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Pregnancy related pelvic pain

Research project
Active research
Project owner
Institute of Health and Care Sciences

Short description

Treatment of pregnancy-related pelvic pain has been studied in four randomized controlled trials (RCTs). A longitudinal follow-up has also been performed and it showed that about 10% of the women had problems that affected their daily lives up to 11 years after the birth. Experiences of living with pelvic pain and living with a pregnant woman with pelvic pain have been described in qualitative interview studies. These describe the great impact on women's bodies and the ability to function in everyday life, as a mother, partner and in working life. The men described the time as "challenging and strenuous". A specific new pain provocation test has been developed (MAT test) and a self-test for provocation of pregnancy related pelvic pain that has been shown to be valid.

The Pelvic Girdle Questionnaire, PGP, has been validated and tested in a Swedish cohort study. Mapping of diagnostics and treatment of BS has been carried out by the Swedish National Agency for Medical and Social Evaluation, where Helen Elden was an expert in the project group.

Background 

Pelvic pain affects about 30 percent of all pregnant women and usually starts around pregnancy week 18, but can sometimes start as early as in pregnancy weeks 8-10 and as late as  three weeks after delivery. Pelvic pain can also come after trauma to the pelvis. The cause of pregnancy-related pelvic pain is unknown, but secretion of the hormone relaxin, the growing stomach and the altered posture are considered to play a role. The hormone secretion means that the mobility in all joints of the body increases and that a softening of connective tissue in the joints takes place that specifically aims to increase the mobility in the pelvis to facilitate the baby's passage during childbirth. These factors place greater demands on muscles and ligaments and increase the risk of pelvic pain.

Suggested risk factors for pelvic pain that have been investigated in several studies are age, Body Mass Index  and smoking, but a systematic review describing the role of these risk factors for developing pelvic pain during pregnancy is lacking.

The diagnosis is made after a standardized examination where lower back pain has been ruled out and pain provocation tests have been able to cause pelvic pain. The specific history includes pain located between the iliac crests and the hamstring folds, together with or without pain in the pubic bone. The pain can move from side to side and often radiates down to the thighs.

The women describe a negative impact on the experience of being pregnant, function, partnership, motherhood, the opportunity to work and worries  that the problems will persist after the birth.

Treatment 

The treatment consists of information about the condition, ergonomic advice, a pelvic belt, acupuncture, crutches, muscle stabilizing training and full-time or part-time sick leave. A report in 2021 shows that out of the 33 relevant systematic reviews that were identified, 15 had a low to moderate risk of bias. Fourteen of these reviews have studied one or more of the treatment methods general exercise (eg yoga, group exercise, aqua aerobics), torso stabilizing exercise, pelvic floor exercise, pelvic girdle, relaxation exercises, massage, acupuncture, and manipulation of the pelvis in the form of massage, osteopathy and chiropractic treatments.

The outcomes studied are pain, function, quality of life, sick leave, persistent pelvic pain after childbirth and side effects of the treatment. Although the results of the reviews are not unambiguous, the individual reviews show that there are both scientific knowledge gaps and some evidence for the treatment methods. There is no scientific evidence for classification systems.

Prognosis 

Most women who get pelvic pain have problems throughout pregnancy but recover in the first months after giving birth, regardless of whether they received treatment for it during pregnancy or not, but it can also be the beginning of a chronic pain condition. Pelvic pain after childbirth has been reported in 17.5, 8.5 and 10 percent of women after 3 months, 2 years and 11 years. The risk of recurrence of pelvic pain during a new pregnancy is great but not definitive. Women with previous lower back pain and pain in all pelvic joints (both sacroiliac joints plus the symphysis) and  positive pain provocation tests during pregnancy, have the greatest risk of chronic problems, which has an impact on function in everyday life and thus give a reduced quality of life. For some women, anxiety about recovering pelvic pain make them to choose not to become pregnant again.

 

References

  1. Fagevik Olsen M, Körnung P, Kallin S, Elden H, Kjellby Wendt G, Gutke A. Validation of self-administered tests for screening for chronic pregnancy-related pelvic girdle pain. Accepted 210218. BMC Muskuloskeletal Disorders
  2. Gutke A, Stuge B, Elden H, Sandell C, Asplin G, Fagevik-Olsen M, Gutke A. (2019) The Swedish version of the pelvic girdle questionnaire. Disabil Rehabil. 2020 Apr;42(7):1013-1020. doi: 10.1080/09638288.2018.1515991. Epub 2019 Feb 1.PMID: 30707631
  3. Elden HGutke AKjellby-Wendt G, Fagevik-Olsen M, Ostgaard HC. Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study. BMC Musculoskelet Disord 2016:17(1):276. doi: 10.1186/s12891-016-1154-0.PMID: 27406174. PMID: 29879940
  4. Elden H, Lundgren I, Robertson E. Demanding and challenging: Men's experiences of living with a pregnant woman with pelvic girdle pain: An interview study. Clinical Nursing Studies: 2014, 2 (4):17-29. http://dx.doi.org/10.5430/cns.v2n4p17.
  5. Elden H, Lundgren I, Robertson E. Effects of craniosacral therapy as experienced by pregnant women with severe pelvic girdle pain: An interview study. Clinical Nursing Studies: 2014, 2 (3):140-151. http://dx.doi.org/10.5430/cns.v2n3p140
  6. Fagevik Olsen M, Elden H, Gutke A. Evaluation of self-administered tests for pelvic girdle pain in pregnancy. BMC Musculoskeletal Disorders, 2014, 15:138 doi:10.1186/1471-2474-15-138
  7. Elden H, Lundgren I, Robertson E. The pelvic ring of pain: Pregnant women’s experiences of severe pelvic girdle pain. Clinical Nursing Studies: 2014, 2 (2): ISSN 2324-7940
  8. Elden H, Ostgaard H, Glantz A, Marciniac P, Linnér A, Fagevik Olsen M. Effects of craniosacral therapy as adjunct to standard treatment for pelvic girdle pain in pregnant women: A multicentre, single blind, randomised controlled trial. Acta Obstet Gynecol Scand. 2013 Jul;92(7):775-82. doi: 10.1111/aogs.12096. Epub 2013 Mar 4.PMID: 23369067
  9. Elden H, Lundgren I, Robertson E. Life’s pregnant pause of pain: Pregnant women’s experiences of pelvic girdle pain related to daily life: A Swedish interview study. Sex Reprod Healthc. 2013 Mar;4(1):29-34. doi: 10.1016/j.srhc.2012.11.003. Epub 2012 Nov 23.PMID: 23427930.
  10. Fagevik Olsen M, Gutke A, Elden H, Kjellby-Wendt G. Self-administered tests as a screening procedure for pregnancy-related pelvic girdle pain. Eur Spine J. 2009 Aug;18(8):1121-9. doi: 10.1007/s00586-009-0948-2. Epub 2009 Mar 28.PMID: 19330361 
  11. Elden H. Needle penetration does not improve pelvic girdle pain among women receiving adjunctive acupuncture care. Focus on Alternative and Complementary Therapies, 06/2009, 14, (2); author reply. DOI: 10.1211/fact.14.2.0014
  12. Elden H, Fagevik-Olsen M, Ostgaard HC, Stener Victorin E, Hagberg H. Acupuncture as an adjunct to standard treatment for pelvic girdle pain in pregnant women: randomised double-blinded controlled trial comparing acupuncture with non-penetrating sham acupuncture. BJOG. 2008 Dec;115(13):1655-68. doi: 10.1111/j.1471-0528.2008.01904.x. Epub 2008 Oct 15.PMID: 18947338
  13. Elden H, Hagberg H, Olsen MF, Ladfors L, Ostgaard HC. Regression of pelvic girdle pain after delivery: follow-up of a randomised single blind controlled trial with different treatment modalities. Acta Obstet Gynecol Scand. 2008;87(2):201-8. doi: 10.1080/00016340701823959.PMID: 18231889
  14. Elden H, Ostgaard HC, Fagevik-Olsen M, Ladfors L, Ostgaard HC. Treatments of pelvic girdle pain in pregnant women: adverse effects of standard treatment, acupuncture and stabilising exercises on the pregnancy, mother, delivery and the fetus/neonate. BMC Complement Altern Med. 2008 Jun 26;8:34. doi: 10.1186/1472-6882-8-34.PMID: 18582370
  15. Olsen MF, Elden H, Janson ED, Stener Victorin E. A comparison of high- versus lowintensity, high-frequency transcutaneous electric nerve stimulation for painful postpartum uterine contractions. Acta Obstet Gynecol Scand. 2007;86(3):310-4. doi: 10.1080/00016340601040928.PMID: 17364305
  16. Elden H, Ladfors L, Olsen MF, Ostgaard HC, Hagberg H. Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial. BMJ. 2005 Apr 2;330(7494):761. doi: 10.1136/bmj.38397.507014.E0. Epub 2005 Mar 18.PMID: 15778231 
     
  17. Elden H#, Englund-Ögge L#, Wikström AK#. Domeij H,* Silverstein R*, Syversson A*, Jonsson AK*, Ahlberg M*, Nilsson M*, Kartläggning av metoder för diagnos och behandling av bäckensmärta. Identifiering av evidens och vetenskapliga kunskapsluckor utifrån systematiska översikter. SBU Kartläggerrapport 320_1. Publicerad 2 februari 2021. =sakkunniga, *=Kansli
     
  18. Elden H. ISRCTN13438272 https://doi.org/10.1186/ISRCTN13438272
  19. Effects of a newly developed mattress and pillow for pelvic girdle pain during pregnancy. (2018)
  20. Elden H. Http://www.controlled-trials.com/ISRCTN11374571. Craniosacral Therapy as a Complement to Standard Treatment for the Treatment of Well-defined Pelvic Girdle Pain in Pregnant Women. (2009): Http://Www.Controlled-Trials.Com/ISRCTN11374571, (2009).
  21. Elden H. Http://www.controlled-trials.com/ISRCTN30566933 Acupuncture as a Complement to Standard Treatment for the Treatment of Well-defined Pelvic Girdle Pain in Pregnant Women: Http://Www.Controlled-Trials.Com/ ISRCTN30566933, 2006, Iss. ISRCTN30566933. (2006)

     
  22. 2021 Elden H. Bäckensmärta i samband med graviditet. Uppdatering. I Lindgren H, Kristensen K, Dykes A. (eds.) Barnmorskans kompetensområde. Lund: Studentlitteratur AB; Manuskript 

    2016 Elden H. Bäckensmärta i samband med graviditet. I Lindgren H, Kristensen K, Dykes A. (eds.) Barnmorskans kompetensområde. Lund: Studentlitteratur AB; 2016, pp 393-398. Boken används som kurslitteratur på alla Barnmorskeutbildningar i Sverige.

  23. Elden H*, Englund L*, Wikström A-K*, Domeij H**, Silverstein R**. Kartläggning av metoder för diagnostik och behandling av graviditetskomplikationen graviditetsrelaterad bäckensmärta. Identifiering av evidens och vetenskapliga kunskapsluckor utifrån systematiska översikter. SBU rapport 320-1. 210202. *sakkunniga i projektgruppen, ** från SBU i projektgruppen. https://www.sbu.se/320