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Journal of Education & Teaching in... Apr 2024This scenario was developed to educate emergency medicine residents on the diagnosis and management of two concurrent conditions: septic abortion and disseminated...
AUDIENCE
This scenario was developed to educate emergency medicine residents on the diagnosis and management of two concurrent conditions: septic abortion and disseminated intravascular coagulation (DIC).
INTRODUCTION
Patients with an abortion (spontaneous or induced) of less than twenty weeks gestation may present with concurrent uterine infection, also known as septic abortion. One of the complications of septic abortion is DIC. Early management of both underlying etiology (septic abortion) and subsequent complications (DIC) is crucial to minimize morbidity and mortality.
EDUCATIONAL OBJECTIVES
At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history including pregnancy history, medication use, and past medical history. 2) Develop a differential for fever and vaginal bleeding in a pregnant patient. 3) Discuss management of septic abortion, including empiric broad-spectrum antibiotics and obstetric consultation for source control with dilation and curettage (D&C). 4) Discuss expected laboratory findings of disseminated intravascular coagulation (DIC). 5) Discuss management of DIC, including identification of underlying etiology and supportive resuscitation with blood products. 6) Review the components of blood products. 7) Identify appropriate disposition of the patient to the intensive care unit (ICU).
EDUCATIONAL METHODS
This session was conducted using high-fidelity simulation followed by a debriefing session and discussion about the diagnosis, differential, and management of both septic abortion and DIC. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. In this technique, the facilitator described something they observed in the case, outlined their reasoning as a facilitator why this observation was important or why they had questions, and then asked the learners to share their frame of reference at the time. An example: "I heard the team leader state that the platelets were normal, but then another resident disagreed. No one paused to come to a consensus. I'm wondering why this wasn't explored further in real time. Tell me more." This scenario may also be run as an oral boards case or adapted for other learners such as critical care fellows.
RESEARCH METHODS
Our residents were provided a survey at the completion of the debriefing session so they could rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form,1 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7.
RESULTS
Thirteen learners completed a feedback form out of seventeen participants. This session received all six and seven scores (consistently effective/very good and extremely effective/outstanding, respectively) other than two isolated 4 scores.
DISCUSSION
This is a cost-effective method for reviewing septic abortion and DIC. The case may be modified for appropriate audiences, such as simplifying the case to septic abortion without DIC. You can also consider not showing an initial temperature with the initial set of vitals unless it is specifically asked for by the participants. We encourage readers to utilize bleeding moulage techniques as a visual stimulus to increase psychological buy-in.
TOPICS
Medical simulation, septic abortion, pregnancy complications, hematology emergencies, obstetric emergencies, disseminated intravascular coagulation, emergency medicine.
PubMed: 38707944
DOI: 10.21980/J8GH1G -
American Journal of Obstetrics and... Mar 2024Although the optimal length of the second stage of labor to minimize maternal and neonatal morbidities and optimize spontaneous vaginal delivery is not known, available... (Review)
Review
Although the optimal length of the second stage of labor to minimize maternal and neonatal morbidities and optimize spontaneous vaginal delivery is not known, available evidence suggests that increasing length of the second stage is associated with increasing maternal and neonatal morbidity. Thus, evidence-based strategies to safely shorten the second stage, such as initiating pushing when complete dilation is reached among those with neuraxial anesthesia, is prudent. Many aspects of optimal management of the second stage of labor require future study to continue to guide clinical second-stage management.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Labor Stage, Second; Time Factors; Delivery, Obstetric; Anesthesia; Anesthesiology
PubMed: 38462261
DOI: 10.1016/j.ajog.2022.07.017 -
Journal of Clinical Pharmacology Aug 2023This study aimed to evaluate the efficacy and safety of evening primrose oil (EPO) for cervical ripening before gynecologic procedures and compare it to misoprostol. In... (Randomized Controlled Trial)
Randomized Controlled Trial
This study aimed to evaluate the efficacy and safety of evening primrose oil (EPO) for cervical ripening before gynecologic procedures and compare it to misoprostol. In this study, 40 hysteroscopy and dilation and curettage candidates were enrolled. Patients were randomly assigned to receive either 2000 mg of vaginal EPO (n = 20) or 200 μg of vaginal misoprostol (n = 20) 2 hours before the expected procedure. The measured outcomes were the size of the Hegar dilator that passed through the cervix effortlessly, uterine cervicovaginal complications, and drug-related side effects. The two groups were not significantly different in age, number of gravity, parity, type of delivery, and menopausal status (P > .05). The mean ± SD size of the first dilator was 5.25 ± 1.55 in the misoprostol group and 7.30 ± 1.08 in the EPO group (P < .001). The pain complaint in the EPO group was significantly lower (P = .027), but the two groups were not significantly different in terms of other complications. No cases of uterine or cervical rupture were seen in either group. The present study showed that 2000 mg of vaginal EPO was significantly more effective for cervical ripening than 200 μg of vaginal misoprostol before gynecological surgery. Therefore, it is recommended to use EPO as an alternative to misoprostol.
