PUBIC SYMPHYSIS DIASTASIS IN PREGNANCY AND DELIVERY (REVIEW)

Cover Page


Cite item

Abstract

Purpose of the study — to generalize and arrange the data published in scientific literature and to present current views on epidemiology, diagnostics and treatment options for pubic symphysis diastasis during pregnancy and delivery.

 Semeiotic separation wider than 10 mm is considered pubic symphysis diastasis during pregnancy and delivery. Diastasis above 14-25 mm might be associated with ruptures of sacroiliac joints. Frequency of such pathology is reported in the range from 0,03 to 2,8%. Key risk factors of this pathology include multiparity and repeated labor. Symptoms of pubic separation include pain and signs of pelvic instability manifesting immediately after delivery or within a short period of time after the delivery. AP roentgenography is the principal diagnostics method however lately ultrasound exam is done more frequently. Conservative option prevails in treatment of pubic symphysis diastasis. Surgical procedures are recommended in case of separation above 30-50 mm, ruptures of sacroiliac joints, open lesions, failed conservative treatment and urological dysfunction. In such cases preferred option is the internal fixation by plate and screws. Some authors use external fixation. Late-term outcomes of both methods do not demonstrate significant differences.

 Pain regress after the surgery is observed within 3 weeks to 6 months postoperatively, walking with partial load is restored in 5-14 days, full load on the lower limbs is possible 6 months postoperatively. Indications for removal of implants after internal fixation are not clearly defined. Following surgical treatment of pubic symphysis diastasis the majority of authors incline to subsequent operative delivery.

About the authors

A. L. Petrushin

Karpogorsky Central District Hospital .

Author for correspondence.
Email: fake@neicon.ru

Alexander L. Petrushin — Cand. Sci. (Med.), head of the Surgical Department.

47, ul. Lenina, 164600, Karpogory, Archangelsk Oblast.

Russian Federation

A. V. Pryaluchina

Karpogorsky Central District Hospital .

Email: fake@neicon.ru

Anastasia V. Pryaluchina — obstetrician-gynecologist.

47, ul. Lenina, 164600, Karpogory, Archangelsk Oblast.

