Pregnancy-related lumbopelvic pain: what have we learned?

Abstract

w ( d b p h g t t t d t o 2 r a fi p In this issue of the American Journal of Obstetrics and Gynecology, 2 research teams have published interesting manuscripts on the common yet often ignored problem of pain related to pregnancy. Bjelland et al reported on mode of delivery and persistence of pelvic girdlesyndrome(PGS)6monthspostpartum.PGS,definedassevere pain that affects both the anterior (pubic symphysis region) and posterior (bilateral sacroiliac joint region) pelvis, is believed to represent the most severe pain cases. Contrary to clinical intuition, the investigators foundthatcesareansectionwasassociatedwithpersistentpain on 6-month follow-up. At first glance, the reader might erroneously presume that cesarean section is what leads to persistent postpartum pelvic girdle pain. This cannot be known with certainty, as pain may be the clinical indication for cesarean in many of these women. Nevertheless, the results suggest that cesarean section has no beneficial or protective effect in the management of pain. Thestudywasmost impressive inthat it includedprospective, selfadministered questionnaires obtained from 10,400 women. Pain defined as strictly PGS probably underestimated the significant pain, as manypatientspresentwithunilateralpainandarequitedisabled.The investigators strengthened their results by evaluating many confounding variables including indication for cesarean as well as infant size. They performed high-quality statistical analyses and found that obstetric complications of birth were not associated with the persistence of pain 6 months postdelivery. Additionally, use of crutches in pregnancy (ie, those were the most disabled) was associated with a much higher risk of reporting severe pelvic girdle pain after delivery. These findings illustrate that, as I tell all my pregnant patients, there is simply no way out of “taking a hit to the core” with impending labor and delivery. Whether it is the abdominal core or the pelvic floor, muscular disruption is inevitable and can lead to dysfunctional muscle activation patterns. The authors make an interesting point that additional operative pain in connection with cesarean section may contribute to an increased risk of persistent pain following surgery, especially in those women with greater pain intensity and severity during pregnancy. Perhaps the more functionally disabled women are more likely to have central pain sensitization that is exacerbated by a surgical insult, thereby precluding a typical musculoskeletal recovery.