A 38-year-old woman, gravida 5 para 5, is evaluated for difficult and painful ambulation on postpartum day 1. The patient has no pain while lying down but reports sharp lower midline abdominal pain that radiates down her legs while ambulating. She has voided twice without difficulty and has no dysuria. She has passed flatus but has had no bowel movement since delivery. She has not had numbness or foot drop. The patient received epidural analgesia during labor and had a vaginal delivery of a 4400 g (9 lb 8 oz) infant that was complicated by a shoulder dystocia relieved by the McRoberts maneuver and suprapubic pressure. Temperature is 37.2 C (99 F), blood pressure is 120/80 mm Hg, pulse is 90/min, and respirations are 18/min. Neurologic examination shows normal strength, sensation, and reflexes of the lower extremities. Abdominal examination shows focal tenderness to palpation just inferior to the bladder. Pelvic examination reveals normal lochia, no vaginal masses, and a nontender uterine fundus just below the umbilicus. There is moderate edema bilaterally in the lower extremities but no pain or erythema. Which of the following is the most likely diagnosis in this patient?

Question

A 38-year-old woman, gravida 5 para 5, is evaluated for difficult and painful ambulation on postpartum day 1.  The patient has no pain while lying down but reports sharp lower midline abdominal pain that radiates down her legs while ambulating.  She has voided twice without difficulty and has no dysuria.  She has passed flatus but has had no bowel movement since delivery.  She has not had numbness or foot drop.  The patient received epidural analgesia during labor and had a vaginal delivery of a 4400 g (9 lb 8 oz) infant that was complicated by a shoulder dystocia relieved by the McRoberts maneuver and suprapubic pressure.  Temperature is 37.2 C (99 F), blood pressure is 120/80 mm Hg, pulse is 90/min, and respirations are 18/min.  Neurologic examination shows normal strength, sensation, and reflexes of the lower extremities.  Abdominal examination shows focal tenderness to palpation just inferior to the bladder.  Pelvic examination reveals normal lochia, no vaginal masses, and a nontender uterine fundus just below the umbilicus.  There is moderate edema bilaterally in the lower extremities but no pain or erythema.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_da51_e608_bc81_01febe69d248_MD0003_00 During pregnancy, increased levels of progesterone and relaxin increase pelvic mobility and promote a physiologic widening (diastasis) of the pubic symphysis to facilitate vaginal delivery. However, after a traumatic delivery, patients can develop a symptomatic pubic symphysis diastasis. Risk factors include fetal macrosomia, forceps-assisted vaginal delivery, and multiparity. Symptomatic pubic symphysis diastasis typically presents with suprapubic pain that radiates to the back, hips, thighs, or legs and is exacerbated by walking, weight-bearing, or position changes. The diagnosis is made clinically; patients have point tenderness to palpation over the pubic symphysis and sometimes have a waddling gait. Management is typically conservative with supportive care (eg, pelvic support, physical therapy), and most patients recover within the first 4 weeks postpartum. (Choice A) Epidural abscess, a complication of epidural analgesia, typically presents with back/spinal pain, fever, and focal neurologic deficits, none of which are seen this patient. (Choice B) Femoral nerve damage can occur during delivery as a result of hyperflexion of the thigh (eg, McRoberts maneuver). It presents with numbness over the anterior and medial thigh, inability to extend the leg or flex the hip, and diminished patellar reflexes, none of which are seen in this patient. McRoberts maneuver (Choice C) Herniated intervertebral disks present with back, rather than suprapubic, pain that often radiates down the lower extremities and with focal neurologic deficits. (Choice D) Pelvic abscess is a complication of cesarean delivery that typically presents with suprapubic or pelvic pain and a fever that is unresponsive to antibiotics. This patient had a vaginal delivery and is afebrile. (Choice F) A retroperitoneal hematoma occurs as a result of injury to branches of the internal iliac artery during delivery. Clinical manifestations include hemodynamic instability, a palpable mass, and possibly fever. This patient is hemodynamically stable, making this diagnosis unlikely. (Choice G) Sciatica, a lumbosacral radiculopathy, typically presents with low back or unilateral hip pain that radiates down the lower extremity. Patients have associated motor and sensory deficits on examination. This patient's intact neurologic examination makes this diagnosis less likely. Educational objective: Pubic symphysis diastasis can occur after a traumatic delivery and presents with radiating suprapubic pain that is exacerbated by ambulation or weight-bearing. Treatment is conservative with supportive care. References: Peripartum pubic symphysis separation--current strategies in diagnosis and therapy and presentation of two cases. (http://www.ncbi.nlm.nih.gov/pubmed/25816704)

A 38-Year-Old Woman, Gravida 5 Para 5, Is Evaluated for Difficult