Injury, Int. J.

Care Injured 46 (2015) 10741080

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Peripartum pubic symphysis separation Current strategies

in diagnosis and therapy and presentation of two cases
C. Herren a,*, R. Sobottke b, A. Dadgar c, M.J. Ringe b, M. Graf b, K. Keller d, P. Eysel d,
P. Mallmann e, J. Siewe d
a
University Clinic RWTH Aachen, Department of Trauma and Reconstructive Surgery, Pauwelsstrae 30, 52074 Aachen, Germany
b
Medical Center of the City/Region Aachen GmbH, Center for Orthopedic and Trauma Surgery, Mauerfeldchen 25, 52146 Wurselen, Germany
c
University of Oklahoma-Tulsa, Department of Orthopedics, 2424 E 21st Street Suite 320, Tulsa, 74113 OK, United States
d
University Hospital Cologne, Clinic and Polyclinic for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937 Koln, Germany
e
University Hospital Cologne, Clinic and Polyclinic for Obstetrics and Gynecology, Kerpener Str. 62, 50937 Koln, Germany

A R T I C L E I N F O A B S T R A C T

Article history: Background: During spontaneous vaginal delivery, pubic symphyseal widening is normal. Common
Received 18 October 2014 changes are reversible after complication-free birth. However, cases of peripartum symphysis separation
Received in revised form 26 January 2015 are rare. There is no consensus in the literature on how to treat pregnancy-related pubic symphysis
Accepted 28 February 2015
separation.
Methods: This review used a literature-based search (PubMed, 19002013) and analysis of 2 own case
Keywords: reports. Studies with conclusions regarding management were particularly considered.
Pubic symphyseal separation
Results: Characteristic symptoms, suprapubic pain and tenderness radiating to the posterior pelvic
Therapy
girdle or lower back, may be noted 48 h after delivery. Pain on movement, especially walking or climbing
Strategies
Pregnancy stairs, is often present. Conservative treatments, such as a pelvic brace with physiotherapy and local
Postpartum interventions such as inltration, are successful in most cases. Symptom reduction within 6 weeks is the
most common outcome, but can take up to 6 months in some cases. Surgical intervention is needed in
cases of persistent separation. Anterior plate xation is offered as a well-known and safe procedure.
Minimally invasive SI joint screw xation is required in cases of combined posterior pelvic girdle lesions.
Summary: Postpartum symphyseal rupture can be indicated with the rare occurrence of pelvic pain
post-delivery, with sciatica or lumbago and decreased mobility. The diagnosis is made on clinical
ndings, as well as radiographs of the pelvic girdle. Conservative treatment with a pelvic brace is the gold
standard in pre- and postpartum cases of symphysis dysfunction.
2015 Elsevier Ltd. All rights reserved.

Introduction short intervals, epidural anaesthesia, and previous pelvic trauma

Peripartum separation of the pubic symphysis is dened as a
traumatic disruption of the joint and ligamentous structures while
giving birth. It is a rare clinical entity caused by the irreversible
overextension of the lower birth canal during passage of the
newborn. Quoted incidence ranges from 1:300 to 1:30,000 [1]. In
the literature, pubic symphyseal separation is reported with
various synonyms: symphysis rupture, birth-associated pelvic
pain [2], postpartum pelvic instability [3], and pelvic insufciency
[4]. Large foetuses, smaller pelvic outlet, fast contractions with
* Corresponding author. Tel.: +49 241 80 35369.
E-mail address: cherren@ukaachen.de (C. Herren).
have been listed as predisposing factors [5]. In the hospital, these
patients often complain of severe pain in the region of the pubic
symphysis from the rst postpartum day with attempted
mobilisation. Rarely there is an impressive waddling gait,
because active hip exion is painful. Along with clinical examina-
tion, imaging techniques of ultrasound, conventional radiographs,
computed tomography (CT), and magnetic resonance imaging (MRI)
may be indicated. The treatments of symphyseal separation range
from conservative methods and operative therapy in cases of severe
ndings. Due to its infrequency, evidence-based decision making for
optimal treatment is lacking. The authors here will summarise the
current knowledge of pathophysiology and clinical ndings and
offer an overview of current strategies used for the diagnosis and
treatment of postpartum pubic symphyseal separation.

http://dx.doi.org/10.1016/j.injury.2015.02.030
00201383/ 2015 Elsevier Ltd. All rights reserved.
 C. Herren et al. / Injury, Int. J. Care Injured 46 (2015) 10741080 1075

Methods Table 2
Common symptoms of symphysis diastasis.

