Ultrasound-Guided Symphysis Pubis Injection in Pregnancy

Abstract

To the Editor Many physicians find the management of nonobstetric pain during pregnancy difficult because of the many issues to be considered involving both maternal and fetal well-being. Pain during pregnancy is common and often underestimated and undertreated. The use of nonpharmacological techniques can be extremely useful throughout pregnancy because there are risks associated with the use of oral analgesic agents to both the mother and the fetus. Pelvic pain is common in pregnancy, with an overall incidence of 20%, with the pubic symphyseal joint contributing 2.3%.1 We describe a case report and technique for using a portable ultrasound scanner and a curvilinear transducer (4 to 5 MHz) (Sonosite Micromaxx Sonsite, Inc., Bothwell, Washington) to guide symphysis pubis injection in pregnancy. A 30-year-old healthy primigravida was experiencing severe symphysis pubis pain from week 20 of gestation, increasing in severity and restricting activities of daily living. Her pain was rated as 10 of 10 (numerical rating scale). The ultrasound transducer was orientated in a transverse orientation at the level of the symphysis pubis (Fig. 1). The joint was located at 4 cm depth. Real-time imaging was used to direct a 22-g spinal needle into the symphysis pubis joint and 10 mL of 0.25% levobupuvicaine and 40 mg triamcinolone was injected. The patient's pain decreased over the next 2 hours, to a level of 2 of 10 (numerical rating scale), together with an improvement in mobility. This pain relief was sustained for the remainder of her pregnancy, and a repeat procedure was not necessary.Figure 1: Ultrasound-guided symphysis pubis joint injection. Arrowheads outline needle.Ultrasound guidance does not expose the pregnant patient and medical personnel to radiation and is readily assessible. The use of fluoroscopy would be contraindicated in this case because of the risk to the fetus, and this ultrasound technique provides a visual means of performing this procedure. Fiona Annette Desmond Dominic Harmon, MB, BCh, BAO, FCARCSI Mid-Western Regional Hospital Doradoyle Limerick, Ireland [email protected]