The PGM Method - Pregnancy and Postpartum Considerations

Original Editor - Deborah Riczo

Top Contributors - Wanda van Niekerk, Kim Jackson, Vidya Acharya and Tarina van der Stockt  

Hormonal Changes

Relaxin

• Increases during pregnancy so that the body has the ability to stretch
• Often seen as the culprit for problems during pregnancy
• Research indicates that there is no link between pelvic girdle pain and relaxin serum levels during pregnancy
• Relaxin relaxes the uterus and myometrium, as well as cervix
• Also allows for the pubic symphysis area widening during the first trimester
• During first 12 weeks of pregnancy – hormone increases 10 times and then starts to taper off
• Women in early stages of pregnancy already having back pain due to surge of relaxin in the system to prepare for childbirth – decreases to about 50 % of peak value by 20th week

Estrogen

• Levels increase during pregnancy
• Responsible for water and sodium retention
• Relaxing effect on muscles and ligaments
• Increases vascularity in the respiratory membrane and signs of this include:
  • frequent nosebleeds, nasal stuffiness (congestion), voice changes

Progesterone

• Increases body temperature
• Hyperventilation
• Decrease in gastric mobility
• Decrease in smooth muscle tone

Thyroid Hormone

• Increases basal metabolic rate (BMT) by 25% during pregnancy
• Thyroid disorders second most common endocrine disorder in pregnancy and postpartum (diabetes is the most common)
• Subclinical hypothyroidism (increased need for thyroxin during pregnancy)
• Symptoms of hypothyroid:
  • Difficulty concentrating/ brain fog
  • Excessive weight gain
  • Cold
  • Extreme fatigue
  • Muscle cramping
  • Constipation
• Symptoms of hyperthyroid:
  • Nervousness/anxiety
  • Weight loss/low weight gain
  • Hot
  • Fatigue, difficulty sleeping
  • Tremor
  • Increased and/or irregular heart rate
  • Morning sickness and vomiting

It is very important that the healthcare provider should monitor any thyroid problems and thyroid levels!

Gestational Diabetes

• Monitored with glucose intolerance test
• Requires medical management
• Can be affected by exercise and education (diet and lifestyle)
• Risk factors linked to diet and lifestyle factors
• Increased risk of:
  • Hypertension
  • Future diabetes for mother and child
  • Caesarean section
  • Preeclampsia
    • Serious medical condition – life threatening
    • Preeclampsia.org (Preeclampsia Foundation)
    • Monitor blood pressure and protein in urine
    • If blood pressure > 140/90 mmHg and excessive protein in urine
    • Symptoms such as:
      • Headaches
      • Vision changes
      • Nausea
      • Vomiting
      • Rib pain in right side
      • Low urine output
      • Sudden weight gain
      • Swelling, oedema
      • Shortness of breath
      • Impaired liver function

Other Systems

Gastrointestinal System

• Gallbladder problems
  • Higher risk of gallbladder problems and disorders during pregnancy
  • Key sign of gallbladder problems is R upper abdominal quadrant pain
  • Pain can also refer to lower back and scapula
  • Pain triggered by fatty foods
• Reflux and heartburn
• Nausea and vomiting
• Constipation

Urogenital System

During pregnancy women are at higher risk for urinary tract infections (UTI’s). Symptoms of this would include burning and pain.

Integumentary System

• Abdominal itching is usually normal
• If during late pregnancy, and experiencing itching in hands and feet with no rash – could possible be symptoms of cholestasis
• If accompanied by right upper quadrant pain, nausea, vomiting, loss of appetite, fatigue – patient needs to be referred to their obstetrician

Cardiovascular Changes

Overview of Cardiovascular Considerations

• Blood volume increases 35% – 50% during pregnancy
• Venous pressure increases during standing due to uterus size – this may result in increased oedema in the lower extremity
• Heart rate increases 10 to 20 beats per minute and rhythm disturbances are common during pregnancy
• Cardiac output increases 30% – 60% during pregnancy
• Blood pressure decreases early in pregnancy rises during mid-pregnancy but should be similar to pre-pregnancy by the end of the pregnancy – if there are irregularities during pregnancy and if blood pressure is increasing, this may be a sign of preeclampsia.
• Important to monitor blood pressure regularly!

Supine Hypotension

• Occurs when a person is supine, but can also occur in standing
• During pregnancy it usually occurs after the 1st trimester, during the 2nd half of pregnancy
• Caused by compression of the vena cava by the enlarged uterus
• Symptoms of supine hypotension:
  • Increased foetal movement
  • Feeling faint, dizzy
  • Shortness of breath (SOB)
  • Pallor
  • Headaches
  • Restless feeling
  • Chest pain
  • Numbness/Paraesthesia, cold legs, weakness
  • Fatigue
  • Cyanosis, yawning, convulsions

How to Relief Supine Hypotension?

Changing positions increases blood flow to the lower extremities

• Changing from supine or static standing
• Position of choice is to lie on L side – this relieves the pressure on the vena cava and aorta on right side
• Can improve circulation by placing a pillow, towel roll, wedge under right hip

Important to be aware of this, especially during static treatment positions for prolonged periods of time!

Maternal Sleep Position

• Education on sleep position during pregnancy is important
• Sleeping in the supine position places stress on the foetus
• Triple risk model for stillbirth:
  • High risk or vulnerable foetus
  • Maternal comorbidities such as age, obesity, parity, gestational diabetes, gestational hypertension
  • Foetal stressor such as supine sleep position
  • The foetus cannot adapt to repeated nightly exposure to this stressor and ultimately dies as a result.

Venous Thromboembolism

Increased incidence of deep vein thrombosis (DVT) in the prenatal and postpartum population. The risk for DVT’S increases with:

• Smoking
• Hypertension
• Older than 40 years of age
• Obesity
• Varicose veins
• Previous DVT
• Blood type other than O
• Congenital or acquired thrombophilia
• Immobility
• Congestive heart failure
• Malignancy
• Caesarean birth
• Preeclampsia and eclampsia

Pulmonary Embolism

A condition where one or more of the arteries in the lungs become blocked by a blood clot. This is caused by blood clots traveling from the legs or other parts of the body (deep vein thrombosis).

Symptoms of a pulmonary embolism are:

• Shortness of breath or dyspnoea
• Chest pain
• Cough
• Tachycardia
• Syncope
• Haemoptysis (blood in sputum)

Physical signs of DVT are:

Thigh pain (may be diffuse)

May be in inguinal region or in calf region

Skin discoloration

Swelling/oedema

Prominent superficial veins

Positive Homan’s sign may or may not be present

Sudden increase in pain in calf or popliteal space with passive dorsiflexion

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