OB Patients Flashcards
Why do more than 60% of pregnant patients report LBP?
- Changes in maternal structure and biomechanics
- Changes in hormones
- Fluid circulation
Research in pregnant women who underwent OMT
Previous research indicates that all women in that study had back pain, but those that are treated with OMM have better functional scoring.
Pregnant woman with scoliosis: how does it change during pregnancy?
- Curvature does NOT increase,
- Pain may increase.
- Possible increased risk of premature bb.
Pregnant woman with Rheumatoid arthritis: how does it change during pregnancy?
- Symptoms improve from [conception => post-partum]
Pregnant woman with Ankylosing Spondylitis: how does it change during pregnancy?
- Worsened with pregnancy due to increase stress on SI joint
What MSK Changes occur during pregnancy?
- LB
- Neck
- Shoulder
- Abdominal muscles
- Anterior and posterior longitudinal L
- Pelvis
- SI joint/ pubic symphysis
- Structures
- Ligaments
- ↑ lordosis in LB
- Neck flexes forward
- Shoulders move downward
- Abdominal muscles weaken/ seperate
- Anterior and posterior longitudinal L => joint laxity
- Pelvis tilts ANTERIORLY
- SI joints/Pubic symphysis widen and increase mobility
- Fluid retention => compression of structures
- Ligamentous laxity
What affect does forward/anterior tilting of the pelvis cause?
↑ lordosis in lower back to counterbalance => ↑ stress on vertebra and ↑ shear across IV discs
As pregnancy progesses, distension of the abdomen =>
weakens muscls ability to counterbalance
A 29 yo primigravid (pregnant for the first time) female presents to her OB for her 37 week appointment. The patient complains of back pain that has been present for several months but is “becoming unbearable.” The pain worsens with 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 patient reports worse back pain at night, especially with turning. Which of the following will most likely be found on physical exam?
A.+1/4 Achilles reflex bilaterally
B.Decreased ROM of lumbar spine
C.3/5 Muscle strength of hip flexor bilaterally
D.Increased pain on pelvic compression
E.Leg length discrepancy
B. decreased ROM of lumbar spine
What is the etiology of LBP in the past patient?
- Posterior pelvic pain => LBP (distal and lateral lumbosacral junction) due to relaxation of ligaments => down posterior thigh & knee.
- No muscle weakness
- No sensory impairment
- NL reflexes (2/4)
Alarm findings: What s/sxwould grant referral for further evaluation in a patient with posterior pelvic pain (located distal and lateral to lumbosacral junction)?
- Severe pain that interferes with fx, esp if laying asleep at night
- Pain increases w cough, sneezing or valsalva
- Neuro problems (bowel/bladder dyx, weakness, sensory deficits, ABNL reflezes)
Pregnant women who has radicular pain
- Etiology:
- Due to:
- Presenatation:
- Etiology: Bulging disc (40%); herniated disk (10)
- Due to: Ligmentous structures apply pressure on nerve root of (geniitofemoral or ilioinguinal nerve)
- -Presentation: paresthesias and “ lightening pain” in ilioinginal/genitofemoral nerve root distribution (anterior thight)
RF for LBP in pregnancy (7)
- ◦Previous history of LBP
- ◦Pain during menstruation
- ◦Multiparity
- ◦Higher BMI
- ◦Smoking
- ◦Age
- ◦Strenuous work
Outcome of LBP in pregnancy
80-95% resolve
During pregnancy, changes do we see in lymphatics, venous and hormoneal
- Increase intersitial fluids by 6.5 L due to increased demand of pelvic organs
- Tissue edema due to Increase [estrogen, progesterone and adrenal hormones]
What are the non-painful palpable bumps patients can get during pregnancy?
Vulvular variscosities
How to treat vulvular variscotisies that occur in pregnancy?
Tell pt to sleep left LR.
How is Left LR a treatment for vulvular varisocities in pregnancy?
Increases CO
- When supine: ↓ CO => ↓ preload => ↓ SVR => ↑ HR, seen mostly at > 20 weeks
Cardiac output is higher when the pregnant woman lays _____
on her left side
What changes in pregnancy are MOST common in 3rd Trimester?
↑ venous stasis => decrease lymphatic flow => Hemorrhoids, vulvar, and LE varicosities
What are the causes of decreased lymphatic flow (pressure gradient) in pregnancy?
1. Fascial torsions
2. Organ hypertrophy
3. Diaphragm restriction
Pregnant patient has LBP that hurts MORE THAT NIGHT, even though she is very active during the day. What is her problem?
Venous stresses: more blood (fluid) gets to the tissues than can be returned/removed by the venous and lymphatic systems => stagnant hypoxia of the neural and vertebral tissues => delayed LBP
Abdominal organs are getting ____ blood flow during pregnancy
MORE
What is the pathophysiology of DELAYED LBP?
- Dependent edema moves back into the vasculature due to [osmotic gradient + Direct dressure on IVC by uterus]
- => ↓ flow in pelvis
- => Stagnant hypoxia of neural/vertebral tissue
- => delayed LBP
What causes to ↑ LBP in your 1st trimester, but ↓ in early 2nd trimester?
Relaxin (hormone)
How does relaxin cause ↑ LBP in 1st trimester, but ↓ in 2nd?
↑ widening and mobility of [SI joint & pubic symphysis]
Starts @ 10-12 weeks
How does progesterone cause changes during pregnancy?
