|SYMPOSIUM ON PELVIC TRAUMA
|Year : 2014 | Volume
| Issue : 1 | Page : 23-28
Pelvic trauma in women of reproductive age
Sarita Agrawal1, Prasanta Kumar Nayak1, Subarna Mitra1, Alok Chandra Agrawal2, Asha Jain3, Vinita Singh1
1 Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur (C.G.), Chhattisgarh, India
2 Department of Orthopaedics, All India Institute of Medical Sciences, Raipur (C.G.), Chhattisgarh, India
3 Department of Consultant Gynecologist, SriMaa Sarada Arogyadham, Raipur, Chhattisgarh, India
|Date of Web Publication||6-Jun-2014|
Departments of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur - 492 001, Chhattisgarh
Source of Support: None, Conflict of Interest: None
The pelvic trauma can be a simple isolated one or can involve multiple skeletal structures or viscera also. Women of childbearing age who suffer from pelvic trauma have always a question in their mind regarding the future fertility and type of delivery they are going to have. The final functional outcome of pelvic injury depends on the severity of trauma and the type of surgical management. The aim of this article is to review the female pelvic anatomy, pelvic injuries, management options and future reproductive potential and other impacts of pelvic trauma in women of childbearing age.The pelvic trauma can be a simple isolated one or can involve multiple skeletal structures or viscera also. Women of childbearing age who suffer from pelvic trauma have always a question in their mind regarding the future fertility and type of delivery they are going to have. The final functional outcome of pelvic injury depends on the severity of trauma and the type of surgical management. The aim of this article is to review the female pelvic anatomy, pelvic injuries, management options and future reproductive potential and other impacts of pelvic trauma in women of childbearing age.
Keywords: Pelvic fractures, pregnancy, radiation in pregnancy
|How to cite this article:|
Agrawal S, Nayak PK, Mitra S, Agrawal AC, Jain A, Singh V. Pelvic trauma in women of reproductive age. J Orthop Traumatol Rehabil 2014;7:23-8
|How to cite this URL:|
Agrawal S, Nayak PK, Mitra S, Agrawal AC, Jain A, Singh V. Pelvic trauma in women of reproductive age. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 May 27];7:23-8. Available from: http://www.jotr.in/text.asp?2014/7/1/23/134007
| Introduction|| |
The pelvis is a stabilizing structure of the lower extremity and trunk with major structures passing through including genitourinary, vascular, neurological, and gastrointestinal structures. Hence pelvic fractures represent a major injury for women of childbearing age. There can be major problems in terms of functional recovery. Pelvic trauma can be a simple isolated one or can involve multiple skeletal structures or viscera. Pelvic fractures with or without dislocation in 105 females, aged above 15 years have been observed in a study 1 . 47.6% of the fractures were through the antero-posterior ring. Among the complications, genital organ injury happened in 15 patients (14.5%): Rupture of uterus in five (three wombs conceived over three months, one in period of nursing, one in normal state), rupture of ovary in two, rupture of ovarian tube in one and laceration of vagina in seven. Women of childbearing age who suffer from pelvic trauma are always having concerns regarding their fertility and mode of delivery in future. Traumatic injury to the pelvis can lead to long-term sexual dysfunction and urinary dysfunction as well. In addition, occurrence of post-traumatic stress and decreased functional outcomes among female trauma patients is a matter of concern. The final functional outcome of pelvic injury depends on the severity of trauma and the type of surgical management and restoration of pelvic shapes.
| Importance of pelvic shape in child bearing|| |
The female pelvis differs from the male pelvis, being overall broader with a rounded brim that is conducive to its specific role in childbearing. The physiological changes that take place during the course of pregnancy causes alterations in the composition of the pelvis, its shape, and the plane of inclination and internal dimensions of the true pelvis. All of these changes serve to support the pregnant uterus throughout the term of pregnancy and assist with the normal mechanisms of childbirth. There are distinct differences between the female and male pelvis are as follows [Figure 1]. The female pelvis is broader than the male pelvis and the female pelvic bones, including neck of femur, are more slender than those of a man.
