Lecture 2: Osteopathic Consideration for Obstetric Patient

Question 1

Which chronic MSK condition may have improved sx’s with pregnancy and which may be aggravated?

Answer 1

• Improved = rheumatoid arthritis
• Aggravated = ankylosing spondylitis (due to ↑ stress on SI joints)

Question 2

What changes occur to the SI joints and pubic symphysis during pregnancy?

Answer 2

Widening and ↑ mobility

Question 3

What changes occur to the pelvis, lower back, shoulders, and neck during pregnancy?

Answer 3

• Anterior tilt of pelvis
• Exaggerated lordosis of lower back
• Forward flexion of neck
• Downward movement of shoulders

Question 4

Excessive CT stretching and microtrauma during pregnancy can cause LBP during pregnancy, where is the pain typically localized?

Answer 4

SI region

Question 5

What are some characteristics of the posterior pelvic pain due to the mechanical stress associated with pregnancy (i.e., location, radiation, exam findings)?

Answer 5

• Distal and lateral to lumbosacral jct
• Radiates down posterior thigh to knee
• NO muscle weakness or sensory impairment + normal +2/4 reflexes
• Pain may be due to relaxation of ligaments

Question 6

List 3 alarm features of LBP in pregnancy which would necessitate referral for further evaluation?

Answer 6

• Severe pain that interferes w/ function, particularly non-positional persistent pain AT NIGHT
• ↑ pain w/ cough, sneezing, valsalva
• Neuro deficits: either by hx or on exam

Question 7

The majority of cases of radicular pain during pregnancy are due to what?

Answer 7

• Herniated disc (40%)
• Bulging disc (10%)

Question 8

How would radicular pain due to a bulging or herniated disc present in a pregnant pt?

Answer 8

• As paresthersias in ilioinguinal and genitofemoral nerve distribution
• “Lightning pains”

Question 9

How large of an increase in interstitial fluids is seen during pregnancy?

Answer 9

6.5 L over the course

Question 10

How do increased estrogen, progesteronem and adrenal hormones affect the lymphatic and venous stress seen w/ pregnancy?

Answer 10

Promote fluid retention (tissue edema)

Question 11

What occurs to SVR and CO during the 1st trimester?

Answer 11

• SVR progressively ↓
• CO progressively ↑

Question 12

What happens to CO, SV, and HR while in the supine position during the 3rd trimester?

Answer 12

• ↓ CO + ↓ SV + ↑ HR
• Enlarged uterus can compress the IVC and ↓ venous return to heart

Question 13

What are 3 causes of decrease lymphatic flow during pregnancy?

Answer 13

• Fascial torsions
• Organ hypertrophy
• Diaphragm restriction

Question 14

What are some signs/sx’s associated with decreased lymphatic flow during pregnancy and during which trimester are they most often seen?

Answer 14

• Hemorrhoids
• Vulvar and LE varicosities due to sluggish venous return
• Most sx’s in 3rd trimester

Question 15

The decreased lymphatic flow in pregnancy is due to a less effective what?

Answer 15

Less effective pressure gradient

Question 16

Motion of what structure helps drive the pressure gradient for venous return?

Answer 16

Thoracic cage motion

Question 17

Venous stresses during pregnancy can lead to CNS congestion which causes what signs/sx’s?

Answer 17

HA, nausea, and light-headedness

Question 18

How can venous stresses during pregnancy cause delayed LBP (occurring during the evening)?

Answer 18

• Dependent edema moves back into vasculature + direct pressure on IVC by uterus
• ↓ flow in pelvis —> stagnant hypoxia of neural and vertebral tissue

Question 19

Pregnant women incapacitated by LBP have higher levels of what hormone?

Answer 19

Relaxin

Question 20

Which hormone leads to a change in the mechanical configuration of the thoracic cage during pregnancy?

Answer 20

Progesterone

Question 21

What are 2 relative contraindications for OMM in the OB patient?

