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BPT 17 - Geriatric > 8 - PT IN PREGNANT POPULATION > Flashcards

8 - PT IN PREGNANT POPULATION Flashcards

1
Q

Early symptoms of pregnancy

A
  • Delay in period
  • Fatigue
  • Nausea & vomiting
  • Increased breast size
  • Increased urinary frequency
  • Constipation (progesterone)
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2
Q

Hormones changes: names & function of each

A

Tableau

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3
Q

Physiological changes: types

A

Cardiovascular
Respiratory
Cognitive
Urinary
GI tract
Bone density
Weight gain

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4
Q

Description of cardiovascular changes: 2 types & description of each

A

Arterial system
- Cardiac output ➚ —> due to stroke volume + HR increase (10-20 beats/min)
- Blood volume ➚ 50% around 6th months
- BP ➘ (systolic and diastolic) —> due to vasodilatation & ➘ vascular resistance
- Same amount of red blood cells, but anemia because of increased blood volume —> dilution uIron supplementation —> constipation

Venous system
- Hypotonia of smooth muscles fibers + hypo-contractability (progesterone) —> ➚ diameter of veins in lower extremities
- At same time : compression of venous system in pelvis & lower extremities by growing uterus + weight gain ➜ varicosities in legs
➜ vulvar varicosities : 18-22% of pregnant women
⇛ use compression : support stocking, v-supporters
- Supine hypotension syndrome (vena cava syndrome) : uterus compress vena cava —> fainting, BP drop… => ACOG 2021 guidelines : pregnant patients should NOT exercise in supine position after 20 weeks

  • Other possible vascular problems : venous thromboembolism, pulmonary embolism, edema, leg cramps (33% of pregnant women increased demand on plantar flexors + hypocalcemia + electrolyte imbalance)
  • BP Guidelines : resting blood pressure > or = to 140/90 mmHg : exercise contraindicated + immediate physician follow up
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5
Q

Description of respiratory changes

A
  • Respiratory rate ➚ from 12- 15 to 18 breath/min
  • O2 consumption ➚ up to 20%
  • Ribs position changes : flare out & up
  • Diaphragm elevation by 4 cm and chest wall widening by 2 cm —> « bell rung up »
  • Reorganization of wall chest geometry, but not volume ➜ no lung restriction
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6
Q

Cognitive changes

A
  • Baby brain : Brain fog, ➘ concentration, absent mindedness
  • Decline in story recall between 2nd & 3rd trimester, return to normal 3 months postpartum
  • ➘ brain volume by 4% in pregnancy, return to normal postpartum
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7
Q

Urinary changes

A
  • Growing uterus compresses bladder + ➚ renal blood flow ➜ ➚ urinary frequency
  • ➘ anti diuretic hormone ➜ ➚ urination during the night
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8
Q

GI tract changes

A
  • Progesterone : ➘ peristalsis ➜ constipation
  • Problem : constipation while pregnant ➚ UI postpartum by 50% + ➚ fecal incontinence + ➚ POP postpartum &
    later in life
  • What can we do ?
  • Water + fibers
  • Physical activity
  • Squatty potty
  • Avoid downward pressure
  • Never ignore call of bowel (gastro colic reflex)
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9
Q

Bone density changes

A
  • ➚ need for calcium by fetus. Taken from mother via :
  • ➚ intestinal calcium absorption
  • calcium conservation by kidneys
  • mobilization of calcium from maternal skeleton
  • Bone mineral density ➘ with loss of trabecular bone. On average :
  • ➘ 1.8 to 3.4 % in lumbar spine
  • ➘ 3.2 ± 0.5 % at hip
  • ➘ 4.2 ± 0.7% at distal forearm
  • ➘ 4.3 % in femoral neck
  • ➘ 6 % at calcaneus
  • Risk of fracture during pregnancy & post-partum (lactating !)
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10
Q

Weight gain changes

A
  • Baby: 3-4 kg
  • Amniotic fluid: 800g
  • Placenta: 650 g
  • Uterus ➚ : 950 g
  • Breast ➚ : 400 g
  • Maternal blood volume ➚ : 1,5 kg
  • Interstitial fluid ➚ : 2 kg
  • Fat & nutrient store : 3 kg

AVERAGE : 9-12 kg, with huge variability
- Risks of weight gain : High BP, gestational diabetes, pre-eclampsia, macrosomia, premature birth, miscarriage
- For women suffering from gestational diabetes, vigorous physical activity (such as running) reduces from 54% risk of too much weight gain

