Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Airway management in obstetrics patientHASSAN RASHID
OBSTETRICAL PATIENTS POSE A CHALLENGE TO THE ANAESTHESIA PROVIDER. APART FROM VARIOUS PHYSIOLOGICAL CHANGES, AIRWAY CHANGES ALSO ARE OF IMPORTANT CONSIDERATION
Advances in the field of labour analgesia have tread a long journey from the days of ether and chloroform in 1847 to the present day practice of comprehensive programme of labour pain management using evidence-based medicine. Newer advances include introduction of newer techniques like combined spinal epidurals, low-dose epidurals facilitating ambulation, pharmacological advances like introduction of remifentanil for patient-controlled intravenous analgesia, introduction of newer local anaesthetics and adjuvants like ropivacaine, levobupivacaine, sufentanil, clonidine and neostigmine, use of inhalational agents like sevoflourane for patient-controlled inhalational analgesia using special vaporizers, all have revolutionized the practice of pain management in labouring parturients.
Anaesthetic management of ruptured ectopic pregnancy by Arowojolu BoluwajiArowojolu Samuel
anaesthetic management of a patient with ruptured ectopic pregnancy. helping anaesthetist to know what to do in emergency anaesthesia. this is an emergency case. salpingectomy. arowojolu boluwaji
General anesthesia & obstetrics- c-section part ISandro Zorzi
→ Discuss indications of general anesthesia for operative delivery
→ Explain aspiration risk for general anesthesia in pregnancy and prevention strategy
Outline anaesthesia plan of care for induction, maintenance and emergency
Describe effect of volatile anaesthetics on uterine blood flow and tone
Discuss intraoperative strategies to prevent postoperative nausea and vomiting
Discuss other complications of general anaesthesia and clinical management
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Airway management in obstetrics patientHASSAN RASHID
OBSTETRICAL PATIENTS POSE A CHALLENGE TO THE ANAESTHESIA PROVIDER. APART FROM VARIOUS PHYSIOLOGICAL CHANGES, AIRWAY CHANGES ALSO ARE OF IMPORTANT CONSIDERATION
Advances in the field of labour analgesia have tread a long journey from the days of ether and chloroform in 1847 to the present day practice of comprehensive programme of labour pain management using evidence-based medicine. Newer advances include introduction of newer techniques like combined spinal epidurals, low-dose epidurals facilitating ambulation, pharmacological advances like introduction of remifentanil for patient-controlled intravenous analgesia, introduction of newer local anaesthetics and adjuvants like ropivacaine, levobupivacaine, sufentanil, clonidine and neostigmine, use of inhalational agents like sevoflourane for patient-controlled inhalational analgesia using special vaporizers, all have revolutionized the practice of pain management in labouring parturients.
Anaesthetic management of ruptured ectopic pregnancy by Arowojolu BoluwajiArowojolu Samuel
anaesthetic management of a patient with ruptured ectopic pregnancy. helping anaesthetist to know what to do in emergency anaesthesia. this is an emergency case. salpingectomy. arowojolu boluwaji
General anesthesia & obstetrics- c-section part ISandro Zorzi
→ Discuss indications of general anesthesia for operative delivery
→ Explain aspiration risk for general anesthesia in pregnancy and prevention strategy
Outline anaesthesia plan of care for induction, maintenance and emergency
Describe effect of volatile anaesthetics on uterine blood flow and tone
Discuss intraoperative strategies to prevent postoperative nausea and vomiting
Discuss other complications of general anaesthesia and clinical management
Blood loss of >/ 500 ml within 24 hours of vaginal birth or 1000 ml after caesarean section or any blood loss sufficient to compromise haemodynamic instability
MINOR PPH- 500- 1000ml blood loss
MAJOR PPH- > 1000ml Blood loss
MASSIVE PPH- >2000ml Blood loss
This slide presents some Gynecologic diseases and disorders in females and their proper management. It is a third-year course for those wishing to major PA or Nursing.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
2. OBSTETRIC HAEMORRHAGE
Worlds leading cause of maternal mortality
Major obstetric haemorrhage complicates up to
10.5% of all births
In India obstetric haemorrhage contributes to
22.34% of all maternal deaths
3. Obstetric haemorrhage is can be classified as
Antepartum haemorrhage
defined as bleeding from vagina after 24 wks. of
gestation and before delivery
Post partum haemorrhage
defined as blood loss within 24hrs of delivery
which is more than 500ml following vaginal delivery
,more than 1000ml following caesarean section
5. PLACENTA PREVIA
placenta previa is present when the placenta implants in
advance of the foetal presenting part
incidence of placenta previa is approximately 1 in 200
pregnancies
total placenta previa ---completely covers the cervical os
partial placenta previa--- covers part, but not all of the cervical
os
marginal placenta previa ---lies close to, but does not cover the
cervical os
7.
