BASICS
DESCRIPTION
- Persistent musculoskeletal pain localized from the level of the posterior iliac crest and gluteal fold over the anterior and posterior elements of the bony pelvis
- May radiate across hip joint and thigh bones
- Usually starts around the 18th week of pregnancy; can start in 1st trimester or present as late as 3 weeks postpartum
- Pelvic girdle pain (PGP) is a separate entity from pregnancy-related lower back pain.
- Synonyms: pelvic arthropathy; osteitis pubis; pelvic insufficiency; pelvic instability; pelvic relaxation pain; pelvic girdle relaxation; posterior pelvic pain; pregnancy-related pelvic girdle pain (PPGP); symphysis pubis dysfunction; lumbopelvic pain; peripartum pelvic pain; pelvic girdle syndrome
EPIDEMIOLOGY
Incidence
45% of all pregnant women, 25% of all postpartum women suffer from pelvic girdle pain, although likely underreported
Prevalence
4 " 76%; wide range may be based on varying criteria and designs of studies.
ETIOLOGY AND PATHOPHYSIOLOGY
Generally agreed up pathophysiology hypothesis involves both hormonal and biomechanical factors
- Increased amounts of relaxin produced by the corpus luteum and uterine decidua during pregnancy
- Relaxin acts on connective tissue, leading to greater ligament laxity especially in joints of the pelvis that normally serve to provide pelvic stability.
- Increased laxity causes widening and separation of the symphysis pubis, as well as sacroiliac joints.
- Increased motion in pelvic joints decreases efficiency of load bearing and increases shearing forces across the joints.
RISK FACTORS
- Risk factors with consistent findings
- History of low back pain
- Previous PGP
- Previous trauma to the pelvis
- Progesterone intrauterine device (1)
- Probable risk fators with inconsistent findings
- Increased workload
- Physically demanding job
- Pluripara
- Parity
- Increased BMI
- Stress (1)
- Operative delivery (2)
- Not a risk factor with consistent findings
- Smoking
- Oral contraceptive pills
- Age
- Interval between pregnancies (1)
DIAGNOSIS
Diagnosis is mainly based on history, physical exam, and excluding other more serious pathologies.
HISTORY
- Stabbing, dull, shooting, or burning pain located at the general area of the pelvic girdle
- Can be posterior, close to sacroiliac joints, and extending to gluteal region or anterior, in the vicinity of the pubic symphysis
- May radiate to the groin, perineum, or posterior thigh
- Lacks typical nerve root distribution
- Pain is difficult to localize, may change during course of pregnancy.
- Insidious or sudden onset of pain
- Usually peaks in 3rd trimester between 24 and 36 weeks but can start at any time from 1st trimester of pregnancy to 1st month postpartum
- Pain is generally less severe in postpartum than during pregnancy.
- Exacerbated by changing position from sitting to standing, prolonged sitting or standing, sexual intercourse, and increased intra-abdominal pressure (coughing, sneezing, micturition, defecation)
- The Pelvic Girdle Questionnaire(PGQ) is recommended for evaluating symptoms of PGP during pregnancy and postpartum (3)[B].
PHYSICAL EXAM
- May reveal alteration in gait patterns (inability to cover long distances, "catching " sensation, slower walking velocity, increased amplitude of horizontal rotation of the pelvis)
- Few patients have signs of inflammation locally, including erythema, warmth, and edema.
- Characteristic findings are positive pain provocation tests
- Posterior pelvic pain provocation test: Patient lies supine with hip flexed 90 degrees. Examiner exerts pressure on the knee, along the femur to the hip, while stabilizing the pelvis with a hand on the opposite anterior iliac spine. Positive if pain is elicited in the ipsilateral buttock
- Patrick/FABER test: Patient is placed supine with one leg flexed, abducted, and externally rotated such that the heel rests on the opposite knee. Patient is told to relax and allow the weight of the leg to draw the knee toward the floor. Positive if pain is produced anywhere in the pelvic girdle.
