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IMPORTANCE: Knowledge on the interpregnancy interval (IPI) among women with an obstetric anal sphincter injury (OASI) is both limited and not well understood. OBJECTIVES: The objectives of this study were to describe the IPI among women with OASI and to compare women with OASI based on the route of subsequent obstetric delivery and OASI recurrence. STUDY DESIGN: This was a retrospective single-cohort study of women who had an OASI between 2013 and 2015 at a tertiary academic medical center. Demographics, obstetric delivery data, postpartum sequelae, and subsequent pregnancy delivery data from 2013 to 2021 were collected. The IPI was defined as the time from date of first vaginal delivery to date of conception of the subsequent pregnancy. Women without a subsequent pregnancy were censored at the date of last contact. The IPI was evaluated using a survival analysis (Kaplan-Meier estimator). RESULTS: A total of 287 women experienced an OASI, and subsequent pregnancy occurred for 178 (62.0%) women. The median IPI was 26.4 months (95% confidence interval: 23.7-29.9) for women with a prior OASI. Of the 97 women who did not have a subsequent pregnancy documented during the study, the median follow-up was 64.0 months (interquartile range: 5.7-80.0). Subsequent delivery route data were available for 171 women; of those, 127 (74.3%) experienced a subsequent vaginal delivery and 44 (25.7%) experienced a cesarean delivery. Of the 127 women who experienced a subsequent vaginal delivery, 3 (2.4%) experienced a recurrent OASI. CONCLUSION: The IPI among women with OASI is similar to the IPI for all women in Ohio and in the United States.
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IMPORTANCE: This study identifies how neighborhood-level socioeconomic status (SES) may affect patients' treatment decisions for pelvic organ prolapse (POP). OBJECTIVE: This study aimed to evaluate the association of neighborhood-level SES with the decision of surgical versus conservative POP management. STUDY DESIGN: This was a retrospective cohort study of patients newly diagnosed with POP at a tertiary medical center between 2015 and 2021. Patients lost to follow-up or poor surgical candidates were excluded. Patient characteristics, demographics, and treatment selection were abstracted from the electronic health record. Conservative management was defined as expectant, pessary, and/or pelvic floor physical therapy. Five-digit zip codes were linked to the Area Deprivation Index and used as a surrogate for neighborhood-level SES. Area Deprivation Indices were dichotomized at or below the sample median (less disadvantaged area) and above the sample median (more disadvantaged area). Logistic regression models estimated the odds of choosing surgical versus conservative management as a function of the Area Deprivation Index. RESULTS: A total of 459 patients met the eligibility criteria (non-Hispanic White, 88.2%). The median age was 63 years (interquartile range, 52-70 years), and the majority had stage 2 POP (65.7%). Of all patients, 59.3% had Medicare/Medicaid, 39.9% were privately insured, and 0.9% were uninsured. Furthermore, 74.7% selected surgical management, and 25.3% chose conservative management. Increasing age and higher Pelvic Organ Prolapse Quantification System stage were significantly associated with selecting surgery (P = 0.01). Women residing in a more disadvantaged area had a 67% increased odds of choosing surgical over conservative management (adjusted odds ratio, 1.67; 95% confidence interval, 1.06-2.64) after adjusting for age, race/ethnicity, body mass index, and Pelvic Organ Prolapse Quantification System stage. CONCLUSIONS: Residing in a more disadvantaged zip code was associated with 67% increased odds of choosing surgical versus conservative POP management.
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Medicare , Prolapso de Órgano Pélvico , Femenino , Humanos , Anciano , Estados Unidos , Persona de Mediana Edad , Estudios Retrospectivos , Etnicidad , Clase Social , Prolapso de Órgano Pélvico/epidemiologíaRESUMEN
PURPOSE OF REVIEW: The aim of this study was to describe the common postpartum urinary sequelae including urinary retention and incontinence, and to summarize the management of these conditions. RECENT FINDINGS: Despite the high frequency of urinary disorders in obstetrics, screening and management protocols are rarely utilized by providers. Large variation exists in the literature regarding assessment of postpartum urinary retention, values of postvoid residuals and management of indwelling catheters in the immediate postpartum population. Recent expert guidance outlines a strategy for managing this condition.Research also highlights that screening for peripartum urinary incontinence is not a routine practice. The diagnosis is made more challenging by the fact that patients commonly understate and over-normalize their symptoms. Emerging studies have found that pelvic floor muscle training is cost-effective, preventive, and may improve symptoms in the postpartum setting. SUMMARY: Increased awareness of urinary disorders in pregnancy and postpartum is imperative for appropriate diagnosis and management. Instituting standardized voiding protocols postpartum will allow providers to avoid undiagnosed postpartum urinary retention and its repercussions. Improved screening and education regarding urinary incontinence in the peripartum is important for early management, such as pelvic floor muscle training, and improved quality of life.
