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digital clinical resources. 
Welcome back to another episode 

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00:01:46,040 --> 00:01:51,440
of the Success NP Podcast. 
I'm your host today, Jackie, and

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I'm excited because today's case
study is right in my wheelhouse.

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It is OBGYN. 
It's been everything I've done 

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since I became a nurse. 
And so I'm super excited about 

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today's case study. 
We're going to be diving into 

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the postpartum world. 
It's a space full of rapid 

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physiological changes, healing, 
and sometimes hidden 

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complications. 
Today's case is going to be a 

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postpartum mystery. 
That might look like a typical 

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recovery issue at first, but as 
we peel back the layers, 

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something unexpected is going to
emerge. 

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Can you figure it out before the
end of the episode? 

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Let's see. 
Let's step into the story of 

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Maya. 
Maya is a 29 year old first time

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mom. 
She had a scheduled caesarean 

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00:02:39,200 --> 00:02:42,960
Section 2 weeks ago after a long
stalled labor. 

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Baby girl was born healthy. 
Her surgery was reported as 

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uncomplicated. 
She was discharged on postpartum

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day three, which if you know OB,
that's pretty typical for a 

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regular caesarean section to be 
discharged on postpartum day two

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or three. 
So now she's in your clinic and 

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you're the nurse practitioner 
seeing her. 

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She's complaining of abdominal 
pain that's not getting any 

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better, but as you begin to 
listen to her story, you realize

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they're they're more being maybe
more to uncover than just 

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typical recovery. 
Maya describes her pain as a 

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dual aching pressure low in her 
pelvis. 

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She says it's worse when she's 
sitting up or standing for long 

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periods and is not well 
controlled with ibuprofen. 

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She also reports mild 
intermittent fevers, the highest

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being 100.8°F last night. 
She has some mild foul smelling 

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lochia, which she assumed was 
normal. 

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She's breastfeeding, feeling 
tired and describes quote a 

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weird fullness in her lower 
belly. 

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You dig a little bit deeper into
her pregnancy, Maya tells you 

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that she had gestational 
hypertension that started around

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35 weeks. 
She was managed conservatively, 

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but her blood pressure was 
trending up and she had 

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significant lower extremity 
swelling towards the end of the 

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pregnancy. 
At 39 weeks pregnant, she went 

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into spontaneous labor. 
But excuse me. 

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But after 24 hours with no 
cervical change, she did undergo

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that caesarean section. 
She also mentioned that during 

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her hospital stay, she needed a 
blood transfusion after her 

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hemoglobin dropped 
postoperatively. 

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She doesn't recall the exact 
numbers, but she does say she 

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was feeling dizzy and 
lightheaded. 

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She denies urinary urgency or 
dysuria. 

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She denies chest pain, shortness
of breath or lower extremity 

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swelling. 
Now there's a few more variables

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on the board. 
Now let's go over her review of 

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systems, kind of summarize what 
we just learned about Maya. 

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She has no headaches or vision 
changes, no new vaginal bleeding

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beyond the normal lochia 
postpartum, no nausea or 

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vomiting, some mild fatigue and 
night sweats, and increase 

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00:05:02,160 --> 00:05:05,040
tenderness with movement, 
especially when bending or 

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00:05:05,040 --> 00:05:07,360
lifting. 
So far. 

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00:05:07,360 --> 00:05:09,920
I mean, you know, you might say 
these are all very typical 

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00:05:09,920 --> 00:05:12,400
postpartum special for 
C-section, right? 

90
00:05:12,440 --> 00:05:15,960
I hate to interrupt a good 
conversation, but I have to tell

91
00:05:15,960 --> 00:05:19,360
you about the newest sponsor for
the Success NP Podcast. 

