PELVIC PAIN AND PREGNANCY

Symphysitis is a manifestation of instability of the cartilaginous connection of the bones of the pubis (symphysis) as a result of hormonal changes in the body. Most often, symphysitis appears during pregnancy under the influence of hormones that prepare the woman’s body for childbirth. The mobility of the joint leads to pain in the pelvic area, which occurs even during any movement. There are many ways to help reduce the intensity of pain. In most cases, after childbirth, symphysitis goes away on its own.

As a result, symphysitis appears

A woman's body undergoes many changes during pregnancy. One of them is changes in hormonal levels. Hormones are produced that are responsible for the preservation of pregnancy and the safe bearing of the baby. The hormone relaxin helps soften ligaments. Thanks to this, the pubic symphysis becomes mobile, and the internal size of the small pelvis increases by several millimeters. This facilitates the easiest passage of the fetus through the birth canal. In most cases, symphysitis appears in the third trimester of pregnancy, in rare cases - much earlier, around 22-24 weeks of pregnancy.

When the first symptoms of symphysitis appear, you should consult a doctor monitoring your pregnancy. This is necessary in order to exclude diseases that are dangerous for the mother and child - urinary tract infections or inflammation of the pelvic organs.

Pain treatment

If the sacrum hurts severely during pregnancy, the problem is not necessarily pathological; it is often physiological in nature. But if the doctor determines that not all processes in the expectant mother’s body are proceeding properly, appropriate treatment methods will be used. Sometimes, for greater safety, a pregnant woman is placed in storage, where she will be under the constant supervision of doctors, and the risks of deterioration in health and termination of pregnancy are significantly reduced. Separately, we will say that if you are overtaken by pain in the sacrum, do not try to self-medicate, but immediately consult a doctor, since taking many medications during pregnancy is prohibited, and you, unknowingly, can harm the health of the child.

Aggravating factors

In addition to hormone production, there are several factors that provoke sprains of the pubic ligaments:

disturbance of calcium-phosphorus metabolism;
lack of vitamin D;
increase in body mass index
history of three or more pregnancies;
injuries to the pelvic bones, even old ones;
hereditary diseases of the musculoskeletal system;
high fetal weight (the expected weight of the child at the time of birth is 4 kg or more);
insufficient amount of physical activity of the mother.

If the pain is severe

If the expectant mother has severe pain in her pelvic bones during pregnancy, we may also be talking about symphysitis. This is a discrepancy of the symphysis pubis, which arose against the background of its increased mobility. In this case, the pain is severe and constant, it increases while walking, changing body position and other physical activity.

The exact causes of symphysitis are unknown, but doctors associate this disease with an excess of relaxin and a lack of calcium in the body. Treatment is based on anti-inflammatory and painkillers, taking multivitamins, wearing a bandage and performing exercises for pregnant women. Childbirth is most often carried out surgically. Read more about how to choose and wear a bandage during pregnancy →

How to recognize symphysitis

The main clinical manifestations of symphysitis during pregnancy are:

sharp shooting pains in the pelvic area;
aching pain in the lumbar region, radiating to the abdominal cavity and inner thigh;
the occurrence of acute pain when raising a leg, transferring weight from one leg to another, or spreading the legs;
the occurrence of pain with the slightest physical activity, even when walking;
a pronounced click when performing sudden movements in the pubic area;
pain in the pubic symphysis during sexual intercourse;
severe fatigue and fatigue.

The level of pain with symphysitis during pregnancy can vary from mild, almost unnoticeable, to very severe. The pain becomes significantly stronger at the following moments:

when lifting objects;
during physical activity in which the hips are actively involved;
while maintaining a static body position for a long time without changing posture.