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11
Q

Postural adjustments

A
  • Foot pronation ➚
  • Hyperextension knees ➚
  • Anterior pelvic tilt ➚
  • Forward shift pelvis
  • Lumbar lordosis ➚
  • Thoracic kyphosis ➚
  • Cervical lordosis ➚
  • Forward head movement ➚
  • Scapula protraction ➚
  • Thoracic perimeter ➚ - 5-7 cm, may not return postpartum
  • Subcostal angle ➚ from 68° before being pregnant to 100° at delivery
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12
Q

Balance challenge

A
  • Displacement of centre of gravity
  • Compensatory gait:
  • Gait length ➘
  • Speed ➘
  • Double support time ➚
  • Step width ➚
  • Base of support ➚
  • Alteration of balance
    ➜ Increase risk of fall : rate of fall = 26.8% during pregnancy = women over age of 65 years
  • Cause maternal & fœtal complications : maternal bone fractures, head injuries, internal hemorrhage,
    abruption placenta, rupture of uterus & membranes, maternal death or intra-uterine fœtal death
  • Preventative strategies, such as physical exercise & use of maternity support belts ➜ Increase postural stability & reduce risk of falls during pregnancy
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13
Q

Medical complications: 5 types & description of each

A

Tableau

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14
Q

Red flags: different parts & red flags of each

A

Tableau

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15
Q

Benefits of physical activities during pregnancy

A
  • ➘ neonatal complications
  • ➘ C-section number & assisted
  • Help control weight gain
  • ➘ depression risk, ➚ mood
  • ➘ gestational diabetes
  • ➘hypertension
  • ➘ risk of pre-eclampsia
  • ➘UI
  • ➘ intensity of LBP during pregnancy & immediate postpartum
  • ➚ venous return
  • ➚sleep
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16
Q

Joint SOCG / CSEP Canadian guidelines

A
  • All women without contraindications should be physically active
  • At least 150 mins
  • Minimum 3 days/week
  • Women not active before can safely start exercising to meet recommendations
  • Exercising can start at any time during pregnancy
  • Every type of PA contribute : walking, aerobic exercise, resistance training, soft stretching, yoga..
  • Combining aerobic exercise & resistance training = more effective at improving health outcomes
  • Also possible to train pelvic floor muscles daily
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17
Q

Sport to avoid during physical activity

A
  • Diving —> risk relative to maternao-fœtal blood flow with risk of fetus death in utero
  • Activities with risk of abdominal trauma, risk of falling, physical contact : downhill skiing, horse riding,
    gymnastics…
  • Exercises supine after 4 months -> supine hypotension syndrome
  • Activities in hypoxic situation, cold & humid climate
  • Any activity above 1600 to 2500m must be performed by experts sport-women used to altitude
  • Caution with stretching
18
Q

Warning symptoms to physical activity

A

=> Stop activity + medical referral
- Regular & painful uterine contractions
- Important shortness of breath
- Important thoracic pain
- Vertigo or weakness
- Persistent liquid leakage from vagina (membranes rupture)
- Vaginal bleeding, even light
- Unusual pain at abdomen
- High level of fatigue

19
Q

Absolute contraindication to physical activity during pregnancy

A
  • Delay in fetal grow
  • Risk of premature labour
  • High multiple pregnancy (triplets or more)
  • Incompetent cervix
  • Bleeding
  • Respiratory or cardiac insufficiency
  • Placenta praevia after 26 weeks
  • Pre-eclampsia
  • Some uterus malformations
  • Early rupture of the membranes
20
Q

Which intensity for physical activity during pregnancy

A
  • Low to moderate
  • Talk test: able to maintain conversation during exercise
21
Q

Common pathologies linked with pregnancy: 2 types & why PT matter

A

Low back pain (LBP) & Pelvic girdle pain (PGP)

Why physiotherapy matter?
- Significant impact on daily life
- Perinatal PGP & LBP associated with ➚ postpartum depression
- 20% of women with severe PGP during pregnancy reported avoiding future pregnancies - Elevated pain intensity during pregnancy linked to worse postpartum recovery rates

22
Q

LBP: def & treatment

A

Tableau

23
Q

Pelvic girdle pain: definition, symptoms, risk factors, treatment & special tests

A

Tableau

24
Q

Symphysis pubis diastases: def, signs/symptoms, special tests & treatment

A

Tableau

25
Q

General tips to avoid hip, pelvic & LBP

A
  • Avoid positions of asymmetry & adductor over activity: crossing legs, persistent weight one one leg, high resistance biking (if painful)
  • Best sleeping position: lying on left side with pillow supported under head, neck, between knees & underbelly (long breastfeeding pillow)
  • Roll on side before getting up
26
Q

