Severe pelvic pain, post-partum

[WolfmanHarris]

Fairly straightforward call that left me with one problem.

Called at ~0500 for a 36 y/o F, 4 days post-partum, c/o abdo pain.

Upon Pt. contract presented with a 36 y/o F, semi-prone in bed, nursing, in obvious distress, though somewhat stoic. Pt. reports 8/10 suprapubic pain radiating through legs and back; intermittent increase in pain to 10/10, described as similar to contractions though "much worse." Symptoms onset during pregnancy, though much less severe and prenatal investigation found no clear diagnosis (told "normal" at that time.) Symptoms have been worsening since delivery and have become unbearable today.

Pt. is gravada 4, parity 4. No complications during pregnancy or delivery. No complications with previous pregnancies. All children delivered by vaginal birth. Pt. is a smoker, unclear how much. No medications, NKDA. Pt. diagnosed with kidney and gall stones prior to pregnancy, though she neglected to mention that until transport.

Physical assessment inconclusive; Pt. in such pain that everything appears tender and all movement or palpation aggravates pain.

Patient is on a third floor of a townhouse and required stair chair wheeling down a long path to reach vehicle. EVERY, movement, bump, change in position or vibration induced further pain to the point of screaming, writhing and shortness of breath.

I can't recall exact vitals. Pt. was slightly tachycardic, hypertense, tachypnic, satting at 96-99% on room air. Monitor showed sinus tachycardia. Pt. afebrile, though husband reports her being warm to the touch previous day.

Pt. has taken nothing to control symptoms.

My working diagnosis is renal colic, but I'll admit I'm basing that more on history than my assessment findings. I'm curious what others may have as a differential.

My other question is that we offered to call ACP back-up for pain management. In discussion with the patient see declined when I informed her that she may not be able to nurse immediately after being given the fentanyl. Pt. unwilling to even temporairly switch to formula. Unfortunately, I couldn't tell her how long that would be for, since I have no idea. I respect her decision to not feed formula at all, I do take issue with some of the taboos that have now surrounded this and the pressure it creates on a new mom (dealing with this a bit with my pregnant wife and her own anxiety regarding breastfeeding); but I feel I wasn't able to fully inform my patient and guide her decision. Certainly the half-life and therapeutic window are easy to find, but I'm having a heck of a time finding resources on the interaction of medications and breastfeeding. Thoughts on this?

Cheer,

- Matt

[ERDoc]

My ddx would include renal colic, pyelonephritis, endometritis, PID (not as likely but still possible), appendicitis, retain products of conception, constipation.

As for safety in pregnancy, if you have access to Micromedex it will tell you breastfeeding safety. Tarascon's Pharmacopea (http://secure2.acep.org/BookStore/p-10083-tarascon-pocket-pharmacopoeia-2011-deluxe-lab-coat-edition.aspx)also has the safety. Narcotics are generally considered safe, but some say they can make the baby a little sleepy.

[Happiness]

What was the bleeding like, because kind of sounds like a bit of the placenta may not have been delivered.

[Doczilla]

Endometritis would be my #1 worrisome diagnosis in this patient. Typically occurs postpartum or post D&amp;C. Fever and cervical motion tenderness would more or less clinch the diagnosis. Admission, antibiotics, and close monitoring. These patients can get pretty sick.</p>

Regarding pain control, we generally advise mothers to stop breastfeeding for a couple of days. If she's been diligently pumping, she should have a supply of breast milk stored up, but at 4 days, probably doesn't. Unfortunately, there is some dogma out there about formula, which is mostly untrue. Breastfeeding confers some immunity that the formula doesn't, but millions of babies across the world are raised on formula without breastfeeding and do extremely well (my own daughter included, since she was adopted at birth). Formula is so expensive because it is highly engineered to meet the baby's needs, and does an outstanding job.

'zilla

Edited October 1, 2011 by Doczilla

[DFIB]

I would wonder if the patient presented any abnormal discharge, bleeding or foul vaginal odor.

I would also want to know the quality and frequency of urination, Does she present hematuria? Dysuria?

Has she had intercourse since the childbirth or inserted anything into her vagina? Tampons? Although unlikely it is possible.

The fact that she was afebrile would be worrisome as well. Definitely a case for a good workup.

[Kiwiology]

Incomplete passing of placentae is my suspected diagnosis, although it could be gastro, gallstones, renal colic or any one of 400 different things

Hypertension and smoking increases her risk of ectopic pregnancy and pre-eclampsia/eclampsia but she already gave birth so strike those two off

Could be first onset of renal colic or gallstones but I wouldn't think so, you never know tho!

I would be starting a broad spectrum antibiotic, if she has retained POC could turn septic and that sepsis is something we've missed a bit of lately, sneaky bastard that sepsis almost like his cousin meningitis and meningococcial septicaemia .... sneakier than that Noid bloke who used to nick the pizza off the telly in the eighties.

[zmedic]

Not sure I'd start antibiotics. Especially since 1) she had similar symtoms before delivering (thereby less likely that it's a new problem)

2) The uterus is usually examined after the delivery, so less likely that the has a big retained piece.

3) A quick ultrasound can rule out retained products. Before you start thinking she's septic from retained products, does she have a fever? Sounds like no. vaginal discharge?

Is she writhing around? More typical for kidney stones. Does the pain radiate to the right shoulder or get worse with food? More likely gallstones (especially since she's had them.

Appendicitis, round ligament pain are also on my differential.

Truth it it doesn't really matter. She needs rapid transport, an OB/GYN consult, ultrasound, maybe a CT. And ideally pain control, but if she wants to suffer that's her choice.