1) Bleeding in early pregnancy, defined as before 22 weeks, can be caused by miscarriage, ectopic pregnancy, molar pregnancy, or other issues. A rapid assessment including vital signs and exam is needed.
2) Miscarriages are categorized as safe, unsafe, threatening, inevitable, incomplete, or septic and management depends on the category and gestational age. Manual vacuum aspiration is preferred for evacuating the uterus under 16 weeks.
3) Post-miscarriage care involves screening for physical and mental health issues, providing counseling and information, and discussing family planning options.
CTG Interpretation, evidence based approach
Cardiotocography (CTG) or electronic fetal monitoring (EFM) is the most widely used technique for assessing fetal wellbeing in labour in the developed world. The primary purpose of fetal surveillance by CTG is to prevent adverse fetal outcomes. Continuous electronic foetal monitoring is recommended to assure fetal wellbeing in labour in high risk pregnant women. Understanding pathophysiology of fetal heart rate variation will help appropriate interpretation of the CTG.
Features & classification of CTG according to RCOG will be demonstrated in this presentation with sufficient trace demonstration.
CTG Interpretation, evidence based approach
Cardiotocography (CTG) or electronic fetal monitoring (EFM) is the most widely used technique for assessing fetal wellbeing in labour in the developed world. The primary purpose of fetal surveillance by CTG is to prevent adverse fetal outcomes. Continuous electronic foetal monitoring is recommended to assure fetal wellbeing in labour in high risk pregnant women. Understanding pathophysiology of fetal heart rate variation will help appropriate interpretation of the CTG.
Features & classification of CTG according to RCOG will be demonstrated in this presentation with sufficient trace demonstration.
THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI
PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE
under and post graduate best presentation ever about the assisted vaginal delivery,operative vaginal delivery, or instrumental vaginal delivery.
done by waill salan al.timeemi/stager 2014-2015/ Iraq-al.qadisiyyah college of medicine.
Intra Partum Cardiotocography - dr vivek patkardrvivekpatkar
Cardiotocography ( CTG )
is a procedure of graphically ( graph) recording fetal heart activity and uterine contractions ( Toco ) – both recorded in the same time scale simultaneously and continuously through uterine quiscience and contractions
Labour induction
Induction of labour
Guidelines on induction of labour
Guidelines on labour induction
induction of labour is not risk free
prostaglandins for induction of labour
Bishop score
Cervical ripening techniques
mechanical and pharmacological induction of labour
Post dates induction
options for cervical ripening
oral vs. vaginal misoprostol
advantages diadvantages and techniques for induction of labour
gynecology & obstetrics
Labour induction methods
review of guidelines for labour induction
Vacuum delivery is one of the most important art to learn in labour ward. Kiwi is a simplified vacuum device. Mastering the techniques these devices can achieve good outcomes.
Abortion and other Causes of Early Pregnancy Bleeding.pdfChantal Settley
Describe common causes of bleeding in early pregnancy.
Describe the clinical classifications of abortion, the legal aspects of abortion in Ethiopia, and the safe methods used in health facilities.
Identify the warning signs and the emergency treatment required before referral for early pregnancy bleeding.
Describe the features of woman-friendly comprehensive post-abortion care, including the post-abortion family planning service
THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI
PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE
under and post graduate best presentation ever about the assisted vaginal delivery,operative vaginal delivery, or instrumental vaginal delivery.
done by waill salan al.timeemi/stager 2014-2015/ Iraq-al.qadisiyyah college of medicine.
Intra Partum Cardiotocography - dr vivek patkardrvivekpatkar
Cardiotocography ( CTG )
is a procedure of graphically ( graph) recording fetal heart activity and uterine contractions ( Toco ) – both recorded in the same time scale simultaneously and continuously through uterine quiscience and contractions
Labour induction
Induction of labour
Guidelines on induction of labour
Guidelines on labour induction
induction of labour is not risk free
prostaglandins for induction of labour
Bishop score
Cervical ripening techniques
mechanical and pharmacological induction of labour
Post dates induction
options for cervical ripening
oral vs. vaginal misoprostol
advantages diadvantages and techniques for induction of labour
gynecology & obstetrics
Labour induction methods
review of guidelines for labour induction
Vacuum delivery is one of the most important art to learn in labour ward. Kiwi is a simplified vacuum device. Mastering the techniques these devices can achieve good outcomes.
