Postpartum pubic symphysis diastasis-conservative and surgical treatment methods, incidence of complications: Two case reports and a review of the literature

Hips Do Not Lie: Atypical Pain From Peripartum Pubic Symphysis Diastasis

Pubic symphysis diastasis (PSD) is the widening of the pubic symphysis which can occur during the peripartum period. PSD commonly presents as pelvic pain with associated neuropathies rarely reported. In this report we describe the unique presentation of PSD with associated motor and sensory deficits in a 19-year-old postpartum patient. Two days following vaginal delivery, the patient complained of diffuse body pain, generalized weakness, and lower extremity paresthesia without any other neurological deficits. PSD was diagnosed by radiograph of the pelvis and her symptoms swiftly improved following conservative management of the diastasis. Further, we discuss the potential etiology of this patient's presentation as well as differential diagnosis with similar presentations.

Tratamento cirúrgico de lesão periparto do anel pélvico: Relato de caso

Durante o período gestacional, ocorre a dilatação da sínfise púbica, de forma a permitir o parto vaginal. No entanto, o alargamento exacerbado pode indicar lesão ligamentar, instabilidade pélvica, e desencadear queixa álgica importante. Tal quadro é uma condição incomum, denominada disjunção da sínfise púbica periparto (DSPP). Neste artigo, relatamos o caso de uma paciente com idade gestacional de 38 semanas que mantinha queixa álgica intensa na região lombar e pélvica, irradiada para o quadril e o joelho direito, após parto normal de gestação única, sem intercorrências obstétricas. A paciente apresentava extenso edema e equimose vulvar, e exames radiográficos evidenciaram disjunção da sínfise púbica de 7 cm e abertura da articulação sacroilíaca direita. Há controvérsias na literatura quanto à indicação do tratamento desses casos, mas os achados clínicos e radiográficos motivaram a opção pelo tratamento cirúrgico. Realizou-se o fechamento da sínfise púbica com placas ortogonais, além da estabilização da articulação sacroilíaca com parafuso percutâneo. A paciente fez acompanhamento ambulatorial por seis meses, com boa evolução e sem intercorrências, e retornou às atividades laborais com dor mínima, boa função e satisfação com o tratamento.

Postpartum Pubic Symphysis Diastasis: A Case Report

We present the case of a 25-year-old African American female patient (G1P0) with a past medical history of brain arteriovenous malformation repair, pneumonia, and a urinary tract infection who was admitted to the labor and delivery floor at 39 weeks for a spontaneous vaginal delivery of a 4.025 kg female baby. In the immediate postpartum (PP) period, the patient presented with severe pelvic pain and trouble ambulating. Conservative management of oral non-narcotic analgesics was initiated until the diagnosis of PP pubic symphysis diastasis (PSD) was made. Due to the persistence of pelvic pain, the patient underwent a pubic symphysis joint steroid injection and was discharged on day 8. Within 24 hours of discharge, the patient was readmitted to the emergency department with severe pain and an inability to walk. Her pain was managed conservatively with intravenous narcotics and non-steroidal anti-inflammatories, which quickly dissipated the pain. She was observed and discharged once she reported improvement in pain, and she was reassessed five days later at her obstetrician's clinic. In the clinic, the patient presented with mild tenderness in the pubic symphysis region but demonstrated improvement in her antalgic gait with an ability to walk and urinate without difficulty. Despite a lack of follow-up imaging, the patient was reassured that her PSD and associated tenderness should completely resolve within three to four months.

Postpartum pubic symphysis diastasis resulting in a prepubic abscess and osteomyelitis

Postpartum pubic symphysis diastasis (PSD) refers to an abnormal widening of the pubic symphysis after delivery. It is a rare and underdiagnosed condition that causes severe pain and can be complicated by osteomyelitis and abscess formation. This article reports a case of a para 4 woman in her 30s with postpartum PSD after vaginal delivery who presented with a prepubic abscess. Multimodal treatment consisted of incision and drainage, physiotherapy and prolonged antibiotic treatment.

