Review: 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
Effect of progesterone on thoracic cage and fluid retention
Changes in mechanical configuration of thoracic cage — circumference increases 5-7cm, increased subcostal angle, diaphragm pushed superiorly, increased tidal volume
Promotes fluid retention —> congestion
Indications for OMT in OB/GYN pt
Somatic dysfunction
Scoliosis or structural condition associated with pregnancy
Edema, congestion, or other pregnancy-associated condition amenable to OMT
Relative contraindications to OMT in pregnancy
Premature rupture of membranes
Premature labor (regular contractions of uterus resulting in changes in cervix that start before 37 weeks of pregnancy)
Absolute contraindications to OMT in pregnancy
Undiagnosed vaginal bleeding
Prolapsed umbilical cord
Placental abruption
Ectopic pregnancy
Placenta previa
Threatened or incomplete abortion
Severe pre-eclampsia/eclampsia (low seizure threshold)
Osteopathic assessment in first trimester (0-13 weeks)
Complete history
Physical — look for dysfunction that may alter compensatory mechanisms, postural exam, thoracic inlet fascia, thoracic cage, pelvis and sacrum, CRI
Tx any somatic dysfunctions that are found
Areas to evaluate/tx if pt presents with hyperemesis gravidarum
C2 and T5-9
5 models approach in 1st trimester
Biomechanical: SD of C/T/L, Ribs, pelvis/sacrum SD
Neuro: T10-L2 SNS to pelvic organs, S2-4 PNS to pelvic organs
Resp/circ: —-
Metabolic/energic/immune: prenatal vitamins, address hyperemesis gravidarum
Behavioral: smoking/alcohol/caffeine screening, sexual behavior screen, exercise
What SDs may be expected in the second trimester (14-26 wks)?
Pelvis rotation anterior about right/left axis (forward torsion)
Increased pelvic tilt
Increased lumbar lordosis
Compensatory increase of thoracic kyphosis — may produce cervical strain
Common condition in pregnancy d/t edematous state, tx with palliative tx including stretches and night-time splinting
Carpal tunnel syndrome
Can you treat mom in supine position in 2nd trimester?
Yes — as long as she is comfortable
5 model approach in 2nd trimester
Biomech: SDs of C/T/L, LBP tx, sacral/pelvic SDs, abdominal wall MFR
Neuro: CTS — MFR
Resp/circ: rib raising, diaphragm tx
Met/en/imm: prenatal vitamins, constipation — pelvic diaphragm release
Behavioral: self care home stretching, exercise as tolerated
Third trimester (27-40 wks) is associated with maximal mechanical and structural changes and increased complaints of loss of balance, back pain, gait changes, constipation, GERD, etc. The increase in uterus size is associated with edema, supine hypotension, and increased work of diaphragm. What are some treatment considerations?
Address edema — MFR, ST, lymphatics
Viscerosomatics for upper GI T5-9, adrenal and ovaries T10-L2
Pelvic diaphragm for constipation
What technique must be avoided in third trimester because it may provoke uterine contractions?
