{"id":2724,"date":"2022-03-29T17:02:57","date_gmt":"2022-03-29T17:02:57","guid":{"rendered":"http:\/\/hjog.org\/?p=2724"},"modified":"2022-04-13T20:22:15","modified_gmt":"2022-04-13T20:22:15","slug":"_research-article-12-2-19","status":"publish","type":"post","link":"https:\/\/hjog.org\/?p=2724","title":{"rendered":"Intrapartum pubic symphysis diastasis in a primigravida woman"},"content":{"rendered":"

Case Report<\/span><\/p>\n

HJOG 2022, 21 (1), 47-52 | doi: 10.33574\/hjog.0405<\/p>\n

Marinos Nikolaou1<\/sup>, Maria Katsafarou2<\/sup>, Georgios Papadocostakis3<\/sup>, Theodoros Katasos1<\/sup><\/p>\n

1<\/sup>Department of Obstetrics and Gynecology, General Hospital of Agios Nikolaos, Crete, Greece
\n2<\/sup>Department of Orthopedics and Traumatology, General Hospital of Agios Nikolaos, Crete, Greece
\n3<\/sup>Department of Orthopedics and Traumatology, University Hospital of Heraklion, Crete, Greece<\/p>\n

Correspondence:\u00a0<\/em>Marinos Nikolaou, MD, PhD, Dept. of Obstetrics and Gynecology, General Hospital of Agios Nikolaos, 72100 Lasithi, Crete, Greece, Tel: +30 2841343578 \/ +30 6972897699, Fax: +30 2841026774, e-mail: nikolaoumarinos@yahoo.gr<\/a><\/p>\n

\"\"<\/a><\/p>\n

\n
Abstract<\/strong><\/h5>\n

Pubic symphysis diastasis\u00a0in\u00a0pregnancy\u00a0is a rare obstetric complication. A case of a 35 year old primigravid woman with severe pubic symphysis diastasis and sacroiliac joint relaxation during non-operative vaginal delivery is reported and the literature reviewed. The patient was successfully treated by open reduction and internal fixation with plate and screws. During a 5 year follow-up, the patient presented with no pain and complete recovery to pre-injury functional level. Early diagnosis and immediate intervention by pelvic stabilization and in severe cases surgical intervention are the key points for the management of pubic symphyis diastasis, which optimize the maternal outcome.<\/p>\n

Keywords:<\/em> Pubic symphysis diastasis, pregnancy, vaginal delivery, internal fixation<\/p>\n

Introduction<\/strong><\/h5>\n

Pubic symphysis diastasis is recognized as a serious and under diagnosed obstetric problem. The reported incidence varies widely, from 1 in 300 pregnancies to 1 in 30.000 pregnancies1<\/sup>. These differences in incidence might be due to ethnic origins and the physician\u2019s awareness2<\/sup>.<\/p>\n

In a non-pregnant woman, the normal pubic symphysis gap ranges from 4 to 5 mm. In normal pregnant cases, the physiologic widening at the\u00a0pubic symphysis\u00a0increases by at least 2 to 3 mm. Therefore, moderate\u00a0diastasis of pubic symphysis\u00a0and sacroiliac joints relaxing provide birth canal widening, thereby facilitating vaginal delivery.\u00a0These common changes are reversible after complication-free vaginal birth3<\/sup>.<\/p>\n

Although numerous theories have been proposed, the pathogenesis of the condition is still unclear. It seems likely to be multi-factorial in origin4<\/sup>.\u00a0In most cases, the pregnancy-induced hormonal and physical changes increase the risk of musculoskeletal problems in\u00a0pregnancy and are the main causes for\u00a0pregnancy-related pelvic ring disease, including the separation of the\u00a0pubic\u00a0symphysis\u00a0and sacroiliac joints. During\u00a0pregnancy, high progesterone and relaxin levels produce physiological ligament relaxation on the pelvis5<\/sup>.<\/p>\n

