前一陣子，盤腿時一不小心會有大腿根部猛然抽一下的感覺，因為偶爾才會有，所以不以為意，這幾天不小心碰到恥骨，發現竟然有一種莫名的疼痛感，感覺好像是骨頭在發炎，但沒碰沒事，一碰就痛，一查之下，原來這也是孕婦可能會碰到的問題之一，恥骨疼痛。再仔細研究一下，發現恥骨三角地帶，一直到髖骨的部分，其實都有一點痠軟的感覺，這應該是來自於同樣的問題。其實，進入懷孕中期，腳都有一種微微的痠痛感，但很輕微，有時候動一動，這種痠痛感就會不見，想來，是從那個時候起，我身體所分泌的黃體素和遲緩素已經開始發生作用了啊!

看了大家的分享，發現疼痛的程度不一，但真的痛起來也是會要人命的。希望我的恥骨疼痛可以維持現在這樣，或是更不痛，讓我可以在不碰觸它時，幾乎可以忘了它的存在。

8/29 耶!恥骨不痛了!~~

9/14 這一個禮拜以來，漸漸覺得髖骨開始崩解，一直微微的痠痛著，不能很敏捷的走路。不知道是不是最近常穿穿夾腳拖鞋的關係，走路姿勢影響髖骨的承重力，看來如果可以的話，出門走遠路還是穿舒適的慢跑鞋比較妥當。

許多懷孕的婦女會抱怨恥骨附近疼痛，但在就診時往往被告知這是妊娠伴隨的不適症狀之一，是微不足道而必須忍受的，有的甚至以此來作為剖腹產的理由。究竟，恥骨疼痛的原因為何？有什麼方法可以減輕它的不適？

文．圖片提供／耕莘醫院產科主任鄧森文　執行／楊文玉
在懷孕的時候，弛緩素和黃體素這兩種荷爾蒙可以鞤助韌帶鬆弛，而使得骨盆的伸縮性變大，給予胎兒更多的成長空間，並有利於分娩之進行，因此恥骨聯合分離，幾乎發生在所有妊娠的婦女。但在有些產婦，可能由於上述荷爾蒙的分泌過多；或韌帶對荷爾蒙的敏感度太高，使得這個區域非常的鬆弛；或因骨盆的排列有問題，讓這個關節處承受了較多的壓力，而導致了恥骨聯合過度分離的發生。
根 據文獻的統計，一個未懷孕的婦女，其兩片恥骨間的正常距離為4～5mm，一旦懷孕，荷爾蒙會使兩者間的距離至少增加2～3mm，因此若恥骨間寬度在9mm 以下，在妊娠的情況下是屬於正常的範圍，通常沒有症狀，即便有疼痛也較為不明顯；一旦兩者之間的距離超過4～5mm以上，則屬於恥骨聯合過度分離，就會引 起較厲害的疼痛。

【醫學小辭典】 恥骨聯合
骨盆是一種圓形的骨頭，從兩側至前面中央會合，而這個前端中央的部分就叫做恥骨。恥骨是兩片骨頭，中間有空隙而非緊靠在一起，而是靠幾個韌帶構成的纖維軟骨性的組織聯接起來，這個區域就叫恥骨聯合。

恥骨在那

診斷與機率
懷孕中，分娩時或生產 後都有可能會發生恥骨聯合的過度分離，其機率的報導從1/300到1/30,000均有，與病人的體型無關。診斷方面主要是依據臨床症狀而來，而一些影像 學的檢查，例如骨盆腔的X光攝影（生產後），超音波檢查（懷孕中），或核磁共振的掃描，可以做為輔助性的診斷工具。

妊娠12週即可能產生不適
恥骨聯合分離的症狀差異很大，但一般而言，均有實質上的恥骨疼痛。
疼痛程度
1.其疼痛可延伸到兩側股骨轉子，使髖關節無法內收及外展，或造成下背疼痛。
2.任何抬腳或使兩腿分離的動作都會引起特別的疼痛。
3.有的孕婦甚至從床上起身或在床上轉個身都會相當的困難，很多的動作都會變成非常困難去完成。
4.許多孕婦同時會抱怨有坐骨神經的疼痛，走起路來骨盆會卡搭地響，造成搖搖擺擺的步伐。
5.嚴重的甚至伴隨著膀胱功能的障礙及大便失禁的情形。
而這些症狀，從妊娠12週起就有可能會發生。

小心6大危險因素
造成恥骨聯合分離的真正原因並不是很確定，但有一些危險因素可能與它有關。
1. 多胎。
2. 曾生過過大之胎兒。
3. 關節之前即有存在之問題。
4. 以前就有恥骨痛或背痛。
5. 因車禍等原因導致之骨盆骨折。
6. 產鉗之使用等都曾被提出。
此外，恥骨聯合分離若是因骨盆排列不正常而來，則常會伴隨有胎位不正，枕後位，斜頭產式或複合產式。

