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Management of puerperal separation of the symphysis pubis
Int. J. Gynaecol. Obstet.. 1985, 23: 125-128 International Federation of Gynaecology & Obstetrics
125
MANAGEMENT OF PUERPERAL SEPARATION OF THE SYMPHYSIS PUBIS
Z. SCHWARTZ, Z. KATZ and M. LANCET Department of Obstetricsand Gynecology, Kaplan Hospital, Rehovot (Israel)* (Received September 24th, 1984) (Accepted December 14th, 1984)
Abstract
Introduction
Schwartz 2, Katz Z, Lancet M (Department of Obstetrics and Gynecology, Kaplan Hospital, Rehovot, Israel). Management of puerperal separation of the symphysis pubis. Int J Gynaecol Obstet 23: 125-128, 198.5 Thirteen post-partum patients with symphysiolysis were treated by intra-symphysial injection of a combination of hydrocortisone, chymo trypsin and lidocain. The injection was given once a day and the full treatment consisted of between three to seven injections according to the severity of the symptoms. No other medication was given. Immediate relief was obtained in all cases after the first injection and all symptoms disappeared after the completion of treatment. The average time of hospitalization was 9.8 days. No complications were seen as a result of the treatment and the patients resumed their normal activities after being discharged from hospital. In comparison with other modes of treatment, the intra-symphysial injection of the above drug combination shortened the time of morbidity and effected complete recovery.
Separation of the symphysis pubis may occur before or during delivery as a result of spontaneous rupture of the pubic ligaments. The reported incidence ranges from 1 per 521 deliveries to 1: 5000 [ 1,4,7]. This accident carries with it a high morbidity, necessitating bed-rest for 6-8 weeks and may trouble the patient for several months more. Until recently, the goal of the treatment was reapproximation and immobilization of the separated symphysis. Different methods of treatment have been reported and the most common method of early treatment is the use of strong complete circular bandage around the patient’s hips and this has to be worn for several weeks. Early postpartum mobilization is important, and this can be achieved only by reducing the pain and the inability of the patient to flex her hips.
Keywords: Symphysis pubis; Symphysiolysis; Delivery.
*Affiliated to the Medical School of the Hebrew University and Hadassah, Jerusalem. 0020-7292j85fSO3.30 0 1985 International Federation ofGynaecolopy Published and Printed in Ireland
Patients and methods During 5 years, 13 patients with postpartum symphysiolysis of pregnancy were treated at the Kaplan Hospital, giving an incidence of 1: 22 18 deliveries. The mean age was 29.3 and the mean parity 2.5 (Table I). Delivery from the time of admission lasted for a mean of 5.2 h and the mean weight of the infants was 3584 g. and all patients were at term. There were no complications during labor. All the infants were delivered spontaneously. In this study true Int J Gynaecol Obstet 23
&Obstetrics
126
Schwarh
et al.
Table I.
Clinical data of 13 cases of postpartum symphysiolysis.
No.
Me
Parity
Weeks at delivery
Duration of labor (h)
Infant wt.
No. of injections
Days of hospitalization
1 2 3 4
35 21 31 26 29 21 25 30 30 32 34 27 34
4 2 3 4 1 1 2 2 2 3 2 4 4
41 37 39 40 42 42 40 40 38 42 39 37 39
2 1 10 10 4 12 2 2 5 4 3 9 4
3550 3650 3760 so00 3380 4140 3250 4130 3150 2670 3050 3060 3800
7 7 5 3 3 4 4 5 4 5 3 6 5
11 12 10
5 6 7 a 9 10 11 12 13
separation was diagnosed according to clinical symptoms. These were: severe pain in the symphysial region, with inability to turn in the bed, to stand or to walk. In some lighter cases the patient could walk with a ‘waddling gait’. On physical examination the patients had tenderness over the symphysis, a gap which was sometimes palpable between the rami and eversion of the lower extermities with external rotation of the acetabula. Pathognomonic signs were severe pain at the symphysis upon pressure from both greater trochanters towards the midline, and inability to flex the hips with extended legs. Symptoms of symphysiolysis were seen between 24 to 48 h after delivery and separation of the symphysis was confirmed by X-ray in nine patients (between 0.9 cm to 5 cm). The width of the separation did not correlate with the severity of the symptoms. When the diagnosis was established, a course of intra-articular injections was started. The patient was placed in a supine position with the legs adducted, the mons pubis was shaved and disinfected. The solution consisted of 50 mg hydrocortisone and 5000 n.f. units of chymotrypsin diluted in 5 cc lidocain 1%. This was injected into the symphysis itself, in a depth of about Int I Gynaecol Obstet 23
a a 11 9 9 10 9 a 10 10
2 cm. Special care was taken to insert the needle perpendicularly. The treatment was done once a day, and continued until the patient was symptom-free. The women were reexamined between 6 to 12 months after delivery.
