One of the most important causes of maternal mortality is major obstetric haemorrhage. Major haemorrhage can occur in parturients either during the antepartum period, during delivery, or in the postpartum period. Early recognition and a multidisciplinary team approach in the management are the cornerstones of improving the outcome of such cases. The management consists of fluid resuscitation, administration of blood and blood products, conservative measures such as uterine cavity tamponade and sutures, and finally hysterectomy. Blood transfusion strategies have changed over the last decade with emphasis on use of fresh frozen plasma, platelets, and fibrinogen. Point-of-care testing for treating coagulopathies promptly and interventional radiological procedures have further revolutionized the management of such cases.
Vaginal bleeding in placenta previa is classically painless and is usually seen in second or third trimester of pregnancy. Caesarean delivery is the procedure of choice in such cases with an increased risk of severe blood loss due to inadvertent incision through the placenta during surgery.
Abruptio placentae refers to the abnormal separation of the normally sited placenta; the bleeding occurs due to separation of the placental lining from the uterus. This bleeding may occur per vagina or may be concealed in the form of a retroplacental clot. Clinical features include abdominal pain, increased uterine tone, vaginal bleeding, and premature labor with signs of foetal distress. In case the bleeding is concealed, clinical presentation could be of haemorrhagic shock, acute renal failure, and foetal death.
Placenta accreta is a condition when the placenta is abnormally attached to the myometrium. Rarely blood vessels within the placenta or the umbilical cord traverse the foetal membranes overlying the lower uterine segment, and this condition is known as vasa previa.
One of the most devastating causes of APH is uterine rupture, and it is associated with a very high incidence of foetal and maternal mortality. Clinical features include abdominal pain, uterine tenderness, nonassuring foetal heart rate, and ultimately hypovolaemic shock, which could lead to maternal death. Maternal resuscitation along with emergency surgery is the only definitive treatment. Surgical procedures needed could vary from any of the following: foetal delivery with repair of the ruptured uterine wall, ligation of the uterine and internal iliac arteries, or hysterectomy.
This document defines postpartum hemorrhage as blood loss exceeding 500ml following childbirth. It occurs in 1% of hospital deliveries and can be primary (within 24 hours of delivery) or secondary (later). The main causes are an atonic uterus, trauma during delivery, or issues with blood coagulation. An atonic uterus accounts for 80% of cases as the uterus is unable to contract and retract fully after delivery. Risk factors include grand multiparity, overdistension of the uterus, malnutrition, prolonged labor, and mismanaged delivery of the placenta. Diagnosis involves visible vaginal bleeding and a flabby uterus that firms with massage. Prevention focuses on antenatal screening and care of high-
This document provides an overview of postpartum hemorrhage (PPH), including its definition, causes, risk factors, prevention, and medical management. PPH is a leading cause of maternal mortality worldwide. The document discusses the physiology of blood loss after childbirth and classifies PPH as primary (occurring within 24 hours of delivery) or secondary (occurring after 24 hours to 6 weeks postpartum). Prevention focuses on risk assessment, treatment of anemia, and active management of the third stage of labor. Medical management follows the acronym H.A.E.M.O.S.T.A.S.I.S and includes uterine massage, uterotonic drugs, balloon tamponade,
1. Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide, especially in developing countries. Active management of the third stage of labor with oxytocin or carbetocin administration can reduce the risk of PPH by about 60%.
2. PPH is classified as minor (blood loss 500-1000ml with no shock) or major (blood loss >1000ml or signs of shock). Management involves simultaneous communication, resuscitation, monitoring, and arresting the bleeding. Resuscitation of major PPH includes rapid intravenous access and fluid replacement with blood transfusion when available.
3. Monitoring of major PPH involves frequent vital sign monitoring, intravenous access, and laboratory
This document discusses the medical management of postpartum hemorrhage (PPH). It begins by outlining the objectives of understanding PPH risk factors, diagnosis, and treatment. It then presents a case study of a woman who experienced severe PPH and died. The document emphasizes that PPH is one of the leading causes of maternal mortality. It promotes a multi-step approach to PPH involving predicting those at risk, preparing for possible hemorrhage, and having plans in place to rapidly handle a hemorrhage. The most common cause of PPH is uterine atony, so the document focuses on proper evaluation and medical treatment of the uterus.
