symphysis pubis dysfunction
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  • Symphysis pubis dysfunction
    • experienced by pregnant women and may start insidiously during pregnancy or abruptly in the peripartum period
    • occurs when the laxity of the ligaments increases. This occurs secondary to hormonal changes during pregnancy e.g. increased levels of relaxin
      • the ligament laxity associated with pregnancy may cause instability and possible separation of the symphyseal joint (i.e. diastasis)
    • degree of separation of separation of the pubic symphysis can be determined in pregnancy with ultrasound or radiologically in the post-partum period
      • separation of up to 9 mm is considered physiological in pregnancy, but pathological if the gap across the pubis is greater than 10 mm (4 mm in non-pregnant females) (1)
      • amount of separation does not always correlate with the severity of symptoms or the degree of disability
      • symphysis pubis dysfunction can occur even without demonstrable separation
    • epidemiology
      • incidence has been quoted at between 1:300 and 1:20000 of pregnancies depending on the diagnostic criteria used
        • however a UK based study found a prevalence of 1/36 women (2). The study authors suggested that this incidence probably reflected their interest in the condition - however they stated that they believed that this figure still represents an underestimate of the problem
      • more prevalent in Scandinavian countries - this increased prevalence may possibly be due to a genetic link
      • symptoms tend to increase as pregnancy progresses
      • may recur with subsequent pregnancies
      • multiparous women are at increased risk
      • a large study based in Norway found that for the majority the symptoms started in the first trimester and that symptoms persisted after delivery for a mean of 6.5 years (3)
    • clinical features
      • these include pain/discomfort over the symphysis pubis with radiation to the groins and the medial aspects of the thighs, and pain over the sacroiliac joints
        • symptoms appear to vary widely - for some women it may be no more than a discomfort but for others it can become completely debilitating
        • walking is often difficult and a waddling gait is adopted
        • symptoms may be precipitated by any movement that puts stress on the symphysis pubis joint such as standing on one leg during walking, dressing or climbing stairs
      • clinical examination
        • may reveal point tenderness over the symphysis pubis joint and pressure applied over the trochanters reproduces the pain
        • occasionally symphysis oedema may be present
        • a gap at the symphysis pubis may be palpable
        • may exhibit a duck-like waddling gait
    • treatment
      • generally supportive with analgesia and physiotherapy
      • if persistent symptoms and pelvic instability then surgical treatment may be an option - however surgical reduction in pregnancy has a high risk of miscarriage
      • epidural analgesia has been used to treat this condition during pregnancy (1)

Notes:

  • important to distinguish between symphysis pubis dysfunction and rupture of the symphysis pubis joint

Reference:

  1. Scicluna JK et al. Int J Obstet Anesth. 2004 Jan;13(1):50-2. Epidural analgesia for acute symphysis pubis dysfunction in the second trimester.
  2. Owens K et al. Symphysis pubis dysfunction-a cause of significant obstetric morbidity. Eur J Obstet Gynecol Reprod Biol. 2002 Nov 15;105(2):143-6
  3. Maclennan AH, Maclennan AC. Symptom-giving pelvic girdle relaxation of pregnancy, postnatal pelvic joint syndrome and developmental dysplasia of the hip. The Norwegian Association for Women with Pelvic Girdle Relaxation. Acta. Obstet. Gynecol. Scand. 1997;76: 760–764.