Menstrual irregularities are the problems with a girl's normal monthly menses. For example, missed periods, have them too frequently, having painful periods, or have excessively heavy flow. Menstrual irregularities can sometimes be a sign of an underlying health problem.
Menstrual irregularities are the problems with a girl's normal monthly menses. For example, missed periods, have them too frequently, having painful periods, or have excessively heavy flow. Menstrual irregularities can sometimes be a sign of an underlying health problem.
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The PPT contains detailed information about Abnormal uterine action, its classifications, causes, sign and symptoms and management.
it contains a presentation on injuries that occur during baby birth
summary:
Maternal injuries following childbirth process are quite common.
VULVA
PERINEUM
RISK FACTORS FOR THIRD DEGREE PERINEL TEAR
REPAIR OF COMPLETE PERINEAL TEAR
VAGINA
CERVIX
PELVIC HEMATOMA
DIAGNOSIS OF RUPTURE UTERUS
what is endometriosis? Theories in endometriosis, sites of endometriosis. types and clinical presentation. signs and symptoms.
Investigations :TVS, CA125
laparoscopic findings
chocolate cyst and extrapelvic endometriosis.
Classification of endometiosis
Diffential diagnosis
Management :of asymptomatic and symptomatic cases
drugs and minimally invasive surgery
surgey and preventive measures in endometiosis.
Obstetrics and Gynecological Nursing
The PPT contains detailed information about Abnormal uterine action, its classifications, causes, sign and symptoms and management.
it contains a presentation on injuries that occur during baby birth
summary:
Maternal injuries following childbirth process are quite common.
VULVA
PERINEUM
RISK FACTORS FOR THIRD DEGREE PERINEL TEAR
REPAIR OF COMPLETE PERINEAL TEAR
VAGINA
CERVIX
PELVIC HEMATOMA
DIAGNOSIS OF RUPTURE UTERUS
what is endometriosis? Theories in endometriosis, sites of endometriosis. types and clinical presentation. signs and symptoms.
Investigations :TVS, CA125
laparoscopic findings
chocolate cyst and extrapelvic endometriosis.
Classification of endometiosis
Diffential diagnosis
Management :of asymptomatic and symptomatic cases
drugs and minimally invasive surgery
surgey and preventive measures in endometiosis.
What to Expect if You’ve Been Diagnosed with Placenta PreviaMiami ObGyns
www.miamiobgyns.com/blog/diagnosed-placenta-previa/
If you’ve been diagnosed with Placenta Previa you are sure to have many questions about the causes, risks and treatments. Here’s what to expect...
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• Oligohydramnios refers to amniotic fluid volume that is less than expected for gestational age. It is typically diagnosed by ultrasound examination and may be described qualitatively (eg, reduced amniotic fluid volume) or quantitatively (eg, amniotic fluid index ≤5 cm, single deepest pocket <2 cm).
• Oligohydramnios may be idiopathic or have a maternal, fetal, or placental cause The fetal prognosis depends on several factors, including the underlying cause, the severity (reduced versus no amniotic fluid), and the gestational age at which oligohydramnios occurs. Because an adequate volume of amniotic fluid is critical to normal fetal movement and lung development and for cushioning the fetus and umbilical cord from uterine compression, pregnancies complicated by oligohydramnios from any cause are at risk for fetal deformation, pulmonary hypoplasia, and umbilical cord compression.
• Oligohydramnios is associated with an increased risk for fetal or neonatal death, which may be related to the underlying cause of the reduced amniotic fluid volume or due to sequelae of the reduced amniotic fluid volume.
• This topic will discuss issues related to oligohydramnios. Methods of amniotic fluid volume assessment are reviewed separately.
• Oligohydramnios occurs when the amniotic fluid is < 5th centile for gestational age.
• The most common causes are premature rupture of membranes (often missed by the mother) and placental insufficiency, however structural abnormalities such as renal agenesis should be considered.
• Prognosis is linked to gestation at diagnosis and likely development of pulmonary hypoplasia and premature delivery.
• Treatment is by optimising gestation of delivery
This Note is Prepared by A OBGYN resident @ SPHMMC, Addis Ababa, Ethiopia (March 2019)
For further notes, you can join us on our Telegram group @obgynsphmmc2019
Tel: +251920257863
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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!
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
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- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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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
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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
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.
