Symphyseal separation (A case report)

Özet

Simfizis pubis ayrışması doğumun, nadir görülen ve genellikle asemptomatik seyreden bir komplikasyondur.

Olgu

Bazı olgularda,postpartum periyodun erken döneminde semptomatik olup ,genellikle uygun konservatif tedaviyle doğum sonrası 8 hafta içinde semptomları düzelmektedir.

Sonuç

Bu çalışmada,spontan vaginal doğumdan bir gün sonra tipik semptomalarıyla ortaya çıkan simfizis ayrışması olan bir olgu rapor edilidi ve literatur eşliğinde tartışıldı.

Anahtar Kelimeler

Doğam,simfizis ayrışması.

Giriş

During pregnancy, due to stretching effects the joint interval between pelvic bones and sacroiliac bones can be increased. This is physiologic and returns to its previous size in postpartum period. Also the susceptibility of the ligamentous structures of the symphysis pubis is increased because of relaxing estrogenic hormones just prior to delivery. Exagerrated effects such as delivery of macrosomic infants or use of forceps can cause symphysis pubis rupture or dislocation that results in severe pelvic pain over symphysis pubis by palpation in postpartum period (1).dditionally, waddling and painful gait may be seen.

Olgu

A 22 year old woman, gravida 1, was admitted in active labor at 40 weeks 2 days gestation after an unremarkable prenatal course. While active phase lasted for 12 hours, second stage lasted only 5 minutes with patient delivered of a healthy 3800gr male infant. There was no shoulder distocia or fetal injury. Approximately 24 hours after delivery, patient began to complain pain over the symphysis pubis while gaiting. Her vaginal and neurovascular examination was found normal and no pathology detected. But palpation of abdomen over symphysis pubis was very painful and radiologic evaluation of P-A pelvic graphy confirmed an 1cm symphyseal separation (Figure 1).
In our case, external or internal reduction were not performed. We only gave conservative treatment as taking patient in to absolute bed rest in the full lateral (right or left) position and kept in lateral compression on the symphysis. The pain complaint of our case was getting decreased progressively and by the day 5 of treatment, there was no pain at resting position, but painful and waddling gait of patientís complaint contiuned for a month. By postpartum day 6, we discharged our case to home with advicement of absolute bed rest and for control coming after six weeks. P-A pelvic graphy of patient was repeated 1 year 8 months later delivery, at this time we measured interval between pubic bones as a 0.4 cm (Figure 2).

Tartışma

The joint surfaces of symphysis pubis is covered by a thin hyalen cartilage and fibrocartilogenous disc fullfilled interval area of joint. The supporting structures for joint is anterior pubic, posterior pubic, superior arcuate and inferior arcuate ligaments.During pregnancy the susceptibility of ligamenteous structures is due to increased amount of liquid in connective and fibrocartilagenous tissue resulting from relaxing effects and increseased levels of sex steroids.
While Reis and coworkers postulated that there was no relaxation of symphysis pubis relating to pregnancy, Barners and coworkers. detected pelvic relaxation in 55 %of 180 pregnant women and according to Heyman and coworkers the symphysis pubis joint interval was increased in all pregnant women. It is possible that the symphyseal separation may have arisen as a result of the delivery process itself, especially with a macrosomic infant, forced and rapid delivery, cephalopelvic discordance (CPD), abnormal presentation or abnormal bony pelvic structures such as previously traumatized pelvic-arch, congenital dysplasia, osteomalacia, chondromalacia and tuberculose arthritis,.
The delivery process of our case was relevantly forced and rapid but pelvic structures of her was assessed as normal. The estimated incidence for symphyseal separation during delivery is varied between 1/521-1/20000 (5,6,11). The incidence is getting decreased in time because use of forceps in the case of CPD and abnormal presentation is replaced by abdominal cesaeran section. Wishner and Mayer. described five cases with postpartum symphyseal separation associated with localized pain in the region of the pubic-arch and waddling gait due to posterior displacement of the hip joint. All this findings were also present in our case.
The treatment of postpartum symphyseal separation is generally non operative and conservative. Patients with less than 1 cm symphyseal separation require only conservative treatment. If separation is equal or more than 1 cm, partial or complete rupture may be possible ,that requires pelvic bandage in a way of a 3 inch wide circumferantial strep that runs below than iliac crests and above than trochanters, she should be adviced to return to bed rest in full lateral position and to keep lateral compression on the symphysis, and reduction. Our case admitted to us with symptoms of pain over the pubic arch, waddling and painful gait by postpartum 1 day. The separation was measured on PA pelvic graphy as an 1 cm. So that we were taking her in absolute bed rest on full lateral position. According to literature knowledge, the avarege time for bed rest is varying between 2 days to 8 months. Symptoms are usually resolved at the end of the 8 weeks of delivery,. The symptoms of our patient began to resolve by the 6 days of treatment and 1 month later delivery no symptom was present and she returns to her usual daily activities.

