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BMC Pregnancy and Childbirth

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Open Access 01-12-2021 | Osteitis Pubis | Research article

Postpartum septic symphysitis, a rare condition with possible long-term consequences: a cohort study with long-term follow-up

Authors: Helen Elden, Monika Fagevik Olsen, Nasrin Farah Hussein, Lisa Wibeck Axelsson, Verena Sengpiel, Michael Ullman

Published in: BMC Pregnancy and Childbirth | Issue 1/2021

Abstract

Background

Postpartum septic symphysitis (PPSS) is defined as acute onset of severe pain around the symphysis, restricted movement, fever, and elevated inflammatory parameters. It is a rare but serious condition requiring urgent diagnosis and treatment. The aim of this study was to describe the incidence, symptoms, diagnosis, treatment, and long-term follow-up of PPSS.

Methods

This follow-up study included 19 out of 21 women diagnosed with PPSS from 1989 to 2017 at one tertiary care hospital in Sweden. Clinical data were retrieved from hospital records and compared to those retrieved from a regional registry. Women completed a postal questionnaire, and those who reported lumbopelvic pain (LPP) were offered a clinical examination.

Results

1) PPSS was diagnosed after a normal postpartum period of 24 to 50 h by blood tests (n = 19/19), ultrasonography (n = 9 /19), computer tomography (n = 8/19) or magnetic resonance imaging (n = 16/19) Treatment included aspiration of symphyseal abscesses, i.v. antibiotics and different physiotherapeutic interventions. Women with PPSS more frequently were primiparous (n = 14/19, p = 0.001), had an instrumental delivery (n = 14/19, p = 0.003), longer time of active labour (p = 0.01) and second stage of labour (p = 0.001) than women in the regional registry. 2) Ten out of 19 (52%) women reported LPP at follow-up. These women more often suffered impaired function related to LPP (Pelvic Girdle Questionnaire, 27 versus 0, p < 0.0001), a poorer health-related quality of life (EuroQol-5 dimensions p = 0.001 and EuroQol-visual analogue scale, 65 mm versus 84 mm, p = 0.022) and higher levels of anxiety and depression (Hospital Anxiety Depression Scale (HADS) HADS-Anxiety, 7 versus 2, p = 0.010; and HADS-Depression, 1 versus 0, p = 0.028) than women with no pain. 3). Of the eight women who were clinically assessed, one had lumbar pain and seven had pelvic girdle pain (PGP).

Conclusions

In the largest cohort of patients with PPSS to date, primiparas and women with instrumental vaginal delivery were overrepresented, indicating that first and complicated deliveries might be risk factors. Approximately half of the women reported PGP at follow-up, with considerable consequences affecting health-related quality of life and function decades after delivery. Prospective multicentre studies are needed to establish risk factors, long-term consequences, and adequate treatment for this rare pregnancy complication.

Cosma S, Borella F, Carosso A, Ingala A, Fassio F, Robba T, et al. Osteomyelitis of the pubic symphysis caused by methicillin-resistant Staphylococcus aureus after vaginal delivery: a case report and literature review. BMC Infect Dis. 2019;19(1):952. https://doi.org/10.1186/s12879-019-4595-x.CrossRefPubMedPubMedCentral

Eskridge C, Longo S, Kwark J, Robichaux A, Begneaud W. Osteomyelitis pubis occurring after spontaneous vaginal delivery: a case presentation. J Perinatol. 1997;17(4):321–4.PubMed

Lovisetti G, Sala F, Battaini A, Lovisetti L, Guicciardi E. Osteomyelitis of the pubic symphysis, abscess and late disjunction after delivery. A case report. Chir Organi Mov. 2000;85(1):85–8.PubMed

Gamble K, Dardarian TS, Finstein J, Fox E, Sehdev H, Randall TC. Osteomyelitis of the pubic symphysis in pregnancy. Obstet Gynecol. 2006;107(Supplement):477–81.CrossRef

Ikpeme I, Archibong A, Udoh J, Nya A, Archibong G. Chronic osteomyelitis of the pubis in the peri-partum period–a rare presentation: case report and a review of the literature. Int J Third World Med. 2008;6:1–4.