The most characteristic event in placenta previa is
painless hemorrhage.
This usually occurs near the end of or after the
second trimester.
The initial bleeding is rarely so profuse as to prove
fatal.
It usually ceases spontaneously, only to recur.
Placenta previa may be associated with placenta
accreta, placenta increta or percreta.
Coagulopathy is rare with placenta previa.
8. DIAGNOSIS
should always be suspected in women with uterine
bleeding during the latter half of pregnancy.
appropriate evaluation, including sonography
examination of the cervix is never permissible unless the
woman is in an operating room with all the preparations
for immediate cesarean delivery, because even the
gentlest examination of this sort can cause torrential
hemorrhage.
safest method is transabdominal sonography.
MRI
At 18 weeks, 5-10% of placentas are low lying. Most
‘migrate’ with development of the lower uterine segment
10. ANAESTHETIC MANAGEMENT
For Double Set-Up examination
Rarely performed
performed in the operating room
full preparation for cesarean section which includes
maternal monitors,
insertion of two large-gauge intravenous
cannulae,
administration of a nonparticulate antacid
sterile prep , draping of the abdomen
Two units of packed red blood cells (PRBCs
11. FOR CAESAREAN SECTION
choice of anaesthetic technique depends on the
indication and urgency for caesarean section
and the degree of maternal hypovolemia
High risk of intra operative blood loss due to
obstetrician may cut into the placenta during
uterine incision
lower uterine segment implantation site does
not contract well
increased risk for placenta accreta
12.
A retrospective study with 350 cases of
placenta previa [ 60 % regional , 40 % GA ]
found
decraesed EBL with RA vs. GA
decrased transfusions needs with RA
no difference in hypotension
N Parekh et al Br J Anaesth 2000;84;725
13. PREOPERATIVE PREPARATION
patient evaluation, resuscitation, and
preparation for operative delivery all proceed
simultaneously
careful assessment of the parturient's airway
and intravascular volume
Two large-gauge intravenous catheters
four units of PRBCs
Blood administration sets
fluid warmers
equipment for invasive monitoring
14. Rapid-sequence induction of general anesthesia
is the preferred technique
avoid sodium thiopental
propofol should not be used in hypovolemic
patients
Ketamine (0.5 to 1.0 mg/kg) and etomidate (0.3
mg/kg) are the best induction agents for
bleeding patients
patients with severe hypovolemic shock,
intubation may require only a muscle relaxant
15. MAINTENANCE
nitrous oxide and oxygen with a low concentration
of a volatile halogenated agent
concentration of nitrous oxide can be reduced (or
omitted) in cases of foetal distress
Oxytocin (20 U/L) immediately after delivery
lower uterine segment implantation site does not
contract as well as the fundus
All uterine relaxants should be eliminated if
bleeding continues
best to eliminate the volatile halogenated agent after
delivery
substitute nitrous oxide (70%) and an intravenous
opioid
16. ABRUPTIO PLACENTA
Placental abruption is defined as separation of
the placenta from the decidua basalis before
delivery of the foetus
Incidence 1 in 100 pregnancies
Risk factors
hypertension
advanced age and parity
tobacco use
cocaine use
trauma
premature rupture of membranes
a history of previous abruption
18. OBSTETRIC MANAGEMENT
definitive treatment is delivery of the fetus and
placenta
degree of abruption is minimal
the fetus shows no signs of distress
Maternal haemodynamics stable
Hospitalisation
Foetal HR monitoring
Serial ultra sonography
Maternal haemodynamic monitoring
Delivered after foetal lung maturation
19. ANAESTHETIC MANAGEMENT
Preoperative preparation
airway assessment
Assessment of volume status
Maternal Haemodynamic monitoring
FHR monitoring
Two large bore IV catheters
Blood for cross matching , haematocrit ,
coagulation
Maintain supplemental oxygen
Left uterine displacement
20. FOR LABOUR AND NORMAL DELIVERY
Epidural analgesia can be given only if
coagulation studies are normal
no intravascular volume deficit
Vincent et al.[36] observed that epidural anesthesia
significantly worsened maternal hypotension, uterine blood
flow, and fetal PaO2 and pH during untreated hemorrhage (20
mL/kg)
21.