Topics: Pregnancy; Humans; Female; Misoprostol; Cervix Uteri; Oxytocics; Gynecologic Surgical Procedures; Administration, Intravaginal
PubMed: 37102338
DOI: 10.1002/jcph.2253 -
Factors associated with epidural-related maternal fever in low-risk term women: a systematic review.International Journal of Obstetric... Nov 2023The underlying mechanism of epidural-related maternal fever (ERMF) is not fully understood. This systematic review aimed to identify factors associated with ERMF in... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The underlying mechanism of epidural-related maternal fever (ERMF) is not fully understood. This systematic review aimed to identify factors associated with ERMF in low-risk, full-term women using neuraxial analgesia.
METHODS
PubMed, Embase, Web of Science, CENTRAL, and Wanfang Data were searched from inception to September 10, 2022 with no language restriction. Studies reported descriptive data regarding the factors associated with ERMF. A random effects model meta-analysis was used to pool the raw data of univariate analyses for each identified factor. Sensitivity and subgroup analyses were performed to explore possible sources of heterogeneity.
RESULTS
Eighteen observational studies involving 33 427 women were included, with 18 factors eligible for meta-analyses. Higher body mass index, baseline temperature, admission maternal interleukin-6 levels and white blood cell counts, nulliparity, increasing gestational age, longer duration of labor and rupture of membranes, increasing number of vaginal examinations, oxytocin use, higher birth weight, lower cervical dilation at initiation of analgesia, and longer analgesia duration were associated with increased risk of ERMF, while intermittent compared with continuous epidural dosing was associated with a decreased risk of ERMF (odds ratio 0.25, 95% CI 0.16 to 0.48, P < 0.001). However, heterogeneity among studies was high and the quality of evidence was low for these meta-analyses, except for intermittent epidural dosing.
CONCLUSIONS
Many factors are associated with ERMF but may not be independent or causal. Further study is needed to clarify the interactions of these factors in ERMF development and whether modification of these factors might influence risk of ERMF.
Topics: Pregnancy; Female; Humans; Analgesia, Epidural; Labor, Obstetric; Risk; Pain Management; Oxytocin; Analgesia, Obstetrical
PubMed: 37625990
DOI: 10.1016/j.ijoa.2023.103915 -
AJOG Global Reports Aug 2023Labor progression curves are believed to differ between spontaneous and induced labors. However, data describing labor progression patterns with different modes of...
BACKGROUND
Labor progression curves are believed to differ between spontaneous and induced labors. However, data describing labor progression patterns with different modes of induction are insufficient.
OBJECTIVE
This study aimed to compare the progress patterns between labors induced with slow-release prostaglandin E vaginal analogue and those induced with a double-balloon catheter.
STUDY DESIGN
This retrospective cohort study included all nulliparous women who delivered at term and who underwent cervical ripening with prostaglandin E vaginal analogue or a double-balloon catheter from 2013 to 2021 in a tertiary hospital in Israel. Included in the analysis were women who achieved 10 cm cervical dilatation. The time intervals between centimeter-to-centimeter changes were evaluated.
