Pubic symphysitis is a pathological change in the tissues of the pubic symphysis during pregnancy, accompanied by a divergence of the pubic bones. It is manifested by shooting or pulling superficial pains over the pubis, which are intensified when walking, turning, other physical exertion, gait changes, the inability to perform certain movements. It is diagnosed using ultrasound of the pubic joint, radiography of the pelvic bones. Calcium preparations, anti-inflammatory and analgesic agents are used for treatment. Choosing the method of delivery, take into account the severity of the disorder. In most cases, a woman is able to give birth on her own, if there are indications, a caesarean section is performed.
S33.4 Traumatic rupture of the pubic symphysis [pubic articulation]
Soreness in the pubic area is observed in 48-56% of pregnant women, which is associated with the natural mechanisms of preparing the pelvic ring for the upcoming birth. Symphysiopathy (pubic symphysitis) is spoken of when there is severe pain and instrumentally confirmed divergence of the pubic bones by more than 5 mm. Since the softening of the ligaments that strengthen the pubic symphysis begins at 6-7 months of gestational age, clinical symptoms of the disease usually occur in the third trimester of pregnancy, less often in the second, extremely rarely in the first, during or after childbirth. In exceptional cases, pubic symphysitis is not associated with pregnancy or childbirth, but is a consequence of injuries, significant physical and athletic exertion.
The etiology of pubic symphysitis has not been definitively established to date. Probably, inflammatory processes in the area of the pubic joint are associated with the peculiarities of metabolic processes in a woman’s body during pregnancy and after childbirth. In obstetrics and gynecology, two theories are considered to explain the key causes of symphysitis:
- Increased secretion of relaxin. To compensate for the loads experienced by the bone-cartilaginous ring of the pelvis, long before childbirth, the ovaries and placenta of a pregnant woman begin to produce relaxin. This hormone has a specific loosening effect on the ligaments and articular joints, which contributes to the expansion of the pelvis and the free passage of the child through the birth canal. With an excessive level of relaxin, an overgrowth of the pubic symphysis occurs.
- Calcium deficiency. During pregnancy, the female body’s need for calcium is at least 1.0 g per day. This mineral is necessary for the formation of the fetus and the preparation of the musculoskeletal system of a pregnant woman for future childbirth. Hypocalcemia is provoked by a diet low in calcium and vitamin D, a lack of natural insolation, smoking, drinking large amounts of coffee, strong tea, tonic drinks with caffeine.
A number of predisposing factors have been identified, in the presence of which the probability of developing pubic symphysitis increases significantly. The disease is often detected in patients with hereditary pathology of the musculoskeletal system – Ehlers—Danlos syndrome, in which there is excessive joint mobility caused by abnormal collagen structure. The risk group also includes women who have given birth many times, patients with pelvic injuries and a history of pubic symphysitis, pregnant women who bear a large fetus, lead a sedentary lifestyle, suffer from chronic pyelonephritis and other urological diseases accompanied by increased excretion of calcium in the urine.
During the normal development of pregnancy, under the influence of relaxin, ligaments, cartilaginous tissue of the pubic symphysis, other articular joints of the pelvis loosen, swell. As a result, the pelvic ring expands — the distances between the articular surfaces increase, and the joints themselves become more mobile. At normal calcium concentrations, these processes are compensated by sufficient muscle tone and adequate bone remodeling.
Hyperproduction of relaxin causes excessive relaxation of the ligamentous apparatus, while against the background of increased mobility of the pubic articulation, local microcirculation is disrupted, edema occurs, inflammatory mediators are released, which enhance pathological processes and reduce the pain threshold of receptors. The situation is aggravated by calcium deficiency, which leads to neuromuscular disorders, weakening of connective tissue and increased permeability of cell membranes. Additional pathogenetic links affecting the development of symphysitis after childbirth are an increased load on the pubic symphysis when the child is expelled from the birth canal and increased hypocalcemia due to high calcium consumption during breast milk secretion.
The systematization of the forms of pubic symphysitis associated with pregnancy and childbirth takes into account the size of the divergence of the bones of the pubic articulation. The choice of the classification criterion is due to the direct relationship of the clinical picture of the disorder with the distance between the bones that the pubic symphysis connects. Based on this parameter, obstetricians and gynecologists distinguish 3 degrees of severity of the disease:
- Grade I: the bones of the pubic articulation diverge by 0.5-0.9 cm;
- Grade II: the size of the discrepancy in the symphysis is 1.0-1.9 cm;
- Grade III: the distance between the pubic bones exceeds 2.0 cm.
Symptoms of pubic symphysitis
The main manifestation of the disease is a pain syndrome that occurs in the second half of the gestational period or after childbirth. The pain is usually felt as superficial and localized in the pubic area. Soreness with pubic symphysitis increases at night, during sex, when trying to pull the hip (spread the legs apart), pressing the hand on the bosom. Often there are pulling or aching pain in the hip joints and lower back. The patient experiences significant difficulties when performing certain movements — lifting the straightened legs up from the supine position, walking on the stairs.