22. CAESAREAN SECTION
General anaesthesia is preferred for most of the
cases
Regional anaesthesia can be given for a patient
with stable haemodynamics ,good intravascular
volume ,minor abruption, NO foetal distress
Ketamine and etomidate are inducing agents of
choice
Rapid sequence induction is preferred
Large doses of ketamine may increase uterine
tone during early gestation
So dose of ketamine should be limited to single
dose of 1mg/kg
23.
Aggressive volume resuscitation with both
crystalloids and colloids
Blood transfusion
Central venous catheter and arterial catheter may be
necessary
High risk for uterine atony and coagulopathy
Oxytocin 20U/L infused immediately after the
delivery
Coagulation abnormalities may require FFP
Recover quickly and completely after delivery
prolonged hypotension, coagulopathy, and massive
blood volume/product replacement, are best
monitored in a multidisciplinary intensive care unit.
24. UTERINE RUPTURE
Rupture of the gravid uterus can be disastrous to
both the mother and foetus
It may be of two types
uterine scar dehiscence
complete uterine rupture
Scar dehiscence
foetal distress less common
no excessive haemorrhage
rarely requires emergency section
Uterine rupture
foetal distress
massive haemorrhage
requires emergency caesarean section
27. ANAESTHETIC MANAGEMENT
Preoperative evaluation , resuscitation and
preparation of OT simultaneously
GA is often required
RA can be given in haemodynamically stable
patients , who already have a epidural catheter
,absence of foetal distress
Aggressive volume replacement
maintenance of urine output
Invasive hemodynamic monitoring
28. VASAPREVIA
Occurs rarely 1 in 2000 to 3000 deliveries.
Vasa previa is associated with a velamentous insertion of the
cord where foetal vessels traverse the foetal membranes ahead
of the foetal presenting part.
Highest foetal mortality rates 50% to 75%
No threat to the mother
Early diagnosis and treatment are essential to reduce the
chance of foetal death
Requires immediate delivery by caesarean section
Neonatal resuscitation, neonatal volume replacement
Choice of anaesthetic technique depends on the urgency of
caesarean section
29. POST
PARTUM HAEMORRHAGE
Major cause of maternal morbidity and mortality
Types
Primary postpartum haemorrhage occurs
during the first 24 hours after delivery
secondary postpartum haemorrhage occurs
between 24 hours and 6 weeks postpartum
Causes
Uterine atony
Genital trauma
Coagulopathy
Placental abnormalities
30.