RESULTS
A total of 1087 women were included of whom 786 (72.3%) were induced using prostaglandin E vaginal analogue and 301 (27.7%) were induced using a double-balloon catheter. The time from induction to birth was similar between the groups (32.5 hours for the prostaglandin E vaginal analogue group [5th-95th percentiles, 6.5-153.8] vs 29.2 hours for the double-balloon group [5th-95th percentiles, 9.1-157.1]; =.100). The median time of the latent phase (2-6 cm dilation) was longer for the double-balloon catheter group than for the prostaglandin E vaginal analogue group (7.3 hours [5th-95th percentiles, 5.6-14.5] vs 6.0 hours [5th-95th percentiles, 2.4-18.8]; =.042). The median time of active labor (6-10 cm dilatation) was similar between groups (1.9 hours [5th-95th percentiles, 0.3-7.4] for the prostaglandin E vaginal analogue group vs 2.3 hours [5th-95th percentiles, 0.3-6.5] for the double-balloon catheter group; =.307).
CONCLUSION
Deliveries subjected to cervical ripening with a double-balloon catheter were characterized by a slightly longer latent phase than deliveries induced by prostaglandin E vaginal analogue. After reaching the active phase of labor, the mode of cervical ripening did not influence the labor progress pattern.
PubMed: 37645656
DOI: 10.1016/j.xagr.2023.100198 -
BMJ (Clinical Research Ed.) Mar 2024To compare the effectiveness of cervical pessary and vaginal progesterone in the prevention of adverse perinatal outcomes and preterm birth in pregnant women of... (Comparative Study)
Comparative Study Randomized Controlled Trial
Cervical pessary versus vaginal progesterone in women with a singleton pregnancy, a short cervix, and no history of spontaneous preterm birth at less than 34 weeks' gestation: open label, multicentre, randomised, controlled trial.
OBJECTIVE
To compare the effectiveness of cervical pessary and vaginal progesterone in the prevention of adverse perinatal outcomes and preterm birth in pregnant women of singletons with no prior spontaneous preterm birth at less than 34 weeks' gestation and who have a short cervix of 35 mm or less.
DESIGN
Open label, multicentre, randomised, controlled trial.
SETTING
20 hospitals and five obstetric ultrasound practices in the Netherlands.
PARTICIPANTS
Women with a healthy singleton pregnancy and an asymptomatic short cervix of 35 mm or less between 18 and 22 weeks' gestation were eligible. Exclusion criteria were prior spontaneous preterm birth at less than 34 weeks, a cerclage in situ, maternal age of younger than 18 years, major congenital abnormalities, prior participation in this trial, vaginal blood loss, contractions, cervical length of less than 2 mm or cervical dilatation of 3 cm or more. Sample size was set at 628 participants.
INTERVENTIONS
1:1 randomisation to an Arabin cervical pessary or vaginal progesterone 200 mg daily up to 36 weeks' of gestation or earlier in case of ruptured membranes, signs of infection, or preterm labour besides routine obstetric care.
MAIN OUTCOME MEASURES
Primary outcome was a composite adverse perinatal outcome. Secondary outcomes were rates of (spontaneous) preterm birth at less than 28, 32, 34, and 37 weeks. A predefined subgroup analysis was planned for cervical length of 25 mm or less.
RESULTS
From 1 July 2014 to 31 March 2022, 635 participants were randomly assigned to pessary (n=315) or to progesterone (n=320). 612 were included in the intention to treat analysis. The composite adverse perinatal outcome occurred in 19 (6%) of 303 participants with a pessary versus 17 (6%) of 309 in the progesterone group (crude relative risk 1.1 (95% confidence interval (CI) 0.60 to 2.2)). The rates of spontaneous preterm birth were not significantly different between groups. In the subgroup of cervical length of 25 mm or less, spontaneous preterm birth at less than 28 weeks occurred more often after pessary than after progesterone (10/62 (16%) 3/69 (4%), relative risk 3.7 (95% CI 1.1 to 12.9)) and adverse perinatal outcomes seemed more frequent in the pessary group (15/62 (24%) 8/69 (12%), relative risk 2.1 (0.95 to 4.6)).