Sonuç

Symphyseal separation is rarely seen complication in pregnant women, especially in multipars, after delivery and only conservative treatment is usually sufficient. It is generally resolved during the 8 weeks of postpartum period with appropriate conservative treatment.

Kaynaklar

1. Helmuth Vorherr: Insufficiency and Birth Injuries of Pelvic Joints. In: Sciarra JJ, Preston VD. Gynecol Obstet, 1987; 90:32-3.
2. Ronald WL, Robert EL, Douglas GW, Dario RN: Separation of the Symphysis Pubis in Assosiation with Child Bearing: A Case Report. J Bone and Joint Surg, 1988; 70: 289-292.
3. Roberts RE: Discussion. In the physiology and pathology of pelvic joints in relation to childbearing. Brooke R, Roberts RE, Bristow WR (Eds) Proc RoySoc Med, 1934; 27: 1217-1225.
4. Barnes JM: The Symphysis Pubis in Female. Am J Roentgenol,1934; 32: 333-352.
5. Boland BF: Rupture of the symphisis pubis articulation during delivery. Surg Gynecol Obstet, 1933; 57: 517-22.
6. Reis RA, Baer JL, Arens RA: Traumatic separation of the symphisis pubis during spontaneous labor. With a clinical and X-ray study of the normal symphisis pubis during pregnancy and the puerperium. Surg Gynecol Obstet, 1932; 55:336-54.
7. Thoms H: Relaxation of the symphisis pubis in pregnancy. J Am Med Assn, 1936; 66: 281-93.
8. Abramson D, Roberts SM, Wilson PD: Relaxation of the Pelvic Joints in Pregnancy. Surg Gynecol Obstet, 1934; 58: 595-613.
9. Heyman J, LundqvistA: The symphysis Pubis in Pregnancy and Parturation. Acta Obstet Gynecol Sandinavica, 1932; 12:191-226.
10. Callahan JT: Separation of the symphysis pubis. Am J Obstet Gynecol, 1953; 66: 281-93.
11. Boorstein SW: Separation of the Symphysis Pubis. With a Report of six cases. Am J Obstet Gynecol, 1927; 13: 345-51.
12. Brehm W, Weirauk HV: Separation of the symphysis pubis during labor. Am J Obstet Gynecol, 1928; 15:187-91.
13. Charles A. Rookwood, JR., David R, Green: Fractures in Adults. 2nd Ed. Philadelphia, J.B Lippincott Company, 1984; 1129-1130.
14. Elchanan JL, Ron A, Samuel D: Traumatic separation of the symphysis pubis during pregnancy : A case report. The Journal of Trauma: Injury, infection and Critical care, 1995; 38: 255-6.

	Dosya / Açıklama
	Resim 1 Symphyseal separation at the postpartum first day (1 cm)
	Resim 2 The interval of Symphysis pubis articulation one year eight months later delivery