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Traumatic disruption of pubis symphysis with accompanying posterior pelvic injury after natural childbirth.

November 2007 E167 Parturition-induced pelvic instability is a rare pathogenetic entity. Reports of the incidence of symphyseal rupture after vaginal delivery have varied from 1 in 300 to 1 in 30,000 deliveries.1-6 The extent of symphyseal changes during pregnancy and delivery may vary significantly. Peripartum ligamentous relaxation with moderate widening of symphysis pubis and sacroiliac (SI) joints is physiologic and occurs regularly.7,8 Anterior separation of the pubic symphysis of more than 2.5 cm progressively causes injury to the posterior pelvic ring, including disruption of the SI joint or sacral fractures.9 When symphyseal rupture does occur, it typically happens during delivery or shortly after labor and is characterized by a sharp and immediate onset of severe pain over the pubic symphysis and may extend posteriorly into the SI joint region accompanied by an audible crack. Treatment of a ruptured pubic symphysis is predominately nonoperative and consists of pelvic binder application, immobilization and bed rest, analgesia, and physical therapy.10 Operative treatment has been described in selected cases, particularly when nonoperative treatment is unsuccessful.1,11,12 Symphyseal rupture that may indicate posterior pelvic arch instability requires reduction and stable fixation. These injuries result in an unstable pelvic disruption and may correspond to traumatic anteroposterior compression (APC) II or III or Tile type B or C pelvic injuries.9,13 These women should be managed as one would a trauma patient with a pelvic fracture—including vigilant monitoring of hemodynamic status and aggressive resuscitation, appropriate diagnostic imaging studies, and timely operative reduction and fixation of the pelvis. In this report, we present the case of a woman in her early 30s suffering from traumatic symphysis diastasis with accompanying disruption of left and right SI joints after natural childbirth. The patient, who was successfully treated with open reduction and internal fixation (ORIF) of the symphysis and percutaneous screw fixation of the SI joints, recovered from this disabling injury.