SPD (pelvic pain) in pregnancy

What is symphysis pubis dysfunction?

Symphysis pubis dysfunction (SPD) is a problem with the pelvis.

Your pelvis is mainly formed of two pubic bones that curve round to make a cradle shape. The pubic bones meet at the front of your pelvis, at a joint called the symphysis pubis. The joint’s connection is made strong by a dense network of tough tissues (ligaments).

During pregnancy, swelling and pain can make the symphysis pubis joint less stable, causing SPD.

Health professionals classify any type of pelvic pain during pregnancy as pelvic girdle pain (PGP).

SPD is one type of pelvic girdle pain. Diastasis symphysis pubis (DSP) is another type of pelvic girdle pain and is related to SPD (POGP 2015). DSP happens when the gap in your symphysis pubis joint widens too far (Bell and Skandhan nd). DSP is rare, and can only be diagnosed by an X-ray, ultrasound scan or MRI scan (POGP 2015).

What are the symptoms of SPD in pregnancy?

Pain in the pubic area and groin are the most common symptoms, though you may also experience pain:

• in your back or hips
• at the back of your pelvis
• down the inside of your thighs or between your legs

The pain may be worse:

• By parting your legs, walking, going up or down stairs, or moving around in bed.
• At night, stopping you from sleeping well. Getting up to go to the toilet in the middle of the night can be especially painful.
  (POGP 2015)

You may also notice a grinding or clicking sensation or noise in your pubic area.

What causes SPD in pregnancy?

SPD is thought to be caused by a combination of changes in your body during pregnancy.

Your body produces a hormone called relaxin, which softens your ligaments to help your baby pass through your pelvis during birth. Increased levels of progesterone and oestrogen may also help loosen things up (Casagrande et al 2015). This means that the joints in your pelvis become more lax.

Relaxed ligaments and increased flexibility are normal during pregnancy, and don’t usually cause pain (Aldabe et al 2012, POGP 2015, Vøllestad et al 2012). SPD is thought to happen when your body doesn't adapt so well to the stretchier, looser ligaments caused by relaxin.

SPD can be triggered by:

• the joints in your pelvis moving unevenly
• changes to the way your muscles work to support your pelvic girdle joints
• one pelvic joint not working properly and causing knock-on pain in the other joints of your pelvis
  (POGP 2015)

You’re more likely to develop SPD if:

• you had pelvic pain before you became pregnant
• you’ve had a previous injury to your pelvis
• you’ve had pelvic girdle pain in a previous pregnancy
• you have hypermobility in all your joints
  (Casagrande et al 2015, DH 2018, POGP 2015, Vermani et al 2010, Walters et al 2018)

Some research suggests that being overweight before you became pregnant increases your likelihood of SPD, but the evidence is mixed (Walters et al 2018).

When does SPD in pregnancy happen?

SPD can occur at any time during your pregnancy or after giving birth, but usually starts late in the first trimester (Casagrande et al 2015, Keriakos et al 2011).

You may notice it for the first time during the middle of your pregnancy or not until the very end (Keriakos et al 2011).

How is SPD in pregnancy diagnosed?

Talk to your doctor or midwife if you’re feeling pain anywhere during pregnancy. He’ll check that your pain isn’t due to any other health problems.

Pelvic pain in pregnancy, including SPD, is becoming more widely understood by doctors, physiotherapists and midwives. Your doctor or midwife should refer you to a women's health physiotherapist.

Your physiotherapist will test the stability, movement and pain in your pelvic joints and muscles, to check whether your pain is being caused by SPD or something else (Bermas 2017, Casagrande et al 2015, Walters et al 2018).

How is SPD in pregnancy treated?