Effects of perineal massage

A
  • ➘episiotomy
  • ➘ perineal tear, particularly severe tears
  • ➘ perineal pain
  • ➘ anal incontinence
27
Q

Urinary incontinence description

A
  • At least 50 % of all pregnant women (often for first time)
  • Stress UI most common
  • UI onset during pregnancy predicts postpartum UI
  • PFMT effective to ➘ UI
28
Q

Diastases recti abdominis: def & description

A

= midline separation of rectus abdominis muscles along linea alba
- No agreement on the exact cut of point
- Most commonly used:
* 7 mm (+/- 2mm) at xiphoïd process
* 13 mm (+/- 7 mm) 3cm above umbilicus
* 8 mm (+/- 6 mm) 2 cm below umbilicus
- Prevalence : 100% at delivery
- But no one ever measured the average DRA of pregnant women

29
Q

Neuropathy: different types & description of each

A

Compression neuropathy
= due to pressure of growing uterus, postural deviations, retention of fluid & sustained posture’s during labor & delivery

Carpal tunnel syndrome
2nd most common MSK symptoms in pregnancy
- Pain & paresthesia in thumb, index & middle finger (median nerve), worse at night
- Clinical test = Tinel’s test & Phalen’s test
- Usually bilateral
- Can take 6-20 months to fully resolve. Affect up to 25% of women
- Treatment : splinting of wrist in neutral, nerve glides, education (how to carry baby…)

Meralgia paresthetica
- Burning pain & numbness in anterolateral thigh (lateral femoral cutaneous nerve)
- Compression between growing uterus & anterior superior iliac spine
- Treatment : nerve glide, education (avoid prolonged hip flexion, change positions in labor…) - Sciatalgia
- Pudendal nerve

30
Q

De quervain tenosynovitis: def & description

A

= inflammation of abductor pollicis longus & extensor pollicis brevis tendons (2nd most common hand and wrist problem during pregnancy and post partum)
- Pain along radial aspect of wrist
- Clinical test : Finkelsteins test
- Treatment : education (how to handle baby, avoid repetitive thumb & wrist movements, avoid painful
movements…)

31
Q

For delivery, what can we do as PT for pelvis

A
  • Pregnancy —> change in pelvic diameters due to facial & ligamentous changes because of, among others, relaxin
  • Pelvic diameters related to following joints: lumbar-iliac, lumbosacral & sacrococcyngeal junctions, sacroiliac femoral acetabular & pubic symphysis joints
  • Bony dimensions not fixed
  • Moving / changing one’s posture may generate greater pelvic mobility than comparable static posture
  • Upright birthing position significantly ➚ pelvis
  • Loading conditions -> ➚ ligament laxity -> expand the pelvis
  • Flexible sacrum positions in the second stage of labour (pushing) : ➘ operative delivery, ➘ instrumental vaginal delivery, ➘ caesarean section, ➘ episiotomy, ➘ severe perineal trauma, ➘ severe pain and shorten the duration of active pushing phase
  • Internal rotation of femurs ➚ pelvis outlet diameter
32
Q

For delivery, what can we do as PT for pain

A
  • Birth ball ➘ pain during labor for women without epidural
  • Cold ➘ pain after episiotomy
  • Warm ➘ pain during vaginal deliveries
  • TENS ➘ pain 1h after caesarean
33
Q

For delivery, what can we do as PT for breathing

A
  • Breathing exercises = beneficial preventive intervention in ➘ duration of second stage of labour
34
Q

Physiological changes in post-partum

A
  • Uterus (weight ➘ from 1000 g to 50 g) & vagina return to pre- pregnancy size in 5-8 weeks
  • Bleeding : typically lasts 2 to 4 weeks
  • Plasma volume returns to normal at 2 weeks postpartum
  • Hormones
  • Body weight
35
Q

Pelvic floor in post partum

A
  • Perineal trauma occurs in 85 % of vaginal births with greater than two- thirds (60- 70 %) requiring surgical repair
  • UI at 1 year post-partum = 32 %. Stress UI (54 %) is the most prevalent type
  • Anal incontinence = 3 % initially postpartum, less than 1 % at 8 weeks
  • Constipation = 49 % at 1 week, 20.5 % at 4 – 8 weeks postpartum
  • Hemorrhoid Prevalence = 10 %
  • Dyspareunia = 42 % at 2 months, 22 % at 6–12 months postpartum – also after caesarean

