BRIEF COMMUNICATIONS Table 1 Laboratory indices of hemoglobin and hematocrit, and total blood loss.a Indicator
Group 1 (n = 400)b
Group 2 (n = 400)c
P value
Hemoglobin level before labor, g/L Hemoglobin level after labor, g/L Hematocrit level before labor,% Hematocrit level after labor,% Total blood loss, mL
115 113 36.5 34.9 200
116 115 36.7 35.4 200
0.115 0.771 0.079 0.035 0.356
a b c
(108–124) (105–122) (34.1–38.8) (32.05–37.4) (150–280)
(110–124) (106–122) (35–39) (32.6–38) (150–250)
Values are given as median (interquartile range). Active management of the third stage of labor with controlled cord traction. Active management of the third stage of labor without controlled cord traction.
85
In the present study, the absence of CCT did not have a significant effect on volume of blood loss in the third stage of labor; postpartum hemoglobin levels; or frequency of PPH, blood transfusion, use of additional uterotonics, manual removal of the placenta, or additional surgical procedures. However, patients who underwent the full package of AMTSL, which included CCT, had a significantly lower hematocrit level after labor compared with women who did not undergo CCT. Conflict of interest The authors have no conflicts of interest. References
2.5% in both groups. Manual removal of the placenta occurred in only 1.7% of women in group 1 and 2.8% of women in group 2 (P = 0.340). Blood transfusion and additional surgical procedures were required for 1 woman in group 1, and 2 women in group 2 (P=0.563). Hysterectomy and ligation of vessels were not performed. There was a significant reduction in hematocrit and hemoglobin levels after labor in both groups (P b 0.0001). Hematocrit levels in group 1 were significantly lower after labor than those in group 2 (P = 0.035). There were no significant differences between the groups in hemoglobin level after labor.
[1] Begley CM, Gyte GM, Murphy DJ, Devane D, McDonald SJ, McGuire W. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2010;7:CD007412. [2] WHO. Recommendations for the Prevention of Postpartum Hemorrhage. Geneva: WHO; 2007. [3] Gülmezoglu AM, Lumbiganon P, Landoulsi S, Widmer M, Abdel-Aleem H, Festin M, et al. Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. Lancet 2012;379(9827):1721–7. [4] Miranda JE, Rojas-Suarez J, Paternina A, Mendoza R, Bello C, Tolosa JE. The effect of guideline variations on the implementation of active management of the third stage of labor. Int J Gynecol Obstet 2013;121(3):266–9.
0020-7292/$ – see front matter © 2013 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. http://dx.doi.org/10.1016/j.ijgo.2013.07.028
Rectal injury following delivery as a possible consequence of endometriosis of the rectovaginal septum Erika Menzlova a, Josef Zahumensky b,⁎, Robert Gürlich c, Eduard Kucera b a b c
Department of Gynecology and Obstetrics, First Medical Faculty, Charles University and Bulovka Hospital, Prague, Czech Republic Department of Gynecology and Obstetrics, Third Medical Faculty, Charles University, Prague, Czech Republic Department of Surgery, Third Medical Faculty, Charles University, Prague, Czech Republic
a r t i c l e
i n f o
Article history: Received 22 May 2013 Received in revised form 20 June 2013 Accepted 27 September 2013 Keywords: Keywords: Carcinoma Delivery Fitz–Hugh–Curtis syndrome Rectal injury Ovary Rectovaginal septum endometriosis
Obstetric rectal injuries generally result from tears extending from the perineal body to the region of the anal sphincter muscles and the wall of the rectum. Commonly regarded as a fourth-degree perineal injury, they occur in 0.4% of deliveries, often as a complication of forceps deliveries [1]. An isolated perforation of the rectum with an intact perineum is an extremely rare situation because the injury develops from the opposing direction owing to excessive dilation of the rectovaginal septum caused by passage of the infant’s head. Only a few cases exist
⁎ Corresponding author at: Department of Gynecology and Obstetrics, Third Medical Faculty, Charles University, Ruska 87, 100 00 Prague 10, Czech Republic. Tel.: +420 776 230 086; fax: +420 267 313 391. E-mail address: [email protected] (J. Zahumensky).