恥骨痛的生產5大注意事項
在生產的方式上，除非妊娠婦女有嚴重的恥骨聯合過度分離且非常的疼痛，可以考慮採取選擇性的剖腹產外，一般還是以自然生產為主，但是在生產的過程中，有幾點必須要特別注意的：
1. 事先告知病情：需要確定醫護人員均知道恥骨聯合分離的資訊，怎麼樣的動作會傷害到妳。
2. 避免採馬鐙狀生產：需要特別小心生產的姿式，避免一般所採用的馬鐙狀方法。
3. 避免介入性分娩：避免平時最常使用的一些介入性分娩方法，因為它們常造成恥骨聯合處的傷害。
4. 避免麻醉：避免接受硬膜外的麻醉，因為它常和更嚴重的傷害有關。
5. 兩腳勿過度張開：任何常規的操作，兩腳均不能張的太開。
一 般而言，此類病人的預後均非常的良好，但有少數人其恥骨聯合分離的原因，是因為骨盆排列的錯誤，而非單純因對荷爾蒙的敏感的，則此疼痛可能會持續。大部分 的婦女在下一胎懷孕時，恥骨聯合分離的現象會再發生，但通常都不會比第一胎厲害，哺餵母乳所產生的荷爾蒙變化，亦不會造成產後的恥骨疼痛，孕婦不必過度擔 心。

【13種方法減輕恥骨疼痛】
一般而言，恥骨聯合分離所造成的骨盆腔不舒服，大部分在幾週內就會明顯改善，以下有13種方法，可以減輕這個結構變化所帶來的不適。
1. 睡覺時放置枕頭於兩腿間。
2. 在床上移動腳和臀部時，應該平行或對稱的行動。
3. 使用水床可能有幫忙。
4. 游泳可以幫忙減輕關節的壓力。
5. 站立時兩腿要對稱性的站著。
6. 避免跨坐。
7. 儘量坐著穿衣。
8. 放置冰袋於恥骨區。
9. 慢速移動。
10. 骨盆腹帶的使用。
11. 坐著時背後放置腰枕。
12. 下背接受按摩。
13. 避免提重物。

臨床治療方法
在治療方面，一般對於孕婦均採保守療法，主要是在減輕病人因恥骨聯合分離所產生的疼痛。
保守療法
1.臥床休息。
2.止痛及抗發炎藥物之使用。
3.身穿支持性的衣物。
4.在國外還有病人接受按摩術。
5.整骨術之矯正。
其目標是藉由人為的調整，來重新序列骨盆之骨頭、韌帶和軟體組織。

另類療法
1.針灸。
2.中藥。
3.壓力點之使用。
4.定極性之治療。
5.經由皮下電極對神經之刺激等方法，亦有人嘗試。

醫療手術
1.若是疼痛在產後仍然持續且非常的嚴重，則可以將類固醇直接打入關節處。
2.採取外科的方法，從髖關節處取一些骨頭作成板塊，來鎖住恥骨聯合處以固定此處之關節。

醫師名稱:耕莘醫院產科主任鄧森文
醫師學歷:
現任 耕莘醫院產科主任‧陽明大學婦產科學系臨床副教授
經歷 前台北榮民總醫院婦產部主治醫師
學歷 中國醫藥學院醫學系畢業

(資料來源：95年2月號媽媽寶寶(228期)　生產情報單元)

Pelvic Girdle Pain

Pelvic pain in pregnancy affects up to one in five women. Pelvic pain is also known as Pelvic Girdle Pain (PGP).

It is also is known as:

• Symphysis Pubis Dysfunction (SPD)
• pelvic joint pain
• twisted hips
• pelvic relaxation
• pelvic arthropathy
• osteitis pubis

Pelvic joint pain explained

Although it appears to be a firmly fixed circle of bone, the pelvis is actually four separate bones jointed together - the sacrum and coccyx at the back and at the sides the two hip bones which curve around to meet at the front. These are joined at the front by the symphysis pubis.

"In pregnancy the hormone relaxin is released to soften the joints in preparation for the birth of your baby, but in around one in 35 women the hormone causes the ligaments to soften and stretch too much and become painful," says Ann Johnson, superintendent physiotherapist in women's health at Leeds General Infirmary.

It is normal for there to be a gap of 4-5mm between the two pubic points at the symphysis pubis joint and during any pregnancy this widens by another 2-3mm. If this gap widens more than this pain may occur and in some cases a severe form of the condition called diastasis symphysis pubis is diagnosed.

The job of the symphysis pubis joint is to hold the pelvis steady when we're using our legs, and if the ligaments have softened or stretched too much it won't work properly and strain is put on the other pelvic joints, causing pain.

