External fixation of pubic symphysis diastasis from postpartum trauma

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.

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

BACKGROUND

Widening of the pubic joint of more than 10 mm is diagnostic and defined as pubic symphysis diastasis and is considered a complication of vaginal childbirth or pregnancy. As it is a rare pathology (ranging from 1 in 300 to 1 in 30000 pregnancies), no gold standard treatment has been defined.

CASE SUMMARY

This study examines two cases, a 27-year-old woman (gravida 1, para 1) and a 32-year-old woman (gravida 2, para 2), who presented to the clinic after uneventful vaginal deliveries. A normal pregnancy with no complications was observed in both patients. Severe pain in the pubic region occurred after labour and was accompanied by complicated locomotion. Pubic symphysis diastasis was confirmed radiologically and bed rest with lateral decubitus positioning was recommended. Oral non-steroidal antiinflammatory drugs were administered to relieve pain exacerbations. The symptoms decreased after treatment. Post-treatment magnetic resonance imaging (MRI) in the first case showed a reduction in symphyseal separation with no signs of osteitis. Three years later the symptoms recurred; MRI examination showed no further symphyseal widening or signs of osteitis. A relapse of symphyseal separation was diagnosed and conservative treatment was re-administered resulting in successful recovery. In the second case, pain recurred when the patient conceived for the second time. This time no benefit following conservative treatment was observed. Persistent pain and complicated locomotion led to scoliotic deformation of the lumbar part of the spine and leg length discrepancy, thus surgical treatment was chosen and internal pubic synthesis was performed.

CONCLUSION

Overall, surgical treatment resulting from insufficient conservative treatment showed a high risk of postoperative complications following the treatment of postpartum pubic symphysis diastasis.

[Chronic instability of the pubic symphysis : Etiology, diagnostics and treatment management]

The most frequent causes of chronic instability of the pubic symphysis are sports-related continual overload and traumatic symphyseal injuries. Acute injury of the pubic symphysis may be the result of external forces acting on the anterior pelvic ring or the result of internal forces, such as those arising during parturition. The postpartum form of instability following a complication-free birth is reversible and usually returns to normal within a few months through strengthening of the pelvic floor muscles. Residual instability of the pubis symphysis is on the whole a rare complication. Although established therapy options for acute symphyseal separation can be found in the literature, there are only a few case reports on chronic symphyseal instability. There are no guidelines on standardized therapy options. This review article examines the etiology, clinical findings, diagnostic techniques and management options for patients suffering from chronic symphyseal instability.

Postpartum symphysis pubis diastasis

The pubic symphysis is a midline, nonsynovial joint that connects the right and left superior pubic rami. The interposed fibrocartilaginous disk is reinforced by a series of ligaments that attach to it. The joint allows very limited movement of approximately 0.5-1mm. Under hormonal stimulation during pregnancy, there is widening of the symphysis pubis and the sacroiliac joints. Diastasis wider than 15 mm is considered subdislocation and is generally associated with pain, swelling, and occasionally deformity. Most cases can be treated conservatively. However, internal or external surgical stabilization may occasionally be required.

Simultaneous Disruption of the Pubic Symphysis and Sacroiliac Joint during Vaginal Birth

Background. Puerperal diastasis of the pubic symphysis is a rare intrapartum complication. This report presents the case of a woman who experienced synchronous pubic symphysis and sacroiliac joint separations induced by vaginal delivery. Case. A 32-year-old woman (gravida 2, parity 2) with an uncomplicated prenatal course developed acute-onset anterior pubic pain during vaginal delivery. The pain persisted postpartum and was exacerbated by leg movement. Physical and radiographic examinations showed a pubic symphyseal separation of 2.4 cm, accompanied by a 10 mm disruption of the left sacroiliac joint. The patient was treated conservatively with pain-relief medication; bed rest, mostly in the left lateral decubitus position; closed reduction and application of a pelvic binder; use of a walker; and physical therapy. Conclusion. The patient responded to conservative management. She was essentially pain-free and regained movement and ambulation by 12 weeks postpartum.

Peripartum pubic symphysis separation--Current strategies in diagnosis and therapy and presentation of two cases

BACKGROUND

During spontaneous vaginal delivery, pubic symphyseal widening is normal. Common changes are reversible after complication-free birth. However, cases of peripartum symphysis separation are rare. There is no consensus in the literature on how to treat pregnancy-related pubic symphysis separation.

METHODS

This review used a literature-based search (PubMed, 1900-2013) and analysis of 2 own case reports. Studies with conclusions regarding management were particularly considered.

