Pelvic girdle pain

The severity of pelvic girdle pain (symphysis pubis dysfunction) during pregnancy varies widely. Advice should be aimed towards minimising pain.

59.1 Background

Pelvic girdle pain has been described as a collection of signs and symptoms of discomfort and pain in the pelvis and lower back (lumbopelvic) area, including musculoskeletal pain radiating to the upper thighs and perineum. Symptoms occur due to relaxation of the pelvic ligament and increased joint mobility in pregnancy. Symptoms vary from mild discomfort to severe and debilitating pain that can hinder mobility. Other causes of pain in the pelvic area (eg urinary tract infection, preterm labour) should be excluded (Kanakaris et al 2011). Pelvic girdle pain usually resolves spontaneously after the birth (Elden et al 2008), although symptoms may recur during subsequent pregnancies (Leadbetter et al 2004).

59.1.1 Incidence in pregnancy

• The true incidence of pelvic girdle pain in pregnancy is unknown and estimates from low-level evidence are contradictory, ranging from approximately 4% to 84% Bastiaanssen et al 2005, Morgren & Pohjanen 2005, Robinson et al 2006, Robinson et al 2010. The wide variation can be attributed to various factors including the absence of a precise definition and diagnostic criteria, differences in study design and selection of the study population.
• The incidence of pelvic girdle pain has been found to be higher in late pregnancy Gutke et al 2006, Leadbetter et al 2004, Van de Pol et al 2007, Robinson et al 2010, Kovacs et al 2012 and among women with a higher BMI (Kovacs et al 2012).
• There is currently no evidence regarding the incidence of pelvic pain in specific population groups.

59.1.2 Factors influencing pelvic girdle pain

Low-level evidence indicates that Morgren 2005; Albert et al 2006; Eberhard-Gran & Eskild 2008; Biering 2010:

• pelvic pain is more common in women with a previous history of low back pain Albert 2006, Bjelland et al 2010 or trauma of the back or pelvis Albert 2006
• risk factors for developing pelvic pain include: increased number of previous pregnancies Albert 2006, Bjelland et al 2010, Robinson et al 2010; physically demanding work Morgren 2005, Bjelland et al 2010; high BMI Albert 2006, Eberhard-Gran & Eskild 2008, Bjelland et al 2010; emotional distress (Bjelland et al 2010) smoking Albert 2006, Biering et al 2010.

The evidence on age as a risk factor for pelvic pain in pregnancy is inconsistent Eberhard-Gran & Eskild 2008, Bjelland et al 2010.

59.2 Discussing pelvic girdle pain

NICE 2008 found little evidence on which to base clinical practice. Subsequent evidence is limited by the heterogeneity and low quality of studies and the inconsistency of findings.

59.2.1 Treatments for pelvic pain

Systematic reviews into interventions for women with pelvic girdle pain have found low-level evidence:

• women receiving acupuncture or physiotherapy reported less intense pain in the morning or evening than women receiving usual antenatal care and acupuncture was more effective in reducing evening pain than physiotherapy (Pennick & Young 2007)
• acupuncture was more effective than standard treatment, physiotherapy, or stabilising exercises (Ee et al 2008)
• exercise, pelvic support garments and acupuncture improved functional outcomes (Richards et al 2012)
• exercise during pregnancy may decrease pelvic girdle pain Schiff Boissonnault et al 2012.

RCTs have found benefits from a multimodal approach (manual therapy, stabilisation exercises, patient education) (George et al 2012) and no reduction of pain with exercise Eggen et al 2012, Stafne et al 2012.

Lower level evidence supports acupuncture as an effective intervention (Ekdahl & Petersson 2010). No serious adverse effects were reported (minor side effects included bruising, pain on needle insertion, bleeding, haematoma and fainting).

59.2.2 Advice on managing pelvic girdle pain

There is consensus from low-level evidence and clinical reviews about providing advice on minimising pain, including Vleeming et al 2008, Leadbetter et al 2004, Aslan & Fynes 2007:

• wearing low-heeled shoes
• seeking advice from a physiotherapist regarding exercise and posture
• reducing non-essential weight-bearing activities (eg climbing stairs, standing/walking for long periods of time)
• avoiding standing on one leg (eg by sitting down to get dressed)
• avoiding movements involving hip abduction (eg taking care getting in/out of cars, baths or squatting)
• applying heat to painful areas.

59.3 Practice summary: pelvic girdle pain

When

A woman has pelvic girdle pain.

Who

• Midwife
• GP
• obstetrician
• Aboriginal and Torres Strait Islander Health Practitioner
• Aboriginal and Torres Strait Islander Health Worker
• multicultural health worker
• physiotherapist.

What

• Provide advice
  Reassure the woman that pelvic girdle pain will not harm her or her unborn child, and is likely to resolve after the birth. Advise the woman about steps she can take to minimise pain.
• Take a holistic approach
  Consider possible barriers to women being able to make changes to minimise their pain (eg work requirements, cultural attitudes to exercise, costs of allied health services).

59.4 Resources

• Remote Primary Health Care Manuals (2017). Common discomforts of pregnancy. In: Women’s Business Manual (6th edition). Alice Springs, NT: Centre for Remote Health.