Abdominal Muscle Separation Common Pregnancy Problem, Not Always Discussed

It’s normal for pregnant women to experience separation of the parallel muscle band of the anterior mid-abdominal wall known as diastasis recti abdominis (DRA) — about two thirds of mothers-to-be do. But the condition sometimes persists into the postpartum period or long afterward and needs medical attention.

On the surface, DRA manifests as an unesthetic midline bulge. In its worst form, usually diagnosed in the 6-12 weeks after delivery but seen in some women up to a year after giving birth, DRA can lead to serious symptoms such as muscle pain, organ displacement, digestive issues, image dysphoria, and psychological distress.

It is advisable to warn obstetrical patients about the possibility of developing a noticeable DRA ridge, as they may not have heard of this consequence of pregnancy. “This condition doesn’t affect all mothers, but it’s important to tell women how to prevent it as part of counseling on having a healthy pregnancy,” Alessandra I. Hirsch, MD, an assistant professor of obstetrics and gynecology at Columbia University Irving Medical Center in New York City, told Medscape Medical News.

The biggest risk factors are multiple pregnancies, large-sized babies, and nonsingleton births, added Matthew R. Carroll, MD, an assistant professor in the Department of Obstetrics and Gynecology at Baylor College of Medicine in Houston. “There are also genetic risk factors that affect the abdominal wall structure and the connective tissues. And obesity, or anything else that weakens the abdominal wall, can be a risk factor,” he said.

But even with today’s rising obesity rates, there are no data to suggest DRA is increasing, Hirsch said. “Prevalence remains stable.”

DRA may limit what simple everyday things women can do, said Carroll. “For instance, it may be hard for a woman with DRA to get up from a reclining position. And treatment options are more limited than what we would like to see.”

Although preponderantly affecting women, DRA can also develop in men who engage in yo-yo dieting, improper abdominal exercise, and overly heavy lifting.

The best preventive approach, according to Hirsch, is to focus on exercise to strengthen the abdominal muscles and stabilize the core and back both during pregnancy and postpartum. “If the condition persists after delivery with a more than 3-cm separation, it can cause considerable back pain later in life,” she said.

In her practice, Hirsch starts with recommending abdomen-strengthening exercise. If that is ineffective, she refers patients to physiotherapy. “Some data suggest that wearing a corset-like binder in addition to exercise is helpful, but this approach has not been well validated,” she said.

Carroll explicitly raises the issue of DRA and safe exercise with mothers-to-be at the 12- to 15-week education visit. “We talk about it in the context of exercise contributing to a healthy pregnancy and making sure they limit heavy lifting after 20 weeks for the sake of the fetus,” he said, noting that no evidence suggests that a prepregnancy exercise regimen can prevent DRA.

“At the end of the day, the most reliable way to avoid surgery is safe workouts during pregnancy, which can reduce the risk of postpartum DRA by up to 35%,” Hirsch said. And in Carroll’s experience, “most cases of separation will heal but not necessarily fully close.”

Surgery

For women with bothersome ongoing symptoms or distress about their appearance due to the persistent ridge, surgery is an option and is usually done by plastic rather than general surgeons.

“The repair should ideally be done only once, after childbearing is done,” said Scott Hollenbeck, MD, president of the American Society of Plastic Surgeons and chair of the Department of Plastic and Maxillofacial Surgery at University of Virginia Medical School in Charlottesville, Virginia.

“Sometimes, that’s hard to predict and plan, but that is the ideal.” If there’s a later pregnancy, the repair can fail. Beyond that, it’s hard to predict who will have a lot of abdominal muscle stretching and who will not, he added.

It is not typically necessary to reverse an abdominal muscle repair in the setting of a new pregnancy, but the previous repair is likely to pull apart or stretch out, resulting in failure, Hollenbeck added. “It is conceivable that an extensive repair that involved permanent synthetic mesh could interfere with the expansion of the abdominal cavity, but typically, we would expect the mesh attachments or sutures to pull away or fail, resulting in normal abdominal wall expansion during pregnancy.”

He noted that a few case reports in the literature describe uneventful pregnancies after abdominoplasty and diastasis repair.

Besides improving the contour and appearance of the abdomen, another potential benefit of surgery is improving the strength and function of the core muscles. “The rectus abdominis or ‘six-pack’ muscles are long and extend from the chest cavity to the pelvis. They perform better when they are closely aligned together in the middle rather than being separated by a stretched-out connection,” Hollenbeck said.

Hirsch, Hollenbeck, and Carroll reported no conflicts of interest.

Diana Swift is an independent medical journalist based in Toronto, Ontario, Canada.