Many women complain of pelvic pain sooner or later after childbirth. Based on 4 case histories of this syndrome, known as symphysiolysis is discussed. It consists of 3 entities, symphysiolysis, rupture of the symphysis and pelvic or symphysis pain. Symphysiolysis is characterized by a gap between the two pubic bones and instability. the treatment is rest, banding of the pelvis and physiotherapy. Acute rupture of the symphysis is extremely painful and should be treated with bed rest and banding. Pelvic pain is characterized by tenderness of the symphysis and over the sacroiliac joints.. The complaints usually recur after a next pregnancy. In a small group of patients serious complaints persist. Operative treatment ic symphysectomy symphysiodesis, eventually combined with arthrodesis if the sacroiliac joints should be considered in these cases.. Good results can be expected in 60-70% of patients, hence the procedure should be performed with reserve. Martini Hospital, PO Box 30033, 9700 RM Groningen, Netherlands. Dep. Gynaecology and Obstetrics: Ms MJA Engelen, assistant physician, internal medicine; Dr WFA Mensink, gynecologist. Dep. Orthopedics: Dr. RL Diercks, surgeon. Correspondence address: Ms MJA Engelen. M

Many pregnant and postpartum women, as well as a certain number of women for whom several years may have passed since their last pregnancy, complain of pelvic pain.
We would like to discuss this complaint in detail, starting with four case studies. Patient A., 27 years old, first pregnancy, consulted a gynecologist with amenorrhea lasting 25 weeks due to complaints of pain in the lower abdomen, which intensified over time.
Complaints appeared at about 12 weeks of pregnancy. A. reported that the pain in the lower abdomen was most severe in the middle and from there spread to the groin; along with this, pain in the lower back was sometimes also noted. The pain was provoked by physical stress and disappeared if the patient rested quietly for some time. A. has not worked for the past 4 weeks; she previously performed a sedentary job as an administrative employee, but was able to sit at a desk for less and less time without experiencing pain. The examination revealed a relaxed uterus, the fundus height of which corresponded to the duration of amenorrhea. The fetal heartbeat was clearly audible using a phonograph. Pain was noted in the femoral adductor bed and symphysis without obvious clinical hypermobility. Additional endoscopic examination of the lower abdomen, uterus and fetus revealed no abnormalities. X-ray examination of the pelvis was not performed due to pregnancy.

Rice. 1. X-ray image in the “stork position” of the pelvis of patient V., which shows abnormal mobility of the symphysis.

Rice. 2. X-ray of the pelvis of patient S., discrepancy, asymmetry and sclerosis of the symphysis are visible.

Rice. 3. X-ray of the pelvis of patient D., on which, in addition to the divergence of the symphysis, an old rupture and ossification of the soft tissues are also visible.

Rice. 4. Computed tomography scan of the pelvis of patient D. with asymmetry of the sacroiliac joints due to slight displacement. Rice. 5. A tight, non-elastic pelvic band that can be adjusted in size using Velcro. The bandage passes along the sacroiliac joints, covers the wings of the iliac bones, passes forward on the left and right directly above the greater trochanters of the femur and fastens over the symphysis.

A conversation was held with the patient about pain in the pelvic area during pregnancy, and wearing a pelvic band was recommended, thanks to which her condition clearly improved. With the help of a physiotherapist, the patient learned to avoid heavy loads on the symphysis. The pregnancy then proceeded well and ended with a quick spontaneous birth; a boy weighing 3500 g was born. After giving birth, the patient wore a pelvic band for quite a long time. A follow-up examination 6 weeks later revealed that the pain still appeared, but only with great physical stress. 3 months after birth, the bandage was finally removed. Patient V., 38 years old, second pregnancy, the first ended in caesarean section due to non-progressive opening. A boy was born weighing 3850 g. The current pregnancy proceeded without complications and at 41 weeks (duration of amenorrhea) labor began spontaneously. The opening phase proceeded quickly, but the expulsion of the fetus was delayed, despite the patient's optimal tension. They began to prepare V. for artificial resolution of labor with the help of a birthing stand, but when she went back to bed, labor still occurred. The fetus (a boy weighing 4040 g) was born in an occipital presentation. The patient later reported that she felt a “click” during this phase.

