Pubic Symphysis Separation and Regression in Vaginal versus Cesarean Delivery.

OBJECTIVE: To quantify the association of pubic symphysis separation with mode of delivery and follow the resolution of this physiologic separation in the postpartum period. METHODS: Prospective observational cohort study that recruited two cohorts of primiparous women: those undergoing vaginal and cesarean delivery (45 and 46 patients, respectively). Chart review collected intrapartum factors. Patients were followed with serial anterior-posterior radiographs within 48 hours of delivery and at 6, 12, and 24 weeks postpartum, to evaluate the extent of pubic symphysis separation. Differences between the two cohorts in intrapartum factors were assesses as was pubic symphysis separation at each time point. RESULTS: Mean age of women was 25.8 (SD 5.1) years, and 56% were White. Mean birth weight was 3.5 (SD 0.52) kg. Mean immediate postpartum pubic symphysis separation was 7.6 (SD 2.2) mm and did not differ between groups, at 7.18 mm for vaginal delivery versus 8.04 mm for cesarean delivery (CD; P = 0.08). Pubic symphysis separation was not significantly different for CD with and without labour. Black race and obesity were associated with increased pubic symphysis separation. No intrapartum events were related to extent of separation. Normalization of pregnancy pubic symphysis separation to 4-5 mm occurred by 6 weeks postpartum. Separation of >10mm and <15mm occurred in 10 of the 91 women and occurred after vaginal and cesarean delivery. The widest pubic symphysis separation was observed in 3 patients after vaginal delivery. CONCLUSION: Physiological pubic symphysis separation occursduring pregnancy and regresses postpartum with minimal effects from labour and delivery. Cesarean deliverydoes not prevent physiological pubic symphysis separation.

Fixation failure in patients with traumatic diastasis of pubic symphysis: impact of loss of reduction on early functional outcomes.

BACKGROUND: Failure of fixation (FF) in pubic symphysis diastasis (SD) ranges between 12 and 75%, though whether it influences functional outcomes is still debated. The objective of this study is to evaluate the impact of anterior pelvic plate failure and loss of reduction on Majeed's functional scores. METHODS: Single center retrospective review of consecutive patients with acute SD treated by means of anterior pubic plating. Thirty-seven patients with a mean age 45.7 ± 14.4 years were included. Demographics, AO classification, pelvic fixation and secondary procedures were recorded. Majeed's functional scores at minimum 6 months follow-up were compared according to the presence of FF and loss of reduction. RESULTS: Fifteen patients presented FF. Eight presented an additional loss of symphyseal reduction. Mean Majeed´s score (MMS) in patients with and without FF was 64.4 ± 13.04 and 81.8 ± 15.65, respectively (p = 0.0012). Differences in MMS in patients without FF and those with FF and maintained or loss of anterior reduction were 11.3 [70.5 vs 81.8] (p = 0.092) and 22.7 [59.1 vs 81.8] (p = 0.001), respectively. Significant association of FF with AO classification was noted. (OR 12.6; p = 0.002). CONCLUSIONS: Differences in MMS in the analyzed groups suggest that loss of reduction might be more relevant than failure of the anterior osteosynthesis in functional outcomes.

A case-control study of clinical characteristics and risk factors of symptomatic postpartum pubic symphysis diastasis.