2. Contents
• Antepartum Hemorrhage
• Causes of Antepartum
hemorrhage
• Definition of Placenta
Previa
• Incidence
• Etiology
• Pathological anatomy
• Types of placenta Previa
12/13/2013
• Clinical Features
• Conformation of
diagnosis
• Complications
• Prognosis
• Management
• Nursing Management
• Research Evidence
• References
2
3. Antepartum hemorrhage
• It is defined as bleeding from or into the genital tract after
the 28th week /22nd week of pregnancy but before the
birth of baby.
• Placenta previa
• Abruptio placenta
• Rupture of uterus
12/13/2013
3
4. Causes of Antepartum Hemorrhage
Presenting symptoms and
Probable
other symptoms and signs Symptoms and signs sometimes present
diagnosis
typically present
Bleeding after 22nd weeks
Shock
Abruptio placenta
gestation
Tense/tender uterus
Intermittent or constant
Decreased/absent fetal movement
abdominal pain
Fetal distress or absent fetal heart sounds
Bleeding (intra abdominal
and/or vaginal)
Severe abdominal pain
(may
decrease
after
rupture)
12/13/2013
Shock
Abdominal distention/free fluid
Abnormal uterine contour
tender abdomen
Easily palpable fetal parts
Absent fetal movements and fetal heart
sounds
Rapid maternal pulse
Ruptured uterus
4
5. Causes of antepartum hemorrhage cont…
Presenting
symptoms Symptoms and signs sometimes present Probable
diagnosis
and other symptoms and
signs typically present
Bleeding after 22 weeks
gestation
12/13/2013
Shock
Bleeding may be precipitated by
intercourse
Relaxed uterus
Fetal presentation not in pelvis/lower
Uterine pole feels empty
Normal fetal condition
Placental
previa
5
6. Causes of antepartum hemorrhage
A.P.H.
Placental bleeding
(70%)
Placenta previa (35%)
and
Abruptio placenta
(35%)
12/13/2013
Unexplained
(25%) Or
Intermediate
Extra placental causes (5%)
Local cervico-vaginal lesions:
Cervical polyp
Carcinoma cervix
Varicose vein
Local trauma
6
7. Placenta previa
• When placenta is implanted partially or completely over
the lower uterine segment it is called placenta previa.
12/13/2013
7
8. Incidence of Placenta Previa
United States:
• 0.3-0.5% of all pregnancies.
• Risks increase 1.5- to 5-fold with a history of cesarean delivery.
• Meta analysis: Rate of placenta previa increases with a rate of
1% after 1 cesarean delivery, 2.8% after 3 cesarean deliveries,
and as high as 3.7% after 5 cesarean deliveries.
• Of all placenta previas, the frequency of complete placenta
previa ranges from 20-45%, partial placenta previa accounts
for approximately 30%, and marginal placenta previa accounts
for the remaining 25-50%.
12/13/2013
8
9. Etiology
• Dropping down theory
• Persistence of chorionic activity in the decidua
capsularis and its subsequent development into
capsular placenta
• Defective decidua
• Big surface area of the placenta
12/13/2013
9
10. Predisposing factors
• Multiparity
• Increased maternal age (> 35 years)
• History of previous caesarean section or any other scar in
the uterus (myomectomy or hysterotomy)
• Placental size and abnormality
• Smoking-causes placental hypertrophy or compensate
carbonmonoxide induced hypoxemia
12/13/2013
10
11. Pathological anatomy
Placenta:
• Placenta may be large and thin.
• Tongue shaped extension from the main placental
mass.
• Extensive areas of degeneration with infarction and
calcification may be evident.
• Morbidly adherent placenta due to poor decidua
formation in the lower segment.
12/13/2013
11
12. Pathological anatomy cont…
Umbilical cord:
• Cord may be attached to the margin or onto the
membranes.
• Insertion of cord may be close to the internal os or the
fetal vessels may run across the internal os in
velamentous insertion giving rise to vasa previa
Lower uterine segment:
• Lower uterine segment and the cervix becomes soft
and more friable.
12/13/2013
12
13. Types/degree of placenta previa
• Low-lying placenta (Type I)
• Marginal placenta previa (Type II)
• Partial or incomplete placenta previa (Type III )
• Total or central placenta previa (Type IV)
• Vasa previa
12/13/2013
13
16. Cause of bleeding
• As the placental growth slows down in later months and the
lower segment progressively dilates, inelastic placenta is
sheared off the wall of lower segment.
