There were 21 cases of PPSS identified during the 28-year period (range 1 to 28 years (mean 8 years) with approximately 10 000 deliveries per year in the Gothenburg region. This indicates a PPSS incidence of 0.01%. Nineteen of twenty invited women returned their written consent forms and completed the questionnaire. Hospital records were unavailable for one woman thus, the hospital records of 18 women who consented to participate were retrieved to determine the baseline characteristics. Ten women reported LPP at follow-up and were offered a physical examination including an established pain provocation assessment [22]. Two women declined the visit; thus, eight women were examined. All eight women reported chronic LPP, i.e. that LPP had always been present since the postpartum period of the index pregnancy. Figure 1 shows the progress of patients throughout the study.
Study population characteristics
Table 1 shows the baseline characteristics obtained from the hospital records of the women with PPSS; the women were grouped according to the presence or absence of LPP at follow-up and compared to those in the same region during the same period, as reported by the Swedish National Board on Health and Welfare. The average age for women with PPSS at delivery was 33 years, and that of the general population during the same period was 29.6 years. However, there were more primiparous women (p=<0.001) and more women with a vaginal instrumental delivery (p=<0.003) in the PPSS group than in the women who gave birth in the same area during the same period (Table 1). Additionally, more women with PPSS reported PGP during the index pregnancy (n=9/19) and had classified PGP at follow-up (n= 8/19) than stated in the literature [22, 24, 42]. One of the women required an emergency caesarean section.
Table 1. Baseline characteristics. Women with PPSS and women in the same region during the same period1.
Variable
|
All women with PPSS
(n=19)
|
SoS data VGR 1989–2017 (min-max)1
|
LPP at follow-up
(n=10)
|
No LPP at follow-up
(n=9)
|
P-value for comparison of persistent pain versus no pain at follow-up
|
P-value for comparison of all women in SoS1 versus all women with PPSS during pregnancy
|
Primipara during index delivery
|
14 (74)
|
(43.5)
(39.7 in 1994 to 46.3 in 2008)
|
8
|
6
|
0.444
|
<0.001
|
2nd/3rd delivery
|
5
|
|
2
|
3
|
|
|
Pelvic girdle pain during index pregnancy*
|
9 (47)
|
-
|
4
|
5
|
1.000
|
|
Age at delivery, years
|
33
(27-43)
|
29.6
(28.0 in 1989 30.5 in 2017)
|
33
(28-34)
|
32
(27-43)
|
0.768
|
|
Body mass index at first antenatal care visit
|
25.4
(17.0-34.9)
|
24.4
(23.4 in 1992 to 25.1 in 2017)2
|
26.1 (20.3-29.3)
|
24.8
(17.0-34.9)
|
0.624
|
|
Gestational weeks at delivery, min-max
|
40
(34-42)
|
-
|
40
(38-42)
|
40 (34-4)
|
0.666
|
|
Spontaneous contractions
|
15 (79)
|
(89.3
(82.7 in 2017 to 92.3 in 1991)3
|
7
|
8
|
0.582
|
|
Missing data
|
4
|
|
3
|
1
|
|
|
Induction of labour
|
4 (21)
|
10.6
(7.7 in 1991 to 17.3 in 2017)3
|
3
|
1
|
0.582
|
0.408
|
Use of oxytocin