92
00:05:19,720 --> 00:05:23,120
Picmonic is a quick and 
effective aid to help you pass 

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00:05:23,120 --> 00:05:26,880
your NP boards. 
They utilize 2 minute videos 

94
00:05:27,080 --> 00:05:29,640
that connect difficult to 
remember facts with 

95
00:05:29,840 --> 00:05:33,520
unforgettable characters. 
By tying facts together into 

96
00:05:33,520 --> 00:05:37,640
ridiculously memorable stories, 
you'll be able to retain the 

97
00:05:37,640 --> 00:05:41,360
information for testing. 
They help reinforce what you 

98
00:05:41,360 --> 00:05:45,440
learn and track your progress 
with thousands of built in rapid

99
00:05:45,440 --> 00:05:49,760
review multiple choice quizzes. 
The use of the intelligence 

100
00:05:49,760 --> 00:05:53,560
based repetition algorithms 
automatically adjust to your 

101
00:05:53,560 --> 00:05:56,840
learning needs, so you'll be 
reminded to review the right 

102
00:05:56,840 --> 00:06:01,000
information at the right time, 
increasing long term retention. 

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00:06:01,520 --> 00:06:06,120
Picmonic is also integrated into
the true learned question me so 

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you can study exactly what you 
need and test your knowledge. 

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00:06:09,720 --> 00:06:13,000
Check them out today if you're 
preparing for board link in the 

106
00:06:13,000 --> 00:06:16,200
show notes. 
But we don't want to assume 

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00:06:16,200 --> 00:06:18,920
anything at this point. 
Let's get into her physical 

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00:06:18,920 --> 00:06:21,600
exam, kind of explore those 
vital signs and go from there. 

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00:06:22,520 --> 00:06:26,320
We have a temperature of 100.6°F
in the clinic. 

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00:06:26,760 --> 00:06:31,480
Her heart rate is 94, her blood 
pressure is 124 / 78, 

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00:06:32,480 --> 00:06:37,120
respiratory rate is 16 and your 
O2 saturation on room air is 

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98%. 
You perform your physical exam. 

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She appears tired but alert on 
palpation of her abdomen. 

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00:06:46,480 --> 00:06:48,600
You note that it is soft but 
tender. 

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00:06:48,600 --> 00:06:52,560
Need a super crew. 
On palpation of her abdomen, you

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00:06:52,560 --> 00:06:55,640
note that it is soft but tender 
in the suprapubic region. 

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00:06:56,360 --> 00:07:00,720
Her C-section is healing well. 
There's no erythema or drainage.

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00:07:01,600 --> 00:07:05,520
Her uterus is firm but slightly 
enlarged and mildly tender. 

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00:07:06,520 --> 00:07:11,000
You note no adenexal masses, no 
rebound or guarding, and there's

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00:07:11,000 --> 00:07:13,640
still just a trace of edema on 
the lower extremities near the 

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00:07:13,640 --> 00:07:17,640
ankles, but no signs of DVT. 
No signs of mastitis. 

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00:07:18,080 --> 00:07:21,280
Lungs and heart are normal, so 
you're still forming that 

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00:07:21,280 --> 00:07:26,000
broader differential. 
All right, let's just think 

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00:07:26,000 --> 00:07:29,200
about it for a second. 
What are differential diagnosis?

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00:07:29,200 --> 00:07:30,640
What could this be? 
Right? 

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00:07:30,640 --> 00:07:32,320
You're the nurse practitioner, 
you're seeing this postpartum 

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00:07:32,320 --> 00:07:38,920
patient and you're thinking this
could be endometriitis, 

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00:07:39,720 --> 00:07:45,000
hematoma, retained products, a 
urinary tract infection, 

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00:07:45,760 --> 00:07:51,000
postpartum preeclampsia, a 
pelvic Abscess or something more

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00:07:51,480 --> 00:07:54,400
of a surgical complication, 
adhesion, bowel injury. 

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00:07:55,400 --> 00:07:58,080
So you think about running labs 
and ordering some imaging. 

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00:08:07,600 --> 00:08:15,760
Your initial work up includes 
ACBCACMPACRPAUAA, pelvic 

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00:08:15,760 --> 00:08:18,400
ultrasound, and in the back of 
your head you're thinking about 

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00:08:18,400 --> 00:08:21,640
maybe ACT If that ultrasound is 
not quite clear. 