Abortion and other Causes of Early Pregnancy Bleeding.pdfChantal Settley
Describe common causes of bleeding in early pregnancy.
Describe the clinical classifications of abortion, the legal aspects of abortion in Ethiopia, and the safe methods used in health facilities.
Identify the warning signs and the emergency treatment required before referral for early pregnancy bleeding.
Describe the features of woman-friendly comprehensive post-abortion care, including the post-abortion family planning service
The presentation can be used for training of Doctors and Staff nurses on Emergency Obstetric care and MMR reduction strategies in Low Resource settings.
Covers the basic information about abortions that you need to know with in depth discussion of the different types of abortions and their characteristics
Understand why an antepartum haemorrhage should always be regarded as serious.
Provide the initial management of a patient presenting with an antepartum haemorrhage.
Understand that it is sometimes necessary to deliver the fetus as soon as possible, in order to save the life of the mother or infant.
Diagnose the cause of the bleeding from the history and examination of the patient.
Correctly manage each of the causes of antepartum haemorrhage.
Diagnose the cause of a blood-stained vaginal discharge and administer appropriate treatment.
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
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
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.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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.
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
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
1. Bleeding in early pregnancy
(miscarriage)
Themba Hospital DipObs Tutorials
By Dr N.E Manana
2. Intro
• Complications in early pregnancy however require specific skills best
provided by competent midwives and medical practitioners
appropriately trained to manage any problems in early gestation
• Seven to 10 per cent of pregnancies are associated with
complications in early gestation and account for 5.2 per cent of all
institutional maternal deaths recorded in South Africa.
• Facilities providing maternity service must have a system in place to
ensure that women with early pregnancy complications are managed
by health professionals with the relevant skills
3. BLEEDING IN EARLY PREGNANCY
• Bleeding in early pregnancy is defined as vaginal bleeding that occurs
within the first 22 weeks of gestation.
Diagnosis and treatment: Do a rapid assessment of the patient including
• Vital signs: pulse rate, respiration rate and BP
• Abdominal assessment: tenderness, size of uterus
• Other: vaginal examination, pallor, assess the extent of vaginal bleeding
(vaginal bleeding is regarded as “heavy” if a new pad is soaked within five
minutes and “light” if it takes more than five minutes to soak)
• Usually spontaneous but could be induced processes. Induced miscarriages
(termination of pregnancy) could have been done through legal or illegal
sources.
• Consider physical trauma and domestic violence as a cause.
4. BLEEDING IN EARLY PREGNANCY
Assess for complications
• If shocked, the patient needs active resuscitation
• Determine if the patient has had a safe or unsafe miscarriage
Differential Diagnosis
• Pregnancy test positive: consider miscarriage, ectopic pregnancy or molar
pregnancy.
• Pregnancy test negative: consider pelvic inflammatory disease (PID),
torsion of an ovarian cyst, acute appendicitis.
• Safe miscarriages are those unlikely to have a serious adverse outcome to
the patient.
• Unsafe miscarriages are more likely when done illegally or where existing
conditions makes it likely for the women to develop sepsis.
5.
6. MISCARRIAGE
• All types of miscarriages may be very distressing for the woman, whether
the pregnancy was intended or not, and whether she knew she was
pregnant or not.