How to recognise SPD

The main symptoms are pain in your pubic area, groin, the inside of your thighs and sometimes in your lower back and hips. "The pain is worse when you walk or move and climbing stairs is especially painful. Getting in and out of the car or turning in bed is also painful," says Ann Johnson. You might hear a clicking sound when you walk and feel as though the bones are grinding together. Opening your legs is difficult and painful.

If you are experiencing these symptoms, don't let your doctor or midwife dismiss them as 'part of being pregnant'. The condition is now more widely recognised than it was a few years ago, says Ann Johnson. It can be diagnosed by examining your pelvic joints and watching how you move. If it occurs after giving birth, as it does in a few cases, a pelvic X-ray or scan can be done. "You'll normally have a urine sample taken too to exclude any other causes of pain such as a urine infection," says Ann Johnson.

SPD normally happens from the second trimester of pregnancy onwards, but can occur at any stage in any pregnancy, even if you've never suffered before.

Treating SPD

• The best person to treat SPD is an obstetric physiotherapist, and usually your GP or midwife can refer you.
• The physiotherapist can give you a pelvic support garment to wear such as a belt or Tubigrip bandage, and crutches if walking is difficult. You'll also be given gentle exercises to help strengthen the muscles supporting the joint and general advice about posture and activities to avoid. S/he will also discuss delivery options and positions with you. If necessary, you can also be referred to an occupational therapist for other aids to make your daily life easier.
• Your doctor can prescribe safe painkillers to take in pregnancy, usually paracetamol.
• The most effective alternative therapies, according to the British SPD Support Group, include chiropractic and osteopathy which help to relieve joint pain.
• In most cases you'll be fully recovered in six months after giving birth, but if the pain continues, surgery to fix the joints together may be considered.
• Rest as much as you can - it really does help.
• Avoid movements that place extra strain on the symphysis pubis. When you get out of bed, roll out with both legs together. When climbing stairs, go one step at a time. Avoid breast stroke when swimming.

How will it affect my labor?

• Make sure anyone attending you is aware that you have SPD. Your midwife should measure how far you can comfortably widen your legs at the onset of labour and ensure that you don't exceed this.
• "If you have an epidural or spinal block injection, it's particularly important to ensure you don't exceed the comfortable gap as you won't be able to feel any damage you do," says Ann Johnson.
• In very severe cases, an elective caesarean may be considered.
• Make sure you're in a comfortable position before any internal examinations are performed.
• Experiment with different positions for giving birth - kneeling on all fours may be more comfortable for you.

Can I avoid it happening again?

Unfortunately, there's no way of predicting whether you'll suffer in subsequent pregnancies, and if you do whether it'll be more or less severe than your first experience of SPD. However, if you have experienced it in one pregnancy, be aware of any signs of pain from the start of a subsequent pregnancy and see your midwife. Being referred to a physiotherapist early on and receiving treatment can help to reduce the pain as much as possible. "However, it's best to avoid a subsequent pregnancy until your baby is walking independently, as lifting your child will be especially difficult if you suffer SPD again," says Ann Johnson.

Nichola tells her story: 'The pain began suddenly and severely at 26 weeks...'

Nichola Morse, 32, from Leeds - full-time mum to Matthew 10, Jacob three and Annie four weeks, and moderator for SPD forum at babyworld tell us how she copes with SPD

"The pain began when I was pregnant with my second son Jacob, although it was my sixth pregnancy as I'd had miscarriages. The pain began suddenly and severely at 26 weeks. I could feel my pelvic bones grinding together when I moved, and walking was very painful. I rang the hospital and they referred me to a specialist and told me not to move until I'd seen him.

"I saw a physiotherapist at the hospital and was given a Tubigrip support, a brace and crutches. I was advised to be careful with any movement that involved separating the legs.

"I drove everywhere and we lived off microwave meals for rest of the pregnancy. In labour the gap between my legs was measured and I had an epidural. The pain slowly improved, but three weeks after giving birth I picked up Jacob in his carrycot and the bones all separated again and I was in pain for the next two years. I was on strong prescription painkillers, I had a wheelchair and crutches. I also had lots of physiotherapy and was given two spinal block injections. At one stage I had a 14mm gap between the pubic joints.

"I've just had my third child, Annie, now four weeks old. I had a much better pregnancy this time as I was better prepared and very careful. The pain is easing, though I can't walk far yet."

More information

• The Pelvic Partnership was founded by women who have experienced SPD and their website offers information and support -www.pelvicpartnership.org.uk/
• Scottish Charity for Symphysis Pubis Dysfunction - PINS (Pelvic Instability Network Scotland) website www.pelvicinstability.org.uk

by Sarah Purcell

(resource from Baby World)