Implementation of a Clinical Protocol to Reduce Urinary Tract Infections Among Women With Urinary Retention After Pelvic Reconstructive Surgery: A Prospective Quality Improvement Study

ObjectiveWe implemented and assessed a clinical practice quality improvement protocol aimed at decreasing postoperative urinary tract infections (UTIs) among patients with transurethral catheters.MethodsThis was a quality improvement study with pre- and post-intervention comparisons. Patients requiring postoperative transurethral catheters underwent 3 interventions: (1) shortening the time from surgery to repeat voiding trials to 3–5 days for pelvic reconstructive surgeries and to 1–3 days for mid-urethral slings, (2) avoiding routine urine cultures at the time of voiding trials, and (3) recommending 2 L of water intake daily until 3 days after the voiding trial. The primary outcome was the percentage of patients receiving antibiotics for UTIs within 6 weeks. Secondary outcomes included rates of failing office voiding trials, UTI symptoms/cultures, adherence to hydration, and health care resource utilization.ResultsWe included 31 patients before and 40 patients after the intervention. The 2 cohorts had similar demographic and clinical characteristics. Among patients requiring catheterization, rates of antibiotic treatment for UTIs decreased from 65% to 40% after the intervention (P = 0.04). UTI symptoms and urine cultures sent for analysis decreased significantly (P = 0.04 and P = 0.005, respectively). There was high adherence (84%) to increased hydration. Rates of failing office voiding trials remained similar. The number of phone calls decreased by 43% (P = 0.003), and there was no increase in office or emergency department visits. Multivariate regression showed that UTIs were 2.04 times more likely before than after the intervention.ConclusionOur quality improvement intervention was practical to implement and effective in reducing postoperative UTIs among patients with urinary catheters.     

The effect of placental removal method on the incidence of postcesarean infections

OBJECTIVE: Our purpose was to determine whether the incidence of postoperative endometritis and wound infection is associated with the method of placental removal at the time of cesarean section.STUDY DESIGN: Parturients undergoing cesarean delivery were prospectively randomized to have the placenta removed manually or spontaneously. Patients were excluded from participation if they had received intrapartum prophylactic antibiotics or had been determined to have chorioamnionitis. After delivery of the infant women in the manual group had the placenta extracted by the primary surgeon, whereas women in the spontaneous group had the placenta delivered by gentle traction on the umbilical cord. All study subjects received perioperative prophylactic antibiotics. The primary outcome variable was a postcesarean infection, defined as postcesarean endometritis or wound cellulitis requiring drainage and antibiotic therapy.RESULTS: A total of 333 women were enrolled in the investigation, with 165 assigned to the manual removal group and 168 allocated to have spontaneous removal. There were no statistically significant differences in mean gestational age, frequency or duration of ruptured membranes, frequency or duration of labor, or mean number of vaginal examinations between the two study groups. Postoperative infections occurred in 25 of 168 (15%) women in the spontaneous delivery group compared with 44 of 165 (27%) women in which the placenta was manually extracted (relative risk 0.6, 95% confidence interval 0.4 to 0.9, p = 0.01). Subset analysis of patients delivered with ruptured membranes similarly demonstrated a statistically significant reduction in the incidence of postoperative infections with spontaneous placental removal compared with manual extraction (20% vs. 38%, relative risk 0.5, 95% confidence interval 0.3 to 0.9, p = 0.02). There was a similar trend toward a reduction in postdelivery infections associated with spontaneous placental removal in women with intact membranes; however, this difference did not attain statistical significance.CONCLUSIONS: Spontaneous delivery of the placenta after cesarean delivery is associated with a decrease in the incidence of postcesarean infections. (Am J Obstet Gynecol 1997;176:1250-4.)     

宫内节育器类型及置器年限与女性生殖道感染关系研究

目的 探讨宫内节育器的类型及置器年限与女性生殖道感染的关系。方法 回顾性分析中国医科大学附属盛京医院计划生育门诊于2013年1月至2014年6月行宫内节育器取出术的1350例患者的临床资料,研究宫内节育器的类型及置器年限与女性生殖道感染的相关性,并探讨女性生殖道感染的发生是否与年龄、孕产次及绝经与否有关。结果 带尾丝型宫内节育器置器10年及10年以上的女性生殖道感染的发生率为33.9%,置器10年以下的女性生殖道感染的发生率为14.3%,两者比较差异有统计学意义（P<0.05)。无尾丝型宫内节育器置器10年及10年以上的女性生殖道感染的发生率为20.7%,置器10年以下的女性生殖道感染的发生率为16.9%,两者比较差异无统计学意义（P>0.05)。带尾丝型宫内节育器因置器年限长而导致的女性生殖道感染的高发率与年龄、孕产次及绝经与否无明显关系。年龄较大者女性生殖道感染的发生率略低,为29.4%;妊娠次数少者女性生殖道感染的发生率略低,为26.5%;绝经者女性生殖道感染的发生率略低,为30.7%,但各组间的差异无统计学意义（P>0.05)。结论 带尾丝型宫内节育器置器年限过长,可导致女性生殖道感染的发生率升高。     

