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Cureus Oct 2023Fournier's gangrene, a not-so-common urological emergency, is a fast-progressing necrotizing bacterial infection that affects the perineum and external genitalia and can...
Fournier's gangrene, a not-so-common urological emergency, is a fast-progressing necrotizing bacterial infection that affects the perineum and external genitalia and can be rapidly fatal unless diagnosed and aggressively managed promptly. Fever, erythematous edema of the scrotum, and palpation of classic scrotal crepitation are among the clinical symptoms. The treatment involves rapid administration of empirical broad-spectrum antibiotics with gram-positive, gram-negative, and anaerobic coverage and rigorous surgical debridement down to the bleeding tissues. The medium-term complications of this condition are primarily associated with extended stay in an intensive care unit and cardiorespiratory, thromboembolic, and cutaneous complications, whereas the long-term complications are mainly functional, aesthetic, and psychological. Also, there are complications inherent to ancillary interventions such as penectomy, orchidectomy, reconstructive surgery, and restoration of digestive continuity. Herein, we present the case of a 40-year-old diabetic male who was admitted with an initial diagnosis of scrotal abscess, which turned out to be Fournier's gangrene. Despite developing multiple complications and numerous surgeries, he made a full recovery and was discharged home after a prolonged hospital stay.
PubMed: 38034187
DOI: 10.7759/cureus.48036 -
BMC Pregnancy and Childbirth Apr 2024The objective of this study was to identify and qualify, by means of a three-dimensional kinematic analysis, the postures and movements of obstetricians during a...
BACKGROUND
The objective of this study was to identify and qualify, by means of a three-dimensional kinematic analysis, the postures and movements of obstetricians during a simulated forceps birth, and then to study the association of the obstetricians' experience with the technique adopted.
METHOD
Fifty-seven volunteer obstetricians, 20 from the Limoges and 37 from the Poitiers University hospitals, were included in this multi-centric study. They were classified into 3 groups: beginners, intermediates, and experts, beginners having performed fewer than 10 forceps deliveries in real conditions, intermediates between 10 and 100, and experts more than 100. The posture and movements of the obstetricians were recorded between December 2020 and March 2021 using an optoelectronic motion capture system during simulated forceps births. Joint angles qualifying these postures and movements were analysed between the three phases of the foetal traction. These phases were defined by the passage of a virtual point associated with the forceps blade through two anatomical planes: the mid-pelvis and the pelvic outlet. Then, a consolidated ascending hierarchical classification (AHC) was applied to these data in order to objectify the existence of groups of similar behaviours.
RESULTS
The AHC distinguished four different postures adopted when crossing the first plane and three different traction techniques. 48% of the beginners adopted one of the two raised posture, 22% being raised without trunk flexion and 26% raised with trunk flexion. Conversely, 58% of the experts positioned themselves in a "chevalier servant" posture (going down on one knee) and 25% in a "squatting" posture before initiating traction. The results also show that the joint movement amplitude tends to reduce with the level of expertise.
CONCLUSION
Forceps delivery was performed in different ways, with the experienced obstetricians favouring postures that enabled observation at the level of the maternal perineum and techniques reducing movement amplitude. The first perspective of this work is to relate these different techniques to the traction force generated. The results of these studies have the potential to contribute to the training of obstetricians in forceps delivery, and to improve the safety of women and newborns.
Topics: Pregnancy; Humans; Female; Infant, Newborn; Extraction, Obstetrical; Obstetricians; Delivery, Obstetric; Obstetrical Forceps; Posture
PubMed: 38589802
DOI: 10.1186/s12884-024-06457-4 -
GMS Interdisciplinary Plastic and... 2023Soft-tissue defects of the lower abdomen, perineum, groin, and trochanteric area often involve the loss of composite tissue components and are technically challenging to...
