Lecture 2: Osteopathic Consideration for Obstetric Patient Flashcards
Which chronic MSK condition may have improved sx’s with pregnancy and which may be aggravated?
- Improved = rheumatoid arthritis
- Aggravated = ankylosing spondylitis (due to ↑ stress on SI joints)
What changes occur to the SI joints and pubic symphysis during pregnancy?
Widening and ↑ mobility
What changes occur to the pelvis, lower back, shoulders, and neck during pregnancy?
- Anterior tilt of pelvis
- Exaggerated lordosis of lower back
- Forward flexion of neck
- Downward movement of shoulders
Excessive CT stretching and microtrauma during pregnancy can cause LBP during pregnancy, where is the pain typically localized?
SI region
What are some characteristics of the posterior pelvic pain due to the mechanical stress associated with pregnancy (i.e., location, radiation, exam findings)?
- Distal and lateral to lumbosacral jct
- Radiates down posterior thigh to knee
- NO muscle weakness or sensory impairment + normal +2/4 reflexes
- Pain may be due to relaxation of ligaments
List 3 alarm features of LBP in pregnancy which would necessitate referral for further evaluation?
- Severe pain that interferes w/ function, particularly non-positional persistent pain AT NIGHT
- ↑ pain w/ cough, sneezing, valsalva
- Neuro deficits: either by hx or on exam
The majority of cases of radicular pain during pregnancy are due to what?
- Herniated disc (40%)
- Bulging disc (10%)
How would radicular pain due to a bulging or herniated disc present in a pregnant pt?
- As paresthersias in ilioinguinal and genitofemoral nerve distribution
- “Lightning pains”
How large of an increase in interstitial fluids is seen during pregnancy?
6.5 L over the course
How do increased estrogen, progesteronem and adrenal hormones affect the lymphatic and venous stress seen w/ pregnancy?
Promote fluid retention (tissue edema)
What occurs to SVR and CO during the 1st trimester?
- SVR progressively ↓
- CO progressively ↑
What happens to CO, SV, and HR while in the supine position during the 3rd trimester?
- ↓ CO + ↓ SV + ↑ HR
- Enlarged uterus can compress the IVC and ↓ venous return to heart
What are 3 causes of decrease lymphatic flow during pregnancy?
- Fascial torsions
- Organ hypertrophy
- Diaphragm restriction
What are some signs/sx’s associated with decreased lymphatic flow during pregnancy and during which trimester are they most often seen?
- Hemorrhoids
- Vulvar and LE varicosities due to sluggish venous return
- Most sx’s in 3rd trimester
The decreased lymphatic flow in pregnancy is due to a less effective what?
Less effective pressure gradient
Motion of what structure helps drive the pressure gradient for venous return?
Thoracic cage motion
Venous stresses during pregnancy can lead to CNS congestion which causes what signs/sx’s?
HA, nausea, and light-headedness
How can venous stresses during pregnancy cause delayed LBP (occurring during the evening)?
- Dependent edema moves back into vasculature + direct pressure on IVC by uterus
- ↓ flow in pelvis —> stagnant hypoxia of neural and vertebral tissue
Pregnant women incapacitated by LBP have higher levels of what hormone?
Relaxin
Which hormone leads to a change in the mechanical configuration of the thoracic cage during pregnancy?
Progesterone
What are 2 relative contraindications for OMM in the OB patient?
- Premature rupture of membranes
- Premature labor
List 7 absolute contraindication for OMM in the OB patient?
- Undiagnosed vaginal bleeding
- Prolapsed umbilical cord
- Placental abruption
- Ectopic pregnancy
- Placenta previa
- Threatened or incomplete abortion
- Severe pre-eclampsia/eclampsia
Which factor if established before pregnancy can decrease the likelihood of a Mom suffering LBP during pregnancy?
Established exercise routine
The effect of touch when treating a pregnant patient with OMM can be classified by using which of the 5-models?
Behavioral
What are 2 areas of focus when treating hyperemesis gravidarum with OMM during the first trimester?
Tx areas C2 and T5-9
Recommending prenatal vitamins and treating hyperemesis gravidarum fits under which of the 5-models of OMM?
Metabolic-energetic-immune
Which type of pelvic torsion should you expect to find during the second trimester (14-26 weeks) when evaluating a pregnant patient?
Pelvis rotating anterior about right/left axis (forward torsion)
There may be a compensatory increase of the thoracic kyphosis during the second trimester of pregnancy causing what type of strain?
Cervical strain
OMM during the second trimester should focus on what?
- Fascial release (indirect/direct)
- Tx sacrum and pelvis (any modality that is comfy to pt)
Which syndrome may arise during the second trimester due to the edematous state?
Carpal Tunnel Syndrome
What are 2 focuses of tx during the 2nd trimester using the metabolic-energetic-immune model?
- Prenatal vitamins
- Constipation: pelvic diaphragm release, stool softeners, laxatives
What are the viscerosomatic levels for the adrenals, ovaries, and uterus which should be trargeted with OMM during the 3rd trimester?
T10-L2
Which viscerosomatic levels for the bladder should you focus OMM towards during the 3rd trimester?
S2-4
Using the behavioral model what are some recommendations for dealing with the hypotension and GERD associated w/ the 3rd trimester?
- HoTN: drink plenty of fluids
- GERD: elevate head of bed, dietary modifications
Which OMM tx may help regulate uterine contractions during labor?
Thoracic spine ST via sympathetic innervation
What are some of the signs/sx’s associated with rupture of the pubic symphysis?
- Acute pain radiating to back and/or thighs
- Palpable gap w/ local tissue edema
- Waddling gait —> ↑ pain on gait or bending
What are some components of the conservative tx approach to rupture of the pubic symphysis?
- Bed rest –> lateral recumbent
- Pelvic binder –> reduces separation
- OMM –> spine and pelvis (indirect)
Infant and lithotomy position post-partum encourages what type of sacral and cranial SD?
Anterior sacral base (flexion) w/ cranial extension
The infant and lithotomy position assoc. w/ an anterior sacral base (cranial extension) may cause what sx’s in the patient?
Fatigue, depression, and low energy
Utilizing OMM in the first visit post-partum is important before which changes occur?
Tx prior to resolution of hormonal changes on ligamentous structures (i.e., relaxin)
When should the second screening for SD’s occur during the post-partum period?
4 weeks post-partum
What are 2 pregnancy specific relative contraindications to aerobic exercise?
- Intrauterine growth restriction (IUGR) in current pregnacy
- Unevaluated maternal cardiac arrhythmia