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Trastornos del Suelo Pélvico , Incontinencia Urinaria , Retención Urinaria , Femenino , Humanos , Terapia por Ejercicio/métodos , Diafragma Pélvico , Periodo Posparto/fisiología , Calidad de Vida , Incontinencia Urinaria/diagnóstico , Incontinencia Urinaria/etiología , Incontinencia Urinaria/terapia , Retención Urinaria/diagnóstico , Retención Urinaria/etiología , Retención Urinaria/terapiaRESUMEN
IMPORTANCE: Sexual dysfunction, which is common in the postpartum period, often does not resolve by 6 months and is likely more severe in women with severe obstetric lacerations. OBJECTIVES: The aims are to describe sexual function at 6 months postpartum in women who experienced obstetric anal sphincter injury (OASI) and to compare sexual function between women with mild and severe OASI. STUDY DESIGN: This is a prospective cohort study of women with OASI. At 6 months postpartum, women were surveyed regarding sexual function using the Postpartum Pelvic Floor Birth Questionnaire, which compares current sexual function to sexual function before vaginal birth. RESULTS: One hundred fifty-one women were included. Eighty-one (53.6%) women had spontaneous vaginal delivery, and 70 (46.4%) had operative vaginal delivery. One hundred seventeen (77.5%) experienced a mild OASI, and 34 (22.5%) experienced a severe OASI. On the Postpartum Pelvic Floor Birth Questionnaire sexual activity domain, median score for all women was 2.6 (interquartile range, 2.1-3.0) with scores <3.0, indicating worse functioning. The sexual activity domain median scores were 2.4 (1.9-3.0) for mild OASI and 2.8 (2.6-3.0) for severe OASI ( P = 0.011), indicating worse scores for women with mild OASI. Within the sexual activity domain, women with mild OASI had worse median scores than women with severe OASI when reporting on enjoyment of sexual activity, frequency of intercourse, and enjoyment during sexual intercourse. CONCLUSIONS: Women who experience OASI have worse sexual function compared with predelivery. Discussion of sexual function is critical for postpartum women, especially for those who are at increased risk after experiencing OASI.
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Canal Anal , Parto Obstétrico , Embarazo , Femenino , Humanos , Masculino , Canal Anal/lesiones , Estudios Prospectivos , Parto Obstétrico/efectos adversos , Periodo Posparto , CoitoRESUMEN
Postpartum urinary retention is a relatively common condition that can have a marked impact on women in the immediate days following childbirth. If left untreated, postpartum urinary retention can lead to repetitive overdistention injury that may damage the detrusor muscle and the parasympathetic nerve fibers within the bladder wall. In rare circumstances, postpartum urinary retention may even lead to bladder rupture, which is a potentially life-threatening yet entirely preventable complication. Early diagnosis and timely intervention are necessary to decrease long-term consequences. There are 3 types of postpartum urinary retention: overt, covert, and persistent. Overt retention is associated with an inability to void, whereas covert retention is associated with incomplete bladder emptying. Persistent urinary retention continues beyond the third postpartum day and can persist for several weeks in rare cases. Recognition of risk factors and prompt diagnosis are important for proper management and prevention of negative sequelae. However, lack of knowledge by providers and patients alike creates barriers to accessing and receiving evidence-based care, and may further delay diagnosis for patients, especially those who experience covert postpartum urinary retention. Nationally accepted definitions and management algorithms for postpartum urinary retention are lacking, and development of such guidelines is essential for both patient care and research design. We propose intrapartum recommendations and a standardized postpartum bladder management protocol that will improve patient outcomes and contribute to the growing body of evidence-based practice in this field.