Russian Federation

References

  1. Khorashadi L., Petscavage J.M. Richardson M.L. Postparum symphysis pubis diastasis. Radiolog Case Rep. 2011;6(3):1-3. doi: 10.2484/rcr.v6i3.542.
  2. Becker I., Woodley S.J., Stringer M.D. The adult human pubic symphysis: a systematic review. J Anat. 2010; 217(5):475-487. doi: 10.1111/j.1469-7580.2010.01300.x.
  3. Samuel C.S., Butkus A., Coghlan J.P., Bateman J.F. The effect of relaxin on collagen metabolism in the nonpregnant rat pubic symphysis: the influence of estrogen and progesterone in regulating relaxin activity. Endocrinol. 1996;137(9):3884-3890. doi: 10.1210/endo.137.9.8756561.
  4. Marnach M.L., Ramin K. D, Ramsey P. S., Song S.-W., Stensland J. J., and An K.-N. Characterization of the relationship between joint laxity and maternal hormones in pregnancy. Obstet Gynecol. 2003;101(2):331-335. doi: 10.1016/S0029-7844(02)02447-X.
  5. Schauberger C.W., Rooney B.L., Goldsmith L., Shenton D., Silva P.D., Schaper A. Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels. Am J Obstet Gynecol. 1996;174:667-671. doi: 10.1016/S0002-9378(96)70447-7.
  6. Najibi S., Tannast M., Klenck R.E., Matta J.M. Internal fixation of symphyseal disruption resulting from childbirth. J Orthop Trauma. 2010;24:732-739. doi: 10.1097/BOT.0b013e3181d70259.
  7. Jain S., Eedarapalli P., Jamjute P., Sawdy R. Symphysis pubis dysfunction: a practical approach to management. Obstet Gynaecolog. 2011;24(3):153-158. doi: 10.1576/toag.8.3.153.27250.
  8. Çıçek H., Keskın H., Tuhanıoğlu Ü., Kiliçarslan K., Oğur H. Simultaneous disruption of the pubic symphysis and sacroiliac joint during vaginal birth. Case Rep Orthop. 2015;2015:1-5. doi: 10.1155/2015/812132.
  9. Chawla J.J., Arora D., Sandhu N., Jain M., Kumari A. Pubis symphysis diastasis: a case series and literature review. Oman Med J. 2017;32(6):510-514. doi: 10.5001/omj.2017.97.
  10. Сергеева О.П. Состояние лонного сочленения при беременности и в послеродовом периоде по данным эхографии. Казанский медицинский журнал. 2003;84(4):261-263.
  11. Yamaguchi M., Morino S., Nishiguchi S., Fukutani N., Tashiro Y., Shirooka H. et al. Compartion of pelvic alightment among never-pregnant women, pregnant women and postpartum women (pelvic alightment and pregnancy). J Womens Health Care. 2016;5(1):1-5. doi: 10.4172/2167-0420.1000294.
  12. Hierholzer C., Ali A., Toro Arbelaez J.B., Suk M., Helfet D.L. Traumatic disruption of pubis symphysis with accompanying posterior pelvic injury after natural childbirth. Am J Orthop (Belle Mead NJ). 2007;36:E167-170.
  13. Laadioui M., Slimani W., Jayi S., Alaoui F.F., Bouguern H., Chaara H., Melhouf M.A. Disjonction symphysaire apre un accouchement par voie basse dystocique: a propos d’un cas. Pan African Med J. 2014;17:33. doi: 10.11604/pamj.2014.17.33.3441.
  14. Гудушаури Я.Г., Лазарев А.Ф., Верзин А.В. Оперативная коррекция последствий акушерских разрывов лобкового симфиза. Вестник травматологии и ортопедии им. Н.Н. Приорова. 2014;(4):15-21.
  15. Shnaekel K.L., Magnan E.F., Ahmadi S. Pubic symphysis rupture and separation during pregnancy. Obstet Gynecol Surv. 2015;70(11):713-718. doi: 10.1097/OGX.0000000000000247.
  16. Owens K., Pearson A., Mason G. Symphysis pubis dysfunction-- a cause of significant obstetric morbidity. Eur J Obstet Gynecol Reprod Biol. 2002;105(2):143-146. doi: 10.1016/S0301-2115(02)00192-6.