RESULTS

Characteristic symptoms, suprapubic pain and tenderness radiating to the posterior pelvic girdle or lower back, may be noted 48 h after delivery. Pain on movement, especially walking or climbing stairs, is often present. Conservative treatments, such as a pelvic brace with physiotherapy and local interventions such as infiltration, are successful in most cases. Symptom reduction within 6 weeks is the most common outcome, but can take up to 6 months in some cases. Surgical intervention is needed in cases of persistent separation. Anterior plate fixation is offered as a well-known and safe procedure. Minimally invasive SI joint screw fixation is required in cases of combined posterior pelvic girdle lesions.

SUMMARY

Postpartum symphyseal rupture can be indicated with the rare occurrence of pelvic pain post-delivery, with sciatica or lumbago and decreased mobility. The diagnosis is made on clinical findings, as well as radiographs of the pelvic girdle. Conservative treatment with a pelvic brace is the gold standard in pre- and postpartum cases of symphysis dysfunction.

Incidence and risk factors of symptomatic peripartum diastasis of pubic symphysis

This study was undertaken to determine incidence, associated risk factors, and clinical outcomes of a diastasis of pubic symphysis. Among 4,151 women, who delivered 4,554 babies at the Department of Obstetrics of Seoul National University Bundang hospital from January 2004 to December 2006, eleven women were diagnosed as having a symptomatic diastasis of pubic symphysis. We estimated the incidence of the diastasis and identified the associated risk factors. To evaluate the pain relief and reduction of diastasis we followed up the 11 diastatic patients. The incidence of the diastasis was 1/385. Primiparity (P = 0.010) and twin gestation (P = 0.016) appeared as risk factors for diastasis by univairable analysis; and twin gestation appeared to be the only risk factor (P = 0.006) by logistic analysis. Two patients were operated due to intractable pain; and the remaining nine patients were treated conservatively. The diastatic gap decreased to less than 1.5 cm by 2 to 6 weeks after the diagnosis and then remained stationary. At a mean follow-up of 22.1 months (range, 12 to 47 months), five of 11 patients had persistent symphysis pubis dysfunction. Diastasis is more frequent than generally acknowledged. Pregnant women with multiple gestations should be informed about the potential risk of pubic symphysis diastasis.

Treatment of parturition-induced rupture of pubic symphysis after spontaneous vaginal delivery

Parturition-induced rupture of pubic symphysis is an uncommon but severe complication of delivery. Characteristic symptoms are an immediate onset of suprapubic and/or sacroiliac pain within the first 24 hours postpartum, often accompanied by an audible crack. Diagnosis can be confirmed by imaging including X-ray, Magnet Resonance Imaging (MRI), and ultrasound. However, there is no consensus on the optimal therapy. Conservative treatment is predominantly used. It has been reported that, in cases of extreme symphyseal rupture with pelvic instability or persisting pain after conservative therapy, operative treatment achieves a successful outcome. In this report, we present a case of a twenty-year-old primigravida who developed suprapubic pain after a nonoperative vaginal birth with shoulder dystocia. A rupture of pubic symphysis with a gap of 60 mm was confirmed by means of X-ray and MRI. Simultaneously, other pelvic joint injuries could be excluded. Operative treatment by an open reduction and internal plate fixation yielded excellent results.

Peripartum pubic symphysis separation: a case report and review of the literature

Although peripartum pubic symphysis diastasis is an uncommon complication of delivery, it can lead to considerable and sometimes long-term disability. Although the initial clinical examination and diagnostic workup for this complication are relatively straightforward, the best treatment for a peripartum pubic symphysis diastasis is less clear. Historically, nearly all women were treated conservatively with bed rest and pelvic binders. However, more recent case reports have described more invasive orthopedic procedures being used to help speedy recovery. In this study, we present a case of a 22-year-old primigravida who had a severe pubic symphysis separation after a vaginal delivery complicated by a shoulder dystocia. We also reviewed the literature on this topic over the past 20 years to gain a better understanding of the clinical factors surrounding peripartum pubic symphysis separation and the treatment option available to women with this complication.

TARGET AUDIENCE

Obstetricians & Gynecologists.

LEARNING OBJECTIVES

After completing this CME activity, physicians should be better able to identify the clinical factors that associated with peripartum pubic symphysis separation; perform a diagnostic workup when a peripartum pubic symphysis separation is suspected; distinguish the conservative and invasive orthopedic interventions available for the treatment of peripartum pubic symphysis separation; and show that the degree of patient disability after peripartum pubic symphysis separation varies greatly and no clinical factors or diagnostic studies effectively predict the course of patient recovery.