Postpartum Pubic Diastasis with Significant Widening: A Rare Case Series

Abstract

Postpartum pubic symphysis diastasis is a relatively rare entity. It is usually associated with cephalopelvic disproportion, macrosomia, multiparity, precipitate labor, difficult labor, difficult forceps delivery, any other pelvic bone pathologies, and underlying connective tissue disorders. Management is typically conservative in most cases, but surgical intervention is sometimes required in cases where pubic symphysis is >4 cm and not responding to conservative management. Case with more than 4 cm of pubic diastasis is usually associated with disruption of the symphyseal ligament, sacroiliac joint capsule, and ligaments. Surgical management promotes early ambulation with good functional recovery and decreases the chances of symphyseal sclerosis, functional disability, and chronic pain. Four female patients with postpartum pubic diastasis of more than 7 cm with an age ranging from 20 to 30 years underwent open reduction and internal fixation using plates and screws. In all four cases, the patient got early ambulation and full functional recovery without any pain, discomfort, and disability at 3 months of follow up. Although conservative management has been advocated for postpartum pubic diastasis typically, surgical intervention should be sought for significant pubic diastasis (more than 4 cm) to promote early full functional recovery and avoid chronic pain, functional disability, and symphyseal sclerosis.

INTRODUCTION

Pubic symphysis diastasis following normal vaginal delivery is a relatively rare condition in the postpartum period. Its incidence varies from 1:300 to 1:30,000 births.[1] However, a more recent study suggests that this condition is more common and is in between 1:385 and 1:500 births.[2,3] Its incidence increases now a days; may be due to better identification of cases, proper reporting and better assess of radiological investigations for diagnosis.

During pregnancy, relaxation of fibrocartilage of pubis symphysis occurs due to hormones such as relaxin and progesterone which prepare the pelvis for delivery. Normally pubis symphysis is 4–5 mm wide and undergoes widened by 2–3 mm during pregnancy.[1] Causes of postpartum pubic diastasis are largely unknown but typically associated with cephalopelvic disproportion, macrosomia, multiparity, precipitate labor, difficult labor, difficult forceps delivery, any other pelvic bone pathologies, and underlying connective tissue disorders.[4,5,6,7]

Diagnosis is made clinically and supported by radiological investigations. Clinically, patients complain of pain over the pubic region with radiation toward the thigh and lower back along with walking difficulty. These complaints may mimic sciatica, osteitis pubis, and traumatic symphyseal rupture. One had to exclude this diagnosis before reaching the diagnosis of postpartum pubis symphysis diastasis. One of the classical signs is the pain over the pubic region which exacerbates manual compression of greater trochanters toward the midline, and the patient is unable to flex her hip with extended knee.[4] Diagnosis can be confirmed by plain X-ray of the pelvis, ultrasonography, computed tomography scan, and magnetic resonance imaging which may show widened pubic symphysis of >1.0–1.3 cm.[1]

Management is typically conservative in most cases with bed rest, nonsteroidal anti-inflammatory drugs, pelvic binder, and physical therapy. Normally patients get relief and good recovery with conservative management;[4,5,6] however, recovery time may become prolonged in some cases. Typically conservative management is advised in these cases where pubic symphyseal separation is <2.5 cm.[8] However, a recent study suggests that conservative management is effective up to 4 cm of pubic symphysis widening.[5]

Surgical intervention is required in cases with pubic symphysis widening >4 cm where disruption of the symphyseal ligament is more likely and may be associated with rupture of sacroiliac joint capsule and ligaments. Surgical intervention is also required in cases of postpartum pubic diastasis where conservative management in the postpartum period (4–6 weeks) fails.[9]

We are presenting a series of four cases of significant postpartum pubic diastasis (more than 7 cm) managed surgically by open reduction and internal fixation using plates and screws. All four cases achieved excellent functional outcomes.