CONCLUSIONS
In women with a singleton pregnancy with no prior spontaneous preterm birth at less than 34 weeks' gestation and with a midtrimester short cervix of 35 mm or less, pessary is not better than vaginal progesterone. In the subgroup of a cervical length of 25 mm or less, a pessary seemed less effective in preventing adverse outcomes. Overall, for women with single baby pregnancies, a short cervix, and no prior spontaneous preterm birth less than 34 weeks' gestation, superiority of a cervical pessary compared with vaginal progesterone to prevent preterm birth and consecutive adverse outcomes could not be proven.
TRIAL REGISTRATION
International Clinical Trial Registry Platform (ICTRP, EUCTR2013-002884-24-NL).
Topics: Adult; Female; Humans; Infant, Newborn; Pregnancy; Administration, Intravaginal; Cervix Uteri; Pessaries; Premature Birth; Progesterone; Vagina
PubMed: 38471724
DOI: 10.1136/bmj-2023-077033 -
American Journal of Obstetrics and... Mar 2024Having a cesarean delivery at full dilatation has been associated with increased subsequent risk of spontaneous preterm birth. The Aberdeen Maternity and Neonatal...
BACKGROUND
Having a cesarean delivery at full dilatation has been associated with increased subsequent risk of spontaneous preterm birth. The Aberdeen Maternity and Neonatal Databank provides a rare opportunity to study subsequent pregnancy outcomes after a previous cesarean delivery at full dilatation over 40 years, with an ability to include a detailed evaluation of potential confounding factors.
OBJECTIVE
This study aimed to investigate if having an initial cesarean delivery at full dilatation is associated with spontaneous preterm birth or other adverse pregnancy outcomes in the subsequent pregnancy.
STUDY DESIGN
A retrospective cohort study was conducted including women with a first and second pregnancy recorded within the Aberdeen Maternity and Neonatal Databank between 1976 and 2017, where previous cesarean delivery at full dilatation at term in the first birth was the exposure. The primary outcome was spontaneous preterm birth (defined as spontaneous birth <37 weeks). Multivariate logistic regression was used to investigate any association between cesarean delivery at full dilatation and the odds of spontaneous preterm birth. Cesarean delivery at full dilatation in previous pregnancy was compared with: (1) any other mode of birth, and (2) individual modes of birth, including planned cesarean delivery, cesarean delivery in first stage of labor (<10-cm dilatation), and vaginal birth (including spontaneous vaginal birth, nonrotational forceps, Kielland forceps, vacuum-assisted birth, breech vaginal birth). Other outcomes such as antepartum hemorrhage and mode of second birth were also compared.
RESULTS
Of the 30,253 women included, 900 had a previous cesarean delivery at full dilatation in the first pregnancy. Women with previous cesarean delivery at full dilatation had a 3-fold increased risk of spontaneous preterm birth in a second pregnancy (unadjusted odds ratio, 2.63; 95% confidence interval, 1.82-3.81; adjusted odds ratio, 3.31; 95% confidence interval, 2.17-5.05) compared with those with all other modes of first birth, adjusted for maternal age, diabetes mellitus, body mass index, smoking, preeclampsia, antepartum hemorrhage, socioeconomic deprivation (Scottish Index of Multiple Deprivation 2016), year of birth, and interpregnancy interval (in second pregnancy). When compared with women with vaginal births only, women with cesarean delivery at full dilatation had 5-fold increased odds of spontaneous preterm birth (adjusted odds ratio, 5.37; 95% confidence interval, 3.40-8.48). Compared with first spontaneous vaginal birth, first instrumental births (nonrotational forceps, Kielland forceps, and vacuum births) were not associated with increased risk of spontaneous preterm birth in the second birth. After an initial cesarean delivery at full dilatation, 3.7% of women had a repeated cesarean delivery at full dilatation and 48% had a planned cesarean delivery in the second birth.
