The basics - Pelvic girdle pain in pregnancy

Pelvic girdle pain may have a high degree of psychosocial impact, explains Dr Anna Cumisky.

Sleeping with a pillow between the knees prevents strain on the pelvis (Photograph: SPL)
Sleeping with a pillow between the knees prevents strain on the pelvis (Photograph: SPL)

Pelvic girdle pain (PGP) is an important condition of pregnancy and postpartum, with around one in five women experiencing a degree of pelvic discomfort.

A proportion of these will have severe pain that may persist well into the postpartum period. It is important for GPs to look out for diagnostic clues and optimise management early to help reduce morbidity for both mother and child.

Various terms have been used to describe conditions relating to pelvic pain in pregnancy, such as pubic symphysis dysfunction and pelvic hypermobility. PGP is the term now used to encompass these.

1. Causes
Factors thought to contribute to the onset of PGP include the postural changes and alteration to the centre of gravity that come with pregnancy, the influence of the pregnancy-related hormone relaxin on the pelvic joints and the increasing weight and position of the growing baby.

However, as not all pregnant women develop PGP, it appears that these factors only become important in susceptible individuals. Women at risk include those with a past history of PGP, lower back pain or any past pelvic trauma.

Incidence also appears to be increased in pluriparous pregnancies and in women operating under high levels of stress at work.

Other factors, such as contraceptive pill use, height, weight and smoking status, have been shown not to affect the risk of developing PGP.1

2. Onset
The onset of pain is usually during later pregnancy although it may start in the first trimester. Occasionally PGP is sudden, usually brought on following an episode of trauma, such as a fall, or a movement that puts strain on the pelvic joints.

In some, the onset is after the pelvic strain of childbirth itself. A common misconception is that PGP is a phenomenon of pregnancy alone and that it will spontaneously resolve once the baby is born. This is rarely the case.

3. Clinical features
The hallmark of PGP is persistent pain felt within the pelvis. It may be felt in the pubic symphysis and/or the sacroiliac joints and often radiates to the groin, the lower abdomen or the upper thigh.

Pain is often worse with excessive movement or with prolonged periods of sitting or standing and further exacerbated by carrying or pushing a heavy load. Normal activities, such as dressing, washing and moving in bed are painful.

PGP often has a high psychosocial impact, potentially putting strain on the woman's relationship with both the partner and the new baby.

On examination, there is often a waddling gait and an audible click on movement. The symphysis pubis and/or sacroiliac joints are often tender and it is usual to find a degree of swelling over the joint.

The range of hip movement can be reduced in all directions, with active straight leg raising markedly reduced. Trendelenburg testing reveals it is difficult or impossible to stand on one leg.

4. Management
The keys to successful management are early diagnosis, patient education and an empathetic and supportive approach. Early referral to physiotherapy is appropriate in suspected cases.

In cases established during pregnancy, multidisciplinary management involving the patient's midwife and birthing team is important.

Hydrotherapy, acupuncture and massage therapy have been shown to be beneficial.

5. Self-help strategies
To prevent exacerbating the problem, patients should avoid standing or sitting for too long and avoid sitting in very low chairs. They should avoid further strain on the pelvis by, for example, sleeping with a pillow between the knees, keeping knees together when rolling in bed, rolling onto their side first when getting up from lying down and bringing legs with knees together down to the floor before pulling upper body vertical.

Patients should be advised to mobilise regularly but to avoid exertion and twisting, bending and squatting movements. A good guide is to ensure all motion is within the limits of pain and interspersed with regular rest periods.

Patient education is vital. Peer groups have been set up for women with PGP to educate and provide support with online forums and discussion (see resources).

6. Pain relief
Simple analgesics, such as paracetamol and low strength opiates, are useful, although advice should be given regarding care not to over-exert oneself when the pain symptoms are masked. Higher strength opiates may be necessary at bedtime.

NSAIDs are usually avoided during pregnancy but some NSAIDs (such as ibuprofen) may be useful postpartum for some patients.

Steroid injections are occasionally considered, although there is little current evidence to support their use.

7. Physiotherapy
Physiotherapy is helpful in both the assessment and management of PGP and is safe at any stage of pregnancy.

Physiotherapists trained in PGP management can perform a detailed physical examination using provocation tests to identify specific areas of concern and develop a management plan accordingly.

Physiotherapists use manipulation and mobilisation to help stabilise and strengthen the lower spine and pelvic girdle while improving mobility and reducing pain.

Physiotherapists can also teach ongoing exercises and give advice on back care, ergonomics and lifting while recommending and providing walking aids when required. Pelvic belts are sometimes issued for short-term use to help support the pelvic girdle.

8. Further investigations
When symptoms persist despite physiotherapy and conservative management, further investigations may be required to identify an alternative cause, such as arthritis or a space occupying lesion.

Red flags including bowel or bladder disturbance, lower limb weakness or persistent sensory change or systemic illness may also prompt further investigations.

In the case of pelvic separation (diastasis), or in those with persistent PGP unresponsive to conservative methods, referral to orthopaedics is appropriate as surgical fixation may be required.

9. Prognosis
For most women, PGP resolves a few weeks postpartum but for a few it can last months or years with ongoing impact on daily life.

Recent statistics suggest that 45 per cent of all pregnant women and 25 per cent of all women postpartum experience PGP.

Of these, 25 per cent suffer severe pain during pregnancy, with severe disability found in 8 per cent. After pregnancy, serious problems persist in only 7 per cent.2 Recovery can take up to two years.

Differential Diagnosis
  • Ankylosing spondylitis.
  • Other arthritides, including those related to inflammatory bowel disease.
  • Space occupying lesions.
  • Referred pain from low back lesions.
  • Dr Cumisky is a locum GP in Bath, Somerset
References
1. Vleeming A, Albert HB, Ostgaard HC, et al. European Guidelines on the diagnosis and treatment of pelvic girdle pain. Eur Spine J 2008; 17(6): 794-819.

2. Wu WH, Meijer OG, Uegaki K, et al. Pregnancy-related pelvic girdle pain (PPP), I: terminology, clinical presentation and prevalence. Eur Spine J 2004; 13: 575-89.

Resources

Featured pain resource - paineurope.com

Pain management resource for healthcare professionals in Europe

paineurope.com is a promotional resource, funded by and prepared with editorial input from Mundipharma International Ltd, as a service to pain management.

Item Code: MINT/PPR-12008

Date of Preparation: May 2012

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