Dunk RA, Langhoff-Roos J. Osteomyelitis of the pubic symphysis after spontaneous vaginal delivery. Case Rep. 2010;2010(oct11 1):bcr0120102610.

Lawford AM, Scott K, Lust K. A case of massive vulvar oedema due to septic pubic symphysitis complicating pregnancy. Aust N Z J Obstet Gynaecol. 2010;50(6):576–7. https://doi.org/10.1111/j.1479-828X.2010.01227.x.CrossRefPubMed

Froberg L, Eckardt H. Osteomyelitis of the pubic symphysis–a case report. J Obstet Gynaecol. 2015;35(8):862–3. https://doi.org/10.3109/01443615.2015.1017561.CrossRefPubMed

Hocedez C, Pelissier A, Mosbah R, Raimond E, Gabriel R, Graesslin O. Arthrite septique de la symphyse pubienne au cours de la grossesse. Gynecol Obstet Fertil. 2015;43(6):472–3. https://doi.org/10.1016/j.gyobfe.2015.03.014.CrossRefPubMed

10.

Kehila M, Majdoub M, Zegha D, Khedher SB, Cheour E, Mahjoub S. La symphysite pubienne du post-partum: un diagnostic difficile. Pan Afr Med J. 2013;16:14.PubMedPubMedCentral

11.

Ross JJ, Hu LT. Septic arthritis of the pubic symphysis. Medicine. 2003;82(5):340–5. https://doi.org/10.1097/01.md.0000091180.93122.1c.CrossRefPubMed

12.

Angoules AG. Osteitis pubis in elite athletes: diagnostic and therapeutic approach. World J Orthop. 2015;6(9):672–9. https://doi.org/10.5312/wjo.v6.i9.672.CrossRefPubMedPubMedCentral

13.

Norvilaite K, Kezeviciute M, Ramasauskaite D, Arlauskiene A, Bartkeviciene D, Uvarovas V. Postpartum pubic symphysis diastasis-conservative and surgical treatment methods, incidence of complications: two case reports and a review of the literature. World J Clin Cases. 2020;8(1):110–9. https://doi.org/10.12998/wjcc.v8.i1.110.CrossRefPubMedPubMedCentral

14.

Wong JSJ, Seaward LM, Ho CP, Anderson TP, Lau EOC, Amodeo MR, et al. Corynebacterium accolens-associated pelvic osteomyelitis. J Clin Microbiol. 2009;48(2):654–5.CrossRef

15.

Jacobson NJ, Van Demark RE, Reeves B. Osteomyelitis pubis treated with wedge resection: a case report with 26-year follow-up and literature review. S D Med. 2018;71(12):538–45.PubMed

16.

Ghislain L, Heylen A, Alexis F, Tintillier M. Septic arthritis of the pubic symphysis: an atypical abdominal pain. Acta Clin Belg. 2014;70(1):46–9. https://doi.org/10.1179/2295333714Y.0000000067.CrossRefPubMed

17.

Yusuf E, Hofer M, Steinrücken J, Trampuz A, Borens O. Septic arthritis of the pubic symphysis caused by Streptococcus mitis. Acta Clin Belg. 2014;69(6):454–5. https://doi.org/10.1179/2295333714Y.0000000059.CrossRefPubMed

18.

Cardoso L, Alves P, Santos F, Ross JJ. Septic arthritis of the pubic symphysis. BMJ Case Rep. 2017;2017:bcr2016216784.CrossRef

19.

Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Br J Sports Med. 2008;45(1):57–64. https://doi.org/10.1136/bjsm.2008.050989.CrossRefPubMed

20.

Budak MJ, Oliver TB. There’s a hole in my symphysis — a review of disorders causing widening, erosion, and destruction of the symphysis pubis. Clin Radiol. 2013;68(2):173–80. https://doi.org/10.1016/j.crad.2012.03.021.CrossRefPubMed

21.