A few hours after delivery, the patient began to complain of severe pain in the symphysis area.
She could hardly stand and only walk backwards in small steps. During the examination, severe pain was noted with pressure on the symphysis; vaginal examination revealed abnormal mobility of the symphysis. The patient could not stand with full weight bearing on one leg and could only carefully, in a bent position, shuffle and back away. It was impossible to take a normal step. X-ray images in the “stork position” showed abnormal mobility of the symphysis (Fig. 1), based on which a symphyseal rupture was diagnosed. The pelvic band was measured and the patient was placed on strict bed rest for 1 week, after which she cautiously began mobilization. When monitored after 14 days, the complaints, except for local pain, basically disappeared, V. rarely wore a belt and was again able to do housework. Patient S., 36 years old, housewife, mother of three children aged 11, 9 and 5 years, was referred to an orthopedic surgeon regarding chronic pain in the symphysis and abnormalities in the X-ray picture.
During the conversation, it became clear that the first and second pregnancies were complicated by pelvic pain.
The birth proceeded without complications; obstetric care was provided by a family doctor. After childbirth, the pain in the pelvic area gradually subsided and completely disappeared within 3 months. During the third pregnancy, pain reappeared; in addition, with amenorrhea lasting 32 weeks, it became difficult for S. to stand and walk. Standing, she felt unsure and walked waddling from side to side. In addition to pain from pressure on the symphysis, the family doctor discovered a palpable space of about 2 cm between the pubic bones and their mobility. A diagnosis of symphysiolysis was made. The consulting orthopedic surgeon prescribed a pelvic band, however, despite this support, S was eventually able to ambulate only in a wheelchair. The birth also took place at home and proceeded without complications. In the postpartum period, after consultation with a physiotherapist, mobilization of the patient was carefully started again using a pelvic band and crutches. The complaints finally disappeared after about 1 year. However, 2 years after the last birth, complaints of pain in the symphysis reappeared. The family physician found pain with pressure on the symphysis without mobility and prescribed a nonsteroidal anti-inflammatory drug (NSAID) and recommended wearing a pelvic band. Over time, the complaints recurred more frequently, despite muscle-strengthening exercises for the pelvic and hip muscles and increased use of NSAIDs to relieve pain. The X-ray image revealed sclerosis, asymmetry and divergence of the symphysis (Fig. 2). During the examination, we found pain with pressure on the symphysis and with compression and decompression of the symphysis. There was no obvious clinical mobility. Taking into account the anamnesis, examination results and x-ray picture, in this case we can assume chronic osteitis pubis or early degeneration of the symphysis. A trial of treatment with local corticosteroid injections was started. Patient D., 32 years old.
Chronic pain and mobility of the symphysis, complaints began after the birth of her only child, almost 4 years ago. The pregnancy proceeded without complications, but the birth was difficult and there was an incomplete rupture of the perineum. From the 1st day after birth, D. complained of severe pain around the symphysis. Mobilization was very difficult. Despite a long period of rest and exercises for the pelvic and femoral muscles under the guidance of a physiotherapist, the complaints persisted. 3 years after giving birth, D. was referred to an orthopedic surgeon. Examination results: otherwise healthy woman, slightly overweight, waddling gait, severe pain when pressing on the symphysis both during external and internal examination, increased mobility of the symphysis. Along with this, there was obvious pain with pressure from behind, in particular with pressure on the right sacroiliac joint. Images in the “stork pose” confirmed the mobility of the symphysis; the old tear and heterotopic ossification of the symphysis were visible (Fig. 3). A CT scan showed possible slight displacement of the sacroiliac joint (Figure 4). Based on the history, physical examination and additional diagnostics, it could be assumed that the cause of the complaints was poor restoration of the symphysis after a rupture. First of all, D. was prescribed local injections of lidocaine and corticosteroids into the symphysis, which gave only a temporary effect.
Then she herself, with the help of a national association of patients, sought contact with various doctors and therapists. At the moment, D. has requested surgical strengthening of the pelvic ring due to severe disability that interferes with normal daily activities. The picture of the disease known as symphysiolysis, upon closer examination, turns out to consist of three separate nosological entities that have their own symptoms and course: symphysiolysis, rupture of the symphysis, and pain in the pelvis or symphysis. Taking into account the therapeutic implications, correct diagnosis is very important. Symphysiolysis is
a known problem in obstetrics;
