Unless a doctor simply chooses not to treat pregnant patients, we all treat pregnant patients. With that fact in mind, it makes it important for everyone to stay well-informed of circumstances women encounter during pregnancy, particularly normal circumstances.
Normal Circumstances of Pregnancy
Amenorrhea (no menses) is to be expected through pregnancy. Higher levels of estrogen, progesterone and human chorionic gonadotropin prevent sluffing of the endometrial tissue lining the uterus. Instead, the tissue increases in size to sustain the fertilized egg. There is no bleeding.
There are exceptions to amenorrhea during pregnancy. Some women have light bleeding during early pregnancy. This can be mistaken for a period. The reason for this is not completely clear. The bleeding should be minor and stop; if it persists and/or increases in volume, immediate consultation with the patient's obstetrician is warranted.
If bleeding does occur, it may be of such immediate concern for the patient that it will not be mentioned during a chiropractic visit. The patient may seek immediate council with her obstetrician. Nonetheless, the doctor of chiropractic should be aware of the criteria for absence of and normal vs. abnormal bleeding.
Morning sickness is common during the first trimester of pregnancy. The patient tends to be nauseated with or without the presence of vomiting. Multiple etiologies have been cited as reasons for morning sickness. Hormonal influence on the GI tract, the growing uterus and emotional situations are among the most common.
Changes in taste and smell also can occur with pregnancy. This can leave the patient hypersensitive to certain tastes or smells; tastes and smells that were not disturbing before. Nausea and/or vomiting may result from these hypersensitivities. These factors affect the expectant mother's appetite.
A circumstance related to morning sickness is weight loss. Nausea and vomiting may prevent adequate nourishment, resulting in weight loss of 5 pounds or less. Weight loss of greater than 5 pounds is a concern and should be investigated.
Breast tenderness due to breast enlargement occurs with pregnancy due to hormonal changes. The related weight gain from enlarged breast tissues can often cause upper back pain. Chiropractic care is effective in decreasing the discomfort encountered from breast enlargement. Care also may be necessary postpartum if the patient breast-feeds.
Doctors of chiropractic should always be aware of the possibility of breast tenderness when placing the expectant patient in a prone posture for adjustment. Asking the patient to inform the doctor when breast tenderness becomes an issue is a proactive approach to this situation. There are also chiropractic tables available that adapt for breast tenderness or patients with large breasts.
As the uterus grows during gestation, the round ligaments supporting the uterus are placed under tension. This tension can lead to stretching, resulting in lower abdominal and/or groin pain. The pain can be unilateral or bilateral and often occurs when the expectant mother shifts positions. This condition is most common in the second trimester.
Long periods of standing and multiple fetuses accentuate the problem. In all cases, rest is a key element in relieving the tension and associated pain.
Fatigue is another common occurrence during pregnancy. Progesterone produced during pregnancy has a mild sedative effect and contributes, along with other factors that induce fatigue: increased energy requirements, stress placed on postural muscles as a result of weight gain, shifts in the center of gravity and sleep disturbances.
Fatigue associated with weight gain will be worse if the patient gains more weight than expected during the pregnancy. Sleep disturbances are often generated by the inability to find a comfortable sleeping position, movement of the fetus and increased frequency of urination at night.
Increased frequency of urination is common in pregnancy for three reasons:
- Blood volume increases, resulting in increased kidney filtration rates.
- As the uterus grows, it places pressure on the bladder.
- As the fetus moves into a head-down position, preparing for birth, the head applies further pressure on the bladder. Obviously urinary frequency will be greatest during the last trimester.
Edema in the extremities is common during pregnancy, especially during the third trimester. This is a result of decreased lymphatic flow and increased venous pressure. Significant swelling of the lower legs occurs as a result of these changes. This can result in changes in shoe size and significant discomfort, especially if the patient does not purchase new shoes to accommodate the temporary changes in foot size.
Edema also can occur in the upper extremities, but it is less common. As with edema in the lower extremities, the edema occurs in the distal end of the upper extremities. Edema in the wrist and hand areas can actually produce carpal tunnel symptoms in as many as 20 percent of expectant mothers. Extremity edema usually resolves shortly after delivery.
