Treatment Strategies for Obstetric Puerperal Genital Hematomas: A Case Series.

BACKGROUND: Puerperal genital hematoma is an infrequent but potentially life-threatening complication of childbirth. There are three approaches to care: expectant management, surgical evacuation, or uterine artery embolization. CASES: This retrospective case series compares the clinical courses of three patients who developed puerperal genital hematoma and were managed differently. We report the length of time to complete resolution of the hematomas and the associated morbidities for each patient. CONCLUSION: All three management approaches of puerperal genital hematoma can be effective. Among our three patients, surgical intervention of the puerperal genital hematoma provided the most prompt and definitive management with resolution of all symptoms in 9 days, compared with 3 weeks for expectant management and 20 weeks for treatment with uterine artery embolization. Intervention should be individualized based on the patient's symptoms, stability, and desires with consideration of the hematoma size and location as well as available institutional resources.

An Innovative Simulation Curriculum to Train General Surgery Residents and Medical Students on Four Commonly Encountered Obstetric and Gynecologic Procedures.

INTRODUCTION: Lack of obstetric and gynecologic (OBGYN) procedure exposure during general surgery residency was recognized as a training gap for military general surgery residents by U.S. Navy trauma and general surgeons serving as simulation leads for the Naval Medical Center Portsmouth general surgery resident program. Program faculty requested the authors develop and implement a recurring simulation curriculum to address this training gap. The primary goal of the simulation curriculum was to increase exposure to and confidence in performing four commonly encountered OBGYN procedures in a deployed setting: spontaneous vaginal delivery (SVD), Bartholin's cyst incision and drainage with Word catheter placement, cesarean delivery, and total abdominal hysterectomy (TAH). We hypothesized that trainees exposed to the new simulation curriculum would demonstrate an increase in knowledge and confidence in these four commonly encountered OBGYN procedures. MATERIALS AND METHODS: The study utilized a pre- and postdesign to determine the efficacy of a newly developed simulation curriculum as measured by participants' knowledge and confidence levels. The annual curriculum was 4 hours in duration and included a targeted lecture followed by the administration of the four OBGYN simulation skills stations: SVD, Bartholin's, cesarean delivery, and total abdominal hysterectomy. Proctors for the simulation stations consisted of OBGYN teaching faculty who had at least 5 years of clinical teaching experience and were experienced simulation instructors. Precourse and postcourse knowledge and confidence were self-rated on a 5-point Likert scale. The learners rated the course using the Simulation Design Scale. Likert scale data were analyzed using the paired Wilcoxon rank sum test. Descriptive statistics were reported for the Simulation Design Scale. P < 0.05 was considered to be statistically significant. This project was classified as nonhuman subjects' research by the Naval Medical Center Portsmouth Institutional Review Board. RESULTS: Over the 2 years since curriculum implementation, 34 trainees participated in the curriculum; no trainees have had the curriculum twice. All trainees confirmed training gaps on baseline self-assessment of knowledge and confidence of all four OBGYN procedures with the most confidence reported for SVD (2.83 mean). Self-rated knowledge and confidence levels improved significantly in all four of the simulated procedures for all 34 participants (P < 0.001). Postcurricular surveys (82% response rate, 28/34) indicated a high satisfaction with all areas of the simulation training (4.74/5.0). CONCLUSIONS: The implemented curriculum increased general surgery trainees' knowledge and confidence in four commonly encountered OBGYN procedures and demonstrated a high level of learner satisfaction and sustainability. The curriculum exhibits high educational impact and could be a valuable adjunctive training for other non-OBGYN physicians who may need to provide OBGYN care in military environments.

Racial Disparities in Prenatal Care Utilization and Infant Small for Gestational Age Among Active Duty US Military Women.

OBJECTIVES: To examine racial disparities in prenatal care (PNC) utilization and infant small for gestational age (SGA) among active duty US military women, a population with equal access to health care and known socioeconomic status. METHODS: Department of Defense Birth and Infant Health Research program data identified active duty women with singleton live births from January 2003 through August 2015. Administrative claims data were used to define PNC utilization and infant SGA, and log-binomial regression models estimated associations with race/ethnicity. To examine whether associations between maternal race/ethnicity and infant SGA were subject to effect measure modification, respective analyses were stratified by demographic and health characteristics. RESULTS: Overall, 12.2% of non-Hispanic White women initiated PNC after the first trimester, compared with 14.8% of American Indian/Alaska Native, 15.1% of Asian/Pacific Islander, 14.2% of non-Hispanic Black, and 13.0% of Hispanic women. Infant SGA prevalence was 2.4% and 1.6% among non-Hispanic Black and White women, respectively (aRR 1.52, 95% CI 1.40-1.64). This disparity persisted across stratified analyses, particularly among non-Hispanic Black versus White women with a preeclampsia or hypertension diagnosis in pregnancy (RR 1.96, 95% CI 1.67-2.29) and those aged 35 + years at infant birth (RR 2.04, 95% CI 1.56-2.67). CONCLUSIONS FOR PRACTICE: In multiple assessments of PNC utilization and infant SGA, non-Hispanic Black military women had consistently worse outcomes than their non-Hispanic White counterparts. This suggests that equal access to health care does not eliminate racial disparities in outcomes or utilization; additional research is needed to elucidate the underlying etiology of these disparities.

Second-Trimester Fetal Loss in a Patient With Hyperemesis Gravidarum Complicated by Refeeding Syndrome.

BACKGROUND: Refeeding syndrome is a rare constellation of electrolyte abnormalities after reintroduction of glucose during an adaptive state of starvation and malnutrition, resulting in fluid shifts, end-organ damage, and, potentially, death. We present a case of fetal death in a patient with hyperemesis gravidarum complicated by refeeding syndrome. CASE: A 32-year-old obese, multigravid patient was admitted at 16 weeks of gestation with hyperemesis gravidarum and laboratory abnormalities concerning for refeeding syndrome after consuming a sugar-rich beverage. She was admitted to the hospital for electrolyte and fluid repletion; however, on hospital day 2, fetal death was diagnosed. CONCLUSION: Refeeding syndrome is a potentially fatal complication of hyperemesis gravidarum. Caution should be taken when reintroducing glucose during prolonged states of malnutrition to prevent the development of refeeding syndrome.

Postpartum herpes simplex virus endometritis and disseminated infection in both mother and neonate.

BACKGROUND: Herpes simplex virus (HSV) is an unusual cause of postpartum endometritis. We describe a rare case of primary disseminated maternal HSV in the postpartum period associated with endometritis. CASE: A previously healthy patient developed fundal tenderness and postpartum fevers after an uncomplicated vaginal delivery. Despite traditional broad-spectrum antimicrobial therapy, she had persistent fevers and systemic symptoms. Concurrently, her neonate developed fevers and a nonvesicular rash, with viral cultures ultimately returning positive for HSV. The patient developed active pharyngeal and genital herpetic lesions and was diagnosed with HSV endometritis and disseminated HSV. Symptoms and fevers in both the mother and neonate responded to antiviral therapy. CONCLUSION: Herpes simplex virus endometritis should be included in the differential diagnosis for postpartum fevers and fundal tenderness that are unresponsive to broad-spectrum antimicrobial treatment.