31. UTERINE ATONY
Risk factors
Multiple gestation
Macrosomia
Polyhydramnios
High parity
Chorioamnionitis
Precipitous labor
Augmented labor
Tocolytic agents
High concentration of a volatile agents
Prolonged labor
32. OXYTOCIN
first-line drug for the prophylaxis or treatment of uterine atony
Endogenous oxytocin is a 9-amino acid polypeptide produced
in the posterior pituitary
exogenous form is a synthetic preparation
20 U of oxytocin to a litre of NS or RL started as infusion
Bolus administration of oxytocin causes peripheral
vasodilation, hypotension
Weis et al.[53] administered oxytocin 0.1 U/kg intravenously to
pregnant women in the first trimester. They noted that heart rate
increased, MAP decreased by 30%, and total peripheral
resistance decreased by 50%
Secher et al.[54] noted that bolus intravenous administration of 5
or 10 U of oxytocin increased pulmonary artery pressures in
pregnant women
cardiovascular changes are short lived (less than 10 minutes).
33. prostaglandin E2
vaginal or rectal suppository 20mg every 2hrly
causes bronchodilation
decreased SVR and blood pressure
increased heart rate , cardiac output
prostaglandin F2-alpha
increases cardiac output
increases systemic and pulmonary artery pressures
Increased PaCO2 and decreased PaO2
alterations of ventilation/perfusion ratios
bronchospasm
15-Methyl prostaglandin F2-alpha (carboprost)
preferred for the treatment of refractory uterine atony
250 μg administered intramuscularly or intramyometrially
Bronchospasm
disturbed ventilation/perfusion ratios
increased intrapulmonary shunt fraction
hypoxemia.
34. Misoprostol
800 -1000 mcg rectally
prostaglandin E1 analogue
effective treatment for postpartum haemorrhage
unresponsive to oxytocin and ergometrine
Ergot alkaloids
0.2mg iv every 2-4 hrs
Ergonovine and methylergonovine
restricted to postpartum use
rapidly produce tetanic uterine contraction
act on alpha-adrenergic receptors
Cause vasoconstriction, hypertension, Pulmonary
artery pressure , Pulmonary oedema
35. GENITAL TRAUMA
Most common injuries at childbirth are lacerations and
hematomas of the perineum, vagina, and cervix
Pelvic hematomas are three types:
vaginal, vulvar, and retroperitoneal
signs and symptoms
restlessness,
lower abdominal pain,
a tender mass above the inguinal ligament
vaginal bleeding
abrupt hypotension
Ileus
unilateral leg oedema
urinary retention
haematuria
36. ANAESTHETIC MANAGEMENT OF GENITAL
TRAUMA
For vulval haematomas and small lacerations
Local infiltration and a small dose of intravenous opioid
For extensive lacerations and vaginal haematomas
pudendal nerve block – technically may not be feasible
neuraxial blockade – may cause hypotension
MAC – most preferred
N2O ,O2 with inhalational agents
low dose ketamine
For retroperitoneal haematoma
laparotomy with general anaesthesia
rapid sequence induction
difficult intubation to be anticipated
37. RETAINED PLACENTAL PRODUCTS
Retained placental fragments are a leading cause of both early
and delayed postpartum hemorrhage
OBSTETRIC MANAGEMENT
manual removal and inspection of the placenta
After removal of the placenta, uterine tone should be
enhanced with oxytocin
38. ANAESTHETIC MANAGEMENT OF RETAINED
PLACENTAL PRODUCTS
If epidural catheter is in situ additional local
anaesthetic drug can be given
Subarachnoid block can be given if patient is
haemodynamically stable
Nitrous oxide analgesia
Low dose ketamine
GA can be given with rapid sequence induction
Methods to facilitate uterine relaxation
halogenated inhalational agents
nitroglycerine
40. Placenta accreta vera is defined as adherence to the
myometrium without invasion of or passage through
uterine muscle
Placenta increta represents invasion of the myometrium
Placenta percreta includes invasion of the uterine serosa
or other pelvic structures
Risk factors
previous uterine trauma
previous caesarean section
low lying placenta
Diagnosis
antepartum diagnosis is rare
difficulty in removal placenta
ultrasonography
MRI
transvaginal colour dopler
41.
Obstetric management
uterine curettage, followed by over-sewing of the bleeding
placental bed.
