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Obs & gynae clinic - symphysis pubis dysfunction

Mr Ismail Hassan and Ms Claire de Jonge-Vors discuss this case of a woman with pubic pain.

The case

A 26-year-old woman in her first pregnancy presented to her GP at 24 weeks gestation with severe pain and grinding in the symphysis pubis, both hips and right sacroiliac joint. It worsened with movement, and when sitting or standing for prolonged periods. The pain was more severe at night, causing insomnia, and it was more difficult to turn in bed and find a comfortable position. She needed her partner to help her to the toilet. She was finding going up and down stairs extremely difficult and generally her daily living activities were curtailed. Referral to a midwife acupuncturist was made. She did not have any exclusion to treatment and a course of six sessions was given. Her pain score was seven at the commencement of treatment and reduced to three by the end. Labour was spontaneous and she gave birth to a 3.4kg male infant at 38 weeks gestation.

The problem

  • Symphysis pubis dysfunction, or pregnancy pelvic girdle pain (PPGP) is a relatively common condition affecting as many as 20% of women.1 
  • The European guidelines for the diagnosis and management of PPGP firstly recognise the pain as usually arising in relation to pregnancy, trauma and arthritis.2
  • It is experienced between the posterior iliac crest and the gluteal fold – particularly near the sacroiliac joints radiating in the posterior thigh – and can also occur in conjunction with or separately in the symphysis. The endurance capacity for standing, walking, and sitting is diminished. 2
  • The aetiology of PPGP is unknown and - although the hormone relaxin is thought to play a role - there is no proven correlation between the level of serum relaxin and joint laxity.1 One of the contributing factors is through the increased lumbar lordosis essential to counteract the increasing weight of the uterus.3,4
  • Strenuous work, previous low back ache, stress and past history of PPGP or pregnancy-related low back pain (PLBP) have been identified as risk factors for PPGP and PLBP.3,5,6 Other risk factors may include raised BMI, or inappropriate posture.

Features

  • Women complaining of pain and difficulty in movement following sitting, standing or walking for prolonged periods of time.
  • Difficulty in activities of daily living – dressing/undressing, lifting climbing or descending stairs.
  • PPGP mainly presents from the 18th week of pregnancy, becoming more intense from 24 weeks onwards. Occasional cases may present in the first trimester and postnatally.4,5
  • Insomnia is a feature of this condition due to the severe pain experienced at night.3
  • Some women become so severely affected that they need to use crutches in their pregnancy, and they may request early induction of labour or Caesarean section.
  • A thorough history is essential to eliminate ‘red flags’ which all need further investigation and include:

o unexplained weight loss

o cancer

o neurological symptoms

o drug abuse

o HIV infection

o a history of being systemically unwell. 5

  • During labour the woman should not over-abduct her hips. Care should be taken to keep the hip movement within her free range. If lithotomy stirrups need to be used then legs should be moved in unison in and out of the stirrups. 5

Examination

  • The diagnosis of PPGP can be reached after exclusion of lumbar causes. The pain or functional disturbances in relation to PPGP must be reproducible by specific clinical tests.2
  • There is no single test for identifying the source of the pelvic pain. Instead, a series of pain provocation tests should be methodically performed.7
  • European guidelines for the diagnosis and treatment of pelvic girdle pain state the tests with the highest sensitivity and specificity for the sacro-iliac joint were the P4, FABER test and Menell’s test. For the pubic symphysis, the recommended tests were palpation of the symphysis and the modified Trendelenburg test.2

Treatment

  • Adequate information and reassurance to the patient, individualised exercises, physiotherapy, analgesia, acupuncture, TENS and hot and cold compresses.3,5.8
  • PPGP is treated by some practitioners with a pelvic belt to try and stabilise the pelvic structure. 1,4,8
  • Although not the preferred method of managing the condition, simple analgesia is also useful.8

Prognosis

PPGP generally resolves within six months of childbirth, though up to 7% of women will still experience severe pain six years following delivery.8 Their pain is mainly concentrated in the posterior superior iliac spine and pubic symphysis.3, 7 

Mr Ismail Hassan is a consultant obstetrician and gynaecologist at Birmingham Women’s NHS Foundation Trust.

Claire de Jonge-Vors is a Midwife in Antenatal Clinic at Birmingham Women’s NHS Foundation Trust.

 

References

  1. Aldabe D, Riberio DC, Milosavljevic S, Bussey MD. Pregnancy-related pelvic girdle pain and its relationship with relaxin levels during pregnancy: a systematic review. European Spine Journal, (2012); 21 (9): 1769-1776
  2. Vleeming A, Albert HB, Ostgaard HC et al. European guidelines for the diagnosis and treatment of pelvic girdle painEuropean Spine Journal, (2008); 17(6): 794-819
  3. Pennick V, Young G. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database of Systematic Reviews, (2007); 18 (2): CD001139
  4. Elden H, Ostgaard H-C, Fagevik-Olsen M et al. Treatments of pelvic girdle pain in pregnant women: adverse effects of standard treatment, acupuncture and stabilising exercises on the pregnancy, mother, delivery and the fetus/neonate. BMC Complementary and Alternative Medicine, (2008); 8(34)
  5. Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy: a review. Pain Practice, (2010); 10 (1): 60-71
  6. Elden H, Hagberg H, Fagevik-Olsen M et al. Regression of pelvic girdle pain after delivery: follow-up of a randomised single blind controlled trial with different treatment modalities. Acta Obstetricia et Gynecologica Scandinavica (2008); 87 (2): 201-208
  7. Nelson P, Apte G, Justiz R, Brismee J-M, Dedrick G, Sizer PS. Chronic female pelvic pain – part 2: differential diagnosis and management. Pain Practice, (2012); 12 (2): 111-141
  8. Elden H, Fagevik-Olsen M, Ostgaard H-C et al. Acupuncture as an adjunct to standard treatment for pelvic girdle pain in pregnant women: randomised double-blinded controlled trial comparing acupuncture with non-penetrating sham acupuncture. BJOG, (2008); 115 (13): 1655-1668

Readers' comments (3)

  • Speaking as a patient, I suffered with this during pregnancy. It was excruciating. I was eventually diagnosed with hypermobile Ehlers Danlos Syndrome and now have to use a wheelchair. Many women with this type of EDS suffer with pubic symphysis dysfunction as pregnancy hormones make the joints even looser than they are anyway.
    Perhaps something to consider on discovery, as EDS is little known and very under-diagnosed. Early diagnosis can mean better outcomes for the individual. It is also genetic.

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  • I too suffered with this through each of my 3 pregnancies, each subsequent on worse than the one before. My last pregnancy the pain started around 16 weeks and by the time I was towards the end of the pregnancy I could not walk down the corridor at work without leaning on the walls, but still was not offered crutches, just the (slightly useless) belt. After lots of begging I was induced on my due date (babies one and two were late by 12 and 15 days respectively).
    I have a fair degree of hypermobility, including my spine, elbows, knees, shoulders and wrists/hands. I am now being investigated under rheumatology because of various symptoms, but it has occurred to me on nosing around the mis-information superhighway that much of my problem could be connected to the hypermobility, especially as daughters one and two are hypermobile and my granddaughter had problems learning to walk independently due to this in her feet and ankles.

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  • would be helpful to have desciptions or links to P4, FABER,Mennell and modified Trendelenberg tests

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