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Postpartum Pubic Symphysis Diastasis
Introduction
Peripartum pubic symphysis diastasis (PPSD) is a condition characterized by excessive separation of the pubic symphysis, a fibrocartilaginous joint that connects the left and right pubic bones at the anterior pelvis.[1] Normally, this joint has minimal mobility, but hormonal changes during pregnancy, particularly increased relaxin and progesterone levels, lead to physiological widening to accommodate childbirth. The pubic bones in a nonpregnant person are separated by 4 to 5 mm, which can increase by 2 to 3 mm in the perinatal period.[2] Moreover, the pubic symphysis width has been shown to increase from 4 mm at 8 weeks gestation to about 7 mm at term.[3] However, while a mild increase in pubic symphysis width is typical during pregnancy, a separation exceeding 1 cm is considered pathological and can result in pain, pelvic instability, and functional impairment.[4]
The reported incidence of complete pubic symphysis separation varies widely, ranging from 1 in 300 to 1 in 30,000 births [5], with many cases likely undiagnosed. Risk factors for PPSD include primigravid patients, multiple gestations, prolonged labor, forceps or vacuum-assisted deliveries, maternal age older than 35, and fetal macrosomia. Additionally, conditions such as excessive thigh abduction during delivery, connective tissue disorders, and previous pelvic trauma may contribute to its occurrence. Patients typically present postpartum with severe anterior pelvic pain, difficulty with ambulation, and, in some cases, urinary retention. Diagnosis is confirmed through imaging, with ultrasound and pelvic radiographs used to assess the extent of separation.
The clinical course of PPSD varies. Some cases spontaneously resolve within weeks to months, while others require treatment. Management is primarily conservative, involving pelvic binders, physical therapy, and pain management with NSAIDs or acetaminophen. Severe cases, particularly those with separations >4 cm, may require surgical intervention, including internal fixation with plates and screws. If left untreated or misdiagnosed, PPSD can lead to chronic pelvic pain and long-term disability. Pain and instability may also affect nearby musculoskeletal structures, causing compensatory gait abnormalities, sacroiliac joint dysfunction, and secondary musculoskeletal complications.
Etiology
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Etiology
Identified risk factors for PPSD include:
- Primigravid patients
- Multiple gestations
- Prolonged active labor [6]
- Forceps or vacuum-assisted deliveries
- Maternal age older than 35
- Deliveries of newborns weighing >4000 g [7][8][9][6]
- Nulliparity (due to less pelvic adaptation and flexibility) [5]
Epidural analgesia and shoulder dystocia or McRoberts maneuver are also reported as possible risk factors.[10] Multiparous patients with weakened pelvic ligaments may also be at risk.[9] Other maternal factors that put a patient at risk for PPSD include excessive abduction of the thighs during delivery, maternal connective tissue disorders, congenital pelvic malformations, rickets, previous history of pelvic trauma, and chondromalacia.[11]
Conversely, several factors were not associated with PPSD in a case-control study. These included body mass index prepregnancy, pregnancy weight gain, gestational diabetes, induction of labor, duration of labor, use of epidural anesthesia, vacuum-assisted vaginal delivery, episiotomy, neonatal sex, and fetal birth weight.[5]
While increased serum relaxin hormone levels have been identified in patients with PPSD, no direct correlation has been proven between these elevated levels and an increased incidence of pubic symphysis separation. With a precipitous labor, increased mechanical forces are present on pelvic structures, leading to a higher chance of PPSD.[8] Other etiologies or predisposing factors that have been suggested to have a potential association with PPSD include:
- The biomechanical strain of the pelvic ligaments and associated hyperlordosis
- Anatomical pelvic variations and "contracted pelvis"
- Metabolic (calcium) and hormonal (relaxin and progesterone) changes leading to ligamentous laxity
- Extreme weakening of the joint
- Tearing of the fibrocartilaginous disc during delivery
- Narrowing, sclerosis, and degeneration of the pubic joint
- Muscle weakness
- A very long or a very short (ie, <30 minutes) second stage of labor [12]
Epidemiology
The pubic symphysis is a nonsynovial joint where the medial surfaces of the pubic bones are lined with hyaline cartilage. A fibrocartilaginous disc lies between the 2 bones, providing cushioning and support. The superior, anterior, inferior, and posterior pubic ligaments strengthen the joint capsule. Additionally, a robust aponeurosis links the reinforced joint capsule to the tendons of the rectus abdominis and adductor longus, contributing to torso stability. Among the key structures maintaining pubic joint stability, the fibrocartilaginous disc and anterior pubic ligament play the most crucial roles.[7]
The incidence of pathologic, complete separation of the pubic symphysis following pregnancy is reported to be 1 in 36 to 1 in 30,000, with many instances likely undiagnosed.[7][13] Recently, the incidence of PPSD has increased, likely due to the increased availability of imaging. A published case series from the University of Pennsylvania School of Medicine reported that the incidence at a single institution was 1 in 569 deliveries over 2 years. Underreporting is likely due to inconsistencies in diagnosis and patients often presenting with mild symptoms and limited debility. Magnetic resonance studies have shown a high incidence of pubic abnormalities (eg, bone marrow edema, bone fracture, and capsule fracture) following vaginal childbirth, even in low-risk pregnancies. However, these injuries usually recover and are not associated with complications, eg, prolapse or incontinence.[14][15][16]
Pathophysiology
Relaxin, a hormone secreted by the placenta during pregnancy, peaks during the first trimester and again in the peripartum period. A modulator of arterial compliance and cardiac output during pregnancy, relaxin also serves to relax the pelvic ligaments and contribute to the softening of the cartilage of the pubic symphysis for the preparation of the birth canal for delivery.[17] Increased laxity of the pubic symphysis and sacroiliac ligaments during pregnancy helps with the passage of the fetus through the pelvis during birth.[18]
As seen in most pelvic ring injuries that separate anteriorly at the pubic symphysis, an associated posterior pelvic ring injury with stretch, partial tears, or complete tears of the sacroiliac ligaments is often noted. Complicated deliveries resulting from complications, including a contracted maternal pelvis, fetal macrosomia, shoulder dystocia, and a prolonged second stage of labor, are prone to soft tissue (levator anis muscle) and bone injury due to the stretching forces.
