I. Definition.
Pubic symphysis separation is a complication of pregnancy due to loosening and rupture of the pubic symphysis ligament, which mostly occurs in the perinatal period. Although the incidence of this disease is low, if the diagnosis and treatment are delayed, it often prolongs the course of the disease and seriously affects maternal health, so it should be taken seriously. The disease mostly occurs in late pregnancy and after spontaneous delivery, and there is a correlation between the age of onset (over 27 years) and the weight of the pregnancy (over 70 kg) and the weight of the newborn. In addition, it is most common in primigravida, especially in patients with high floating fetal head.
Second, the normal pubic symphysis and the change of pubic symphysis during pregnancy and delivery:
The pubic symphysis consists of the left and right pubic symphysis surfaces, which are connected by the interpubic fibrocartilage plate, and in women this cartilage is wide and short, and the pubic symphysis is strengthened by ligaments above and below. The pubic symphysis is an important joint of the birth canal, after pregnancy, due to the effect of relaxin, the joints of the pelvis become lax, resulting in the instability of the pelvis, after the third month of pregnancy is more lax, the width of the pubic symphysis increases, but generally does not exceed 20 mm. during labor, because of the expansion of the fetus in the birth canal, coupled with the fetus is too large, the uterus contraction is too strong, the maternal breath held too hard, can cause the separation of the pubic symphysis, clinically Each case can have different degrees of separation of the pubic symphysis, but not every case shows the symptoms of separation of the pubic symphysis, and only very few women develop the disease. In normal people, the pubic symphysis gap is 4-6 mm, and during pregnancy, the pubic symphysis can be widened by 2-3 mm, and it is generally believed that if the pubic symphysis gap exceeds 10 mm, it will cause symptoms.
Three, the causes of the onset.
1, the occurrence of this syndrome may be related to the variation of maternal own bony birth canal structure, such as the connection of interpubic fibrocartilage, true pelvic structure and pelvic tilt, abnormal changes in the pelvic axis, etc.. as well as congenital developmental abnormalities, chondromalacia.
2, pathological weakness of the symphysis pubis joint, which is considered by some experts to be the underlying cause of the disease
3, difficult delivery, emergency delivery, difficult forceps delivery, improper operation during delivery, variation in the direction of rotation and force of the child’s head in the bony birth canal may also be one of the causes of this disease. Excessive abduction of the thighs during delivery or a history of previous pelvic trauma. —This is the starting point of our obstetricians for the prevention of postpartum symphysis pubis separation.
4. However, it can also be caused by aseptic necrosis of the pubic bone due to local blood circulation disorders, and some people have confirmed by angiography that the blood vessels near the pubic bone are blocked by surgery and cause local congestion and bone decalcification. Therefore, the separation of the pubic symphysis is the result of a combination of factors.
IV. Clinical manifestations
1. Symptoms.
Most cases have varying degrees of pain in the pubic symphysis area, aggravated by activity and turning, radiating pain in the lower back and lower limbs, restricted activity or walking difficulties, and a history of pelvic trauma must be excluded (Note: the onset of late pregnancy is generally slow, with symptoms gradually increasing, from the initial pain at the pubic symphysis, gradually developing to inner thigh pain, increasing pain when changing position, walking difficulties, and in severe cases, unable to get out of bed. Postpartum onset is sudden, with multiple symptoms, pain at the pubic symphysis, pain when turning and changing position, pain radiating to the inner thigh, duck-like walking or bedridden and unable to walk.
2. Physical examination.
The pain at the pubic symphysis is obvious widening and pressure pain, serious condition is accompanied by skin edema at the pubic symphysis, but there is no redness and heat, positive pelvic squeeze separation test, ultrasound measurement of the pubic symphysis gap is greater than 10 mm, left and right misalignment difference ≥ 5 mm or X-ray radiograph results are greater than 10 mm. for late pregnancy patients ultrasound and physical examination and symptoms are the key to diagnosis.
3, Diagnosis.
There are no exact criteria for the diagnosis of this disease . The WHO criteria are used in the perinatal period: from 28 weeks of gestation to one week after delivery, the presence of.
(1) there is obvious local pain and a widened gap can be palpated at the pubic symphysis.
(2) Positive pelvic compression and separation test.
(3) The width of the pubic symphysis is measured >10 mm on pelvic radiographs.
Ultrasound is often used clinically to measure: the width of the pubic symphysis gap >10mm and the difference between left and right misalignment ≥5mm as the basis for diagnosis. Since ultrasound has strong soft tissue resolution, the interface reflection of ultrasound can clearly show the anatomical structure of the pubic symphysis, providing a clear basis for the diagnosis and treatment of pubic symphysis separation, which is an ideal, non-invasive and accurate method.
(4) According to the symptoms such as urgency of onset, with or without radiating pain and difficulty in walking, the patients’ symptoms are classified as mild or severe. Among them, the severity of symptoms is related to the degree of separation of the pubic symphysis. There is no clear grading standard yet.
V. Treatment methods
1. After the diagnosis, all mothers should rest in bed, and those with late pregnancy onset should be delivered by cesarean section as soon as possible to avoid aggravating the disease through vaginal delivery. And give intramuscular injections of vitamin B1, vitamin B12, vitamin B12 and calcium vidin gum, and use infrared instrument to shine at the pubic symphysis for physiotherapy.
2, and for those who develop after delivery, clinical mostly bed rest and symptomatic treatment.
