on that note, podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. And now that we've laid out that zebra, let's take it home.

Foreign.

This has been Dr. Chapa Zobe Gyn, no Spin podcast Podcast family, thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin podcast.

Sam.