What is the appropriate management for a postpartum patient with severe abdominal pain 5 days after vaginal delivery?

Severe Abdominal Pain 5 Days Post-Vaginal Delivery

Severe abdominal pain 5 days after vaginal delivery is unusual and should immediately prompt evaluation for unrecognized complications—this is NOT normal postpartum pain. 1

Immediate Diagnostic Priorities

The differential diagnosis at 5 days postpartum includes life-threatening conditions that require urgent identification:

Most Critical Diagnoses to Rule Out

• Endometritis/pelvic infection: Most common serious cause, accounting for ~20% of acute pelvic pain after delivery, presenting with fever, purulent discharge, and uterine tenderness 2
• Retained products of conception (RPOC): Second most common cause of delayed postpartum hemorrhage and pain, affects ~1% of third trimester deliveries 1
• Ovarian vein thrombophlebitis: Rare but serious, presents with fever and unilateral lower abdominal pain, typically 2-10 days postpartum 3
• Uterine perforation/rupture: Can occur even after vaginal delivery, especially with instrumentation; presents with peritonitis and may have adjacent abscess 4
• Bladder rupture: Extremely rare but life-threatening, presents with acute abdomen and anuria/dysuria 5
• Mesenteric arterial thrombosis: Rare thrombotic complication presenting with severe acute pain out of proportion to exam 6
• Rectus sheath abscess: Can occur even after vaginal delivery via lymphatic spread 7

Initial Workup Algorithm

Step 1: Clinical Assessment

• Vital signs looking for fever (>38°C), tachycardia, hypotension indicating sepsis or hemorrhage 2
• Abdominal exam for peritoneal signs, localized vs diffuse tenderness, rebound 4
• Pelvic exam for purulent discharge, uterine tenderness, cervical motion tenderness 2
• Urinary symptoms: anuria, dysuria, inability to void 5

Step 2: Laboratory Studies

• Complete blood count, comprehensive metabolic panel (elevated creatinine suggests bladder injury) 5
• Coagulation studies if concern for thrombosis 3

Step 3: Imaging

• Transvaginal ultrasound FIRST: Primary diagnostic tool to evaluate for RPOC, fluid collections, abscess, or ovarian vein thrombosis 2
• CT abdomen/pelvis with IV contrast: If ultrasound nondiagnostic OR if concern for perforation, abscess, mesenteric ischemia, or bladder rupture 1, 2, 4, 6, 5

Pain Management While Evaluating

Do NOT simply treat pain without identifying the cause—severe pain demands diagnostic workup first. 1

Appropriate Analgesic Approach

• Acetaminophen: 975 mg every 8 hours OR 650 mg every 6 hours orally 1, 8
• Ibuprofen: 600 mg every 6 hours orally (avoid if preeclampsia or acute kidney injury) 1, 8
• Ketorolac: 15-30 mg IV/IM every 6 hours for maximum 48 hours if oral NSAIDs inadequate 1, 8
• Short-course opioids: Only if severe pain uncontrolled by above; hydrocodone 5 mg, limit to 5-10 tablets total 1, 8

Critical Management Principles

Never dismiss severe postpartum pain as "normal recovery"—the median time to pain resolution after uncomplicated vaginal delivery is 14 days with mild-to-moderate pain only. 1

Red Flags Requiring Urgent Intervention

• Hemodynamic instability (tachycardia, hypotension) 2
• Fever with purulent discharge 2
• Peritoneal signs on exam 4
• Anuria or severe dysuria 5
• Pain worsening or not responding to analgesics 2

Specific Treatment Based on Diagnosis

• Endometritis/abscess: Broad-spectrum IV antibiotics covering polymicrobial pelvic pathogens; surgical drainage if abscess present 2, 7
• RPOC: Surgical evacuation (D&C) if confirmed 1
• Ovarian vein thrombophlebitis: Anticoagulation therapy 3
• Uterine perforation: Emergency laparotomy with repair 4
• Bladder rupture: Emergency surgical repair 5
• Mesenteric ischemia: Emergency thrombectomy and possible bowel resection 6

Common Pitfalls to Avoid

• Underestimating post-delivery complications: Even vaginal delivery carries thrombotic and infectious risks 6, 3
• Delaying imaging: Waiting to see if pain resolves allows complications like perforation or ischemia to worsen 2, 4
• Over-relying on opioids: Masking symptoms without diagnosis is dangerous; opioids are rescue therapy only 1
• Missing bladder injury: Always consider if patient has urinary symptoms with abdominal pain 5

Bottom line: Obtain transvaginal ultrasound immediately, escalate to CT with contrast if ultrasound is nondiagnostic or clinical suspicion remains high, and involve obstetric consultation urgently. 1, 2