Tiemann AH, Röhm C, Hofmann GO. Putrid infectious pubic osteitis: case report and review of the literature on the differential diagnosis and treatment of infectious pubic osteitis and inflammatory pubic osteitis. Eur J Trauma Emerg Surg. 2010;36(5):481–7. https://doi.org/10.1007/s00068-010-0012-2.CrossRefPubMed

22.

Vleeming A, Albert HB, Östgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008;17(6):794–819. https://doi.org/10.1007/s00586-008-0602-4.CrossRefPubMedPubMedCentral

23.

Gashaw M, Gedlu S, Janakiraman B. Burden of pelvic girdle pain during pregnancy among women attending antenatal clinic, Ethiopia: a cross-sectional study. BMC Pregnancy Childbirth. 2020;20:494.CrossRef

24.

Elden H, Gutke A, Kjellby-Wendt G, Fagevik-Olsen M, Ostgaard HC. Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study. BMC Musculoskelet Disord. 2016;17(1):276. https://doi.org/10.1186/s12891-016-1154-0.CrossRefPubMedPubMedCentral

25.

Yan CX, Vautour L, Martin MH. Postpartum sacral insufficiency fractures. Skelet Radiol. 2016;45(4):413–7. https://doi.org/10.1007/s00256-015-2289-z.CrossRef

26.

Brumfield CG, Hauth JC, Andrews WW. Puerperal infection after cesarean delivery: evaluation of a standardized protocol. Am J Obstet Gynecol. 2000;182(5):1147–51. https://doi.org/10.1067/mob.2000.103249.CrossRefPubMed

27.

Data from the Swedish national board on health and welfare. [https://sdb.socialstyrelsen.se/if_mfr_004/val.aspx].

28.

Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder R, Walker BF, et al. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976). 2008;33(1):95–103. https://doi.org/10.1097/BRS.0b013e31815e7f94.CrossRef

29.

Stuge B, Garratt A, Jenssen HK, Grotle M. The pelvic girdle questionnaire: a condition-specific instrument for assessing activity limitations and symptoms in people with pelvic girdle pain. Phys Ther. 2011;91(7):1096–108. https://doi.org/10.2522/ptj.20100357.CrossRefPubMed

30.

Gutke A, Stuge B, Elden H, Sandell C, Asplin G, Olsén MF. The Swedish version of the pelvic girdle questionnaire, cross-cultural adaptation and validation. Disabil Rehabil. 2019;42(7):1013–20. https://doi.org/10.1080/09638288.2018.1515991.CrossRefPubMed

31.

Rabin R, De Charro F. EQ-5D: a measure of health status from the EuroQol group. Ann Med. 2001;33(5):337–43. https://doi.org/10.3109/07853890109002087.CrossRef

32.

Burström K, Johannesson M, Rehnberg C. Deteriorating health status in Stockholm 1998–2002: results from repeated population surveys using the EQ-5D. Qual Life Res. 2007;16(9):1547–53. https://doi.org/10.1007/s11136-007-9243-z.CrossRefPubMed

33.

Huskinsson E. Measurement of pain. Lancet. 1974;304(7889):1127–31. https://doi.org/10.1016/S0140-6736(74)90884-8.CrossRef

34.

Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–70. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x.CrossRef

35.

Swedish version of the general self-efficacy scale. Från Freie Universität[http://userpage.fu-berlin.de/~health/swedish.htm]. Accessed 12 Oct 2020.

36.

Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the hospital anxiety and depression scale. J Psychosom Res. 2002;52(2):69–77. https://doi.org/10.1016/S0022-3999(01)00296-3.CrossRefPubMed

37.

Bandura A. Self-efficacy–the exercise of control. New York: Freeman and Company; 1997.

38.

Sullivan MJL, Bishop SR, Pivik J. The pain catastrophizing scale. Psychol Assess. 1995;7(4):524–32.CrossRef

39.

Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Exp Rev Neurother. 2009;9(5):745–58. https://doi.org/10.1586/ern.09.34.CrossRef

40.