This overview is based on an extensive, selective literature Symphysis pain Pain radiating to the lower
search (PubMed, 19002013) as well as analysis of 2 of our own abdomen, back, perineum,
case reports. The following key words were used: pubic anterior/inner thigh

symphyseal separation, pelvic instability, pregnancy, post- Motion-dependent pain Impairment in activities of daily living
partum, birth-associated pelvic pain, symphysis rupture and (walking, standing, (bending forward, standing on one leg,
one foot standing standing from sitting, climbing stairs,
therapy. Articles allowing conclusions based on various available
lying in bed, etc.)
therapies were preferably selected. Title and abstract of all Pain relief with resting
identied studies were examined by one reviewer (C.H.). Then, Hearable clicking or rubbing Typical waddling gait
the entire article was obtained and assessed for suitability by three in the symphysis region
of the authors (C.H, M.J.R., P.M.). Any issue pertaining to eligibility Urinary Retention Urinary and/or stool incontinence

of studies was solved via discussion with the senior author (J.S.).

Anatomy and pathophysiology Clinical manifestation

The pelvic girdle is formed from the ilium and sacrum. The
posterior ring is formed by the posterior aspects of the ilium,
sacroiliac joints bilaterally and the sacrum. The anterior ring involves
the anterior aspects of the ilium bilaterally and the pubic symphysis.
The posterior pelvic ring, along the iliosacral joint, as well as the
anterior pelvic ring, at the pubic symphysis, is held together through
tight ligamentous connections. The symphysis itself develops from a
diarthrosis with anterior and posterior capsule, joint space, and
articular cartilage [6]. For further stabilisation there is a strong three-
part ligamentous apparatus between the two pubic bones. Pressure,
shearing, tensile, and friction forces act on the symphysis during
reclining, ambulation, standing upright on both legs, and standing on
one leg. These forces show varying forms of expression, and are
described by Kamieth and Reinhardt [7]. In the normal state, the joint
exhibits minimal mobility with rotation of 38 and a physiological
width of 26 mm in adults [8,9].
During pregnancy, and especially in the rst trimester and
during birth, the hormones progesterone and relaxin cause
loosening of the pelvic support structures to enable birth
[10,11]. There is 35 mm of widening evident radiologically.
Peripartum symphysis widening is physiologic and returns
completely to normal proportions within 5 months of a
complication-free birth through strengthening of the pelvic oor
muscles [8,12].
Aetiology
The release of relaxin does not correlate with the grade of
symphysis widening [13]. However, poor regulation of relaxin is
still considered a possible cause for a persistent postpartum
symphysis widening [14]. Metabolic, enzymatic, traumatic and
also degenerative factors have been reported as causes of
symphysis widening (see Table 1) [15,16]. Overall, faulty endocrine
regulation and concomitant laxity of the symphyseal ligamentous
apparatus appear responsible for symphyseal rupture; however,
the exact pathogenesis cannot be detected [17].
Table 1
Overview of aetiology.
The pathophysiologic correlations yield characteristic com-
plaints depending on the loading forces acting on the symphysis.
Most patients complain of typical symptoms within 48 h
postpartum. However, the complete clinical picture is generally
formed later, once patients are returning for ambulatory postpar-
tum care. Manifestation of the complaints can also occur up to
6 months after birth [18,19]. Patients often complain of pain
radiating to the iliosacral region and in the anterior thigh.
Particular complains occur in the transition from lying to standing.
Standing on one leg is possible only with pain or not at all
[2,4,16,18,19]. The most common symptoms are summarised in
Table 2.
Depending on the width of the separation, there can be a
palpable gap and tenderness over the mons pubis, along with
possible redness or swelling upon examination. With pronounced
ndings, tenderness of the iliosacral joints on one or both sides
may be present as well as a positive Trendelenburg sign, or
unilateral/bilateral Lasegue sign; Patricks Fabere sign is often
positive [20]. Table 3 compares the specicity and sensitivity of
typical clinical investigations [18].
For further diagnostic ndings, the following questions are also
useful [19]:
- One or more positive answers:
o Do you have difculty turning in bed?
o Do you have difculty ascending/descending stairs?
o Is it difcult to complete a full stride length?
o Is it difcult to stand up from a low chair?
- Two or more positive answers:
o Do you have pelvic pain when carrying light loads?
o Do you have pain when turning in bed?
o Do you have pain on standing from a chair or climbing stairs?
According to Wellock et al. and Fry et al., the diagnosis of symphyseal
dehiscence can be made when [19,21]:
- there is a history of pelvic pain after a vaginal birth,
- other differential diagnoses are excluded,
- the clinical signs are clear.