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Retención Urinaria , Embarazo , Humanos , Femenino , Retención Urinaria/diagnóstico , Retención Urinaria/etiología , Retención Urinaria/terapia , Vejiga Urinaria , Periodo Posparto , Parto Obstétrico/efectos adversos , Parto , Cateterismo Urinario/métodosRESUMEN
OBJECTIVE: To evaluate the role of antibiotics on preventing wound complications following obstetric anal sphincter injuries (OASI). METHODS: This is a cohort study with retrospective and prospective components of women who sustained an OASI at vaginal delivery. The primary objective of this study was to assess the impact of prophylactic antibiotics at the time of delivery on perineal wound complications. Women were grouped based on peripartum antibiotic administration: no antibiotics (NABX), antibiotics for OASI wound complication prophylaxis (PABX), antibiotics for therapeutic indications (TABX), and antibiotics for any indication (AABX, PABX + TABX). RESULTS: Four hundred and twenty-five women with OASI were included in this analysis. Most women experienced a third-degree perineal laceration (358, 84.2%). One hundred and sixteen (27.3%) women received NABX, 195 (45.9%) women received PABX, and 114 (26.8%) women received TABX. Cefazolin was the most common antibiotic in the PABX group. Perineal wound complications occurred in 51 (12.0%) women: 14 (12.4%) in NABX, 26 (13.3%) in PABX, 11 (9.6%) in TABX, and 37 (12.0%) in AABX. The incidence of perineal wound complications did not differ between groups. CONCLUSIONS: In this cohort study, peripartum antibiotics did not reduce wound complication incidence following OASI. It is likely that a first-generation cephalosporin is not the ideal antibiotic in this clinical setting.
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Laceraciones , Complicaciones del Trabajo de Parto , Embarazo , Femenino , Humanos , Masculino , Antibacterianos/uso terapéutico , Canal Anal/lesiones , Estudios Retrospectivos , Estudios de Cohortes , Estudios Prospectivos , Periodo Periparto , Parto Obstétrico/efectos adversos , Complicaciones del Trabajo de Parto/epidemiología , Perineo/lesiones , Laceraciones/epidemiología , Factores de RiesgoRESUMEN
IMPORTANCE: Data on the incidence of pelvic organ prolapse (POP)-related pain, risk factors for its development, and treatment effects of surgery remain sparse. OBJECTIVES: The aims of the study were to evaluate the incidence and characteristics of POP-related pain in patients presenting with POP and assess the outcome of pain after surgery. STUDY DESIGN: This was a retrospective study of patients presenting for initial evaluation of POP from May 2019 to May 2020. Using a standardized questionnaire, patients were asked "Do you have pain associated with your prolapse (not pressure or fullness)?" and to indicate pain severity and location(s). Patients who underwent surgery were asked postoperatively if their POP-related pain resolved. Patient and perioperative characteristics were obtained from the medical record and used to evaluate relationships between the presence and resolution of POP-related pain. RESULTS: Of the 795 patients who met inclusion criteria, 106 (13.3%) reported POP-related pain. The mean age of all patients was 59.9 years, 38.1% had stage 3 or greater POP, and 52.1% were sexually active. Women with POP-related pain reported a median severity of 5 of 10. The most common pain locations were the vagina (46.6%), lower abdomen (27.4%), and back (9.6%). Fifty-seven women with pain (53.8%) underwent surgery, and 40 (70.2%) reported postoperative pain resolution. Of those who did not have resolution, pain improved or remained stable in severity. No patients reported worsening pain after surgery. CONCLUSIONS: Pain is a symptom experienced by more than 1 in 8 women presenting with POP, with 70% reporting resolution of their pain postoperatively.
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INTRODUCTION AND HYPOTHESIS: Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery. METHODS: A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members. RESULTS: All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs. CONCLUSIONS: The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.