Flink IK, Mroczek MZ, Sullivan MJ, Linton SJ. Pain in childbirth and postpartum recovery: the role of catastrophizing. Eur J Pain. 2009;13(3):312–6. https://doi.org/10.1016/j.ejpain.2008.04.010.CrossRefPubMed

41.

Hakim AJ, Grahame R. A simple questionnaire to detect hypermobility: an adjunct to the assessment of patients with diffuse musculoskeletal pain. Int J Clin Pract. 2003;57(3):163–6.PubMed

42.

Olsson CB, Grooten WJA, Nilsson-Wikmar L, Harms-Ringdahl K, Lundberg M. Catastrophizing during and after pregnancy: associations with lumbopelvic pain and postpartum physical ability. Phys Ther. 2012;92(1):49–57. https://doi.org/10.2522/ptj.20100293.CrossRefPubMed

43.

McCaffrey N, Kaambwa B, Currow DC, Ratcliffe J. Health-related quality of life measured using the EQ-5D–5L: south Australian population norms. Health Qual Life Outcomes. 2016;14(1):133. https://doi.org/10.1186/s12955-016-0537-0.CrossRefPubMedPubMedCentral

44.

Hinz A, Herzberg PY, Lordick F, Weis J, Faller H, Brähler E, et al. Age and gender differences in anxiety and depression in cancer patients compared with the general population. Eur J Cancer Care. 2019;28(5):e13129. https://doi.org/10.1111/ecc.13129.CrossRef

45.

Bonsaksen T, Lerdal A, Heir T, Ekeberg Ø, Skogstad L, Grimholt TK, et al. General self-efficacy in the Norwegian population: differences and similarities between sociodemographic groups. Scand J Public Health. 2018;47(7):695–704. https://doi.org/10.1177/1403494818756701.CrossRefPubMed

46.

Severeijns R, van den Hout MA, Vlaeyen JWS, Picavet SJH. Pain catastrophizing and general health status in a large Dutch community sample. Pain. 2002;99(1):367–76. https://doi.org/10.1016/S0304-3959(02)00219-1.CrossRefPubMed

47.

Wu CH. Factor analysis of the general self-efficacy scale and its relationship with individualism/collectivism among twenty-five countries: application of multilevel confirmatory factor analysis. Pers Individ Dif. 2009;46(7):699–703. https://doi.org/10.1016/j.paid.2009.01.025.CrossRef

48.

Olsson CB, Nilsson-Wikmar L, Grooten WJA. Determinants for lumbopelvic pain 6 months postpartum. Disabil Rehabil. 2011;34(5):416–22. https://doi.org/10.3109/09638288.2011.607212.CrossRefPubMed

49.

Severeijns R, Vlaeyen JW, van den Hout MA, Picavet HS. Pain catastrophizing and consequences of musculoskeletal pain: a prospective study in the Dutch community. J Pain. 2005;6(2):125–32. https://doi.org/10.1016/j.jpain.2004.11.006.CrossRefPubMed

50.

Papageorgiou AC, Croft PR, Ferry S, Jayson MIV, Silman AJ. Estimating the prevalence of low back pain in the general population. Spine (Phila Pa 1976). 1995;20(17):1889–94. https://doi.org/10.1097/00007632-199509000-00009.CrossRef

51.

Wuytack F, Curtis E, Begley C. Experiences of first-time mothers with persistent pelvic girdle pain after childbirth: descriptive qualitative study. Phys Ther. 2015;95(10):1354–64. https://doi.org/10.2522/ptj.20150088.CrossRefPubMed

Title: Postpartum septic symphysitis, a rare condition with possible long-term consequences: a cohort study with long-term follow-up
Authors: Helen Elden
Monika Fagevik Olsen
Nasrin Farah Hussein
Lisa Wibeck Axelsson
Verena Sengpiel
Michael Ullman
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Osteitis Pubis
Pyarthrosis
Osteomyelitis
Published in: BMC Pregnancy and Childbirth / Issue 1/2021
Electronic ISSN: 1471-2393
DOI: https://doi.org/10.1186/s12884-021-04023-w

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Postpartum septic symphysitis, a rare condition with possible long-term consequences: a cohort study with long-term follow-up

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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