What is the best next step in managing a 34-year-old woman, gravida 3 para 2, at 30 weeks gestation with a symptomatic abdominal bulge, diagnosed as a likely diastasis recti (separation of the rectus abdominis muscles), given her history of chronic constipation, two prior cesarean deliveries (C-sections), and current symptoms of protrusion upon Valsalva maneuver?

From the Guidelines

The best next step in management for this patient is reassurance and conservative management, as the patient is likely experiencing a rectus diastasis, a common and benign condition during pregnancy. The patient's symptoms, including a protrusion between the rectus muscles during Valsalva maneuver that disappears when supine, absence of pain, and history of multiple pregnancies, support this diagnosis 1. Conservative management includes avoiding heavy lifting, using proper body mechanics when changing positions, and potentially using an abdominal support band for comfort. The patient should continue her stool softener to prevent straining during defecation, which can exacerbate the condition, as recommended by recent guidelines on pregnancy-related gastrointestinal and liver disease 1.

Key Considerations

• The patient's condition is likely to resolve spontaneously after delivery and does not require surgical intervention during pregnancy.
• Postpartum exercises focusing on core strengthening may be recommended after delivery to help the muscles return to their normal position.
• It is essential to distinguish rectus diastasis from a hernia, which would typically present with a palpable fascial defect and potential complications like incarceration or strangulation.
• The patient's chronic constipation should be managed with dietary fiber, lactulose, or polyethylene glycol–based laxatives, as recommended by recent guidelines 1.
• The patient should be advised to avoid straining during bowel movements and to use relaxation techniques to prevent exacerbating the condition.

Management Plan

• Reassurance and conservative management
• Avoid heavy lifting and use proper body mechanics
• Continue stool softener to prevent straining during defecation
• Consider using an abdominal support band for comfort
• Postpartum exercises focusing on core strengthening may be recommended after delivery
• Manage chronic constipation with dietary fiber, lactulose, or polyethylene glycol–based laxatives, as recommended by recent guidelines 1.

From the Research

Diagnosis and Management

The patient's symptoms and physical examination suggest a diagnosis of a abdominal wall hernia, likely a diastasis recti or an incisional hernia given her history of two cesarean deliveries. The best next step in management would be to:

• Confirm the diagnosis with imaging studies if necessary
• Consider the use of an abdominal binder to provide support and alleviate symptoms, as studies have shown that abdominal binders can reduce postoperative pain and improve outcomes after hernia repair 2, 3, 4
• Develop a plan for definitive treatment, such as surgical repair, after the patient has delivered her baby

Considerations for Pregnancy

It is essential to consider the patient's pregnancy status when developing a management plan. The use of an abdominal binder may be beneficial in reducing symptoms and preventing complications, but it is crucial to monitor the patient's condition closely and adjust the plan as needed 5, 6.

Potential Benefits of Abdominal Binders

The use of abdominal binders has been shown to have several potential benefits, including:

• Reduced postoperative pain 2, 3, 4
• Improved mobility and reduced activity limitation 3, 4
• Decreased risk of surgical site infection 3
• Improved patient-reported outcomes, such as reduced discomfort and improved well-being 6, 4