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Postpartum pubic separation associated with prolonged urinary retention following spontaneous delivery

2006; Informa; Volume: 85; Issue: 10 Linguagem: Inglês

10.1080/00016340600608501

1600-0412

D. V. Valsky, Eyal Y. Anteby, Nurith Hiller, Hagai Amsalem, Simcha Yagel, DRORITH HOCHNER‐CELNIKIER,

Pelvic and Acetabular Injuries

Acta Obstetricia et Gynecologica ScandinavicaVolume 85, Issue 10 p. 1267-1269 Free Access Postpartum pubic separation associated with prolonged urinary retention following spontaneous delivery DAN V. VALSKY, DAN V. VALSKY Department of Obstetrics and GynecologySearch for more papers by this authorEYAL Y. ANTEBY, EYAL Y. ANTEBY Department of Obstetrics and GynecologySearch for more papers by this authorNURITH HILLER, NURITH HILLER Department of Radiology, Hadassah University Hospital, Mt Scopus, Jerusalem, IsraelSearch for more papers by this authorHAGAI AMSALEM, HAGAI AMSALEM Department of Obstetrics and GynecologySearch for more papers by this authorSIMCHA YAGEL, SIMCHA YAGEL Department of Obstetrics and GynecologySearch for more papers by this authorDRORITH HOCHNER-CELNIKIER, Corresponding Author DRORITH HOCHNER-CELNIKIER Department of Obstetrics and Gynecology: Drorith Hochner-Celnikier, Department of Obstetrics and Gynecology, Hadassah University Hospital, Mt Scopus, PO Box 24035, Jerusalem, Israel hochner@hadassah.org.ilSearch for more papers by this author DAN V. VALSKY, DAN V. VALSKY Department of Obstetrics and GynecologySearch for more papers by this authorEYAL Y. ANTEBY, EYAL Y. ANTEBY Department of Obstetrics and GynecologySearch for more papers by this authorNURITH HILLER, NURITH HILLER Department of Radiology, Hadassah University Hospital, Mt Scopus, Jerusalem, IsraelSearch for more papers by this authorHAGAI AMSALEM, HAGAI AMSALEM Department of Obstetrics and GynecologySearch for more papers by this authorSIMCHA YAGEL, SIMCHA YAGEL Department of Obstetrics and GynecologySearch for more papers by this authorDRORITH HOCHNER-CELNIKIER, Corresponding Author DRORITH HOCHNER-CELNIKIER Department of Obstetrics and Gynecology: Drorith Hochner-Celnikier, Department of Obstetrics and Gynecology, Hadassah University Hospital, Mt Scopus, PO Box 24035, Jerusalem, Israel hochner@hadassah.org.ilSearch for more papers by this author First published: 31 December 2010 https://doi.org/10.1080/00016340600608501Citations: 10AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Separation of the symphysis pubis accompanied by urinary retention is an uncommon obstetric complication. We describe a case of a woman with rupture of the symphysis pubis and prolonged overt urinary retention following spontaneous uncomplicated delivery. The clinical, diagnostic, and therapeutic aspects of this complication are discussed, and the relevant literature is reviewed. Case report A 37-year-old woman, gravida 4, para 3 was admitted to the delivery room in active labor with regular uterine contractions and fully effaced cervix, dilated to 5 cm. For pain relief, epidural catheter was introduced into the epidural space. She reached full dilatation within 4 hr. The second stage of the delivery lasted 7min. She delivered a normal female new-born, weighing 3545 g. Apgar scores were 8 and 10 at 1 and 5 min, respectively. The epidural catheter was removed 1 hr after labor. Five hours later, the patient complained of severe sharp supra-pubic pain, and a minute later, she was unable to walk, stand, or move from side to side. Her physical examination revealed intense tenderness over the pubic area, exacerbated by active or passive abduction. The neurological examination was normal. She underwent pelvic X-ray, demonstrating diastasis of the symphysis pubis of 5 cm (Figure 1a). Pelvic computed tomography (CT) scan confirmed the diagnosis of separation of the symphysis pubis with a demonstration of hematoma of 5×5 cm in the area of symphysis (Figure 1b). CT scan ruled out any pathological findings in the epidural space secondary to the insertion of the epidural catheter. Figure 1Open in figure viewerPowerPoint a) X-ray of the pubis demonstrating marked separation of the symphysis pubis (arrows). b) Computed tomograhy of the pubis showing marked distasis pubis with a large hematoma. The hematoma is bulging posteriorly and compressing the urethra (arrows), c) X-ray of the pubis after 4 months showing complete resolution of the distasis pubis (arrows). The patient was unable to urinate. A full bladder was palpated and demonstrated by ultrasound; therefore, a Foley catheter was introduced into the bladder. The patient was first managed with bed rest as well as strong circular bandage around the hips and narcotic and non-narcotic analgesics. On the third postpartum day, the patient was able to walk with great difficulty supported by a walker. Several attempts to withdraw the bladder catheter were unsuccessful owing to recurrent urinary retention. During her hospitalization, the patient was treated with intravenous antibiotics for urinary tract infection with Enterococcus, with satisfactory response. Following 2 weeks' hospitalization, the patient was discharged home with a catheter in the bladder and able to walk only with a walker. She resumed normal bladder function 8 weeks following delivery upon removal of the catheter and returned to her normal activities 3 months later. A pelvic X-ray performed 4 months after discharge revealed reversal of the separation to the normal prelabor state (Figure 1c). Discussion Rupture of the symphysis pubis is a rare complication that can occur before, during, and after delivery, usually following spontaneous non-traumatic rupture of the pubic ligaments. The risk of this complication is estimated between 1:600 and 1:2218 deliveries 1, 2, although frequency as rare as 1:30 000 is also mentioned in the literature 3. The diagnosis is made following sudden co-appearance of severe suprapubic pain and inability to move and walk, and tenderness over the symphysis with or without palpation of diastasis pubis on physical examination. The diagnosis is confirmed by pelvic X-ray or CT scan. Bladder dysfunction is also mentioned as part of the clinical