Gynae Compilation
Gynae Compilation
Gynae Compilation
Dr Abdullah
INTRODUCTION
TO
GYNECOLOGY
& OBSTETRICS
OBSTETRICS
FAIZA AMJAD
LEC 2
• In the late nineteenth century the physiotherapy, nursing and
midwifery professions shared a common rootstock.
DAME ROSALIND PAGET
• In 1886, Dame Rosalind Paget, a
nursing sister at the London Hospital
who was also a midwife, joined the
Midwives Institute, which later became
the Royal College of Midwives (RCM)
• In 1902 she was involved in the
formation of the Central Midwives
Board and appears as number two on
their list of members.
• Also in 1886 Dame Rosalind became
interested in a new therapy – Swedish
massage
DAME ROSALIND PAGET
• The role of the Health Visitor in this field is to offer advice to the
parents-to-be on the many health, psychological and social implications
of becoming parents and the development of the child.
• She is in a very special position in the family scene to inform them of the
services available and encourage them to use them.
• The health visitor should always have a participatory role within the
team to provide continuity of care to the family.
THE OBSTETRIC PHYSIOTHERAPIST
• The role of the Obstetric Physiotherapist is to promote health
throughout the childbearing period and to help the woman adjust
advantageously to the physical and psychological changes of
pregnancy and the post-natal period so that the stresses of
childbearing are minimised.
• Antenatally and post-natally she advises on physical activity
associated with both work and leisure and is a specialist in selecting
and teaching appropriate exercises to gain and/or maintain fitness
including pelvic floor education.
• Where necessary she gives specialised treatment e.g. therapeutic
ultrasound post-natally to alleviate perineal discomfort.
• She also assesses and treats musclo-skeletal problems such as
backache and pelvic floor muscle weakness.
• In addition she is a skilled teacher of effective relaxation, breathing
awareness and positioning and thus helps the woman to prepare for
labour.
THE AIMS OF PARENTHOOD
EDUCATION
• To enable parents to develop a confident and relaxed
approach to pregnancy, childbirth and parenthood.
• To enable parents to be aware of the choices in care
based on accurate and up to date information.
• To provide continuity of high quality care as
previously defined to parents by means of team
collaboration and co-operation between
professionals including specialized treatments where
needed
• To ensure that appropriate, consistent and clear
advice is given with full safety factors.
• To promote health and preventative medicine.
• Frequently new methods
of education in
parenthood are
introduced e.g. aqua-
natal and fitness classes.
• In such instances it is
necessary for guidance to
be sought on appropriate
exercises from the local
obstetric physiotherapist
or alternately the
Chartered Society of
Physiotherapy,
Anatomy
FEMALE PELVIC
THE PELVIS
• protective shield
• supports the trunk
• pelvis consists of the two innominate bones and the sacrum to
which coccyx is attached
• The innominates and the sacrum articulate at the symphysis
pubis, and at the right and left sacroiliac joints, to form a firm
bony ring.
• The ring of bone is
deeper posteriorly
than anteriorly and
forms a curved
canal.
• The inlet to this
canal is at the level
of the sacral
promontory and
superior aspect of
the pubic bones
• The outlet is formed by the
pubic arch, ischial spines,
sacrotuberous ligaments and the
coccyx.
• The enclosed space between the
inlet and outlet is called the true
pelvis, with the plane of the inlet
being at right angles to the plane
of the outlet.
• The female true pelvis differs from the male in being
shallower, having straighter sides, a wider angle between the
pubic rami at the symphysis and a proportionately larger
pelvic outlet.
Female Male
Pelvic Inlet
Pelvic Outlet
Pelvic Cavity
Pelvic Arch
• The ideal or gynaecoid pelvis is recognised by its well-rounded
oval inlet
• The inlet has its longest dimension from side to side, whereas
at the outlet the longest dimension is anteroposteriorly
• The foetal skull is longest in its anteroposterior
dimension.
• Most commonly in labour the head enters the
inlet of the maternal pelvis transversely placed
(i.e. long axis to long axis), rotates in mid-
cavity and leaves by the outlet with its longest
dimension lying anteroposteriorly.
Different shapes of pelvic
• Difficulties can be experienced in childbirth from such adverse
features as protuberant ischial spines, a heart-shaped inlet
produced by an invasive sacral prominence, or an
asymmetrical pelvis (e.g. as a result of rickets or trauma).
• It is also possible for the inlet or outlet to be too small to allow
the foetal head to pass through
• It has recently been demonstrated that a narrow suprapubic
arch is associated with a consequential prolonged labour and
postpartum anal incontinence
sacrum
• The wedge-shaped sacrum is virtually suspended between the
innominates by the exceptionally tough interosseous and
posterior sacroiliac ligaments,
• However, the ventral sacroiliac ligament is less substantial and
is thought to tear during childbirth
• The upper sacrum is stabilized by the illiolumbar ligaments via
its attachment to the fourth and fifth lumbar vertebra and the
lower sacrum by the sacrospinous and sacrotuberous
ligaments attachments to the posterior iliac spines and ischial
tuberosities
Loading during pregnancy
• Loading of the sacral prominence (e.g. in pregnancy) is often,
but not invariably, accompanied by lumbar lordosis and its
associated adaptations, hip and knee flexion, thoracic kyphosis
and cervical extension with a forward-thrusting chin.
• It should be noted that in this case it is the sacrum that moves
on the ilia and that the pelvis as a whole does not tilt forward
to produce the lumbar lordosis. The pelvic tilt may well remain
constant
Sacrum rotation
Lumbar lardosis
Symphysis pubis
Vertical plane
Ileum
Pubis
Ischium
Acetabulum
Obturator foramen
Sacrotuberous
ligament
Sacrospinous
ligament
Sacrospinous
ligament
Sacrotuberous
ligament
Greater sciatic
foramen
Lesser sciatic
foramen
Piriformis
Piriformis
Obturator internus
Common Iliac A
Internal Iliac A
External Iliac A
Common Iliac V
Internal Iliac V
The Lumbosacral Plexus
Sciatic nerve
Pudendal nerve
Obturator nerve
Sacrotuberous
ligament
Sacrospinous
ligament
Obturator canal
Obturator internus
Muscle
Covered by
Fascia
Pudendal canal
Line of
attachment of
levator ani
Critical pelvic
dimensions
Pelvic inlet
Critical pelvic
dimensions
Pelvic midplane
Critical pelvic
dimensions
Pelvic outlet
Female Male
Pelvic inlet
Pelvic outlet
Pelvic cavity
Pubic arch
Iliac crest
Pelvic brim
Ischial tuberosity
Rectum
Obturator
Internus
With Fascia
Levator ani
Plus coccygeus
Makes
Pelvic diaphragm
Peritoneum
Subperitoneal
space
Contains:
Pubocervical
Trans cervical
Sacrocervical
Ligaments
Perineum
everything under
pelvic diaphragm
Ischiorectal fossae
Obturator
membrane
Obturator canal
Pubic arch Symphysis pubis
Inferior pubic
ramus
Ischial ramus
Ischial tuberosity
Sacrotuberous
ligament
Sacrum / coccyx
Pelvic outlet
Urogenital
triangle
Anal triangle
Bladder
Above the
Rectum
Pubocervical
ligament Above the
Pelvic diaphragm
Above the
Pelvic diaphragm
Transverse
cervical ligament
Above the
Pelvic diaphragm
Sacrocervical
ligament
Pelvic diaphragm
Levator ani:
Pubococcygeus
Iliococcygeus
Ischiococcygeus
Coccygeus
Urogenital
diaphragm
Superior layer
of fascia
Urogenital
diaphragm
Sphincter urethrae
Deep transverse
peroneal muscles
Perineal
membrane
Structures in
Superficial pouch
Bulb of vestibule
Vestibular glands
Muscles in
Superficial pouch
Ischiocavernosus
Bulbospongiosus
Supl transverse
peroneal muscles
Perineal body
Labium majus
Labium minus
Mons pubis
Prepuce of clitoris
Vestibule
vagina
Fourchette
Peritoneum
Sacrocervical
ligament
Pubocervical
ligament
Pelvic diaphragm
Urogenital
diaphragm
Rectum
Sacrum
Deep
Superficial
Subcutaneous
parietal
coronal eminence
sutures
frontal lambdoid
bones sutures
occiput
anterior
fontanelle
posterior
saggital fontanelle
suture
PASSENGER
the shoulders contact the pelvic floor and rotate so that the bisacromial
diameter lies in an anteroposterior orientation
the head therefore continues to rotate - external rotation
THE ABDOMINAL MUSCLES
• The anterior and lateral abdominal wall is formed by the
abdominal muscles
• The deepest of the group is the transversus abdominis muscle,
which lies internally to the internal and external oblique
muscles
• The aponeurosis is reinforced by the two rectus
abdominis muscles, which run in sheaths formed in the
aponeurosis on either side of the linea alba.
