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POST PARTUM PUBIC SYMPHYSEAL DIASTASIS

YOGESH K PITHWA*, KUNAL P KALRA**, SANJAY B DHAR***

*Chief Resident; **Registrar; ***Associate Professor and Unit-Chief, Department of Orthopaedics, TN Medical College and BYL Nair Hospital, Mumbai.

A case of post partum pubic symphyseal diastasis is reported. The patient recovered with conservative treatment. Review of literature also supports this form of treatment for this relatively uncommon condition.

INTRODUCTION


A young mother in the immediate post-delivery period, walking into the Consultant's (Orthopaedic Surgeon or Gynaecologist) room with complaints of anterior pubic pain is likely to either get side-lined as a 'Nothing Unusual' case or be X-rayed to be discovered to be having symphyseal diastasis, a probable indication for surgery!!

This would represent a case of extremes : underdiagnosis on one hand and overtreatment on the other. The aim of this article is to straighten a few facts related to this problem of post partum pubic symphyseal diastasis.

CASE REPORT

A 30 year old female patient presented in our OPD ten days post-delivery with complaints of anterior pubic pain. The pain started post delivery. This was her second full-term normal delivery, the first one being uneventful.

On examination, she had a waddling gait with anterior pubic symphyseal tenderness and positive sacroiliac joint stress tests (pelvic compression, pelvic distraction and 'figure of four' tests). X-rays of the pelvis with both hips showed the interpubic distance to be 3 cm (Fig. 1).

The patient was advised to restrict strenuous activities and wear a pelvic binder. At a follow-up 1-1/2 months after this, the patient confessed non-compliance of treatment. She had not used the pelvic binder as she found it uncomfortable for personal hygiene. All the same, the follow-up X-ray showed reduction of the interpubic distance to 1.5 cm (Fig. 2). Symptomatically, the patient had improved. Examination showed a significant decrease in the symphyseal tenderness. Sacroiliac joint stress tests were now almost painless.

fig.1
Fig 1 :Imm. Post partum interpubic distance (3.9 cm).


fig.2
Fig 2 :Six weeks post-partum decrease in diastasis (1.8 cm).


DISCUSSION

The normal physiology of childbirth leads to an escalation of the levels of relaxin and progesterone that facilitates the relaxation and consequent widening of the birth passage. This predisposes to symphyseal diastasis secondary to childbirth, the incidence of which has been quoted in literature[1] to be anywhere from 1 in 600 to 1 in 3400.

We feel that it is important to term this condition as 'diastasis' rather than 'disruption'. 'Diastasis' would indicate an exaggeration of the normal, which, it does in fact, appear to be. This contention of ours is validated by the fact that it responds very well to conservative treatment for a period of 6 weeks post-delivery that is also the time required for the maternal relaxin and progesterone to return to normal non-pregnancy levels. If it were a 'disruption' (traumatic), then an inter-pubic distance of > 2.5 cm classified as a 'Type II open book' injury[2] would not heal with conservative treatment. But our case report as well as others quoted in the literature[3-9] quite strongly favour conservative management. There has been only one documentation[10] advocating external fixation for this condition.

As regards the prognosis, there is a possibility that the diastasis may recur in the future pregnancies, but would still be amenable to conservative treatment. There does not appear to be any correlation between the extent of interpubic distance and the final outcome.[6]

CONCLUSIONS

Pubic diastasis is an uncommon injury that should be considered when evaluating patients in the postpartum period who are experiencing suprapubic, sacroiliac or thigh pain. Although the symptoms are dramatically severe in presentation, a conservative management approach is effective.

REFERENCES

1.Senechal PK. Symphysis pubis separation during childbirth. J Am Board Fam Pract 1994; 7 (2) : 141-4.

2.Tile M. Fractures of the pelvis In: Schatzker J and Tile M. The Rationale of Operative Fracture Care 133-172, Springer-Verlag, 2nd ed.

3.Dhar S, Anderton JM. Rupture of the symphysis pubis during labor. Clin Orthop 1992; 283 : 252-7.

4.Musumeci R, Villa E. Symphysis pubis separation during vaginal delivery with epidural anesthesia. Reg Anesth 1994; 19 : 289-91.

5.Luger EJ, Arbel R, Dekel S. Traumatic separation of the symphysis pubis during pregnancy : a case report. J Trauma 1995; 38 : 255-6.


6.Scriven MW, Jones DA, 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.

7.Snow RE, Neubert AG. Peripartum pubic symphysis separation : box series and review of literature. Obstet Gynecol Surv 1997; 52 (7) : 438-43.

8.Taylor RN, Sonson RD. Separation of pubic symphysis : Yet under recognized peripartum complication. J Reprod Med 1986; 31 : 203-6.

9.Penning D, Gladbach B, Majchrowski W. Disruption of the pelvic ring during spontaneous childbirth. J Bone Joint Surgery 1997; 79 : 438-40.

10.Petersen AC, Rasmussen KL. External skeletal fixing as treatment for total puerperal rupture of the pubic symphysis. Acta Obstet Gynecol Scand 1992; 71 : 308-10.


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