• This leads to opening up of utero-placental vessels and
leads to an episode of bleeding.
• As it is a physiological phenomena which leads to the
separation of placenta, the bleeding is said to be inevitable.
• The separation of the placenta may be provoked by trauma
including vaginal examination, coital act, external version or
during high rupture of membranes.
12/13/2013
16
17. Clinical features
Symptoms:
• Painless, apparently
hemorrhage
causeless
and
recurrent
• Hemorrhage from the implantation site in the lower
uterine segment may continue after placental delivery.
Signs:
• General condition and anemia are proportionate to
the visible blood loss.
12/13/2013
17
18. Clinical features cont…
Abdominal examination
– Size of uterus is proportionate to POG.
– Uterus feels relaxed, soft and elastic.
– Persistence of malpresentation like breech or transverse or
unstable lie is more frequent. There is also frequency of
twin pregnancy.
– Head is free floating in contrast to POG.
– FHS is usually present, unless there is major separation of
the placenta with the patient in exsanguinated condition.
12/13/2013
18
19. Clinical features cont…
Vulval inspection
• Only inspection has to be done to note the amount,
character of blood.
• Blood is bright red in colour.
Vaginal examination
• Must not be done outside the operation theater in the
hospital.
12/13/2013
19
20. Confirmation of diagnosis
Localization of placenta
• Sonography: Transabdominal ultrasound (TAS)
• Transvaginal ultrasound (TVS)
• Transperineal ultrasound
• Colour Doppler flow study
Clinical
• By internal examination (Double setup examination)
• Direct visualization during caesarean section
• Examination of the placenta following vaginal delivery
12/13/2013
20
21. Complications
Maternal
During Labour:
During pregnancy:
• APH
with
varying
degrees of shock
• Malpresentation
• Premature labour
12/13/2013
•
•
•
•
•
Early rupture of membrane
Cord prolapse
Slow dilatation of cervix
Intrapartum hemorrhage
Increased incidence of
operative interference
• PPH
• Retained placenta
21
22. Complications cont…
Puerperium
• Sepsis is increased due to
– Increased
operative
interference
– Placental site near to
vagina and anemia
– Subinvolution
– Embolism
12/13/2013
Fetal
• Low birth weight
• Asphyxia
• Intrauterine death
• Birth injuries
• Congenital
malformation
22
23. Prognosis
Maternal
• Substantial reduction of maternal deaths in placenta
previa throughout globe.
• Ultimate cause of death are hemorrhage and shock.
• Morbidity is raised due to hemorrhage and operative
interference
Fetal
• Perinatal mortality ranges from 10-25%.
• The causes of death are prematurity, asphyxia and
congenital malformation.
12/13/2013
23
24. Prognosis cont…
• Maternal mortality rate ranges from 2-3%.
• Maternal mortality is 0.03% in the United States.
• Neonatal mortality associated with placenta previa is as
high as 1.2%
12/13/2013
24
25. Prevention
• Adequate antenatal care to improve the health status of
women and correction of anemia
• Antenatal diagnosis of low lying placenta at 20 weeks with
routine ultrasound needs repeat ultrasound examination
at 34 weeks to confirm diagnosis.
• Significance of warning hemorrhage should not be
ignored
• Family planning and limitation of births reduce the
incidence.
12/13/2013
25
26. Management
At home:
• The patient is immediately put in bed.
• To assess the blood loss
• Inspection of clothing soaked with blood
• To note the pulse, blood pressure and degree of anemia
• Quick but gentle abdominal examination to mark height of
uterus, to auscultate the FHS and to note any tenderness on
the uterus.
• Vaginal examination must not be done.
12/13/2013
26
27. Treatment
1. Immediate attention: Quickly assess
• Amount of blood loss: General condition, pallor, pulse rate and
blood pressure.
• Blood samples: Cross matching, group and hemoglobin.
• An infusion of normal saline is started and blood transfusion
• Gentle abdominal palpation: Uterine tenderness and auscultation
to note the fetal heart rate.
• Inspection of vulva to note the presence of any active bleeding.
Confirmation of diagnosis: History, physical examination and
sonographic examination.