• Of particular relevance is the fact that the sheaths are
elastic longitudinally and less so transversely.
• Each rectus abdominis muscle has three transverse
fibrous intersections, which are firmly attached to the
anterior wall of the enclosing sheath.
• The lowest intersection is about the level of the
umbilicus, and the sheaths are deficient posteriorly in
the lowest portion
Anterior wall of the abdomen
Nerve suply
• The oblique and transversus muscles are innervated by the
lower six thoracic nerves, and the iliohypogastric and
ilioinguinal nerves.
• The recti are innervated by the lower six thoracic nerves
Visceroptosis
• The shape of the anterior abdominal wall depends on the
tone of its muscles.
LOWER MIDLINE
SUBUMBILICAL INCISION VERTICAL INCISION
FOR LAPAROSCOPY
PFANNENSTIEL VERTICAL
INCISION INCISION
ANATOMY OF FEMALE
REPRODUCTIVE SYSTEM
Define the terms listed.
Identify the female external
reproductive organs.
Explain the functions and structures of
pelvic floor.
Collectively, the external
female reproductive
organs are called the
Vulva.
Mons Pubis.
Labia Majora
Labia Minora.
Clitoris.
Vestibule.
Perineum
Is rounded, soft fullness of
subcutaneous fatty tissue, prominence
over the symphysis pubis that forms
the anterior border of the external
reproductive organs.
It is covered with varying amounts
of pubic hair.
The labia Majora are two rounded,
fleshy folds of tissue that extended
from the mons pubis to the perineum.
Cortex
Medulla
Hilum
Figure 28–14
Secrete estrogen & progesterone.
Production of ova
UTERUS
The uterus is a hollow, pear shaped
muscular organ.
Figure 16.20 (1 of 3)
Stages of Labor
• Expulsion
– Infant passes through the cervix and
vagina
– Can last as long as 2 hours, but
typically is 50 minutes in the first birth
and 20 minutes in subsequent births
– Normal delivery is head first (vertex
position)
– Breech presentation is buttocks-first
Stages of Labor
Figure 16.20 (2 of 3)
Stages of Labor
• Placental stage
– Delivery of the placenta
– Usually accomplished within 15 minutes
after birth of infant
– Afterbirth—placenta and attached fetal
membranes
– All placental fragments should be
removed to avoid postpartum bleeding
Stages of Labor
Figure 16.20 (3 of 3)
New arrival
COMPLICATIONS
OF PREGNANCY
AABCDEGPPP
ANEMIA
• Anemia is very common in pregnancy, and is accepted to be
significant at a hemoglobin level of less than 10.5 g/100 mL or
less and is due in most cases to an iron deficiency.
• The majority of the depletion of the maternal stores are due to the
increasing demands of the pregnancy hemoglobin levels fall,
pallor, dyspnea and edema
• Severe anemia is said to be present if the hemoglobin levels fall
below 6.5 g/100 mL
ANTEPARTUM HEMORRHAGE
• Antepartum hemorrhage (APH) is a serious complication,
defined as bleeding from the genital tract at any stage
from 24 weeks’ gestation to the birth.
• Bleeding during labor is often called ‘intrapartum
hemorrhage’
CARDIAC DISEASE
• Cardiac output increases by 30–50% during pregnancy
• There is also a risk of cardiac decompensation, especially
during labor and in the 4 days following parturition.
• Those with a valve replacement may require
anticoagulant therapy.
DIBETES MELLITUS
• The total or relative lack of insulin can result in
dehydration, hyperglycemia, ketosis, polyuria and
polydipsia.
• Perinatal death, pre-eclampsia, fetal abnormalities.
• Some are Macrosomic babies
• A macrosomic fetus is at greater risk of birth trauma
especially brachial plexus lesion due to shoulder
dystocia
• some of the babies are very small owing to placental
dysfunction
• C-section delivery
GESTATIONAL DIABETES
• This is a temporary condition associated with pregnancy.
Those women that develop hyperglycemia (detected with
an impaired glucose tolerance test during pregnancy) may
have an adverse neonatal outcome if left untreated.
ECTOPIC PREGNANCY
• The fertilized ovum occasionally implants
outside the uterus, most commonly in the
fallopian tube at the ampulla or the
isthmus – the junction of the tube with the
uterus.
• As the pregnancy develops, distension of
the tube results in pain, and if left
untreated, eventual rupture of the tube or
bleeding leads in some patients to shock
and even maternal collapse.
PLACENTA PREVIA
• Where the placenta has embedded low on the uterine
wall, close to or even across the isthmus and cervix
OLIGOHYDRAMNIOS &
POLYHYDRAMNIOS
• Oligohydramnios is a rare condition where the liquor
amnion is much reduced and milky
• Fetal abnormalities (e.g. talipes, torticollis) owing to
the lack of space for movement.
• The baby’s skin is very dry and leathery
• Polyhydramnios is the presence of an abnormally
large quantity of amniotic fluid so that the uterus is
tense and distended to a degree inconsistent with the
gestation dates, and it may be impossible to palpate
the fetus
• esophageal atresia,
• open neural tube defect
PREGNANCY INDUCED HYPERTENSION/ PRE-
ECLAMPSIA
• Pregnancy-induced hypertension is the most common
and potentially serious complication of pregnancy for both
mother and fetus
BREECH POSITION
• Right before birth, most babies are in a head
down position in the mother's uterus. Sometimes,
the baby is in a bottom first (or feet first)position. When
a baby is in that position before birth, it's called a
breech birth or breech baby.