CASE REPORTS

Case 1

A 20-year-old primipara female patient came to our outpatient department referred from the obstetrics and gynecology department after 20 days of parturition in the postpartum period. She had complaints of continued pain over the pubic region which radiates toward the inner aspect of bilateral thighs. She was unable to bear weight. On physical examination, there were localized tenderness and a palpable gap over the pubic region. On manual compression over greater trochanters bilaterally toward the midline, there was an exacerbation of pain and appreciable closing movement over the pubic symphysis. On detailed history, the patient mentioned that she had a history of prolonged labor pain followed by normal assisted vaginal delivery elsewhere and then referred to our center for further management. The weight of the baby was 3.3 kg, and the presentation was cephalic.

On radiological evaluation, there was significant pubic diastasis with a gap of about 9 cm [Figure 1]. Noncontrast computed tomography (NCCT) of the pelvis including both hip joints was also suggestive of pubic diastasis without sacroiliac joint disruption. The patient was optimized and planned for open reduction and internal fixation using plates and screws. The patient underwent operative intervention, and the intraoperative procedure was uneventful [Figure 2]. Follow-up of the patient was done at 3-month and at 6-month intervals [Figure 3]. She was walking comfortably without any pain and disability.

Figure 1.

X-ray of the pelvis including both hip joints showing a gap in the pubic area of about 9 cm

Figure 2.

Intraoperative photograph showing reduced pubic symphysis with implant

Figure 3.

Postoperative X-ray pelvis showing reduced pubic symphysis with an implant in situ

Case 2

A 27-year-old primipara female came to our outpatient department with a chief complaint of pain over the pubic region for 3 weeks. On detailed history, the pain was dull in nature and localized over the pubic region with occasional radiation toward the inner aspect of the thigh and lower back. She also had a history of giving birth to female newborn 3 weeks before. Delivery was normal assisted vaginal delivery with the help of local dai. On clinical examination, there was tenderness over the pubic region with a palpable gap appreciable over there. She was unable to bear full weight. On manual compression over greater trochanters bilaterally toward the midline, there was an exacerbation of pain and appreciable closing movement over the pubic symphysis.

On radiological evaluation, there was significant pubic diastasis with a gap of about 7.5 cm. The patient was optimized and underwent operative intervention with plate and screw fixation. Follow-up of the patient was done at 3-month and at 6-month intervals. She was walking comfortably without any pain and disability.

Case 3

A 23-year-old patient came to our outpatient department with a complaint of pain over the pubic region with occasional radiation toward the inner aspect of the thigh and lower back along with walking difficulty. On examination, there was mild tenderness and a palpable gap over the pubic region. The pain was constant and dull in nature which exacerbates on manual bitrochanteric compression toward the midline.

On further detailed inquiries, she gave the history of giving birth to her first baby 17 days back through assisted normal vaginal delivery with the help of local dai at her residence. A newborn baby was healthy. Radiological evaluation had been done after proper clinical examination. Plain X-ray of the pelvis including both hip joints was suggestive of severe pubic diastasis with a gap of about 7 cm.

After optimization, the patient underwent open reduction and internal fixation using plates and screws. Intraoperative and postoperative periods were uneventful, and the patient was discharged on the 5^th day with advice. Follow-up of the patient was done regularly at 1 month, 3 months, and 6 months of interval. She had no complaints, and she was walking comfortably and doing all her regular activities also.

Case 4

A 30-year-old multiparous patient came to our outpatient department with a chief complaint of pain over the pubic region with radiation to the inner aspect of the thigh and occasionally to the lower back along with difficulty in walking. On examination, there were localized tenderness and a palpable gap over the pubic region. The pain was constant, dull in nature, and localized over the pubic area with radiation toward the lower back and inner aspect of the thigh. Pain got exacerbated on manual bitrochanteric compression towards the midline.