3, for heavy symptoms, some scholars use 2% lidocaine to strengthen the pine for local closure. The principle of drug action of closure therapy is as follows: lidocaine can prevent the adverse stimulation from the lesion to the center, which is conducive to the nutrition of the local tissue lesion and can immediately reduce pain; while prednisone can reduce the effectiveness of hyaluronidase, regulate the dynamic balance between hyaluronic lipids and hyaluronidase, and has the effect of stabilizing the lysosomal membrane, inhibiting sterile inflammatory reaction and reducing edema. Local closure allows the drug to form a high local concentration at the separation of the pubic symphysis, which is gradually absorbed, thus promoting the early healing of the separation and eliminating the acute inflammatory reaction caused by ligament and soft tissue injury. The method is as follows: the patient is placed in the supine position, the skin of the injection area is disinfected, 2% lidocaine 4 ml, dexamethasone 5 mg, chymotrypsin 4000 u, 5 ml of water for injection, mixed and drawn into a 10 ml syringe, with a No. 7 needle, the skin of the most obvious pressure pain in the pubic symphysis is injected vertically into the needle 3 ~ 4 mm, 1 ~ 2 min slowly inject the drug, there is a significant local augmentation, press the needle hole for 1 ~ 2 min after the needle is discharged After the needle was released, the needle hole was pressed for 1~2 min to prevent the drug from spilling, and no other treatment was used. If there is still pain at the pubic symphysis after 48 h of closure, repeat the closure treatment every 48 h as the above method until the symptoms disappear.
4, external fixation of pelvic ligament restraint is an important part of promoting healing, the first treatment without other combined injuries as long as the ligament position and elasticity is appropriate, regardless of the degree of separation can be completely reset to normal form and width. In addition to congenital developmental factors of the pelvis and ligaments, pregnant women in late pregnancy should avoid standing for too long and tense the pelvis with a pelvic lap band until it heals.
5. Combined treatment methods.
(1) Pain point block.
A mixture of 5% procaine 2 ml + prednisone 10~15 mg + vitamin B120?5 mg + saline 10 ml is slowly injected into the ligaments at the upper and lower edges of the PS cleft respectively, once every other day, 2~3 times in total.
(2) Local rubbing.
Fotarine emulsion 2~3 g rubbed for 5~10 min, 2 times a day.
(3) External pelvic fixation.
Relative pelvic braking with pelvic clamps or multi-headed lap band for 1~3 weeks. Advantages: Combination therapy uses short-term bed rest, painful point block, and local rubbing for mild-moderate pubic symphysis separation, while severe cases are supplemented with a combination of external pelvic fixation such as pelvic clamps. The drugs used in this method all act locally, minimizing the amount of drugs absorbed into the circulation, thus fitting the principles of drug administration during pregnancy and lactation. Among them, local anesthetics can be analgesic and inhibit inflammation, hormones have strong anti-inflammatory and promote the healing of injury, and fotarine emulsion is a steroidal topical anti-inflammatory drug, which can eliminate the acute inflammatory reaction caused by ligaments and soft tissues and improve the symptoms significantly. And external fixation is an important part of promoting healing. The combined treatment method significantly shortens the healing time and has no adverse effects on the mother and the newborn. Therefore, this method is simple, easy and quick to recover, and is worthy of further clinical promotion.
Prognosis
The clinical symptoms of late pregnancy onset are heavier than those at the time of delivery, but the recovery is fast, and the clinical symptoms usually disappear within one month after delivery, while those at the time of delivery take about three months to recover. For maternal separation of pubic symphysis, the diagnosis should be clear and appropriate treatment should be given first, and the prognosis is generally good.
VII. Prevention
1, in clinical work to further strengthen the prenatal examination of pregnant women, and actively do prenatal health care work, often appropriate stretching thigh exercise during pregnancy, to enhance the muscle and ligament tension and tolerance, regular understanding of the pubic symphysis, timely detection of mild disease, to take relative measures; guide pregnant women to reasonable nutrition diet, control body mass, appropriate exercise, reduce the incidence of large children, for full-term pregnancy estimated For pregnant women with fetal mass ≥4000g, the indications for cesarean section should be relaxed, especially for huge fetuses and those with thin stature and possible bony birth canal stenosis, key examination should be made.
2, pay close attention to contractions, timely detection of strong contractions and deal with them, eliminate medical emergency delivery, and change to cesarean delivery after determining cephalopelvic disproportion, in order to reduce or avoid the occurrence of postpartum symphysis pubis separation.
3, correctly guide the mother in the second stage of labor, avoid excessive force and violence to give abdominal pressure, reduce the sudden increase in pelvic pressure.
4.The midwife forbids to press both thighs of the mother during delivery, and avoid excessive abduction of both thighs, and not to operate violently in vaginal births where the fetal head is large and difficult.
5.For those who have separated the pubic symphysis before delivery, in order to avoid aggravation of separation and prolongation of the second stage of labor, patients should be advised to end by cesarean section.
For those who choose to deliver vaginally, pay close attention to the progress of labor after delivery, and actively perform cesarean section if labor stagnation occurs, so as to minimize the occurrence of vaginal assisted delivery, which can effectively reduce the occurrence of symphysis pubis separation.
VIII. Cure criteria.
The clinical symptoms disappear, that is, no obvious pressure pain in the pubic symphysis, no pain in changing position and walking, and negative pelvic extrusion test.