Peripartum Pubic Symphysis Diastasis

Importance

Peripartum separation of the pubic symphysis is a rare but potentially severe complication of childbirth, which may lead to prolonged immobilization. Thus, prompt diagnosis and treatment are paramount.

Objective

The purpose of this review is to define peripartum separation of the pubic symphysis and provide a thorough review of its etiology, clinical manifestations, diagnostic imaging techniques, management, and prognosis.

Evidence Acquisition

This was a literature review using PubMed and Google Scholar.

Results

Peripartum pubic symphysis separation is defined as disruption of the pubic symphysis joint and ligamentous structures with greater than 1 cm of separation during delivery. Risk factors include fetal macrosomia, nulliparity, and precipitous labor. Patients often present with a sensation of something "giving way" in the pubic symphysis area at the time of delivery, or with severe pain in the pubic symphysis region with attempted mobilization postpartum. In severe cases, associated hematomas, pelvic fractures, sacroiliac joint disruption, and urinary tract injury may be seen. Imaging such as x-ray or ultrasound may be used to confirm the diagnosis. Although most patients recover well with conservative management, orthopedic surgical intervention may be indicated in more severe or unresolved cases.

Conclusions and Relevance

Pubic symphysis separation is increasingly identified peripartum due enhanced accessibility and utilization of imaging modalities. It can be debilitating and lead to prolonged immobility postpartum. Therefore, early recognition and diagnosis are important, as this can guide decision-making for management. A multidisciplinary team approach, including coordination with obstetrics, orthopedic surgery, physical therapy, and occupational therapy should be used for early detection and treatment to ensure optimal patient outcomes.

Incidence of vaginal birth-related rupture of the pubic symphysis: A nationwide register study in Finland from 1998 to 2018

BACKGROUND AND PURPOSE

To assess the incidence of vaginal birth -related rupture of the pubic symphysis in Finland from 1998 to 2018.

METHODS

A retrospective cohort study using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register. As participants we included all ≥ 22-week pregnancies of women aged between 15 and 49 years from January 1, 1998 to December 31, 2017. Pubic symphysis rupture was classified based on the ICD-10 code S33.4 and operations were gathered with pelvis-specific operation codes of the Nordic NOMESCO-classification. Incidence per 100 000 deliveries with 95% confidence intervals (CI) was calculated for symphysis rupture and surgery using Poisson's exact test.

RESULTS

For a total 1 175 326 deliveries, a total of 9 pubic symphysis ruptures occurred during the intrapartum and puerperal periods. All ruptures occurred after vaginal delivery. Of these, 4 ruptures were treated operatively. The incidence of rupture for vaginal delivery was 0.9 per 100 000 deliveries (CI 0.1 to 1.0). No perinatal mortality was observed.

CONCLUSIONS

Birth -related ruptures of the pubic symphysis are rate events and are mostly associated with vaginal delivery with most ruptures being treated conservatively.

Postpartum septic symphysitis, a rare condition with possible long-term consequences: a cohort study with long-term follow-up

BACKGROUND

Postpartum septic symphysitis (PPSS) is defined as acute onset of severe pain around the symphysis, restricted movement, fever, and elevated inflammatory parameters. It is a rare but serious condition requiring urgent diagnosis and treatment. The aim of this study was to describe the incidence, symptoms, diagnosis, treatment, and long-term follow-up of PPSS.

METHODS

This follow-up study included 19 out of 21 women diagnosed with PPSS from 1989 to 2017 at one tertiary care hospital in Sweden. Clinical data were retrieved from hospital records and compared to those retrieved from a regional registry. Women completed a postal questionnaire, and those who reported lumbopelvic pain (LPP) were offered a clinical examination.

