What is Postpartum Pubic Symphysis Diastasis?
A rare but serious condition that can happen after giving birth naturally is known as Pubic Symphysis Diastasis (PSD). This is when the joint in your pelvic area widens more than it should. During pregnancy and childbirth, this joint naturally expands to make room for the baby, but it can sometimes separate too much (typically more than 1 cm), which can cause severe pain and difficulty moving.
The rate of occurrence of PSD ranges from 1 in 300 to 1 in 30,000 cases. It’s likely that many cases go unreported or undiagnosed. As a result, orthopedic surgeons, doctors who specialize in the musculoskeletal system, are often faced with tough decisions on how to treat patients with PSD. This is because women who have recently been pregnant present complexities in surgical procedures, while the chronic pain and disability associated with PSD can impact their ability to care for their newborns. Various treatment options exist and have been discussed in medical literature.
These options include non-surgical treatments such as applying a pelvic binder along with physical therapy and immediate weight-bearing exercises, or rest and no weight-bearing. Other options mentioned are closed reduction, which involves resetting the joint and applying a binder, as well as surgical methods such as external fixators with or without screw fixation in the sacroiliac joint (joint located in the lower back), or internal fixation using plates and screws.
It’s crucial that a team of healthcare professionals from different disciplines works together to detect and treat this condition early on to make sure patients have the best outcome possible.
What Causes Postpartum Pubic Symphysis Diastasis?
There are several factors that can increase the risk of the pubic bone separating after childbirth, a condition known as postpartum pubic symphysis diastasis. These include being a first-time mother, carrying multiple babies, and experiencing a long active labor period. Other elements to consider are the use of forceps during delivery, babies that weigh more than 4000 grams, and unusually large babies, also known as macrosomia. An epidural for pain relief, difficulty delivering the baby’s shoulders (known as shoulder dystocia), or the use of the McRoberts maneuver (a specific position to aide in delivery) can also raise the risk. Furthermore, the condition seems to be more common among Scandinavian women.
Some think that the hormone relaxin, which increases in the body during pregnancy to loosen the joints, may play a role but no direct connection has been found. Still, women who experience pubic separation after delivery have shown higher relaxin levels. There is a range of theories about the root cause of postpartum pubic symphysis diastasis:
One theory is that the natural changes in the shape of the spine and tension of the ligaments holding the pelvic bones together during pregnancy can stress the pelvis. Structural variations in the pelvis itself, known as ‘contracted pelvis’, can also contribute.
Others believe that the hormonal and metabolic changes that happen during pregnancy, including the rise in relaxin and progesterone levels as well as changes in calcium metabolism, can lead to lax (loose) ligaments. This, in turn, could increase the risk of the joint weakening significantly or the fibrocartilaginous disc (the cushioning between the pubic bones) ripping during delivery.
Another possible cause is the narrowing and hardening (or sclerosis) of the pubic joint, along with its degeneration. Muscle weakness, high weight gain during pregnancy, an unusually long or short second stage of labor (the pushing stage) could also play a role.
Risk Factors and Frequency for Postpartum Pubic Symphysis Diastasis
Pathologic, complete separation of the pubic symphysis after pregnancy is not very common. The chances of this happening range from 1 in 300 to 1 in 30,000, and it is often undiagnosed. The University of Pennsylvania School of Medicine conducted a study and found that in their institution, this condition occurred in 1 out of every 569 deliveries over two years. Some cases may not be reported due to difficulties in diagnosing and mild symptoms.
Magnetic resonance studies have revealed that lesions in the pubic area, including bone marrow edema and bone fracture, following vaginal childbirth are quite common. These are even found in low-risk pregnancies. However, these usually heal on their own and do not lead to other conditions such as prolapse or incontinence.
Signs and Symptoms of Postpartum Pubic Symphysis Diastasis
Pubic symphysis diastasis, or the separation of the pubic joint, can occur before childbirth, during labor, or most often, after childbirth. This issue is typically spotted after childbirth, but it can sometimes go unnoticed because the pain can be masked by the pain relievers given during delivery, such as spinal epidural anesthesia.
The key sign of pubic symphysis diastasis after pregnancy is constant pain in the front part of the pelvis and the area above the pubic bone. This pain might be accompanied by pain in the sacroiliac joints at the back of the pelvis due to an injury to the ligaments in the pelvic ring. The pain from the front of the pelvis can spread to the hip joints and down the legs. Women with this condition often find it very difficult to bear weight and might hold in urine, sometimes requiring the use of a catheter to help with urination.
Other problems may include:
- Difficulty lifting either leg straight up (active straight leg raise)
- Difficulty adjusting position in bed (changes in bed positioning)
- Noticeable distress due to pain
- Pain upon touching or trying to move the pelvis (pain with palpation or attempted manipulation of the pelvic girdle)
- Pain when trying to bear weight or walk (pain with attempted weight-bearing or ambulation)
Research has also found that some women may have swelling or a blood-filled swelling (hematoma) on the pubic bone and perineum, as well as a noticeable gap in the pubic symphysis. However, there is no reported nerve and vascular injury associated with this condition.
Testing for Postpartum Pubic Symphysis Diastasis
If your doctor suspects that you have a condition called postpartum pubic diastasis after giving birth, they may suggest an ultrasound scan. This is a safe and easy way to take a look at your body and see if anything is not usual.
