Case study: You check your schedule after lunch and note that you will be seeing a new patient today whose presenting complaint is “hernia.” When you walk into the exam room, you see a 26-year-old woman in no apparent distress, reading a magazine. Next to her is an infant in a baby carrier. The patient, Heather, introduces herself and tells you that she thinks she may have an abdominal hernia. She has always been healthy and physically active. When she became pregnant, she had an uneventful pregnancy and an uncomplicated vaginal delivery of a 7 lb. 2 oz. baby four months ago. She presents to clinic today because she has noticed a persistent bulge in her abdomen that has not disappeared since she delivered her baby. In fact, she worries that she still looks pregnant. What do you ask Heather?
You ask Heather to tell you more about her symptoms. She tells you that she gained 30 lbs while pregnant and has lost 25 lbs through breast feeding, eating nutritious meals, and jogging regularly. However, she still has this unsightly, protruding area in her abdomen that has not resolved. Associated symptoms include back pain. On physical exam, her vital signs are normal, her heart rate and rhythm are normal, and her breath sounds are clear bilaterally. She does not have any abdominal tenderness. You examine her in a supine, flexed-knee position and ask her to perform a half sit-up. You note that she has a three finger-breadth wide separation between her abdominal muscles when you palpate above her umbilicus.
You suspect that Heather has a diastasis recti, the midline separation of the rectus abdominis muscles frequently seen in postpartum women. During pregnancy, the linea alba thins and stretches out to accommodate the growing uterus. In conjunction with the laxity of abdominal muscles, diastasis recti can result in bulging of the abdomen. However, unlike true hernias, there is low risk of incarceration or strangulation. What do you do next?
You decide to refer Heather to a physical therapist specializing in postpartum abdominal care. Unlike groin or incisional hernias, this midline abdominal muscle separation can often be treated conservatively through physical therapy. Interventions frequently involve targeted exercises to strengthen the core and abdominal muscles during the antenatal and post-natal periods. These exercises can also be done before pregnancy to help minimize or prevent diastasis. Many patients see improvement in the appearance of their diastasis, though it rarely completely resolves and often recurs in subsequent pregnancies. In severe cases, patients may be referred to plastic surgeons for additional management. Surgical intervention can involve laparoscopic or open procedures, including placation and modified hernia repair techniques. Each of these interventions has side effects, including seromas, hematomas, wound infections, and high rates of recurrence. However, many patients are pleased with the cosmetic outcome after surgical intervention.
How do you manage your patients with diastasis recti?
Akram J, Matzen SH. Rectus abdominis diastasis. J Plast Surg Hand Surg. 2014;48(3):163-9.
Bursch SG. Interrater reliability of diastasis recti abdominis measurement. Phys Ther. 1987;67(7):1077-9.
Mommers EHH, Ponten JEH, Al omar AK, De vries reilingh TS, Bouvy ND, Nienhuijs SW. The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options. Surg Endosc. 2017;31(12):4934-4949.
Dr. V. Silverstein
Published on 2/5/18