CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA PRA Category 1 Credits™ can be earned in 2015. Instructions for how CME credits can be earned appear on the last page of the Table of Contents. Pubic Symphysis Rupture and Separation During Pregnancy Kelsey L. Shnaekel, BS,* Everett F. Magann, MD,† and Shahryar Ahmadi, MD‡ *Medical Student, †Professor of Obstetrics/Gynecology and Maternal-Fetal Medicine, and ‡Assistant Professor of Orthopedics, Departments of Obstetrics and Gynecology and Orthopedics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR Objective: The aim of this study was to determine the risk factors, clinical and radiologic criteria for diagnosis, and management of this unusual complication of pregnancy. Methods: A PubMed and Web of Science search was undertaken with no limitations on the number of years searched. Results: There were 36 publications identified, with 19 articles being the basis of this review. Multiple risk fac- tors have been identified including multiparity, macrosomia, cephalopelvic disproportion, forceps deliveries, pre- cipitous labor, malpresentation, prior pelvic trauma, and use of the McRoberts maneuver. The diagnosis is usually made clinically, confirmed by imaging, and considered pathological when the intrapubic gap is greater than 10 mm. Magnetic resonance imaging appears to be superior to pelvic x-ray and computed tomography scan in visualization of the bone separation. Conservative treatment remains the first choice for therapy, but women who do not respond to conservative therapy or women with large separations may need surgical stabi- lization with external or internal fixation. Conclusions: Widening of the pubic symphysis greater than 10 mm is pathologic. The diagnosis is clinical and confirmed by imaging studies, with magnetic resonance imaging being the superior technique. Conservative treatment is the first line of therapy. Failure of conservative therapy is treated by surgical stabilization. Target Audience: Obstetricians and gynecologists, family physicians. Learning Objectives: After completion of this educational article, the reader will be able to evaluate the pub- lished literature regarding peripartum pubic symphysis rupture and associated outcomes; recognize clinical pre- sentation of pubic symphysis rupture following vaginal delivery; differentiate between normal and pathological separation on imaging; determine the most beneficial treatment strategy; and review recommendations regard- ing management of subsequent pregnancies after pubic symphysis rupture. There are many physical changes that occur normally during pregnancy. As the gravid uterus enlarges, there is stretching of surrounding tissues that places a vari- ety of strains on the maternal musculoskeletal system. The pubic symphysis is a synovial joint separated by a fibrocartilaginous disk and reinforced by 4 pubic liga- ments. As pregnancy advances, the maternal skeleton prepares for parturition by increasing pelvic joint laxity. The increased laxity of the ligaments of the pubic sym- physis and the sacroiliac (SI) joints is considered a nor- mal physiologic change that begins in the first trimester, increase in the second and third trimesters, and returns to baseline in the postpartum period. 1 Widening of the symphysis pubis to a width of 1 to 3 mm is commonly observed and is considered normal, and that degree of separation is usually asymptomatic. 2 Pubic symphysis rupture is considered an unusual intrapartum complication with a reported incidence in the literature ranging from 1 in 300 to 1 in 30,000 preg- nancies. The wide range of incidences in the literature could be attributable to underreporting because of mild and self-limited symptoms. 3 Separation is considered All authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any com- mercial organizations pertaining to this educational activity. Correspondence requests to: Everett F. Magann, MD, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, 4301 W Markham St, Slot 518, Little Rock, AR 72205. E-mail: efmagann@uams.edu. www.obgynsurvey.com | 713 Volume 70, Number 11 OBSTETRICAL AND GYNECOLOGICAL SURVEY Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. CME REVIEW ARTICLE 31 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.