Postpartum pubic symphysis diastasis (PPSD) refers to the separation of pubic symphysis after delivery. It is typically diagnosed based on clinical symptoms and radiologic findings. This study tried to assess clinical characteristics and risk factors of PPSD. This was a nested case-control study matched for year of delivery and gestational age at delivery using a retrospective cohort of women who delivered vaginally at a single institution. The incidence of PPSD was 0.156% (33/21,131). The incidence rate increased from 0.08% (7/9328) in 2000-2004 to 0.13% (9/7138) in 2005-2009 and to 0.36% (17/4665) in 2010-2016, simultaneously with an increase of maternal age (30.7 ± 3.5 years in 2000-2004 to 31.8 ± 3.8 years in 2005-2009 and 32.8 ± 3.8 years in 2010-2016). Nulliparity was associated with a higher incidence of PPSD (81.8% in cases vs. 57.6% in controls, p = 0.01). Other factors including pre-pregnancy body mass index, weight gain during pregnancy, gestational diabetes, induction of labor, duration of labor, epidural anesthesia, vacuum-assisted delivery, episiotomy, neonatal sex and birth weight failed to show difference between the two groups. In short, the incidence of PPSD increased with time along with an increase of maternal age. Nulliparity was the only significant risk factor for PPSD.

Incidence and risk factors of symptomatic peripartum diastasis of pubic symphysis.

This study was undertaken to determine incidence, associated risk factors, and clinical outcomes of a diastasis of pubic symphysis. Among 4,151 women, who delivered 4,554 babies at the Department of Obstetrics of Seoul National University Bundang hospital from January 2004 to December 2006, eleven women were diagnosed as having a symptomatic diastasis of pubic symphysis. We estimated the incidence of the diastasis and identified the associated risk factors. To evaluate the pain relief and reduction of diastasis we followed up the 11 diastatic patients. The incidence of the diastasis was 1/385. Primiparity (P = 0.010) and twin gestation (P = 0.016) appeared as risk factors for diastasis by univairable analysis; and twin gestation appeared to be the only risk factor (P = 0.006) by logistic analysis. Two patients were operated due to intractable pain; and the remaining nine patients were treated conservatively. The diastatic gap decreased to less than 1.5 cm by 2 to 6 weeks after the diagnosis and then remained stationary. At a mean follow-up of 22.1 months (range, 12 to 47 months), five of 11 patients had persistent symphysis pubis dysfunction. Diastasis is more frequent than generally acknowledged. Pregnant women with multiple gestations should be informed about the potential risk of pubic symphysis diastasis.

Pubic symphysis diastasis with urinary incontinence: collaborative surgical management.

Pubic symphysis diastasis during obstetric delivery occurs rarely. Symptoms usually respond to conservative management. A nulliparous 39-year-old delivered spontaneously with an audible pop noted. Pubic symphysis diastasis of 4.6 cm was diagnosed on pelvic X-ray. She developed severe pain with ambulation and stress urinary incontinence. After neither of these symptoms improved significantly in response to conservative management, the patient underwent open reduction internal fixation with plating of her pubic symphysis, and bladder neck sling placement using autologous rectus fascia. Postoperatively she experienced urinary retention, which resolved with continuous bladder drainage for 1 week. Both her urinary incontinence and pain resolved, and she had resumed normal activities 3 months following her surgery. Pubic symphysis diastasis is a rare obstetric complication with a paucity of literature to guide its management. A coordinated multidisciplinary approach to management is necessary when multiple organ systems are involved.

Symphysis pubis width in the pediatric population: A computerized tomography study.

BACKGROUND: Defining pathologic widening of the pubic symphysis in the pediatric population continues to be a clinical challenge. The purpose of this study is to define a normal range of pubic symphyseal widths in various age and gender groups using axial computerized tomography (CT) scans. METHODS: Axial CT images of 140 patients aged between 2 years and 15 years were obtained from our database of preexisting scans. Using a commercially available software package, the single image with the narrowest pubic symphyseal width was identified and measured. Patients were further stratified based on gender and by age into three groups: group A (age 2-5 years), group B (age 6-11 years), and group C (age 12-15 years). RESULTS: The mean width ± 95% confidence interval for all cases was 4.59 mm ± 0.18 mm. The mean width for male and female patients was 4.86 mm ± 0.26 mm and 4.33 mm ± 0.24 mm, respectively. Based on the two-way analysis of variance, both age group and gender had a statistically significant effect. Post hoc testing demonstrated a statistically significant difference in mean symphyseal width between groups A and C (p < 0.0001) and groups B and C (p = 0.0025) but not between groups A and B (p = 0.055). When grouped by age, the mean male pubic symphyseal width was found to be 5.10 mm, 4.93 mm, and 4.45 mm, while the mean female width was found to be 4.94 mm, 4.33 mm, and 3.54 mm at 2 to 6 years, 7 to 11 years, and 12 to 15 years of age, respectively. CONCLUSION: In the pediatric population, males seem to have a wider pubic symphysis than females of the same age group. In both males and females, pubic symphyseal width decreases during the transition from infancy toward skeletal maturity. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Is fixation failure after plate fixation of the symphysis pubis clinically important?