Post Partum Haemorrhage - A Summary of Managementmeducationdotnet
This document discusses postpartum haemorrhage (PPH), defined as blood loss over 500-1000ml after birth. The main causes of PPH are uterine atony (failure to contract), trauma during delivery, and retained tissue. Risk factors include placenta previa, multiple pregnancy, preeclampsia, induction of labor, and operative delivery. Prevention involves active management of the third stage of labor with oxytocin. Management of PPH includes addressing airway and circulation, treating potential causes like atony, and monitoring for signs of shock. Uterine massage, uterotonics, balloon tamponade, and arterial ligation may be used to treat atonic bleeding.
The document summarizes postpartum haemorrhage (PPH), defined as blood loss of 500 ml or more within 24 hours of birth. The main causes of PPH are uterine atony, retained placenta, genital tract trauma, and coagulation disorders. Management of PPH involves communication, resuscitation including fluids and blood products, monitoring investigations, and measures to arrest bleeding such as uterine massage, medications to improve uterine tone, and surgical techniques if bleeding persists.
Postpartum hemorrhage is a leading cause of maternal mortality. Uterine atony accounts for 95% of cases. The 4Ts framework is used to evaluate causes: Tone (uterine atony), Tissue (retained placenta), Trauma (lacerations), and Thrombin (coagulopathy). Prevention focuses on active management of the third stage of labor using uterotonics like oxytocin and ergometrine. Management involves assessing blood loss, vital signs, and treating the underlying cause, such as through uterine massage, manual exploration, additional uterotonics, or surgical interventions if needed.
This document defines postpartum hemorrhage as blood loss exceeding 500ml following childbirth. It occurs in 1% of hospital deliveries and can be primary (within 24 hours of delivery) or secondary (later). The main causes are an atonic uterus, trauma during delivery, or issues with blood coagulation. An atonic uterus accounts for 80% of cases as the uterus is unable to contract and retract fully after delivery. Risk factors include grand multiparity, overdistension of the uterus, malnutrition, prolonged labor, and mismanaged delivery of the placenta. Diagnosis involves visible vaginal bleeding and a flabby uterus that firms with massage. Prevention focuses on antenatal screening and care of high-
This document provides an overview of postpartum hemorrhage (PPH), including its definition, causes, risk factors, prevention, and medical management. PPH is a leading cause of maternal mortality worldwide. The document discusses the physiology of blood loss after childbirth and classifies PPH as primary (occurring within 24 hours of delivery) or secondary (occurring after 24 hours to 6 weeks postpartum). Prevention focuses on risk assessment, treatment of anemia, and active management of the third stage of labor. Medical management follows the acronym H.A.E.M.O.S.T.A.S.I.S and includes uterine massage, uterotonic drugs, balloon tamponade,
1. Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide, especially in developing countries. Active management of the third stage of labor with oxytocin or carbetocin administration can reduce the risk of PPH by about 60%.
2. PPH is classified as minor (blood loss 500-1000ml with no shock) or major (blood loss >1000ml or signs of shock). Management involves simultaneous communication, resuscitation, monitoring, and arresting the bleeding. Resuscitation of major PPH includes rapid intravenous access and fluid replacement with blood transfusion when available.
3. Monitoring of major PPH involves frequent vital sign monitoring, intravenous access, and laboratory
This document discusses the medical management of postpartum hemorrhage (PPH). It begins by outlining the objectives of understanding PPH risk factors, diagnosis, and treatment. It then presents a case study of a woman who experienced severe PPH and died. The document emphasizes that PPH is one of the leading causes of maternal mortality. It promotes a multi-step approach to PPH involving predicting those at risk, preparing for possible hemorrhage, and having plans in place to rapidly handle a hemorrhage. The most common cause of PPH is uterine atony, so the document focuses on proper evaluation and medical treatment of the uterus.
Post Partum Haemorrhage - A Summary of Managementmeducationdotnet
This document discusses postpartum haemorrhage (PPH), defined as blood loss over 500-1000ml after birth. The main causes of PPH are uterine atony (failure to contract), trauma during delivery, and retained tissue. Risk factors include placenta previa, multiple pregnancy, preeclampsia, induction of labor, and operative delivery. Prevention involves active management of the third stage of labor with oxytocin. Management of PPH includes addressing airway and circulation, treating potential causes like atony, and monitoring for signs of shock. Uterine massage, uterotonics, balloon tamponade, and arterial ligation may be used to treat atonic bleeding.
The document summarizes postpartum haemorrhage (PPH), defined as blood loss of 500 ml or more within 24 hours of birth. The main causes of PPH are uterine atony, retained placenta, genital tract trauma, and coagulation disorders. Management of PPH involves communication, resuscitation including fluids and blood products, monitoring investigations, and measures to arrest bleeding such as uterine massage, medications to improve uterine tone, and surgical techniques if bleeding persists.