in the literature and clear recommendations concerning the surgical repair of these injuries are lacking [2]. A 32-year-old primipara was admitted at term with regular contractions. Her medical history indicated that she had undergone laparoscopic surgery 3 years earlier for removal of an endometrial cyst, which also revealed rectovaginal septum endometriosis. The patient was treated with gonadotropin-releasing hormone analogs and subsequently became pregnant. The first and second stages of labor progressed without complication and a male newborn weighing 3590 g was delivered. A second-degree perineal tear, in conjunction with total perforation of the rectal mucosa extending 1.5 cm in length at a distance of 2 cm above the intact external sphincter, was identified immediately after delivery (Fig. 1). The woman was informed of the need to undergo surgical repair and the possibility of a temporary sigmoidostomy; informed consent was signed. The attending colorectal surgeon first mobilized the rectum and then sutured the rectal mucosa in 2 layers with absorbable suture material, subsequently suturing the rectovaginal fascia in 1 layer. Finally, the vaginal wall and second-degree perineal tear were routinely repaired. Antibiotic coverage (cefuroxime and metronidazole) was administered in combination with a low-fiber diet and lactulose for 5 days. On the fifth day, the patient was discharged in good health and underwent a series of follow-up examinations at 14 days, 3 months, and 1 year after delivery. The patient was devoid of any complaints and was fully continent; a rectoscope examination did not show any signs of rectal lesions. The present case report should be considered of interest for 2 reasons. The first is the mechanism by which the tear of the rectal mucosa
86
BRIEF COMMUNICATIONS
probably occurred—that is, as a result of the decreased elasticity of the posterior vaginal wall and the rectovaginal septum due to fibrosis and scarring from endometriosis. The second is that the case proves that it is not necessary to perform a sigmoidostomy for proper healing to occur. Acknowledgments The present work was supported by the research project PRVOUKP32, awarded by Charles University, Prague, Czech Republic. Conflict of interest The authors have no conflicts of interest. References [1] Samuelsson E, Ladfors L, Lindblom BG, Hagberg H. A prospective observational study on tears during vaginal delivery: occurrences and risk factors. Acta Obstet Gynecol Scand 2002;81(1):44–9. [2] Diepenhorst GM, van Buijtenen JM, Renckens CN, Sonneveld DJ. Obstetric rupture of the rectovaginal septum and sphincter complex despite an intact perineum: report of three cases. Clin Exp Obstet Gynecol 2012;39(3):399–401.
Fig. 1. Digital rectal examination before repair of injury. Abbreviations: MSA, intact external anal sphincter; RL, lesion of rectal wall and rectovaginal septum. 0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.06.038
Effects of young maternal age and short interpregnancy interval on infant mortality in South Asia Anita Raj a,b,⁎, Lotus McDougal a,b,c, Melanie L.A. Rusch d a
Division of Global Public Health, University of California at San Diego School of Medicine, La Jolla, USA Center on Gender Equity and Health, University of California, San Diego, La Jolla, USA c Joint Doctoral Program in Public Health (Global Health), San Diego State University/University of California, San Diego, San Diego, USA d Vancouver Island Health Authority, Victoria, British Columbia, Canada b
a r t i c l e
i n f o
Article history: Received 25 May 2013 Received in revised form 19 July 2013 Accepted 2 October 2013 Keywords: Keywords: Carcinoma Adolescent childbirth Fitz–Hugh–Curtis syndrome Birth spacing Ovarymarriage Child Perihepatic adhesions Infant mortality Interpregnancy interval Maternal age South Asia
⁎ Corresponding author at: Division of Global Public Health, Department of Medicine, University of California, San Diego, 10111 N. Torrey Pines Rd, MC0507; Institute of the Americas, La Jolla, CA 92093-0507, USA. Tel.: +1 858 246 00662; fax: +1 858 534 7566. E-mail address: [email protected] (A. Raj).
One in 14 births to young mothers in Bangladesh, India, Nepal, and Pakistan ends with the death of a child within the first year [1]. Recent analysis of nationally representative data from these nations documents that young maternal age at birth and short interpregnancy interval are significant drivers of infant death among births to young mothers. The aim of the present study was to quantify the proportion of infant deaths attributable to these factors. Using the most recent nationally representative Demographic and Health Survey (DHS) data [2], nation-specific logistic regression analyses were conducted to assess associations of younger maternal age at birth (b 18 years vs ≥18 years) and preceding interpregnancy interval (b 24 months vs ≥24 months or firstborn) with infant mortality among births to 15–24 year olds. Based on multivariate regression models, the percent of infant deaths attributable to each independent variable of interest was quantified using the population attributable fraction [3]. Population attributable fractions were then applied to 2012 population estimates [4] and age-specific fertility rates [2] to produce an estimate of the number of infant deaths attributable to the factors of interest.
