This document discusses antepartum haemorrhage (APH), defined as bleeding from or into the genital tract occurring after 22 weeks of pregnancy but before birth. APH complicates 3-5% of pregnancies and is a leading cause of perinatal and maternal mortality. The main causes of APH are placenta praevia, abruptio placentae, vasa praevia, and local cervical/vaginal bleeding of unknown origin. Management depends on the severity and cause of bleeding, and may involve bed rest, steroids, monitoring, blood transfusions, or delivery by vaginal birth or caesarean section.
Presented by:
Ahmad mukhtar
MD.,M.B.B.Ch., M.Sc Obstetrics and GynecologyConsultant and Lecturer of Obstetrics and Gynecology, Faculty of
MEDICINE, Zagazig University.
Amniotic fluid maintain the perfect homeostasis between mother and fetus. It protect both mother and fetus from various complications. Details is enclosed in presentation.
Presented by:
Ahmad mukhtar
MD.,M.B.B.Ch., M.Sc Obstetrics and GynecologyConsultant and Lecturer of Obstetrics and Gynecology, Faculty of
MEDICINE, Zagazig University.
Amniotic fluid maintain the perfect homeostasis between mother and fetus. It protect both mother and fetus from various complications. Details is enclosed in presentation.
Antepartum Haemorrhage Presentation- Dr. Jauyo.pdfOumaJauyo
CME presentation slides on Antepartum Haemorrhage
Bleeding from or in to the genital tract, occurring from 24
weeks (>500g) of pregnancy and prior to the birth of the
baby
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
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Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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3. Definition
Antepartum haemorrhage (APH) is defined as bleeding
from or in to the genital tract, occurring from 22 weeks
(>500g) of pregnancy and prior to the birth of the baby.
complicates 3–5% of pregnancies
leading cause of perinatal and maternal mortality
worldwide.
Up to one-fifth of very preterm babies are born in
association with APH
Most of the time unpredictable.
RCOG
4. Severity
NO consistent definitions of the severity of APH.
It is recognised that the amount of blood lost is often
underestimated .
The amount of blood coming from the introitus may not
represent the total blood lost (for example in a
concealed placental abruption).
It is important to assess for signs of clinical shock. The
presence of fetal compromise or fetal demise is an
important indicator of volume depletion.
RCOG Guidelines
5. Different terminologies used:
Spotting – staining, streaking or blood spotting noted on
underwear or sanitary protection
Minor haemorrhage – blood loss less than 50 ml that has
settled
Major haemorrhage – blood loss of 50–1000 ml, with no
signs of clinical shock
Massive haemorrhage – blood loss greater than 1000 ml
and/or signs of clinical shock.
Recurrent APH - > one episode
RCOG Guidelines
6. Etiology
Placenta praevia
Abruptio placenta
Vasa praevia
Excessive show
Local causes ( bleeding from cervix, vagina and
vulva )
Inderterminate APH
7. Placenta Praevia (PP)
Implantation of placenta over or near the internal
os of cervix.
Confirm diagnosis of PP can be done at 28 weeks
when LUS forming.
Leading cause of vaginal bleeding in the 2nd and 3rd
trimester.
9. Risk Factors of Placenta Praevia
Previous placenta praevia (4-8%)
Previous caesarean sections ( risk with numbers of c-section)
Previous termination of pregnancy
Multiparity
Advanced maternal age (>40 years)
Multiple pregnancy
Smoking
Deficient endometrium due to presence or history of:
- uterine scar
-endometritis
-manual removal of placenta
- curettage
-submucous fibroid
Assisted conception
RCOG
10. Clinical classification
Minor :
Type 1 (anterior/posterior)
Type 2 anterior
Major:
Type 2 posterior (dangerous type)
Type 3
Type 4
Deliver vaginally
Type 1 Posterior > likelihood of
fetal distress
Caesarean section
Type 2 posterior >
chance of fetal distress
Type 3 & 4 anterior –cut
through placenta to
deliver. Hence need to be
fast and efficient.
11. Abruptio Placenta (AP)
Separation of normally located placenta after 22
weeks of gestation ( > 500g) and prior to delivery
of fetus.
12. Risk factors:
- Previous history of AP
- Maternal hypertension
- Advanced maternal age
- Trauma ( domestic violence, accident, fall)
- Smoking/alcohol/cocaine
- Short umbilical cord
- Sudden decompression of uterus (
PROM/delivery of 1st twins)
- Retroplacental fibroids
- Idiopathic
13. Obstetrics Emergency!!
Diagnosed CLINICALLY :
Painful vaginal bleeding -80%
Tense and tender abdomen/back pain (70%)
Fetal distress( 60%)
Abnormal uterine contractions (hypertonic and high
frequency)
Preterm labour ( 25%)
Fetal death ( 15%)
Ultrasound is NOT USEFUL to diagnose AP.
Retroplacental clots (hyperechoic) easily missed.
Obstetrics today
14. Vasa Praevia (VP)
Rupture of fetal vessels that run in membrane
below fetal presenting part which is unsupported
by placenta/ umbilical cord.
Predisposing Factors:
-Velamentous insertion of the umbilical cord
-Accesory placental lobes
-Multiple gestations
Obstetrics today
15. The term velamentous
insertion is used to
describe the condition in
which the umbilical cord
inserts on the
chorioamniotic
membranes rather than on
the placental mass.