Pelvic stability
Enzymatic causes
Endocrine causes
Metabolic causes
Traumatic causes
Inammatory processes Sacroiliitis, pubic symphysitis
Degenerative causes
Other causes
Congenital asymmetry, hyperlordosis, Differential diagnosis must exclude deep lumbar back pain with
pathologic spino-pelvic parameters or without radiation to the lower extremity (lumbago or sciatica).
Faulty regulation of collagen synthesis
Increased release of relaxin, oestrogen,
progesterone Table 3
Disturbances in calcium/vitamin D regulation Evidence of typical clinical tests.
Previous pelvic trauma
Clinical evaluation method Specicity Sensitivity
Arthritic changes Point tenderness 99% 60%
Increased birth weight, maternal age, Trendelenburg sign 99% 60%
multiparosity, previously difcult Patricks Fabere test 99% 40%
transvaginal birth
Postpartum pelvic pain.
1076 C. Herren et al. / Injury, Int. J. Care Injured 46 (2015) 10741080
Infections of the female urogenital tract can also present similar
symptoms. Deep pelvic/leg vein thrombosis, malignant osteolysis,
and osteomyelitis are also rare but possible differential diagnoses
[2224].
Diagnostic imaging
The diagnostic imaging of choice for initial ndings is conven-
tional radiographs of the pelvis: Inlet, Outlet, and AP views. Here,
symphyseal width is easy to determine. Accompanying pathology of
the posterior ring may also be assessed on these views [25].
Because of the anatomic conditions of the area, ultrasound of
the symphysis is also ideally suited to make the diagnosis. The
combination of thin soft tissue coverage and minimal distance
from the transducer to the bone leads to very good picture quality
[26]. Two Swedish studies have indicated that ultrasound offers a
safe, simple, and cost-efcient method for evidence of symphyseal
widening [13,27]. In addition, ultrasound offers a radiation-free
option for meaningful control studies over follow-up [28].
Specic issues can be claried with computer tomography (CT)
and/or magnetic resonance imaging (MRI). Furthermore, the use of
MRI or CT produces detailed information about the symphyseal
region as well as involvement of the SI joints. However, MRI is
superior in demonstrating soft-tissue injuries (esp. ligamentous
complex of the SI joints and symphysis pubis) and osteous oedema
of the subchondral bone. During pregnancy, MRI is the modality of
choice because of its lack of radiation.
Therapeutic options
The recognition and treatment of peripartum symphyseal
rupture or symptomatic postpartum symphyseal dehiscence
requires a rapid and consistent therapeutic approach [29]. Because
of the low incidence, there are no prospective or randomised studies
available to answer the question of the optimal type of therapy.
Non-operative treatment is the initial therapy of choice. One
cornerstone is circular compression of the pelvis with a symphysis
belt brace [see Fig. 1]. This is accompanied by bed rest in a special
lateral decubitus position and progressing with moderate physio-
therapy (and pelvic oor strengthening exercises) [24]. One other
important point is appropriate analgesia [30]. The use of
acetaminophen or brief administration of NSAIDs is safe during
lactation [31]. In addition, intermittent local ice pack application is
effective. Mobilisation with crutches in a 4-point gait or use of a
walker can offer additional benets.
Local inltration therapy with hydrocortisone and ropivacain
has also been used with success [15]. Generally, marked
improvement of symptoms should occur within 6 weeks. However,
it can take up to 6 months for patients treated conservatively to be
completely symptom-free [32].
Should conservative treatment fail, the indications for operative
therapy can be discussed [17,18,24]. Indications are persistent pain,
inadequate reduction of symphyseal widening, and renewed
diastasis after removal of the pelvic brace [33]. Anterior plate
xation is the operative treatment of choice [34,35]. Because of the
risk of pin infections and the associated loosening, external xators
are seldom used as a primary procedure [36]. Acute injuries from
birth associated trauma, symphyseal rupture and lesions of the
urogenital tract are indications for immediate operative therapy