Group 1 (n = 400)b
Group 2 (n = 400)c
P value
Hemoglobin level before labor, g/L Hemoglobin level after labor, g/L Hematocrit level before labor,% Hematocrit level after labor,% Total blood loss, mL
115 113 36.5 34.9 200
116 115 36.7 35.4 200
0.115 0.771 0.079 0.035 0.356
a b c
(108–124) (105–122) (34.1–38.8) (32.05–37.4) (150–280)
(110–124) (106–122) (35–39) (32.6–38) (150–250)
Values are given as median (interquartile range). Active management of the third stage of labor with controlled cord traction. Active management of the third stage of labor without controlled cord traction.
85
In the present study, the absence of CCT did not have a significant effect on volume of blood loss in the third stage of labor; postpartum hemoglobin levels; or frequency of PPH, blood transfusion, use of additional uterotonics, manual removal of the placenta, or additional surgical procedures. However, patients who underwent the full package of AMTSL, which included CCT, had a significantly lower hematocrit level after labor compared with women who did not undergo CCT. Conflict of interest The authors have no conflicts of interest. References
2.5% in both groups. Manual removal of the placenta occurred in only 1.7% of women in group 1 and 2.8% of women in group 2 (P = 0.340). Blood transfusion and additional surgical procedures were required for 1 woman in group 1, and 2 women in group 2 (P=0.563). Hysterectomy and ligation of vessels were not performed. There was a significant reduction in hematocrit and hemoglobin levels after labor in both groups (P b 0.0001). Hematocrit levels in group 1 were significantly lower after labor than those in group 2 (P = 0.035). There were no significant differences between the groups in hemoglobin level after labor.
[1] Begley CM, Gyte GM, Murphy DJ, Devane D, McDonald SJ, McGuire W. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2010;7:CD007412. [2] WHO. Recommendations for the Prevention of Postpartum Hemorrhage. Geneva: WHO; 2007. [3] Gülmezoglu AM, Lumbiganon P, Landoulsi S, Widmer M, Abdel-Aleem H, Festin M, et al. Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. Lancet 2012;379(9827):1721–7. [4] Miranda JE, Rojas-Suarez J, Paternina A, Mendoza R, Bello C, Tolosa JE. The effect of guideline variations on the implementation of active management of the third stage of labor. Int J Gynecol Obstet 2013;121(3):266–9.
0020-7292/$ – see front matter © 2013 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. http://dx.doi.org/10.1016/j.ijgo.2013.07.028
Rectal injury following delivery as a possible consequence of endometriosis of the rectovaginal septum Erika Menzlova a, Josef Zahumensky b,⁎, Robert Gürlich c, Eduard Kucera b a b c
Department of Gynecology and Obstetrics, First Medical Faculty, Charles University and Bulovka Hospital, Prague, Czech Republic Department of Gynecology and Obstetrics, Third Medical Faculty, Charles University, Prague, Czech Republic Department of Surgery, Third Medical Faculty, Charles University, Prague, Czech Republic
a r t i c l e
i n f o
Article history: Received 22 May 2013 Received in revised form 20 June 2013 Accepted 27 September 2013 Keywords: Keywords: Carcinoma Delivery Fitz–Hugh–Curtis syndrome Rectal injury Ovary Rectovaginal septum endometriosis
Obstetric rectal injuries generally result from tears extending from the perineal body to the region of the anal sphincter muscles and the wall of the rectum. Commonly regarded as a fourth-degree perineal injury, they occur in 0.4% of deliveries, often as a complication of forceps deliveries [1]. An isolated perforation of the rectum with an intact perineum is an extremely rare situation because the injury develops from the opposing direction owing to excessive dilation of the rectovaginal septum caused by passage of the infant’s head. Only a few cases exist
⁎ Corresponding author at: Department of Gynecology and Obstetrics, Third Medical Faculty, Charles University, Ruska 87, 100 00 Prague 10, Czech Republic. Tel.: +420 776 230 086; fax: +420 267 313 391. E-mail address: [email protected] (J. Zahumensky).