12/13/2013
27
28. Treatment cont…
2. Formulation of line of treatment
• Depends upon the duration of pregnancy, fetal and maternal status
and extent of the hemorrhage.
a. Expectant treatment
• Vital prerequisites: Availability of blood for transfusion, facilities for
caesarean section
• Selection of cases:
– Mother is in good health status (Hemoglobin ≥ 10 gm%,
hematocrit > 30%),
– Duration of pregnancy is <37 weeks,
– Active vaginal bleeding is absent,
– Fetal well being is assured.
12/13/2013
28
29. Treatment cont…
Conduct of expectant treatment:
• Bed rest with bathroom facilities
• Investigations: Hemoglobin estimation, blood grouping and urine
for protein
• Periodic inspection of the vulval pads and fetal surveillance with
USG at interval of 2-3 weeks
• Supplementary hematinics if the patient is anemic.
• When patient is allowed out of bed a gentle speculum examination
is made to exclude local cervical and vaginal lesions for bleeding.
12/13/2013
29
30. Treatment cont…
Termination of the expectant treatment: Expectant treatment is
carried upto 37 weeks of pregnancy.
• Premature termination may have to be done in conditions, such as
– Recurrence of brisk hemorrhage and which is continuing
– The fetus is dead
– The fetus is found congenitally malformed on investigation
• Steriod therapy: If the duration of pregnancy is less than 34 weeks.
12/13/2013
30
31. Treatment cont…
Active interference:
• Bleeding occurs at or after 37 weeks of pregnancy.
• Patient is in labour
• Patient is in exsanguinated state on admission
• Bleeding is continuing and of moderate degree
• Baby is dead of known to be congenitally deformed.
12/13/2013
31
32. Definitive treatment
1. Vaginal examination in operation theatre followed by low rupture
of membranes or Caesarean section.
2. Caesarean section without internal examination
1. Vaginal examination: Double setup examination should be done in
operation theatre keeping everything ready for caesarean section.
• Contraindications of vaginal examination are:
– Patient is in exsanguinated state
– Major degree of placenta previa
– Associated complicating factors: Malpresentation, elderly
primigravida, history of previous caesarean section, contracted
pelvis etc.
12/13/2013
32
33. Definitive treatment cont…
a. Low rupture of membrane: Done in lesser degree of placenta
previa (Type I and Type II anterior).
b. Caesarean section: The indication are:
– Severe degree of placenta
– Lesser degree of placenta previa where amniotomy fails to stop
bleeding or fetal distress appears.
– Complicating factors associated with lesser degrees of placenta
previa where vaginal delivery is unsafe.
– Caesarean section without internal examination
12/13/2013
33
34. Nursing Assessment
• Determine the amount and type of bleeding; also, review any
history of bleeding throughout this pregnancy.
• Inquire as to the presence or absence of pain in association
with the bleeding.
• Record maternal and fetal vital signs.
• Palpate for the presence of uterine contractions.
• Evaluate laboratory data on hemoglobin and hematocrit
status.
• Assess fetal status with continuous fetal monitoring.
12/13/2013
34
35. Nursing Diagnoses
• Ineffective Tissue Perfusion, Placental, related
excessive bleeding causing fetal compromise
to
• Deficient Fluid Volume related to excessive bleeding
• Risk for Infection related to excessive blood loss and open
vessels near cervix
• Anxiety related to excessive bleeding, procedures, and
possible maternal-fetal complications
12/13/2013
35
37. Definition
• It is one form of antepartum hemorrhage where bleeding
occurs due to premature separation of normally situated
placenta.
12/13/2013
37
38. Pathology
• Initiated by hemorrhage into the decidua basalis.
• The decidua then splits, leaving a thin layer adhered to the
myometrium.
• Consequently, the process in its earliest stages consists of the
development of a decidual hematoma that leads to
separation, compression, and ultimate destruction of the
placenta adjacent to it.
• Inflammation—infection—may be a contributor to causal
pathways.
12/13/2013
38
39. Pathology cont…
• Early stage: May be no clinical symptoms, and separation
is discovered upon examination of the freshly delivered
placenta.
– There is a circumscribed depression on the placenta's maternal
surface.
– Usually measures a few centimeters in diameter and is covered
by dark, clotted blood.
• In some instances, a decidual spiral artery ruptures to
cause a retroplacental hematoma, which as it expands,
disrupts more vessels to separate more placenta.