it is associated, in particular, with repeat births, high birth weight and multiple pregnancies. The disease can manifest itself as pain in the symphysis and the so-called “duck gait”. A physical examination reveals mobility of the symphysis, which may not be accompanied by pain. Mobility of the symphysis can be detected by external palpation or vaginal examination. Sometimes the symphysis diverges to such an extent that the space between both pubic bones is palpable. By applying pressure to one of the pubic bones, mobility can be induced. If the symphysis does not diverge, but is still mobile, you can sometimes hear a “click” or palpate crepitus. If external examination does not give a definitive answer, a vaginal examination can be performed with palpation of the symphysis to identify mobility; if necessary, the patient can be asked to move her legs in the hip joints. X-ray examination should be avoided during pregnancy, but if the patient is not pregnant, it is certainly indicated as an additional method of examination. During symphysiolysis, photographs in the “stork pose” show a displacement of both pubic bones relative to each other in the vertical direction, when the patient alternately stands on her left and then on her right leg. Treatment:
dosed rest, wearing a pelvic band (Fig. 5) and, if necessary, performing muscle-strengthening exercises for the pelvic and hip muscles under the guidance of a physiotherapist. There are different types of pelvic bands. Some pregnant women prefer an elastic bandage that is wider than shown in Fig. 5, and which also supports the stomach. During pregnancy, recovery is rare, and all of these measures are aimed at preventing the condition from worsening. After childbirth, complaints may persist for several months. Additional measures such as NSAIDs or local infiltration of corticosteroids may be recommended. A symphysis tear is diagnosed when the symphysis ruptures during childbirth or as a result of trauma. Rupture of the symphysis occurs in 1 case out of 2200 births. An example of this is the medical history of patient B. In acute rupture of the symphysis, the pain is often so severe that it makes it difficult to establish mobility by palpation. When treating a tear, which can be considered an acute ligament injury, the first step is to rest. You can use a pelvic band for support, even in bed. Sometimes lying on your side brings relief. After 3 to 7 days of bed rest, mobilization is carefully begun, possibly with the help of crutches. The pelvis is a ring consisting of the left and right os coxae and os sacrum. These bones are connected to each other through the symphysis and both sacroiliac joints. If the symphysis is separated due to trauma or lysis by more than 2.5 cm, then, of course, the sacroiliac joint ligaments will also be affected. This happened to Patient D. In addition to women with symphysis or symphyseal tears, there is a much larger group of women who have pain in the symphysis or lower back without an obvious cause (as in Patient A). Women's complaints of pain in the lower back can be largely due to the condition of the sacroiliac joints. Symphysis pain and pain originating from the sacroiliac joints can be collectively referred to as “pelvic pain.” Physical examination reveals pain with pressure on the symphysis and/or sacroiliac joints, but no mobility. The cause of this pain in the pelvic area is associated with weakening of the ligaments during pregnancy. The pelvis becomes, so to speak, less rigid, which is favorable for childbirth. The causative factor is the hormone relaxin, produced by the corpus luteum, the decidua of the uterus and the chorion. Not every pregnant woman has complaints. At an international conference dedicated to this problem, they also discussed physiological relaxation of the pelvic girdle, as opposed to “symptomatic” relaxation. From these positions, symphysiolysis can be considered as an extreme form of weakening, in which, perhaps, a higher concentration of relaxin is accompanied by a greater load on the pelvis. As for treatment for pain in the pelvic area, it is the same as for symphysiolysis: dosed rest, pelvic bandage and, if necessary, muscle strengthening exercises. During subsequent pregnancies, the complaints usually recur and often become more severe than before. This is illustrated by the medical history of patient S. Childbirth in women with pelvic pain or symphysiolysis proceeds generally without complications, and can be managed by a midwife or family doctor. A rupture of the symphysis that occurs during childbirth is most often successfully cured and, in principle, is not an indication for a cesarean section in the next pregnancy. A small group of patients continue to have real complaints, despite all conservative measures. The following surgical treatment options exist: symphysectomy, i.e. removal of the dorsal portion of both ends of the pubic bones, and symphysiodesis, possibly in combination with artodesis of both sacroiliac joints. According to the limited literature data, satisfactory and good results can be achieved in no more than 60 - 70% of cases, so we can talk about the unpredictability of the effect of such an intervention. In this regard, a very restrained attitude towards surgical intervention is understandable, especially taking into account the natural course of the disease. We hope that the analysis of these case reports will lead to a better understanding of the problem of pelvic pain associated with pregnancy. Along with the relatively easily diagnosed rupture of the symphysis, pain in the pelvic area, even if not accompanied by mobility, deserves attention. Apparently, we can talk about a blurred boundary between the physiological preparation of the pelvis for childbirth and pathological chronic mobility. We hope that early recognition of the latter condition will help reduce the number of chronically ill women.

