Pelvic Pain in Pregnancy: Causes, Symptoms and Relief

Pelvic pain in pregnancy represents one of the most frequent and debilitating musculoskeletal syndromes that can arise during the three trimesters of gestation. This condition, clinically also known as pelvic girdle pain (Pelvic Girdle Pain – PGP), pregnancy-related pubalgia, or symphysis pubis dysfunction (Symphysis Pubis Dysfunction – SPD), affects a significant percentage of expectant mothers, with estimates varying from 20% to 45% depending on clinical case series (Wu et al., 2004). The symptomatology typically manifests as acute, sharp, or dull pain localized at the sacroiliac joint, the pubic symphysis, with possible radiation towards the lumbar region, buttocks, and medial aspect of the thighs. The impact on quality of life is significant, limiting normal daily activities, ambulation, and work capacity. The management of this clinical picture requires a multidisciplinary approach, in which physiotherapy plays a primary role in pain control and the maintenance of motor function. It is essential to emphasize that, should such symptomatology appear, it is always necessary to consult your doctor or physical therapist for an accurate diagnostic assessment and to rule out other obstetric or gynecological conditions.

Anatomy and Physiology: Understanding pelvic pain in pregnancy

Pelvic pain in pregnancy is discomfort in the lower abdomen and pelvic region caused by hormonal changes, postural shifts, and increased joint mobility during gestation. To fully understand the genesis of pregnancy-related pubalgia and symphyseal dysfunction, it is essential to analyze the anatomical and physiological changes that the maternal pelvis undergoes. The pelvic girdle is a ring-like structure composed of three main bones: the two iliac bones and the sacrum. These bones articulate posteriorly via the two sacroiliac joints and anteriorly through the pubic symphysis, a fibrocartilaginous joint. The stability of this ring is ensured by a complex system of ligaments and surrounding musculature, according to the biomechanical model of “Form Closure” (form closure, provided by bony interlocking) and “Force Closure” (force closure, guaranteed by musculoligamentous compression) described by Vleeming et al. (1992).

The role of hormonal changes

During gestation, the endocrine system undergoes profound changes. The production of hormones such as relaxin and progesterone increases significantly. Relaxin, in particular, has the physiological task of remodeling collagen, inducing greater laxity of the pelvic ligaments (MacLennan et al., 1986). This process is biologically essential to allow pelvic expansion and facilitate the passage of the fetus during delivery. However, this physiological laxity reduces “Form Closure”, making the pelvic joints more hypermobile and vulnerable to mechanical stress. When the neuromuscular system (“Force Closure”) fails to adequately compensate for this joint instability, a pattern of biomechanical dysfunction develops that results in pain.

Postural and biomechanical alterations

Alongside hormonal changes, fetal growth and the increase in uterine volume cause an anterior shift of the body’s center of gravity. To maintain balance, the spine accentuates the physiological lumbar lordosis, while the pelvis undergoes anteversion. This new postural configuration alters the force vectors acting on the pelvic girdle, overloading the sacroiliac joints and the pubic symphysis. The abdominal musculature, stretched by uterine expansion, loses part of its stabilizing effectiveness, forcing the paravertebral muscles, gluteal muscles, and pelvic floor muscles into compensatory overwork that often results in painful contractures and early fatigue.

Causes and Risk Factors associated with pelvic pain in pregnancy

The etiology of pelvic girdle pain is multifactorial. There is no single triggering cause, but rather a combination of predisposing and precipitating factors that alter the biomechanical balance of the pelvis. Early identification of these factors is crucial for establishing appropriate preventive and therapeutic strategies, always under the supervision of your doctor or physical therapist.

Anamnestic and physical factors

Scientific literature has identified several individual risk factors. A previous history of low back or pelvic pain, either in previous pregnancies or outside the gestational state, represents one of the strongest predictors for the development of the condition (Albert et al., 2006). Previous pelvic trauma, generalized joint hypermobility, and a high pre-pregnancy Body Mass Index (BMI) have also been associated with a higher incidence of the disorder. Interestingly, maternal age, height, and the use of oral contraceptives before pregnancy do not appear to have a statistically significant correlation with the onset of the syndrome.