12/13/2013
39
40. Pathology cont…
• The area of separation rapidly becomes more extensive
and reaches the margin of the placenta.
• Because the uterus is still distended by the products of
conception, it is unable to contract sufficiently to
compress the torn vessels that supply the placental site.
• The escaping blood may dissect the membranes from the
uterine wall and eventually appear externally or may be
completely retained within the uterus.
12/13/2013
40
45. Abruptio placenta cont…
Couvelaire uterus
• Widespread extravasation of blood into the uterine
musculature and beneath the uterine serosa.
• Such effusions of blood are also occasionally seen
beneath the tubal serosa, between the leaves of the
broad ligaments, in the substance of the ovaries, and free
in the peritoneal cavity.
• Incidence is unknown, can be demonstrated only at
laparotomy.
12/13/2013
45
46. Abruptio placenta cont…
• These myometrial hemorrhages seldom interfere with
myometrial contraction to cause atony, and they are not
an indication for hysterectomy.
12/13/2013
46
47. Abruptio placenta cont…
Changes in other organs
• Liver: fibrin knots in the hepatic sinusoids
• Kidney: Acute cortical necrosis or acute tubular necrosis
• Shock proteinuria: is due to renal anoxia which usually
disappears two days after delivery.
12/13/2013
47
48. Abruptio placenta cont…
Blood coagulopathy:
• It is due to excess consumption of plasma fibrinogen due
to DIC and retroplacental bleeding.
• There is overt hypofibrinogenemia (<150mg/dl) and
elevated levels of fibrin degradation products and D
dimer.
12/13/2013
48
49. Clinical classification
Depending upon the degree of placental abruption and its
clinical effects, the cases are graded as follows:
• Grade 0: Clinical feature may be absent.
• Grade 1: External bleeding is slight. Uterus is irritable;
tenderness may or may not be present. Shock is absent.
FHS is good.
12/13/2013
49
50. Clinical classification cont…
• Grade 2: External bleeding is mild to moderate. Uterine
tenderness is always present. Shock is absent. Fetal
distress or even fetal death occurs.
• Grade 3: Bleeding is moderate to severe or may be
concealed. Uterine tenderness is marked. Shock is
pronounced. Fetal death is the rule. Associated
coagulation defect or anuria is present.
12/13/2013
50
51. Clinical features
Depends upon
• Degree of separation of placenta
• Speed at which separation occurs and
• Amount of blood concealed inside the uterine cavity.
12/13/2013
51
52. The clinical features of the revealed and mixed variety are given below:
Revealed
Symptoms:
Mixed
Abdominal discomfort or pain Active intense pain abdomen
followed by vaginal bleeding
followed by slight vaginal bleeding.
The pain becomes continuous.
Character of Continuous dark colour (slight to Continuous dark colour (usually
bleeding
moderate)
slight) or blood stained serous
discharge.
General
Proportionate to visible blood Shock is pronounced which is out
condition
loss, shock is usually absent
of proportion with the visible
blood loss.
Pallor
Related with visible blood loss
Pallor is usually severe and out of
proportion to visible blood loss.
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53. The clinical features of the revealed and mixed variety are given below:
Revealed
Mixed
Features
of May be absent
preeclampsia
Frequent
association
preexisting or appear.
either
Uterine height Proportionate to POG
Disproportionately enlarged and
globular.
Uterine feel
Normal
feel
with
localized Uterus is tense, tender and rigid
tenderness, contractions frequent
and local amplitude
Fetal parts
Can be identified easily
Difficult to make out
FHS
Usually present
Usually absent
Urine output
Normal
Usually diminished
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54. The clinical features of the revealed and mixed variety are given below:
Revealed
Mixed
Laboratory
Blood Hb%
Low value proportionate Markedly lower, out of proportion to
to blood loss
blood loss
Coagulation
profile
Usually unchanged
Variable changes :
Clotting time increased (>6 min)
Fibrinogen level low (<150mg/dl)
Platelet count low
Increased PTT
Increased FDP and D dimer
Urine for protein May be absent
Usually present
Confusion
diagnosis
With acute obstetrical gynecological
surgical complication
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54
55. Abruptio placenta cont…
Sheehan Syndrome
• Severe intrapartum or early postpartum hemorrhage rarely is
followed by pituitary failure.
