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1701902 tn?1307205473

Unable to diagnose severe abdominal pain 11 weeks post-pregnancy

After a textbook pregnancy and vaginal delivery 11 weeks ago, my wife has had a lot of pain in various places.  Since, most of the pain has gone away except three areas of her abdomen which have instead increased in pain. One area is on her right side in sort of a "C" shape and is constant and sharp. The opposite side has a similar pain that comes and goes. Lastly, she has soreness all across the top of her bladder. A crude diagram is shown here: http://dl.dropbox.com/u/6830281/WhereItHurts.jpg

Three weeks ago her OB prescribed her Hydrocodone 5/500mg and told her the pain would subside as the others did.  Last Friday she was scheduled for a rectal CT scan since the pain still only increased and the Hydrocodone was having no apparent effect. Tuesday when she called for the results, her doctor informed her that nothing abnormal was found but to check in to the hospital so they can better address her pain.

The doctor initially said her blood test showed increased levels of sediment which could indicate infection so he put her on an IV antibiotic of Doxycycline and a Dilaudid PCA for the pain. That day she was fairly pain free and was able to sleep. The plan was to wait out the antibiotics and see if the pain subsided. Wednesday she was taken off the PCA and given Hydrocodone again. Her pain returned with full force and after many hours of frustration and begging for pain relief her doctor decided to put her back on the PCA, but with Morphine, and scheduled an exploratory laparoscopic surgery for Thursday but first wanted a second opinion from a colleague. That doctor examined her results and gently pushed on her abdomen before deciding that she didn’t want to subject my wife to any surgery just yet.

Since the regular doctor will be unavailable until Monday he had the OB doctor on call assess her.  She said that both she and our regular doctor had discussed the case extensively and that clinically my wife is stable. They believe that the pain is being caused by a muscular problem in her still recovering abdomen. So, she was taken back off the PCA and instead given Hydrocodone 7.5/750mg and an abdominal binder pending consultation with a general surgeon, which we were told, would not be available until Monday.

The oral pain medicine still had no apparent effect and since she was told she would not be provided any stronger medication she decided she would rather suffer at home and schedule a general surgeon consultation ourselves. She was released last night with the Hydrocodone 7.5/750mg, Methocarbamol 500mg, and Metronidazole 500mg.

We live in a small town in Texas without many other options at this point in time. I will be scheduling the consultation first thing Monday morning and have told her we will travel to a larger city if he is unable to remedy the situation.  Her doctor has 45+ years of experience and will be retiring in two weeks so this adds to the desperation.

If she does in fact have a muscular problem that will go away in time I fear the meantime. She has trouble sleeping and when she isn’t all she can do is cry, moan, and writhe on the bed. She’s afraid if the pain gets worse and we have to go to the ER they will still be unable to handle her pain.  I am looking for any route to pursue in an effort to relieve my wife’s pain. Any advice will be much appreciated.
2 Responses
Avatar universal
Hi, sorry for all the pain your wife has been having. It sounds like she's miserable and the doctors really haven’t been able to tell you what's going on.  I'm not a doctor, but I think I may be able to help some or at least organize some information and make it easier for others to help. I would first like to clarify some points and if you don’t mind ask a few questions. I have some thoughts on what might be going on.

I think a good place to start with your wife. How old is she, was she was previously healthy, was she on any pain medications prior to giving birth?

Then with the pregnancy. You said it was textbook, so I'm assuming the baby is ok, and your wife didn't need blood transfusions or anything like that. Did she have an epidural during the procedure? Any complications with that if she did?  Did she excessive bleeding afterwards that lasted more than 2 days?

Now after the pregnancy, did the pain start right away? I’m also a bit confused about the IV doxycycline. Did she have any fevers? Is she allergic to other antibiotics?  

Any numbness, any back pain? Any pain if you run your fingers down her spine? Any numbness or tinging or pain down her legs? Is she having any trouble peeing? If she having any pain when she pees? Does she have vaginal bleeding or discharge? Is the pain worse after she eats? Is she constipated? What makes the pain better and what makes the pain worse?  What happens when you press on her belly?

Sorry to ask so many questions, but this is complicated and some features are unusual. For example is it unusual that someone needs a Dilaudid PCA pump for a muscle strain.

My first instinct is that is actually a back problem. If she slipped a lower thoracic disc during delivery then you can get pain that would go across the abdomen like you drew. http://chicopmr.org/pain/images/dermatomes.jpg CT Scan of the Abdomen and Pelvis would probably be negative in this case and her abdomen might feel normal. If she had something common like appendicitis (inflammation of the appendix) or cholecystitis (inflammation of the gallbladder) then that should be easy to diagnose. Something called Endometritis (inflammation of the endometrium / lining of the uterus) is definitely high on the list and I suspect this is what the doxycycline was supposed to treat. If for example, there were any retained fragments of placenta after delivery then she has a very good chance of having endometritis. Muscle strain would be unlikely given her need for such strong narcotics so often. A hernia is possible, as well as pelvic abscess but in most cases both of those would be picked up by the CT scan.