Health workers should:
• Show kindness and compassion; (e.g. she can be reassured that she is not
to blame)
• Give clear information about possible causes, procedures and outcomes
• Take informed consent for all procedures and ensure privacy
• If possible, manage the woman away from pregnant women or postpartum
mothers
• Involve partners/companions of the woman, at her choosing
7. Safe miscarriage
Normal vital signs:
• No clinical signs of infection
• Pulse rate <90 beats per minute, Respiratory rate <20 breaths per minute
• Temperature <37.5°Celsius, Haemoglobin ≥10g/dl
• Uterus <12 weeks in size, Products of conception not foul smelling
• No suspicious findings on evacuation of the uterus
• Safe miscarriages can be managed at community health centres and district
hospitals.
• If there is any abnormality among the criteria for safe miscarriage, stabilise
and refer the patient to a district hospital with a 24-hour theatre available.
• If there is any organ dysfunction present, stabilise and refer urgently to a
specialist facility.
8. Signs of organ dysfunction
• Systolic blood pressure <90mmHg
• Respiratory rate >24 breaths per minute
• Oliguria (urine output <30mL for 2 hours despite fluid load)
Signs of tissue hypoperfusion:
• Altered mental status
• Decreased capillary filling
9. THREATENING MISCARRIAGE
• Mild bleeding in early pregnancy without cervical dilatation.
• The uterus size corresponds to the expected gestation.
• Surgical treatment is usually not needed.
• Not necessary to admit patient to hospital.
• Advise the woman to avoid strenuous activity and any sexual activity.
• If bleeding stops, continue antenatal care as scheduled.
• If the bleeding continues, assess for fetal viability with ultrasound
examination.
10. COMPLETE MISCARRIAGE
• After a complete miscarriage the bleeding is usually mild and the
cervical os closes.
• The uterus on palpation is smaller than expected for the gestational
period.
• Medical treatment or surgical evacuation of the uterus is usually not
needed.
• Advise the woman to report any continuous bleeding and make a
booking for post-miscarriage follow-up.
11. INEVITABLE MISCARRIAGE
• When a threatening miscarriage progresses, the volume of vaginal bleeding increases and the
cervix dilates.
• This is usually associated with an increase of cramping lower abdominal pains.
In pregnancy less than 16 weeks gestation:
• Plan for evacuation of uterine contents, if evacuation is not immediately possible:
• Give ergometrine 0.2 mg intramuscularly (repeated after 15 minutes if necessary) /
Syntometrine® OR
• Misoprostol 400 µg by mouth (repeated once after four hours if necessary); then arrange for
evacuation of uterus as soon as possible.
In pregnancy greater than 16 weeks:
• Wait for spontaneous expulsion of the products of conception.
• If products are incomplete on inspection, evacuate the uterus
• If necessary, infuse oxytocin 20 units in one litre intravenous fluids (normal saline or Ringer’s
lactate) over eight hours to help achieve expulsion of products of conception.
• Make sure the woman is booked for follow-up after treatment
12. INCOMPLETE MISCARRIAGE
• The cervix remains open, products of conception may be visible or felt, and the bleeding may be light or heavy.
• The uterus size does not correspond with the gestation.
In pregnancy less than 16 weeks:
• if the bleeding is light, remove visible products of conception with fingers or a ring forceps (swab holding forceps) and
observe.
• If bleeding remains light, no further action will be required
• if the bleeding is heavy after visible removal of products of conception the uterus must be evacuated
• Manual vacuum aspiration is the preferred method of evacuation if the uterine size is <12-14 weeks.
• (Sharp curettage should only be done if MVA is not available or possible)
In pregnancy greater than 16 weeks:
• Later in the pregnancy, chances are better that complete spontaneous expulsion of the products of conception may occur.
• Set up an intravenous line and infuse oxytocin 20 units in 1 litre ringers lactate every eight hours until expulsion of the
products of conception occurs.
• Misoprostol 200 µg orally four hourly may be given if the abortion does not progress on oxytocin (maximum 800 µg).
• After expulsion, examine the uterus and evacuate any remaining products of conception.