SPD is managed in the same way as other pelvic girdle pain. Treatment options include:

• Exercises to strengthen your spinal, tummy, pelvic girdle, hip and pelvic floor muscles. These will improve the stability of your pelvis and back (POGP 2015, Walters et al 2018). Aquaerobics can sometimes help (Liddle and Pennick 2015, POGP 2015).
• Gentle, hands-on treatment of your hip, back or pelvis to correct stiffness or imbalance (POGP 2015, RCOG 2015). A physiotherapist will gently move your joints to get them back into position and moving normally again (POGP 2015, RCOG 2015).
• Modifying how you do daily activities, to make them less painful. For example, your doctor or physiotherapist can show you the best way to get out of your car, roll over in bed and climb stairs.
• Acupuncture, which is safe during pregnancy and which some research suggests may help some women with SPD (Bermas 2017, Liddle and Pennick 2015, Walters et al 2018). Make sure your practitioner is trained and experienced in working with pregnant women (DH 2018, POGP 2015).
• Other manual therapies, such as osteopathy, may help. See a registered practitioner who is experienced in treating pregnant women (Liddle and Pennick 2015).
• A pelvic support belt, girdle, band or brace, which may relieve your pain, particularly when you’re exercising or active (Bermas 2017, DH 2018, Liddle and Pennick 2015, Walters et al 2018).

Your caregiver will also advise you on how to make the birth of your baby easier. He should help you to write a birth plan that takes your SPD symptoms into account (POGP 2015).

How can I ease my SPD pain during pregnancy?

• Be as active as you can, but don't push yourself so far that it hurts.
• Stick to the pelvic floor and tummy exercises that your physiotherapist recommends.
• Ask for and accept offers of help with daily chores.
• Plan ahead so that you reduce or avoid activities that cause you problems. You could use a backpack to carry things around, both indoors and out. Unlike a shoulder bag, a backpack spreads the weight you're carrying evenly across your body, rather than putting more stress on one side.
• Take care not to part your legs further than your pain-free range, particularly when getting in and out of the car, bed or bath. If you’re lying down, pull your knees up as far as you can to make it easier to part your legs. If you’re sitting, try arching your back and sticking your chest out before parting or moving your legs.
• Avoid activities that make your pain worse or that put your pelvis in an uneven position, such as sitting cross-legged, vacuuming or carrying your toddler on your hip. If something hurts, stop doing it. If the pain is allowed to flare up, it can take a long time to settle down again.
• Try to sleep on your side with legs bent and a pillow between your knees. This position is also best for your baby – by the third trimester, sleeping on your side reduces your risk of stillbirth compared to sleeping on your back (Gordon et al 2015, Heazell et al 2018, McCowan et al 2017, Stacey et al 2011).
• Rest regularly. By getting down on your hands and knees, you’ll take the weight of your baby off your pelvis. Try to sit down for activities that you would normally do standing, such as chopping vegies and ironing.
• Try not to do heavy lifting or pushing. Supermarket trolleys can often make your pain worse, so shop online or ask someone to shop for you.
• When climbing stairs, take one step at a time. Step up onto one step with your best leg and then bring your other leg to meet it. Repeat with each step.
• Avoid standing on one leg. When getting dressed, sit down to pull on your undies and pants.
  (POGP 2015)

Will I recover from SPD after I've had my baby ?

You're very likely to recover within a few weeks or months of the birth (Bermas 2017, Vermani et al 2010, Walters et al 2018). If you can, carry on with physiotherapy and try to get help with looking after your baby during the early weeks.

You may find you get twinges every month just before your period is due (POGP 2015). This is caused by hormones that have a similar effect to the pregnancy hormone relaxin.

If you have SPD in one pregnancy, it’s more likely that you'll have it again next time you get pregnant (Casagrande et al 2015, POGP 2015, Vermani et al 2010, Walters et al 2018). Ask your doctor or midwife to refer you to a physiotherapist early on. SPD may not necessarily be as bad next time if it’s managed well from the start of pregnancy (POGP 2015).

It can help if you allow the symptoms from one pregnancy to settle before trying to get pregnant again. Getting fit and to a healthy weight may help reduce the chances of getting any pelvic pain next time (POGP 2015). And waiting until your child can walk means you won't be putting as much stress on your joints by constantly carrying your child while you're pregnant (POGP 2015).

Read more about pelvic pain in pregnancy and what you can do to ease your symptoms.