Results After the first injection, all patients had a great decrease in pain and after the second one the patients were usually able to stand and walk slowly. After the third or fourth injection the patients could walk freely without help. Some women needed more injections because of persistent pain (see Table I). The patients were followed for several days after the last shot. No analgesics were used. The total average time of hospitalization was 9.6 days (range 8-12 days). No side effects or complications attributable to the injected material were noted. None of the patients needed a binder to support the pelvis and they were symptom-free on release. When examined 6-12 months after delivery, no signs or symptoms were detected. Seven of the 13 women delivered again after this episode and symphysiolysis did not recur.
Management of puetperai symphysiolyis
Discussion In this series the diagnosis was based mainly on the clinical symptoms. In some cases the changes in the symphysis can be established by X-ray, but this examination is probably the least important aid in diagnosis. It may reveal anything from mild to marked separation and others have also not found any correlation between the findings in X-ray and the severity of symptoms [4,5,71. The precise reason for the separation is not obvious. It may be assumed that except for the possible trauma during rapid labor, there may be some previous pathological condition in the symphysis itself which occurs during pregnancy, since in some cases symphysiolysis appears before delivery, in the third trimester of pregnancy. No antepartum cases were seen in the series reported here. Probably hyaluronidase and the hormone relaxin cause the pathological changes which appear in the symphysis during symphysiolysis [ 5,101. In most centers the treatment is conservative and consists of bed-rest and analgesics 121. In severe cases surgical intervention was carried out by bone grafts and crossed wires [4]. In spite usually of such therapy, the morbidity continued for weeks or months, and recovery was slow and not always complete. Maltz and Strauss [5] described 17 cases in 1963 in which one or two injections of lidocain and hydrocortisone were injected into the symphysial space. Results were considered excellent in nine cases, good in five cases and satisfactory in three. No follow-up was given. In 1968 Wist [ IO] reported a total of 29 patients treated by one injection of hydrocortisone mixed with procain solution, and two injections were given only in one case. The women were discharged within 5-l 2 days of hospitalization and returned to normal activities at home, but not all of them were symptom free. In this series, all the patients were released from hospital
127
after 8-l 2 days, completely free of symptoms and were able to resume their normal activities. In the method described here, the intrasymphysial injection consisted of a combination of three medications hydrocortisone, which prevents or suppresses the development of swelling and tenderness and the early phenomena of inflammation like edema, fibrin deposition, capillary dilatation and migration of leukocytes. It is used widely in orthopedics for diseases of the joints. Another property of hydrocortisone is its ability to decrease the effect of hyaluronidase and regulate the dynamic equilibrium between hyaluronic acid and hyaluronidase [ 5,lO I. Chymotrypsin was used for the prevention and resolution of the inflammatory edema and to relieve local congestion following a traumatic insult. Lidocain reduced the pain in the symphysis immediately. To summarize, puerperal separation of the symphysis pubis is often associated with pain, disability and discomfort, necessitating injecprolonged bed-rest. Intra-symphysial tions proved to be very efficient, simple to perform and with no complications. They shortened the time of morbidity and hospitalization. This method of treatment is therefore recommended in all cases of symphysiolysis. References 1 Boland BF: Rupture of the symphysis pubis articulation during delivery. Surg Gynecol Obstet 57: 517, 1933. 2 Callahan JT: Separation of the symphysis pubis. Am J Obstet Cynecolb6: 281,1953. _ _ _ Heyman J, Lundqvist A: The symphysis pubis in pregnancy and parturition. Acta Obstet Gynaceol Stand 12: 191,1932. Kane R, Erez S, O’Leary JA: Symptomatic symphyseal separation in pregnancy. Surg Gynecol Obstet 124: 1032, 1967. MaJtz S, Strauss H: The treatment of symphysiolysis in the early puerperium. J Int CoJl Surg 40:2.59. 1963. Martindale: The Extra Pharmacopoeia, 28th edn. (ed JEF Reynolds), p. 648. The Pharmaceutical Press, London, 1982.
Int J Gynaecol Obstet 23
12 8
Sch wurfz et al.
7 Reis RA. Baer JL, Arens RA: Traumatic separation of the symphysis pubis during spontaneous labor. Surg Gynecol Obstet 55: 336.1932. 8 Sherman E, ElJison RS: Subjective evaluation of an enzyme preparation in episiotomy pain. Am J Obstet Gynecol82: 863,196l.
Int J Gynaecol Obstet 23
9 Soule SD, Wasserman HC, Burstein R: Oral proteolytic enzyme therapy (chymozym) in episiotomy patients. Am J Obstet Gynecol95: 820.1966. 10 Wist A: Treatment of symphysiolysis with hydrocortisone procaine injections. Ann Chir Cynecol Fenn 57: 98, 1968.