In most cases, the pubic symphysis diastasis\u00a0is usually an incidental radiological finding during\u00a0pregnancy\u00a0and delivery. Predisposing factors contributing to diastasis of the pubic symphysis both antenatally and postnatally are poorly defined. These factors include multi-parity, advanced maternal age, macrosomia, cephalopelvic disproportion, malpresentation, prior pelvic trauma, use of the McRoberts maneuver, a rapid second stage of delivery, or application of forces to abduct the thighs under epidural anesthesia, might have a role in the development of\u00a0pubic\u00a0symphysis diastasis occurred after spontaneous vaginal deliveries2,6<\/sup>.<\/p>\n

The separation of pubic symphysis following vaginal delivery causes potential instability in the\u00a0joint7<\/sup>. The severity of this condition varies from mild self-limiting pain to significant morbidity affecting the quality of life by causing functional limitations to pregnant women4<\/sup>. Women present with inability to weight bearing owing to severe supra-pubic and groin pain and to perform any movement in the bed which involves hip abduction. In the most severe cases, it may be accompanied by urinary dysfunction and inability to walk post partum8<\/sup>.<\/p>\n

Few cases with severe pubic symphysis\u00a0diastasis and separation of sacroiliac joint have reported in the literature6,8-9<\/sup>. The aim of this case is to report an extremely rare case of severe pubic symphysis diastasis after a normal vaginal delivery in a primigravid woman treated surgically with open reduction and internal plate fixation with screws.<\/p>\n

Case Report<\/strong><\/h5>\n

A 35-year-old woman (gravida 1, para 0) with an uncomplicated prenatal course, at nearly 40 weeks\u2019 gestation underwent a spontaneously vaginal delivery. A 3200gr girl was delivered with Apgar score 10 at 1 and 5 minute, respectively.<\/p>\n

After an otherwise normal delivery, she complained immediately of severe acute-onset anterior\u00a0pubic\u00a0pain radiated to the right buttock and thigh and difficulty in walking.\u00a0Clinical examination was undertaken using iliac crest compression and pubic symphysis palpation to verify pelvic ring stability and to investigate for diastasis between pubic rami. It revealed a large symphysis\u00a0gap and the persisted postoperative pain in the hip and groin that was exacerbated with weight bearing and by any leg movement such as abduction and adduction at both hips. The diagnosis of pubic symphysis diastasis was confirmed by an anterior-posterior (AP) pelvic X-ray showed a\u00a0pubic separation of 10 cm and a widening of the right sacroiliac joint (Figure 1).<\/p>\n

\"\"<\/p>\n

Figure 1.<\/strong> Pelvic X-ray in antero-posterior (AP) view shows the postpartum pubic symphysis diastasis. It exist abnormal widening of the symphysis pubis to a maximal transverse measurement of 10cm. There is right sacroiliac joint widening and moderate vertical displacement of the left superior pelvis.<\/p>\n

Initially, simple intravenous analgesics were prescribed, but the pain remained intense and uncontrolled. The patient was hemodynamically stable. However, later she developed important perineal-labia major edema and hematoma. The patient was treated initially conservatively with bed rest, and pelvic stabilization with a circuferemtial pelvic binder (sheet) applied at the great trochanter level in order to perform pelvic ring closure and to prevent hemorrhage due to pelvic venous plexus injury (Figure 2). Thromboprophylaxis with graduated stockings and daily subcutaneous low molecular weight heparin were instituted due to decreased mobility of the patient.<\/p>\n

\"\"<\/p>\n

Figure 2.<\/strong> Pelvic X-ray in antero-posterior (AP) view demonstrates marked reduction of the pubic symphysis diastasis after the use of circumferential pelvic binder.<\/p>\n