OBJECTIVES
Soft-tissue defects of the lower abdomen, perineum, groin, and trochanteric area often involve the loss of composite tissue components and are technically challenging to reconstruct. The goals of reconstruction should include the replacement of the defect with a suitable soft-tissue flap that provides stable coverage while protecting important exposed structures. However, there are limited locations in this region for the creation of pedicled flaps for complex defect reconstruction. The pedicled anterolateral thigh (ALT) flap is considered superior to other comparable flaps due to its varying soft-tissue components and long pedicle with consistent anatomy that allow the reconstruction of locations that are difficult to reach without significant flap donor site morbidity. Herein, we present a case series of our experience of using a pedicled ALT flap to reconstruct regional defects over a range of locations.
METHODS
The present study comprised ten patients who underwent surgical reconstruction of soft-tissue defects of the lower abdomen, groin, trochanteric, scrotal, and penoscrotal defects using a pedicled ALT flap over a two-year period. The flap was customized according to the defect when required.
RESULTS
In our case series, flap loss was not observed with only a few minor complications. All patients accepted the aesthetic appearance of the flap recipient site area without requesting revision surgery. The donor site was closed primarily in half of all cases, with split skin grafting applied in the remaining patients. Graft take at the flap donor site was satisfactory in all cases.
CONCLUSION
A pedicled ALT flap is a reliable and suitable option for complex soft-tissue reconstruction for regional soft-tissue defects of the lower abdomen and perineum.
PubMed: 37577728
DOI: 10.3205/iprs000174 -
Anales de Pediatria Jun 2024
Topics: Humans; Perineum
PubMed: 38431449
DOI: 10.1016/j.anpede.2024.02.008 -
AJOG Global Reports Feb 2024Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately... (Review)
Review
OBJECTIVE
Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship.
DATA SOURCES
MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies.
STUDY ELIGIBILITY CRITERIA
Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations.
METHODS
Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity.
RESULTS
A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting.
CONCLUSION
Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.
PubMed: 38283323
DOI: 10.1016/j.xagr.2023.100296 -
European Journal of Midwifery 2023Spontaneous lacerations at vaginal birth are everyday events, but their classification and management still challenge midwifery care. This study aims to measure and...
INTRODUCTION
Spontaneous lacerations at vaginal birth are everyday events, but their classification and management still challenge midwifery care. This study aims to measure and describe first-degree and second-degree perineal lacerations resulting from vaginal birth, describe their repair, and the education provided for care.
METHODS
A descriptive study was conducted in a public maternity hospital in São Paulo, Brazil, with 87 parturients. Data were collected between October 2017 and June 2018 using a structured instrument containing obstetric variables and a description of lacerations. The obstetricians and nurse midwives assisted with births, determining the degree of laceration and intervention, and the researchers measured and reported them.
RESULTS
The majority of parturients (82.7%) had lacerations only in the anterior region, 8% had them in the posterior region, and 9.2% in both regions. The lacerations were classified as first-degree (78.1%) or second-degree (21.8%). Among the 32 nulliparous parturients, 27.6% had first-degree lacerations, and 9.2% had second-degree. Of the 55 multiparous parturients, 50.6% had first-degree, and 12.6% had second-degree. Among the lacerations assessed as first-degree, 25% had deeper tissue layers compromised in addition to the skin and mucosa. There were 180 lacerations, with an average length of 33.1 mm, depth of 19.8 mm, and width of 23.8 mm. Half of the parturients did not receive guidance on laceration care. There was no association between parity and size, number, location, or degree classification of lacerations.
CONCLUSIONS
This study provides a broad description of the characteristics of perineal lacerations and presents measurement techniques as a complementary resource for evaluating lacerations.
PubMed: 38125555
DOI: 10.18332/ejm/174310 -
Acta Obstetricia Et Gynecologica... Oct 2023Pelvic floor pain and dyspareunia are both important entities of postpartum pelvic pain, often concomitant and associated with perineal tears during vaginal delivery....
INTRODUCTION
Pelvic floor pain and dyspareunia are both important entities of postpartum pelvic pain, often concomitant and associated with perineal tears during vaginal delivery. The association between postpartum sonographic anal sphincter defects, pelvic floor pain, and dyspareunia has not been fully established. We aimed to determine the prevalence of postpartum anal sphincter defects using three-dimensional endoanal ultrasonography (3D-EAUS) and evaluate their association with symptoms of pelvic floor pain and dyspareunia.