ASSOCIATED PATHOLOGY
• Fibroids
• Genital herpes
• HIV
• Intrauterine growth retardation & death
• Multiple pregnancies
TYPES OF DELIVERY
• Episiotomy
• Forceps delivery
• Vacuum extraction
• Cesarean section
ANTENATAL CARE
PREGNANCY BACK CARE
• Postural, hormonal and weight changes,
• Ergonomic education involving sitting and working
positions, bending, lifting and household activities
Symphysis pubis dysfunction (SPD)
• Symphysis pubis dysfunction, or SPD,
means the ligaments that normally keep
your pelvic bone aligned during pregnancy
become too relaxed and stretchy too soon
before birth (as delivery nears, things are
supposed to start loosening up). This, in
turn, can make the pelvic joint — unstable,
causing some pretty strange sensations
and sometimes pelvic pain
Pelvic floor and
pelvic-tilting exercises
• Women who had learnt and practiced PFM contractions
during pregnancy experienced less urinary incontinence
postpartum
Exercises for circulation and cramp
• Ankle dorsiflexion and plantar flexion, and foot
circling carried out for 30
• women should be advised not to cross the knees
when sitting.
• The technique of stretching in bed with the foot
dorsiflexed and not plantar flexed for preventing
and easing calf cramp
• Additionally, cramp relief include avoiding long
periods of sitting, a pre-bedtime walk, calf
stretches, a warm bath, and foot and ankle
exercises in bed before going to sleep
Cardiovascular
• Both exercise and pregnancy increase:
– Heart rate
– Stroke volume
– Cardiac output
• Theoretical risk: Competing effects on regional blood flow
distribution
– Both glucose and oxygen delivery to placental site is reduced
Cardiovascular II
• Women who perform regular weight
bearing exercise
– Augment pregnancy associated increases in
plasma volume
– Increase placental volume
– Increase cardiac output
• What does this suggest?
– Increased rate of placental blood flow at rest
– Increase in 24 h glucose & oxygen delivery
Walking
Contraindications to Exercise
Contraindications (PPPPP II)
Pregnancy-induced hypertension
Preterm rupture of membranes
Preterm labor during or prior during pregnancy
Placenta previa
Persistent second- or third-trimester bleeding
Incompetent cervix
Intrauterine growth retardation
Relative contraindications (CCTV)
Chronic hypertension
Cardiac disease
Thyroid function abnormality
Vascular disease
Urinary function and dysfunction
continence
• ‘Incontinence’ has been defined as the involuntary or inappropriate passing of urine or faeces,
or both, that has an impact on social functioning or hygien.
• This definition applies only after early childhood.
• society places demands that voiding occurs at a time and in a place that is acceptable to the
majority.
• For example, when out for a walk in the countryside, it is acceptable to empty one’s bladder
behind a hedge on the edge of a deserted field, but to do so behind a hoarding in a crowded
street is not acceptable.
• If a person passes urine or feces into clothing, in a bed or chair, on to the ground or into a
receptacle not designated for the purpose the person is likely to be labelled as ‘incontinent’.
• Incontinence of urine or feces is a symptom or a sign with a cause, not a condition or a
specific disease.
• It may be a temporary state associated with a transient cause (e.g. transient
unconsciousness, infection, or drug side-effects), or it may be persistent resulting from
longer-lasting or even permanent causes (e.g. trauma in childbirth, stroke)
• it can lead to isolation, depression, loss of self-esteem, and ill health, for example infections
Prevention of continence problems
• Repetitive coughing, smoking, frequent constipation, obesity, repeated heavy lifting and
poorly controlled diabetes are just some of the factors that can lead to continence problems
and over which an individual has some control
• Following childbirth, it is important to regain pre-pregnancy strength of the pelvic floor
muscles (PFMs) as far as humanly possible
• As a prophylactic measure, every woman should be encouraged from a young age to make a
regular habit of PFM contractions (Wall & Davidson 1992), and it is never too late to start!
• patients with hay fever, asthma, chronic chest conditions, back problems, stroke, multiple
sclerosis, Parkinson’s disease, Alzheimer’s disease, hypertension and diabetes, those
undergoing hip replacement, the elderly, the obese, those on crutches and those confined to
a wheel chair are all at particular risk of developing bladder and bowel dysfunction
NORMAL LOWER URINARY TRACT FUNCTION
• Ureters
• Bladder
• urethra
THE MICTURITION CYCLE
• The micturition cycle consists of two phases:
• bladder filling
• bladder emptying
• During the filling phase, the detrusor muscle is compliant and the detrusor pressure is usually
less than 15 cm H2O
• At a volume of 150–200 ml the first mild desire to void is commonly felt.
• Normally this desire can be postponed, at least to allow for completion of the necessary
preparations for voiding, although more often it is postponed for longer
• Eventually, with increasing stored volume, the pressure within the bladder begins to rise and
the sensation of fullness becomes more consciously apparent and persistent.
• A decision to void is taken, a socially acceptable site is found and necessary preparations are
made.
• The levator ani and urethral sphincter muscles relax and then the detrusor muscle contracts.
• On completion of the void the levator ani and sphincter muscle contract and the detrusor
muscle stops contracting and is ready to store again
STORAGE OF URINE
• The normal bladder’s compliance accommodates and stores the incoming urine without a
significant rise in pressure within the bladder, and without involuntary contractions of the
detrusor even with provocation (e.g. a cough, change of position).
• The actual pressure in the bladder is the sum of intra-abdominal pressure on the bladder
from outside and the pressure produced by the elasticity of the connective tissue and muscle
of the bladder wall.
compliance
• The elastic ability of the bladder to accommodate an increasing volume of fluid without a
rise of pressure is called ‘compliance’,
• Urine is prevented from leaving the stable bladder via the urethra by a considerable closure
pressure, about 50–70 cm H2O in premenopausal women and 40–50 cm H2O for
postmenopausal women
• As filling continues, the limit of distensibility of the bladder wall is
reached and the pressure then begins to rise.
• The average daytime tolerable bladder capacity in women is between
350 and 500 ml; the first void of the day may be greatest and may be
greater than 500 ml.
• Continence is maintained so long as the pressure within the bladder is
lower than the closure pressure of the urethra.
• Even in a normal, healthy person there is a point, as bladder pressure
rises, at which urethral pressure could be overwhelmed and leakage
occur.
VOIDING OF URINE
• The flow rate, that is, the volume of liquid in millilitres expelled via the urethra per second,
has a strong dependency on the total voided volume
• A normal flowmetry chart will show a smooth bell-shaped curve rising to a peak (maximal
urine flow rate – MUFR) and falling back to zero.
• From such a trace, the average urine flow rate is calculated (AUFR).
• In women with no gynaecological problems the AUFR may vary between 5 and 15 mL/s for a
voided volume of 100 mLand between 12 and 25 mL/s for 400 mL
THE NEUROLOGICAL CONTROL OF CONTINENCE
• Storage symptoms are experienced during the storage phase (e.g. abnormal bladder
sensations, frequency, urgency and leakage of urine).
• Voiding symptoms are experienced during the voiding phase, and include any description or
deviation from a speedy and continuous flow of urine (e.g. a slow or intermittent stream,
hesitancy at the start of micturition, terminal dribble).
