Pregnancy Flashcards
LBP
low back pain
2/3 pregnant women have LBP.
**Biomechanical instability: most common cause
-If due to biomechanical instability, usually has low anterior or posterior pelvic pain, aggravated by activity, relieved by rest; occasionally may have pain radiate down one or both buttocks into the posterior thighs to the knees
Pregnancy Effects on Posture
Changes in maternal structure and biomechanics, increased body fluid circulation, and hormonal changes all contribute to low back pain
Organ hypertrophy and mechanical stress produce structural changes:
– increased anterior pelvic tilt
- Lumbar spine has increased lordosis
- Thoracic spine has increased kyphosis
compensation of pregnancy posutre
Shoulders back Head forward Increase in lordosis Sacrum nutates - flexion Ribs flare Feet flatten Stance widens in ambulation
lumbar changes?
= lumbar lordosis Increased load on facets Shearing of intervertebral disc spaces Posterior paraspinal muscles shorten and are unbalanced by overstretched abdominals Psoas muscles shorten
pelvic rotation increases which way?
= anterior pelvic rotation
Strains lumbar spine and SI joints
As relaxin levels increase, lumbar spine and pelvis are increasingly strained
pubic symphsysis changes
widens due to the effects of relaxin and estrogen
Begins during the 10th-12th week of pregnancy
Palpation may refer pain to the low back
May also refer pain down medial thighs
Gets worse with walking
thoracic spine changes?
increased kyphosis
neuropathies?
** often d/t soft
tissue edema
Peripheral nerves are susceptible to injury via compression, traction, and ischemia
Uterus puts pressure on neighboring pelvic organs, ligaments, lumbosacral plexus, and lower limb peripheral nerves
ex: carpal tunnel syndrome, meralgia paresthetica
meralgia paresthetica
Meralgia paresthetica – compression of the lateral femoral cutaneous nerve which can cause burning, pain, or numbness to the waist band area and down into the anterolateral thigh. Goes from L3 toward the pelvis, passes medial and inferior to ASIS, exits the pelvis beneath the inguinal ligament
lumbar lordosis can cause this more
lumbosacral plexopathies
May occur from prolonged standing, sitting, or squatting - Proximal or distal lower limb weakness may occur
Plexus-associated foot drop may be the result of compression of the peroneal division of the sciatic nerve in the pelvis or compression of the common peroneal nerve at the fibular head
True lumbar disc herniation is rare
Previous sciatica may become aggravated
spondylolisthesis
One vertebral body is anteriorly displaced on the one below
Most common site is L5 on S1
May be due to a defect in the pars interarticulares (L5-S1) or from degeneration (L4-5)
Women who have had children had a significantly higher incidence at L4-5 than nulliparous women
May or may not progress with pregnancy
hip pain
May be referred from the low back or pelvis
Intra-articular hip pathology may refer pain to the back and pelvis
Must perform hip ROM to rule out a hip joint problem such as:
Transient osteoporosis of the hip
Avascular necrosis of the femoral head
- suspect if patients gait is off
Transient osteoporosis of the hip
Rare and occurs in the 3rd trimester
Pain increases with weightbearing.
***Limited hip ROM – normal women have normal ROM
Etiology unknown
Pain may be sudden or insidious
Tx is reduced weightbearing (bedrest or wheelchair).
Failure to dx may result in fracture.
Dx via X-ray, MRI, or pelvic US.
Avascular necrosis of the femoral head
Rare and thought to be due to higher adrenocorticoid metabolism combined with weight gain, increased levels of estrogen and progesterone, and increased joint pressure and strain.
Symptoms are pain in the hip, pelvis, or groin with weight bearing in the 3rd trimester. It may radiate to the knee, thigh, or back.
***Dx by pain with hip ROM testing.
Tx is reduced weightbearing (walker, crutches, wheelchair) to allow revascularization of the femoral head.
vascular causes of LBP?
