OAT OB/gyn Patient Flashcards
3 factors that influence SD in pregnant pts
Change in maternal structure and biomechanics
Body fluid circulation
Hormone changes
Effects of pregnancy on chronic MSK conditions
Scoliosis — curvatures do not increase, may develop more pain, possible increased risk of premature birth
Rheumatoid arthritis — pregnancy improved symptoms (conception to 6 weeks post partum)
Ankylosing spondylitis — aggravated by pregnancy d/t increased stress on SI joints
MSK changes in lower back, neck, shoulders, abdominal muscles, and spinal ligaments with pregnancy
Exaggerated lordosis of lower back
Forward flexion of the neck
Downward movement of shoulders
Weakness, separation of abdominal muscles
Joint laxity of anterior and posterior longitudinal ligaments of spine
MSK changes in ligamentous laxity, compression of structures, pelvis tilt, and mobility of SI joints and pubic symphisis in pregnancy
Increased ligamentous laxity
Compression of structures d/t fluid retention
Anterior tilt of pelvis
Widening and increased mobility of SI joints and pubic symphysis
A 29 y/o primigravid female presents to her OB for her 37 wk appt. She c/o back pain present for several months that is becoming unbearable. The pain worsenswith activity and is alleviated by rest. The pain is generally localized to her low back, but at times radiates down the back of her thighs. Her sleep has progressively deteriorated during the pregnancy, but the pt reports worse back pain at night, especially with turning. Which of the following will most likely be found on PE?
A. +1/4 achilles reflex b/l B. Decreased ROM of lumbar spine C. 3/5 strength of hip flexors D. Increased pain on pelvic compression E. Leg length discrepency
B. Decreased ROM of lumbar spine
Etiologies of back pain in pregnancy
Postural changes
Muscle weakness
Excess CT stretching and microtrauma — pain usually in SI region; trunk extensors attempt to balance increased pelvic tilt
Posterior pelvic pain
Radicular pain
Visceral disease
If a pt is presenting with LBP in pregnancy, what are some “alarm findings” that would grant referral for further evaluation?
Severe pain that interferes with function, particularly non-positional persistent pain at night
Increased pain w/ cough, sneezing, valsalva
Neuro deficits — bladder, bowel incontinence, paresis, weakness, sensory deficits, abnormal reflexes
Describe presentation of posterior pelvic pain as an etiology of LBP in pregnancy
distal and lateral to lumbosacral region; radiates down posterior thigh to knee. No muscle weakness or sensory impairment, normal 2/4 reflexes. Pain may be d/t relaxation of ligaments
Describe radicular pain as an etiology to back pain in pregnancy
Etiology of radicular pain itself is similar across all populations — herniated disc (10%), bulging disc (40%)
Likely d/t mechanical pressure of ligamentous structures of the spine on nerve root
Present as paresthesias in ilioinguinal and genitofemoral nerve distribution — “lightening pains”
Risk factors for LBP in pregnancy
Previous hx of LBP (in pregnancy or not)
Multiparity
Higher BMI
Smoking
Age
Strenuous work
Pain during menstruation
[note: LBP resolves in 80-95% of cases postpartum]
Lymphatic, venous, and hormonal physiologic stresses in pregnancy
Increase in interstitial fluids (over 6.5L increase over course of pregnancy; increased demand to pelvic organs for metabolic needs of fetus)
Increase in estrogen, progesterone, and adrenal hormones — promotes fluid retention —> tissue edema
Decrease in efficiency of excess fluid removal (d/t fascial torsions, organ hypertrophy, and diaphgram restriction —> less effective pressure gradient)
Hemodynamic changes in pregnancy in terms of CO, blood volume, systemic vascular resistance, BP, plasma volume, and Hct
CO increases
Blood volume increases
SVR decreases
BP decreases
Plasma volume increases
Hct decreases
Best course of action for vulvar varicosities in pregnancy
Recommend pt sleep in left lateral recumbent positioning and apply pressure to the area
Lymphatic stresses in pregnancy are d/t conditions causing less effective pressure gradient. Pts are most symptomatic in what trimester? What are the associated sx?
3rd trimester — hemorrhoids, vulvar and lower extremity varicosities d/t sluggish venous return
19 y/o primigravid female presents at 37 weeks gestation c/o back pain that awakens her at night. Her pregnancy has been unremarkable up to this point other than mild nausea during 1st trimester, LBP that was previously relieved by heat and acetaminophen, and vulvar varicosities identified 3 wks ago. She reports that she bought a device to minimize the size of the varicosities, wears compression socks most days and makes an effort to sleep on her left side but typically wakes up on her back. The pt wants to know why her back hurts more at night, even though she is more active during the day. The pt most likely has LBP d/t which of the following?
A. Increased pressure on left ILA d/t R/L sacral torsion
B. Decreased RR at night leading to pelvic diaphragm congestion
C. Stagnant hypoxia of neural and vertebral tissues at night
D. Undiagnosed RA aggravated by stagnant position
E. Increased pressure on nerve root when supine d/t bulging disc
C. Stagnant hypoxia of neural and vertebral tissues at night
[d/t venous stresses: dependent edema moves back into vasculature d/t osmotic gradient + direct pressure on IVC by uterus —> decreased flow in pelvis —> stagnant hypoxia of neural and vertebral tissues —> delayed low back pain]
T/F: diaphragmatic excursion is impaired in pregnancy
False — it is not impaired
Thoracic cage motion helps drive the pressure gradient
Hormone elevated during first trimester and declines early in second trimester associated with widening and mobility of SI joints and pubic symphysis at 10-12 weeks gestation; women incapacitated by LBP tend to have higher levels
Relaxin