|
9 (47)
|
-
|
4
|
5
|
1.000
|
|
Missing data
|
2
|
|
2
|
|
|
|
Established contractions to delivery, hours, (min-max)
|
8.4
(1.5-18)
|
-
|
10.6 (3.5-18)
|
6.4
(1.5-11.8)
|
0.152
|
|
Missing data
|
5
|
|
3
|
2
|
|
|
Duration of second stage of labour, minutes, (min-max)
|
38
(7-310)
|
-
|
36
(16-60)
|
38
(7-310)
|
0.864
|
|
Missing data
|
4
|
|
4
|
0
|
|
|
Birth position
|
|
|
|
|
|
|
On the side
|
1
|
-
|
1
|
0
|
0.281
|
|
Lithotomy
|
8 (44)
|
|
3
|
5
|
|
|
Semi-sitting
|
3
|
|
0
|
3
|
|
|
Dorsal Recumbent
|
5
|
|
4
|
1
|
|
|
Missing data
|
1
|
|
1
|
0
|
|
|
Occiput anterior position at delivery
|
17
(89)
|
-
|
8
|
9
|
1.000
|
|
Missing data
|
3
|
|
2
|
1
|
|
|
Vaginal instrumental delivery
|
4 (21)
|
6.4
(5.0 in 1989 and 2017 to 7.7 in 2009)
|
2
|
2
|
0.509
|
0.003
|
Mid-vacuum extraction
|
3
|
-
|
2
|
1
|
NA
|
|
Low-vacuum extraction
|
1
|
-
|
0
|
1
|
NA
|
|
Caesarean section (emergency)
|
1
|
13.9
(10.0 in 1991 to 16.7 in 2016)
|
1
|
0
|
|
|
Total bleeding, ml
|
375
(200-1400)
|
-
|
350 (200-1100)
|
425
(300-1400)
|
0.508
|
|
Episiotomy
|
3
|
-
|
1
|
2
|
0.582
|
|
Vaginal tear
|
10 (53)
|
-
|
4
|
6
|
0.637
|
|
Perineal tear
|
12 (63)
|
-
|
5
|
7
|
0.620
|
|
Third- or fourth-degree tears
|
2
|
-
|
1
|
1
|
1.000
|
|
Characteristics of newborns
|
|
|
|
|
|
|
Weight (g), min-max
|
3800
2335-4610
|
3516.7
(3488.7 in 2008 in to 3541.8 in 1994)
|
3980
2980-4610
|
3670
2335-4610
|
0.4888
|
|
Sex (girl)
|
6 (31.6)
|
-
|
3
|
3
|
1.000
|
|
Sex (boy)
|
13 (68)
|
-
|
7
|
6
|
1.000
|
|
Apgar score ≤ 7 at 5 min
|
2
|
(1.2)
(0.9 in 1994 to 1.4 1996)
|
2
|
0
|
0.259
|
NA
|
Perinatal mortality
|
1 (0.05)
|
0.79
(0.60 in 2015 to 1.05 in 1990)
|
1
|
0
|
1.000
|
NA
|
Data from hospital records. LPP, Lumbar Pelvic Pain; PPSS, Postpartum Septic Symphysitis. SoS data1, Data from the Swedish National Board on Health and Welfare *Patient-reported data. Median (min-max) or n (%, only for the whole group). The chi-square test or Fisher’s exact test for non-ordered categorical variables and the Mann-Whitney U-test for continuous variables were used. NA, Not applicable.
1 https://sdb.socialstyrelsen.se/if_mfr_004/val.aspx
2 Data available from only 1992
3Data available from only 1991 and for vaginal deliveries only.
Clinical presentation at diagnosis (hospital record-based data)
Table 2 shows descriptive data on symptoms, diagnosis and treatment from hospital records for all women and separated for women with and without LPP at follow-up.
PPSS was diagnosed after delivery and an uncomplicated post-puerperal period of 24 to 50 hours. Diagnosis was established by blood tests (n=19), MRI (n=13/19), ultrasonography (n=8/19) or CT (n= 3/19) (Figures 2-4). Blood culture or wound exudate swabs were positive in three women, presumably because i.v. antibiotics were administered before culture samples were collected. Treatments included i.v. antibiotics, aspiration of symphyseal abscesses (n=2/19) and physiotherapy.
Table 2 Hospital records: Descriptive data on symptoms, diagnosis and treatment of PPSS.