13. MANAGEMENT OF A SEPTIC MISCARRIAGE
Septic miscarriages should be managed at a specialist hospital; make immediate arrangements for the transfer. Stabilise
before referral as follows:
• Do a rapid assessment of the patient- circulation, airway and breathing
• Insert an intravenous infusion and start rehydration with Ringer’s lactate or normal saline
• Prescribe antibiotics and give the first dose before transfer:
• Ampicillin or Cephalosporin (usually one gram six hourly intravenously). Use Clindamycin (600 mg eight hourly
intravenously) as alternative for penicillin allergy
• Metronidazole 400 mg three times per day orally
• Reduce the toxic load through surgical removal of source within two to four hours after commencing antibiotics
• If the patient is shocked (pulse rate > systolic blood pressure), determine if the shock is due to hypovolemia or sepsis:
• Give one litre Ringer’s lactate rapidly over 20 minutes in an attempt to raise the blood pressure levels and decrease the
pulse rate
• If the blood pressure value increases and the pulse rate normalises, it is most likely hypovolemic shock due to
haemorrhage. Continue resuscitation
• If there is poor response (blood pressure values do not increase), repeat with another litre of Ringer’s lactate
• If there is still no response in spite of adequate fluid therapy, the patient is in septic shock
• All women in septic shock with organ dysfunction MUST be managed at a specialist hospital
14. POST-MISCARRIAGE/ABORTION FOLLOW-UP
• Woman who have had a miscarriage often experience distress at the time of the
miscarriage, shortly afterwards or in the future.
• Kind and gentle emotional support by the healthworker may be very useful.
• Explore the feelings of the woman and validate these.
• These may be grief, guilt, emptiness, fear, loneliness, confusion, out of control.
• If she feels guilty, reassure her she is not to blame with clear explanations.
• Explore who she would like to be with for emotional support.
• It is possible to develop mental health problems because of the grief.
• Depression and anxiety are common, but some women may develop Post-
Traumatic Stress Disorder.
• If the woman has a mental health history, refer for mental health support.
• If little available in your setting, give her numbers SADAG 0800 456 789/ 0800 70
80 90 or Lifeline 0861 322 322 or FAMSA.
15. Information
Women who have had a miscarriage must be provided with appropriate
information.
• Inform her that spontaneous miscarriage is common and occurs in one out
of every seven pregnancies.
• Reassure her that the chances of a subsequent pregnancy being successful
are good
• Women should only consider a next pregnancy after full recovery from the
miscarriage.
• Women who have had an unsafe miscarriage must be counselled regarding
the factors that affected her pregnancy, and how to prevent this in future.
• Appropriate counselling must be done for family planning.
• Hormonal pills, injections, implants as well as intrauterine devices and
tubal ligation may be provided immediately.
16. MANUAL VACUUM ASPIRATION TECHNIQUE
• Manual Vacuum Aspirations (MVA) is the best technique for the removal of products of
conception in women with incomplete abortions, inevitable abortions prior to 16 weeks
gestation, molar pregnancies or delayed post-partum haemorrhage due to retained
placental fragments.
Advantages of MVA:
• Can be done as an out-patient procedure
• Does not require anaesthesia or an operation theatre
• Significantly reduces blood loss and the need for blood transfusion
Initial steps:
• Inform the patient of the diagnosis and treatment options
• Obtain informed written consent
• The patient must empty her bladder just before the procedure
• Provide emotional support and encouragement
• Provide pre-procedure analgesics: Paracetamol 500 mg 30 minutes before the procedure
17. MANUAL VACUUM ASPIRATION TECHNIQUE
When starting the procedure:
• Make sure the bladder is empty, prepare a Karman syringe with the vacuum by locking the plunger arms
• Give the patient 10 units oxytocin intramuscularly to make the myometrium firmer, perform a bimanual
examination to assess the size and position of the uterus
• Insert a vaginal speculum and clean the vagina and cervix with an antiseptic solution (water based), check
the cervix for tears or products of conception. (If products are visible, remove with a sponge holding forceps)
• Gently grasp the anterior lip of the cervix with sponge holding forceps, gently introduce the widest gauge
suction cannula through cervical os, push the cannula into uterine cavity until it touches the fundus (max 10
cm) and pull back slightly
• Attach the MVA syringe to the cannula and release the valves to transfer vacuum to the uterine cavity
• Evacuate uterine contents by gently rotating the syringe and moving the cannula backward and forward
Check for signs of completion:
• Red or pink foam but no more tissues, a grating sensation, uterus contracts around the cannula withdraw
the cannula.
