Postpartum separation of the pubic symphysis

Separación de la sínfisis púbica postparto

Pubic symphysis separation following normal vaginal delivery is uncommon. The etiology has not been fully elucidated and is associated with multiparity, macrosomia, physiological weakening of the joint or excessive force applied to the pelvic ring. Symptoms include pain around the symphysis pubis joint, hips, groin, lower abdomen and inner thigh associated with tenderness in the affected area. Imaging studies show the distance between the pubic bones. Medical management is variable and the potential results are yet poorly understood. Delay in diagnosis carries severe acute or long-term health consequences in patients. We present a case in an 18-year-old patient who complained of shearing pain in the pubic area on postnatal day 2. Past history included a normal full term pregnancy, normal spontaneous uncomplicated vaginal delivery and live-born infant. On physical examination patient had moderate pain over the pubic region associated with difficulty in walking and active leg movements. An anteroposterior radiograph of the pelvis in a supine position revealed a pubic symphyseal separation of 25 mm, with no other bone or congenital anomalies. She was treated conservatively with complete resolution of symptoms after 3 months.

1. Becker I, Woodley SJ, Stringer MD. The adult human pubic symphysis: a systematic review. J Anat. 2010;217:475-87. doi: 10.1111/j.1469-7580.2010.01300.x.
2. Herren C, Sobottke R, Dadgar A, Ringe MJ, Graf M, Keller K, Eysel P, Mallmann P, Siewe J.. Peripartum pubic symphysis separation--Current strategies in diagnosis and therapy and presentation of two cases. Injury. 2015;46:1074-80. doi: 10.1016/j.injury.2015.02.030.
3. Moiety FM, Azzam AZ. Fundal pressure during the second stage of labor in a tertiary obstetric center: a prospective analysis. J Obstet Gynaecol Res. 2014;40:946-53. doi: 10.1111/jog.12284.
4. Hashem G, Zhang Q, Hayami T, Chen J, Wang W, Kapila S. Relaxin and beta-estradiol modulate targeted matrix degradation in specific synovial joint fibrocartilages: progesterone prevents matrix loss. Arthritis Res Ther. 2006;8:R98.
5. Zou Y, Fan F, Ma A, Yue Y, Mao W, Ma X. Hormonal changes and somatopsychologic manifestations in the first trimester of pregnancy and post partum. Int J Gynaecol Obstet. 2009;105:46-9. doi: 10.1016/j.ijgo.2008.12.001.
6. Mathews R, Gearhart JP, Bhatnagar R, Sponseller P. Staged pelvic closure of extreme pubic diastasis in the exstrophy-epispadias complex. J Urol. 2006;176:2196-8.
7. Aydın S, Bakar RZ, Aydın ÇA, Özcan P. Assessment of postpartum symphysis pubis distention with 3D ultrasonography: a novel method. Clin Imaging. 2016;40:185-90. doi: 10.1016/j.clinimag.2015.10.015.
8. Yoo JJ, Ha YC, Lee YK, Hong JS, Kang BJ, Koo KH. Incidence and risk factors of symptomatic peripartum diastasis of pubic symphysis. J Korean Med Sci. 2014;29:281-6. doi: 10.3346/jkms.2014.29.2.281.
9. Budak MJ, Oliver TB. There's a hole in my symphysis -- a review of disorders causing widening, erosion, and destruction of the symphysis pubis. Clin Radiol. 2013;68:173-80. doi: 10.1016/j.crad.2012.03.021.
10. Hierholzer C, Ali A, Toro-Arbelaez JB, Suk M, Helfet DL. Traumatic disruption of pubis symphysis with accompanying posterior pelvic injury after natural childbirth. Am J Orthop (Belle Mead NJ). 2007;36:E167-7