CONCLUSION
This study is a substantial addition to the body of evidence on the risk of subsequent spontaneous preterm birth after cesarean delivery at full dilatation, and demonstrates a strong association between cesarean delivery at full dilatation in the first birth and spontaneous preterm birth in subsequent pregnancy, although the absolute risk remains small. This is a large retrospective cohort and includes a comprehensive assessment of potential confounding factors, including preeclampsia, antepartum hemorrhage, and lengths of first and second stage of labor. Future research should focus on understanding possible causality and developing primary and secondary preventative measures.
Topics: Female; Infant, Newborn; Pregnancy; Humans; Retrospective Studies; Premature Birth; Cohort Studies; Pre-Eclampsia; Dilatation; Hemorrhage
PubMed: 37598995
DOI: 10.1016/j.ajog.2023.08.013 -
Journal of Education & Teaching in... Apr 2024Uterine perforation is a rare but potentially life-threatening complication of gynecologic procedures. Serious complications include hemorrhage, infection, and injury to...
UNLABELLED
Uterine perforation is a rare but potentially life-threatening complication of gynecologic procedures. Serious complications include hemorrhage, infection, and injury to surrounding organ systems (eg, gastrointestinal, urological, vascular, etc.). Risk factors include advanced maternal age, prior gynecologic surgeries, and other anatomical features that impact the difficulty of accessing the uterine cavity. In this case report, we discuss a patient who presented to the emergency department (ED) with diffuse abdominal pain and vaginal bleeding that occurred after an elective dilation and curettage (D&C) for a termination of pregnancy. The diagnosis was suspected clinically and confirmed by imaging including ultrasound (US) and computed tomography (CT) of the abdomen and pelvis. The patient was managed operatively with a multidisciplinary approach including Gynecology, General Surgery, and Urology. The patient was stabilized and eventually discharged. Uterine perforation should be included in the differential for patients with a history of recent gynecologic instrumentation presenting with abdominal pain and vaginal bleeding. The stabilization of these patients requires aggressive volume resuscitation, controlling the source of bleeding, and emergent surgical consultation.
TOPICS
Gynecology, vaginal bleeding, ultrasound, computed tomography.
PubMed: 38707940
DOI: 10.21980/J83643 -
The Journal of Sexual Medicine Oct 2023Shallow-depth vaginoplasty (SDV), also referred to as vaginoplasty without creation of a vaginal canal, is an understudied alternative to full-depth vaginoplasty (FDV),...
Shallow-depth vaginoplasty: preoperative goals, postoperative satisfaction, and why shallow-depth vaginoplasty should be offered as a standard feminizing genital gender-affirming surgery option.
BACKGROUND
Shallow-depth vaginoplasty (SDV), also referred to as vaginoplasty without creation of a vaginal canal, is an understudied alternative to full-depth vaginoplasty (FDV), or vaginoplasty with creation of a vaginal canal. SDV is associated with fewer short- and long-term risks and shorter recovery, and does not require a lifelong commitment to vaginal dilation and douching.
AIM
To describe a surgical technique for SDV that creates a dimpled introitus, together with clinical outcomes, decision-making prioritization, and satisfaction data. We hypothesize that SDV patients prioritize comparable appearance and sexual function to FDV over shorter-term risk factors, and experience high satisfaction.
METHODS
We describe (1) a surgical technique for SDV; (2) the proportion of patients who underwent SDV vs. FDV, with SDV complication rates; and (3) the results of an anonymous, electronic questionnaire administered via Qualtrics that assessed SDV patient demographics, terminology preferences, prioritization of decision-guiding factors for choosing SDV over FDV, and postoperative satisfaction across various domains.
OUTCOMES
A total of 110 patients underwent primary feminizing genital gender-affirming surgery at a single institution between April 2017 and July 2022: 35 (32%) of 110 underwent SDV and 75 (68%) underwent FDV. The 35 SDV patients were invited to answer the study questionnaire, of which 29 (83%) completed it (mean age 51.9 ± 16.7 years, mean body mass index 27.3 ± 5.3 kg/m2).