• Postmicturition symptoms are experienced immediately after micturition (e.g. a feeling of
incomplete emptying, and postmicturition dribble).
Some useful definitions
Posture-Related Back
Joint Laxity
Pain
Interventions
Low back pain symptoms can be treated effectively with many traditional low back
exercises, proper body mechanics, posture instructions, improvement in work
techniques, along with superficial modality application.
The use of deep heating agents, electrical stimulation, and traction is generally
contraindicated during pregnancy.
Sacroiliac/Pelvic Girdle
Pain
Sacroiliac/Pelvic Girdle
Pain
Characteristics
Characteristics
Pain may radiate into the posterior thigh or knee but not into the
foot.
Sacroiliac/Pelvic Girdle
Pain
Symptoms
Symptoms
interventions
interventions
Activity modification.
interventions
Exercise modification.
interventions
External stabilization
Characteristics
Varicosities can present in the first trimester and are more prevalent with
repeated pregnancies.
They can occur in the lower extremities, the rectum (hemorrhoids), or vulva.
Symptoms usually include heaviness or aching discomfort, especially with
dependent leg positions;
intensity may become severe as the pregnancy progresses.
In addition, pregnant women are more susceptible to deep vein thrombosis.
Interventions
Posture-Related Back
Joint Laxity
Pain
Interventions
Low back pain symptoms can be treated effectively with many traditional low back
exercises, proper body mechanics, posture instructions, improvement in work
techniques, along with superficial modality application.
The use of deep heating agents, electrical stimulation, and traction is generally
contraindicated during pregnancy.
Sacroiliac/Pelvic Girdle
Pain
Sacroiliac/Pelvic Girdle
Pain
Characteristics
Characteristics
Pain may radiate into the posterior thigh or knee but not into the
foot.
Sacroiliac/Pelvic Girdle
Pain
Symptoms
Symptoms
interventions
interventions
Activity modification.
interventions
Exercise modification.
interventions
External stabilization
Characteristics
Varicosities can present in the first trimester and are more prevalent with
repeated pregnancies.
They can occur in the lower extremities, the rectum (hemorrhoids), or vulva.
Symptoms usually include heaviness or aching discomfort, especially with
dependent leg positions;
intensity may become severe as the pregnancy progresses.
In addition, pregnant women are more susceptible to deep vein thrombosis.
Interventions
Lec-16P
Cesarean Childbirth
• A cesarean section is the delivery of a baby through an incision
in the abdominal wall and uterus rather than through the
pelvis and vagina.
• General, spinal, or epidural anesthesia may be used.
INDICATIONS
• usually performed when a vaginal delivery is a risk for mother
or baby,
• complications of labor and factors impeding vaginal delivery
:small pelvis,dystocia
cord prolapse
hypertension
placental problems
abnormal
presentation
macrosomia
• other complications of
pregnancy, preexisting
conditions and
concomittant disease
pre-eclampsia
multiple births
sexually transmitted infections such as genital herpes
Risk
RISK FOR MOTHER
• associated with risks of post-operative adhesions
• incisional hernias
• wound infections
• severe blood loss
• post spinal headaches
RISK FOR THE CHILD
• neonatal depression
• fetal injury
• breathing problems
demography
• Cesarean section (C-section) delivery is now at an all-time high
and is the most commonly performed surgical procedure in
the United States.
• In 2007, the total number of C-sections was almost 1.5 million,
for a record high rate of 31.8% .This statistic has fluctuated in
the past three to four decades
INTERVENTIONS
High-Risk Pregnancy
• A high-risk pregnancy is one that is complicated by disease or
problems that put the mother or fetus at risk for illness or
death before, during, or after delivery.
• Conditions may be preexisting, induced by pregnancy, or
caused by an abnormal physiologic reaction during pregnancy.
• The goal of medical intervention is to prevent preterm delivery,
usually through use of bed rest, restriction of activity, and
medications, when appropriate
• Prolonged bed rest can impact not just the musculoskeletal
system but also pulmonary, cardiovascular, and metabolic
functions.
• Although these women may initially be seen in the home, the
deconditioning present continues to create functional
restrictions for the postpartum client in terms of strength and
endurance,
High-Risk Conditions
Premature onset of labor
• If cervical dilation, effacement, and/or uterine contractions
begin before 37 weeks’ gestation, this is considered preterm
labor.
• Clearly, the health of the baby is of primary concern if these
signs are present. The mechanism for this condition is still
unclear.
Preterm rupture of membranes
• The amniotic sac breaks, and amniotic fluid is lost before onset of
labor.
• This can be dangerous to the fetus if it occurs before fetal
development is complete.
• Labor may begin spontaneously after the membranes rupture.
• The chance for fetal infection also increases when the protection of
the amniotic sac is lost.
• Leakage of amniotic fluid is an indication for immediate medical
attention
Incompetent cervix
• An incompetent cervix is the painless dilation of the cervix that
occurs in the second trimester (after 16 weeks’ gestation) or
early in the third trimester of pregnancy.
• This may lead to premature membrane rupture and delivery of
a fetus too small to survive
Placenta previa
• The placenta attaches too low on the uterus, near the cervix.
As the cervix dilates, the placenta begins to separate from the
uterus and may present before the fetus, thus endangering
fetal life.
• The primary symptom is intermittent, recurrent, or painless
bleeding that increases in intensity.
Pregnancy-related hypertension or preeclampsia
• Characterized by hypertension, protein in the urine, and
severe fluid retention, preeclampsia can progress to maternal
convulsions, coma, and death if it becomes severe (eclampsia).
• It usually occurs in the third trimester and disappears after
birth. The cause is not understood
Multiple gestation
• More than one fetus develops.
• Complications of multiple gestations include premature onset
of labor and birth, increased incidence of perinatal mortality,
lower birth weight infants, and increased incidence of maternal
complications (e.g., hypertension).
Diabetes
• Diabetes can be present before pregnancy or may
• occur as a result of the physiological stress of pregnancy.
• Gestational diabetes, which presents or is first recognized in
pregnancy, affects 7% of pregnant women and usually
disappears after pregnancy; however, as many as 50% of these
women may develop type 2 diabetes within 10 years
Thank you
Guidelines for Managing the Pregnant
Woman
Proper positioning
• Do not exceed 5 minutes of supine positioning at any one time
after the first trimester of pregnancy
• to avoid vena cava compression by the uterus.
• Educate your patients that compression of the vena cava also
occurs with motionless standing.
• For supine exercise, place a small wedge or rolled towel under the
right hip to lessen the effects of uterine compression on abdominal
vessels and to improve cardiac output. The wedge turns the patient
slightly toward the left
• This modification is also helpful during physical therapy evaluation
and treatment when the patient is positioned supine.
orthostatic hypotension
• To avoid the effects of orthostatic hypotension, instruct the
woman to always rise slowly when moving from lying down or
sitting to standing positions.
breath-holding
• Discourage breath-holding, and avoid activities that tend to
elicit Valsalva’s maneuver because this may lead to
undesirable downward forces on the uterus and pelvic floor.