Answer 21

• Premature rupture of membranes
• Premature labor

Question 22

List 7 absolute contraindication for OMM in the OB patient?

Answer 22

• Undiagnosed vaginal bleeding
• Prolapsed umbilical cord
• Placental abruption
• Ectopic pregnancy
• Placenta previa
• Threatened or incomplete abortion
• Severe pre-eclampsia/eclampsia

Question 23

Which factor if established before pregnancy can decrease the likelihood of a Mom suffering LBP during pregnancy?

Answer 23

Established exercise routine

Question 24

The effect of touch when treating a pregnant patient with OMM can be classified by using which of the 5-models?

Answer 24

Behavioral

Question 25

What are 2 areas of focus when treating hyperemesis gravidarum with OMM during the first trimester?

Answer 25

Tx areas **C2** and **T5-9**

Question 26

Recommending prenatal vitamins and treating hyperemesis gravidarum fits under which of the 5-models of OMM?

Answer 26

Metabolic-energetic-immune

Question 27

Which type of pelvic torsion should you expect to find during the second trimester (14-26 weeks) when evaluating a pregnant patient?

Answer 27

**Pelvis** rotating **anterior** about **right/left axis** (**forward torsion**)

Question 28

There may be a compensatory increase of the thoracic kyphosis during the second trimester of pregnancy causing what type of strain?

Answer 28

**Cervical strain**

Question 29

OMM during the second trimester should focus on what?

Answer 29

- **Fascial release** (**indirect**/**direct**) - **Tx sacrum** and **pelvis** (any modality that is comfy to pt)

Question 30

Which syndrome may arise during the second trimester due to the edematous state?

Answer 30

**Carpal Tunnel Syndrome**

Question 31

What are 2 focuses of tx during the 2nd trimester using the metabolic-energetic-immune model?

Answer 31

- **Prenatal vitamins** - **Constipation**: pelvic diaphragm release, stool softeners, laxatives

Question 32

What are the viscerosomatic levels for the adrenals, ovaries, and uterus which should be trargeted with OMM during the 3rd trimester?

Answer 32

**T10-L2**

Question 33

Which viscerosomatic levels for the bladder should you focus OMM towards during the 3rd trimester?

Answer 33

**S2-4**

Question 34

Using the behavioral model what are some recommendations for dealing with the hypotension and GERD associated w/ the 3rd trimester?

Answer 34

- **HoTN:** drink plenty of fluids - **GERD:** elevate head of bed, dietary modifications

Question 35

Which OMM tx may help regulate uterine contractions during labor?

Answer 35

**Thoracic** spine **ST** via **sympathetic innervation**

Question 36

What are some of the signs/sx's associated with rupture of the pubic symphysis?

Answer 36

- **Acute** pain **radiating** to **back** and/or **thighs** - **Palpable gap** w/ local tissue **edema** - **Waddling gait** ---\> ↑ pain on gait or bending

Question 37

What are some components of the conservative tx approach to rupture of the pubic symphysis?

Answer 37

- **Bed rest** --\> **lateral recumbent** - **Pelvic binder** --\> reduces separation - **OMM** --\> spine and pelvis (**indirect**)

Question 38

Infant and lithotomy position post-partum encourages what type of sacral and cranial SD?

Answer 38

**Anterior sacral base (flexion)** w/ **cranial extension**

Question 39

The infant and lithotomy position assoc. w/ an anterior sacral base (cranial extension) may cause what sx's in the patient?

Answer 39

**Fatigue**, **depression**, and **low energy**

Question 40

Utilizing OMM in the first visit post-partum is important before which changes occur?

Answer 40

Tx **prior** to resolution of hormonal changes on ligamentous structures (i.e., **relaxin**)

Question 41

When should the second screening for SD's occur during the post-partum period?

Answer 41

**4 weeks post-partum**

Question 42

What are 2 pregnancy specific relative contraindications to aerobic exercise?

Answer 42

- **Intrauterine growth restriction (IUGR)** in **current pregnacy** - **Unevaluated maternal cardiac arrhythmia**