Literature:

1. Gamble JG, Simmons SC, Freedman M. The symphysis pubis. Anatomic and pathologic considerations. Clin Orthop 1986;203:261-72. 2. Sequeria W. Diseases of the symphysis, Semin Arthritis Rheum 1986;16:11-21. 3. Schwartz Z, Katz Z, Lancet M. Management of puerperal separation of the symphysis pubis. Int J Gynaecol Obstet 1985;23:125-8. (and other 10 sources). A complete list of references can be obtained from the publisher. Taken from Ned Tijdschr Geneeskd 1995;139(30):1961-4 with permission of the editor-in-chief and authors.

Severity of the condition

In modern medicine, three degrees of the disease are expressed

1st degree - the width of the divergence of the bones of the pubic symphysis is 5-9 mm. The condition is tolerated quite easily; the pregnant woman experiences minor pain that occurs during long walks or during physical activity;
2nd degree - the width of the divergence of the bones of the pubic symphysis is 10-19 mm. Pain appears, noticeable with any intense movement;
Grade 3 - the width of the divergence of the bones of the pubic symphysis is 2 centimeters or more. Painful sensations appear even at rest.

Prevention

The answer to the question why the pelvic bones hurt during pregnancy may be a lack of calcium, high loads and other factors. To prevent pain from occurring, it is enough to follow simple preventive measures:

taking multivitamins prescribed by a gynecologist-obstetrician;
refusal of intense physical activity, for example, long walks in the second half of pregnancy;
inclusion of calcium-fortified foods in the diet;
body weight control;
wearing a special bandage that effectively distributes the load on the spine and pelvic bones;
it is advisable to sleep on an orthopedic mattress with pillows designed for pregnant women - all this helps to relax tired muscles;
regular exercises for expectant mothers, aimed at strengthening the muscles and the body as a whole;
wearing comfortable clothes and shoes that do not interfere with a woman’s normal movements.

Following these tips will help minimize the risk of developing pathologies that cause pain in the pelvic bones during pregnancy. In order to start treatment in a timely manner, if any negative changes in well-being occur, the woman should report this to the gynecologist.

Author: Olga Rogozhkina, obstetrician-gynecologist, especially for Mama66.ru

Author Olga Rogozhkina Author of the portal Mama66.ru Share You are here: Home » Pregnancy » Pelvic pain in pregnant women: causes and methods of elimination Contents

Often, expectant mothers complain to doctors about the appearance of pain in the pelvic bones. This manifestation is quite severe for many women. This article will help you understand in what situations and why the pelvic bones hurt during pregnancy.

How to reduce pain intensity

After confirming the diagnosis, the doctor leading the pregnancy should give some tips and recommendations that will help reduce the level of pain.

Most often this is:

use of a special bandage;
taking medications containing calcium and vitamin D;
monitoring weekly weight gain and monitoring weight in case of excessive work, as excess weight increases pain;
adherence to a sleep and rest regime, in some cases complete physical rest should be adhered to;
applying a warm heating pad to the area of the ligaments (here the doctor must tell you about the importance of maintaining a thermal regime);
light massage at home;
use of a special orthopedic pillow for the pelvic area;
lightweight gymnast;
swimming in the pool (in the absence of contraindications from the doctor).

In some cases, it is permissible to take painkillers. They are prescribed by a doctor. Self-administration of medications during pregnancy without consulting a specialist is prohibited.

Which doctor should I contact if a pregnant woman has pelvic pain?

If the pain is constant, you need to inform the obstetrician-gynecologist at the antenatal clinic. The doctor’s task is to find out why the pelvic bones hurt and help the woman eliminate the discomfort. Most often, a specialist prescribes a biochemical blood test for the expectant mother, based on which he draws conclusions about the state of her body.