➜ Scar massage + rehabilitation by pelvic floor PT

36
Q

Other things to consider in post partum

A
  • Chronic post caesarean pain (CPCSP) after 2 – 6 months = btw 4% and 41.8%. Higher intensity of pain on postoperative day 1 = the most commonly identified factor associated with CPCSP ligament
  • Femoral and peroneal nerve – position in stirups, sustained lithotomy, squatting -> compression at femoral
    head. u Lumbosacral plexus, Sciatic, Obturator…
  • Coccydynia = 4 – 15 %
  • Postpartum depression rate = 14 %
  • Continuous LBP/PGP in 15.3% women at 14 months post-partum
  • Thoracic Outlet Syndrome : due to ➚ thoracic kyphosis and scapular protraction (cause
    adaptive shortening of the anterior cervical and chest muscles)
  • Neuropathies due to labor & delivery, due to sustained posture. Usually results from compression or traction
  • Lateral femoral cutaneous nerve – related to hip positioning at birth – compression or traction at inguinal
37
Q

Diastasis recti abdominis of post-partum

A

Mind the gap
- Not just about gap, may have woman with larger gap able to functionally control abdominal wall & create tension with no problem & woman with smaller gap that not able to create tension = loss of function
- Functional deficits
* Women with DRA -> significantly lower trunk muscle rotation torque & scored lower on sit-up test than those without DRA at 1 year post-partum
- Abdominal support garments before & after birth may help to manage DRA and/or reduce IRD but do not replace focused abdominal strengthening program
- Focusing DRA rehabilitation only on reducing Inter Recti Distance (IRD) could be suboptimal
- Abdominal muscle reeducation exercises with focus on pre-activation of TRA during activities that increased
intra-abdominal pressure resulted in less doming of ventral abdominal cavity & less distortion of linea alba
- Increasing strain of linea alba may be productive
* Decreased mechanical strain ➘ fibroblastic activity, it needs load
* Increase collagen synthesis to strengthen the linea alba may be improved by tensile load created with TRA activation
- Systematic review demonstrated that interventions with significant DRA improvement included traditional abdominal exercises (AE) with deep core stability, AE with pelvic floor muscle exercises, crunch exercises, drawing-in exercises with AE & neuromuscular electrical stimulation with AE

38
Q

Return to exercises on postpartum

A
  • UK guidelines (RCOG 2006) recommend, medical caregiver should be consulted before resuming pre- pregnancy physical activity
  • Exercise may be resumed gradually after birth and as soon as medically safe (ACOG 2021)
  • Adjustments due to physiological changes
  • Operative delivery requires further recovery & consideration prior to return to exercise
  • 6-week postnatal check too long to wait for postnatal women to resume or begin low intensity physical activity program including walking, pelvic floor & abdominal muscle exercises
39
Q

Relative energy deficit in sport of postpartum

A

= impairment of bodily functions due to excess energy expenditure without adequate replacement as result of excessive activity or other lifestyle factors :
- impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis & cardiovascular health
- « The daily demands, physiological effects of breastfeeding and social pressure to return to pre-pregnancy figure/fitness can predispose a postnatal woman to compromised nutrition, poor sleep, excessive exercise and unrealistic expectations. »
- Postnatal women with RED-S are at increased risk of stress fractures

40
Q

Guidelines for return to sport on post partum

A
  • « Running is a high impact sport placing a lot of demand on your body. To be run ready, your body needs time to heal and regain its strength after having a baby.
  • Initial low impact exercises timeline followed by return to running between 3-6 months postnatal.
  • All women, regardless of how they deliver, should seek out a pelvic health assessment with a specialist physiotherapist to evaluate strength, function and co-ordination of the abdominal and pelvic floor muscles which are often impacted by pregnancy and delivery.»
  • Load & impact management assessment
  • Walking 30 minutes
  • Single leg balance 10 seconds
  • Single leg squat 10 repetitions each side
  • Jog on the spot 1 minute
  • Forward bounds 10 repetitions
  • Hop in place 10 repetitions each leg
  • Single leg ‘running man’ 10 repetitions each side
    (Without pain, heaviness, dragging or incontinence)
  • Strength testing (to ensure key muscle groups prepared for running)
  • Single leg calf raise
  • Single leg bridge
  • Single leg sit to stand
  • Side lying abduction
    Aim for 20 repetitions of each test
  • Including walk breaks can be helpful to ➘ fatigue initially & can be gradually ➘ & removed
  • Build training volume (e.g. running distance/time) prior to ➚ training intensity
  • ➚ no more than 10% per week (except at beginning – from 1 to 2 min for ex.)
  • ‘Couch to 5km’ program
  • Includes walk breaks & builds gradually towards 5km of running in 9 weeks
  • NHS ‘couch to 5km’ starts with 3 runs in week 1 beginning with a brisk 5 minute walk then alternating 1 minute of running with 90 seconds of walking for a total of 20 minutes

BPT 17 - Geriatric (11 decks)

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