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digital clinical resources. Welcome back to another episode
of the Success NP Podcast. I'm your host today, Jackie, and
I'm excited because today's case study is right in my wheelhouse.
It is OBGYN. It's been everything I've done
since I became a nurse. And so I'm super excited about
today's case study. We're going to be diving into
the postpartum world. It's a space full of rapid
physiological changes, healing, and sometimes hidden
complications. Today's case is going to be a
postpartum mystery. That might look like a typical
recovery issue at first, but as we peel back the layers,
something unexpected is going to emerge.
Can you figure it out before the end of the episode?
Let's see. Let's step into the story of
Maya. Maya is a 29 year old first time
mom. She had a scheduled caesarean
Section 2 weeks ago after a long stalled labor.
Baby girl was born healthy. Her surgery was reported as
uncomplicated. She was discharged on postpartum
day three, which if you know OB, that's pretty typical for a
regular caesarean section to be discharged on postpartum day two
or three. So now she's in your clinic and
you're the nurse practitioner seeing her.
She's complaining of abdominal pain that's not getting any
better, but as you begin to listen to her story, you realize
they're they're more being maybe more to uncover than just
typical recovery. Maya describes her pain as a
dual aching pressure low in her pelvis.
She says it's worse when she's sitting up or standing for long
periods and is not well controlled with ibuprofen.
She also reports mild intermittent fevers, the highest
being 100.8°F last night. She has some mild foul smelling
lochia, which she assumed was normal.
She's breastfeeding, feeling tired and describes quote a
weird fullness in her lower belly.
You dig a little bit deeper into her pregnancy, Maya tells you
that she had gestational hypertension that started around
35 weeks. She was managed conservatively,
but her blood pressure was trending up and she had
significant lower extremity swelling towards the end of the
pregnancy. At 39 weeks pregnant, she went
into spontaneous labor. But excuse me.
But after 24 hours with no cervical change, she did undergo
that caesarean section. She also mentioned that during
her hospital stay, she needed a blood transfusion after her
hemoglobin dropped postoperatively.
She doesn't recall the exact numbers, but she does say she
was feeling dizzy and lightheaded.
She denies urinary urgency or dysuria.
She denies chest pain, shortness of breath or lower extremity
swelling. Now there's a few more variables
on the board. Now let's go over her review of
systems, kind of summarize what we just learned about Maya.
She has no headaches or vision changes, no new vaginal bleeding
beyond the normal lochia postpartum, no nausea or
vomiting, some mild fatigue and night sweats, and increase
tenderness with movement, especially when bending or
lifting. So far.
I mean, you know, you might say these are all very typical
postpartum special for C-section, right?
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ridiculously memorable stories, you'll be able to retain the
information for testing. They help reinforce what you
learn and track your progress with thousands of built in rapid
review multiple choice quizzes. The use of the intelligence
based repetition algorithms automatically adjust to your
learning needs, so you'll be reminded to review the right
information at the right time, increasing long term retention.
Picmonic is also integrated into the true learned question me so
you can study exactly what you need and test your knowledge.
Check them out today if you're preparing for board link in the
show notes. But we don't want to assume
anything at this point. Let's get into her physical
exam, kind of explore those vital signs and go from there.
We have a temperature of 100.6°F in the clinic.
Her heart rate is 94, her blood pressure is 124 / 78,
respiratory rate is 16 and your O2 saturation on room air is
98%. You perform your physical exam.
She appears tired but alert on palpation of her abdomen.
You note that it is soft but tender.
Need a super crew. On palpation of her abdomen, you
note that it is soft but tender in the suprapubic region.
Her C-section is healing well. There's no erythema or drainage.
Her uterus is firm but slightly enlarged and mildly tender.
You note no adenexal masses, no rebound or guarding, and there's
still just a trace of edema on the lower extremities near the
ankles, but no signs of DVT. No signs of mastitis.
Lungs and heart are normal, so you're still forming that
broader differential. All right, let's just think
about it for a second. What are differential diagnosis?
What could this be? Right?
You're the nurse practitioner, you're seeing this postpartum
patient and you're thinking this could be endometriitis,
hematoma, retained products, a urinary tract infection,
postpartum preeclampsia, a pelvic Abscess or something more
of a surgical complication, adhesion, bowel injury.
So you think about running labs and ordering some imaging.
Your initial work up includes ACBCACMPACRPAUAA, pelvic
ultrasound, and in the back of your head you're thinking about
maybe ACT If that ultrasound is not quite clear.
Results come back with a White County that's slightly elevated
at 13.2, a hemoglobin at 10.9 which is low normal, especially
considering she's postpartum, she received that recent blood
transfusion, Her platelets are normal, her CRP is elevated at
8.4 and her UA is normal. So you signed up for pelvic
ultrasound. Ultrasound results show a
slightly enlarged uterus, no retained products of conception,
but there is an echogenic mass with some posterior shadowing in
the lower uterine segment near the incision site.
So you decide to order a pelvic CT for further evaluation.
While waiting on imaging, Maya mentions that she sometimes feel
like a pulling sensation when she moves, almost like something
is stuck inside. She also says she had a moment
of dizziness this morning when standing up quickly.
So as a nurse practitioner, you consult the OB.
They agree CT is appropriate. The CT results come back.
The CT pelvis shows a well defined soft tissue density with
internal air and radiopack markings consistent with a
retained foreign body. Likely a surgical sponge.
So your final diagnosis. Retain surgical sponge.
Yes guys, retain surgical sponge.
It happens. Maya is referred urgently for
surgical removal. She undergoes laparoscopic
retrieval and recovers well post op with antibiotics and
supportive care. So what did we learn from Maya's
case? Let's go back because I think
there's a lot to be said for this.
Although a retained for an object may not be your everyday
scenario, we can learn a lot about her HPI in what that could
mean for a differential diagnosis.
So what postpartum pain that worsens or fails to improve
absolutely needs thorough evaluation.
Like red flag, right? We should not be getting worse,
we should be getting better, especially two weeks post op
postpartum. A history of surgical delivery
increases the risk for complications like hematoma,
Abscess or retain foreign body. So the fact that she had that
C-section automatically, those are going to be, you know, some
of your differentials right there.
So our ultimate diagnosis of retain foreign sponge is rare
but is definitely serious. These symptoms are often vague
and they mimic common postpartum complaints.
Like I mentioned earlier, all of her symptoms you can just ask.
She's postpartum typical recovery, brush it off, which
could be of course a huge mistake given what ultimate
diagnosis was. Imaging is key.
If ultrasound is inconclusive or concerning ACT can be
invaluable. A history of pregnancy
complications like gestational hypertension and postpartum
anemia can cloud the picture and making it even more critical to
stay open minded. So of course, given that her
pregnancy was complicated with the aforementioned conditions
were automatically, and I think maybe it's related to that.
We do want to take everything that the patient tells us into
consideration, but we need to make sure not to narrow our
vision and always stay with that broad differential until we get
more information clinically. All right, guys, I hope you
enjoyed this quick but super fun case study with me.
I always enjoy going through these with you.
They're honestly my very favorite and I would love to
hear, especially given that I'm in the OBGYN realm.
If you have any postpartum puzzles or surgery related
stories even, you can DM us on Instagram at the Success NP.
Give us a follow, give us any ideas that you want to hear
about. We'd love to hear back from you.
Just give us a little feedback and don't forget to check out
our clinical guide at successnp.etsy.com or on our
website. Until next time, stay curious,
stay sharp, and we'll see you soon.
Thanks for tuning into another episode of Success and P.
We hope today's discussion has shed some light on the diverse
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