History and Physical
Patients can present with PPSD during the pregnancy, intrapartum, or postpartum period. However, symptom onset most commonly occurs postpartum. The presentation of PPSD can be delayed due to the masking of symptoms if intrapartum epidural anesthesia is administered. The typical presentation involving PPSD is unrelenting pain in the anterior pelvis and suprapubic region, with or without pain localized over the sacroiliac joints from associated posterior pelvic ring ligamentous injury. Pain from the anterior pelvis can radiate and manifest in the hip joints and radiate down the legs, making ambulation difficult. Patients will often have extreme difficulty with weight-bearing and, in severe cases, can retain urine, frequently requiring the use of an indwelling Foley catheter.
Patients with PPSD will typically have difficulty with both active and passive straight leg raises and changes in bed positioning. On physical examination, patients will often present in distress secondary to pain. Pain with palpation or attempted manipulation of the pelvic girdle and pain with attempted weight-bearing or ambulation may be noted. Additionally, the literature has described soft tissue edema or hematoma on the pubis and perineum [19], as well as a palpable gap in the pubic symphysis in several case studies.[13] No associated nerve and vascular injury is usually present.
Routine postpartum imaging has shown that pubic symphysis bone marrow edema (fluid in the joint) is present in 75% of patients within the first week postpartum. This bone marrow edema was also noted in the sacroiliac joints. The edema results from bruising, mechanical stress, and even fracture. This finding can also be present in postpartum people after a planned cesarean delivery, likely due to mechanical stress during the pregnancy.[7]
Evaluation
Imaging Studies
When PPSD is suspected clinically, ultrasound can be useful for rapid bedside assessment, but then a standard anteroposterior pelvic radiograph should be obtained.[20][21] On the evaluation of plain film imaging, PPSD >1 cm indicates a pathologic process of the pelvic girdle.[22][9] The bilateral sacral iliac joints should also undergo evaluation on plain radiography for gapping or gross separation.
A computed tomography (CT) scan with a 3-dimensional reconstruction may be helpful in further evaluating the pubic symphysis and sacral iliac joints. If plain radiographs show a significant pubic separation >4 cm, treatment algorithms support obtaining noncontrast-enhanced magnetic resonance imaging to assess for surrounding soft tissue injury of the symphyseal cartilage and surrounding ligaments.[23][24]
Treatment / Management
Conservative Management
Management described for PPSD primarily consists of nonoperative treatment with the application of a pelvic binder coupled with physical therapy and immediate weight-bearing. Advising patients to remain nonweight bearing with bedrest has also been recommended.[25][26][27] In most cases, conservative, nonoperative management is recommended and yields good functional outcomes.
Pelvic binders or braces provide external stabilization and support to the pelvic girdle, reducing pain and facilitating mobility.[28] Physical therapy to strengthen the pelvic floor and core muscles improves stability and promotes functional recovery. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen may help with inflammation and pain.[23][8][25](B2)
Surgical Management
Surgical treatments include closed reduction with the application of binder, application of anterior external fixator with or without sacroiliac screw fixation, and anterior internal fixation with plate and screws. Using plates and screws to stabilize the pubic symphysis has overall shown good outcomes with pain relief and recovery of function.[25][26][27]
While orthopedic consultation and early operative management have been advocated in cases where PPSD measures >4 cm, the peripartum patient is at increased risk for operative complications. Distorted pelvic anatomy, increased pelvic vascularity, and peripartum hypercoagulability may all complicate surgical intervention and must be considered.
Differential Diagnosis
The diagnosis of PPSD is often straightforward; however, other causes of hip, back, and leg pain all warrant consideration by the evaluating clinician. Considerations include an examination for labial and perianal tears and lacerations, venous thromboembolisms, musculoskeletal low back pain, and lumbosacral radiculopathy. Additionally, pubic osteolysis, osteitis pubis, bone infection (eg, osteomyelitis, tuberculosis, or syphilis), tumors, postpartum fracture, and abscess have to be considered.[12] A careful history, clinical examination, and ultrasound or plain film radiography can aid in the diagnostic process.