• Characterized by failure of lactation, amenorrhea, breast atrophy,
loss of pubic and axillary hair, hypothyroidism, and adrenal cortical
insufficiency.
• Exact pathogenesis is not well understood but such endocrine
abnormalities develop infrequently in women who hemorrhage
severely.
• Varying degrees of anterior pituitary necrosis and impaired
secretion of one or more trophic hormones (in some cases)
• Diagnosis: MRI
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56. Distinguishing features of placenta previa and abruptio placenta
Placenta previa
Clinical features
Nature of bleeding
Character
bleeding
of
Painless,
apparently
causeless and recurrent
Bleeding is always revealed
Bright red
Abruptio placenta
Painful, often attributed to
preeclampsia or trauma
and continuous
Revealed, concealed or
usually mixed
Dark coloured
Proportionate to visible blood
General condition loss
Out of proportion to the
and anemia
visible blood loss in concealed
or mixed variety
Features of pre- Not relevant
eclampsia
Present in one-third cases
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57. Distinguishing features contd…
Placenta previa
Abd. examination
Height of uterus
Feel of uterus
Malpresentation
FHS
Placentography
Abruptio placenta
Proportionate height
May be disproportionately
enlarged in concealed type
Soft and relaxed
May be tense, tender and rigid
Malpresentation is common. Head may be engaged
The head is high floating
Usually present
Usually absent specially in
concealed type
Placenta in lower segment
Placenta in upper segment
Vaginal examination Placenta is felt on lower Placenta is not felt on lower
segment
segment. Blood clots should not
be confused with placenta.
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58. Management
• Depending on gestational age and status of mother and fetus.
• With a fetus of viable age, and if vaginal delivery is not
imminent, then emergency cesarean delivery is chosen.
• Resuscitation and acute management, with massive external
bleeding, intensive resuscitation with blood plus crystalloid
and prompt delivery to control hemorrhage are lifesaving for
the mother and hopefully, for the fetus.
• If the diagnosis is uncertain and the fetus is alive but without
evidence of compromise, then close observation can be
practiced in facilities capable of immediate intervention.
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59. Prevention
• Prevention, early diagnosis and effective therapy of
preeclampsia and other hypertensive disorders of pregnancy.
• Needle puncture during amniocentesis should be under
ultrasound guidance.
• Avoidance of trauma specially forceful external cephalic
version under anesthesia
• To avoid sudden decompression of the uterus
• To avoid supine hypotension
• Routine administration of folic acid from early pregnancy.
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60. In the hospital
1. Revealed type: assessment is to be done as regards:
– Amount of blood loss
– Maturity of fetus
– Whether the patient is in labour or not
Preliminaries
• Blood for Hemoglobin and hematocrit estimation, coagulation
profile, ABO and Rh grouping and urine for detection of
protein.
• RL solution drip started with wide bore cannula and
arrangement for blood transfusion.
• Close monitoring of maternal and fetal condition.
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61. Management cont…
Patient is in labour
• Labour is accelerated by low rupture of membranes.
• Oxytocin drip is started to accelerate labour.
The patient is not in labour:
• Pregnancy 37 weeks or more: induction of labour is to be
done by low rupture of membrane with or without
oxytocin.
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62. Management cont…
• Pregnancy less than 37 weeks:
– Bleeding moderate to severe and continuing—low
rupture of membrane, administration of oxytocin drip
– Bleeding slight or has stopped—the patient is put on
conservative management, close observation of the
mother and careful monitoring is essential.
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63. Management cont…
2. Mixed or concealed type
Principles of management of concealed type are:
• To correct hypovolemia and to restore blood loss. Normal
saline or hemaccel infusion is started
• To bring about effective uterine contraction and termination
of the abruption process.
• To observe blood coagulation profiles at two hourly interval.
• Close monitoring of maternal and fetal condition is
maintained.
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64. Management cont…
• Vaginal delivery
• Caesarean section:
– Early: Unfavourable cervix where speedy vaginal delivery is not
possible and there is good prospect of fetal survival.
– Late: If inspite of amniotomy and oxytocin, the progress of
labour is delayed (6-8 hours) and instead, the general condition
gradually deteriorates with appearance of complicating factors
like oliguria or falling fibrinogen level or there is evidence of
fetal distress.
