A 34-year-old woman, gravida 3 para 2, at 30 weeks gestation comes to the clinic for evaluation of an abdominal bulge. The patient first noticed this bulge 2 weeks ago when she was sitting up to get out of bed. She also sees the mass when she is straining to defecate or picking up her toddler. The patient has no nausea, vomiting, or abdominal pain, and her last bowel movement was 2 days ago. She has chronic constipation for which she takes a daily stool softener, and her prior surgeries include 2 cesarean deliveries. Temperature is 37.2 C (99 F), blood pressure is 124/76 mm Hg, and pulse is 92/min. Prepregnancy BMI is 19 kg/m². When the patient sits up and performs the Valsalva maneuver, a nontender abdominal mass protrudes between the rectus abdominis muscles. When the patient is placed supine, no fascial defects are palpated. Bowel sounds are normoactive and there is no rebound or guarding. The uterus is nontender and the fundal height is 30 cm. Which of the following is the best next step in management of this patient?

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11ec25c8_da82_6c3b_bc81_5999e82ba36d_MD0003_00 This patient has rectus abdominis diastasis due to weakening of the linea alba, the fascia that lies between the rectus abdominis muscles and keeps them in close proximity. Risk factors for rectus abdominis diastasis include chronic abdominal stretching (eg, pregnancy, multiparity), surgical weakening (eg, prior cesarean deliveries), and increased intraabdominal pressure (eg, constipation)-all of which weaken the linea alba. As the linea alba weakens, abdominal contents bulge between the rectus abdominis muscles (especially with Valsalva), resulting in a nontender midline mass. Unlike a true hernia, rectus abdominis diastasis has no associated fascial defect, and patients have no associated pain, acute gastrointestinal symptoms, or risk of bowel strangulation or incarceration. Therefore, patients are managed conservatively with observation and reassurance. Rectus abdominis diastasis typically resolves postpartum; surgery is typically reserved for cosmetic reasons in patients whose diastasis does not resolve. (Choice A) Abdominal binders place external compression on the abdomen and may cause fetal growth restriction; therefore, they are not recommended in pregnancy. (Choice B) Immediate surgical repair is indicated for hernias complicated by strangulation or incarceration. This patient has no fascial defect and a nonacute abdomen (ie, no rebound or guarding), making this diagnosis unlikely. (Choice C) MRI can be used to identify unclear anterior wall defects and associated structures. The diagnosis of rectus abdominis diastasis can typically be made clinically. (Choice E) Small bowel follow-throughs are used to assess for small bowel obstruction. This patient has no nausea, vomiting, or abdominal pain to suggest obstruction. Educational objective: Rectus abdominis diastasis is a weakening of the linea alba between the rectus abdominis muscles that can present as a nontender abdominal bulge in pregnant or postpartum patients. Management is conservative with observation and reassurance. References: Normal width of the interrecti distance in pregnant and postpartum primiparous women. (http://www.ncbi.nlm.nih.gov/pubmed/29494833) The general surgeon's perspective of rectus diastasis. A systematic review of treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/28597282)

A 34-Year-Old Woman, Gravida 3 Para 2, at 30 Weeks