The outline of the male pelvic brim is heart shaped and the brim is widest toward the back of the pelvis, whereas the female pelvic brim is transversely oval with its widest diameters further forwards. This is due to the female sacral promontory being less prominent
The female pelvis is designed for childbirth; therefore, the pelvic cavity is much roomier with the outlet is also wider than that of the male pelvis to facilitate vaginal birth.
The male supra-pubic angle is acute, often likened to the shape of a Gothic-style arch, whereas in the female pelvis, it is more rounded like a Roman-style arch.
The shape of the female pelvis determines the availability of pelvic diameters during childbirth. Amongst the four parent types of pelvis according to shape as per classification by Caldwell & Moloy in to Gynaecoid, Android, Anthropoid & Platypelloid; the android pelvis which has triangular inlet, prominent ischial spines, sub pubic arch is less than 90o, funnel-shaped, deep cavity; and straight sacrum is the least favorable for achieving a vaginal birth. In the anthropoid and platypelloid pelvis usually the labors tend to be unproblematic; however, abnormal fetal positions are common and may lead to difficulty in labor due to cephalo-pelvic disproportion. Deformity and asymmetry in shapes of pelvis resulting due to diseases like rickets, osteomalacia, tuberculosis or due to injury causes pelvic contraction and therefore, problems in labor can occur.
| Previous pelvis trauma and its long-term impact|| |
Even in the obstetric community, there is a belief women who have had pelvic fractures cannot deliver vaginally. ,,, Many women are not even given a chance for a trial of labor once the obstetrician is aware of the history of pelvic fracture. It is difficult to predict the mode of delivery a woman will have once she becomes pregnant following a pelvic fracture. Authors have reported variable rates of Cesarean section after pelvic fractures, ranging from 8% to 66%. ,, Though many articles showed a very high rate of Cesarean section even upto the double of the standard rates still vaginal delivery after pelvic fracture is possible.  Care should be taken while nonoperative treatment of these fractures or operative treatment with iliac wing fixation, external fixator, and/or ramus screws that it should not generally affect the pelvic proportions or mobility of the symphysis and sacroiliac joints. Given the importance of the mobility of the symphysis and sacroiliac joints during delivery, concern may be warranted if there is fixation across the pubic symphysis and possibly the sacroiliac joints.
Injury to female genitalia
Gynecological and vaginal injuries are rare with pelvic fracture; however, thorough evaluation for deep vaginal tears and for pelvic hematoma is required as they may be the constant cause or bleeding. The most gynecological injuries occur in women who are pregnant. It can lead to trauma to the uterus resulting in subtle bleeding to abruption, fetal demise, and even rupture of the uterus. A thorough per speculum and per vaginal examination should be done in women having pelvic fracture and bleeding per vagina.
Sexual dysfunction can be a long-term problem.  In a study of 233 women with pelvic fractures and major lower extremity trauma, 45% of women reported feeling less sexually attractive and 39% reported a decrease in sexual pleasure and in another study, 45% of the women reported less interest in sexual intercourse and reaching orgasm less than before their fracture.  Some patients experienced difficulty in sexual activity because of spoiled vagina, being involved by displaced bone fragment intrusion or by cicatricial contracture of itself leading to secondary infertility.
Pelvic fractures are known to affect genitourinary function, persistent urinary symptoms are more common in women with residual pelvic fracture displacement. While assessment of pelvic fracture, apart from thorough assessment of bony and ligamentous injury, a careful detailed examination should always be performed to assess the urethral and genital injury.
| Pelvic trauma during pregnancy and management|| |
Cases of preterm labor, abortions, uterine rupture with fetal death, abruption of placentae, thromboembolism and coagulopathy have been reported with pelvic trauma. Direct fetal injuries in the form of fetal spine fractures, fetal skull fracture are most common with a mortality rate up to 42%. Therefore, a thorough evaluation on fetus by ultrasonography should be done in all cases of pelvic or abdominal trauma. Apart from assessing fetal well being, retroplacental clot and pelvic hematoma should be looked for. An expert sonologist with a good ultrasonography machine sometimes may be helpful in evaluating pelvic fractures.