  17. Yoo J.J., Ha Y.C., Lee Y.K., Hong J.S., Kang B.J., Koo K.H. Incidence and risk factors of symptomatic peripartum diastasis of pubic symphysis. J Korean Med Sci. 2014;29(2):281-286. doi: 10.3346/jkms.2014.29.2.281.
  18. Albert H., Godskesen M., Westergaard J. Prognosis in four syndromes of pregnancy-related pelvic pain. Acta Obstet Gynecol Scand. 2001;80(6):505-510. doi: 10.1034/j.1600-0412.2001.080006505.x.
  19. Gillaux C., Eboue C., Herlicoviez M., Dreyfus M. Antécédent de disjonction pubienne et modalités d’accouchement. Journal de Gynécologie Obstétrique et Biologie de la Reproduction. 2011;40(1):73-76. doi: 10.1016/j.jgyn.2010.07.004.
  20. Pires R.E.S., Labronici P.J., Giordano V., Kojima K.E., Kfuri M., Barbisan M. et al. Impartium pubic symphiysis disruption. Ann Med Health Sci Res. 2015;5(6):476-479. doi: 10.4103/2141-9248.177980.
  21. Morel T.M., Ruiz A.R., Alonso M.M., Marquez G.GT., Odrizola F.J.M. [Two cases of postpartum pubis diastasis mistaken for neurological complication of epidural analgesia]. Rev Esp Anestesiol Reanim. 2004;51(8):448-451. (in Spanish).
  22. Bonnin M., Bolandard F., Storme B., Sibaud F., Rabishond B. Douleur pelvienne par disjonction pubienne apres accoochement par voie basse. Ann Franc d’Anesth Reanim. 2006;25(6):644-647. doi: 10.1016/j.annfar.2006.03.036.
  23. Heath T., Gherman R.B. Symphyseal separation, sacro-iliac joint dislocation and transient lateral femoral cuta-neous neuropathy associated with McRoberts’ maneu-ver. A case report. J Reprod Med. 1999;44(10):902-904.
  24. Van Heukelum M., Blake C. Major disruption of the pelvis ring during normal vaginal delivery: a case report. SA Orthop J. 2010;16(1):25-27. doi: 10.17159/2309-8309/2017/v16n1a2.
  25. Urraca-Gesto M.A., Plaza-Manzano G., Ferragut-Garcias A., Pecos-Martin D., Gallego-Izquierdo T., Romero Franco N. Diastasis of symphesis pubis and labor: Systematic review. J Rehabilit Research Develop. 2015;52(6):629-640. doi: 10.1682/JRRD.2014.12.0302.
  26. Серов В.Н., Ананьев Е.В. Оценка тяжести дисфункции лонного сочленения и выбор метода родоразрешения. Российский вестник акушера-гинеколога. 2011;(3):45-48.
  27. Buitenduk M., Brennan B., Vora P., Smith P., Winsor S. Acute intrapartium rupture of the pubic sym-physis requiring resuscitations and surgical interven-tion: a case report. J Obstet Gynaecol Can. 2018;40(1): 68-71. doi: 10.1016/j.jogc.2017.05.028.
  28. Jain N., Sternberg L.B. Symphyseal separation. Obstet Gynecol. 2005;105(5 Pt 2):1229-1232. doi: 10.1097/01. AOG.0000149744.82912.ea.
  29. Gabriel A.O., Oladire O., Jovita D.A., Ethelbert O.O., Chukwuemeka O.C. Transcutaneous electrical nerve stimulation (TENS) in the management of peripartium diastasis symphysis pubis (DSP): cases report. Ind J Physiotherap Occup Therap. 2015;9(3):221-225. doi: 10.5958/0973-5674.2014.00001.X.
  30. Snow R.E., Neubert A.G. Peripartum pubic symphysis separation: a case series and review of the literature. Obstet Gynecol Surv. 1997;52:438e43.
  31. Erickson D., Low J., Shumway J. Management of postpartum diastasis of the pubic symphysis. Orthopedics. 2016;39(2):367-369. doi: 10.3928/01477447-20160307-02.
  32. Mulchandani N.B., Jauregui J.J., Abraham R., Seger E., Illical E. Post-partum management of severe pubic diastasis. Clin Exp Obstet Gynecol. 2017;44(3):464-466. doi: 10.12891/ceog3533.2017.
  33. Palvia V., Kim S., Warholic H., Anasti J. Severe pubic symphysis diastasis managed conservatively: case report and review. Case Rep Clin Med. 2017;6:120-126. doi: 10.4236/crcm.2017.64010.