BACKGROUND: Plate fixation is a recognized treatment for pelvic ring injuries involving disruption of the pubic symphysis. Although fixation failure is well known, it is unclear whether early or late fixation failure is clinically important. QUESTIONS/PURPOSES: We therefore determined (1) the incidence and mode of failure of anterior plate fixation for traumatic pubic symphysis disruption; (2) whether failure of fixation was associated with the types of pelvic ring injury or pelvic fixation used; (3) the complications, including the requirement for reoperation or hardware removal; and (4) whether radiographic followup of greater than 1 year alters subsequent management. METHODS: We retrospectively reviewed 148 of 178 (83%) patients with traumatic symphysis pubis diastasis treated by plate fixation between 1994 and 2008. Routine radiographic review, pelvic fracture classification, method of fixation, incidence of fixation failure, timing and mode of failure, and the complications were recorded after a minimum followup of 12 months (mean, 45 months; range, 1-14 years). RESULTS: Hardware breakage occurred in 63 patients (43%), of which 61 were asymptomatic. Breakage was not related to type of plate, fracture classification, or posterior pelvic fixation. Five patients (3%) required revision surgery for failure of fixation or symptomatic instability of the symphysis pubis, and seven patients (5%) had removal of hardware for other reasons, including late deep infection in three (2%). Routine radiographic screening as part of annual followup after 1 year did not alter management. CONCLUSIONS: Our observations suggest the high rate of late fixation failure after plate fixation of the symphysis pubis is not clinically important.

Dolor pélvico en la embarazada. Disfunción de la sínfisis púbica. Revisión de la literatura / Pelvic pain in pregnancy. Pubic symphysis dysfunction. Literature review

La diástasis de la sínfisis púbica en la mujer embarazada es una entidad frecuente e infravalorada, que se relaciona con importante repercusión sobre la morbilidad maternal y con alta prevalencia de dolor crónico pélvico en las mujeres. La impotencia funcional que llega a ocasionar y el importante dolor con el que se relaciona, implica la utilización de un grupo de alternativas terapéuticas, que van desde el reposo en cama, hasta una compleja corrección quirúrgica que refuerza la importancia y la necesidad de un correcto abordaje de la patología. Nuestro objetivo será, a partir de varios casos remitidos a la Unidad de Tratamiento del Dolor de nuestro centro, el realizar una revisión de esta patología, con una aproximación a las pacientes, revisando las alternativas terapéuticas con las que contamos para este tipo de cuadros y su repercusión sobre la calidad de vida del binomio materno-fetal y cronificación del dolor (AU)

Pubic symphysis diastasis in pregnancy is a frequent and underestimated problem that has important repercussions on maternal morbidity and high prevalence of chronic pelvic pain in women. The functional impotence that it causes and the associated severe pain, entails the use of a number of therapeutic alternatives, ranging from bed rest to complex corrective surgery, reinforcing the importance and necessity of a correct approach to this pathology. Our aim is, after studying many cases referred to the Pain Treatment Unit at our centre, to carry out a review of this pathology, contacting patients, reviewing the therapeutic alternatives available for these types of conditions and their repercussions on the quality of life of the maternal-foetal binomial and chronic pain (AU)