- Active straight leg raise (ASLR): Patient is placed supine with straight legs extended on the table, feet about 20 cm apart. Patient raises each leg, one at a time, 30 degrees above the table without bending the knee. Positive test if the patient describes a heaviness or difficulty in lifting the leg. Second part of test involves posterior compression of the iliac crests in a lateral to medial fashion with patient performing straight leg raise again. Positive if ease of motion is greater. This test gives an indication of lumbopelvic stability.
- Long dorsal ligament palpation: Patient lies on her side with slight flexion in both knees and hips. The long dorsal sacroiliac ligaments are palpated directly caudomedially from the posterior iliac spine to the lateral dorsal border of the sacrum to elicit pain or tenderness.
- Gaenslen test: Patient lies on side with upper leg (test leg) hyperextended at the hip and holds lower leg in flexion against the chest while the examiner stabilizes the patient 's pelvis and extends the hip of the test leg. Positive if pain is provoked in the ipsilateral pelvic girdle
- Pubic symphysis palpation: Patient is placed supine, and the pubic symphysis is palpated to elicit pain or tenderness.
- Modified Trendelenburg test: Patient stands on one leg and flexes the other leg at 90 degrees at the knee and hip. Positive if pain is experienced at the pubic symphysis.
DIFFERENTIAL DIAGNOSIS
- Painful visceral pathologies of the pelvis (urogenital, gastrointestinal)
- Lower back pain syndromes (lumbar disc lesion/prolapse, radiculopathies, spondylolisthesis, rheumatism, sciatica, spinal stenosis, lumbar spine arthritis)
- Osteomyelitis or soft tissue infections (typical or atypical such as tuberculosis or syphilitic lesions of the pubis)
- Urinary tract infection
- Femoral vein thrombosis
- Obstetric complications (preterm labor, abruption, round ligament pain, chorioamnionitis, red degeneration of uterine fibroid, pregnancy-associated osteoporosis)
- Bone or soft tissue tumors
DIAGNOSTIC TESTS & INTERPRETATION
- Usually normal: may reveal mild, nonspecific elevations in acute phase reactants
- Lab testing is not necessary. CBC, BMP, UA may be done to help rule out other pathologies if there is lack of clarity in presentation.
- MRI can be used to exclude ankylosing spondylitis, or for patients who have "red flag " signs or may need surgical intervention (4)[C].
- Safe in pregnancy
- Conventional radiography, CT scans, and scintigraphy are not well supported.
- Transvaginal or transperineal US may be useful for diagnosing and monitoring the progress of pelvic girdle pain involving the pubic symphysis.
- In postpartum patients, standard anteroposterior, inlet and outlet pelvic films can be done to measure degree of symphyseal separation and identify cortical sclerosis, spurring, or rarefaction:
- Detection of step-off of >2 mm in standard AP view or 7 mm in flamingo view is considered by some as the threshold of pelvic instability (4).
Diagnostic Procedures/Other
Guided local anesthetic injections into sacroiliac or pubic symphysis joint, if this yields adequate relief of pain, thought to be 100% specific for intra-articular pathologies.
TREATMENT
Activity modification with rest, physical therapy, and symptomatic care are generally accepted as the safest and most effective options for both antepartum and postpartum patients.
- During pregnancy, individual or group therapy has positive outcomes on amount of sick leave taken, as well as on pain intensity (4)[B].
- Postpartum, individualized programs involving stabilizing exercises were shown to have greater effect (4)[B].
MEDICATION
- Acetaminophen: safe for use in pregnancy but may be inadequate for pain control (4)[A]
- NSAIDs: not safe for use in pregnancy (primarily in 3rd trimester) but do provide more effective pain control; may be used safely after delivery
- Opioids such as morphine, codeine, tramadol: limited studies, and may be beneficial to aid with pain at night. Not routinely recommended for use in pregnancy (Category C) or in patients who are lactating because of risk of neonatal abstinence syndromes (4)[B]
ADDITIONAL THERAPIES
- Yoga has been shown to be more effective than stretching (5)[B].