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00:08:23,920 --> 00:08:27,000
Results come back with a White 
County that's slightly elevated 

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00:08:27,000 --> 00:08:32,200
at 13.2, a hemoglobin at 10.9 
which is low normal, especially 

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00:08:32,200 --> 00:08:35,080
considering she's postpartum, 
she received that recent blood 

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00:08:35,080 --> 00:08:40,120
transfusion, Her platelets are 
normal, her CRP is elevated at 

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00:08:40,120 --> 00:08:45,320
8.4 and her UA is normal. 
So you signed up for pelvic 

140
00:08:45,320 --> 00:08:47,880
ultrasound. 
Ultrasound results show a 

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00:08:47,960 --> 00:08:51,840
slightly enlarged uterus, no 
retained products of conception,

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00:08:53,000 --> 00:08:58,360
but there is an echogenic mass 
with some posterior shadowing in

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00:08:58,360 --> 00:09:00,520
the lower uterine segment near 
the incision site. 

144
00:09:02,280 --> 00:09:05,440
So you decide to order a pelvic 
CT for further evaluation. 

145
00:09:09,480 --> 00:09:13,240
While waiting on imaging, Maya 
mentions that she sometimes feel

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00:09:13,240 --> 00:09:16,960
like a pulling sensation when 
she moves, almost like something

147
00:09:16,960 --> 00:09:20,920
is stuck inside. 
She also says she had a moment 

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00:09:20,920 --> 00:09:23,360
of dizziness this morning when 
standing up quickly. 

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00:09:24,640 --> 00:09:26,640
So as a nurse practitioner, you 
consult the OB. 

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00:09:27,840 --> 00:09:32,400
They agree CT is appropriate. 
The CT results come back. 

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00:09:34,400 --> 00:09:38,640
The CT pelvis shows a well 
defined soft tissue density with

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00:09:38,640 --> 00:09:42,000
internal air and radiopack 
markings consistent with a 

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00:09:42,000 --> 00:09:45,440
retained foreign body. 
Likely a surgical sponge. 

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00:09:46,280 --> 00:09:50,360
So your final diagnosis. 
Retain surgical sponge. 

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00:09:51,800 --> 00:09:53,440
Yes guys, retain surgical 
sponge. 

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00:09:53,440 --> 00:09:57,360
It happens. 
Maya is referred urgently for 

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00:09:57,360 --> 00:10:00,720
surgical removal. 
She undergoes laparoscopic 

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00:10:00,720 --> 00:10:03,720
retrieval and recovers well post
op with antibiotics and 

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00:10:03,720 --> 00:10:08,520
supportive care. 
So what did we learn from Maya's

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00:10:08,520 --> 00:10:10,760
case? 
Let's go back because I think 

161
00:10:10,960 --> 00:10:12,480
there's a lot to be said for 
this. 

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00:10:12,480 --> 00:10:16,320
Although a retained for an 
object may not be your everyday 

163
00:10:16,320 --> 00:10:21,240
scenario, we can learn a lot 
about her HPI in what that could

164
00:10:21,240 --> 00:10:22,720
mean for a differential 
diagnosis. 

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00:10:23,800 --> 00:10:27,440
So what postpartum pain that 
worsens or fails to improve 

166
00:10:27,720 --> 00:10:30,760
absolutely needs thorough 
evaluation. 

167
00:10:31,040 --> 00:10:34,240
Like red flag, right? 
We should not be getting worse, 

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00:10:34,240 --> 00:10:37,440
we should be getting better, 
especially two weeks post op 

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00:10:37,440 --> 00:10:41,320
postpartum. 
A history of surgical delivery 

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00:10:41,640 --> 00:10:44,320
increases the risk for 
complications like hematoma, 

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00:10:44,720 --> 00:10:48,160
Abscess or retain foreign body. 
So the fact that she had that 

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00:10:48,160 --> 00:10:50,560
C-section automatically, those 
are going to be, you know, some 

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00:10:50,560 --> 00:10:51,800
of your differentials right 
there. 

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00:10:53,920 --> 00:10:57,440
So our ultimate diagnosis of 
retain foreign sponge is rare 

175
00:10:57,440 --> 00:11:01,360
but is definitely serious. 
These symptoms are often vague 

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00:11:01,360 --> 00:11:03,320
and they mimic common postpartum
complaints. 

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00:11:03,320 --> 00:11:05,640
Like I mentioned earlier, all of
her symptoms you can just ask. 