On further detailed inquiry, she gave the history of giving birth to her 4^th newborn baby 15 days back through normal vaginal delivery. A newborn baby was healthy and her weight was 3.5 kg at the time of birth and her presentation was cephalic. Radiological evaluation had been done after proper clinical examination. Plain X-ray of the pelvis including both hip joints was suggestive of severe pubic diastasis with a gap of about 8 cm [Figure 4]. NCCT of the pelvis including both hip joints was also done suggestive of right-sided sacroiliac joint disruption [Figures 5 and 6]. After optimization, the patient underwent open reduction and internal fixation using plates and screws. Right-sided sacroiliac screw fixation had been also done simultaneously [Figure 7]. Intraoperative and postoperative periods were uneventful and the patient was discharged on the 5^th day with advice. Follow-up of the patient was done regularly at 1 month, 3 months, and 6 months of interval. The patient was walking comfortably without any complaints and doing her regular activities.

Figure 4.

X-ray of the pelvis including both hip joints showing a gap in the pubic area of about 8 cm

Figure 5.

Showing anterior view of computed tomography of pelvis including both hip joints while. Upper arrow: Disrupted right sacroiliac joint, Lower arrow: Pubic diastasis with significant widening

Figure 6.

Showing posterior view of computed tomography of pelvis including both hip joints. Upper arrow: Disrupted right sacroiliac joint, Lower arrow: Pubic diastasis with significant widening

Figure 7.

X-ray of the pelvis including both hip joints showing fixation of the right sacroiliac joint and pubic symphysis with implant in situ. Black arrow: Reduced right sacroiliac joint with implant in situ

DISCUSSION

Management of postpartum pubic diastasis is typically conservative with bed rest, analgesics, pelvic binder, and physical therapy. Usually, patients got relief and good functional recovery, but many patients with significant pubic diastasis (more than 4 cm) may not achieve full functional recovery and complain of continued chronic pain with walking difficulties. If conservative management fails after the postpartum period (4–6 weeks), surgical intervention is then considered.[4,5,6,9]

There is continued debate on the management of significant postpartum diastasis (more than 4 cm). There are few reports of pubic diastasis available in the literature where conservative management has been done even with separation of 9–11 cm but, these cases showed continued pain even after 6 months of follow-up. Significant pubic symphysis diastasis is more associated with rupture of the symphyseal ligament, sacroiliac joint capsule, and ligament rupture which make the pelvis unstable.[2,7] In general, patients do not wish to undergo operative intervention in the puerperal period and so the clinician also advises conservative management. Conservative management of significant pubic diastasis cases may also increase the chances of symphyseal sclerosis, functional disability, chronic pain, and recurrence of pubic diastasis in upcoming pregnancies.[2,4,5,6] There are few reports suggesting that early surgical intervention for postpartum diastasis of pubic symphysis can result in improved outcomes. Pauwels et al. suggested surgical intervention for pubic diastasis with widening more than 2.5 cm.[8] Kharrazi et al. suggest that conservative management has good outcomes and can be efficient in cases with wider separations. Therefore, surgery is now indicated only in cases where the diastasis is more than 4 cm.[5] Hou et al. favored for open reduction and internal fixation in symptomatic wide disruption cases that does not decrease significantly.[9] Zhiyong H et al. also suggested open reduction and internal fixation for pubic diastasis of more than 2.5 cm and not responding to conservative management after 6 weeks.[9]

In cases of pubic diastasis of more than 4 cm, conservative management frequently fails and surgical reduction should be done by open reduction and internal fixation or external fixation. The delay in surgical intervention prolongs recovery and increases the likelihood of persistent pain and functional disability.

In our all the four cases, pubic diastasis was more than 7 cm, and hence, based on a review of the literature, we had done pubic symphysis fixation using plates and screws. NCCT of the pelvis including both hip joints was also done in all cases, and depending on sacroiliac joint disruption and stability, fixation of sacroiliac joints was done accordingly. Functional outcome is also good in all cases.

CONCLUSION

Postpartum pubic diastasis is a relatively rare condition. Although conservative management has been advocated for postpartum pubic diastasis typically, surgical intervention should be sought for significant pubic diastasis (more than 4 cm) to promote early full functional recovery and avoid chronic pain, functional disability, and symphyseal sclerosis.

Based on this case series and other available literature, the author suggests the need of further study on a large number of cases, longer follow-up duration, and early surgical management to boost our conclusion. The limitation of our study is that only 4 cases had been included and almost all were managed after 3 weeks of injury.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.