• In addition, breath-holding causes stress to the cardiovascular
system in terms of blood pressure and heart rate
fluid replenishment
• Break frequently for fluid replenishment.
• The risk of dehydration during exercise is increased in
pregnancy.
• Avoid exercising in high temperature or humidity.
• Increase water intake in proportion to time spent exercising
and as environmental temperature increases.
• Encourage complete bladder emptying before exercise.
• A full bladder places increased stress on an already weakened
pelvic floor.
• Include appropriate warm-up and cool-down activities.
• Modify or discontinue any exercise that causes pain.
• Limit activities in which single-leg weight bearing is required,
such as standing leg kicks.
• In addition to possible loss of balance, these activities can
promote sacroiliac or pubic symphysis discomfort
Stretching/flexibility
• Choose stretching exercises that are specific to a single muscle or
muscle group; do not involve several groups at once.
• Asymmetrical stretching or stretching multiple muscle groups can
promote joint instability.
• Avoid ballistic movements.
• Do not allow any joint to be taken beyond its normal physiological
range.
• Use caution with hamstring and adductor stretches.
Overstretching of these muscle groups can increase pelvic
instability or hypermobility.
PRECAUTIONS
• Observe participants closely for signs of overexertion or
complications. The following signs are reasons to discontinue
exercise
• Persistent pain, especially in the chest, pelvic girdle, or low back
• Leakage of amniotic fluid
• Uterine contractions that persist beyond the exercise session
• Vaginal bleeding
• Decreased fetal movements
• Persistent shortness of breath
• Irregular heartbeat
• Tachycardia
• Dizziness/faintness
• Swelling/pain in the calf
• Difficulty in walking
Muscle performance and aerobic fitness.
Recommendations for Fitness Exercise
• It is strongly recommended for all women to participate in mild
to moderate exercise, for both strength and cardiopulmonary
benefits, 15 to 30 minutes/session, most days of the week.
• Individualized programs, based on prepregnancy fitness level,
are preferable
• Currently, there are no data in humans suggesting that pregnant women
need to decrease their intensity of exercise or lower their target heart
rates, but because of decreased oxygen supply, they should modify
exercise intensity according to their tolerance.
• Conventional (age-based) target heart rate zones may be too aggressive for
the average pregnant patient.
• Use of the Borg scale of perceived exertion is more appropriate in this
population, with exertion between 12 and 14 suggested during
uncomplicated pregnancy.
• When fatigued, a woman should stop exercising, and she should never
exercise to exhaustion
The scale starts with “no feeling of exertion,” which rates a
6, and ends with “very, very hard,” which rates a 20.
Moderate activities register 11 to 14 on the Borg scale
(“fairly light” to “somewhat hard”), while vigorous
activities usually rate a 15 or higher (“hard” to “very, very
hard”)
• Activities to avoid include contact sports,
anything with a high risk of abdominal trauma
or falling, high-altitude activities (greater than
6,000 ft), and scuba diving. The fetus is at
increased risk of decompression sickness
during scuba diving
• Nonweight-bearing aerobic exercises, such as stationary
cycling, swimming, or water aerobics, will minimize the risk of
injury throughout pregnancy and the postpartum period.
• If the woman cannot safely maintain balance because of the
shifting and increasing weight, have her modify exercises that
could result in falling and injuring herself or the fetus.
• Resumption of prepregnancy exercise routines during the
postpartum period should be gradual.
• Initiation of pelvic floor exercises immediately postpartum may
reduce symptoms and duration of incontinence
• Physiological and morphological changes of pregnancy
continue for a minimum of 4 to 6 weeks postpartum— longer if
the woman is breastfeeding. Encourage continued joint
protection.
• Breastfeeding women can be reassured that moderate exercise does not
impair quantity or quality of breast milk or infant growth.
• Lactating women will have slower weight loss in the postpartum period;
an additional 500 calories/day are needed to support production of breast
milk.
• Water intake continues to be important; 12 or more glasses per day are
recommended.
• There may be a short-term increase in lactic acid secreted in breast milk
after high-intensity exercise; if the baby appears to eat less after an
exercise session, this can easily be remedied by nursing before exercise
Precautions and Contraindications to
Exercise
Absolute Contraindications
PPP MMM IVR
• Placenta previa: placenta is located on the uterus in a position in
which it may detach before the baby is delivered
• Preeclampsia: pregnancy-induced hypertension
• Premature labor: labor beginning before the 37th week of
pregnancy
• Multiple gestation with risk of premature labor
• Maternal heart disease, thyroid disease, or serious respiratory
disorder
• Maternal type 1 diabetes
• Incompetent cervix: early dilation of the cervix before the
pregnancy is full term
• Intrauterine growth retardation
• Vaginal bleeding, especially second or third trimester
• Rupture of membranes: loss of amniotic fluid before the onset of
labor
Precautions to Exercise
• The woman with one or more of the following conditions
may participate in an exercise program under close
observation by a physician and a therapist as long as no
further complications arise. Exercises may require
modification.
• Gestational diabetes
• Severe anemia
• Systemic infection
• Extreme fatigue
• Musculoskeletal complaints and/or pain
• Overheating
• Extreme obesity or extreme underweight/eating disorder
• Diastasis recti
Thank u
TYPES OF EXERCISES IN PREGNANCY
• Critical Areas of Emphasis and Selected Exercise
Techniques
• Pelvic Floor Awareness, Training, and Strengthening
• Relaxation and Breathing Exercises for Use
During Labor
TYPES OF EXERCISES IN PREGNANCY
Pelvic clock
Dynamic Trunk Exercises
Pelvic Motion Training
• These exercises are helpful in cases of
posture-related back pain; they are beneficial
for improving proprioceptive awareness, as
well as lumbar, pelvic, and hip mobility.
Pelvic tilt exercises
• Begin in quadruped (on hands and knees).
• Instruct the patient to perform a posterior pelvic tilt.
While the patient keeps her back straight, have her
isometrically tighten (imagine drawing in) the lower
abdominals and hold, then release and perform an
anterior tilt through very small range.
• For additional exercise, while holding the abdominals in and
the back straight, have the woman laterally flex the trunk to
the right (side-bend to the right), looking at the right hip, then
reverse to the left.
• Have the woman practice pelvic tilt exercises in a variety of
positions, including side-lying and standing.
Pelvic clock
• With the woman hook-lying, ask her to visualize the face of a clock
on her lower abdomen. The umbilicus is 12 o’clock and the pubic
symphysis is 6 o’clock. The patient’s legs may move slightly while
performing this exercise.
• Have her begin with gentle movements back and forth between 12
and 6 o’clock (the basic pelvic tilt exercise).
• Then ask her to move back and forth between 3 o’clock (weight
shifted to left hip) and 9 o’clock (weight shifted to the right hip).
• Then move in a clockwise manner from 12 to 3 to 6 to 9 and then
back to 12 o’clock, then reverse.
• With practice, these will become very smooth and rhythmical
movements and will not require such concentration on each
number of the clock.
• Continue relaxed breathing throughout the exercise, and do
not force any part of the movement.
• If the patient has difficulty with the motion, make the clock
“smaller” until coordination improve
Pelvic clock progressions
• Use the visual imagery of cutting the face of the clock in half so that
there is a right side and a left side or a top half and a bottom half.