Variable
|
All women
(n = 19)
|
LPP at follow-up
(n = 10)
|
No LPP at follow-up
(n = 9)
|
Year of diagnosis
|
|
|
|
1989-1999
|
3
|
3
|
0
|
2000-2010
|
7
|
2
|
5
|
2011-2018
|
9
|
5
|
4
|
Age, years
|
33 (27-43)
|
33 (28-43)
|
33 (27-43)
|
Last recorded BMI in pregnancy, kg/m2
|
27 (20-36)
|
29 (23-36)
|
25 (20-34)
|
Symptoms
|
38.0 (64.8)
|
24.6 (29.0)
|
49.8 (81.9)
|
PPSS debut, hours after delivery, min-max
|
0-264.0
|
8.2-72.0
|
0-264.0
|
Pain location
|
|
|
|
Symphysis pubic
|
14/15 (93)
|
7/7
|
7/8
|
Sacroiliac joint/s plus hip joints
|
11/14 (79)
|
5/7
|
6/7
|
Temperature ≥37.5°C
|
15
|
7
|
8
|
≥37.5°C, days
|
3.3 (1-7)
|
3.2 (1-7)
|
3.5 (1-6)
|
Diagnosis
|
|
|
|
Ultrasound
|
10 (53)
|
3
|
7
|
CT
|
6
|
3
|
3
|
MRI + Ultrasound
|
8
|
3
|
5
|
MRI + CT
|
1
|
0
|
1
|
MRI + CT+ Ultrasound
|
3
|
1
|
2
|
MRI
|
|
1
|
0
|
Only CT
|
1
|
0
|
1
|
Neither MRI nor CT
|
1
|
0
|
1
|
Blood tests
|
|
|
|
CRP >5 at diagnosis
|
17 (89)
|
8
|
9
|
Leucocytes at diagnosis ×109/L
|
15.4 (6.3-20)
|
10.8 (7.3-20)
|
15.8 (6.3-20)
|
Blood culture
|
10 (53)
|
6
|
4
|
Wound exudate cultivation
|
2
|
1
|
1
|
Aspiration of abscess
|
1
|
1
|
0
|
Positive blood culture or wound exudate cultivation
|
3
|
2
|
1
|
Treatment
|
|
|
|
Antibiotics
|
19 (100)
|
10
|
9
|
Physiotherapy
|
14 (74)
|
6
|
8
|
Wheel-chair, crutches, walker
|
13 (68)
|
6
|
7
|
Pelvic belt
|
7
|
4
|
3
|
Pain killers, paracetamol
|
16 (84)
|
7
|
9
|
Pain killers, NSAIDs
|
11 (58)
|
4
|
7
|
Pain killers, opioids
|
13 (68)
|
6
|
7
|
Patient-controlled analgesia
|
1
|
1
|
0
|
TENS
|
2
|
0
|
2
|
Follow-up visit to physician
|
14 (74)
|
7
|
7
|
Data from hospital records. PPSS=Post-partum Septic Symphysitis, LPP, Lumbar Pelvic Pain; MRI= Magnetic Resonance Imaging, CT=Computed Tomography, CRP= C-reactive Protein, NSAID=Non-steroidal Anti-inflammatory Drugs, TENS=Transcutaneous Nerve Stimulation. The chi-square test or Fisher’s exact test for non-ordered categorical variables and the Mann-Whitney U-test for continuous variables were used. Median (min-max) or n (%, only for the whole group). All p-values are ≥0.05.
Comparison between women with and without LPP (hospital record-based data)
Comparisons of data from hospital records of women who reported LPP and women without LPP at follow-up indicated that there were no differences in baseline characteristics or the diagnosis of PPSS (Tables 1-2).
The mean time from delivery to the onset of symptoms was 25 hours in the women with LPP at the time of the follow-up and 50 hours in the women with no LPP. Of the women with no LPP, three women had given birth once, two women had given birth twice, and one woman had given birth three times after PPSS at delivery. Of the women with LPP, six women had given birth once, and one woman had given birth twice after PPSS at delivery. There were no differences in time since PPSS onset, education level, or physical activity level between women with LPP and women without LPP (Table 3).
Table 3 Characteristics and patient-reported outcomes at follow-up.
