Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.

BACKGROUND: Retained sponges (gossypiboma) following vaginal delivery are an uncommon occurrence. Although significant morbidity from such an event is unlikely, there are many reported adverse effects, including symptoms of malodorous discharge, loss of confidence in providers and the medical system, and legal claims. OBJECTIVE: To report a protocol intended to reduce the occurrence of retained sponges following vaginal delivery. METHODS: After identification of limitations with existing delivery room protocols, we developed a sponge count protocol to reduce occurrence of retained vaginal sponges. We report our experience at Naval Medical Center Portsmouth, a large tertiary care military treatment facility with our efforts to implement a sponge count protocol to reduce retained sponges following vaginal delivery. CONCLUSIONS: With appropriate pre-implementation training, protocols which incorporate post-delivery vaginal sweep and sponge counts are well accepted by the health care team and can be incorporated into the delivery room routine.

Concurrent interstitial ectopic pregnancy and appendicitis: a case report.

BACKGROUND: Concurrent ectopic pregnancy and acute appendicitis is rarely encountered. Since 1960, only 22 cases have been reported. No case of concurrent interstitial ectopic pregnancy and appendicitis has ever been reported. CASE: A 24-year-old, African American woman, gravida 4, para 3, had a right interstitial ectopic pregnancy. She was managed as an inpatient with parenteral methotrexate and her beta-human chorionic gonadotropin level decreased appropriately. She was discharged 3 days after treatment but subsequently returned with right lower quadrant pain, nausea, vomiting and fever. The patient underwent laparoscopy with removal of a suppurative appendix. A stable interstitial ectopic pregnancy was visualized and left in situ. CONCLUSION: The discipline to consider concomitant abdominal pathology is paramount. The perceived rarity of an ectopic pregnancy and appendicitis should not obscure a thorough clinical evaluation.

Anorectal symptoms in pregnancy and the postpartum period.

OBJECTIVE: To determine the frequency of anorectal complaints in nulliparous, pregnant women before and after delivery. STUDY DESIGN: This was a prospective, observational study. Nulliparous, pregnant women attending an active-duty prenatal clinic completed a 6-item anorectal symptom questionnaire that assessed anal continence and defecatory symptoms. RESULTS: Seventy-five active-duty, nulliparous women completed 158 questionnaires. Anorectal symptoms were reported both antepartum (AP) and postpartum (PP): straining to defecate (AP: 28-59%; PP: 30%), hard or lumpy stools (AP: 48-59%; PP: 66%), incomplete emptying (AP: 38-53%; PP: 38%), uncontrolled loss of gas or stool from the rectum (AP: 18-29%; PP: 15%), unpreventable soilage of underwear (AP: 15-33%; PP: 13%) and splinting (AP: 3-9%; PP: 9%). Constipation symptoms were reported most frequently in the first trimester (p = 0.031) and anal incontinence most often in the third trimester but loss of gas or stool "often" more in the postpartum period (p = 0.027). Anal incontinence was more frequent in women who delivered by forceps (p = 0.007). CONCLUSION: Anorectal symptoms are common both during pregnancy and in the postpartum period. Anal incontinence is reported more frequently in women who delivered by forceps.

Pelvic organ support in pregnancy and postpartum.

The purpose of this study was to evaluate pelvic organ support during pregnancy and following delivery. This was a prospective observational study. Pelvic organ prolapse quantification (POPQ) examinations were performed during each trimester of pregnancy and in the postpartum. Statistical comparisons of POPQ stage and of the nine measurements comprising the POPQ between the different time intervals were made using Wilcoxon's signed rank and the paired t-test. Comparison of POPQ stage by mode of delivery was made using Fisher's exact test. One hundred thirty-five nulliparous women underwent 281 pelvic organ support evaluations. During both the third trimester and postpartum, POPQ stage was significantly higher compared to the first trimester (p<0.001). In the postpartum, POPQ stage was significantly higher in women delivered vaginally compared to women delivered by cesarean (p=0.02). In nulliparous pregnant women, POPQ stage appears to increase during pregnancy and does not change significantly following delivery. In the postpartum, POPQ stage may be higher in women delivered vaginally compared to women delivered by cesarean.

An active duty woman with anal incontinence after vaginal delivery: an elusive diagnosis.

Anal sphincter injury as a result of birth trauma is the leading cause of fecal incontinence in women presenting to surgical clinics. A 36-year-old active duty woman was referred to the Urogynecology Clinic at Madigan Army Medical Center for evaluation of a deficient perineal body. She reluctantly reported a 12-year history of anal incontinence since the birth of her first child, predating her entry into the naval service. Examination revealed defects of the perineum and anal sphincter resembling a cloacal deformity. Uncomplicated overlapping anal sphincteroplasty and perineorrhaphy were performed, restoring perineal anatomy and continence. Anal incontinence and other anatomic defects attributable to lacerations sustained at childbirth may go undetected during routine screening examinations. Interview and examination techniques should be emphasized in primary care settings.

Pelvic organ support in nulliparous pregnant and nonpregnant women: a case control study.

OBJECTIVE: Our purpose was to compare pelvic organ support in nulliparous pregnant and nonpregnant women at a single institution. STUDY DESIGN: This was a case-control study. Pregnant patients and nonpregnant control subjects were matched according to age and race. Subjects underwent pelvic organ support evaluation by use of the pelvic organ prolapse quantification (POPQ) examination as part of routine prenatal or gynecologic care. The Pearson chi(2) statistic was used for statistical analysis, with a P value of 5% set for significance. RESULTS: A total of 21 pregnant and 21 nonpregnant nulliparous women between the ages of 18 and 29 years were included. All patients in the nonpregnant group had a POPQ stage of 0 or 1, whereas 47.6% of the pregnant subjects had POPQ stage 2 (P <.001). Individual components of the POPQ examination were compared. Significant differences were noted for points Aa and Ba, Ap and Bp, and PB and TVL. CONCLUSIONS: In nulliparous women, pregnancy is associated with increased POPQ stage compared with nonpregnant control subjects.