Trevor Silver Memorial Essay Prize 2016 First Prize

The Beached Whale

By Dr Jamila Groves MBBS MRCGP DRCOG DFSRH DCG PGCE (dist)

August 2016

In she hobbled. Her husband had driven her here and dropped her at the surgery entrance, and
she had just about managed, slowly, and with the aid of two crutches, to pull herself into my
consultation room. Juliet (not her real name) was a 39 year old lady with a history of
high achievement. She had run the London marathon as a university student raising
significant amounts of money for local charities during her university years. She now
kept herself fit and healthy by regularly attending the gym, cycling and swimming as
well as backpacking treks with her husband. She didn't smoke, she didn't drink alcohol,
her BMI was ideal, but over the past 4 months her mobility had been decreasing
steadily bringing her to her current state. She was, as her friends jeered, a 'beached
whale'; spending her days and nights lying on the sofa or bed, only getting up when
absolutely necessary. She could no longer climb stairs or even crawl on the floor. She
rolled over in bed with a yelp, and when out of doors was reliant on others to push her
in a wheelchair, or otherwise could manage very limited distances with the crutches.
So what was it that laid a previously fit and well young lady down like this? Not
accident nor injury, not infection nor dysfunction, simply pregnancy. She was 28 weeks
pregnant and suffering from the poorly understood condition known as pregnancy-related pelvic
girdle pain (PPGP).

Juliet's first pregnancy at the age of 34 years went smoothly; she walked an hour to and from work
each day until the second trimester, then slowed down a bit, wearing a pelvic support belt from 34
weeks gestation for comfort, and enjoyed a spontaneous vaginal delivery at home. The second
pregnancy was also straight-forward; she walked with the pelvic support belt from 28 weeks
gestation that time, and carried around a lumbar support cushion for use when sitting. Labour was
induced at 40 weeks for prolonged rupture of membranes, using iv oxytocin (syntocinon) which
resulted in a hyperstimulated very painful delivery. Juliet recovered well though, and within three
months was able to walk several miles carrying her new baby in a sling. With the third baby, Juliet
started having lower back pains from about 10 weeks gestation. By 28 weeks she was unable to
work any longer due to severe pain on walking and difficulty getting to her first floor office. She
saw an NHS physiotherapist at this point who offered her crutches and said there wasn't anything
more they could offer. Juliet then saw a private physiotherapist who suggested a Dynair water
cushion for the car, and gave general advice on how to turn in bed etc. There was no follow-up and

Juliet suffered at home for several weeks. She had a vaginal delivery in hospital that was induced at
42 weeks as she hadn't gone into spontaneous labour (presumably due to her immobility).
Thankfully, she was up on her feet again fairly soon after giving birth, and although had a fair
amount of ongoing pain she returned to work after 6 months, and managed well, being able to
walk about 2-3 miles pushing the baby in a buggy. No sling this time, and no ability to run, but not
in bad shape overall.

Now in a fourth pregnancy within a five year period Juliet was in dire straits. By 8 weeks gestation
she had required crutches again and by 15 weeks she was up all night crying with severe pains. By
20 weeks she could only walk very small distances despite the aid of the crutches. She saw a
private physiotherapist twice who manipulated the sacro-iliac joints which provided good relief,
but only for a few days. She also saw the Senior Obstetric Physiotherapist attached to her
maternity unit who performed further manipulations, and advised her to rest the pelvis as much as
possible. Workplace adaptations had been put into place but the pain and immobility had
worsened to such an extent that she had to leave work three months before her due date. Being
the main earner, going off work this early meant significant financial strain for her, her husband
and their children.

Her questions to me, her GP, were:
1. Is there anything that can be done to alleviate, or manage this pain?
2. If not, are there any ways that you suggest help me endure the pain?
3. How bad can this condition get, will it simply keep worsening? How will I be in another
three months time? How will I cope?
4. Why me? All the pregnant women I know are waltzing around with ease.
5. Will I ever get better, or does this result in permanent damage?

I felt completely unprepared for this consultation, and inadequate in both my knowledge and
experience of what was going on. However I was sufficiently moved by Juliet's anguish and
desperation, and struck by her lack of support so far, that I felt the need to research the topic.
Subsequently this essay resulted...
Pregnancy-related Pelvic Girdle Pain (PPGP)

PPGP is a pregnancy related condition which causes pain in one or more joints of the pelvis and
consequent difficulty walking that can be disabling1. PPGP was coined as a term in 2005 to describe
the experience of pain between the posterior iliac crest and the gluteal fold (ie over the sacroiliac
joints), and/or pain over the symphysis pubis (which used to be referred to as symphysis pubis
dysfunction). Pain over the sacro-iliac (SI) joints radiates to the buttocks and thighs, while pain
over the symphysis pubis radiates to the vulva and inner thighs. PPGP is classically worst when
walking or weight bearing on one leg, but sitting (especially in a car or other cramped
environment) and sexual intercourse may exacerbate the pain also. Signs on clinical examination
include antalgic gait, tenderness and/or erythema over the affected joints2.
Many doctors perceive pelvic pain to be 'expected' during pregnancy and as such often offer few
solutions and little recognition3. Sufferers however can experience considerable disability2 that
affects their quality of life, work productivity, sexual satisfaction, as well as their enjoyment of
pregnancy and motherhood as they struggle to bond with a baby that caused them so much pain.
PPGP affects up to 25% pregnant women to some extent4.
The exact mechanisms that cause PPGP are multifactorial, and in many cases unclear5.