Dilemma presented in a multitrauma situation at various stages of pregnancy necessitates making management modifications involving timing of surgery and delivery, use of radiation for imaging, and choice of appropriate surgical procedure. However, with limited use of intra and postoperative X-ray and surgery performed by specialist with experience in acetabular and pelvic surgery, successful surgical fixation of acetabulum and pelvic fractures in pregnancy with good feto-maternal outcome have been reported in literature. , Abdominal and pelvic CT are considered high-risk procedures for the teratogenic effect on fetus, one must weigh the risks and benefits.
Preventing radiation hazards during pregnancy
Fetal adverse effects are unlikely if radiation dose less than 5 rads , or distance more than 10 cm. In order to reduce the radiation risk one must always take history of pregnancy, reduce the number of exposures, use abdominal shield (provided not obstructing the field of interest) and attach thermoluminescent dosimeter to mother to evaluate radiation exposure. The radiation exposure dose in different procedures is shown in [Table 1].
|Table 1: Radiation exposure for the unshielded uterus in various imaging studies|
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MRI in pregnancy
In general, it should be noted that most studies evaluating MRI safety during pregnancy show no ill effects.
| Surgical management of pelvic fractures during pregnancy|| |
The basic principles of trauma management apply to injured pregnant women, and therefore, maternal resuscitation is the first priority under all conditions. Moreover, maternal condition has been found to be the main determinant of fetal outcome in trauma during pregnancy. Evaluation and treatment procedures require modification, including scheduling surgery in relation to time of delivery. The degree of fetal maturity, estimated gestational weight at the time of injury, presence or absence of initial fetal or maternal distress, severity of maternal injury, displacement of the pelvic or acetabular fracture, how recently the fracture occurred, are all factors that should be included in deciding whether to do a cesarean versus vaginal delivery in the patient with a pelvic fracture. Vaginal delivery or dilatation and surgical evacuation should not be contraindicated after fractures have occurred in the early pregnancy period. Many a times the labor starts spontaneously or she aborts. However, when the fetus is alive and beyond the age of viability and fetal heart rates are non-assuring, delivery of fetus by Cesarean section followed by definitive treatment for pelvic fractures should be done. In case where fetus is less than the age of viability or a dead fetus, management in coordination with obstetrics as well as the orthopedic team, the patient may be allowed for induction of labor or termination of pregnancy to deliver the fetus vaginally. Once stable after delivery, an internal fixation is to be done. If hemodynamic status of women does not permit emergency section or induction of labor, in such situation conservative management till maternal stabilization or an external fixator to control the bleeding can be a viable option. When surgical intervention is considered in a near-term pregnancy, there is the possibility of delaying the operation until after the delivery or inducing a preterm delivery. Risk for prematurity should be weighed against the mother's morbidity in cases in which induced labor is considered. In certain cases, the orthopedic surgical procedure can be combined with the obstetric procedure, such as a Cesarean section, or with terminating the pregnancy.
In the case of pelvic fracture during pregnancy, a precise anatomical reduction may not be mandatory, and there is some leeway regarding final reduction of the fracture in the interest of shortening surgery and reducing radiation exposure as long as the goal of functional outcome is unimpaired. The surgical approach can be adjusted as far away from the uterus as possible. Sometimes a posterior approach may be used to the acetabulum instead of the preferred ilioinguinal approach. In the preoperative stage of the procedure, several preparations should be made: Fetal monitoring and other necessary equipment should be placed in reach in the event that an emergency Cesarean section must be performed; the mother's abdomen must be protected both posteriorly and anteriorly against radiation. Starting at midpregnancy, the pregnant patient lying supine should have a left lateral tilt, including at surgery (this maximizes cardiac output by reducing uterine pressure on the inferior vena cava and allows optimal venous return).