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Antieméticos , Alcaloides Opiáceos , Femenino , Humanos , Estados Unidos , Goma de Mascar , Fibrinolíticos , Escritura , Antibacterianos , DexametasonaRESUMEN
IMPORTANCE: Postpartum urinary retention (PUR) is a multifactorial condition that requires a high degree of clinical suspicion for timely diagnosis and proper intervention. OBJECTIVES: The aims of the study are to describe PUR incidence and to compare natural history, obstetric characteristics, and associated risk factors for protracted PUR (extending ≥3 days postpartum) versus PUR. STUDY DESIGN: This is a retrospective cross-sectional study of women who underwent an obstetric delivery over 24 months at an academic institution. International Classification of Diseases, Tenth Revision, codes were used to identify PUR. Patient characteristics, obstetric delivery data, and peripartum care surrounding delivery were collected. A P value of 0.05 or less was significant. RESULTS: Between January 1, 2018, and December 31, 2019, there were 23,844 deliveries (vaginal and cesarean section) and 77 patients (0.32%) experienced PUR. Within this group, 12 (0.05%) experienced protracted PUR. Patients with protracted PUR had a significantly later postpartum diagnosis day (median 1 [interquartile range, 1-2] vs 1 [0-1], P = 0.004), longer time to retention onset (22.0 [10.7-37.0] vs 10.7 [7.9-19.4] hours, P = 0.03), and greater retention duration (12.5 [5.5-17.0] vs 1.0 [0.0-1.0] days, P < 0.001) compared with those with PUR. There were no significant differences in patient or delivery characteristics for those delivering vaginally between the groups. CONCLUSIONS: Protracted PUR is rare, occurring in 0.05% of deliveries. Women with protracted PUR were more likely to have a greater onset time, later diagnosis date, and longer retention duration, out to 47 days, compared with women with PUR resolution before postpartum day 3.
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Trastornos Puerperales , Retención Urinaria , Humanos , Femenino , Embarazo , Retención Urinaria/epidemiología , Cesárea/efectos adversos , Estudios Retrospectivos , Incidencia , Trastornos Puerperales/diagnóstico , Estudios Transversales , Periodo Posparto , Factores de RiesgoRESUMEN
INTRODUCTION AND HYPOTHESIS: Subspecialty peripartum pelvic floor disorder (PFD) clinics provide care to a unique patient population. We aim to describe the experiences of such a clinic in the first 36 months after its establishment. METHODS: This is a descriptive case series of all women who presented to a subspecialty PFD clinic at an academic medical center over 36 months (January 2018-December 2020). Patient characteristics, referral patterns, and care plans will be described. RESULTS: Four hundred eighty-three women presented for care. Women were a mean age of 31.0 ± 4.2 years, most were primiparous (404, 83.6%), and over half (279, 57.8%) had a spontaneous vaginal delivery. Three hundred eighteen women (66.9%) had obstetric anal sphincter injury (OASI), which was also the primary referral indication in 313 (64.8%). Most consultations were from an obstetrician (246, 51.3%), and the median time from delivery to evaluation was 17 days (IQR 11.0-34.0). The majority of women had one additional follow-up visit (330, 68.3%). One hundred forty-one (29.9%) women underwent minor office procedures, and 26 (5.4%) underwent surgery. The number of referrals sequentially increased from year 1 (59, 12.2%) to year 3 (215, 44.5%). CONCLUSIONS: The 36-month experiences in our growing subspecialty peripartum PFD clinic demonstrate both sustainability and feasibility of this new service line, with consistent clinical growth over time and 483 new consultations, 2/3 of which were for OASI and the other 1/3 for a variety of peripartum pelvic floor indications. Our data outline a model for care, including timeline for follow-up, treatments administered, and number of interventions, both office and surgical.