[37]. For patients with posterior pelvic pain, there is an additional
indication for minimally invasive sacroiliac screw insertion [23,38].
After successful operative stabilisation, rapid mobilisation and
partial loading are possible. In cases of another pregnancy,
caesarian section might be necessary, although complication-free
vaginal deliveries after plate xation of the anterior/posterior
pelvic rings have also been reported [39].
Therapeutic options during pregnancy
During pregnancy, generally the same therapeutic options are
present as postpartum. These include supportive pelvic/symphy-
seal belt, analgesics (acetaminophen), and physiotherapy
[40]. Physiotherapy should include isometric and non-isometric
exercises and not lead to unilateral loading of the pelvis. The goal of
therapy should be strengthening of the deep trunk and pelvic
musculature.
In cases of severe mobility limitations, underarm crutches,
walker, or wheelchair can be used [25]. Ice pack application,
protection, acupuncture, and massage are not evidence-based
measures, but can also result in symptom reduction
[41,42]. Operative therapy, as already discussed, is not standard
therapy. The existing symphysis rupture is not a hard indication for
caesarian section; however, C-section can be indicated in
individual cases and according to the judgement of the treating
obstetrician. No clear conclusions have been presented in the
literature; however, our opinion is that with symphysis diastasis
>15 mm with accompanying changes of the posterior pelvic ring
or with the occurrence of a cephalopelvic discrepancy [43], there is
an indication for caesarian birth to prevent consequential pelvic
injuries and complications from the birth process.
In very rare cases, in patients with extreme symphyseal
widening, operative therapy with either symphysis suture or
symphysis wedge osteotomy has been reported [16].
Case 1
A 37-year-old patient (gravida 1, para 0) with a complication-
free pregnancy presented to our clinic 2 days postpartum from a
vacuum-extraction birth. She complained of severe pain in the
pubic region, since post-partem day one. Ambulation and stair
climbing was possible only with great difculty. In addition,
standing from the bed or chair was extremely painful. She
showed a left sided antalgic gait. Physical examination revealed
redness, palpable swelling and tenderness over the mons pubis.
The patients active hip motion was also limited bilaterally due to
pain (extension/exion: 5/0/958). Diagnostic imaging showed a
symphysis widening of 14.5 mm (Fig. 2). This nding was
conrmed on ultrasound and documented. With the entire
clinical picture in mind, conservative therapy was selected and a
symphysis belt brace tted. In addition, a prescription for
accompanying physiotherapy to strengthen the pelvic oor
muscles was issued.
The patient presented again 4 weeks later for a scheduled
clinical/radiologic follow up appointment. The symphysis belt had
been consistently worn, and the physiotherapy completed. She
reported marked reduction in complaints; however, there was
continued pain anteriorly along the symphysis, particularly with
sitting on her coccyx and with reclining on her side. Clinically, the
patient showed an unremarkable gait with the symphysis belt that
no longer t appropriately. On examination, the pelvis was stable
with mild tenderness over the symphysis and both anterior
superior iliac spines. Radiology and sonography showed reduction
of the symphysis gap from 14.5 to 7.5 mm (Fig. 3). The pelvic belt
was re-tted and the patient was recommended to continue
physiotherapy.
Further ambulatory therapy was carried out by the established
Obstetrician/Gynaecologists. Sonography of the symphysis gap
showed further reduction. At the 4 month follow up visit, the
patient was almost completely free of complaints. Only long
walking distances caused her continued problems. On clinical
examination, there was no symphyseal tenderness to palpation,
and both iliosacral joints were unremarkable. The patient was
encouraged to keep the pelvic belt in place until completely
symptom free, and to continue exercises to strengthen her pelvic
 C. Herren et al. / Injury, Int. J. Care Injured 46 (2015) 10741080 1077