Have the woman move her pelvis through the arc on the one side
and back through the middle of the clock, and then move the pelvis
through the opposite side and back through the middle. Initially, the
woman may notice asymmetry when comparing the halves; this will
improve with time.
• Once the patient understands and is able to perform the clockwise
pattern, have her do counterclockwise motions with all of the
activities mentioned previously, and then progress the exercises to
the sitting position.
Modified Upper and Lower Extremity
Strengthening
Standing Push-Ups
Patient position and procedure:
Standing, facing a wall, feet pointing
straight forward, shoulder-width apart,
and approximately an arm-length away
from the wall. The palms are placed on
the wall at shoulder height. Have the
woman slowly bend the elbows, bringing
her upper body close to the wall,
maintaining a stable trunk and pelvic
position, and keeping the heels on the
floor. Her elbows should be shoulder
height. She then slowly pushes with her
arms, bringing the body back to the
original position.
Supine Bridging
Patient position and procedure:
Supine in the hook-lying position.
Have the woman perform a
posterior pelvic tilt and then lift
her pelvis off the floor. She can do
repetitive bridges or hold the
bridge position and alternately
flex and extend her upper
extremities to emphasize the
stabilization function of the hip
extensors and trunk musculature
Quadruped Leg Raising
• Patient position and procedure: On hands
and knees (hands may be in fists or palms
may be open and flat). Instruct the woman
to first perform a posterior pelvic tilt and
then slowly lift one leg, extending the hip to
a level no higher than the pelvis while
maintaining the posterior pelvic tilt
• She then slowly lowers the leg and repeats
with the opposite side. The knee may
remain flexed or can be straightened
throughout the exercise. Monitor this
exercise, and discontinue if there is stress on
the sacroiliac joints or ligaments. If the
woman cannot stabilize the pelvis while
lifting the leg, have her just slide one leg
posteriorly along the floor and return
Modified Squatting
• Wall slides and supported squatting exercises are
used to strengthen the hip and knee extensors
for good body mechanics and also to help stretch
the perineal area for flexibility during the
delivery process. In addition, if the woman
wishes to use squatting for labor and delivery,
the muscles must be strengthened and
endurance trained in advance.
• Patient position and procedure: Standing with
back against a wall and her feet shoulder-width
apart. Have the woman slide her back down the
wall as her hips and knees flex only as far as is
comfortable, then slide back up.
• Patient position and procedure: Standing with
feet shoulder width apart or wider, facing a
counter, chair, or wall on which the woman can
rest her hands and/or forearms for support. Have
the woman slowly squat as far as is comfortable
Perineum and Adductor Flexibility
• these flexibility exercises prepare the
legs and pelvis for childbirth.
Self-Stretching
• Patient position and procedure: Supine
or side-lying. Instruct the woman to
abduct the hips and pull the knees
toward the sides of her chest and hold
the position for as long as is
comfortable (at least to the count of
10).
• Patient position and procedure: Sitting
on a short stool with the hips
abducted as far as possible and feet
flat on the floor. Have her flex forward
slightly at the hips (keeping the back
straight), or have her gently press her
knees outward with her hands for an
additional stretch.
Pelvic Floor Awareness, Training, and
Strengthening
• Begin pelvic floor exercise
training with an empty bladder.
• Gravity-assisted positioning (hips
higher than the heart, such as
supported bridge ) may be
indicated initially for some
women with extreme weakness
and proprioceptive deficits
Development Hormones
Size & Weight
Male : 1260cm3
Female : 1130 cm3
The adult human brain weighs on average about 3lb (1.5 kg)
Male brains are about 10% larger than female brains and
weigh 11-12% more than that of a woman.
Men's heads are also about 2% bigger than women's. This is due to the larger
physical stature of men. Male’s larger muscle mass and larger body size
requires more neurons to control them.
New born baby boy and a baby girl will have similar brain sizes.
Brain Volume
Cerebellum
Posture and Balance
Control consciousness(pons) : Larger in
men
Corpus Callosum
Larger in Left-handed males .
Among women there was no difference between right-
handers and left-handers.
Inferior-Parietal Lobule (IPL)
IPL correlates with the mathematical ability.
This part was larger in the brain of Albert Einstein
Left IPL : Larger in Males
Right IPL : understanding relationships and the ability to
sense relationships between body parts
Left IPL : perception of time and speed, and the ability to
rotate 3-D figures in the brain.
Amygdala..involved in producing emotional
reactions.
Hormonal levels have been implicated in the fact that women are
at increased risk of developing arrhythmias.
Drug addiction
Gender diffrences:use and response to medication
Be wise. what you don’t know can hurt you. prevention is also a
medication.
Physiotherapy
in
Obstetrics & Gynaecology
Obstetrics concerns itself with
pregnancy, labour, delivary &the care
of the mother after child birth
Preventive measures
Physiological changes during pregnancy
Pregnancy wt. gain - 9.70 to 14.55 kg.
CVS.
Physiological changes during pregnancy
Musculoskeletal system.
a. Stretching of abdominal muscles
1. Prenatal exercises
2. Preparation for labour
3. Postnatal exercises
Prenatal Exercise:
Abdominal exercise
Stabilization exercise
Includes:-
Strengthening exercise
Stretching exercise
STRETCHING EXERCISES
Head Lift
2. Trunk curls
3. Leg sliding
Leg Sliding
Forwards leaning
facilitates ante version
Woman should be
encouraged
To change position
during first stage of
labour
Positions attended during
1st stage are
Sitting with head
&shoulder resting on a
table.
Standing leaning against
a wall either facing or with
back support.
Stride sitting across a
chair resting the head &
arms on the back.
On all four on floor
supported by partner,
standing, resting head on
his shoulder.
KEGALS EX. DURING 1ST STAGE OF LABOUR
These are labour inducing exercise.
Lithotomy
Dorsal (recumbent)
4.Visual imagery.
sitting standing
feeding
others
lying
CESAREAN CHILDBIRTH
It is an operative procedure whereby the fetuses
after the end of 28th wk. are delivered through an
incision on the abdominal &uterine wall.
Impairments /Problem Due To Cs
1. Risk of pneumonia
2. Postsurgical pain.
3. Risk of adhesion.
4. Formation at incisional site.
5. Risk of vascular complication.
6. Faulty posture.
7. Pelvic floor dysfunction.
8. Abdominal weakness
GOAL PLAN OF CARE
1.Improve pulmonary Breathing ex. Coughing
function & decrease the &huffing.
risk of pneumonia
2.Decrease incisional 2. Postnatal TENS
pain associated with support incision with
coughing hands when coughing.
3. Friction massage &
3. Prevent postsurgical scar mobilisation.
adhision formation
4.Prevent postsurgical 4.Active leg ex. ,early
vascular complication ambulation
5.Correct posture & 5.Postural instruction
protected activities of &positioning for ADL
daily living
6. Pelvic floor ex.
6. Prevent pelvic floor
dysfunction
7. Abdominal ex.
7. Develop abdominal
strength
SUGGESTED ACTIVITIES FOR THE PT. WITH A CS.
.1. Exercises
All prenatal ex. Should be done.
The women should be instructed to begin
preventive ex. As soon as possible during
recovery period.