RESULTS
All but one survey respondent met one or more of the following characteristics: (1) ≥40 years of age, (2) exclusively feminine-identifying sexual partners, and/or (3) significant aversion to performing long-term vaginal dilation and douching. Ranking of 8 decision-guiding factors revealed prioritization of long-term over short-term outcomes. Postoperatively, patients reported high satisfaction across all 3 domains. When asked if they had to choose between SDV and FDV over again, 86% reported that they would choose SDV. While 14% would choose FDV, all but one reported new interest in receptive vaginal intercourse due to finding masculine-identifying partners post-SDV surgery. A total of 27% of SDV patients experienced complications that required additional surgeries; 82% of complications were related to urinary spraying.
CLINICAL IMPLICATIONS
SDV is a lower-risk alternative to FDV and is associated with reduced postoperative maintenance and high postoperative satisfaction.
STRENGTHS AND LIMITATIONS
This study describes the clinical outcomes of the largest documented cohort of patients to undergo SDV to date. Limitations include recall bias due to the retrospective survey and use of nonvalidated questions attributed to the paucity of validated gender-affirming surgery questionnaires.
CONCLUSION
SDV's appeal to a large subset of patients (32% in this study), low complication rate, high satisfaction, and low decisional regret suggests that this surgical option should be offered to all patients seeking feminizing genital gender-affirming surgery.
Topics: Female; Humans; Adult; Middle Aged; Aged; Sex Reassignment Surgery; Transgender Persons; Retrospective Studies; Goals; Vulva; Vagina
PubMed: 37721184
DOI: 10.1093/jsxmed/qdad111 -
International Urogynecology Journal Dec 2023There are sparse data on the use of postoperative pelvic floor physical therapy (PFPT) in patients undergoing vaginoplasty. The primary objective of this study was to... (Randomized Controlled Trial)
Randomized Controlled Trial
A randomized trial comparing perioperative pelvic FLOor physical therapy to current standard of care in transgender Women undergoing vaginoplasty for gendER affirmation: the FLOWER Trial.
INTRODUCTION AND HYPOTHESIS
There are sparse data on the use of postoperative pelvic floor physical therapy (PFPT) in patients undergoing vaginoplasty. The primary objective of this study was to compare the impact of PFPT on the ease of vaginal dilation after vaginoplasty in transgender women. We hypothesized that patients undergoing PFPT would report better ease of vaginal dilation following surgery.
METHODS
This was a randomized trial of transgender women undergoing vaginoplasty. Patients were randomized to either no PFPT or PFPT 3 and 6 weeks following surgery. Subjects completed the Pelvic Floor Disorders Inventory and the Pelvic Floor Impact Questionnaire at baseline and at 12 weeks. At 12 weeks, subjects underwent vaginal length measurement and completed the Patient Global Impression of Improvement and a visual analogue scale (0-10) for ease of vaginal dilation and pain with dilation. A total of 17 subjects in each arm were needed to detect a significant difference in ease of dilation between the two groups.
RESULTS
Forty-one subjects were enrolled and 12-week data were available for 37 subjects (20 PFPT, 17 no PFPT). Mean age and BMI were 31 ± 13 years and 24.9 (± 4.0) kg/m. Subjects were on hormone therapy for a median of 39 (20-240) months and 5 (13.5%) patients had undergone previous orchiectomy. At 12 weeks, the median vaginal length was 12.5 (10-16) cm, reported mean ease of dilation was 7.3 (± 1.6), and pain with dilation was 2.4 (± 1.7). There were no differences in these outcomes or in pelvic floor symptoms between the groups.
CONCLUSIONS
In this study, routine postoperative PFPT did not improve outcomes in patients undergoing vaginoplasty.
Topics: Female; Humans; Pelvic Floor; Pelvic Pain; Physical Therapy Modalities; Standard of Care; Transgender Persons; Adult; Male
PubMed: 37688620
DOI: 10.1007/s00192-023-05623-0