The symphysis disjunction syndrome is an under-evaluated and poorly treated pathology, diagnosed mainly in the post-partum period, which can be responsible for significant morbidity. A rapid and adapted management is essential. Its diagnosis is evoked clinically before insidious pains occurring in the pregnant woman or brutally in postpartum and can be confirmed by radiology of pelvis face. We report the observation of a patient with symphysis disjunction syndrome following a delivery with instrumental extraction.
Mrs. MR, aged 35, fourth pregnancy gesture, and the current pregnancy was followed by a midwife, apparently normal course, notably no notion of pelvic pain or other dysgravidia, carried to term, the patient was sent to us from a peripheral maternity for lack of expulsion.
On examination, the patient was conscious with correct arterial tension, obstetrical examination objectivized an engaged cephalic presentation, fetal heart sounds were present, instrumental extraction by forceps was performed with customary precautions allowing extraction of a live baby weighing 4 400 grams, perineal repair occurred without special problems and the postpartum examination was normal. On the second day postpartum, the patient presented severe abdomino-pelvic pain without special irradiation with impotence of the right lower limb as well as bladder retention; clinical examination showed a greater abdomino-pelvic sensitivity to palpation of the pubic symphysis. The radiology of the frontal pelvis (Figure 1) showed an enlargement of the symphyseal space of 16 mm, therapeutic management was preventive discharge and anti-coagulation with analgesic treatment based on paracetamol and nonsteroidal anti-inflammatory. The outcome was marked by a decrease in pain as well as an improvement in the lower limb impotence, and the resumption of a spontaneous diuresis, it was declared outgoing on day 14 postpartum. Controls showed a decrease in pubalgia but walking difficulties and positron pains sat, a reprise of professional activities was allowed at eight months postpartum with complete disappearance of clinical genes.
Figure 1 Radiology of the pelvis of the face objectifying an enlargement of the inter-symphyseal space
Pregnancy is accompanied by changes in pelvic geometry, micro mobility of the sacroiliac joints and the pubic symphysis, and a general laxity of the connective tissues of hormonal origin, estrogens and relaxin act on the ligaments, muscles and enthuses of the pelvic region, for the purpose of facilitating childbirth. In addition, biomechanical stresses increase during pregnancy; as a result the enlargement of the pubic symphysis is physiological during pregnancy and childbirth (Timsit, 2004). However, pubic disjunction syndrome is an underestimated and often poorly managed condition. The incidence of this syndrome in per partum is evaluated between 1/300 and 1/30,000 in the literature (Williams et al., 1966) and can cause pubic pain and / or iliac wings accentuated by movements and palpation, in pre-, per- or post-partum 22% of the parturientes may have pain in the pubic symphysis, these pains are atrocious in 5-8% of the parturientes. 7% of parturients have this symptomatology in postpartum (Albert et al., 2001).
The etiologies of this disorder remain unclear although several authors have reported the frequent association of symphyseal disjunction and certain risk factors including fetal macrosomia, extraction maneuvers, rapid expulsion, shoulder dystocia, twinness, joint pathologies and trauma of the pubic joint (Culligan et al., 2002). Our patient had many risk factors, namely multiparty, macrosomia and the practice of instrumental extraction.
The diagnosis is based on the symptomatology reported by the patient and the clinical examination, in the case of pubic disjunction, the pain may be of varying intensity, responsible in the most severe cases for total functional impotence but the minor forms remain the more frequent (Timsit, 2004). Urinary complications in case of severe disjunction (bladder wound, hematoma, incontinence or urinary tract infection) are possible (Scicluna et al., 2004).
The typical symptomatology appears to include pain in the pubic symphysis with inguinal irradiation associated with pain in the sacroiliac joint (Scicluna et al., 2004). The clinical examination notes an exquisite pain in the palpation of the pubic symphysis, even seeing an edema of the symphysis and the palpation of an inter-symphysary space (Luger et al., 1995).
The clinical picture in our observation was fairly typical.
The paraclinic diagnosis is based on radiology of the frontal pelvis showing an inter-symphyseal space greater than 10 mm (Scicluna et al., 2004), this space was evaluated at 16 mm in the case of our patient. The degree of separation observed does not appear to be correlated with the severity of the symptoms (Snow and Neubert, 1997) and a symptomatology remains possible even in the absence of radiological signs (Culligan et al., 2002), some authors proposed the ultrasound as diagnostic means in particular during of pregnancy where a standard X-ray is not authorized, but conclude that the examination is not predictive (Scriven et al., 1995).
The treatment modalities include rest, analgesics and anti-inflammatories, local infiltration, physiotherapy, osteopathy, physiotherapy, even pelvic bandage and surgical treatment with fixation in case of significant diastasis greater than 4 cm (Kharrazi et al., 1997), preventive anticoagulation is necessary in case of prolonged immobilization.
In the course of pregnancy, according to some authors (Scicluna et al., 2004), the failure of a local infiltration proposed could justify the implementation of an epidural analgesia. In postpartum, local infiltration in the pubic symphysis appears effective. According to the recommendations, it must be performed in the operating room under strict aseptic conditions and use a solution associating a local anesthetic with a corticoid (Kharrazi et al., 1997). In our case, it was a symptomatology appeared in immediate postpartum with radiological signs. The conservative medical treatment combining discharge, analgesics and preventive anticoagulation allowed a favorable development with improved pain.
The recovery time of pelvic pain syndromes related to pregnancy is less than one month in 62.5% of cases, with complete disappearance of the isolated pains of the pubic symphysis within six months (Mogren, 2008).
For the prognosis of subsequent pregnancy, there is little evidence for the importance of a preventive caesarean section in the event of a history of pubic disjunction (Snow and Neubert, 1997).The risk factors for recurrence mentioned in the articles are fetal macrosomia, multiparty, extraction maneuvers, rapid expulsion, shoulder dystocia, twinning and trauma of the pubic joint (Culligan et al., 2002).In reality the problem of the traumatic experience in the postpartum and maternal anguish of recidivism are at the origin of the discussion of the mode of delivery between the patient and the obstetric team. It is a question of balancing the risks of recidivism, poorly established, uncertain and the possible complications of caesarean section.
The risk factors and pathophysiological mechanisms of pubic disjunction remain unclear, with a risk of recurrence difficult to establish, but its diagnosis must be evoked before any pelvic pain in pregnancy and postpartum, confirmed easily by radiology of the pelvis face, a fast and adapted support is essential.
R.H: Editing and supervision, read and approved the final manuscript; D.A: participated in the drafting of the observation, read and approved the final manuscript; B.N: participated in the drafting of the discussion, read and approved the final manuscript; A.A: checking references. All authors read and approved the final manuscript.
We thank the radiology department of Ibn El Jazzar Hospital, Kairouan.
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