MATERIAL AND METHODS
This prospective cohort study followed 239 primiparas from birth to 12 months post delivery. Anal sphincters were assessed with 3D-EAUS 3 months postpartum, and self-reported pelvic floor function data were obtained using a web-based questionnaire distributed 1 year after delivery. Descriptive statistics were compared between the patients with and without sonographic defects, and the association between sonographic sphincter defects and outcomes were analyzed using logistic regression.
RESULTS
At 3 months postpartum, 48/239 (20%) patients had anal sphincter defects on 3D-EAUS, of which 43 (18%) were not clinically diagnosed with obstetric anal sphincter injury at the time of delivery. Patients with sonographic defects had higher fetal weight than those without defects, and a perineum <2 cm before the suture was a risk factor for defects (odds ratio [OR], 6.9). Patients with sonographic defects had a higher frequency of dyspareunia (OR, 2.4), and pelvic floor pain (OR, 2.3) than those without defects.
CONCLUSIONS
Our results suggest an association between postpartum sonographic anal sphincter defects, pelvic floor pain, and dyspareunia. A perineal height <2 cm, measured by bidigital palpation immediately postdelivery, was a risk factor for sonographic anal sphincter defect. We suggest offering pelvic floor sonography around 3 months postpartum to high- risk women to optimize diagnosis and treatment of perineal tears and include perineum <2 cm prior to primary repair as a proposed indication for postpartum follow-up sonography.
Topics: Pregnancy; Humans; Female; Anal Canal; Prospective Studies; Pelvic Floor; Dyspareunia; Postpartum Period; Delivery, Obstetric; Ultrasonography; Lacerations; Pelvic Pain; Fecal Incontinence
PubMed: 37350333
DOI: 10.1111/aogs.14606 -
The Cochrane Database of Systematic... Apr 2024Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife... (Review)
Review
BACKGROUND
Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.
OBJECTIVES
To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.
SELECTION CRITERIA
All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.
MAIN RESULTS
We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.
AUTHORS' CONCLUSIONS
Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.
Topics: Infant; Pregnancy; Infant, Newborn; Female; Humans; Midwifery; Cesarean Section; Perinatal Death; Birth Weight; Premature Birth; Continuity of Patient Care; Randomized Controlled Trials as Topic
PubMed: 38597126
DOI: 10.1002/14651858.CD004667.pub6 -
Annals of Translational Medicine Apr 2024Descending perineal syndrome (DPS) was described by Parks as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of... (Review)
Review
Descending perineal syndrome (DPS) was described by Parks as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of the. DPS is associated with obstructed defecation, with increased bulging of the perineum with straining, although perineal descent can also be seen at rest. In their review, Chaudhry and Tarnay stated: "". The deep transversus perinei (DTP) ligaments are the suspensory ligaments of the perineal body (PB). DTP are approximately 4 cm long. They attach behind the upper 2/3 and lower 1/3 of the descending ramus. If, at childbirth, the PB is overstretched and displaced laterally and inferiorly, the DTP lengthens. DPS is described as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of the symphysis. DPS is associated with obstructed and often, assisted defecation, with increased bulging of the perineum with straining descent of the anus on straining. The surgical methodology begins as a standard PB repair which dissects the rectum from the vagina and PB and approximates the displaced components of the PB. We added an additional step: identifying the DTPs, shortening and reinforcing them with the Tissue Fixation System (TFS) minisling or No. 2 polyester sutures. High cure rates for obstructed defecation were achieved with the TFS minisling, and initial results using No. 2 polyester sutures are favourable. The key messages from both operations is DPS is caused by stretching and elongation of DPS ligaments, and these are surgically repairable.
PubMed: 38721449
DOI: 10.21037/atm-23-1803 -
Asian Journal of Surgery Jul 2024
Topics: Humans; Teratoma; Fibroma; Perineum; Infant, Newborn; Soft Tissue Neoplasms; Female; Male
PubMed: 38604844
DOI: 10.1016/j.asjsur.2024.03.151