With pronounced pubic symphysitis, lameness is possible, the nature of the gait changes noticeably, which becomes waddling (“duck”). When walking or palpating the womb, crackling, clicking, “grinding” are sometimes heard or felt. To reduce pain, the patient can take a characteristic “frog pose”: lying on her back, slightly bend her knees, turn outward and spread her hips. The probable calcium deficiency, as the cause of the disease, is indicated by rapid fatigue, brittle nails, tooth decay, nocturnal cramps of the lower leg muscles, impaired sensitivity, the occurrence of paresthesia. Extremely rarely, when the symphysis diverges, a slight subfebrility occurs with an increase in temperature to 37.3-37.4 ° C.
The most formidable consequence of pubic symphysitis is symbiosis — rupture of the pubic joint with complete damage to the ligaments that stabilize the pubic symphysis, inability to walk, lift your legs and even stand on them. Severe pain syndrome and motor disorders limit a woman’s ability to take care of herself, a child, and conduct everyday life. A significant decrease in the quality of life can lead to emotional disorders — from depression and tearfulness to deep hypochondria and postpartum depression. In 68-85% of patients, symphysiopathy occurs in the following pregnancies and childbirth.
Usually, the typical clinical picture and the occurrence of the disease due to gestation allow you to quickly establish the correct diagnosis. To confirm pubic symphysitis, physical and instrumental studies are used to confirm the divergence of the pubic bones and to clarify the degree of the disorder. The most informative in diagnostic terms are:
- Gynecological examination. During vaginal examination, a woman feels pain from the inside of the pubic symphysis. A significant discrepancy is detected palpationally in the form of a palpable finger indentation at the junction of the pubic bones.
- Ultrasound of the pubic articulation. Noninvasive sonographic examination provides anatomically accurate visualization of the pubic area. Determining the degree of symphysis stretching is an important criterion for choosing the method of delivery.
- Radiography of the pelvic bones. It is carried out in the postpartum period. According to the X-ray image, the distance between the pubic bones is easily clarified, their possible displacements to the side and up / down in relation to each other are revealed.
- Biochemical blood testing. Since one of the probable causes of the disease is a violation of calcium metabolism, blood tests for calcium and magnesium levels are recommended. With pubic symphysitis, their content is reduced by almost 2 times.
In doubtful cases, the disorder has to be differentiated with acute cystitis, pubic osteitis and osteomyelitis, bone tuberculosis, other pelvic bone osteopathies, lumbago, lumboishialgia, femoral vein thrombosis, ankylosing spondylitis. Usually the patient is examined by an orthopedic traumatologist. If necessary, prescribe consultations of a phthisiologist, neurologist, urologist, phlebologist.
The detection of the pathology of the pubic symphysis in a woman is the basis for correcting the pregnancy management plan and a more thorough approach to choosing the method of delivery. To alleviate the patient’s condition, complex drug therapy is recommended, aimed at various links of pathogenesis, which is supplemented with physiotherapy and other non-drug methods. Usually a pregnant woman or a woman in labor is prescribed:
- Calcium preparations. Since hypocalcemia is considered one of the most likely causes of symphysitis and is detected in most patients with such a diagnosis, the use of vitamin and mineral complexes containing calcium is justified. Magnesium preparations and vitamin D contribute to better assimilation of the mineral .
- Nonsteroidal anti-inflammatory drugs. Pathophysiological changes characteristic of the inflammation process are observed in the tissues of the symphysis. The use of NSAIDs can reduce the production and reduce the activity of inflammatory mediators, as well as increase the threshold of pain sensitivity of receptors.
Of the physiotherapeutic methods for the treatment of symphysitis, magnetic therapy of the pubic area is the most effective. To reduce the load on the pelvic ring, a woman is recommended to wear a bandage, strengthen the muscles of the pelvis, lower back, hips with a special set of gymnastic exercises, exercise sufficient motor activity, observe sleep and rest.
With grade I symphysitis, which is diagnosed most often, natural childbirth is possible. The divergence of the symphysis by 1 cm or more is an indication for cesarean section. Operative delivery is also recommended for severe pain syndrome, gestation of a large fetus, anatomically narrow pelvis. After childbirth, women with grade II-III symphysitis are recommended 2-6 weeks of bed rest with tight pelvic bandaging and subsequent wearing of a bandage. Thanks to the use of special corsets to hold the pelvic bones in a certain position, strict bed rest can be reduced to 3-5 days. Such corsets are recommended to be worn for 3-6 months.
Prognosis and prevention
The prognosis for symphysitis depends on the degree of its severity and the timeliness of correction. Clinical manifestations almost completely disappear by 4-6 months of the postpartum period, although some soreness in the pubic area may persist for up to 1 year. For preventive purposes, a diet with a sufficient content of calcium-rich foods (milk, sour cream, cottage cheese, hard cheese, buckwheat, legumes, leafy greens, nuts), taking vitamin and mineral supplements, sufficient insolation and motor activity, performing exercises to strengthen the pelvic muscles is recommended.