After the ultrasound, the doctor may want to get an X-ray of your pelvis (a standard AP pelvis radiograph), which can confirm the issue. When they view your X-ray, they’ll look for a gap in your pubic bones that’s more than 1 cm wide. This size of gap suggests a problem with your pelvic girdle, the framework of bones that support your pelvis.
The doctor will also review the X-ray to see if there are any gaps or significant separation in your sacral iliac joints. These are the joints where your spine, pelvis and sacrum (a bone at the bottom of your spine) connect. If any separations are there, it could suggest additional problems.
To get a better idea of what might be going wrong, your doctor may suggest a type of X-ray called a computed tomography (CT) scan, which can show more detail. Because it takes images from different angles, it can create a three-dimensional picture of your pubic symphysis (the area where your pubic bones meet) and your sacral iliac joints.
If the X-ray shows a gap in your pubic bones that’s more than 4 cm wide, this is considered a significant separation. In this case, your doctor might recommend a magnetic resonance imaging (MRI) scan without using a contrast agent. An MRI can give a detailed image of the tissues around your pubic bones and can help the doctor assess if there’s any other injury involved.
Treatment Options for Postpartum Pubic Symphysis Diastasis
Pelvic diastasis, a condition where the two halves of the pelvis move further apart than normal, can be managed by various treatment methods. These include non-surgical strategies such as using a pelvic binder (a supportive band around the hip) along with physical therapy and letting the patient bear their own weight immediately. Other methods involve not allowing weight on the affected part and complete bed rest, or re-aligning the pelvis (closed reduction) along with using a pelvic binder.
Some cases may necessitate surgical methods, such as putting on an anterior external fixator (a stabilizing frame outside the body) with or without sacroiliac screw fixation (putting screws into a joint in the lower part of the spine for stability). Alternatively, anterior internal fixation may be used, which involves utilizing plates and screws to hold the pelvis in place from inside the body.
Generally, non-surgical management is recommended, leading to satisfactory recovery results. But in some more severe cases, where the pelvis has been displaced more than 4 cm, early surgical management might be advisable. However, surgical intervention during the post-birth period comes with increased risks for complications during or after the procedure. Factors such as changes in pelvic structure, increased blood circulation to the pelvis, and the body’s escalated tendency to form blood clots after childbirth can complicate surgical procedures and must be considered before deciding on the course of treatment.
What else can Postpartum Pubic Symphysis Diastasis be?
When diagnosing pubic symphysis diastasis, which is a separation of the pubic bones, medical professionals also check for other causes of hip, back, and leg pain. To ensure an accurate diagnosis, other health issues they might have to rule out include:
- Tears and cuts around the labia and the area around the anus
- Blood clots in veins
- Pain in the lower back that is caused by issues with muscles and bones
- Nerve pain in the lower back and legs (known as lumbosacral radiculopathy)
- Wearing down of the pubic bones (pubic osteolysis)
- Inflammation of the pubic bones (osteitis pubis)
- Infections in the bone, which could be caused by various diseases such as tuberculosis, syphilis, or a general bone infection (osteomyelitis)
- Growths in the bone (tumors)
- Fractures that happen after childbirth
- Pockets of infection (abscess)
- Inflammation and infection of the bone (osteomyelitis)
Medical professionals use patient’s medical history, a physical examination, and imaging techniques like ultrasound or X-ray to correctly diagnose the problem.
What to expect with Postpartum Pubic Symphysis Diastasis
Most patients who deal with postpartum pubic symphysis diastasis—a condition where the joint in the front of the pelvis widens more than it should after childbirth—have a very good recovery outlook. In most instances, patients fully recover without any lingering pain.
Follow-up medical imaging in most case studies shows that the joint nearly fully closes again and all symptoms typically resolve within 3 months. Some patients might need physical therapy for up to 6 months to help with their recovery.
As of now, there are no long-term side effects associated with this condition. Also, there are no specific instructions on how to change medical care for any future pregnancies. This is an area that would benefit from further research in the future.
Possible Complications When Diagnosed with Postpartum Pubic Symphysis Diastasis
Complications from pregnancy-related separation of the pubic symphysis are uncommon. When they do occur, difficulties in urinating, bleeding under the skin called a hematoma, and sustained pain while walking are the most frequently reported issues in case studies. Some reports have also linked blood clot formations (venous thrombus embolism) to this condition, typically due to the individual being immobile for a long period.
Common Complications:
- Urinary outflow obstruction
- Hematoma formation
- Sustained painful ambulation
- Venous thrombus embolism from prolonged immobility
Preventing Postpartum Pubic Symphysis Diastasis
It’s important for women to understand that while PSD, or Pubic Symphysis Diastasis, is rare, lesions in the pubic area are common. PSD is a condition where the joint at the front of the pelvis widens more than usual. Factors that increase the chance of this happening come from both the baby and the mother, and often relate to the baby being larger than average (macrosomia), or the mother having pelvic imbalances which can make the childbirth process more difficult.
Previous pelvic injuries from past deliveries, or pain in the lower back and pelvic area during pregnancy can also increase the risk of hard labour, or dystocia. The good news is these are preventable risks, so understanding and managing them can reduce the chance of difficult childbirth.