Occupational factors and INAIL data

Work activity plays a decisive role in the exacerbation of symptomatology. According to the guidelines and data provided by INAIL (the Italian National Institute for Insurance against Accidents at Work) regarding the protection of working mothers (Legislative Decree 81/08 and subsequent amendments), certain job roles expose pregnant women to high ergonomic and biomechanical risk. The professional categories at greatest risk include healthcare workers (nurses, healthcare assistants), retail sales workers, manufacturing workers, and agricultural sector workers. Specific occupational risk factors include:

• Prolonged standing (more than 3-4 continuous hours).
• Manual handling of loads, even of modest size, if repetitive.
• Adoption of awkward postures, such as frequent trunk flexion and rotation.
• Working on uneven surfaces or requiring frequent use of stairs.

INAIL emphasizes the importance of specific risk assessment for pregnant workers, recommending workstation adaptation, the introduction of frequent breaks, and, in cases of incompatibility between the job role and health status, early leave from work due to occupational risk, subject to medical certification.

Symptomatology and Clinical Presentation

The clinical presentation of symphysis pubis dysfunction and pregnancy-related pubalgia is characterized by a well-defined symptom complex, although the intensity may vary from mild discomfort to disabling pain. The cardinal symptom is pain, typically localized at the pubic symphysis (anteriorly) and/or at the sacroiliac joints (posteriorly, at the level of the dimples of Venus). The pain may radiate toward the inguinal region, the perineum, and the medial or posterior aspect of the thighs, in some cases mimicking sciatica.

Pain characteristics and aggravating factors

The pain is often described as sharp, burning, or as a sensation of “giving way” or “tearing” at the pubic level. A fundamental diagnostic element is the mechanical nature of the pain: it worsens during specific motor activities that require asymmetric loading of the pelvis. Among the most common aggravating factors are:

• Walking for long distances or on uneven terrain.
• Climbing or descending stairs.
• Standing on one leg (e.g., when dressing or putting on shoes).
• Spreading the legs (hip abduction), such as when getting out of a car.
• Turning over in bed during the night.

In more severe forms, the pregnant woman may develop a waddling gait (anserine gait), characterized by short steps and a marked lateral sway of the pelvis, in an attempt to minimize movement of the pelvic joints and reduce pain.

Assessment and Physiotherapy Diagnosis

The diagnosis of pelvic girdle pain is eminently clinical and is based on an accurate history and a specific physical examination. It is imperative that the assessment be conducted by your doctor or physical therapist, in order to exclude other conditions (differential diagnosis) such as urinary tract infections, threatened preterm labor, lumbar disc herniation with sciatica, or hip pathologies. The use of radiological investigations (such as pelvic X-ray) is generally contraindicated during pregnancy due to fetal exposure to ionizing radiation, although in exceptional cases and postpartum, MRI or ultrasound may be employed to assess pubic symphysis diastasis.

Clinical provocation and functional tests

The physiotherapy assessment utilizes internationally validated clinical tests to confirm involvement of the sacroiliac joints and pubic symphysis (Albert et al., 2000). These tests aim to reproduce the patient’s familiar pain by applying specific mechanical stresses. Among the most commonly used tests are:

Physiotherapy Treatment and Conservative Management

The management of pelvic pain in pregnancy must be timely, personalized, and progressive. The primary goal of physiotherapy treatment is not the total elimination of ligamentous laxity (which, as discussed, is physiological and necessary), but the optimization of pelvic biomechanics, pain reduction, and improvement of quality of life. The treatment plan must always be agreed upon and supervised by your doctor or physical therapist, taking into account the gestational age and the patient’s general clinical conditions.

Manual Therapy and Myofascial Release

Manual therapy represents an effective approach for relieving the compensatory muscle tensions that develop around the pelvis. Therapeutic massage techniques, myofascial release, and trigger point treatment are indicated for relaxing the lumbar paravertebral muscles, gluteal muscles, piriformis, and hip adductor muscles. Joint mobilizations, if performed, must be extremely gentle and low-grade, avoiding high-velocity manipulations (thrust) that could exacerbate joint instability or be contraindicated in pregnancy.

Specific Therapeutic Exercise

Therapeutic exercise is the cornerstone of rehabilitation for symphyseal dysfunction and sacroiliac pain. The goal is to restore “Force Closure”, that is, the active stability of the pelvis, by strengthening the muscles that act as a natural corset. Exercise protocols (Stuge et al., 2004) focus on:

• Core Activation: Exercises targeting the recruitment of the transversus abdominis muscle and pelvic floor muscles. These muscles work synergistically to stabilize the pelvic ring anteriorly and inferiorly.
• Gluteal Strengthening: The gluteus maximus and medius are essential for posterior and lateral stability of the pelvis. Exercises on all fours or in side-lying position (adapted for pregnancy) are frequently prescribed.
• Selective Stretching: Gentle lengthening of hypertonic muscles, particularly the adductors, hip flexors (iliopsoas), and lumbar musculature, taking care not to force the range of motion due to relaxin-induced laxity.