Abnormalities or changes of the lumbar epidural venous plexus
Posterior placental location
Pain may occur as the enlarging uterus strains the vascular bed to which the placenta is attached
Placental abruption
Consider if a history of trauma like a fall or MVA
Requires emergent C-section
visceral causes of LBP?
Urinary:
- Pyelonephritis: dull, persistent pain often with fever and chills
- Nephrolithiasis: colicky pain with palpatory tenderness of the costovertebral angle
GI:
- Constipation from slowed bowel function and decreased fluid intake
- Preterm labor from infection or irritation of the sympathetic nervous system on uterine activity
- endometriosis
- ectopic pregnancy in 1st trimester
- threatened abortion
- ovarian cyst
- pelvic infection
- uterine fibroid
- labor
postpartum depression
can be a cause of lumbo-pelvic pain
sciatica vs. meralgia paresthetica?
Sciatica – posterior distribution down the post leg to the heel
Meralgia paresthetica – burning and numbness at waistband and lateral thigh
tx of LBP?
Avoid excess heat (hot tubs, hot baths, hot packs, etc)
Nutrition – Vitamin D, calcium, fish oil, mag
Exercise – gentle, normal temp pool is good
Maternity back supports and sacroiliac support belts may be helpful
OMT And massage
CI to OMT w/ preg?
- Undiagnosed vaginal bleeding
Threatened or incomplete abortion
Ectopic pregnancy
Placenta previa (painless bleeding)
Placental abruption (painful bleeding)
PROM
preterm labor (relative CI)
prolapsed umbilical cord
preeclampsia/eclampsia
tx of pregnant pt?
Address all postural stressors
Treat any specific somatic dysfunctions
- saves pts. energy: MSK dysfunction increases demands up to 300%
early structural stage
(0-12 weeks)
exam: postural, thoracic inlet, thoracic cage, pelvis, sacrum, chapman’s
Viscerosomatic reflexes:
- T10-L2 levels for sympathetics – uterus (contractions, pain)
- S2-S4 for parasympathetics – cervix (dilation)
congestive stage
(weeks 28-36)
- increased uterine size and pressure on venous and lymphatic return from LE’s and IVC –> edema
- increased interstitial fluids
Increased uterine size:
- Produces a “ball-valve” effect on the veins of the lower extremities = edema
- Some may get HYPOTENSIVE when supine (vena caval compression/supine compression syndrome)
- Size impedes diaphragmatic and rib excursion
- Diaphragm works harder due to volume and pressure changes
(best to lay in lateral recumbant position)
- increased mechanical stress, loss of balance, back pain, GERD, constipation, leg edema
** use MFR, soft tissue, effleurage and petrissage to mobilize fluids **
preparatory stage
36 weeks to delivery
- Maintain good structural balance and lymphatic flow
- Build psychological support while planning for delivery
recovery/maintenance stage
delivery - 6 weeks after
- start post-partum day 2
- look for any SD, and resolve mechanics:
**Evaluate sacral mechanics:
- Infant and lithotomy position encourage a bilaterally flexed sacrum (sacral nutation/cranial extension) and extended L5
Associated with symptoms of fatigue, depression, and low energy
late structural stage
12-28 weeks
expect to find: pelvis anterior, lumbar lordosis, thoracic kyphosis (may cause cervical pain, and cervical lordosis)
tx:
- fascial release of abdominal wall (pain above pubes)
- anterior CS points L3-5 may help round ligament pain
- treat sacrum and pelvis
carpal tunnel syndrome:
- increased incidence in pre-eclampsia and HTN
broad ligament CP?
– from the trocanter downward on the outer aspect of the femur to within 2” of the knee joint
P: – between PSIS and spinous process of L5
uterus CP?
a: - laterally on either side of the pubic symphysis – extends downward and outward at an angle, for about 2” across the inner, lower margin of the obturator foramen
p: tip of TP of L5 toward iliac crest