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Incontinencia Fecal , Trastornos del Suelo Pélvico , Embarazo , Humanos , Femenino , Adulto , Masculino , Trastornos del Suelo Pélvico/terapia , Trastornos del Suelo Pélvico/epidemiología , Periodo Periparto , Diafragma Pélvico/lesiones , Canal Anal/lesiones , Parto Obstétrico/efectos adversos , Parto Obstétrico/métodos , Incontinencia Fecal/etiología , Incontinencia Fecal/terapia , Incontinencia Fecal/epidemiologíaRESUMEN
INTRODUCTION AND HYPOTHESIS: There is growing interest in and performance of uterine-preserving prolapse repairs. We hypothesized that there would be no difference in pelvic organ prolapse (POP) recurrence 2 years following transvaginal uterosacral ligament hysteropexy (USLH) and sacrospinous ligament hysteropexy (SSLH). METHODS: This is a retrospective cohort study with a cross-sectional survey of women who underwent transvaginal uterine-preserving POP surgery from May 2016 to December 2017. Patients were included if they underwent either USLH or SSLH. POP recurrence was defined as a composite of subjective symptoms and/or retreatment. A cross-sectional survey was used to assess pelvic floor symptoms and patient satisfaction. RESULTS: A total of 47 women met the criteria. Mean age was 52.8 ± 12.5 years, and all had a preoperative POP-Q stage of 2 (55.3%) or 3 (44.7%). Thirty (63.8%) underwent SSLH and 17 (36.2%) underwent USLH. There were no differences in patient characteristics or perioperative data. There was no difference in composite recurrence (26.7% [8] vs 23.5% [4]) and retreatment (6.7% [2] vs 0%) retrospectively between SSLH and USLH groups at 22.6 months. Survey response rate was 80.9% (38) with a response time of 30.7 (28.0-36.6) months. The majority of patients (84.2%) reported POP symptom improvement, and both groups reported great satisfaction (89.5%). In respondents, 13.2% (5) reported subjective recurrence and 5.3% (2) underwent retreatment, with no differences between hysteropexy types. There were no differences in other pelvic floor symptoms. CONCLUSIONS: Although 1 in 4 women experienced subjective POP recurrence after transvaginal uterine-preserving prolapse repair and <5% underwent retreatment at 2 years, our results must be interpreted with caution given our small sample size. No differences in outcomes were identified between hysteropexy types; however, additional studies should be performed to confirm these findings. Both hysteropexy approaches were associated with great patient satisfaction.
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Prolapso de Órgano Pélvico , Prolapso Uterino , Adulto , Anciano , Estudios Transversales , Femenino , Procedimientos Quirúrgicos Ginecológicos/métodos , Humanos , Persona de Mediana Edad , Prolapso de Órgano Pélvico/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Prolapso Uterino/cirugíaRESUMEN
Often considered a condition of aging women, pelvic floor disorders may initially present in pregnancy and postpartum, having a negative impact on quality of life during this important time in a woman's life. This review outlines the clinical approach to implementing pelvic health into obstetric care through education and promotion of pelvic health in pregnancy, screening for pelvic floor disorders routinely, and providing support through resources, treatment, and referrals if pelvic floor disorders develop during pregnancy and postpartum.
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Incontinencia Fecal , Trastornos del Suelo Pélvico , Parto Obstétrico , Femenino , Humanos , Trastornos del Suelo Pélvico/diagnóstico , Trastornos del Suelo Pélvico/terapia , Periodo Posparto , Embarazo , Calidad de VidaRESUMEN
OBJECTIVES: This study aimed to compare the incidence of adverse events and postoperative health care resource utilization, as well as to determine satisfaction in patients after a same-day discharge (SDD) protocol compared with routine care (discharge ≥postoperative day 1). METHODS: This is a prospective cohort study of SDD after minimally invasive sacrocolpopexy. Eligibility criteria included age younger than 80 years, American Society of Anesthesiologists grade I/II, caretaker for ≥24 hours postoperatively, and surgical start before 1 pm. Perioperative data were obtained through the medical record and direct patient inquiry. A satisfaction survey was administered at the postoperative visit. A historical control group was used to compare outcomes. RESULTS: Forty-seven women met the eligibility criteria. Mean age was 62 (±9) years. Most were White (95.7%), were overweight (body mass index, 27.7 ± 5.5 kg/m2), and had stage 3 prolapse (63.8%). Same-day discharge was achieved for 37 patients (78.7%). Patient characteristics of the SDD cohort were similar to the routine-care cohort, with the exception of previous hysterectomy (57.5% vs 100.0%, P < 0.001) and the American Society of Anesthesiologists score (2 [1-2] vs 2 [1-3], P = 0.002). There were significantly fewer postoperative telephone calls in the SDD cohort but no other differences in health care resource utilization. Adverse events did not differ between groups. The SDD cohort reported high satisfaction and would recommend SDD to family or friends independent of whether or not SDD was achieved (91.9% vs 80.0%, P = 0.29). CONCLUSIONS: Nearly 80% of women undergoing minimally invasive sacrocolpopexy on an SDD protocol went home as planned. Compared with routine care, there was no increase in adverse events or postoperative health care resource utilization. Patient satisfaction in the SDD cohort was high. CLINICAL TRIAL REGISTRATION: Same-day discharge after minimally invasive sacrocolpopexy, https://clinicaltrials.gov/ct2/show/NCT03730103?term=same+day+discharge&cntry=US&state=US%3AOH&city=Cleveland&draw=2&rank=1; NCT03730103.