• Empty contents of the syringe into a strainer
• Remove the speculum and perform bimanual examination to check the uterus size and firmness
18. MANUAL VACUUM ASPIRATION TECHNIQUE
Post procedure care
• Give analgesia (Paracetamol 1 g six hourly orally as needed)
• Encourage the woman to eat, drink and walk around as she wishes
Offer other health services before discharge:
• Family planning
• HIV and syphilis testing and counselling
• Rh blood group screen if not known
19. MANUAL VACUUM ASPIRATION TECHNIQUE
Discharge the patient in one to two hours if there are no complications and
advise her to watch for symptoms that would require immediate action.
Ask the patient to return if she experiences:
• Prolonged cramping (more than two days)
• Prolonged bleeding (more than two weeks)
• Bleeding more than a menstruation
• Severe or increasing pain
• Fever, chills or malaise
• Fainting
• It is important to carefully document all actions, procedures and
observations.
20. ECTOPIC PREGNANCY
• A woman with a positive pregnancy test and an acute abdomen mostly
likely has a ruptured ectopic pregnancy.
• This is a surgical emergency and the patient must be taken to the operating
theatre immediately for explorative laparotomy.
• Order blood, but do not wait for the blood to arrive before doing the
laparotomy.
• Ultrasound may assist with the diagnosis, especially if it shows an empty
uterus and free fluid in the abdomen, but with an acute abdomen the
investigation of choice is surgery.
• If ultrasound and serum beta-HCG is not available and the diagnosis is
doubtful, a culdocentesis may be of value; if non-clotting blood is obtained,
start treatment immediately
21. ECTOPIC PREGNANCY
Surgical management
• Do adequate fluid resuscitation on the way to theatre, but do not delay surgery,
the woman is bleeding actively and unless you stop the bleeding surgically, she
will die.
• Do a midline (up-and-down) incision in the abdomen, as there may be other
unexpected pathology. A Pfannenstiel incision allows very limited exposure and
should only be used for elective surgery or if the site of the ectopic pregnancy can
be clearly identified on ultrasound.
• Be careful not to damage the bowel when opening the peritoneum
• Use a large suction and your hand to remove as much blood clots as possible to
quickly visualise the tubes; if there is too much blood put your hand behind the
uterus and feel on which side the ruptured tube is.
• Clasp the ruptured tube between your fingers to temporarily stop the bleeding;
then remove all the clots until you have good visibility.
• Identify both ovaries and make sure they are left intact (except if one is involved
in the mass). Inspect the other tube and the uterus.
22. ECTOPIC PREGNANCY
Surgical management
• If there is extensive damage to the tube, the surgery of choice is partial or total
salpingectomy.
• Apply clamps on both sides of the ectopic or ruptured tube with 45 degree angles to the
tube, so that their points touch.
• Excise the ruptured part and then gently tie off each clamp, ensuring good haemostasis.
• Be careful not to damage or tear the very friable tissue below the tube
• As soon as haemostasis is obtained, remove all the remaining clots and rinse the
abdomen with saline.
• Inspect the rest of the abdomen and remove all swabs.
• Inform the anaesthetist of the amount of blood loss.
• Close the abdomen. Do not do any additional surgery at this stage
• In your notes, state which side was removed and how much, the condition of the
remaining tube and of the ovaries, and if any additional pathology was present
23. ECTOPIC PREGNANCY: Anaesthetic
management
• When a patient is too unstable for a referral to a specialist centre, but the anaesthetic skills to manage such
an unstable patient are not available at the district hospital, the management of such a case is difficult.