Prognosis
The prognosis is very good for the majority of patients who experience PPSD. In most cases, full recovery without persistent pain is the expectation.[10] Follow-up radiographs in most case studies show near-complete closure of the pubic symphysis and complete resolution of symptoms within 3 months. Some patients do require further physical therapy for up to 6 months. No significant long-term sequelae have been identified. Currently, no definitive recommendations exist regarding the alteration of care for future pregnancies.
Complications
PPSD can lead to significant morbidity, including severe pelvic pain, impaired mobility, and difficulty with activities of daily living. In severe but rare cases, pubic symphysis fracture may occur. If not promptly diagnosed and managed, complications may include chronic pelvic instability, prolonged functional limitations, and psychological distress. In severe cases, persistent diastasis can necessitate prolonged rehabilitation, surgical intervention, or both. Additionally, inadequate pain control and mobility restrictions can impact postpartum recovery and infant care, further affecting patient well-being. Urinary outflow obstruction, hematoma formation, and sustained painful ambulation are the most common complaints noted in case studies. Venous thromboembolism is also reported and likely attributable to prolonged immobilization.
Childbirth is the primary risk factor for pelvic floor dysfunction. Pelvic organ support depends on the integrity of the birth canal. Damage to any part of the birth canal, including the pubic symphysis, can compromise this support, leading to pelvic organ prolapse and loss of pelvic organ stability.[29]
Deterrence and Patient Education
Deterrence of PPSD begins with patient education and attempts to mitigate PPSD risk factors, including macrosomia, prolonged labor, instrumental delivery, and previous pelvic trauma. Pregnant individuals should receive guidance on proper body mechanics, core strengthening exercises, and pelvic support options to minimize strain on the pubic symphysis.
Clinicians should inquire about clinical symptoms indicative of PPSD during postpartum assessment and encourage patients to report concerning symptoms (eg, severe pelvic pain and difficulty walking) to facilitate early recognition and timely evaluation. Postpartum patients should be counseled on a gradual return to activity, the use of pelvic stabilization devices if needed, and the importance of physical therapy for recovery. Open communication with clinicians ensures appropriate management and reduces long-term complications.
Pearls and Other Issues
PPSD is a rare but painful condition characterized by pelvic instability, impaired mobility, and severe pain. Diagnosis is clinical, confirmed by imaging, and management is typically conservative with pelvic binders, pain control, and physical therapy, though severe cases may require surgery. Misdiagnosis can delay recovery, leading to chronic pain and functional limitations.
Prevention includes prenatal core strengthening, controlled delivery techniques, and postpartum support with early symptom recognition. Most cases are managed as outpatients. Severe pain or instability may require hospitalization or specialist referral. Prompt diagnosis and interprofessional care improve outcomes and reduce complications.
Symphysiotomy is performed for the treatment of obstructed labor and shoulder dystocia in countries where a cesarean delivery is not immediately available and maternal mortality from cesarean delivery remains high.[30] A retrospective study shows that symphysiotomy is a safe procedure, conferring a permanent enlargement of the pelvic inlet and outlet, facilitating vaginal delivery in future pregnancies, and is a life-saving operation for the child. Severe complications are rare.[31] Chronic pain during movement or intercourse might result from a residual separation of >2.5 cm.[30]
Oswald et al have suggested that chiropractic care is effective and safe for treating mechanical low back and pelvic pain during pregnancy.[32] This aligns with the findings of Conner et al, who support the nonpharmacologic benefits of the use of chiropractic care for musculoskeletal pain in pregnancy.[33]
Enhancing Healthcare Team Outcomes
Enhancing outcomes for patients with PPSD requires a collaborative, interprofessional approach to ensure early detection, accurate diagnosis, and effective treatment. Physicians and advanced practitioners play a key role in recognizing symptoms, ordering appropriate imaging such as ultrasound and anterior-posterior pelvis radiographs, and initiating timely referrals to specialists. Obstetric and orthopedic clinicians must communicate effectively to coordinate care, ensuring that PPSD is identified early and managed appropriately. Nurses are essential in assessing patient discomfort, monitoring mobility limitations, and educating patients about symptom management and recovery expectations. Pharmacists contribute by optimizing pain management strategies, ensuring safe medication use, and minimizing the risk of adverse effects, particularly in postpartum and breastfeeding patients.
Interprofessional collaboration extends to physical medicine, rehabilitation, and therapy teams, who implement individualized treatment plans to restore function and mobility. Physical and occupational therapists provide essential guidance on movement strategies, pelvic stabilization exercises, and assistive device use to promote recovery while preventing further injury. Effective communication among all healthcare professionals ensures seamless care transitions and alignment of treatment goals, ultimately enhancing patient safety and long-term outcomes. By prioritizing coordinated, patient-centered care, the healthcare team can reduce complications, improve quality of life, and support a comprehensive recovery process for individuals affected by PPSD.
References
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