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Recuperación Mejorada Después de la Cirugía , Tiempo de Internación , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Prolapso de Órgano Pélvico/cirugía , Anciano , Estudios de Casos y Controles , Femenino , Humanos , Persona de Mediana Edad , Satisfacción del Paciente , Complicaciones Posoperatorias/etiología , Cuidados Preoperatorios/métodos , Estudios ProspectivosRESUMEN
INTRODUCTION AND HYPOTHESIS: The objective of this study is to evaluate obstetric providers' knowledge and practice patterns since the establishment of a peripartum pelvic floor disorder clinic. METHODS: This is a prospective, cross-sectional survey study of obstetric providers at an academic tertiary care health system. A 22-question survey was designed to collect provider demographic data, indications for and barriers to referrals, provider satisfaction, and impact of the clinic's existence on peripartum pelvic floor dysfunction diagnosis and management. Eligibility criteria included obstetrics and gynecology trainees, attending physicians, certified nurse midwives, and advanced practice providers. RESULTS: There were 86 survey responses yielding a response rate of 72.1%. The majority of respondents were staff obstetricians (57.0%) or trainees (26.7%). Most commonly reported referral indications were third- and fourth-degree lacerations (94.9%), complex lacerations (70.5%), wound breakdown (57.7%), and urinary retention (53.8%). Regarding satisfaction with the peripartum pelvic floor disorder clinic, of referring providers, 77 (98.7%) agreed or strongly agreed that evaluations were useful for patients and 78 (100%) agreed or strongly agreed that evaluations were useful for themselves. Seventy-six (97.4%) respondents reported that they were very satisfied with the peripartum pelvic floor disorder clinic overall. The majority of respondents agreed or strongly agreed that the clinic increased their awareness of both obstetric anal sphincter injuries and their impact on maternal health (84.6%). CONCLUSION: The introduction of a peripartum pelvic floor disorder clinic results in high obstetric provider satisfaction and positively impacts patient care through increased provider knowledge and awareness on the management of obstetric anal sphincter injuries.
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Incontinencia Fecal , Trastornos del Suelo Pélvico , Canal Anal , Estudios Transversales , Parto Obstétrico , Incontinencia Fecal/etiología , Incontinencia Fecal/terapia , Femenino , Humanos , Trastornos del Suelo Pélvico/terapia , Periodo Periparto , Embarazo , Estudios ProspectivosRESUMEN
Obstetrical perineal and anal sphincter lacerations can be associated with considerable sequelae. The diagnosis of short-term bowel, bladder, and healing problems can be delayed if patients are not seen until the traditional postpartum visit at 4 to 6 weeks. Specialized peripartum clinics create a unique opportunity to collaborate with obstetrical specialists to provide early, individualized care for patients experiencing a variety of pelvic floor issues during pregnancy and in the postpartum period. Although implementation of these clinics requires thoughtful planning and partnering with care providers at all levels in the obstetrics care system, many of the necessary resources are available in routine gynecologic practice. Using a multidisciplinary approach with pelvic floor physical therapists, nurses, advanced practice providers, and other specialists is important for the success of this service line and enhances the level of care provided. Overall, these clinics provide a structured means by which pregnant and postpartum women with pelvic floor symptoms can receive specialized counseling and treatment.