RESULTS

1) PPSS was diagnosed after a normal postpartum period of 24 to 50 h by blood tests (n = 19/19), ultrasonography (n = 9 /19), computer tomography (n = 8/19) or magnetic resonance imaging (n = 16/19) Treatment included aspiration of symphyseal abscesses, i.v. antibiotics and different physiotherapeutic interventions. Women with PPSS more frequently were primiparous (n = 14/19, p = 0.001), had an instrumental delivery (n = 14/19, p = 0.003), longer time of active labour (p = 0.01) and second stage of labour (p = 0.001) than women in the regional registry. 2) Ten out of 19 (52%) women reported LPP at follow-up. These women more often suffered impaired function related to LPP (Pelvic Girdle Questionnaire, 27 versus 0, p < 0.0001), a poorer health-related quality of life (EuroQol-5 dimensions p = 0.001 and EuroQol-visual analogue scale, 65 mm versus 84 mm, p = 0.022) and higher levels of anxiety and depression (Hospital Anxiety Depression Scale (HADS) HADS-Anxiety, 7 versus 2, p = 0.010; and HADS-Depression, 1 versus 0, p = 0.028) than women with no pain. 3). Of the eight women who were clinically assessed, one had lumbar pain and seven had pelvic girdle pain (PGP).

CONCLUSIONS

In the largest cohort of patients with PPSS to date, primiparas and women with instrumental vaginal delivery were overrepresented, indicating that first and complicated deliveries might be risk factors. Approximately half of the women reported PGP at follow-up, with considerable consequences affecting health-related quality of life and function decades after delivery. Prospective multicentre studies are needed to establish risk factors, long-term consequences, and adequate treatment for this rare pregnancy complication.

Peripartum Pubic Symphysis Diastasis-Practical Guidelines

Optimal development of a fetus is made possible due to a lot of adaptive changes in the woman’s body. Some of the most important modifications occur in the musculoskeletal system. At the time of childbirth, natural widening of the pubic symphysis and the sacroiliac joints occur. Those changes are often reversible after childbirth. Peripartum pubic symphysis separation is a relatively rare disease and there is no homogeneous approach to treatment. The paper presents the current standards of diagnosis and treatment of pubic diastasis based on orthopedic and gynecological indications.

A case-control study of clinical characteristics and risk factors of symptomatic postpartum pubic symphysis diastasis

Postpartum pubic symphysis diastasis (PPSD) refers to the separation of pubic symphysis after delivery. It is typically diagnosed based on clinical symptoms and radiologic findings. This study tried to assess clinical characteristics and risk factors of PPSD. This was a nested case-control study matched for year of delivery and gestational age at delivery using a retrospective cohort of women who delivered vaginally at a single institution. The incidence of PPSD was 0.156% (33/21,131). The incidence rate increased from 0.08% (7/9328) in 2000-2004 to 0.13% (9/7138) in 2005-2009 and to 0.36% (17/4665) in 2010-2016, simultaneously with an increase of maternal age (30.7 ± 3.5 years in 2000-2004 to 31.8 ± 3.8 years in 2005-2009 and 32.8 ± 3.8 years in 2010-2016). Nulliparity was associated with a higher incidence of PPSD (81.8% in cases vs. 57.6% in controls, p = 0.01). Other factors including pre-pregnancy body mass index, weight gain during pregnancy, gestational diabetes, induction of labor, duration of labor, epidural anesthesia, vacuum-assisted delivery, episiotomy, neonatal sex and birth weight failed to show difference between the two groups. In short, the incidence of PPSD increased with time along with an increase of maternal age. Nulliparity was the only significant risk factor for PPSD.

Late-Onset Sacroiliac Osteoarthritis After Surgical Symphysiotomy: A Case Report

A 35-year-old female presented with right-sided gluteal pain and difficulty in walking 10 years after surgical symphysiotomy. Radiograph of the pelvis and bilateral hip joints showed osteoarthritis of the right sacroiliac joint with pubic diastasis of 1.5 cm. She was operated with pubis symphysis reduction and fixation using two orthogonal plates with one iliosacral screw. Postoperative period was uneventful. She was able to walk independently after three months of fixation. Follow-up at 18 months showed complete relief of symptoms with maintenance of reduction and no hardware breakage. The Lindahl score was 78, indicating an excellent outcome.