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00:11:05,640 --> 00:11:09,560
She's postpartum typical 
recovery, brush it off, which 

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00:11:09,560 --> 00:11:13,240
could be of course a huge 
mistake given what ultimate 

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00:11:13,240 --> 00:11:17,040
diagnosis was. 
Imaging is key. 

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00:11:17,560 --> 00:11:21,520
If ultrasound is inconclusive or
concerning ACT can be 

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00:11:21,520 --> 00:11:24,960
invaluable. 
A history of pregnancy 

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00:11:24,960 --> 00:11:27,840
complications like gestational 
hypertension and postpartum 

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00:11:27,840 --> 00:11:31,720
anemia can cloud the picture and
making it even more critical to 

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00:11:31,720 --> 00:11:34,520
stay open minded. 
So of course, given that her 

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00:11:34,520 --> 00:11:38,080
pregnancy was complicated with 
the aforementioned conditions 

187
00:11:38,080 --> 00:11:40,600
were automatically, and I think 
maybe it's related to that. 

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00:11:40,760 --> 00:11:43,160
We do want to take everything 
that the patient tells us into 

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00:11:43,160 --> 00:11:46,520
consideration, but we need to 
make sure not to narrow our 

190
00:11:46,520 --> 00:11:49,400
vision and always stay with that
broad differential until we get 

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00:11:49,400 --> 00:11:53,640
more information clinically. 
All right, guys, I hope you 

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00:11:53,680 --> 00:11:57,120
enjoyed this quick but super fun
case study with me. 

193
00:11:57,120 --> 00:11:58,600
I always enjoy going through 
these with you. 

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00:11:58,800 --> 00:12:03,040
They're honestly my very 
favorite and I would love to 

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00:12:03,040 --> 00:12:06,360
hear, especially given that I'm 
in the OBGYN realm. 

196
00:12:06,640 --> 00:12:09,520
If you have any postpartum 
puzzles or surgery related 

197
00:12:09,520 --> 00:12:13,080
stories even, you can DM us on 
Instagram at the Success NP. 

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00:12:13,360 --> 00:12:16,760
Give us a follow, give us any 
ideas that you want to hear 

199
00:12:16,760 --> 00:12:18,160
about. 
We'd love to hear back from you.

200
00:12:18,160 --> 00:12:20,760
Just give us a little feedback 
and don't forget to check out 

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00:12:20,760 --> 00:12:24,600
our clinical guide at 
successnp.etsy.com or on our 

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00:12:24,600 --> 00:12:27,040
website. 
Until next time, stay curious, 

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00:12:27,040 --> 00:12:28,200
stay sharp, and we'll see you 
soon. 

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00:12:28,240 --> 00:12:31,080
Thanks for tuning into another 
episode of Success and P. 

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00:12:31,160 --> 00:12:34,200
We hope today's discussion has 
shed some light on the diverse 

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00:12:34,240 --> 00:12:37,280
career options or taught you how
to improve your clinical 

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00:12:37,280 --> 00:12:38,840
practice as a nurse 
practitioner. 

208
00:12:39,200 --> 00:12:41,720
Remember, whether you're 
considering a specialization, 

209
00:12:41,840 --> 00:12:45,240
pursuing advanced certification,
or exploring non traditional 

210
00:12:45,240 --> 00:12:48,120
roles, there's a wealth of 
opportunities out there waiting 

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00:12:48,120 --> 00:12:50,440
for you. 
Be sure to subscribe to the show

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00:12:50,440 --> 00:12:53,120
so you don't miss an episode and
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00:12:53,360 --> 00:12:56,760
It helps the podcast grow. 
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214
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You can always message us at 
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218
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00:13:14,240 --> 00:13:17,680
Until next time, take care, stay
curious, and keep advancing your

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00:13:17,680 --> 00:13:20,760
careers as a nurse practitioner.
And just a friendly reminder, 

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00:13:20,920 --> 00:13:23,640
the information on this podcast 
is for educational purposes 

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00:13:23,640 --> 00:13:25,360
only. 
The information should not be 

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00:13:25,360 --> 00:13:27,960
used and substitute for 
professional care by a medical 

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00:13:27,960 --> 00:13:30,120
provider. 
The information on this podcast 

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00:13:30,120 --> 00:13:33,160
does not represent medical or 
professional advice or services.

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Bye for now.