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Canal Anal/lesiones , Laceraciones/terapia , Obstetricia , Trastornos del Suelo Pélvico/terapia , Modalidades de Fisioterapia , Atención Posnatal/organización & administración , Atención Prenatal/organización & administración , Parto Obstétrico/efectos adversos , Dispareunia/terapia , Incontinencia Fecal/terapia , Femenino , Humanos , Laceraciones/etiología , Grupo de Atención al Paciente , Diafragma Pélvico/lesiones , Trastornos del Suelo Pélvico/etiología , Prolapso de Órgano Pélvico/terapia , Dolor Pélvico/terapia , Perineo/lesiones , Periodo Periparto , Embarazo , Derivación y Consulta , Incontinencia Urinaria/terapiaRESUMEN
Obstetric anal sphincter injuries represent the minority of obstetric lacerations, but can have a significant long-term impact on urinary and fecal continence, as well as pelvic organ support. Accurate diagnosis of lacerations, appropriate repair, and close follow-up are essential to healthy healing and to improve outcomes for women. The infrequency of these injuries has resulted in a lack of familiarity with laceration repair and postpartum care of this population at all levels of practice. As such, continuing education strategies aimed at simulation, increased clinical exposure to anal sphincter injuries, and evidence-based repair techniques are important for mitigating the deficits in the current obstetric environment. Ensuring that patients have access to timely multidisciplinary postpartum care and education on the laceration incurred is essential to promote healthy healing and to optimize pelvic floor outcomes.
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Canal Anal/lesiones , Competencia Clínica , Laceraciones/diagnóstico , Laceraciones/cirugía , Complicaciones del Trabajo de Parto/diagnóstico , Complicaciones del Trabajo de Parto/cirugía , Obstetricia/educación , Parto Obstétrico/métodos , Episiotomía , Incontinencia Fecal , Femenino , Humanos , Diafragma Pélvico/lesiones , Perineo/lesiones , Atención Posnatal , Embarazo , Fístula Rectovaginal , Entrenamiento SimuladoRESUMEN
INTRODUCTION AND HYPOTHESIS: While pelvic organ prolapse (POP) recurrence is believed to increase over time, outcomes of young women who undergo POP surgery are unclear. We hypothesized POP recurrence incidence among women <49 years would be higher after vaginal versus abdominal colpopexy. METHODS: This is a retrospective cohort study with a cross-sectional survey of women 18-49 years who underwent primary POP surgery from January 2003 to September 2013. Patients were identified by CPT codes for vaginal and abdominal colpopexy. POP recurrence was defined as vaginal bulge symptoms, POP retreatment (pessary or surgery) or both. Validated questionnaires were used to assess pelvic floor symptoms, patient satisfaction and improvement. RESULTS: Three hundred thirty-three women met the criteria. Mean age was 43 (+ 5.3) years; 29.1% (97) had an abdominal colpopexy and 70.9% (236) had a vaginal colpopexy. The recurrence incidence overall was 32.0% (31) in the abdominal group and 24.2% (57) in the vaginal group (p = 0.15), with a 10.3% (10) retreatment incidence in the abdominal group and 5.9% (14) in the vaginal group (p = 0.16). Forty-five percent (149) responded to the survey at a median time of 7.9 (3.1-15.2) years since surgery. The overall recurrence incidence in respondents was 13.7% (7) in the abdominal group and 15.3% (15) in the vaginal group (p = 0.80), with a retreatment incidence of 5.9% (3) in the abdominal and 5.2% (5) in the vaginal group (p = 0.85). CONCLUSIONS: One in four young women experienced subjective POP recurrence and/or retreatment, but only 5-10% underwent retreatment. There does not appear to be a difference in the incidence of recurrence between vaginal and abdominal colpopexy.
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Prolapso de Órgano Pélvico , Adulto , Estudios Transversales , Femenino , Humanos , Prolapso de Órgano Pélvico/epidemiología , Prolapso de Órgano Pélvico/cirugía , Pesarios , Estudios Retrospectivos , Resultado del Tratamiento , Vagina/cirugíaRESUMEN
PURPOSE: To evaluate the general knowledge of female graduate students on reproductive aging and fertility preservation options, as well as to investigate the perceptions, personal beliefs, and desires regarding fertility and preservation modalities. MATERIALS AND METHODS: A cross-sectional online survey study of female graduate students and medical trainees from academic institutions in Ohio was performed. Women were excluded if the online survey was incomplete or if they were >45 years. RESULTS: Analysis of 590 surveys was performed (response rate of 26.3%). Ninety-four percent (557/590) of subjects were between 20 and 35 years. Our respondents tended to be nulliparous (87%), married or in a relationship (51%) and interested in future fertility (77%). The reasons cited for delaying childbearing were multi-factorial, with career building noted most commonly (69%). Nearly 60% of women reported they would consider fertility preservation in the future; however, the majority (87%) cited two or more barriers. When asked about their desire for information on fertility preservation, 28% desired to receive education on their choices and 36% wanted their Ob/Gyn to discuss fertility preservation options. Women >30 years were significantly more likely to desire future fertility, want more fertility preservation education and consider pursuing fertility preservation in the future. CONCLUSIONS: Graduate-level women often delay childbearing for professional pursuits. This study demonstrates a need for increased fertility preservation awareness and education, especially by Ob/Gyn providers.
