ABSTRACT
Genital tract trauma and obstetric anal sphincter injuries are known complications of normal vaginal and assisted vaginal delivery. Cervical tears are an uncommon complication that can lead to significant postpartum haemorrhage and may have implications for future pregnancies. Careful evaluation of the genital tract, including the cervix, along with adequate resuscitation are essential to reduce maternal morbidity and mortality. This is a case report of a 36-year-old primigravida woman at 41 + 6 weeks of gestation with delay in the second stage requiring Neville Barnes forceps delivery. She then went on to have a major postpartum haemorrhage, initially thought to be a result of uterine atony. However, inadequate response to uterotonics led to identification of a cervical buttonhole tear with an intact external os. She required repair under general anaesthesia. A rigid sigmoidoscope was utilised to ensure cervical canal patency during the repair. Previous reports have described annular cervical tears, thought to occur from the extension of a cervical buttonhole tear, but to the best of our knowledge the latter has not previously been reported. The case demonstrates the importance of awareness of such tears and proposes a novel technique for repair with the use of a rigid sigmoidoscope.
ABSTRACT
BACKGROUND: Opioid use disorder (OUD) is characterized by the inability to control opioid use despite attempts to stop use and negative consequences to oneself and others. The burden of opioid misuse and OUD is a national crisis in the United States with substantial public health, social, and economic implications. Although medication-assisted treatment (MAT) has demonstrated efficacy in the management of OUD, access to effective counseling and psychosocial support is a limiting factor and a significant problem for many patients and physicians. Digital therapeutics are an innovative class of interventions that help prevent, manage, or treat diseases by delivering therapy using software programs. These applications can circumvent barriers to uptake, improve treatment adherence, and enable broad delivery of evidence-based management strategies to meet service gaps. However, few digital therapeutics specifically targeting OUD are available, and additional options are needed. OBJECTIVE: To this end, we describe the development of the novel digital therapeutic MODIA. METHODS: MODIA was developed by an international, multidisciplinary team that aims to provide effective, accessible, and sustainable management for patients with OUD. Although MODIA is aligned with principles of cognitive behavioral therapy, it was not designed to present any 1 specific treatment and uses a broad range of evidence-based behavior change techniques drawn from cognitive behavioral therapy, mindfulness, acceptance and commitment therapy, and motivational interviewing. RESULTS: MODIA uses proprietary software that dynamically tailors content to the users' responses. The MODIA program comprises 24 modules or "chats" that patients are instructed to work through independently. Patient responses dictate subsequent content, creating a "simulated dialogue" experience between the patient and program. MODIA also includes brief motivational text messages that are sent regularly to prompt patients to use the program and help them transfer therapeutic techniques into their daily routines. Thus, MODIA offers individuals with OUD a custom-tailored, interactive digital psychotherapy intervention that maximizes the personal relevance and emotional impact of the interaction. CONCLUSIONS: As part of a clinician-supervised MAT program, MODIA will allow more patients to begin psychotherapy concurrently with opioid maintenance treatment. We expect access to MODIA will improve the OUD management experience and provide sustainable positive outcomes for patients.