Balloon occlusion
embolization techniques
postpartum hysterectomy – definitive
Anaesthetic management
preoperative diagnosis of placental abnormalities
identifying patients with high risk for placenta accreta
preparation for hysterectomy
availability of blood products
42. UTERINE INVERSION
Turning inside out of all or part of the uterus
Occur in 1 In 5000 to 1 in 10,000 pregnancies
Risk factors
uterine atony
inappropriate fundal pressure
umbilical cord traction
uterine anomalies.
An abnormally implanted placenta
(i.e., placenta accreta)
Obstetric management
Early replacement of the uterus is the best treatment
Once the uterus has been replaced.
Oxytocin (20 U/L) should be infused initially,
additional drugs (15-methyl prostaglandin F2-alpha)
may be needed
43. ANAESTHETIC MANAGEMENT OF UTERINE
INVERSION
uterine tone precludes immediate replacement,
uterine relaxation is needed before successful replacement can be
performed
Ideal technique should have
rapid uterine relaxation
no side effects
short duration
restoration of uterine tone after replacement of the uterus
GA with inhalational agents most preferred
Equipotent doses of all volatile halogenated agents produce a
similar degree of uterine relaxation
Endotracheal intubation is mandatory
Other modes
terbutaline, magnesium sulfate, organic nitrates
44. INVASIVE TREATMENT FOR OBSTETRIC
HAEMORRHAGE
Includes
angiographic arterial embolization
balloon occlusion
surgical arterial ligation
hysterectomy
Embolization
local anaesthesia
complications are few
preservation of fertility is likely
Can be done in presence of a coagulopathy
Requires rapid access to angiographic facility
Requires skilled radiologist
Logistic problems
45. Bilateral surgical ligation
uterine, ovarian, and internal iliac arteries
preservation of fertility
damage to other pelvic structures (ureter)
vascular anatomy is variable
lower extremity ischemia
postpartum hysterectomy
definitive treatment for postpartum haemorrhage
Tissues are oedematous and congested
Amount of blood loss is more
multicentre review showed that the average blood
loss for emergent cases was 2526 mL, with an
average transfusion requirement of 6.6 units of blood
46.
47. ANAESTHETIC MANAGEMENT
obstetrician requires good skeletal muscle relaxation and a quiet operative
field
Choice of technique
Regional anaesthesia
Risk of hypotension
The operative time for caesarean hysterectomy is more
patient may have fatigue and restlessness.
Intraperitoneal manipulation, dissection, and traction result in pain,
nausea, and vomiting.
hyperemic pelvic viscera with engorged, edematous vasculature
require careful dissection facilitated by a quiet operative field
If RA is given then
Maintenance of a T-4 sensory level
prophylaxis against nausea and vomiting
judicious sedation
Most of the cases require GA for emergency obstetric hysterectomy
48. Regardless of the anaesthetic technique used
two large-gauge intravenous catheters
at least two units of packed PRBCs should be
immediately available.
Additional units should be available without
delay.
Vasoactive drugs (e.g., phenylephrine,
dopamine, epinephrine).
establish invasive monitoring.
A fluid warmer
equipment for rapid infusion of fluids
49. RECENT ADVANCES
Intra operative cell salvage
Chance of amniotic fluid embolism
Haemolytic disease in future pregnancies
Leukocyte depletion filter is useful
Separate suction for amniotic fluid advised
Thromboelastography
Useful guide in massive haemorrhage
Provides information regarding coagulation factors , platelet
function, fibrinogen levels , fibrinolysis
Rapid results
Can be done near the patient
50.
Role of tranexaemic acid
Antifibrinolytic
1gm IV stat dose
Followed by a second dose after 30 min if bleeding doesn’t stop
World maternal antifibrinolytic trail
Recombinant factor VIIa
useful in unresponsive massive haemorrhage
Coagulopathy has to be corrected prior
Prerequisites
platelet count >50,000
fibrinogen > 0.5gms /L
ph. >7.2
Dose – 90 mcgs/kg stat dose
followed by 120 mcg/kg if bleeding persists
Thromboembolic events can occur
High cost , lack of availability