16.
17. Diagnosis of VP
Antenatal diagnosis –reduced perinatal mortality and
morbidity.
Painless vaginal bleeding at the time of spontaneous
rupture of membrane or post amniotomy
Fetal bradycardia
Fetal shock or death can occur rapidly at the time of
diagnosis due to blood loss constitutes a major bulk of
blood volume is fetus ( 3kg fetus-300ml)
Hence, ALWAYS check the fetal heart after rupture of
membrane or amniotomy.
Definitive diagnosis by inspecting the placenta and
fetal membrane after delivery.
Obstetrics today
18. Complications of APH
Maternal complications Fetal complications
Anaemia Fetal hypoxia
Infection Small for gestational age and fetal
growth restriction
Maternal shock Prematurity (iatrogenic and
spontaneous)
Renal tubular necrosis Fetal death
Consumptive coagulopathy
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion
RCOG Guidelines
19. Clinical assessment in APH
First and foremost Mother and fetal well
being (mother is the priority)
establish whether urgent intervention is required
to manage maternal or fetal compromise.
Assess the extent of vaginal bleeding,
cardiovascular condition of the mother
Assess fetal wellbeing.
20. Full History
Should be taken after the mother is stable.
associated pain with the haemorrhage?
Continuous pain : Placental abruption.
Intermittent pain : Labour.
Risk factors for abruption and placenta praevia
should be identified.
reduced fetal movements?
If the APH is associated with spontaneous or
iatrogenic rupture of the fetal membranes : ruptured
vasa praevia
Previous cervical smear history possibility of Ca
cervix. Symptomatic pregnant women usually present
with APH (mostly postcoital) or vaginal discharge.
21. Examination
General: PULSE & BP ( a MUST!)
Abdomen:
- The tense, tender or ‘woody’ feel to the uterus
indicates a significant abruption.
- Painless bleeding, high fetal presenting part –
Placenta praevia
- soft, non-tender uterus may suggest a lower
genital tract cause or bleeding from placenta or
vasa praevia.
22. Examination
Speculum :
-identify cervical dilatation or visualise a lower
genital tract cause.
Digital vaginal examination
- Should NOT be done until Placenta Praevia has
been excluded by USG.
RCOG Guidelines
23. Investigations
FBC
Coagulation profile
Blood Grouping and CXM, GSH.
Ultrasound- TRO PP/ IUD
D-dimer : AP
colour doppler TVS – VP
In all women who are RhD-negative, a Kleihauer test
should be performed to quantify FMH to gauge the
dose of anti-D Ig required.
Fetal monitoring:
CTG monitoring
RCOG Guidelines
24. Management
WHEN to admit?
Based on individual assessment
-Discharge after reassurance and counselling
Women presenting with spotting who are no longer
bleeding and where placenta praevia has been
Excluded.
However, a woman with spotting + previous IUD due to
placenta abruption, an admission would be
appropriate.
- All women with APH heavier than spotting and women
with ongoing bleeding should remain in hospital at
least until the bleeding has stopped.
25. Management
If preterm delivery is anticipated, a single course of
antenatal corticosteroids ( dexamethasone 12mg 12 hourly
,2 doses) to women between 24 and 34 weeks 6 days of
gestation.
Tocolytics should NOT be given unless for VERY preterm
women who need time to transfer to hospital with NICU.
For very preterm ( 24-26 weeks) ,
-conservative management if mother is stable .
-Delivery of fetus – life threatening
At these gestations, experienced neonatologists should be
involved in the counselling of the woman and her partner
RCOG
26. Management
For Placenta Praevia
Conservative – MaCafee’s regime
( premature < 37 weeks;mother haemodynamically
stable,no active bleeding, fetus stable)
-advise bed rest, keep pad chart, vital signs
monitoring , Ultrasound, steroids, GSH, Daily
CTG and biophysical profile, fetal movement
count.
Plan for delivery ( >37 weeks)
Crossmatch 4 units of blood.
27. Definitive treatment
Type I,II(ant) Type II( post), III,IV
ARM +/- oxytocin
Satisfactory progress
without bleeding
Vaginal delivery
Bleeding continues
Caesarean section
Caesarean section
28. For Abruptio placenta,(obs
emergency)
ICU admission : Close monitoring and
resuscitation!
- ABC ( high flow O2, aggressive fluid
resuscitation)
- Continuous Vital signs monitoring and urine
output
- Monitor vaginal bleeding – strict pad chart
- Continuous CTG for fetal heart rate
- Crossmatch 4 units of blood
- FFP – coagulopathy
- Dexamethasone – preterm
29. Abruptio Placenta
Decide Mode of delivery
Vaginal delivery – when fetal death
Caesarean section –if maternal/ fetal health
compromised
- Indicated when early DIC sets in
- Consent should be taken for hysterectomy in
case bleeding could not be controlled.
Obstetrics today
30. Management
For Rh negative mothers,
Anti-D Ig should be given to all after any presentation
with APH, independent of whether routine antenatal
prophylactic anti-D has been administered.
In the non-sensitised RhD-negative woman for all
events after 20 weeks of gestation, at least 500 iu
anti-D Ig should be given followed by a test to identify
FMH, if greater than 4 ml red blood cells; additional
anti-D Ig should be given as required.
RCOG Guidelines