125
MANAGEMENT OF PUERPERAL SEPARATION OF THE SYMPHYSIS PUBIS
Z. SCHWARTZ, Z. KATZ and M. LANCET Department of Obstetricsand Gynecology, Kaplan Hospital, Rehovot (Israel)* (Received September 24th, 1984) (Accepted December 14th, 1984)
Abstract
Introduction
Schwartz 2, Katz Z, Lancet M (Department of Obstetrics and Gynecology, Kaplan Hospital, Rehovot, Israel). Management of puerperal separation of the symphysis pubis. Int J Gynaecol Obstet 23: 125-128, 198.5 Thirteen post-partum patients with symphysiolysis were treated by intra-symphysial injection of a combination of hydrocortisone, chymo trypsin and lidocain. The injection was given once a day and the full treatment consisted of between three to seven injections according to the severity of the symptoms. No other medication was given. Immediate relief was obtained in all cases after the first injection and all symptoms disappeared after the completion of treatment. The average time of hospitalization was 9.8 days. No complications were seen as a result of the treatment and the patients resumed their normal activities after being discharged from hospital. In comparison with other modes of treatment, the intra-symphysial injection of the above drug combination shortened the time of morbidity and effected complete recovery.
Separation of the symphysis pubis may occur before or during delivery as a result of spontaneous rupture of the pubic ligaments. The reported incidence ranges from 1 per 521 deliveries to 1: 5000 [ 1,4,7]. This accident carries with it a high morbidity, necessitating bed-rest for 6-8 weeks and may trouble the patient for several months more. Until recently, the goal of the treatment was reapproximation and immobilization of the separated symphysis. Different methods of treatment have been reported and the most common method of early treatment is the use of strong complete circular bandage around the patient’s hips and this has to be worn for several weeks. Early postpartum mobilization is important, and this can be achieved only by reducing the pain and the inability of the patient to flex her hips.
Keywords: Symphysis pubis; Symphysiolysis; Delivery.
*Affiliated to the Medical School of the Hebrew University and Hadassah, Jerusalem. 0020-7292j85fSO3.30 0 1985 International Federation ofGynaecolopy Published and Printed in Ireland
Patients and methods During 5 years, 13 patients with postpartum symphysiolysis of pregnancy were treated at the Kaplan Hospital, giving an incidence of 1: 22 18 deliveries. The mean age was 29.3 and the mean parity 2.5 (Table I). Delivery from the time of admission lasted for a mean of 5.2 h and the mean weight of the infants was 3584 g. and all patients were at term. There were no complications during labor. All the infants were delivered spontaneously. In this study true Int J Gynaecol Obstet 23
&Obstetrics
126
Schwarh
et al.
Table I.
Clinical data of 13 cases of postpartum symphysiolysis.
No.
Me
Parity
Weeks at delivery
Duration of labor (h)
Infant wt.
No. of injections
Days of hospitalization
1 2 3 4
35 21 31 26 29 21 25 30 30 32 34 27 34
4 2 3 4 1 1 2 2 2 3 2 4 4
41 37 39 40 42 42 40 40 38 42 39 37 39
2 1 10 10 4 12 2 2 5 4 3 9 4
3550 3650 3760 so00 3380 4140 3250 4130 3150 2670 3050 3060 3800
7 7 5 3 3 4 4 5 4 5 3 6 5
11 12 10
5 6 7 a 9 10 11 12 13
separation was diagnosed according to clinical symptoms. These were: severe pain in the symphysial region, with inability to turn in the bed, to stand or to walk. In some lighter cases the patient could walk with a ‘waddling gait’. On physical examination the patients had tenderness over the symphysis, a gap which was sometimes palpable between the rami and eversion of the lower extermities with external rotation of the acetabula. Pathognomonic signs were severe pain at the symphysis upon pressure from both greater trochanters towards the midline, and inability to flex the hips with extended legs. Symptoms of symphysiolysis were seen between 24 to 48 h after delivery and separation of the symphysis was confirmed by X-ray in nine patients (between 0.9 cm to 5 cm). The width of the separation did not correlate with the severity of the symptoms. When the diagnosis was established, a course of intra-articular injections was started. The patient was placed in a supine position with the legs adducted, the mons pubis was shaved and disinfected. The solution consisted of 50 mg hydrocortisone and 5000 n.f. units of chymotrypsin diluted in 5 cc lidocain 1%. This was injected into the symphysis itself, in a depth of about Int I Gynaecol Obstet 23
a a 11 9 9 10 9 a 10 10
2 cm. Special care was taken to insert the needle perpendicularly. The treatment was done once a day, and continued until the patient was symptom-free. The women were reexamined between 6 to 12 months after delivery.