Gastrointestinal symptoms are common throughout pregnancy. Esophageal reflux can occur when hormonal changes result in relaxation of the lower esophageal sphincter, allowing stomach contents back up into the esophagus, creating "heartburn." Hormonal changes also decrease the rate of intestinal motility, causing constipation. Constipation can result in irritation of existing hemorrhoids or in some cases, the formation of new hemorrhoids.
As with bleeding, leukorrhea may be of such immediate concern for the patient that it will not be mentioned during a chiropractic visit. The patient may seek immediate council with her obstetrician. Still, the doctor of chiropractic should be aware of the sign. Leukorrhea is a milky, white discharge from the vagina due to vasocongestion of the cervix.
Back Pain and Chiropractic Care
Back pain is the final "normal" circumstance of pregnancy to discuss. Increased abdominal size causes a shift in the center of gravity and increased strain on postural muscles for any patient, female or male. This is further complicated for pregnant patients due to the production of the hormone relaxin during the third trimester. Relaxin's function is to loosen ligaments of the pelvis to allow expansion of the pelvis and birth canal during delivery. The result is increased postural strain on a now-unstable frame.
Complicating this situation is the fact that relaxin is not target specific. Since the hormone circulates systemically, it can affect joints other than those of the pelvis, causing further postural and skeletal complications.
Of the "normal" circumstances of pregnancy, this circumstance is the one most amenable to chiropractic care. Lower back and sacroiliac dysfunction are usually quite responsive to chiropractic care, which is often necessary throughout the pregnancy.
A special point must be made regarding the effects of relaxin. The effects of the hormone are not reversed until three to four months post-partum. This means chiropractic care during the first three to four months post-partum is as important as care during the pregnancy. This is also a period of time when excess weight gained during the pregnancy and breast size due to nursing also must be considered. Biomechanical stresses are far from over after delivery.
An Important Role to Play
While pregnancy is a natural process, it does not mean it is an easy process. Many of the circumstances discussed here interfere with activities of daily living and range from uncomfortable to painful. The circumstances are inconvenient as opposed to being pathological. This statement is not intended to discount their presence, but as stated earlier, the clinician must be able to differentiate the common circumstances of pregnancy versus circumstances of a more concerning and possibly pathological nature.
A final word here concerns patient education. As doctors, we should always encourage patients and their spouses to learn as much about the natural processes of pregnancy and what to expect so care provided during this time can truly be a team effort.
Resources
- Foxcroft K, Callaway L, Byme N, et al. Development and validation of a pregnancy symptoms inventory. BMC Pregnancy and Childbirth, 2013;13:3.
- Bickley LS (ed). Bates Guide to Physical Examination and History Taking, 9th Edition. Lippincott, Williams & Wilkins, 2007.
- Hasan R, Baird D, Herring A, et al. Patterns and predictors of vaginal bleeding in the first trimester of pregnancy. Ann Epidemiol, July 2010;20(7):524-31.
- Koren G. Treating morning sickness PRN? Canadian Family Phys, 2013;59(2):150-51.
- Lalkhen A, Grady K. Non-obstetric pain in pregnancy. Reviews in Pain, 2008;1(2):10-14.
- Voltk A, Mueller J, Farlinger D, et al. Carpal tunnel syndrome in pregnancy. Canadian Med Assoc J, February 1983;128(3):277-81.
- Dehgan F, Haerian BS, Muniandy S, et al. The effect of relaxin on the musculoskeletal system. Scand J Med & Sci in Sports, 2014;24(4):e220-9.
- Lindgren A, Kristiansson P. Finger joint laxity, number of previous pregnancies and pregnancy induced back pain in a cohort study. BMC Pregnancy & Childbirth, 2014;14:61.
- Nordin M, Frankel VH. Basic Biomechanics of the Musculoskeletal System, 3rd Edition. Lippincott, Williams & Wilkins, 2001.
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