  34. Herren C., Sobjttke R., Dagdar A., Ringe M.J., Graf M., Keller K., Eystel P., Mallmann P., Siewe J. Peripartum pubic symphysis separation - current strategies in diagnosis and therapy and presentation of two cases. Injury. 2015;46(6):1074-1080. doi: 10.1016/j.injury.2015.02.030.
  35. Topuz S., Citil I., Lyibozkurt A.C., Dursun M., Akhan S.E., Has R., Berkman S. Pubic symphysis diastasis: imaging and clinical features. Eur J Radiol Extra. 2006;59(3): 127-129. doi: 10.1016/j.ejrex.2006.04.021.
  36. Bahlmann F., Merz E., Macchiella D., Weber G. [Ultrasound imaging of the symphysis fissure for evaluating damage to the symphysis in pregnancy and postpartum]. Z Geburtshilfe Perinatol. 1993;197(1):27-30. (in German).
  37. Svelato A., Ragusa A., Perino A., Meroni M.G. Is x-ray compulsory in pubic symphysis diastasis diagnosis? Acta Obstet Gynecol Scand Suppl. 2014;93:218-220. doi: 10.1111/aogs.12275.
  38. Pennig D., Gladbach B., Majchrowski W. Disruption of the pelvic ring during spontaneous chlidbirth. J Bone Joint Surg Br. 1997;79(3):438-440.
  39. Brandon C.1., Jacobson J.A., Low L.K., Park L., DeLancey J., Miller J. Pubic bone injuries in primiparous women: magnetic resonance imaging in detection and differential diagnosis of structural injury. Ultrasound Obstet Gynecol. 2012;39(4):444-451. doi: 10.1002/uog.9082.
  40. Karantanis E., Fynes M.M., Thum M-Y., Bircher M., Stantjn S.L. Symphyseal diastasis and vestibular rupture during spontaneous vaginal delivery. Am Intern J Obstet Gynecol. 2003;110(6):630-632. doi: 10.1046/j.1471-0528.2003.02122.x.
  41. Klotz I., Derakhshani P., Vorreuther R., Engelmann U. Complete rupture of the urethra in combination with anterior pelvic fracture and symphyseal rupture after spontaneous vaginal delivery. Urologe. 1998;37(1):79-82. doi: 10.1007/s001200050153.
  42. Athanassaopoulos A., Creagh T., McMillan W. Necrotizing fasciitis after the post partum diastasis of the symphysis pubis. New Zel Med J. 2006;119(1247):U2366.
  43. Shippey S., Roth J., Gaines R. Pubic symphysis diastasis with urinary incontinence: collaborative surgical management. Int Urogynecolog J. 2013;234(10):1757-1759. doi: 10.1007/s00192-013-2120-0.
  44. Zhou J.M., Zhang Y.C., Shi G.C., Fang W.S. [Treatment strategies for the diastasis of the symphysis pubis]. Zhonggou Gu Shang. 2008; 21(1): 58-59. (in Chinese).
  45. Dunbar R.P., Ries A.M. Puerperal diastasis of the pubic symphysis. A case report. J Reprod Med. 2002; 47(7):581-583.
  46. Howell E.R. Pregnancy-related symphysis pubis dys-function management and postpartum rehabilita-tion: Two case reports. J Can Chiropr Assoc. 2012;56(2): 102-111. doi: 10.1097/00007632-200202150-00015.
  47. Hou Z., Riehl J.T., Smith W.R., Strohecker K.A., Maloney P.J. Severe postpartum disruption of the pelvic ring: Report of two cases and review of the literature. Patient Saf Surg. 2011;5(1):2. doi: 10.1186/1754-9493-5-2.
  48. Shim J.H., Oh D.W. Case report: Physiotherapy strategies for a woman with symphysis pubis diastasis occurring during labor. Physiotherapy. 2012;98(1):89-91. doi: 10.1016/j.physio.2011.01.005.
  49. Agar N., Gremeau A.S., Bonnin M., Vendittelli F. Local analgesic infiltration and post-partum hyperalgetic symphysis pubis dysfunction. Gynecol Obstetric Case Rep. 2016;2(1):1-3.
  50. Tripathi S.K., Kumar S., Agarwal N.K., Khan A., Jain P., Nanda S.N. Post partum diastasis: a case report. Ann Int Med Dent Res. 2016;2(5):10-11.