CV4
5 model approach in 3rd trimester
Biomechanical: Tx LBP, assess gait changes — feet/innominates/sacrum
Neuro: T5-9 GI, T10-L2 ovaries/uterus, S2-4 bladder
Resp/circ: lymphatics — effleurage, petrissage
Met/en/imm: GERD — sucralfate, ranitidine, cimetidine
Behavioral: drink plenty of fluids, psychologic support for delivery
OMT considerations in labor
Evaluate lumbosacral region and pelvis — use soft tissue or MFR
Thoracic spine ST may regulate uterine contractions via sympathetic innervation
Expect dysfunctions in innominate, sacrum, pubic symph
Women may not tolerate aggressive modalities during labor
5 models approach during labor
Biomechanical: pelvic/sacrum/lower T/lumbar
Neuro: seizure activity/clonus? Pain control
Resp/circ: make sure pt is up and moving for blood clot protection, monitor swelling, BP
Met/en/imm: liquid diet, monitor fluids (esp longer labor), blood sugars in diabetic pts
Behavioral: make sure pt is in control, movement as tolerated
Diagnostic considerations for pubic symphysis rupture (occurs in <1% of pregnancies)
Separation > 1cm (<10mm is normal)
Audible crack, acute pain radiating to back and/or thighs, palpable gap with local tissue edema, waddling gait — increases pain on gait or bending
Potential causes: fetal macrosomia, precipitous labor/rapid second stage, intense uterine contractions, previous pelvic pathology/trauma, forceps delivery
OMT considerations at first visit postpartum
Screen for SD; tx prior to resolution of hormonal changes on ligamentous structures (relaxin)
Evaluate sacral mechanics — infant and lithotomy position encourages an anterior sacral base — cranial extension (associated with symptoms of fatigue, depression, and low energy)
OMT considerations at 4 weeks postpartum
Review structural changes
Screen for SD
Assess need for future contraception
Advise any f/u care for chronic problems
Benefits of exercise in pregnancy
Improves fitness and cardiorespiratory function
Enhances psych well being
Decrease risks for comorbidities of sedentary lifestyle
Prevention and/or reduction in severity of MSK complaints (LBP, pelvic girdle pain)
Reduction in urinary incontinence
ACOG recommends 30+ mins moderate exercise most days of the week
Relative contraindications to aerobic exercise in pregnancy
Severe anemia Chronic bronchitis Poorly controlled T1DM Extreme morbid obesity Extreme underweight (BMI <12) Hx of extremely sedentary lifestyle
Intrauterine growth restriction in current pregnancy
Unevaluated maternal cardiac arrhythmia
Poorly controlled HTN
Orthopedic limitations
Poorly controlled seizure d/o
Poorly controlled hyperthyroid
Absolute contraindications to aerobic exercise
Hemodynamically significant heart disease
Restrictive lung disease
Incompetent cervix
Multiple gestation at risk for premature labor (triplets or more)
IUGR
Persistent second or third trimester bleeding
Placenta previa >28 wks gestation
Premature labor during current pregnancy
Ruptured membranes
Preeclampsia/pregnancy-induced HTN
Pelvic diaphragm release technique in pregnancy
Patient LATERAL RECUMBENT, treatment side up, with knees & hips flexed. Physician seated behind pt. Find ischial tuberosity with outside hand. Introduce fingers of other hand medial to ischial tuberosity, putting pads of fingers on medial surface of ischium. Have patient inhale and exhale. On exhalation, encourage diaphragm to move superiorly by providing fingertip pressure in cephalad direction. Maintain this position and resist motion with inhalation. Follow again in cephalad direction with exhalation. Repeat treatment until both thoracic and pelvic diaphragm come into phase with good amplitude.
Round ligament counterstrain
Palpate most tender round ligament — near iliacus tenderpoint; doc on ipsilateral side
Flex hips and knees until motion is felt under monitoring hand
Cross c/l ankle over the top and spread knees into external rotation (“good over evil”)
Hold 90 seconds
Passively return to neutral and reassess
PROMOTE study by Dr. Hensel
400 women in 3rd trimester assigned to usual care, OMT, or placebo ultrasound treatment
7 treatments over 9 weeks
HVLA tx was excluded-owing to increasing ligamentous laxity that occurs in later pregnancy, the force used in a thrust technique was not generally considered necessary
Goal was to reduce LBP and improve functioning during 3rd trimester
Significant tx effects for pain and functioning in OMT and US group
No higher likelihood of conversion to high-risk status in OMT group
In the immediate postpartum period, how should lower extremities be positioned after being removed from stirrups?
Hips are put through adduction and internal rotation, followed by extension (Still’s)
Reduces potential SI joint dysfunction; approximate scapula by having pt sit up straight and pull shoulder blades together. Pt is supine, knees bent, and raise buttocks; posterior pelvis tilt in supine position