• A spinal anaesthetic must not be administered, as the cardiovascular effects of such an anaesthetic will lead
to severe shock and possibly death.
• Initial attempts to stabilise the patient to a suitable condition for transfer should be made. If the patient has
not responded to two litres of Ringers Lactate then surgery will need to be performed urgently.
• Mobilise the most skilled practitioners available to assist with this case.
• Prepare theatre and all resuscitation equipment. Assess patient and the potential for a difficult airway.
• Monitor the patient with ECG, NIBP and Pulse oximeter. Pre-oxygenate with 100 per cent oxygen.
• Induce anaesthesia by administering Etomidate 0.3 mg/kg intravenously or ketamine two milligram/kilogram
intravenously (provide cricoid pressure if the skills are available).
• Suxamethonium 100 mg intravenously can be given by practitioners confident of intubation.
• The trachea should be intubated.
• Capnography and agent analysis should be utilised
• Ventilation should be provided at 12 breathes per minute and 400 mL tidal volume.
• Where possible PEEP of five centimetreH2O should be applied.
24. ECTOPIC PREGNANCY: Anaesthetic
management
• Isoflurane 0.3 to 1.0 per cent should be titrated to provide anaesthesia.
• Muscle relaxation should be provided by giving Vecuronium 0.1 mg/kg (only after intubation and
commencement of satisfactory ventilation).
• After the abdomen is opened and the bleeding controlled attempt further resuscitation with fluid and blood.
• Once the Systolic blood pressure is >100 mmHg, one miligram IV morphine titration each five minutes can be
commenced until 0.1 mg/kg has been given.
• Treat any resulting hypotension with further fluid and blood administration.
• Reverse the muscle relaxation with 2.5 mg of Neostigmine and 0.4 mg glycopyrrolate once spontaneous
movement has been observed to occur.
• Discontinue the isoflurane and allow the patient to extubate herself.
• If the patient does not stabilise after clamping the abdominal bleeder and fluid resuscitation keep the
patient intubated and ventilated for transport to a more specialised level of care.
• This method of anaesthesia will be associated with a high incidence of awareness, counsel the patient
• If the skills exist to provide more complete and effective anaesthesia
• A stable, unruptured ectopic can be referred to a specialist centre for medical or laparoscopic management,
but it remains an urgent referral as the tube can rupture on the way
25. ECTOPIC PREGNANCY
• If there is access to ultrasound and serum beta HCG (human chorionic
gonadotrophin), it is much easier to diagnose doubtful, early and stable ectopic
pregnancies:
• If the serum beta HCG is ≥1500 mIU/mL and the uterus is empty on ultrasound,
there is a pregnancy of unknown location (ectopic) and further work-up and
surgery is needed.
• If the serum beta HCG is <1500 mIU/mL and the uterus is empty in an otherwise
stable patient, it may be a very early normal pregnancy or an ectopic pregnancy.
• Keep the patient for observation and repeat the beta HCG 48 hours later.
• If the beta HCG value doubles in 48 hours it is most likely an early intra-uterine
pregnancy and ultrasound can be repeated in two weeks’ time
• If the beta HCG value increase by less than ⅔rds it is most likely an ectopic
pregnancy
• If the value decreases it may be possible to manage the patient conservatively or
with medical management; discuss with your specialist referral hospital for
further management
Implants,intrauterine devices and surgery should be delayed if:
Infection is present or suspected. Delay until such infection is cleared
Severe anaemia (Hb <7g/dL). Delay until anaemia has improved
Screen for other health problems and correct if needed:
• anaemia
• Rh factor (if unknown) and Rh prophylaxis if Rh negative
• sexually transmitted diseases (including HIV). All women must be offered HIV counselling and testing
• ask patient to return for a Pap smear
as the bowel will be pushed against the peritoneum by the blood clots in the abdomen.