  51. Culligan P., Hill S., Heit M. Rupture of the symphysis pubis during vaginal delivery followed by two subsequent uneventful pregnancies. Obstet Gynecol. 2002;10(5):1114-1117. doi: 10.1016/S0029-7844(02)02155-5.
  52. Dunivan G., Hickman A., Connolly A. Severe separation of the pubic symphysis and prompt orthopedic surgical intervention. Obstet Gynecol. 2009;114(2 Pt 2):473-475. doi: 10.1097/AOG.0b013e3181998bd1.
  53. Dunbar R.P., Ries A.M. Puerperal diastasis of the pubic symphysis. A case report. J Reprod Med. 2002;47(7):581-583.
  54. Depledge J., McNair J., Keal-Smith C., Williams M. Management of symphysis pubis dysfunction during pregnancy using exercises and pelvic support belt. Phys Ther. 2005;85(12):1290-1300. doi: 10.1093/ptj/85.12.1290.
  55. Richardson C.A., Snijders C.J., Hides J.A., Damen L., Pas M.S., Storm J. The relation between the transversus abdominis muscles, sacroiliac joint mechanics, and low back pain. Spine (Phila Pa 1976). 2002;27(4):399-405.
  56. Cowling P.D., Rangan A. A case of postpartum pubic symphysis diastasis. Injury. 2010;41(6):657-659. doi: 10.1016/j.injury.2010.01.112.
  57. Nitsche J.F., Howell T. Peripartum pubic symphysis separation: a case report and review of the literature. Obstet Gynecol Surv. 2011;66(3):153-158. doi: 10.1097/OGX.0b013e31821f84d9.
  58. Scriven M.W., Jones D.A., McKnight L. The importance of pubic pain following childbirth: a clinical and ultrasonographic study of diastasis of the pubic symphysis. J R Soc Med. 1995;88(1):28-30.
  59. Rommens P. Internal fixation in postpartum symphysis pubis rupture: report of three cases. J Orthop Trauma. 1997;11(4):273-276.
  60. Idrees A. Management of chronic symphysis pubis pain following child birth with spinal cord stimulator. J Pak Med Assoc. 2012;62:71-73.
  61. Kharrazi F.D., Rodgers W.B., Kennedy J.G., Lhowe D.W. Parturition-induced pelvic dislocation: a report of four cases. J Orthop Trauma. 1997;11(4):277-281.
  62. Graf C., Sellei R.M., Schrading S., Bauerschlag D.O. Treatment of parturition-induced rupture of pubic symphysis after spontaneous vaginal delivery. Case Rep Obstet Gynecolog. 2014;2014. doi: 10.1155/2014/485916.
  63. Nayak S.P., Panda C.K. Comparison between conservative and surgical management in postpartum pubic symphysis diastasis: a randomized controlled trail. Int J Res Orthop. 2017;3(6):1211-1217. doi: 10.18203/issn.2455-4510.IntJResOrthop20174716.
  64. Ma K., Zhu L., Fang Y. [Progress in treatment of pubic symphysis diastasis]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2014;28(2):250-254. (in Chinese).
  65. Chang J., Wu V. External fixation of pubic symphysis diastasis from postpartum trauma. Orthopedics. 2008;31(5):1-3. doi: 10.3928/01477447-20080501-05.
  66. Zhou J.M., Zhang Y.C., Shi G.C., Fang W.S. [Treatment strategies for the diastasis of the symphysis pubis]. Zhongguo Gu Shang. 2008;21(1):58-59. (in Chinese).
  67. Osterhoff G., Ossendorf C., Ossendorf-Kimmich N., Zimmermann R., Wanner D.A., Simmen H.P., Werner C.M.L. Surgical stabilization of postpartum symphyseal instability: two cases and a review of the literature. Gynecol Obstet Invest. 2012;73(1):1-7. doi: 10.1159/000331055.
  68. Raman R., Roberts C., Pape H., Giannoudis P. Implant retention and removal after internal fixation of the symphysis pubis. Injury. 2005;36(7):827-831. doi: 10.1016/j.injury.2004.11.012

Copyright (c)



This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies