Journal of Obstetrics and Gynaecology
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Pubic symphysis diastasis after an uncomplicated vaginal delivery: A case report F. Saeed, K. Trathen, A. Want, R. Kucheria & S. Kalla To cite this article: F. Saeed, K. Trathen, A. Want, R. Kucheria & S. Kalla (2015) Pubic symphysis diastasis after an uncomplicated vaginal delivery: A case report, Journal of Obstetrics and Gynaecology, 35:7, 746-747, DOI: 10.3109/01443615.2014.992873 To link to this article: http://dx.doi.org/10.3109/01443615.2014.992873
Published online: 29 Dec 2014.
Submit your article to this journal
Article views: 41
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [University of Pennsylvania]
Date: 06 November 2015, At: 07:27
Journal of Obstetrics and Gynaecology, October 2015; 35: 746–753 © 2015 Taylor & Francis Group, LLC ISSN 0144-3615 print/ISSN 1364-6893 online
OBSTETRIC CASE REPORTS
Pubic symphysis diastasis after an uncomplicated vaginal delivery: A case report F. Saeed1, K. Trathen2, A. Want1, R. Kucheria3 & S. Kalla1 1Department of Obstetrics & Gynaecology, Wexham Park Hospital,
Wexham, Slough, UK, 2Radnor House Surgery, Ascot, UK,
3Department of Orthopaedics, Wexham Park Hospital, Wexham,
Downloaded by [University of Pennsylvania] at 07:27 06 November 2015
Slough, UK
DOI: 10.3109/01443615.2014.992873 Correspondence: Andrew Want, MBBS, Foundation Year 2 Doctor in Obstetrics & Gynaecology, Department of Obstetrics & Gynaecology, Wexham Park Hospital, Wexham, Slough, SL2 4HL, UK. E-mail: [email protected]
Case presentation
The patient was a 38-year-old white British primiparous woman of average height and weight (170cm, BMI: 22), with no history of pelvic girdle pain antenatally. She presented with spontaneous labour at 39 6 weeks’ gestation. Abdominal examination showed cephalic presentation, direct occipito posterior position, with a fundal height of 39 cm. She progressed in labour appropriately using Entonox and Pethidine for pain relief, reaching full cervical dilatation within 10 h. The active second stage of labour lasted 1 h and 20 min and she delivered a healthy male infant weighing 3660 g (head circumference: 36 cm, length: 55 cm) within a total of 13 h of labour. The placenta was delivered via controlled cord traction 17 min later, and she sustained a second-degree tear. Twelve hours after delivery she complained of severe localised grinding pain in the symphysis pubis area. She was unable to walk secondary to the pain, but could bear weight. Examination revealed marked tenderness over the symphysis pubis. Walking was difficult because of the pain on external rotation of the right lower limb. There was no evidence of neurological compromise. An x-ray of the pelvis was requested by the obstetrics team which showed bony avulsion at the symphysis pubis with a diastasis of 2.5 cm (Figure 1). There was no definite sacroiliac joint widening, which would be evidence of a more complicated open-book pelvic injury.
Management and outcome
The patient was treated with use of regular analgesics, bed rest, pelvic binders and prophylactic low-molecular-weight heparin for thromboprophylaxis. Advice was also sought from the Orthopaedic team for further plan of management and follow-up. The Orthopaedic team agreed with conservative management and it was recommended for her to bear weight as tolerated. She was discharged with the advice of regular analgesia, mobilised using a walker, and a plan for physiotherapy sessions and an outpatient review in two weeks was made. Surgical management would only be considered if the patient did not improve with conservative treatment. When she was reviewed three weeks later her pain had steadily improved and she was able to walk without support. She still reported dull ache at this time and her pubic area remained tender. On her second review 6 weeks later, the patient had fully recovered. It was decided that a repeat x-ray was not required now that the patient was clinically asymptomatic.
Discussion
Pubic symphysis diastasis (PSD) is an uncommon condition this case is particularly unusual because it occurred following an uncomplicated pregnancy, and first presented after delivery.
PSD has been recognised as a potential complication of childbirth with the incidence being reported from 1:600 to 1:30,000 (Reis et al. 1932; Bertin 1933), with only around 2% of cases presenting during labour or post-natally (Owens et al. 2002). The vast majority of cases occur during the second or third trimester. There has been a possible increase in prevalence in the United Kingdom described by some authors. However, this could either be a true increase or increase merely due to better awareness of this clinical problem (Owens et al. 2002). The pubic symphysis is a midline, non-synovial joint that connects the two superior pubic rami reinforced by cartilaginous disc and anterior pubic ligaments. This allows limited movement of approximately 0.5–1 mm. However, during pregnancy and after labour, there is widening of pelvic joints including the symphysis pubis and the sacroiliac joints. After delivery, laxity of these ligaments gradually diminishes, the pubic diastasis disappears and pelvic stability is restored. Peripartum ligamentous relaxation with moderate widening of symphysis pubis and sacroiliac joints is physiologic and occurs regularly. It is thought to be hormonally mediated by relaxin and progesterone (Putschar 1976). The cause of post-partum pelvic disruption is thought to be mechanical. The forceful rapid descent and the pressure of the foetal head into the birth canal may cause ligamentous injuries. Predisposition has been attributed to complicated delivery, maternal hip dysplasia, prior pelvic trauma, hyper-abduction of the thighs and epidural anaesthesia (Cappiello and Oliver 1995). Young described pelvic arthropathy of pregnancy in 1940 involving symphyseal and sacroiliac injuries (Young 1940). He believed this to be a pregnancy-related and progressive condition rather than an acute event. Risk factors include foetal macrosomia, precipitous labour or rapid second stage of labour, epidural anaesthesia, previous pelvic pathology or trauma to the pelvic ring, multiparity and forceps delivery (Cappiello and Oliver 1995). These birth injuries are often associated with significant pain and disability for prolonged periods of time after delivery. Increased diastasis is associated with pain, swelling and occasionally deformity. Diagnosis should be made using pelvic x-ray and assessing the width of the symphyseal joint. There is little data regarding standard values of the width of symphyseal joint in pregnant women. It has been reported as widening ranges from 3 to 7 mm and patients often remain asymptomatic. A series of four cases by Kharrazi et al. (Kharrazi et al. 1997) had an average PSD of 6.4(range: 6.1–6.6) cm, but most investigators have stated that separation of more than 1 cm is pathologic (Cowling and Rangan 2010). Older literature has suggested that a diastasis of over 2.5 cm means that the sacroiliac ligaments have been damaged and operative treatment should be recommended (Pauwels 1965). However, there is no evidence that the degree of symphyseal distension determines the severity of pelvic pain in pregnancy or after childbirth (Björklund et al. 1999). The differential diagnosis of PSD when presenting acutely postpartum, as in this case, would include post-partum pelvic fracture, nerve compression and femoral vein thrombosis. When considering differential diagnoses of PSD presenting during second and third trimester, as is more typical, urinary tract infection, round ligament pain, pelvic inflammatory disease and musculoskeletal pain should also be considered. Anatomical pelvic variations may make some patients more susceptible to injury during childbirth that may present as pelvic pain. Treatment of post-partum symphyseal rupture has traditionally been non-operative and conservative (Dunbar 2002), achieved through a combination of ice, analgesia and physiotherapy. It is advisable to consult the orthopaedics team when a diagnosis is made or suspected and x-rays are available, to agree on a management plan. Recovery from symphyseal rupture can be expected within 6
Obstetric Case Reports 747
Downloaded by [University of Pennsylvania] at 07:27 06 November 2015
Figure 1. Pelvic x-ray.
weeks; therefore, follow-up appointments are essential to ensure the effectiveness of non-operative therapy. If symptoms do not resolve or significantly worsen, a repeat pelvic x-ray should be performed to determine if there has been any change in the width of the joint. Although conservative treatment often leads to resolution in the majority of cases, invasive orthopaedic treatment is sometimes needed (Omololu et al. 2001). If conservative treatment is failing to control symptoms of severe pain, then operative treatment of the post-partum unstable pelvis has been advocated to achieve anatomical reduction and greater stability (Hagen 1974). However, due to the risks involved in surgery such as bleeding, damage to surrounding structures and reaction to anaesthesia, surgery should be avoided if possible. Consideration must also be given to the effect a major operation would have on the mother and her ability to care for and bond with her new child. Women must be informed of the high recurrence rate in future pregnancies (Jain et al. 2011). Although risk of recurrences is difficult to predict, vaginal delivery is not contraindicated. This case highlights the importance of recognising that, although uncommon, PSD can present after delivery, following an uncomplicated pregnancy. PSD should therefore be considered as a possible cause of pelvic pain following delivery, with a low threshold for performing pelvic x-ray to confirm the diagnosis if there is a significant clinical suspicion. It is important to take a multidisciplinary approach to the condition and involve other specialties at an early stage to ensure that the patient receives the appropriate management with follow-up in place for the post-natal period. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References
Bertin EJ. 1933. Separation of the symphysis pubis: with report of five cases. American Journal of Roentgenology 30:797–801. Björklund K, Nordström ML, Bergström S. 1999. Sonographic assessment of symphyseal joint distention during pregnancy and post partum with special reference to pelvic pain. Acta Obstetricia et Gynecologica Scandinavica 78:125–130. Cappiello GA, Oliver BC. 1995. Rupture of the symphysis pubis caused by forceful and excessive abduction of the thighs with labor epidural anesthesia. Join Florida Medical Association 82:261–263. Cowling PD, Rangan A. 2010. A case of postpartum pubic symphysis diastasis. Injury 41:657–659. Dunbar RP. 2002. Puerperal diastasis of the public symphysis. A case report. Journal of Reproductive Medicine 47:581–583. Hagen R. 1974. Pelvic girdle relaxation from an orthopaedic point of view. Acta Orthopaedica Scandinavica 45:550–563. Jain S, Eedarapalli P, Jamjute P, Sawdy R. 2011. Symphysis pubis dysfunction: a practical approach to management. The Obstetrician and Gynaecologist 8:153–158.
Kharrazi FD, Rodgers WB, Kennedy JG, Lhowe DW. 1997. Parturition-induced pelvic dislocation: a report of four cases. Journal of Orthopaedic Trauma 11:277–281. Omololu AB, Alonge TO, Salawu SA. 2001. Spontaneus pubic symphysial diastasis following vaginal delivery. African Journal of Medicine and Medical Sciences 30:133–135. Owens K, Pearson A, Mason G. 2002. Symphysis pubis dysfunction - a cause of significant obstetric morbidity. European Journal of Obstetrics and Gynecology and Reproductive Biology 105:143–146. Pauwels F. 1965. Beitrag zur Klarung der Beanspruchung des Beckens, insbesondere der Beckenfugen. In: Pauwels FB et al. editors. Gesammelte Abhandlungen zur funktionellen Anatomie des Bewegungsapparates. Springer-Verlag pp. 183–196. Putschar WG. 1976. The structure of the human symphysis pubis with special consideration of parturition and its sequelae. American Journal of Physical Anthropology 45:589–594. Reis RA, Baer JL, Arens RA, Stewart E. 1932. Traumatic separation of the of the normal symphysis pubis during pregnancy and the puerperium. Surgery, Gynecology and Obstetrics 55:336–338. Young J. 1940. Relaxation of the pelvic joints in pregnancy: pelvic arthropathy of pregnancy. Journal of Obstetrics & Gynecology of the British Empire 47:493–524.
Favourable outcome of pregnancy in a patient with pemphigus vulgaris M. Çayırlı1, M. Tunca2, A. Akar2 & Y. K. Akpak3 1Ankara Mevki Military Hospital, Dermatology Service, Ankara,
Turkey, 2Department of Dermatology, Gulhane School of Medicine, Ankara, Turkey, and 3Ankara Mevki Military Hospital, Obstetrics and Gynecology Service, Ankara, Turkey DOI: 10.3109/01443615.2014.993939 Correspondence: Dr. Mutlu Çayırlı, Ankara Mevki Military Hospital, Dermatology Service, Ankara, Turkey. Tel: 90 537 620 76 79. E-mail: [email protected]
Introduction
Pemphigus vulgaris (PV) is a potentially fatal autoimmune disease characterised by the presence of auto-antibodies against skin cell surface antigens. There are reports that this disease may flare during pregnancy and may be associated with adverse neonatal outcomes.
Case
A female patient, mother of one and wife of a physician, presented to our clinic with oral lesions in 2004. The clinical diagnosis of PV was confirmed by histopathological and immunopathological findings. She was treated with systemic corticosteroid azathioprine for the first time and for the following exacerbations. Five years after she was diagnosed with PV, she presented to our department with an unplanned pregnancy at 9 weeks’ gestation. At the time the pregnancy was diagnosed, although she was free of lesions, she had been taking fluocortolon: 10 mg/day and azathioprine: 25 mg/day, as a maintenance therapy. Although she was informed about the risks, she elected to continue the pregnancy. The patient discontinued both systemic steroid and azothioprine. Two months later, at 18 weeks’ gestation, she had a few oral lesions which resolved over two weeks with only topically applied corticosteroids. Thereafter she remained lesion-free during the rest of the pregnancy. She delivered a healthy, term-appropriate-for-gestational-age baby. During the next 4 years of follow-up, both mother and child remained disease-free without any treatment.
Discussion
PV is the most common form of pemphigus. Although it is usually seen in the fifth decade, a large number of female pemphigus patients, in the childbearing age, have also been identified (Amer and Al Ajroush 2007; Daneshpazhooh et al. 2011). No prospective, controlled studies exist to evaluate the efficacy and
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Pubic symphysis diastasis after an uncomplicated vaginal delivery: A case report F. Saeed, K. Trathen, A. Want, R. Kucheria & S. Kalla To cite this article: F. Saeed, K. Trathen, A. Want, R. Kucheria & S. Kalla (2015) Pubic symphysis diastasis after an uncomplicated vaginal delivery: A case report, Journal of Obstetrics and Gynaecology, 35:7, 746-747, DOI: 10.3109/01443615.2014.992873 To link to this article: http://dx.doi.org/10.3109/01443615.2014.992873
Published online: 29 Dec 2014.
Submit your article to this journal
Article views: 41
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [University of Pennsylvania]
Date: 06 November 2015, At: 07:27
Journal of Obstetrics and Gynaecology, October 2015; 35: 746–753 © 2015 Taylor & Francis Group, LLC ISSN 0144-3615 print/ISSN 1364-6893 online
OBSTETRIC CASE REPORTS
Pubic symphysis diastasis after an uncomplicated vaginal delivery: A case report F. Saeed1, K. Trathen2, A. Want1, R. Kucheria3 & S. Kalla1 1Department of Obstetrics & Gynaecology, Wexham Park Hospital,
Wexham, Slough, UK, 2Radnor House Surgery, Ascot, UK,
3Department of Orthopaedics, Wexham Park Hospital, Wexham,
Downloaded by [University of Pennsylvania] at 07:27 06 November 2015
Slough, UK
DOI: 10.3109/01443615.2014.992873 Correspondence: Andrew Want, MBBS, Foundation Year 2 Doctor in Obstetrics & Gynaecology, Department of Obstetrics & Gynaecology, Wexham Park Hospital, Wexham, Slough, SL2 4HL, UK. E-mail: [email protected]
Case presentation
The patient was a 38-year-old white British primiparous woman of average height and weight (170cm, BMI: 22), with no history of pelvic girdle pain antenatally. She presented with spontaneous labour at 39 6 weeks’ gestation. Abdominal examination showed cephalic presentation, direct occipito posterior position, with a fundal height of 39 cm. She progressed in labour appropriately using Entonox and Pethidine for pain relief, reaching full cervical dilatation within 10 h. The active second stage of labour lasted 1 h and 20 min and she delivered a healthy male infant weighing 3660 g (head circumference: 36 cm, length: 55 cm) within a total of 13 h of labour. The placenta was delivered via controlled cord traction 17 min later, and she sustained a second-degree tear. Twelve hours after delivery she complained of severe localised grinding pain in the symphysis pubis area. She was unable to walk secondary to the pain, but could bear weight. Examination revealed marked tenderness over the symphysis pubis. Walking was difficult because of the pain on external rotation of the right lower limb. There was no evidence of neurological compromise. An x-ray of the pelvis was requested by the obstetrics team which showed bony avulsion at the symphysis pubis with a diastasis of 2.5 cm (Figure 1). There was no definite sacroiliac joint widening, which would be evidence of a more complicated open-book pelvic injury.
Management and outcome
The patient was treated with use of regular analgesics, bed rest, pelvic binders and prophylactic low-molecular-weight heparin for thromboprophylaxis. Advice was also sought from the Orthopaedic team for further plan of management and follow-up. The Orthopaedic team agreed with conservative management and it was recommended for her to bear weight as tolerated. She was discharged with the advice of regular analgesia, mobilised using a walker, and a plan for physiotherapy sessions and an outpatient review in two weeks was made. Surgical management would only be considered if the patient did not improve with conservative treatment. When she was reviewed three weeks later her pain had steadily improved and she was able to walk without support. She still reported dull ache at this time and her pubic area remained tender. On her second review 6 weeks later, the patient had fully recovered. It was decided that a repeat x-ray was not required now that the patient was clinically asymptomatic.
Discussion
Pubic symphysis diastasis (PSD) is an uncommon condition this case is particularly unusual because it occurred following an uncomplicated pregnancy, and first presented after delivery.
PSD has been recognised as a potential complication of childbirth with the incidence being reported from 1:600 to 1:30,000 (Reis et al. 1932; Bertin 1933), with only around 2% of cases presenting during labour or post-natally (Owens et al. 2002). The vast majority of cases occur during the second or third trimester. There has been a possible increase in prevalence in the United Kingdom described by some authors. However, this could either be a true increase or increase merely due to better awareness of this clinical problem (Owens et al. 2002). The pubic symphysis is a midline, non-synovial joint that connects the two superior pubic rami reinforced by cartilaginous disc and anterior pubic ligaments. This allows limited movement of approximately 0.5–1 mm. However, during pregnancy and after labour, there is widening of pelvic joints including the symphysis pubis and the sacroiliac joints. After delivery, laxity of these ligaments gradually diminishes, the pubic diastasis disappears and pelvic stability is restored. Peripartum ligamentous relaxation with moderate widening of symphysis pubis and sacroiliac joints is physiologic and occurs regularly. It is thought to be hormonally mediated by relaxin and progesterone (Putschar 1976). The cause of post-partum pelvic disruption is thought to be mechanical. The forceful rapid descent and the pressure of the foetal head into the birth canal may cause ligamentous injuries. Predisposition has been attributed to complicated delivery, maternal hip dysplasia, prior pelvic trauma, hyper-abduction of the thighs and epidural anaesthesia (Cappiello and Oliver 1995). Young described pelvic arthropathy of pregnancy in 1940 involving symphyseal and sacroiliac injuries (Young 1940). He believed this to be a pregnancy-related and progressive condition rather than an acute event. Risk factors include foetal macrosomia, precipitous labour or rapid second stage of labour, epidural anaesthesia, previous pelvic pathology or trauma to the pelvic ring, multiparity and forceps delivery (Cappiello and Oliver 1995). These birth injuries are often associated with significant pain and disability for prolonged periods of time after delivery. Increased diastasis is associated with pain, swelling and occasionally deformity. Diagnosis should be made using pelvic x-ray and assessing the width of the symphyseal joint. There is little data regarding standard values of the width of symphyseal joint in pregnant women. It has been reported as widening ranges from 3 to 7 mm and patients often remain asymptomatic. A series of four cases by Kharrazi et al. (Kharrazi et al. 1997) had an average PSD of 6.4(range: 6.1–6.6) cm, but most investigators have stated that separation of more than 1 cm is pathologic (Cowling and Rangan 2010). Older literature has suggested that a diastasis of over 2.5 cm means that the sacroiliac ligaments have been damaged and operative treatment should be recommended (Pauwels 1965). However, there is no evidence that the degree of symphyseal distension determines the severity of pelvic pain in pregnancy or after childbirth (Björklund et al. 1999). The differential diagnosis of PSD when presenting acutely postpartum, as in this case, would include post-partum pelvic fracture, nerve compression and femoral vein thrombosis. When considering differential diagnoses of PSD presenting during second and third trimester, as is more typical, urinary tract infection, round ligament pain, pelvic inflammatory disease and musculoskeletal pain should also be considered. Anatomical pelvic variations may make some patients more susceptible to injury during childbirth that may present as pelvic pain. Treatment of post-partum symphyseal rupture has traditionally been non-operative and conservative (Dunbar 2002), achieved through a combination of ice, analgesia and physiotherapy. It is advisable to consult the orthopaedics team when a diagnosis is made or suspected and x-rays are available, to agree on a management plan. Recovery from symphyseal rupture can be expected within 6
Obstetric Case Reports 747
Downloaded by [University of Pennsylvania] at 07:27 06 November 2015
Figure 1. Pelvic x-ray.
weeks; therefore, follow-up appointments are essential to ensure the effectiveness of non-operative therapy. If symptoms do not resolve or significantly worsen, a repeat pelvic x-ray should be performed to determine if there has been any change in the width of the joint. Although conservative treatment often leads to resolution in the majority of cases, invasive orthopaedic treatment is sometimes needed (Omololu et al. 2001). If conservative treatment is failing to control symptoms of severe pain, then operative treatment of the post-partum unstable pelvis has been advocated to achieve anatomical reduction and greater stability (Hagen 1974). However, due to the risks involved in surgery such as bleeding, damage to surrounding structures and reaction to anaesthesia, surgery should be avoided if possible. Consideration must also be given to the effect a major operation would have on the mother and her ability to care for and bond with her new child. Women must be informed of the high recurrence rate in future pregnancies (Jain et al. 2011). Although risk of recurrences is difficult to predict, vaginal delivery is not contraindicated. This case highlights the importance of recognising that, although uncommon, PSD can present after delivery, following an uncomplicated pregnancy. PSD should therefore be considered as a possible cause of pelvic pain following delivery, with a low threshold for performing pelvic x-ray to confirm the diagnosis if there is a significant clinical suspicion. It is important to take a multidisciplinary approach to the condition and involve other specialties at an early stage to ensure that the patient receives the appropriate management with follow-up in place for the post-natal period. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References
Bertin EJ. 1933. Separation of the symphysis pubis: with report of five cases. American Journal of Roentgenology 30:797–801. Björklund K, Nordström ML, Bergström S. 1999. Sonographic assessment of symphyseal joint distention during pregnancy and post partum with special reference to pelvic pain. Acta Obstetricia et Gynecologica Scandinavica 78:125–130. Cappiello GA, Oliver BC. 1995. Rupture of the symphysis pubis caused by forceful and excessive abduction of the thighs with labor epidural anesthesia. Join Florida Medical Association 82:261–263. Cowling PD, Rangan A. 2010. A case of postpartum pubic symphysis diastasis. Injury 41:657–659. Dunbar RP. 2002. Puerperal diastasis of the public symphysis. A case report. Journal of Reproductive Medicine 47:581–583. Hagen R. 1974. Pelvic girdle relaxation from an orthopaedic point of view. Acta Orthopaedica Scandinavica 45:550–563. Jain S, Eedarapalli P, Jamjute P, Sawdy R. 2011. Symphysis pubis dysfunction: a practical approach to management. The Obstetrician and Gynaecologist 8:153–158.
Kharrazi FD, Rodgers WB, Kennedy JG, Lhowe DW. 1997. Parturition-induced pelvic dislocation: a report of four cases. Journal of Orthopaedic Trauma 11:277–281. Omololu AB, Alonge TO, Salawu SA. 2001. Spontaneus pubic symphysial diastasis following vaginal delivery. African Journal of Medicine and Medical Sciences 30:133–135. Owens K, Pearson A, Mason G. 2002. Symphysis pubis dysfunction - a cause of significant obstetric morbidity. European Journal of Obstetrics and Gynecology and Reproductive Biology 105:143–146. Pauwels F. 1965. Beitrag zur Klarung der Beanspruchung des Beckens, insbesondere der Beckenfugen. In: Pauwels FB et al. editors. Gesammelte Abhandlungen zur funktionellen Anatomie des Bewegungsapparates. Springer-Verlag pp. 183–196. Putschar WG. 1976. The structure of the human symphysis pubis with special consideration of parturition and its sequelae. American Journal of Physical Anthropology 45:589–594. Reis RA, Baer JL, Arens RA, Stewart E. 1932. Traumatic separation of the of the normal symphysis pubis during pregnancy and the puerperium. Surgery, Gynecology and Obstetrics 55:336–338. Young J. 1940. Relaxation of the pelvic joints in pregnancy: pelvic arthropathy of pregnancy. Journal of Obstetrics & Gynecology of the British Empire 47:493–524.
Favourable outcome of pregnancy in a patient with pemphigus vulgaris M. Çayırlı1, M. Tunca2, A. Akar2 & Y. K. Akpak3 1Ankara Mevki Military Hospital, Dermatology Service, Ankara,
Turkey, 2Department of Dermatology, Gulhane School of Medicine, Ankara, Turkey, and 3Ankara Mevki Military Hospital, Obstetrics and Gynecology Service, Ankara, Turkey DOI: 10.3109/01443615.2014.993939 Correspondence: Dr. Mutlu Çayırlı, Ankara Mevki Military Hospital, Dermatology Service, Ankara, Turkey. Tel: 90 537 620 76 79. E-mail: [email protected]
Introduction
Pemphigus vulgaris (PV) is a potentially fatal autoimmune disease characterised by the presence of auto-antibodies against skin cell surface antigens. There are reports that this disease may flare during pregnancy and may be associated with adverse neonatal outcomes.
Case
A female patient, mother of one and wife of a physician, presented to our clinic with oral lesions in 2004. The clinical diagnosis of PV was confirmed by histopathological and immunopathological findings. She was treated with systemic corticosteroid azathioprine for the first time and for the following exacerbations. Five years after she was diagnosed with PV, she presented to our department with an unplanned pregnancy at 9 weeks’ gestation. At the time the pregnancy was diagnosed, although she was free of lesions, she had been taking fluocortolon: 10 mg/day and azathioprine: 25 mg/day, as a maintenance therapy. Although she was informed about the risks, she elected to continue the pregnancy. The patient discontinued both systemic steroid and azothioprine. Two months later, at 18 weeks’ gestation, she had a few oral lesions which resolved over two weeks with only topically applied corticosteroids. Thereafter she remained lesion-free during the rest of the pregnancy. She delivered a healthy, term-appropriate-for-gestational-age baby. During the next 4 years of follow-up, both mother and child remained disease-free without any treatment.
Discussion
PV is the most common form of pemphigus. Although it is usually seen in the fifth decade, a large number of female pemphigus patients, in the childbearing age, have also been identified (Amer and Al Ajroush 2007; Daneshpazhooh et al. 2011). No prospective, controlled studies exist to evaluate the efficacy and
