Pubic Symphysis Diastasis
Speaking with women in my clinic and working with the Mommy Ready program, I have many opportunities to listen to birth experiences. In fact, the reason I started the online postpartum program was in response to hearing these stories and looking to address the common concerns my patients were expressing. I recently had the pleasure of visiting with a young mother who is struggling with a less common postpartum concern, but one that affects the core-system directly. With her permission I am sharing her story. Our hope is that by opening up a discussion on this postpartum complication we can derive input from experienced professionals to better direct providers to improve care in the future.
Pubic Symphysis Diastasis (PSD), or separation of the pubic symphysis during the peripartum period is considered relatively uncommon. Reports of incidence range from 1:300 - 1:30,000 (2015) women worldwide between 1:385 to 1:500 in the US (2016). The wide range of incidence alludes to inadequate screening for identifying or differentiating PSD from pubic symphyseal pain or pelvic girdle pain which is considered common (about 20%) after childbirth.
The pubic symphysis is made up of a synovial capsule joining the two pubic bones with a fibrocartilagenous interpubic disc and four ligaments. The mean joint widths, measured at the most anterior portion of the pubic bones in nulliparous women is 2.6 mm in women with 3 or more children the mean width is 12.6 mm. Yet comparison between studies is difficulty because of lack of standardization in measurement locations and previous studies reporting measurements from different locations (such as 7 mm in nulliparous and 20 mm in multiparous women). Nonetheless, once the separation is reaching into the centimeter range the measurements are much more reliable, and separation is obvious. The diagnosis of a Pubic Symphysis Diastasis is made with radiologic evidence of a separation of over 1 cm of the pubic bones.
Symptoms to suspect a Pubic Symphysis Diastasis include:
pain over the pubic symphysis with compression of the hips (pathopneumonic).
pain radiating from the pubic symphysis to the sacrum or thighs.
pain over the pubic symphysis with asymmetric straight leg raise (Laseague Sign).
hip drop on the same side as a lifted foot when standing on one leg (Trendelenburg sign).
pain over the pubic symphysis with a bent leg abduction of the hip (Faber sign).
pain over the pubic symphysis when turning to the side, flexing the hips, weight bearing or any movement of the legs and may or may not include sacroiliac pain.
The characteristic description of a patient with PSD walking is the "waddling gait" demonstrated with externally rotated legs, forward tilted pelvis and narrow gait distance. In all cases the pain may present as severe to mild. Several studies have found no correlation with the intensity of the pain and the width of separation.
Diastasis can be managed conservatively, with "rapid" intervention of a pelvic brace as the gold standard, physical therapy and activity modifications. Surgical intervention is recommended for separation greater than 2.5cm, when the ligaments are torn, and shows much improved outcomes with separation over 4cm and faster return to activity.
Two factors that are suspected in contributing to increased occurrence of a Pubic Symphysis Diastasis are Increased Relaxin (more common with IVF) and McRobert's Maneuver, where the woman's legs are hyperflexed during delivery (often used with failure to progress due to suspected shoulder dystocia).
Now for our patient.
A 31 year old Caucasian, primigravida, physically active prior to an uncomplicated pregnancy, 5'1'', 98lbs pre-pregnancy, gained 20lbs during pregnancy and delivered a 7lb 3oz baby 2 days prior to her due date. She had a spontaneous delivery, elected early on for an epidural for analgesia due to which she labored and spent a 5 hour pushing phase on her back with the legs flexed and supported by two nurses which she describes were "cranking [her] legs back." Her report is that the baby was OA, no shoulder dystocia or cephalopelvic disproportion were determined. The baby had a fetal monitor and experienced no distress during a prolonged pushing phase. No forceps or suction were used.
After delivery, the patient describes that when the epidural wore off, the nurse came in to help her roll to her side and she felt as though her "pelvis had shattered," having intense pain over the pubic symphysis. That day with her insistence she obtained radiographs that showed the a pubic symphysis separation of 3.2 cm. By day 3 in the hospital she was assisted into standing with a walker by a physical therapist, and by day 4 she was discharged on pain medication with instructions to wear a pelvic brace if it felt better and follow up in 2 weeks.
The patient describes her first 3 weeks as having pain 8-9/10 over the pubic bone, with right side "sciatica" from her hip to the heel constantly for the first two weeks then intermittently since then. She was unable to move on her own and was assisted out of bed by her husband with a walker, to sit on her couch or lie in bed on her back from which she began to form bed sores. She was unable to comfortably wear the makeshift abdominal binder that she was using as a hip brace due to the bed sores until after week 3.
At 2 weeks, after her follow-up she was seen by a physical therapist but he was unable to "do anything" because of her pain. By 3 weeks she was able to roll onto her side, and get herself out of bed, using a walker to ambulate with pain, but still unable to carry anything.
By 5 weeks she still described her pain as "intense" 8/10 in the morning without any medications. She can sit with no pain and with Percocet her pain is 2 increasing to 5/10 during the day. At 6 weeks she was re-evaluated and requested another x-ray which determined that her diastasis had now decreased to 0.9cm. She was referred to a physical therapist who had worked with diastasis patients before and was also set up for an orthopedics consult.
The patient nor her initial medical providers had experience with a Pubic Symphysis Diastasis in the past. By bringing up this case and comparing it to the scientific evidence available, we hope to create a better understanding for all medical providers on how to better identify and treat PSD to obtain the best outcome possible for mother and baby.
How common is pubic symphysial pain or diagnosed a pubic symphysis diastasis in your practice?
What other factors may predispose a patient to rupture the pubic symphysis?
How did you make your diagnosis?
What outcomes have you seen with early intervention? surgery? conservative management?
How can we improve peripartum care to better identify and treat Pubic Symphysis Diastasis?
We want to hear from you, your experiences and ideas. Answer in the comments below. Put on your scientist hat and join the discussion, applying what you read above, checking the resources (in green) and enlighten the discussion.