If we are talking about a lack of calcium in the blood, the woman is prescribed vitamins enriched with this microelement. In addition to calcium, the doctor may advise the woman to revise her diet to include more greens, meat, fish and dairy products.

Intra-articular injections and surgeries during pregnancy

Only a doctor can recommend safe painkillers and anti-inflammatory drugs during this period. Intra-articular injections of synovial fluid substitutes, for example, Noltrex or preparations based on hyaluronic acid, are usually not given to women during this period, since many of them are hormonal and are contraindicated for pregnant women.

In difficult cases, when joint replacement is recommended, it is postponed until after the birth of the child, and before that, adequate supportive therapy is prescribed.

Diagnostics

Diagnostic measures are carried out by traumatologists and orthopedists. According to indications, examinations by surgeons, oncologists, and other specialists are prescribed. The examination program may include the following procedures:

Survey
. The specialist finds out the time and circumstances of the onset of the pain syndrome, its nature, frequency, duration, clarifies the connection with external factors, and the presence of other symptoms.
Physical examination
. The doctor evaluates the appearance of the pelvic area, identifies deformities, pathological mobility, forced body position, and examines the mobility of the spine and hip joints.
X-ray of the pelvis.
Basic examination for bone pathology. Detects fractures, signs of inflammation or osteodystrophy, infectious foci, and neoplasms.
Ultrasound
. Prescribed for diseases of soft tissues, suspected symphysitis during pregnancy. It makes it possible to clarify the localization and nature of the pathological process, confirm the presence of inflammation, space-occupying formations, and other changes.
Other imaging techniques
. If the basic methods are insufficiently informative, at the final stage of the examination, examinations are carried out for a detailed study of bone structures and MRI to assess the condition of soft tissues.
Lab tests
. They are used to confirm the inflammatory process, clarify the type of pathogen, and detect specific markers of rheumatic diseases.

Physiotherapy

Features of the course and treatment of osteoarthritis during lactation

During breastfeeding, manipulations are already allowed for the purpose of accurately diagnosing arthrosis - x-rays, biopsy and analysis of synovial fluid, so it is possible to make a diagnosis much faster and more accurately. Treatment tactics depend on the stage of the disease. In addition to painkillers and anti-inflammatory drugs, glycosaminoglycans are shown to protect cartilage from destruction.

The doctor recommends the best physical treatments - magnetic therapy, exposure to electric currents, ultraviolet radiation. An excellent effect can be achieved with the help of thermal procedures, paraffin application and mud therapy. The massage is aimed at restoring the functions of the affected joint - reducing muscle spasms, increasing the tone of weakened muscles. Unfortunately, in severe cases it sometimes comes to endoprosthetics. The issue of intra-articular Noltrex injections is decided on an individual basis.

For osteoarthritis during lactation, exercise therapy is often prescribed

How to get rid of the disease

If you are still overtaken by this disease, first you need to adjust your lifestyle and diet.

Taking into account the fact that a restructuring is taking place in a pregnant woman’s body, she needs so-called “building materials”. These include vitamins (especially vitamins K, B12, B6, C, E - they are all involved in hematopoiesis). Therefore, you should eat meat products (poultry), vegetables (peppers, onions, tomatoes, cucumbers), fruits (oranges, lemons, apples, bananas, kiwi), berries (blueberries, raspberries, strawberries), also legumes, dairy products. Flour products and foods rich in starch should be excluded from the diet.

After adjusting your diet, you need to get your physical activity in order. So, if you are busy with one thing, during which the woman does not move much, you need to periodically perform hand exercises: shake, make circular movements with your hands, clench and unclench your fingers several times, bringing them into a fist.

If possible, you should try to avoid unnecessary stress on your arms (lean less on your arms, use special splints during night sleep). Do not forget that some pain sensations are a sign of the presence of severe or chronic diseases, so you need to talk about these sensations to your doctor, who monitors you throughout your pregnancy. Compliance with all these rules will help you reduce painful sensations, or even get rid of them completely. And also spend your difficult, but very happy nine months in a good mood.