Urinary Tract Injuries in Laparoscopic Hysterectomy: A Systematic Review

The aim of this review was to estimate the incidence of urinary tract injuries associated with laparoscopic hysterectomy and describe the long-term sequelae of these injuries and the impact of early recognition. Studies were identified by searching the PubMed database, spanning the last 10 years. The key words “ureter” or “ureteral” or “urethra” or “urethral” or “bladder” or “urinary tract” and “injury” and “laparoscopy” or “robotic” and “gynecology” were used. Additionally, a separate search was done for “routine cystoscopy” and “gynecology.” The inclusion criteria were published articles of original research referring to urologic injuries occurring during either laparoscopic or robotic surgery for gynecologic indications. Only English language articles from the past 10 years were included. Studies with less than 100 patients and no injuries reported were excluded. No robotic series met these criteria. A primary search of the database yielded 104 articles, and secondary cross-reference yielded 6 articles. After reviewing the abstracts, 40 articles met inclusion criteria and were reviewed in their entirety. Of those 40 articles, 3 were excluded because of an inability to extract urinary tract injuries from total injuries. Statistical analysis was performed using a generalized linear mixed effects model. The overall urinary tract injury rate for laparoscopic hysterectomy was 0.73%. The bladder injury rate ranged from 0.05% to 0.66% across procedure types, and the ureteral injury rate ranged from 0.02% to 0.4% across procedure type. In contrast to earlier publications, which cited unacceptably high urinary tract injury rates, laparoscopic hysterectomy appears to be safe regarding the bladder and ureter.     

腹腔镜诊治女性结核性不孕52例临床分析

目的:探讨腹腔镜在女性生殖器结核性不孕诊治中的价值及有效治疗策略。方法:回顾性分析北京协和医院近20年腹腔镜诊治的女性生殖器结核性不孕52例的临床资料,综合文献复习。结果:本组患者中诊断时平均年龄26.7岁。原发不孕36例,占69.2%;继发不孕患者16例,占30.8%。腹腔镜下病变表现为:粟粒腹水型13例,占25%;盆腔干酪样病变14例,占26.9%;卵巢输卵管包裹粘连形成包块21例,占40.4%;结节钙化型4例,占7.7%。双侧输卵管梗阻患者44例,占全部患者的84.6%,梗阻部位在双侧或单侧输卵管间质部的患者37例。本组患者自然妊娠率为1.92%,正常自然妊娠率为0。3例患者行IVF-ET,2例妊娠;1例失败。结论:女性生殖器结核性不孕患者的症状没有特异性,使早期诊断困难。腹腔镜手术可以提高本病的术中诊断率,抗结核治疗后,患者正常妊娠率低,控制结核后IVF-ET是一个较好的选择。     

Postpartum Perineal Pain in a Low Episiotomy Setting: Association with Severity of Genital Trauma,Labor Care,and Birth Variables

Background: Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative vaginal delivery. Methods: A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the present pain intensity (PPI) and visual analog scale (VAS) components of the validated short‐form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. Results: At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 ± 1.61 vs 1.48 ± 1.40; p < 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, p = 0.002) than women with minor or no trauma. By 3 months, average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non‐Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model, only trauma group and length of active pushing predicted the pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on the level of pain at discharge beyond its effect on the incidence of major trauma. Conclusions: Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain.     

免疫三氧治疗女性复发性生殖器疱疹89例临床分析

目的：初步评价免疫三氧疗法对女性复发性生殖器疱疹的治疗效果。方法：随机将134例患者分为2组,观察组89例,对照组45例,对照组采用微波照射联合常规药物治疗。观察组在微波照射的基础上采用免疫三氧治疗,联合应用自体血液回输法(AHT)和直肠注气法(RI)。观察各组治疗3个月、6个月、12个月后的复发率,记录不良反应发生情况。结果：两组3个月后的控制率差异无显著性(P＞0．5)；6个月、12个月后控制率差异有非常显著性(P＜0．01；P＜0．001)。结论：免疫三氧疗法对女性复发性生殖器疱疹疗效安全、可靠,可以显著地降低生殖器疱疹复发率。     

合并下生殖道人乳头瘤病毒感染妊娠结局和新生儿近期的影响

目的探讨妊娠合并下生殖道人乳头瘤病毒（HPV）感染妊娠结局和新生儿近期影响。方法选取HPV感染的孕妇116例为研究组,其中下生殖道疣55例,亚临床感染59例,潜伏感染2例。另选取HPV阴性的孕妇181例为对照组,对两组合并其他感染情况、妊娠结局、新生儿患病情况及分娩方式等进行分析。结果研究组合并其他感染如风疹病毒等患病率与对照组比较差异有统计学意义（P〈0.05）;研究组剖宫产率及阴道分娩率同对照组比较差异无统计学意义（P〉0.05）;两组中胎膜早破等不良妊娠结局发生率比较差异均无统计学意义（P〉0.05）,研究组未发现新生儿呼吸道乳头瘤患者;研究组经阴道分娩者羊水、脐静脉血感染率及胎盘病理检查阳性率等与剖宫产组比较差异均无统计学意义（P〉0.05）。结论妊娠合并下生殖道HPV感染发生新生儿呼吸道乳头状瘤率低,分娩方式对新生儿患病率影响不大,也不会增加胎膜早破等不良妊娠结局的发病率;下生殖道HPV感染孕妇易合并其他下生殖道感染,如风疹病毒等。     