Hope this helps. There are other rare causes probably not worth mentioning, at least not without more information. I’d appreciate if you could provide some more detail and answer as many questions as you could or deem appropriate. I’m not a doctor and I especially can’t diagnose someone without examining him or her, but I think I can help make sure other things have been considered before she gets an operation that she may not need.  
1701902 tn?1307205473
Hello RareSideEffect, I appreciate your response and your obvious compassion for others.

My wife is 24, weighed 115 lbs before pregnancy, is athletic, and gained an appropriate amount of weight during her pregnancy. She intended to have an unassisted birth but showed no signs of dilation 8 days past her due date. She was put on Oxytocin and started to dilate too quickly so she decided to take the epidural, no complications. She then progressed to 9cm and stopped. After some time, her doctor gave her 30 minutes to gain the last 1cm while he prepped the papers for the c-section. When he came back to check one last time he exclaimed, "Hot damn! You did it!" and 15 minutes of pushing later my son popped right out. No tearing or episiotomy, only two "skidmarks" on the sides that were easily repaired with two stitches each. She did not have any excessive bleeding and her postpartum bleeding stopped after five weeks and there were no problems such as blood clots. She did notice a problem with her vagina 5 or 6 weeks postpartum after the bleeding stopped. When she thought everything should be back to normal, she felt like she had a "bulging" feeling in her vagina but her doctor said it was a cystocele and a rectocele and shouldn't cause her pain because they were moderate, and are a normal occurrence after birth. However she wholeheartedly believes it is more of a severe problem than he does since it does not present itself entirely when he examines her.

She had severe round ligament pains early in her pregnancy and was prescribed Tylenol with Codine. She says if the muscle diagnosis is correct, she feels like she should have had more issues with it throughout her pregnancy and that the severe pains early on may have been her actually injuring something that is now being affected again.

She had all of the normal postpartum pains expected which subsided in three weeks but the abdominal pain steadily grew worse. The specific sharp pain in her right side was noticed a week after giving birth while the opposite side didn't present itself until about a month ago. She did not have a fever and is not allergic to any antibiotics that we are aware of.

She had previously been on Sulfameth/Trimethoprim 800/160 because the doctor wanted to prevent an infection should there be one. He then put her on the IV antibiotics because they were said to be the "big guns" as the nurse referred to them.

She did, in fact, sustain a back injury after being kicked in the spine in cheer-leading when she was 17 that has caused chronic back pain and has never been treated. Before her pregnancy she felt it a few times a month but during it was very prominent and almost constant. She mentioned it to her doctor but maybe it should be readdressed. He did say she had sciatic pains in her hips and left leg. She says now she has knots on the muscles on her hips in the back that are tender to the touch. Also, she still experiences occasional pain in her left leg. The pain goes from midway up her back down to her butt muscles and she has always had tense shoulder muscles which have given her back and neck pain. She was given a gallbladder ultrasound two weeks before the CT scan that ruled out Cholecystitis. He did say that they did tests for appendicitis but she may still very well have it. It will be one of the problems looked for during the exploratory surgery. She feels like sometimes she has to push a little harder to pee with the prolapses. No burning pain when peeing but sharp pressure pain above her pubic bone and her bladder and pain inside her right inside her vaginal opening where the prolapses occure. Vaginal discharge daily but nothing alarming until a large gelatinous "glob as big as her palm" two days before the hospital stay. Her doctor attributed it to some liquid found in the lining of her uterus shown on the CT scan. He said the fluid should cause her no pain but will keep an eye on it and doesn't feel like it has anything to do with the abdominal pain. The pain isn't worse after she eats but a month and a half ago she had diarrhea after eating which she attributed to the antibiotics used to treat an upper respiratory infection. The doctor attempted to treat her abdominal pain with the Codine in the cough syrup he prescribed. She's not constipated. She feels more pain when positioned on her left side. She describes it as "something feels like it's not where it's supposed to be." The PCA pump was the only thing she feels that made it better and pressing on her belly makes her cry.

I would also like to mention our OB doctor is actually quite renowned in the Texas medical community it seems. Victoria is also medically more advanced than one might think since we have a school of nursing at the University of Houston here. She had a specific birth plan and we did our research for the best doctor in our opinion. He used to teach at Baylor and UT and is often accompanied by other student doctors when he evaluates my wife. So, until we can consult with the general surgeon here and meet with the OB again on Friday we won't be leaving for Houston just yet. He says since the symptoms are so strange, being presented so late postpartum, and since he's ruled out other typical problems that now the only thing he can do at this moment is rule out what it's not. I'm trying to use every community resource available to help provide any possible diagnoses that I could suggest in the next week.

Once again, we both greatly appreciate your advice.  
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