Consultation with an orthopedic surgeon was performed. After neither of these symptoms improved significantly in response to conservative management, surgically management was indicated. Due to severe pubic symphysis disruption, the sheet application over the iliac crest remained until she surgically substituted by an internal fixation. One week later, the patient underwent open pubic symphysis reduction with internal fixation using small fragments reconstruction plate and screws via Pfannestiel incision. The plate was placed over the rami (superior position). A percutaneous sacroiliac screw was also placed to close and stabilize the right joint and to promote sacroiliac osteosynthesis, (Figure 3).\u00a0 No complication followed surgery.<\/p>\n

\"\"<\/p>\n

Figure 3.<\/strong> Pelvic X-ray in anteroposterior (AP) view after surgical intervention with internal plate fixation with screws shows well-reduced pubic symphysis gap. A percutaneous sacroiliac screw is placed to close and stabilize the right joint.<\/p>\n

Ambulation was forbidden during the first 6 weeks. Afterwards, the patient started physical therapy and early mobilization. Assessment by the orthopaedic team found the patient to be in good health.<\/p>\n

After, 2 year period, she delivered by cesarean section a 3400 gr male without any perinatal complications. During a 6 year follow-up, the patient presented with no pain and full recovery to pre-injury functional level.<\/p>\n

This study was conducted after an informed consent was obtained by the patient.<\/p>\n

Discussion<\/strong><\/h5>\n

Pubic\u00a0symphysis\u00a0diastasis\u00a0is a rare intra-partum obstetric complication which it may lead to significant maternal morbidity. Therefore, it requires a fast and specialized management approach to improve clinical and functional outcomes to the women10<\/sup>.<\/p>\n

A high index of suspicion and observation of the patient by the clinician\u2019s is needed for early diagnosis and management to prevent complications such as severe pelvic pain and instability which may persist for many years. The definitive diagnosis of this entity is based on clinical findings as well as radiographs of the pelvic girdle, which shows\u00a0diastasis\u00a0of the\u00a0pubic symphysis and separation of the pubic\u00a0rami6<\/sup>. Recently, reports in the literature, advocate that the use of 3D transperineal ultrasonography and magnetic resonance imaging (MRI) scan appears to be superior to pelvic x-ray in the measurement of\u00a0symphysis\u00a0pubis diastasis, recognition of the soft tissue injury and monitoring the follow up of patients11-12<\/sup>.<\/p>\n

Currently, there is no international consensus in the literature on definition, diagnostic criteria, and management of symphysial pelvic dysfunction in pregnant women13<\/sup>. Generally, non-operative management seems advisable in mild and uncomplicated cases and should be based on multidisciplinary approach14<\/sup>. In most cases, conservative management comprising pelvic stabilization with a pelvic binder, analgesia and rest in the lateral decubitus position, it is a reasonable method of management if the diastasis of pubic symphysis is less than 25 mm4<\/sup>. It is vital to minimize the prolonged immobilization of the patients in order to avoid possible complications, such as thromboembolism, decubitus ulcers, pneumonia, urinary tract infections, neuropathy and muscle atrophy15<\/sup>. Previous studies showed clinical improvement and full recovery within 6 weeks with conservative treatment and early mobilization16,17<\/sup>, but can take up to 4-6 months in some cases3,7<\/sup>. The use of physiotherapy, including lumbopelvic and pelvic-floor stabilizing and strengthening exercises\u00a0as the main component of conservative treatment showed that for the majority of women with symphysis pubic diastasis tend to have complete resolution of signs and symptoms in a short-time period18<\/sup>.<\/p>\n

Although conservative treatment of pubic symphysis diastasis is successful in most cases, surgical intervention may be needed to preserve the integrity of the\u00a0joint in cases of persistent, wide separation\u00a0(>4 cm), recurrent\u00a0diastasis, intractable symptoms, and open rupture6,13<\/sup>. Early consultation with an orthopedic surgeon in these cases is encouraged as in our case. Due to failure to progress in reducing pubic symphysis diastasis by conservative methods and instability of sacroiliac joint we proceed to invasive method of treatment.<\/p>\n