Variable
|
All women
(n=19)
|
LPP
(n=10)
|
No LPP
(n=9)
|
P-value
|
Time since PPSS, years, min-max
|
8 (0.5-22)
|
8 (0.5-22)
|
8 (2-12)
|
0.456
|
Highest education level
|
|
|
|
|
Primary/lower secondary school
|
0
|
0
|
0
|
|
Upper secondary school
|
6
|
4
|
2
|
|
Post-secondary vocational education and training
|
2
|
1
|
1
|
|
University degree
|
10 (53)
|
5
|
5
|
0.655
|
Other
|
1
|
0
|
1
|
|
Physically active ≥30 minutes, days/week
|
8 (0-7)
|
5 (1-7)
|
3 (0-7)
|
0.395
|
Sick-leave due to persistent PPSS
|
2
|
2
|
0
|
0.474
|
Sick-leave due to other
|
1
|
0
|
1
|
|
PGQ
|
9 (0-72)
|
27 (9-72)
|
0 (0-6)
|
<0.001
|
EQ-5D score
|
0.880 (0.578-0.969)
|
0.740 (0.578-0.8780)
|
0.914 (0.868-0.969)
|
<0.001
|
EQ–VAS
|
80 (30-100)
|
65 (30-85)
|
84 (66-100)
|
0.022
|
HADS-A, sum of scores
|
5 (0-9)
|
7 (0-17)
|
2 (0-9)
|
0.010
|
HADS-A>8
|
5
|
4
|
1
|
|
HADS-D, sum of scores
|
3 (0-9)
|
4.5 (1-9)
|
1 (0;-)
|
0.028
|
HADS-D, >8
|
1
|
1
|
0
|
|
PCS
|
9 (3-40)
|
8.5 (3-35)
|
9 (1-40)
|
0.968
|
GSE (half-scale)
|
30.5 (23-39)
|
29.5 (23-37)
|
32 (28-39)
|
0.203
|
Questionnaire data. LPP, Lumbar Pelvic Pain; PPSS, Post-partum Septic Symphysitis; PGQ, Pelvic Girdle Questionnaire; EQ-5D score, EuroQol 5-dimension score; EQ–VAS, EuroQol Visual Analogue Scale; HADS-A, Hospital Anxiety Depression Scale-Anxiety; HADS-D, Hospital Anxiety Depression Scale-Depression; PCS, Pain Catastrophizing Scale, GSE, General Self-Efficacy Scale. Median (min-max) or n (%), only for the whole group. The chi-square test or Fisher’s exact test for non-ordered categorical variables and the Mann-Whitney U-test for continuous variables were used.
Patient-reported outcomes (postal questionnaire data)
Nineteen women completed the follow-up questionnaire. Women with LPP stated that LPP impaired function (PGQ, p=<0.0001) and caused a poorer health-related quality of life (EQ-5D, p=0.001, EQ-VAS, p=0.022) and higher levels of anxiety (HADS-A, p=0.010) and depression (HADS-D, p=0.028) than women with no LPP (Table 3). Moreover, four of 10 women with LPP reported PGP during the index pregnancy in the questionnaire (Table 1). These women also described in the open-text answer that PPSS affected their daily life during the acute phase as well as a prolonged period after delivery. Stated problems were inability to care for their new-born baby, play with the infant, participate in everyday life activities such as shopping, cleaning, washing, and gardening and participate in physical exercise and sports.
Clinical examination
Table 4 presents the results from the clinical examinations. Of the eight women who were clinically assessed, one was classified as having lumbar pain, and seven were classified as having PGP; six of these seven women had painful symphysiolysis. Three women had considerably decreased joint mobility, with four cases in the hips and one case in the lumbar spine, and four women fulfilled the criteria for hypermobility [41]. All women indicated pain when the structures in and around the pelvic girdle were palpated. One woman reported decreased sensitivity in the skin around the symphysis, and two women reported pelvic floor muscle dysfunction. All eight women who were examined stated that their pain had been present since the postpartum period of the index pregnancy, and none of these women had PPSS twice. Three women with classified PGP stated that their thighs had been forcefully abducted during delivery by an obstetrician or a midwife.
Table 4 Results of the clinical examination in 8 out of 10 women with LPP at follow-up.
Variable
|
n
|
Positive pain test result
|
6
|
Positive pain provocation tests for symphysis
|
|
Trendelenburg test
|
0
|
MAT-test
|
4
|
Palpation
|
5
|
Positive pain provocation test for SI-joints
|
|
Trendelenburg test
|
0
|
Posterior pelvic pain provocation test
|
3
|
Sacral thrust
|
3
|
Pelvic spring test
|
1
|
Pain when turning in bed
|
6
|
Pain on palpation
|
|
Gluteal muscles
|
4
|
Piriformis muscles
|
6
|
Tendons in the groins
|
5
|
Tendons to the adductor muscles
|
4
|
Trochanter major
|
8
|
Diagnosis
|
|
Only painful symphysiolysis
|
3
|
One-sided sacroiliac pain
|
1
|
One-sided sacroiliac pain + symphysial pain
|
2
|
Double-sided sacroiliac pain
|
0
|
Pelvic girdle syndrome
|
1
|
Other pain (back pain)
|
1
|
Values are n. LPP, Lumbar Pelvic Pain; SPP-test, Symphysis Pubic Pressure test: Pain>30 sec after provocation of the symphysis; SI-joints, Sacroiliac Joints; PGS, Pelvic Girdle Syndrome, symphysial pain+ double sided sacroiliac pain.