in the literature and clear recommendations concerning the surgical repair of these injuries are lacking [2]. A 32-year-old primipara was admitted at term with regular contractions. Her medical history indicated that she had undergone laparoscopic surgery 3 years earlier for removal of an endometrial cyst, which also revealed rectovaginal septum endometriosis. The patient was treated with gonadotropin-releasing hormone analogs and subsequently became pregnant. The first and second stages of labor progressed without complication and a male newborn weighing 3590 g was delivered. A second-degree perineal tear, in conjunction with total perforation of the rectal mucosa extending 1.5 cm in length at a distance of 2 cm above the intact external sphincter, was identified immediately after delivery (Fig. 1). The woman was informed of the need to undergo surgical repair and the possibility of a temporary sigmoidostomy; informed consent was signed. The attending colorectal surgeon first mobilized the rectum and then sutured the rectal mucosa in 2 layers with absorbable suture material, subsequently suturing the rectovaginal fascia in 1 layer. Finally, the vaginal wall and second-degree perineal tear were routinely repaired. Antibiotic coverage (cefuroxime and metronidazole) was administered in combination with a low-fiber diet and lactulose for 5 days. On the fifth day, the patient was discharged in good health and underwent a series of follow-up examinations at 14 days, 3 months, and 1 year after delivery. The patient was devoid of any complaints and was fully continent; a rectoscope examination did not show any signs of rectal lesions. The present case report should be considered of interest for 2 reasons. The first is the mechanism by which the tear of the rectal mucosa
86
BRIEF COMMUNICATIONS
probably occurred—that is, as a result of the decreased elasticity of the posterior vaginal wall and the rectovaginal septum due to fibrosis and scarring from endometriosis. The second is that the case proves that it is not necessary to perform a sigmoidostomy for proper healing to occur. Acknowledgments The present work was supported by the research project PRVOUKP32, awarded by Charles University, Prague, Czech Republic. Conflict of interest The authors have no conflicts of interest. References [1] Samuelsson E, Ladfors L, Lindblom BG, Hagberg H. A prospective observational study on tears during vaginal delivery: occurrences and risk factors. Acta Obstet Gynecol Scand 2002;81(1):44–9. [2] Diepenhorst GM, van Buijtenen JM, Renckens CN, Sonneveld DJ. Obstetric rupture of the rectovaginal septum and sphincter complex despite an intact perineum: report of three cases. Clin Exp Obstet Gynecol 2012;39(3):399–401.
Fig. 1. Digital rectal examination before repair of injury. Abbreviations: MSA, intact external anal sphincter; RL, lesion of rectal wall and rectovaginal septum. 0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.06.038
Effects of young maternal age and short interpregnancy interval on infant mortality in South Asia Anita Raj a,b,⁎, Lotus McDougal a,b,c, Melanie L.A. Rusch d a
Division of Global Public Health, University of California at San Diego School of Medicine, La Jolla, USA Center on Gender Equity and Health, University of California, San Diego, La Jolla, USA c Joint Doctoral Program in Public Health (Global Health), San Diego State University/University of California, San Diego, San Diego, USA d Vancouver Island Health Authority, Victoria, British Columbia, Canada b
a r t i c l e
i n f o
Article history: Received 25 May 2013 Received in revised form 19 July 2013 Accepted 2 October 2013 Keywords: Keywords: Carcinoma Adolescent childbirth Fitz–Hugh–Curtis syndrome Birth spacing Ovarymarriage Child Perihepatic adhesions Infant mortality Interpregnancy interval Maternal age South Asia
⁎ Corresponding author at: Division of Global Public Health, Department of Medicine, University of California, San Diego, 10111 N. Torrey Pines Rd, MC0507; Institute of the Americas, La Jolla, CA 92093-0507, USA. Tel.: +1 858 246 00662; fax: +1 858 534 7566. E-mail address: [email protected] (A. Raj).
One in 14 births to young mothers in Bangladesh, India, Nepal, and Pakistan ends with the death of a child within the first year [1]. Recent analysis of nationally representative data from these nations documents that young maternal age at birth and short interpregnancy interval are significant drivers of infant death among births to young mothers. The aim of the present study was to quantify the proportion of infant deaths attributable to these factors. Using the most recent nationally representative Demographic and Health Survey (DHS) data [2], nation-specific logistic regression analyses were conducted to assess associations of younger maternal age at birth (b 18 years vs ≥18 years) and preceding interpregnancy interval (b 24 months vs ≥24 months or firstborn) with infant mortality among births to 15–24 year olds. Based on multivariate regression models, the percent of infant deaths attributable to each independent variable of interest was quantified using the population attributable fraction [3]. Population attributable fractions were then applied to 2012 population estimates [4] and age-specific fertility rates [2] to produce an estimate of the number of infant deaths attributable to the factors of interest.