Ankle pumping activities &early ambulation to
prevent venous stasis.
Pelvic floor ex. Kegals ex. &pelvic tilting ex.
Abdominal ex. Should be progressed more
slowly.
Deep diaphragmatic breathing
Women should wait at least 6 to 8 wk before
resuming vigrous ex.
2. COUGHING & HUFFING
huffing is a forceful outward breath using the
diaphragm rather then abdominal to push air out of
lungs.
The abdominals are pulled up &in rather then
pushed out causing decreased abdominal pressure
& less strain on the incision.
Support the incision with pillows or hands during
cuffing or huffing.& say “HA” forcefully while pulling
in abdominal muscle.
3. EX TO RELIEVE INTESTINAL GES PAINS
Abd. Massage or kneading while lying on the left
side.
Pelvic tilting ex.
4.SCAR MOBILISATION
HIGH RISK PREGNANCY
A pregnancy that is complicated by disease or
problem that put the mother or fetus at risk for
illness or death . Condition may be preexisting be
induced by pregnancy or an abnormal
physiological reaction during preg.
compress
5.Circulatory problem 5. –prolonged standing
avoided
varicose vein of leg
ankle ex. ,calf stretching
vulval varicose vein
- raising foot end of standing
leg cramps should bed.
-thrombosis & deep kneading massage
- thromboembolism - stocking & breathing ex.
6. Stress incontinence 6. pelvic floor ex
Primary amenorrhea
Absence of menstruation by age 16 in a girl with secondary sex
characteristics
Secondary amenorrhea
Absence of 3 or more consecutive menstrual cycles in a girl who has begun
menstruating
In the 1970’s low body weight or low body fat was thought to
be the primary cause of amenorrhea
Exercise-stress hypothesis
Deficit in energy availability
Hypothalamic Dysfunction
Disruption of
hypothalamic-pituitary-
ovarian axis
Decrease in pulsatile GnRH
disrupts pituitary secretion
of LH and FSH
Disruption of LH and FSH
pulsatility shuts down
stimulation to the ovary,
ceasing production of
estradiol
Prevalence
Definition
Dietary energy intake minus exercise energy expenditure OR
The amount of dietary energy remaining after exercise training to support
physiological processes
Energy balance
Occurs in young adults at an energy availability of 45 kcal per kilogram of
fat-free mass per day (kcal/kg FFM daily)
In exercising women, LH pulsatility is disrupted below 30 kcal/kg FFM per
day
Energy Availability
Energy availability-hypothalamic
dysfunction
Mechanism by which a deficit in energy
availability disrupts GnRH is currently
unknown but research suggests plasma
glucose plays a role via glucose-sensing
neurons in the brain
Glucoregulatory hormones do not
maintain normal plasma glucose
concentrations below energy
availability of 30 kcal/kg FFM per day
Energy Availability
Athletes may be at risk for fractures during their competitive years and
premature osteoporotic fractures in the future
Who is at Risk?
5. All sports medicine professionals including coaches and trainers should learn about
preventing and recognizing the Triad
• Should not pressure girls to lose weight and should know basic nutrition information
• Have referral sources for nutritional counseling and medical and mental health evaluation
6. Parents should not pressure their daughters to be thin and should be educated about
Triad warning signs
7. Sports medicine professionals, athletic administrators, officials of sport
governing bodies share a responsibility to prevent, recognize and treat the
Triad
• Support development of educational programs
8. Physically active girls and women should be educated about proper nutrition,
safe training practices, and warning signs of the Triad
CBC, ESR,
EKG and/or echocardiogram if abnormal cardiac exam
TSH
LH, FSH to rule out premature ovarian failure
Prolactin to rule out pituitary tumor
Consider imaging
If hirsutism, free testosterone, 17-hydroxy-progesterone to screen for adrenal
or ovarian tumors
Bone Density
Bone density
Consider DEXA for the
following: (ABD)
Amenorrheic > one year
BMI < 18
Documented history of stress
fracture
Warning Signs
Food restriction Constipation
Chronic dieting Chronic diarrhea
Skipping meals Frequent weight
Fasting fluctuations
Laxative use Fatigue
Diet pill use Muscle weakness
Obsessive training Muscle cramps
Low self-esteem Dehydration
Dry skin and hair Delayed puberty
Frequent restroom
visits after meals
Treatment Goal
Nutrition education
Emphasis should be placed on concept of food as energy for training and
recovery rather than on body weight
ACSM and American Dietetic Association published a joint position
statement entitled “Nutrition and Athletic Performance” in 2000
Physician Knowledge
Results
48% of physicians, 43% of therapists, 38% of trainers, 32% of medical
students and 8% of coaches could identify all 3 components
When divided into specialties, 69% of PM&R physicians, 63% of
orthopedic surgeons, 53% of family physicians, 36% of pediatricians, 17%
of gynecologists identified all 3 components
Only 9% of physicians felt comfortable treating the disorder
Thanks
ASK???
BREAST CANCER & LYMPH OEDEMA
Structure and Function
of the Lymphatic System
• The primary function of the lymphatic system is to collect
and transport fluid from the interstitial spaces back to the
venous circulation
• This is accomplished with a series of lymph vessels and
lymph nodes.
• The lymphatic system also has a role in the body’s immune
function
• When the lymphatic system is compromised either by
impairment of lymphatic structures or by an overload of
lymphatic fluid, the result is swelling in the tissue spaces.
• Edema is a natural consequence of trauma to and
subsequent healing of soft tissues. If the lymphatic system
is compromised and does not function efficiently,
lymphedema develops and impedes wound healing.
• Lymph edema is an excessive and persistent accumulation of
extravascular and extracellular fluid and proteins in tissue
spaces
• It occurs when lymph volume exceeds the capacity of the
lymph transport system, and it is associated with a
disturbance of the water and protein balance across the
capillary membrane. An increased concentration of proteins
draws larger amounts of water into interstitial spaces, leading
to lymphe dema.
• Furthermore, many disorders of the cardiopulmonary system
can cause the load on lymphatic vessels to exceed their
transport capacity and subsequently cause lymph edema.
Anatomy of the Lymphatic System
• The lymphatic system is an open system.
• The lymphatic capillaries are situated close to the blood capillaries
and are responsible for pulling the fluid into the lymphatic
circulation
• Once inside the lymphatic vessels, the fluid is transported from
lymph nodes to lymphatic trunks.
• The end result is the collection of the lymphatic fluid at the venous
angles.
• In total, the body has 600 to 700 lymph nodes with the largest
grouping found in the head and neck, around the intestines, and in
the axilla and groin.
Physiology of the Lymphatic System
• The main components of lymphatic fluid are water and protein found in the extracellular
spaces.
• In a normal state, the lymphatic system transports this fluid back to the venous circulation.
• The amount of fluid transported is the lymphatic load, and the amount of fluid the
lymphatic system can transport is the transport capacity.
• When the balance in the interstitium is disrupted, whether by an increased lymphatic load
or a decreased transport capacity, lymphedema can develop.
• Lymphatic load is increased when the venous system is unable to transport the required
amount of fluid, which can occur in a patient with a venous insufficiency.