Progesterone
-
changes shape of thoracic cage.
- ↑ circumference of thoracic cage by 5-7 cm
- Subcostal angle widens from 68 => 103 degrees
- Diaphragm pushed superiorly
- ↑ tidal volume =>
-
Fluid retention => congestion
- ↓ O2/metabolism
- ↑ metabolic waste in ST and GI tract
Indications for OMT in prengant pt
- SD
- Scoliosis or structural condition
- Edema, congestion
Relative CI to OMT in pregnant pts
- PPROM (premature preterm rupture of membranes)
- Premature labor: contractrions in the uterus => changes in cervix that occur B4 37 weeks.
Absolute CI to OMT in pregnant pts
- Undx vaginal bleeding
- Prolapsed umbilical cord
- Placental abruptions (bleeding + pain)
- Ectopic PG
- Placentia previa
- Threatening/incomplete abortion
- Severe pre-ecclampsia/eclampsia => seizures
Models of OMT in pregnant pt
Focus on:
- Biomechanical
- Neuro
- Biomechanical: focus on postural/structural aspects
- NEuro: focus on NS through viscerosomatic innervation
Models of OMT in pregnant pt
Focus on:
- Resp/Cirl
- M-E-I
- Respi/Crircul: use MS system to affect arterial,venous and lymph flow
- MEI: improve GI and immune system
Models of OMT in pregnant pt
Focus on:
- Behavioral
- Effect of TOUCH on pt
- Exercise, diet,
Sympathetic and parasympathetic for OB patient
- Sympathetic (T10-L2) = > pelvic organs
- Parasympathetic => S2-4
MEI consideration in 1st trimerster
- Prenatal vitamines
- Hyperemsis gravidarum: C2, T5-9
Common SD due to compensatory changes in 2nd trimester (14-26 weeks)
- Foward torsion: Anterior rotated pelvis about a right/left axis
- Anterior innominate rotation: Increased pelvic tilt
- Increase in lumbar lordosis
- Compensatory increase of thoracic kyphosis
- Round ligament pain = sharp pain in lower abdomen/ groin
Carpel Tunnel Syndrome is most common in what trimester during prengnacy?
2nd: increased fluid retention, congestion, edematous state
Preferred treatment in 2nd trimester
- Indirect/direct MFR (good for abdominal wall pain)
- Treat sacrum/pelvis in anyway comfortable for patient
Position to treat mom in 2nd trimester
supine
How do we treat round ligament pain in mom in 2nd trimester?
anterior counterstrain at L3-5
MEI consideration for PG patient in 2nd trimester
1. PRenatal vitamins =
- Constipation: pelvic diaphragm release and stool softner
How do complications in pregnancy change in 3rd trimester?
- MEchanical/structural changes are MAX
- Edema and diaphragm work increaess: due to Increase in interstitial fluid and uterus size
How does treatment position change in 3rd trimester (27-40 weeks)?
PAtients may get HYPOTENSIVE when supine
Focus of treatment in 3rd trimester
- Treat edema with (MFR, ST, lymphatics: effleurage/petrissage)
-
Viscerosomatics
- UGI: T5-9
- Adrenal and ovaries: T10- L2
- Treat pelvic diaphragm
Focus of biomechical in 3rd timester
- Treat LBP
- Assess gait changes/feet/innominate/sacrum
Focus of neurological in 3rd timester
and MEI
- T5-9 UGI
- T10- L2 Ovaries and uterus
- S2-4 bladder
MEI: GERD
What should you do in the LAST 4 weeks (prepatory stage) of pregnancy?
Evaluate diameters of pelvis to make sure no problems with deliver
- inlet
- Mid-pelvis
- Outlet
What should you focus on during labor?
- ST/MFR to lumbosacral and pelvis
- Regulate uterine contractions via thoracic spine ST via sympathetic innervation
What SD can you expect in labor?
Innominate
Sacrum
Pubic symphysis
PT has
Acute pain radiating to back and/or thighs
Palpable gap with local tissue edema
Waddling gait with increased pain on gait or bending
What does she have?
Rupture of pubic symphysis: seprates > 1cm
Tx for rupture of pubic symphysis
- LR bedrest
- Pelvic binder
- Spine and pelvic Indirect OMM as needed
On post-partum Day 1,
what should you do
- screen for SD
- Treat B4 rseolution of hormonal changes on ligaments due to relaxin
- Eval sacrum
when to come back
- 4 weeks post-partum
Relative CI to aerobic excercise in PG
- Intrauterine growth restriction (IUGR) in current PG
- Unevaluated maternal cardiac arrhythmia
- Poorly controlled T1Dm
- Extremely underweight ( BMI <12)
Absoltute CI for Aerobic Exercise in PG
- ◦Persistent 2nd or 3rd trimester bleeding
- ◦Placenta Previa >28 weeks gestation
- ◦Premature labor during current pregnancy
- ◦Ruptured membranes
- ◦Preeclampsia/pregnancy-induced hypertension
- Incompetant cervix
- Multiple BBs inside => at risk for premature labor
- 400 women in 3rd trimester assigned to usual care, OMT, or placebo US treatment and given 7 treatments over 9 weeks. Goal was to reduce LBP, improve functioning during 3rd trimester
What wasoutcome
- US and OMT group saw decrease pain and better functioning
- OMT group = No higher likelihood to become high-risk