Use of Orthoses and Pelvic Belts

In conjunction with therapeutic exercise, the use of a pelvic support belt or girdle can provide significant symptomatic relief. The belt, positioned at the level of the sacroiliac joints and just above the pubic symphysis, acts by providing external compression that substitutes for the deficient “Form Closure”. The orthosis helps stabilize the pelvis during weight-bearing activities, such as walking or standing. It is advisable that the choice of model, correct positioning, and duration of use be indicated by your doctor or physical therapist, to avoid improper use that could inhibit active muscle activation.

Hydrotherapy (Aquatic Physiotherapy)

Aquatic exercise represents an excellent therapeutic option for pregnant women affected by pelvic pain. Archimedes’ principle reduces the effect of gravity, dramatically decreasing the mechanical load on the sacroiliac joints and pubic symphysis. Warm water also promotes muscle relaxation and pain relief. Hydrotherapy protocols include gentle mobility exercises, muscle strengthening using water resistance, and gait training in a microgravity environment.

Postural Education, Ergonomics, and Behavioral Advice

A fundamental component of physiotherapy treatment consists of educating the patient about the behavioral and postural modifications necessary to manage pain in daily life. Reducing mechanical stresses on the pelvis is essential to prevent symptom exacerbation. The following ergonomic strategies are recommended:

Managing daily activities

• Night rest: It is recommended to sleep in a lateral position (preferably on the left side to promote venous return), placing a sufficiently thick pillow between the knees and ankles. This measure maintains the hips in a neutral position, avoiding the drop of the upper leg that would cause a painful torsion of the pelvis.
• Postural transitions: To get out of bed, it is necessary to adopt the “log roll” technique: turning onto the side while keeping the knees together, letting the legs drop off the edge of the bed, and pushing up with the arms, avoiding asymmetric movements or trunk rotations.
• Dressing: It is recommended to dress (putting on trousers, socks, shoes) while seated, strictly avoiding single-leg standing which overloads the pubic symphysis.
• Getting in and out of a car: When entering a car, it is advisable to first sit on the seat with both legs outside, then rotate the pelvis and bring the legs into the vehicle while keeping the knees together. A plastic bag on the seat can reduce friction and facilitate rotation.

Workplace ergonomics

Following INAIL directives on occupational health, it is essential to adapt the workstation. For office workers, it is necessary to use ergonomic chairs with good lumbar support, avoiding crossing the legs. For tasks requiring standing, the use of anti-fatigue mats, frequent alternation of posture (sitting/standing), and the use of a small footrest to alternately rest the feet to relieve the lumbar and pelvic area are recommended. If ergonomic modifications are insufficient to control the pain, reassessment by the occupational physician and the attending gynecologist is mandatory.

Childbirth and Postpartum Recovery in Symphyseal Dysfunction

The presence of severe pelvic pain or marked symphysis pubis dysfunction often raises concerns about delivery. It is essential to discuss the clinical condition with the obstetric team. In most cases, vaginal delivery is absolutely possible and safe. However, certain precautions need to be adopted during labor and the expulsive phase.

Precautions during labor

It is recommended to avoid positions that require excessive hip abduction (spreading). The measurement of the maximum pain-free range of abduction (Pain-Free Range of Motion) should be performed by the physical therapist in the weeks preceding delivery and communicated to the midwives. During labor, lateral decubitus, all-fours, or supported asymmetric positions are preferred, avoiding the classic lithotomy position with stirrups if it provokes acute pain or exceeds the pain-free abduction limit.

The postpartum rehabilitation pathway

In most women, symptomatology spontaneously resolves within the first weeks or months after delivery, paralleling the restoration of normal hormone levels and ligamentous stabilization. However, in a minority of cases (approximately 7-10%), the pain may become chronic (Albert et al., 2001). Postpartum recovery must be gradual. In the initial phases, it is recommended to continue applying the principles of joint ergonomics learned during pregnancy, paying particular attention to the postures assumed during breastfeeding and lifting the newborn. Subsequently, following assessment by your doctor or physical therapist, a progressive rehabilitation program will be established targeting the recovery of abdominal wall muscle tone (assessing for the possible presence of diastasis recti), pelvic floor function, and overall stability of the lumbopelvic girdle, in order to ensure a safe return to sports and work activities.

Frequently Asked Questions (FAQ)