A Case Of Postpartum Pubic Diastasis

Author Information

Mhaske N*, Madhva Prasad S**, Kharat D***, Fonseca MN****.

(* Second Year Resident, ** Fourth Year Resident, *** Assistant Professor, ****  Professor. Department of Obstetrics and Gynecology, Department of Obstetrics/Gynecology, LTMMC and LTMGH, Mumbai, India)

Abstract

A home-delivered postpartum patient presented on day 5 with pubic diastasis. The patient was successfully managed conservatively.

Introduction

With increasing emphasis on institutional delivery, the focus is shifting from reduction of maternal mortality to prevention of maternal morbidity.^[1] In this setting, a case of home delivery with postpartum pubic diastasis is reported.

Case Report

A 23 year old primipara who was unregistered and unimmunized throughout pregnancy, presented to our hospital, on the fifth day following home delivery, with fever, hip pain and purulent discharge per vaginum. The home delivery was assisted by an untrained traditional birth assistant, and the patient reported that she was having labor pains for about 12 hours. She did not report any major difficulty in delivery, such as need for fundal pressure or baby needing to be pulled out. The patient had delivered a healthy female weighing 3500 g, which cried immediately after birth. Following delivery, she noticed difficulty in walking and getting up. Upon worsening of symptoms, she presented to the hospital. There was no urinary incontinence. There was no significant past medical or surgical illnesses. 

The patient was clinically stable with unremarkable systemic examination. Right paraurethral region was ulcerated with slough, and the pubic bones were grossly visible. Digital examination confirmed separation of the pubic symphysis and exposure of supporting connecting tissue (figure 1). There was no perineal tear and speculum examination revealed no cervical tear. Pervaginal examination revealed an involuting uterus. Per rectal examination was unremarkable. Hemoglobin was 6 g/dL, for which blood transfusion was given, and total white blood cell count was raised. Pelvic ultrasonography was normal. Radiography was suggestive of pubic diastasis (figure 2). Magnetic resonance imaging showed diastasis fracture of pubic symphysis with air speck seen in the pubic symphysis which was extending cranially in subcutaneous plane in anterior abdominal wall. Specialist orthopedic and urology opinion advised conservative line of management, which consisted of intravenous antibiotics, urethral catheterization, daily dressing and pelvic hip binder. With reduction in symptoms, and formation of healthy granulation tissue, the patient was discharged after three weeks.  After one year, though there was evidence of pubic diastasis on radiography, the patient wass asymptomatic and had a normal gait. 

Figure 1. (a) showing diastasis of pubic bone; (b) showing separation of urethra from its supporting tissue.

Figure 2. Arrow shows diastasis with fracture of pubic symphysis.

Discussion

Global met need for Emergency Obstetric Care (EmOC) is about 45%,^[2] and it is estimated that about 53% of deliveries in India are conducted by Traditional Birth Attendants. ^[3] Pubic diastasis is a drastic complication of unattended deliveries and is more common than estimated. The risk factors include nulliparity, macrosomia, shoulder dystocia, fundal or suprapubic pressure, cephalopelvic disproportion and twin gestation^[4]. The clinical symptoms include pain, restricted mobility, urinary incontinence and there can be chronic problems like prolapse, dyspareunia and psychosexual dysfunction. ^[4] Management options include conservative treatment, while surgical interventions like external fixation may be necessary, when bone separation is more than 3 cm.^[5,6,7]  Osteomyelitis, urinary incontinence, retropubic hematoma and bladder entrapment are possible surgical complications.^[6,8,] Physiotherapy is helpful.^[10] Despite appropriate management chronic morbidities persist.^[4]

This case highlights the catastrophic nature of complications that can occur when labor is not supervised by trained personnel. This case serves to emphasize the need for encouragement of institutional delivery.^[3] It is opined that all such occurrences be reported, so as to contribute to the improvement of maternal outcomes and prevention of obstetric morbidity.

References

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Citation

Mhaske N, Madhva Prasad S, Kharat D, Fonseca MN. A Case Of Postpartum Pubic Diastasis. JPGO 2015. Volume 2 No. 3. Available from:  http://www.jpgo.org/2015/03/a-case-of-postpartum-pubic-diastasis.html