- Transcutaneous elective nerve stimulation (TENS): inconsistent evidence to support its use for pelvic girdle pain (4)[B]
- Acupuncture: increasingly used; safe as long as performed by experienced acupuncturist
- Varying reports of its effectiveness for treatment of pelvic girdle pain (4)[C]
- Epidural analgesia may have a potential role for severe PGP but has not been properly evaluated, and evidence is isolated to a few case reports.
- This extreme approach might have a place in patients with severe PGP for symptom control while awaiting fetal maturation, thereby avoiding premature induction/cesarean section (4)[B].
SURGERY/OTHER PROCEDURES
- Guided injections of anesthetics with corticosteroids (4)[B]
- Pelvic fusion surgery: end-stage procedure to be done only after nonoperative methods of treatment fail
- Involves fusion of painful joint or triple fusion of all pelvic articulations (4)[B]
ONGOING CARE
PROGNOSIS
- In most cases (up to 93%), pain will resolve spontaneously by 6 months postpartum (4)[B].
- High levels of pain during pregnancy and during the first 6 months postpartum indicate a poor outcome in self-rated health for women with PGP at 14 months (6)[B].
- Recurrence is common in future pregnancies or with menstrual cycle.
- Risk is increased with more severe symptoms.
- Risk factors for persistent pelvic girdle pain
- Prepregnancy back pain
- Prolonged duration of labor
- High number of positive pain provocation tests
- Low mobility index
- Onset of pain in early gestation
- Inability to lose weight after delivery
- Planned cesarean section (aOR, 2.3; 95% CI, 1.4 " 3.9) (4)[B]
REFERENCES
11 Verstraete EH, Vanderstraeten G, Parewijck W. Pelvic girdle pain during or after pregnancy: a review of recent evidence and a clinical care path proposal. Facts Views Vis Obgyn. 2013;5(1):33 " 43.22 Bjelland EK, Stuge B, Vangen S, et al. Mode of delivery and persistence of pelvic girdle syndrome 6 months postpartum. Am J Obstet Gynecol. 2013;208(4):298.e1 " 298.e7.33 Grotle M, Garratt AM, Krogstad Jenssen H, et al. Reliability and construct validity of self-report questionnaires for patients with pelvic girdle pain. Phys Ther. 2012;92(1):111 " 123.44 Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: an update. BMC Med. 2011;9:15.55 Martins RF, Pinto e Silva JL. Treatment of pregnancy-related lumbar and pelvic girdle pain by the yoga method: a randomized controlled study. J Altern Complement Med. 2014;20(1):24 " 31.66 Bergstr Άm C, Persson M, Mogren I. Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy " pain status, self-rated health and family situation. BMC Pregnancy Childbirth. 2014;14:48.
ADDITIONAL READING
- Howell ER. Pregnancy-related symphysis pubis dysfunction management and postpartum rehabilitation: two case reports. J Can Chiropr Assoc. 2012;56(2):102 " 111.
- Leadbetter RE, Mawer D, Lindow SW. Symphysis pubis dysfunction: a review of the literature. J Matern Fetal Neonatal Med. 2004;16(6):349 " 354.
- Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy: a review. Pain Pract. 2010;10(1):60 " 71.
- Vleeming A, Albert HB, Ostgaard HC, et al. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008;17(6):794 " 819.
CODES
ICD10
- O26.899 Oth pregnancy related conditions, unspecified trimester
- M53.3 Sacrococcygeal disorders, not elsewhere classified
- M25.559 Pain in unspecified hip
ICD9
- 648.70 Bone and joint disorders of back, pelvis, and lower limbs of mother, unspecified as to episode of care or not applicable
- 719.45 Pain in joint, pelvic region and thigh
- 724.6 Disorders of sacrum
SNOMED
- Pain in symphysis pubis in pregnancy (finding)
- Pelvic girdle pain (disorder)
- Bone AND/OR joint disorder of pelvis in mother complicating pregnancy, childbirth AND/OR puerperium (disorder)
- Sacroiliac joint pain (finding)
CLINICAL PEARLS
- Pelvic girdle pain is common in pregnancy and can result in significant disability.
- The PGQ and pain provocation tests can aid providers with establishing the diagnosis of pelvic girdle pain.
- Activity modification, physical therapy, and symptomatic care are the most effective forms of treatment.