In this issue of the American Journal of Obstetrics and Gynecology , 2 research teams have published interesting manuscripts on the common yet often ignored problem of pain related to pregnancy. Bjelland et al reported on mode of delivery and persistence of pelvic girdle syndrome (PGS) 6 months postpartum. PGS, defined as severe pain that affects both the anterior (pubic symphysis region) and posterior (bilateral sacroiliac joint region) pelvis, is believed to represent the most severe pain cases. Contrary to clinical intuition, the investigators found that cesarean section was associated with persistent pain on 6-month follow-up. At first glance, the reader might erroneously presume that cesarean section is what leads to persistent postpartum pelvic girdle pain. This cannot be known with certainty, as pain may be the clinical indication for cesarean in many of these women. Nevertheless, the results suggest that cesarean section has no beneficial or protective effect in the management of pain.

The study was most impressive in that it included prospective, self-administered questionnaires obtained from 10,400 women. Pain defined as strictly PGS probably underestimated the significant pain, as many patients present with unilateral pain and are quite disabled. The investigators strengthened their results by evaluating many confounding variables including indication for cesarean as well as infant size. They performed high-quality statistical analyses and found that obstetric complications of birth were not associated with the persistence of pain 6 months postdelivery. Additionally, use of crutches in pregnancy (ie, those were the most disabled) was associated with a much higher risk of reporting severe pelvic girdle pain after delivery.

These findings illustrate that, as I tell all my pregnant patients, there is simply no way out of “taking a hit to the core” with impending labor and delivery. Whether it is the abdominal core or the pelvic floor, muscular disruption is inevitable and can lead to dysfunctional muscle activation patterns. The authors make an interesting point that additional operative pain in connection with cesarean section may contribute to an increased risk of persistent pain following surgery, especially in those women with greater pain intensity and severity during pregnancy. Perhaps the more functionally disabled women are more likely to have central pain sensitization that is exacerbated by a surgical insult, thereby precluding a typical musculoskeletal recovery.

What can we do about pain in pregnancy? A recent randomized controlled trial out of Missouri by George et al provides realistic advice directed to a diverse socioeconomic US population. This was a prospective trial comparing standard obstetric treatment to a multimodal individualized approach of chiropractic care. The treatment included joint mobilization techniques, stabilization exercises, and patient education once weekly for a total of 4-6 treatments between 24-33 weeks’ gestation. The investigators argued that such an intervention of combined treatments was more real life and less intense although they acknowledge that the trial was not sham controlled. This manuscript sends the clear message that something to treat pain during pregnancy is better than nothing, and that less may be more. In the study, the hard part to discern is whether a specific component was responsible for relief. Was it manual therapy or reassurance or both? Patients were not followed >33 weeks to understand if this treatment actually did prevent chronic pain and the number of treatment sessions was not standardized. This study was different from previous work that focused specifically on pelvic girdle pain. The investigators included both low back with and without radiculopathy and pelvic pain. Subgrouping types of pain and performing multicentered comparative effectiveness trials are clearly the next steps. Consideration of pharmacologic clinical trials should also occur as, to date, there is not a single pain medication study that has been conducted in pregnant women.

In summary, as clinicians and researchers who care for women with pregnancy-related pain, we should remember these points: (1) do not assume pregnancy-related pain simply resolves with delivery; (2) do not assume there are no treatment options–in fact, basic treatment often works; (3) cesarean section does not seem to protect from or minimize pelvic girdle pain, and is associated with higher rates of persistent pain; (4) not all pain is the same–pelvic girdle pain is different from lumbopelvic pain; and (5) pay attention to those in pain–treating the acute pain state may minimize the development of chronic pain. Clearly, greater classification of the types of pain patients experience in future trials will assist in deeper mechanistic understanding and more targeted interventions. Indeed, the US National Institutes of Health and the Office of Research on Women’s Health convened a research forum in 2010 specific to the enrollment of pregnant women in clinical research and have called for the establishment of a strong research agenda to address the health needs of pregnant women. Pain, the fifth vital sign, is clearly a high priority item for all pregnant and postpartum women and for those who care for them.