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65. Nursing Diagnoses
• Ineffective Tissue Perfusion: Placental related to excessive
bleeding, hypotension, and decreased cardiac output,
causing fetal compromise
• Deficient Fluid Volume related to excessive bleeding
• Fear related to excessive bleeding, procedures, and
unknown outcome
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67. Rupture of uterus
• Dissolution in the continuity of uterine wall any time
beyond 28 weeks of pregnancy is called rupture of uterus.
• Injury to the wall of uterus in early months of pregnancy
is called perforation either instrumental or perforating
hydatidiform mole.
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68. Classification of rupture uterus
Uterine rupture typically is classified as either:
• Complete
• Incomplete
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68
70. Causes cont…
Spontaneous
1. During pregnancy: previous dilatation and curettage operation or
MRP, grand multiparity, congenital malformation of the uterus of
bicornuate variety, in couvelaire uterus.
• Usually complete, involves the upper segment and usually occurs in
later months of pregnancy.
2. During labour:
• Obstructive rupture: involves lower segment and usually extends
through one lateral side of the uterus to the upper segment.
• Non-obstructive rupture: Grand multiparae , rupture usually occurs
in early labour, usually involves fundal area and is complete.
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71. Causes cont…
Scar rupture
• Incidence of lower uterine segment scar rupture is about 1-2%,
Classical: 5-10 times higher.
• During pregnancy: Classical or hysterotomy scar is likely to give way
during later months of pregnancy. Lower segment scar rarely
ruptures during pregnancy.
• During labour: The classical or hysterotomy scar is more vulnerable
to rupture during labour.
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72. Causes cont…
Iatrogenic or traumatic:
During pregnancy:
–
–
–
–
Injudicious administration of oxytocin
Use of prostaglandins for induction of abortion or labour.
Forcible external version specially under general anesthesia
Fall or blow on the abdomen
During labour:
– Internal podalic version, Destructive operation
– Manual removal of placenta
– Application of forceps or breech extraction through incompletely
dilated cervix
– Injudicious administration of oxytocin for augmentation of labour.
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73. Dehiscence and scar rupture
Dehiscence:
– Disruption of part of scar and not the entire length
– Fetal membranes remain intact and
– Bleeding is almost nil or minimal
Rupture includes:
– Disruption of the entire length of scar
– Rupture of membranes with varying amount of bleeding from
the margins or from its extension.
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74. Diagnosis
During pregnancy
1. Scar rupture
Classical or hysterotomy
• Dull abdominal pain all over the area with slight vaginal
bleeding.
• Tenderness on uterine palpation.
• FHS may be irregular or absent.
• Sooner or later the rupture becomes complete.
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75. Diagnosis cont…
2. Spontaneous rupture in uninjured uterus:
• Confined to the high parous women.
• Acute onset but sometimes insidious.
• Acute type: Patient has acute pain abdomen with fainting
attacks and may collapse.
• Presence of features of shock, acute tenderness on
abdominal examination, palpation of superficial fetal
parts, if the rupture is complete and absence of FHS.
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76. Diagnosis cont…
3. Rupture following fall, blow or external version or use of
oxytocics:
• History of such accident followed by acute pain abdomen
and slight vaginal bleeding.
• Rapid pulse and tender uterus, confirmation is done by
laparotomy.
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77. Diagnosis cont…
During labour
1. Scar rupture:
• Classical or hysterotomy scar rupture: Features are same as
those occur during pregnancy. The onset is usually acute.
• Lower segment scar rupture (silent rupture): The onset is
insidious, no classical feature of lower segment scar rupture,
confirmation is by laparotomy.
2. Spontaneous or obstructive rupture: Has distinct premonitory
phase prior to rupture.
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78. Diagnosis of spontaneous obstructive rupture cont…
Premonitory phase:
• Multipara in labour with features of obstruction.
• Pain becomes severe in an attempt to overcome the
obstruction and come to quick intervals.
• Gradually the pains become continuous and mainly
confined to the suprapubic region.
• Patient is exhausted and dehydrated.
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79. Diagnosis of spontaneous obstructive rupture cont…
• Pulse rate and temperature rise.
• Distended tender lower segment.
• Bandl’s ring may be visible
• Fetal distress or FHS absent.
• Presenting part is found jammed in the pelvis and the
vagina becomes dry and oedematous.