• The pelvis transmits vertical forces from the spine to the
legs making the stability of the SI and pubic joints crucial
for successful locomotion6. Increased movement of the SI
and pubic joints along with progressive lordosis of the
lumbosacral spine are normal physiological adaptations of
the musculoskeletal system to pregnancy, and it is thought
that the pressure of these changes, when not sufficiently
counteracted by the pelvic floor and abdominal muscles
leads to PPGP.
• The hormonal effects of relaxin and progesterone on the
pelvic ligaments are thought to loosen the joints, with subsequent laxity resulting in
instability of the pelvis (and therefore difficulty walking) along with pain.
• Neuromotor control systems are thought to play a part but again are poorly understood.
• Neuromodular processing of pain is also thought to be contributory.
Despite considerable clinical interest, the physiological processes characterising PPGP remain
obscure5, with risk factors for developing PPGP including both physical and psychosocial factors7:
• Multiparity
• Strenuous physical activity (twisting or bending the back several times an hour)
• History of lower back pain or trauma to back or pelvis
• Previous PPGP
• Previous difficult delivery
• A professional education or self-reported stress
• Poor relationship with spouse
Perhaps surprisingly the following factors are not thought to play a role7:
• Time interval since last pregnancy
• Maternal age
• Maternal body mass index
• Fetal weight
• Bone density

Treatment options for PPGP
1. Bed rest and symptomatic care appear to be the mainstay of PPGP therapy1. Advice on
sleeping position or use of a 'banana pillow' can be helpful.
A supportive belt worn at the level of the anterior superior
iliac spines can increase pelvic stability and thereby increase
walking distance. Mobility aids such as crutches, zimmer
frames or wheelchairs may be required in severe cases.
2. Physical or manual therapy performed by a specialist physiotherapist, osteopath, or
chiropractor can be very effective. This may involve manipulation of one or both of the SI
joints. In addition pelvic tilt exercises with advice on avoidance of exacerbating movements
such as stair climbing is beneficial.
3. A massage therapist can help to treat tight over-active buttock muscles, or this can be done
at home by a partner.
4. There appears to be little that the obstetrician can offer as there is
no evidence at present that a caesarean section results in a more
rapid recovery or conveys any advantage to women with PPGP8.
Labour should occur as normal but avoiding lithotomy position or
squatting, both of which can aggravate PPGP and result in
increased post-partum symptoms. The recommended positions for
labour are all four kneeling or lying laterally with the upper leg
supported.
5. Pain management from an appropriately trained Clinical
Psychologist can be extremely therapeutic9,10.
6. GP care co-ordination is crucial to provide sign-posting to the above agencies and to
provide ongoing support to the mother that will continue after the delivery. The GP should
also consider prescription of analgesia, as well as prophylactic clexane if immobile. A sick
note may be required.
7. There are a few voluntary agencies that help provide information and support regarding
PPGP. Such organisations include the pelvic partnership11 and the pelvic instability
network12.
8. If PPGP is long-standing (persisting beyond pregnancy), and very severe, surgical
arthrodesis can be considered as a procedure of last resort6.
Post-partum Prognosis
In 90% of women who experience PPGP, symptoms resolve completely within 6 months of delivery.
However at two years post-partum there are still 8% of women who feel pelvic girdle pain13, and in
some this pain turns into a severe chronic disabling pain syndrome that is very difficult to manage.

Risk factors associated with the development of ongoing symptoms include5,7:
• Multi-parity
• Onset of pain at early gestation
• Pain in all three of the pelvic joints
• Severe symptoms during the pregnancy
• Previous pain condition, anxiety or depression
• Poor socio-economic status or non-supportive partner

Understanding this, it is important that advice is given to the woman regarding ways and means to
maximise chances of full and fast recovery soon after delivery. That advice includes
recommendation to avoid all aggravating activities until symptoms have completely subsided.
Physiotherapeutic advice should be offered regarding exercises to improve core stability as these
are known to be effective in reducing morbidity14,15. Pulsed short-wave therapy can be offered
which is often very effective in reducing inflammation16.
The European guidelines for PPGP do recommend that analgesia should be prescribed as required
for pain relief17, and once the baby is delivered the GP will be at liberty to do this with greater
freedom than when her suffering was at its worst. However analgesia must be used with caution as
both opiates and NSAIDS are known to contribute to the development of chronic pain syndrome18.
In addition analgesia, although possibly very effective in reducing pain in the short-term, may
result in the woman performing more aggravating activities and thereby unwillingly exacerbating
her condition.

Conclusion
So back to Juliet; she got through the remainder of her fourth pregnancy lying in bed. She was
unable to care for herself or her children at all during that time. By the end of the pregnancy she
required assistance to transfer and a bedside commode. Obstetrics agreed to free her from
pregnancy by inducing labour at 39 weeks. At her six week post-partum check with me the first
thing she asked was “Doctor, doctor, how soon can I be sterilised? The temptation of resuming sex
looms... Please help me!”

References
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Acta Obstet. Gynecol. Scand. 78, 111–115 (1999).
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review of recent evidence and a clinical care path proposal. Facts Views Vis. ObGyn 5, 33–43 (2013).
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12. PINS charity supporting people with Pelvic Girdle Pain/Symphysis pubis dysfunction (SPD):
www.spanglefish.com/pins/pelvicgirdlepain.asp
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