Aggressive treatment of\u00a0severe pubic\u00a0symphysis\u00a0diastasis with external fixation resulted in early ability to ambulate, void, and care for self and baby1<\/sup>. However, external fixation is an alternate method of\u00a0management that has not received significant attention in the literature up to date7<\/sup>.<\/p>\n

To date, most surgical procedures for reduction of\u00a0pubic symphysis diastasis\u00a0have been via internal fixation with plates and screws on the superior\u00a0pubic\u00a0rami. They are well-known and safe procedures and allowed a full functional recovery of the patients6,7,13<\/sup>. Minimally invasive sacroiliac joint screw fixation is required in cases of combined posterior pelvic girdle lesions13<\/sup>. Although internal fixation provides good structural support, this method would be inadequate when multiple organ systems are involved. In these cases due to risk of soft tissue infection or osteomyelitis, a coordinated multidisciplinary approach to management is necessary8<\/sup>.<\/p>\n

In case of subsequent\u00a0pregnancy, mode of delivery will have to be discussed due to traumatic past and maternal fear of recurrence. Recurrent separation of the\u00a0symphysis\u00a0pubis could occur during subsequent deliveries but generally is no worse than the first occurrence19<\/sup>. However,\u00a0few data are available in the literature and risks of recurrence are not well-defined20<\/sup>. Furthermore, issues regarding plate implant removal have not been clearly addressed and no specific indications have been proposed in the literature21<\/sup>.<\/p>\n

Conclusion<\/strong><\/h5>\n

A severe pubic symphysis diastasis is a potential obstetric complication with serious consequences for the women\u2019s quality of life, requiring immediate treatment and follow-up.\u00a0 There is a paucity of information in the literature to guide its management. So, there is an urgent need to introduce new criteria for early recognition and appropriate treatment strategies.<\/p>\n