In this era, when we can perform surgery in pregnant women with more confidence and efficiency, surgical intervention should not be ruled out in cases of unstable pelvic or displaced acetabular fracture. Continuation of pregnancy and successful fetal outcome has been reported in literature following surgeries for pelvic and acetabular fracture during pregnancy. The pros and cons for this treatment should be weighed in each individual case.
| Pelvic injury specific to obstetrics|| |
0Pubic symphysis disruption
Slight separation of pubic symphysis during pregnancy is considered to be physiological caused due to hormone induced ligamentous laxity. A separation more than 10 mm is usually symptomatic causing pain and difficulty in walking. Reports of the incidence of symphyseal rupture after vaginal delivery have varied from 1 in 300 to 1 in 30,000 deliveries.  With the improved maternity care the incidence of obstructed labor and thereby, pubic symphysis disruption has declined. However, still in developing countries like India specially in rural areas where the deliveries are conducted by untrained dais, exaggerated tredelenberg position, hyperflexion and simultaneous over abduction of lower limb along with fundal pressure are the possible cause of this type of injury [Figure 2]. 
When symphyseal rupture does occur, it typically happens during delivery or shortly after labor and is characterized by a sharp and immediate onset of severe pain over the pubic symphysis and may extend posteriorly into the sacroiliac joint region accompanied by an audible crack. Anterior separation of the pubic symphysis of more than 2.5 cm progressively causes injury to the posterior pelvic ring, including disruption of the sacroiliac joint or sacral fractures.
Treatment of a ruptured pubic symphysis is predominately nonoperative and consists of pelvic binder application, immobilization and bed rest, analgesia, and physical therapy. Operative treatment has been described in selected cases:
- When nonoperative treatment is unsuccessful
- Symphyseal rupture that may indicate posterior pelvic arch instability requires reduction and stable fixation,
- Separation is more than 2.5 cm [correspond to traumatic anteroposterior compression (APC) II or III or Tile type B or C pelvic injuries]
- Concomitant genitourinary injuries
Many methods for fixations have been described in literature. Open reduction and internal fixation of (ORIF) using a plate across the pubic symphysis facilitates accurate reduction and is now the most popular method of stabilization for pelvic fractures.  ORIF by Box plate fixation  and external fixation are the other methods described by different authors. Najibi S, et al.  reported a case series of 10 cases of obstetric pubic symphyseal diastasis treated by ORIF. Intervention done were, ORIF in acute (less than 2 weeks from childbirth, four patients) and after failed nonoperative treatment in subacute cases (2 weeks to 6 months after childbirth, three patients) fusion of the symphysis with iliac crest bone graft and plate fixation after failed nonoperative treatment and in chronic cases (greater than 6 months, three patients). They concluded that operative management significantly improved the functional outcomes of all three subgroups and can be an acceptable treatment option for labor induced complete symphysis pubis disruption. Internal fixation is to be avoided on patients who have previously been operated on for abdominal or urologic injuries; fascial planes may be disrupted placing the bladder and other visceral structures at risk during symphsis pubis repair; in such cases consider external fixation.  A new dynamic fixation technique of pubic symphysis diastasis using four Endobuttons (Smith & Nephew, Memphis, TN, USA) might be an alternative to pelvic plate fixation in the treatment of APC-II injuries as reported in a series of 21 APC-II injuries treated.  The endobutton technique is not suitable for APC III injuries as endobutton fixation does not provide vertical support.
Prognosis for recovery is usually excellent. Recurrent separation of the symphysis pubis could occur during subsequent deliveries but generally is no worse than the first occurrence.