Asunto(s)
Preservación de la Fertilidad/psicología , Fertilidad , Conocimientos, Actitudes y Práctica en Salud , Estudiantes/psicología , Adulto , Actitud del Personal de Salud , Estudios Transversales , Femenino , Humanos , Ohio , Encuestas y Cuestionarios , Universidades , Adulto JovenRESUMEN
PURPOSE: To evaluate the available randomized controlled trials (RCTs) in the literature investigating the use of gonadotropin-releasing hormone agonist (GnRHa) co-treatment for ovarian preservation in women receiving chemotherapy. METHODS: A systematic review of the literature was performed from 1960 through 2017 to identify relevant RCTs. Included patients had lymphoma, ovarian cancer, or breast cancer. The primary outcome was the proportion of women who retained ovarian function after chemotherapy. Extracted data points included study design, patient characteristics, and proportion of women who developed premature ovarian failure (POF). A risk of bias assessment was performed according to the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. The pooled odds ratio was calculated, and outcomes of individual studies were compared using the random-effects model with the inverse-variance method and the DerSimonian-Laird estimator. RESULTS: Twenty-nine RCTs were identified, and 10 met criteria for inclusion in the meta-analysis. An analysis of patients who did not develop POF after chemotherapy revealed eight studies supporting the use of GnRHa (OR 1.83; 95% CI 1.34-2.49). The duration of benefit of GnRHa is unclear. An analysis of three studies with outcome data at 2 years revealed a non-significant OR of 0.53 (95% CI 0.22-1.30) for the preservation of ovarian function with GnRHa treatment. CONCLUSION: GnRHa may have a protective effect against the development of POF after gonadotoxic chemotherapy; however, the duration of benefit is unclear and requires further study.
Asunto(s)
Antineoplásicos/efectos adversos , Hormona Liberadora de Gonadotropina/análogos & derivados , Hormona Liberadora de Gonadotropina/agonistas , Gónadas/fisiología , Neoplasias/tratamiento farmacológico , Insuficiencia Ovárica Primaria/prevención & control , Femenino , Hormona Liberadora de Gonadotropina/uso terapéutico , Gónadas/efectos de los fármacos , Humanos , Metaanálisis como Asunto , Embarazo , Insuficiencia Ovárica Primaria/inducido químicamente , Resultado del TratamientoRESUMEN
OBJECTIVE: The aim of this study was to describe the relationship of the uterosacral ligament (USL) to the ureter and rectum along a surgeon's target location for suture placement under conditions simulating live surgery. METHODS: Dissections were performed in 11 unembalmed female cadavers. Steps were taken to identify the USL simulating USL colpopexy. Pins were placed in the midportion of the USL at the level of the IS, and at 1-cm, 2-cm, and 3-cm increments traveling proximally toward the sacrum (Fig. 1). We measured minimum distances from the USL to the ureter and rectum at each target location. RESULTS: In general, the ureters range from 1.3 to 2.0 cm lateral to the USLs along the target length. The rectum ranges from 1.9 to 2.6 cm from the right USL and remains 1.5 cm from the left USL. The mean change in distance between the ureter and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% confidence interval [CI], 0.19-0.24) on the right and 0.2 cm (95% CI, 0.18-0.27) on the left. The mean change in distance between the rectum and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% CI, 0.19-0.24) on the right and 0.0 cm (95% CI, 0-0) on the left. CONCLUSIONS: For every centimeter traveled along the bilateral USLs from the IS toward the sacrum, the ureter moves 0.2 cm laterally away from the ligament, the rectum moves 0.2 cm medially away from the right USL, but maintains its position from the left USL.