References<\/strong><\/h5>\n

1. Dunivan GC, Hickman AM, Connolly A. Severe separation of the pubic symphysis and prompt orthopedic surgical intervention. Obstet Gynecol 2009; 114:473-5.
\n2. Yoo JJ, Ha YC, Lee YK, Hong JS, Kang BJ, Koo KH. Incidence and risk factors of symptomatic peripartum diastasis of pubic symphysis. J Korean Med Sci. 2014; 29:281-6.
\n3. Pires R, Labronici PJ, Giordano V et al Intrapartum Pubic Symphysis Disruption. Ann Med Health Sci Res. 2015; 5:476-9.
\n4. Jain N, Sternberg LB. Symphyseal separation. Obstet Gynecol. 2005; 105:1229-32.0.
\n5. Aslan E, Fynes M. Symphysial pelvic dysfunction. Current Obstet Gynecol. 2007; 19:133-9.
\n6. Shnaekel KL, Magann EF, Ahmadi S. Pubic Symphysis Rupture and Separation During Pregnancy. Obstet Gynecol Surv. 2015; 70:713-8.
\n7. Chang JL, Wu V. External fixation of pubic symphysis diastasis from postpartum trauma. Orthopedics. 2008; 31:493.
\n8. Shippey S, Roth J, Gaines R. Pubic symphysis diastasis with urinary incontinence: collaborative surgical management. Int Urogynecol J. 2013; 24:1757-9.
\n9. Seth S, Das B, Salhan S. A severe case of pubic symphysis diastasis in pregnancy. Eur J Obstet Gynecol Reprod Biol. 2003; 106:230-2.
\n10. Keriakos R, Bhatta SR, Morris F, Mason S, Buckley S. Pelvic girdle pain during pregnancy and puerperium. J Obstet Gynaecol. 2011; 31:572-80.
\n11. Kurzel RB, Au AH, Rooholamini SA, Smith W. Magnetic resonance imaging of peripartum rupture of the symphysis pubis. Obstet Gynecol. 1996; 87:826-9.
\n12. Ayd\u0131n S, Bakar RZ, Ayd\u0131n \u00c7A, \u00d6zcan P. Assessment of postpartum symphysis pubis distention with 3D ultrasonography: a novel method. Clin Imaging. 2016; 40:185-90.
\n13. Herren C, Sobottke R, Dadgar A et al. Peripartum pubic symphysis separation–Current strategies in diagnosis and therapy and presentation of two cases. Injury. 2015; 46:1074-8.
\n14. Norvilaite K , Kezeviciute M , Ramasauskaite D , Arlauskiene A, Bartkeviciene D , Uvarovas V. Postpartum pubic symphysis diastasis-conservative and surgical treatment methods, incidence of complications: Two case reports and a review of the literature. World J Clin Cases. 2020: 8(1):110-119.
\n15. Stolarczyk A, St\u0119pi\u0144ski P , Sasinowski L, Czarnocki T , D\u0119bi\u0144ski M , Maci\u0105g B. Peripartum Pubic Symphysis Diastasis-Practical Guidelines. J Clin Med. 2021; 10(11):2443.
\n16. Fidan U., Ulubay M., Keskin U., et al. Postpartum symphysis pubis separation. Acta Obstet. Gynecol. Scand. 2013;92:1336\u20131337.
\n17. Dhar S , Anderton JM. Rupture of the symphysis pubis during labor. Clin Orthop Relat Res 1992; 283:252-7.
\n18. Urraca-Gesto MA, Plaza-Manzano G, Ferragut-Garc\u00edas A, Pecos-Mart\u00edn D, Gallego-Izquierdo T, Romero-Franco N. Diastasis of symphysis pubis and labor: Systematic review. J Rehabil Res Dev. 2015; 52:629-40.
\n19. Senechal PK. Symphysis pubis separation during childbirth. J Am Board Fam Pract.1994; 7:141-4.
\n20. Gillaux C, Eboue C, Herlicoviez M, Dreyfus M. History of pubic symphysis separation and mode of delivery. J Gynecol Obstet Biol Reprod. 2011; 40:73-6.
\n21. Giannoudis PV, Chalidis BE, Roberts CS. Internal fixation of traumatic diastasis of pubic symphysis: is plate removal essential? Arch Orthop Trauma Surg. 2008; 128:325-31.<\/p>\n","protected":false},"excerpt":{"rendered":"

Marinos Nikolaou, Maria Katsafarou, Georgios Papadocostakis, Theodoros Katasos<\/p>\n

\"\"<\/a><\/p>\n

Pubic symphysis diastasis\u00a0in\u00a0pregnancy\u00a0is a rare obstetric complication. A case of a 35 year old primigravid woman with severe pubic symphysis diastasis and sacroiliac joint relaxation during non-operative vaginal delivery is reported and the literature reviewed. The patient was successfully treated by open reduction and internal fixation with plate and screws …<\/p>\n

“> Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1010],"tags":[1026,87,1025,559],"class_list":["post-2724","post","type-post","status-publish","format-standard","hentry","category-2022-volume-21-issue-1","tag-internal-fixation","tag-pregnancy","tag-pubic-symphysis-diastasis","tag-vaginal-delivery"],"_links":{"self":[{"href":"https:\/\/hjog.org\/index.php?rest_route=\/wp\/v2\/posts\/2724","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hjog.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/hjog.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/hjog.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hjog.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2724"}],"version-history":[{"count":9,"href":"https:\/\/hjog.org\/index.php?rest_route=\/wp\/v2\/posts\/2724\/revisions"}],"predecessor-version":[{"id":2842,"href":"https:\/\/hjog.org\/index.php?rest_route=\/wp\/v2\/posts\/2724\/revisions\/2842"}],"wp:attachment":[{"href":"https:\/\/hjog.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2724"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/hjog.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2724"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/hjog.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2724"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}