Symphysis pubis dysfunction

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Location of pubic symphysis.

Symphysis Pubis Dysfunction (SPD) is a condition that causes excessive movement of the pubic symphysis, either anterior or lateral, as well as associated pain, possibly because of a misalignment of the pelvis. Most commonly associated with pregnancy and childbirth, it is thought to affect up to one in four pregnant women to varying degrees, with 7% of sufferers continuing to experience serious symptoms postpartum.[1][2] Although the condition was recognised by Hippocrates, incidences of SPD appear to have increased in recent years; it is unclear whether this is because the average maternal age is increasing, or because the condition is being diagnosed more frequently. SPD is associated with pelvic girdle pain and the names are often used interchangeably.

Symptoms[edit]

The main symptom is usually pain or discomfort in the pelvic region. This will probably be centred on the joint at the front of the pelvis (the pubic symphysis). Some sufferers report being able to hear the lower back and hip joints, the sacroiliac, clicking or popping in and out as they walk or change position. Sufferers frequently also experience pain in the lower back, hips, groin, lower abdomen, and legs. The severity of the pain can range from mild discomfort to extreme and prolonged suffering.[3] There have been links between SPD and depression on account of the associated physical discomfort.[4][5][6][7] Sufferers may walk with a characteristic waddling gait and have difficulty climbing stairs, problems with leg abduction and adduction, pain when carrying out weight bearing activities, difficulties carrying out everyday activities, and difficulties standing.[8]

Diagnosis[edit]

Early diagnosis is crucial in order to minimize the medium to long term severity of the condition, which can be disabling in its extreme form. Unfortunately not all healthcare practitioners are sufficiently aware of the condition.[9][10] A diagnosis is usually made from the symptoms alone, although after pregnancy, MRI scans, x-rays and ultrasound scanning are sometimes used. Women initially report the condition to a midwife, obstetrician, general practitioner, physiotherapist or an osteopath. On seeing a health professional, women should expect to receive a thorough physical examination to rule out other lumbar spine problems, such as a prolapsed disc, urinary tract infections and Braxton Hicks contractions.

Treatment and management[edit]

While there is no evidence in the medical literature to support any particular treatment, the mainstay of currently accepted treatments are the use of elbow crutches, pelvic support devices and prescribed pain relief. The vast majority of problems will resolve spontaneously after delivery.[11]

In some cases, patients may also receive advice on pelvic floor and core stability exercises. Women should also discuss their birth plan with their midwife or obstetrician, receive daily living advice from an occupational therapist and receive a referral to a pain clinic if this is deemed necessary. In very extreme cases surgery is considered after pregnancy to stabilise the pelvis, but success rates are very poor.[12]

Birth planning[edit]

It is usually recommended that women with SPD give birth in an upright position, with knees slightly apart, and it is often suggested that a woman tie a ribbon to both legs to ensure that the gap never exceeds her maximum comfort zone. Practices such as placing the feet on the midwife's hips during delivery, stirrups, and interventions such as forceps should be avoided in the delivery room if at all possible, as they can strain ligaments further and cause long term problems. If stirrups must be used, for example during suturing, great care must be taken to move the legs in symmetry, manoeuvering them gently into position.[13]

Everyday living[edit]

Typical advice usually given to women includes avoiding strenuous exercise, prolonged standing, vacuum cleaning, stretching exercises and squatting. Women are also frequently advised to:

  • Brace the pelvic floor muscles before performing any activity which might cause pain
  • Rest the pelvis
  • Sit down for tasks where possible (e.g. preparing food, ironing, dressing)
  • Avoid lifting and carrying.
  • Avoid stepping over things.
  • Avoid straddle movements especially when weight bearing.
  • Bend the knees and keep the legs 'glued together' when turning in bed and getting in and out of bed.
  • Place a pillow between the legs when in bed or resting.
  • Avoid twisting movements of the body.

If the pain is very severe, using elbow crutches will help take the weight off the pelvis and assist with mobility. Alternatively, for more extreme cases a wheelchair may be considered advisable.

Pharmacological interventions[edit]

It is not usually considered advisable to take anti-inflammatory medication in pregnancy, which makes SPD a particularly difficult condition to manage. Women are therefore typically often prescribed 30 mg or 60 mg of codeine phosphate to be taken in conjunction with 1,000 mg paracetamol, four times a day. However codeine phosphate is an opiate, and as such carries a risk of depressed respiration in the newborn baby if it is taken near the time of the birth. Therefore it is usually considered advisable to cease taking codeine phosphate 2–4 weeks before the estimated due date, as advised by a medical professional. If this is not possible, then a planned hospital birth is recommended. Other medications in common use include oral morphine.

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