• Transport capacity is affected when the structures of the lymphatic system are impaired,
for example, following surgery to remove lymph nodes in a patient with cancer.
Types of Lymph edema
• Lymph edema can be classified as primary, meaning there is an
inherent problem with the structures of the lymphatic system, or
secondary, meaning there is an injury to lymphatic structures.
• This injury may be in the form of surgery, radiation, trauma, or
infection.
• Lymphedema can also be caused by a combination of lymphatic-
venous dysfunction commonly seen in patients with chronic
venous insufficiency.
• Remember, lymphedema is not a disease but rather a symptom of
a malfunctioning lymphatic system.
Primary Lymph edema
• Primary lymphedema, although uncommon, is the result of
insufficient development (dysplasia) and congenital
malformation of the lymphatic system.
• Primary lymphedema can be divided into the age of
presentation
■ Congenital: presents at birth and is sometimes known as
Milroy’s disease
■ Praecox (early): develops prior to 35 years of age
■ Tarda: develops after 35 years of age
• Primary lymphedema typically affects more females than
males and presents more often in the extremities, more so in
the lower than upper extremities
Secondary Lymphedema
• Most of the patients seen by healthcare practitioners for management of
lymphedema have secondary lymphedema
• By far, the most common causes of secondary lymphedema are related to
the comprehensive management of cancers of the breast, pelvis, and
abdomen.
• Secondary lymphedema is classified by the cause of the injury to the
lymphatic structures including:
■ Surgery
■ Inflammation and infection
■ Obstruction or fibrosis
■ Combined venous-lymphatic dysfunction (chronic venous insufficiency)
Clinical Manifestations of Lymphatic
Disorders
Clinical Manifestations of Lymphatic
Disorders
• Lymph edema
• Location. When lymph edema develops, it is most often apparent in
the distal extremities, particularly over the dorsum of the foot or
hand.
• The term dependent edema describes the accumulation of fluids in
the peripheral aspects of the limbs, particularly when the distal
segments are lower than the heart.
• In contrast, lymphedema can manifest more centrally, for example,
in the axilla, groin, or even the trunk.
• Thorough assessment of the entire limb and regional area is
important to define the extent of swelling.
• Severity.
• The severity of lymph edema may be described quantitatively
or qualitatively.
• Lymph edema is described by the severity of changes that
occur in skin and subcutaneous tissues. The three categories—
pitting, brawny, and weeping edema
Increased Size of the Limb
• As the volume of interstitial fluid in the limb increases, so does
the size of the limb (weight and girth).
• Increased volume, in turn, causes tautness of the skin and
susceptibility to skin breakdown.
• Descriptors, such as mild, moderate, and severe, sometimes
are based on how much larger the size of the edematous limb
is compared to the non involved limb
• However, there are no standard definitions associated with
size and severity
Sensory Disturbance
• Paresthesia (tingling, itching, or numbness) or occasionally a
mild, aching pain may be felt, particularly in the fingers or toes.
• In many instances the condition is painless, and the patient
perceives only a sense of heaviness of the limb.
• Fine finger coordination also may be impaired as the result of
the sensory disturbances.
Stiffness and Limited Range of Motion
• Range of motion (ROM) decreases in the fingers and wrist or
toes and ankle or even in the more proximal joints, leading to
decreased functional mobility of the involved segments
Decreased Resistance to Infection
• Wound healing is delayed; and frequent infections
(e.g.,cellulitis) may occur.
• Early recognition and treatment of cellulitis has shown to be
important in reducing further tissue damage.
Examination and Evaluation
of Lymphatic Function
History and Systems Review
• Note any history of infection, trauma, surgery, or radiation
therapy. If a patient has a history of cancer and received
chemotherapy, a review of the treatment and duration of the
chemotherapy treatment is also important.
• The onset and duration of lymphedema, delayed wound healing,
or previous treatment of lymphedema are pertinent pieces of
information.
• Identify the occupation or daily activities of the patient,
• and determine if long periods of standing or sitting are required.
Specific questioning to determine a pattern to the swelling can also
aid in treatment planning
Examination of Skin Integrity
• Visual inspection and palpation of the skin provide
information bout the integrity of the skin. The location of the
edema should be noted.
• When the limb is in a dependent position, palpate the skin to
determine the type and severity of lymph edema and changes
in skin and subcutaneous tissues.
• Describe the thickness and density of the tissue in each area of
the limb.
• Areas of pitting, brawny, or weeping edema should be noted.
Stemmer sign
• A positive Stemmer sign, an
indication of Stage II or III
lymphedema, may be identified
during palpation
• It is considered positive if the
skin on the dorsal surface of the
fingers or toes cannot be
pinched or is difficult to pinch
compared with the uninvolved
limb.
• A positiveStemmer sign can be
indicative of a worsening
condition
Girth Measurements
• Circumferential measurements of the involved limb should be
taken and compared with the noninvolved limb if the problem
is unilateral.
• Identify specific intervals or landmarks at which
measurements are taken so measurements during subsequent
examinations are reliable.
• Use of circumferential measurements at anatomical landmarks
has been shown to be a valid and reliable method of
calculating limb volume
Volumetric Measurements
• An alternative method of measuring limb size is to immerse
the limb in a tank of water to a predetermined anatomical
landmark and measure the volume of water displaced.
• Although this method also has been shown to be valid and
reliable, for routine clinical use, it is more cumbersome and
less practical than girth measurements.
Management of Lymph edema
Comprehensive Regimens and Components
• Decongestive lymphatic therapy.
• Treatment typically is divided
into two phases. Phase I is the
intensive treatment phase;
Phase II is the maintenance
phase. The goal of Phase I
treatment is reduction, whereas
the goal of Phase II treatment is
longterm management.
Manual lymphatic drainage
• Manual lymphatic drainage (MLD) involves slow, very light
repetitive stroking and circular massage movements done in a
specific sequence with the involved extremity elevated
whenever possible
Breast Cancer-Related
Lymphatic Dysfunction
• Current treatment for breast cancer involves a multimodality
approach.
• Surgery, chemotherapy or hormonal therapy, and radiation
may be employed
• Axillary dissection and removal of lymph nodes interrupt and
slow the circulation of lymph, which in turn can lead to
lymphedema
• Radiation therapy can cause fibrosis of tissues in the area of
the axilla, which obstructs the lymphatic vessels and
contributes to pooling of lymph in the arm and hand
Surgical Procedures
• Surgical treatment of breast cancer falls into two broad
categories—mastectomy and breast-conserving surgery
Mastectomy
• Mastectomy involves removing the entire breast.
• In addition, a mastectomy may involve removing the fascia
over the chest muscle.
• With late-stage, invasive disease, a radical mastectomy in
which the pectoralis muscles also are excised may be required,
leading to significant muscle weakness and impaired shoulder
function.
Breast-Conserving Surgery
• Options for resecting the tumor and preserving a portion of
the breast include lumpectomy, which involves excision of the
mass and a margin of healthy surrounding breast tissue, or
• segmental mastectomy (also known as quadrectomy), which is
excision of the affected quadrant of the breast.
• Rather than mastectomy, these procedures are being used
increasingly in combination with adjuvant therapy for patients
with stage I or II tumors.
Managements guidelines
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