Results After the first injection, all patients had a great decrease in pain and after the second one the patients were usually able to stand and walk slowly. After the third or fourth injection the patients could walk freely without help. Some women needed more injections because of persistent pain (see Table I). The patients were followed for several days after the last shot. No analgesics were used. The total average time of hospitalization was 9.6 days (range 8-12 days). No side effects or complications attributable to the injected material were noted. None of the patients needed a binder to support the pelvis and they were symptom-free on release. When examined 6-12 months after delivery, no signs or symptoms were detected. Seven of the 13 women delivered again after this episode and symphysiolysis did not recur.
Management of puetperai symphysiolyis
Discussion In this series the diagnosis was based mainly on the clinical symptoms. In some cases the changes in the symphysis can be established by X-ray, but this examination is probably the least important aid in diagnosis. It may reveal anything from mild to marked separation and others have also not found any correlation between the findings in X-ray and the severity of symptoms [4,5,71. The precise reason for the separation is not obvious. It may be assumed that except for the possible trauma during rapid labor, there may be some previous pathological condition in the symphysis itself which occurs during pregnancy, since in some cases symphysiolysis appears before delivery, in the third trimester of pregnancy. No antepartum cases were seen in the series reported here. Probably hyaluronidase and the hormone relaxin cause the pathological changes which appear in the symphysis during symphysiolysis [ 5,101. In most centers the treatment is conservative and consists of bed-rest and analgesics 121. In severe cases surgical intervention was carried out by bone grafts and crossed wires [4]. In spite usually of such therapy, the morbidity continued for weeks or months, and recovery was slow and not always complete. Maltz and Strauss [5] described 17 cases in 1963 in which one or two injections of lidocain and hydrocortisone were injected into the symphysial space. Results were considered excellent in nine cases, good in five cases and satisfactory in three. No follow-up was given. In 1968 Wist [ IO] reported a total of 29 patients treated by one injection of hydrocortisone mixed with procain solution, and two injections were given only in one case. The women were discharged within 5-l 2 days of hospitalization and returned to normal activities at home, but not all of them were symptom free. In this series, all the patients were released from hospital
127
after 8-l 2 days, completely free of symptoms and were able to resume their normal activities. In the method described here, the intrasymphysial injection consisted of a combination of three medications hydrocortisone, which prevents or suppresses the development of swelling and tenderness and the early phenomena of inflammation like edema, fibrin deposition, capillary dilatation and migration of leukocytes. It is used widely in orthopedics for diseases of the joints. Another property of hydrocortisone is its ability to decrease the effect of hyaluronidase and regulate the dynamic equilibrium between hyaluronic acid and hyaluronidase [ 5,lO I. Chymotrypsin was used for the prevention and resolution of the inflammatory edema and to relieve local congestion following a traumatic insult. Lidocain reduced the pain in the symphysis immediately. To summarize, puerperal separation of the symphysis pubis is often associated with pain, disability and discomfort, necessitating injecprolonged bed-rest. Intra-symphysial tions proved to be very efficient, simple to perform and with no complications. They shortened the time of morbidity and hospitalization. This method of treatment is therefore recommended in all cases of symphysiolysis. References 1 Boland BF: Rupture of the symphysis pubis articulation during delivery. Surg Gynecol Obstet 57: 517, 1933. 2 Callahan JT: Separation of the symphysis pubis. Am J Obstet Cynecolb6: 281,1953. _ _ _ Heyman J, Lundqvist A: The symphysis pubis in pregnancy and parturition. Acta Obstet Gynaceol Stand 12: 191,1932. Kane R, Erez S, O’Leary JA: Symptomatic symphyseal separation in pregnancy. Surg Gynecol Obstet 124: 1032, 1967. MaJtz S, Strauss H: The treatment of symphysiolysis in the early puerperium. J Int CoJl Surg 40:2.59. 1963. Martindale: The Extra Pharmacopoeia, 28th edn. (ed JEF Reynolds), p. 648. The Pharmaceutical Press, London, 1982.
Int J Gynaecol Obstet 23
12 8
Sch wurfz et al.
7 Reis RA. Baer JL, Arens RA: Traumatic separation of the symphysis pubis during spontaneous labor. Surg Gynecol Obstet 55: 336.1932. 8 Sherman E, ElJison RS: Subjective evaluation of an enzyme preparation in episiotomy pain. Am J Obstet Gynecol82: 863,196l.
Int J Gynaecol Obstet 23
9 Soule SD, Wasserman HC, Burstein R: Oral proteolytic enzyme therapy (chymozym) in episiotomy patients. Am J Obstet Gynecol95: 820.1966. 10 Wist A: Treatment of symphysiolysis with hydrocortisone procaine injections. Ann Chir Cynecol Fenn 57: 98, 1968.