Symphysiotomy is a surgical procedure in which the cartilage of the pubic symphysis is divided to widen the pelvis allowing childbirth when there is a mechanical obstruction. It is also known as pelviotomy, synchondrotomy, pubiotomy, and Gigli's operation (after Leonardo Gigli, who invented a saw commonly used in Europe to accomplish the operation). The most common indications are a trapped head of a breech baby, shoulder dystocia which does not resolve with routine manoeuvres. In cases of obstructed labor at full cervical dilation when there is no facilities of a Cesarean section, symphysiotomy in combination with vacuum extraction can be a life-saving procedure. The procedure is not without risk, including urethral and bladder injury, infection, pain and long-term walking difficulty. Abduction of the thighs more than 45 degrees from the midline may cause tearing of the urethra and bladder. Symphysiotomy should, therefore, be carried out only when there is no safe alternative. Currently the procedure is rarely performed in developed countries, but is still routine in developing countries where Cesarean section is not always an option. 
Management of symphysiotomy includes appropriate analgesic drugs, apply elastic strapping across the front of the pelvis from one iliac crest to the other to stabilize the symphysis and reduce pain, leave the catheter in the bladder for a minimum of 5 days and suggest bed rest for 7 days. After discharge from hospital, encourage the woman to begin to walk with assistance when she is ready to do so. Long-term walking difficulties and pain (occur in 2% of cases) need treatment with physiotherapy.
Symphysis pubis dysfunction during pregnancy
Symphysis pubis dysfunction (SPD) is a condition that causes excessive movement of the pubic symphysis, either anterior or lateral, possibly because of a misalignment of the pelvis and is associated with pelvic girdle pain . It affects up to one in four pregnant women to varying degrees, with 7% of sufferers continuing to experience serious symptoms postpartum.  The main symptom is usually pain or discomfort in the pelvic region mostly centered on the joint at the front of the pelvis (the pubic symphysis) and sometimes pain in the lower back, hips, groin, lower abdomen, and legs. The severity of the pain can range from mild discomfort to extreme and prolonged suffering. Some sufferers report being able to hear the lower back and hip joints, the sacroiliac, clicking or popping in and out as they walk or change position. Sufferers may walk with a characteristic waddling gait and have difficulty climbing stairs, problems with leg abduction and adduction, pain when carrying out weight bearing activities, difficulties carrying out everyday activities, and difficulties in standing.
Diagnosis is usually made from the symptoms alone, although after pregnancy, MRI scans, X-ray, and ultrasound scanning are sometimes used. The mainstays of currently accepted treatments are the use of elbow crutches, pelvic support devices and prescribed pain relief. The vast majority of problems resolve spontaneously after delivery. Physiotherapy, Bowen Technique may also be beneficial. In very extreme cases surgery is considered after pregnancy to stabilize the pelvis, but success rates are very poor.
As far the delivery is concerned, it is usually recommended that women with SPD give birth in an upright position, with knees slightly apart, and it is often suggested that a woman tie a ribbon to both legs to ensure that the gap never exceeds her maximum comfort zone. Interventions such as forceps should be avoided if at all possible, if stirrups must be used, for example during suturing, great care must be taken to move the legs in symmetry. Everyday living advices include avoiding strenuous exercise, prolonged standing, stretching exercises and squatting, lifting and carrying, Bend the knees and keep the legs 'glued together' when turning in bed and getting in and out of bed. Place a pillow between the legs when in bed or resting.
| Conclusions|| |
Female patients with pelvic fractures are concerned about their future fertility and participation in sexual activity. The possible functional, sexual and genitourinary outcomes along with her ability to deliver vaginally after surgical fixation of a pelvic fracture should be discussed with the patient. In view of obstetrics, displaced pelvic fracture-dislocation should be reduced early following resuscitation of the patient, and be maintained steady by traction until union or by internal fixation if needed early and expert involvement of physical therapy, occupational therapy, and rehabilitation services is an essential part of the care of patients with pelvic fractures.
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[Figure 1], [Figure 2]