Fig. 1. Example of a symphysis/pelvic belt brace.

oor musculature. The patient remained neurovascularly intact pelvic oor musculature strengthening programme at 3 months,
throughout the follow up period. she was symptom-free.

Case 2
A 26-year-old patient (gravida 1, para 0) with a complication-
free pregnancy presented to our clinic 6 days postpartum. She
complained of increasing pain in the symphyseal region since the
day after birth. In addition, climbing stairs caused her difculty
along with a palpable swelling over the symphysis without a
detectable defect on clinical examination and limited active hip
motion bilaterally due to pain (extension/exion: 5/0/958).
Because the patient refused radiologic tests, to exclude involve-
ment of the posterior ring, an MRI scan was performed. A
symphysis separation of 11 mm was evident (Figs. 4 and 5).
This nding was conrmed on ultrasound and documented.
Conservative therapy was selected, and a symphysis belt was
tted. The patient continued ambulatory follow up with her
established physician and after her course of physiotherapy and
Discussion
Based on the literature review, as well as own clinical
experience (see Cases 1 and 2), we recommend a treatment
algorithm as shown in Table 4. Treatment of postpartum
symphyseal rupture has traditionally been non-operative, but
there is a need for close follow-up to be certain of the effectiveness
of the conservative therapy [25,40,44].
Operative therapy is indicated if complaints continue. The most
common treatment is anterior xation [34,35]. Hagen et al.
reported on a cohort of 23 patients with symphyseal separation
after childbirth (19 patients had a widening less than 5 mm):
15 patients were treated conservatively; eight of them underwent
surgery: two with anterior plating of the symphysis, four with
sacroiliac arthrodesis and two with a combination of both
1078 C. Herren et al. / Injury, Int. J. Care Injured 46 (2015) 10741080
Fig. 2. Conventional radiograph (pelvis) with symphysis widening of 14.5 mm
Fig. 3. Conventional radiograph (pelvis) with symphysis widening of 7.5 mm
procedures. He recommended an operative therapy in cases with
pubic separation of more than 10 mm in combination with
widening of the sacroiliac joints [18]. Hierholzer et al. suggested
an operative stabilisation in patients with symphysis separation of
more than 25 mm [39]. Furthermore operative treatment is
suggested in cases of posterior pelvic injuries as well [24,38].
In contrast, Jain and Sternberg presented a case of a 35-year-old
woman (gravida 1, para 0) with a symphyseal separation of 95 mm
combined with a 5 mm sacroiliac widening two days after vaginal
delivery. The patient was treated conservatively with a pelvic
binder, walker and physical therapy. After a period of 6 months, the
patient had a slow improvement, leaving a symphyseal widening
of 55 mm [45]. Parker and Bhattacharjee presented a case report of
Fig. 4. MRI pelvis: cut over the symphysis region.
Fig. 5. MRI pelvis: coronal cut over the symphysis region with 10 mm dehiscence.
21-years-old primigravida after vaginal delivery. Pelvic radiology
showed a pubic symphyseal diastasis of 23 mm. The conservative
treatment included bed rest and gradual mobilisation. They
suggested surgery in cases of a separation more than 25 mm
required [46]. In cases of continuing pregnancy, therapy is similar.
Jain et al. showed that an indication for C-section with symphyseal
widening causing a change to the birth canal, or when hip
abduction is severely restricted [17].
In view of the existing literature, we conclude that the amount
of symphysis separation does not correlate with the presence of
symptoms. In cases where ambulation and appropriate analgesia is
possible, pain reduction occurs through physiotherapy and a
correctly tted pelvic belt. Thus, conservative therapy is still the
 C. Herren et al. / Injury, Int. J. Care Injured 46 (2015) 10741080 1079

Table 4
Treatment algorithm for symphysis separation symphysis separation.

Postpartum pelvic pain

Clinical investigation

Pain on movement Symphysis tenderness Painful position

changes

Diagnostic imaging

Symphysis ultrasound Pelvic Radiograph

(radiation-free starting (starting evaluation)
evaluation)

Posterior ring involvement?

CT / MRI
Concomitant injury?
follow-up
Radiation-

Persistent pain 4-6 Combined

Months anterior/posterior pelvic
ring injuries

Conservative Operative
therapy therapy
Symphysis separation <10mm Symphysis separation >10mm

analgesia physiotherapy Pelvic belt Anterior plate Anterior /

ixation posterior
ixation

Clinical follow-up

at 4, 8, and 12 weeks

Clinical follow- ultrasound

up

Continued conservative
management until symptom-free

gold standard and a sufcient option for a recovery within 6 weeks. diastasis. The diagnosis is made on clinical ndings as well as
Because of limited clinical occurrence, no prospective, randomised radiographs of the pelvic girdle. Conservative treatment with a pelvic
clinical studies comparing conservative and operative therapy are brace is the gold standard in pre- and postpartum cases of symphysis
available. dysfunction.

Conclusion
Conict of interest
Pelvic pain post-delivery and radiating pain with decreased
mobility, can indicate the rare occurrence of postpartum symphyseal The authors declare that there is no conict of interest.
1080 C. Herren et al. / Injury, Int. J. Care Injured 46 (2015) 10741080
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