picture, and insertion of a Foley catheter into the bladder is recommended for treatment of acute episode 1, 3. However, prolonged bladder atony associated with pubic separation has not been previously described. Urinary retention is a recognized postpartum complication, with prevalence varying between 1.7 and 17.9% 4. Several factors are associated with its occurrence. Physiologic changes of pregnancy and possible bladder hypotonia, due to elevated progesterone levels, instrumental delivery, epidural analgesia, primiparity, and protracted deliveries, have all been found to be associated with postpartum urinary retention 4, 5. Pelvic trauma, such as pubic separation, may result in mechanical outlet obstruction due to direct bladder trauma with retropubic hematoma pressing on the bladder neck, causing perineal edema. The prolonged urinary retention seen in our case may be attributable to a combination of factors: pain, immobilization, use of narcotic analgesia, and infection. The cause of pubic separation is unknown. Increasing load on the joint from increasing fetal and uterine weight, laxity of ligaments from increased production of relaxin and progesterone, and mechanical forces acting on the pelvic ring during labor all may contribute to symphyseal separation 6. Fewer than 50 cases have been described in the literature 1-3, 6. It is impossible to characterize specific predisposing factors during or following labor. The majority of patients described are multiparous. It has been speculated that these women undergo progressive weakening of the area of symphysis with each delivery, but this is not a consistent finding, and separation during the first delivery has also been described 3. Fetal macrosomia was mentioned by some authors as a contributing factor 1, 3, but this clinical variable also not consistently found. No association with instrumental deliveries or prolonged labor was found. On the contrary, rapid descent of the head and short second stage of labor might predispose to this complication. Variables such as epidural block, oxytocin use, and forceful abduction of the thighs were studied and not found to be associated with symphysis separation 7. Several therapeutic strategies of pubic separation are recommended. The conservative approach includes bed rest during the first most painful days, pelvic binder, analgesia, and early ambulation with the help of a walker. The use of intrasymphyseal injections of a combination of hydrocortisone, chymotrypsine, and lidocaine, given once a day for relief of severe pain was described by Schwartz 2 with good results. In cases with persistent complaints following conservative management, stabilization with open reduction and internal fixation were reported. Three such cases were described by Rommens. He reported good results with removal of the implants after a mean period of 6 months 8. The management of subsequent deliveries after pubic separation is a matter of controversy. The absence of recognized predisposing peripartum factors for separation makes this event very unpredictable. This might justify advocating elective cesarean delivery in subsequent births to prevent the recurrence of this complication. Culligan et al. found 19 accounts of vaginal deliveries in patients with previous separation. Nine deliveries were uneventful, however; 11 women suffered reseparation and/or recurrence of symptoms. The authors recommend elective cesarean delivery for patients with previous symphyseal separation 7. Conversely, Schwartz reported seven of 13 women with a previous separation had uncomplicated delivery in subsequent births 2. Uneventful birth only 10 months following pubic rupture is mentioned in Taylor's case series 1, and a case of normal delivery and postpartum period in a woman with a previous 5-cm separation was documented by Culligan 7. Summary Separation of the symphysis pubis is a relatively rare obstetric complication. It usually occurs following spontaneous uncomplicated delivery. Short second stage might play a role in the causation of this complication. It may be accompanied by prolonged urinary retention due to bladder atony. Early catheterization, bed rest, early ambulation, and circular pelvic bandage are recommended as conservative management. Surgical treatment is reserved only for rare patients who fail to respond to conservative treatment. Management of subsequent deliveries is subject to debate, and the options of elective cesarean section vs. vaginal delivery should be discussed. The prognosis is favorable with complete recovery in most cases after conservative management. References 1 Taylor RN, Sonson RD. Separation of the pubic symphysis. An underrecognized peripartum complication. J Reprod Med 1986; 31: 203– 6CASPubMedWeb of Science®Google Scholar 2 Schwartz Z, Katz Z, Lancet M. Management of puerperal separation of symphysis pubis. Int J Gyneacol Obstet 1985; 23: 125– 8Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 3 Snow RE, Neubert AG. Peripartum pubic symphysis separation: a case series and review of the literature. Obstet Gynecol Surv 1997; 52: 438– 43CrossrefCASPubMedGoogle Scholar 4 Glavind K, Bjork J. Incidence and treatment of urinary retention postpartum. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 119– 21CrossrefPubMedWeb of Science®Google Scholar 5 Carley ME, Carley JM, Vasdev G. Factors associated with clinically overt postpartum urinary retention after vaginal delivery. Am J Obstet Gynecol 2002; 187: 430– 3CrossrefPubMedWeb of Science®Google Scholar 6 Mens JM, Vleemihg A, Stoeckart R, Stam HJ, Snijders CJ. Understanding peripartum pelvic pain. Implications of patient survey. Spine 1996; 21: 1363– 9CrossrefPubMedWeb of Science®Google Scholar 7 Culligan P, Hill S, Heit M. Rupture of symphysis pubis during vaginal delivery followed by two subsequent uneventful pregnancies. Obstet Gynecol 2002; 100: 1114– 7CrossrefPubMedWeb of Science®Google Scholar 8 Rommens PM. Internal fixation in postpartum symphysis pubis rupture: report of three cases. J Orthop Trauma 1997; 11: 273– 6CrossrefPubMedWeb of Science®Google Scholar Citing Literature Volume85, Issue10October 2006Pages 1267-1269 FiguresReferencesRelatedInformation