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80. Phase of rupture in spontaneous obstructive rupture
• Sense of something giving way at height of uterine
contraction.
• Constant pain is changed to dull aching pain with cessation of
uterine contraction.
• Features of exhaustion and shock.
• Abdominal examination: Superficial fetal parts, absence of
FHS, absence of uterine contour and two separate swellings,
one contracted uterus and the other fetal ovoid.
• Vaginal examination: Recession of presenting part and varying
degrees of bleeding.
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81. Diagnosis cont…
3. Spontaneous non-obstructive rupture:
• Rare and confined to high parous women.
• Height of uterine contraction is suddenly seized with an
agonizing bursting pain followed by a relief with cessation
of contractions.
• Presence of shock, evidences of internal hemorrhage,
tenderness over the uterus and varying amount of vaginal
bleeding.
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81
82. Diagnosis cont…
4. Rupture following manipulative or instrumental delivery
• Sudden deterioration of general condition of patient with
varying amount of vaginal bleeding following manipulative
delivery
• Exploration of uterus to feel the rent confirms the diagnosis.
• Shortening of cord immediately following a difficult vaginal
delivery
• Placenta being extruded out into abdominal cavity, through
the rent in the uterus.
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83. Prevention
• At risk mothers likely to rupture should have mandatory
hospital delivery. There are
– Contracted pelvis
– Previous history of caesarean section, hysterotomy or
myomectomy
– Uncorrected transverse lie
– Multiparity with pendulous abdomen
– Grand multiparity
– Known case of hydrocephalous
• General anesthesia should not be used to give undue force in
external version
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83
84. Prevention cont…
• Undue delay in the progress of labour in a multipara with
previous uneventful delivery should be viewed with concern
and cause should be sought for.
• Judicious selection of cases with previous history of caesarean
section for vaginal delivery.
• Judicious selection of cases and careful watch are mandatory
during oxytocin infusion either for induction or acceleration of
labour.
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84
85. Prevention cont…
• Internal podalic version in singleton fetus should never be
done in obstructed labour.
• Attempted forceps delivery or breech extraction through
incompletely dilated cervix should be avoided.
• Destructive vaginal operations should be performed by skilled
personnel.
• Manual removal in morbid adherent placenta should be done
by senior person.
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86. Treatment
Resuscitation and laparotomy
• Depending upon the state of clinical condition, either
resuscitation is to be done followed by laparotomy or in acute
conditions, resuscitation and laparotomy are to be done
simultaneously.
• Any of the following procedures may be adopted following
laparotomy
– Hysterectomy
– Repair
– Repair and sterilization
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87. Nursing Assessment
• Continuously evaluate maternal vital signs; especially note an
increase in the rate and depth of respirations, an increase in
pulse, or a drop in BP indicating status change.
• Observe for signs and symptoms of impending rupture (ie, lack
of cervical dilatation, tetanic uterine contractions,
restlessness, anxiety, severe abdominal pain, fetal bradycardia,
or late or variable decelerations of the FHR).
• Assess fetal status by continuous monitoring.
• Speak with family, and evaluate their understanding of the
situation.
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88. Nursing Diagnoses
• Deficient Fluid Volume related to active fluid loss from
hemorrhage
• Ineffective Tissue Perfusion, Maternal Vital Organ and
Fetal, related to hypovolemia
• Fear related to surgical outcome for fetus and mother
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88
89. References
1.
Fraser DM, Cooper MA. Myles Textbook for Midwives. 15th edition.
Philadelphia: Churchill livingstone elsevier; 2009
2.
Dutta DC. Textbook of obstetrics. 6th edition. Calcutta: New central book
agency;2004
3.
Pillitteri A. Maternal and child health nursing. Care of the childbearing and
childrearing family. Sixth edition. Philadelphia: Lippincott Williams & Wilkins;
2010.
4.
Cunningham, Leveno, Bloom. William’s obstetrics. 23rd edition. United states of
America: Mcgraw Hill companies; 2010.
5.
Placenta Previa. Internet [Updated on 5th June 2012, Cited on 21st October
2013] Available form: http://emedicine.medscape.com/article/262063-overview
6.
Nettina SM, Mills EJ. Lippincott manual of nursing practice. 8th edition.
Baltimore: Lippincott Williams and Wilkins; 2006
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