两种分娩方式对正常生殖道菌群的影响

目的 :观察剖宫产和自然分娩两种分娩方式对正常产妇生殖道菌群的影响。方法 :选择 4 8例无易感因素的正常产妇 ,2 0例择期剖宫产 ,2 8例自然分娩 ,分别在术前、术时、术后行阴道液、宫腔液细菌培养 ,分娩前后不使用任何抗生素 ,观察分娩期和产褥期生殖道菌群的自然变化和产后感染情况。结果 :剖宫产术前阴道细菌培养阳性率为 6 0 % ,术后为 85 % (P>0 .0 5 ) ,术前宫腔细菌培养为阴性 ,术后为 35 .0 % (P<0 .0 1) ,自然分娩时阴道细菌培养阳性率为 39.3% ,分娩后为 78.6 % (P<0 .0 1) ,分娩时宫腔细菌培养阳性率为 7.1% ,分娩后为 32 .4 % (P<0 .0 1) ;剖宫产术后伤口感染率为5 .0 % ,自然分娩伤口感染率为 3.6 % (P>0 .0 5 )。结论 :两种分娩方式均可影响正常生殖道的菌群生态环境 ,造成菌群失调。在无易感因素的条件下 ,不使用抗生素 ,剖宫产与自然分娩的感染率无差异 ,不增加产褥期感染     

剖宫产术中应用头孢类抗生素对生殖道菌群的影响

探讨择期剖宫产术中应用头孢类抗生素对生殖道菌群的影响。方法将４５例择期剖宫产者随机分为３组：Ａ组１５例,手术前、后均不应用任何抗生素;Ｂ组１５例,术后常规应用头孢类抗生素３ｄ;Ｃ组１５例,术中一次性应用头孢类抗生素。每例分别在术前、术后行阴道液、宫腔液细菌培养,,观察手术前、后生殖道菌群变化和术前,后生殖道菌群变化和术后感染情况。结果患者术前生殖道细菌培养的阳性率为３５．７１％,术后为６４．２９％     

Tranexamic Acid Use in the Postpartum Period Since the WOMAN Trial: A Retrospective Chart Review

ObjectiveTo analyze the use of tranexamic acid (TXA) in postpartum patients since the World Maternal Antifibrinolytic (WOMAN) trial.MethodsA retrospective chart review was conducted from May 2017 to March 2020 at a tertiary care centre to identify all patients who received TXA for postpartum bleeding. The primary outcome was to identify the proportion of patients who received TXA as per World Health Organization guidelines created using results of the World Maternal Antifibrinolytic trial.ResultsA total of 231 patients were included in our analysis. Use increased over time with 18 patients in 2017, 51 in 2018, and 134 in 2019 receiving TXA. In all, 203 patients (87.9%) received TXA within recommended guidelines, and these patients were less likely to require surgery or interventional radiology (12.3% vs. 42.9%, P < 0.001) or blood transfusion (23.6% vs. 42.9%, P = 0.030), and they had a lower likelihood of overall adverse outcomes (1.62 (1.6) vs. 2.60 (2.0), P = 0.024). TXA was commonly used as the first-line agent for postpartum bleeding (48.9% of patients), more likely administered at cesarean section (77.0%) and when estimated blood loss did not meet criteria for “true” postpartum hemorrhage (41.6% of patients). Use of TXA as the first medication was associated with fewer overall adverse outcomes than misoprostol (P = 0.035). A shorter time to administration of the first medication was associated with shorter postpartum admission time (P = 0.042).ConclusionsThe majority of patients received TXA within guidelines and experienced fewer adverse outcomes. Further study is needed to identify the best order of TXA administration with additional uterotonics and whether TXA should be used prophylactically in some groups for postpartum bleeding.     

A Case of Distal Vaginal Agenesis Presenting with Recurrent Urinary Tract Infection and Pyuria in a Prepubertal Girl

Background

Isolated distal vaginal agenesis is a rare anomaly and mostly becomes symptomatic after menarche. We describe an unusual presentation of this anomaly in a prepubertal girl.

原发性生殖器恶性黑色素瘤15例临床分析

目的：探讨原发性生殖器恶性黑色素瘤的诊断、治疗特点及影响预后的因素。方法：对我院收治的１５例原发性生殖器恶性黑色素瘤的临床资料进行回顾性分析。结果：发生于外阴、阴道，宫颈的黑色素瘤分别为４例、９例、２例。１１例行手术切除辅以化疗加免疫疗法，４例行化疗和免疫等疗法。１５例中，１例失访，５例生存＜１年，７例＜２年，２例＞３年，其中１例存活１９年。结论：原发性生殖器恶性黑色素瘤预后差。其治疗以手术为主，并辅以化疗和免疫疗法的综合治疗。