Postpartum hemorrhage is a leading cause of maternal mortality. Uterine atony accounts for 95% of cases. The 4Ts framework is used to evaluate causes: Tone (uterine atony), Tissue (retained placenta), Trauma (lacerations), and Thrombin (coagulopathy). Prevention focuses on active management of the third stage of labor using uterotonics like oxytocin and ergometrine. Management involves assessing blood loss, vital signs, and treating the underlying cause, such as through uterine massage, manual exploration, additional uterotonics, or surgical interventions if needed.
This document provides information about managing postpartum hemorrhage (PPH) through drills and preparation. It discusses the key aspects of active management of the third stage of labor to prevent PPH and treating PPH if it occurs. It emphasizes the importance of being prepared through drills, having the necessary infrastructure, drugs, equipment, staff and teamwork in place. It outlines the steps of a PPH drill, including communication, team roles and maintaining situational awareness. It also provides information on assessing blood loss, signs of shock, and algorithms for PPH management.
PPH is a leading cause of maternal mortality. It can occur after vaginal or cesarean delivery. Uterine atony accounts for over 80% of cases. Initial management involves calling for help, uterine massage, IV access, rapid fluid resuscitation, and administration of uterotonic drugs like oxytocin, carboprost, and misoprostol. If bleeding continues, examination to check for lacerations or retained products is needed. Blood transfusion may be required based on Hb, platelets, fibrinogen levels. Secondary interventions include additional uterotonics, tamponade, or laparotomy for uncontrolled bleeding. Prompt recognition and treatment following protocols is key to reducing morbidity from PPH.
This document discusses postpartum haemorrhage (PPH), including its definition, causes, severity, risk factors, and management. PPH is a major cause of maternal mortality, accounting for 35% of deaths in Sarawak. It is defined as blood loss over 500mL within 24 hours or excessive bleeding from 24 hours to 6 weeks postpartum. Causes include uterine atony, retained placenta, trauma, and coagulation defects. Management involves recognition, resuscitation with fluids and blood, arresting the bleed through medications, uterine massage, and potential surgical interventions. Close monitoring of vitals and investigations is crucial, especially during the critical first hour after onset of PPH.
This document discusses the prevention and management of uterine atony, which is the leading cause of primary postpartum hemorrhage. It defines postpartum hemorrhage and describes risk factors. Prevention methods include active management of the third stage of labor and use of uterotonic drugs. Medical management includes uterotonic drugs, fluid resuscitation, blood products, and monitoring for disseminated intravascular coagulation. Surgical techniques like uterine packing, arterial ligation, and hysterectomy may be used if bleeding cannot be controlled medically.
This document discusses postpartum hemorrhage (PPH), including risk factors, clinical findings, and management strategies. PPH is defined as blood loss of 1000cc or more within 24 hours of delivery, or blood loss accompanied by signs of hypovolemia. Estimated blood loss is often half of the actual amount. A 6% decrease in postpartum hematocrit indicates a clinically significant blood loss of over 1000cc for an average woman. Common causes of PPH include uterine atony, trauma, retained placental tissue, and coagulopathy. Risk factors, signs, and treatments are provided for each potential cause. Management may involve bimanual uterine massage, uterotonics, surgical repair, manual removal of
This document discusses postpartum haemorrhage (PPH), defined as blood loss greater than 500ml after a vaginal delivery or 1000ml after a cesarean section. It outlines prevention through risk identification and treatment protocols. Causes of PPH are explored through history and examination. Management is directed at the underlying cause and may include uterotonic drugs, tranexamic acid, uterine massage, and identifying uterine inversion. Knowledge of treatment protocols is assessed through sample cases. Recommended additional reading on diagnosis and management of PPH is provided.
PPH Drill Dr. Jyoti Bhaskar , Dr. Sharda Jain , Dr. Jyoti Agarwal Lifecare Centre
This document provides guidelines for managing postpartum haemorrhage (PPH). It emphasizes the need for immediate action, as death from PPH is usually rapid without treatment. The guidelines recommend following the principles of CALL, RESUSCITATE, MONITOR/INVESTIGATE, and STOP THE BLEEDING. First-line treatment includes uterotonics like oxytocin, ergometrine, and misoprostol. Other measures discussed include bimanual compression, condom catheter tamponade, and surgical techniques if conservative options fail. Early recognition, teamwork, and following standardized protocols are essential to optimize outcomes for mothers experiencing PPH.
Postpartum hemorrhage (PPH) is a leading cause of maternal mortality. All women who carry a pregnancy beyond 20 weeks are at risk. Estimates of blood loss are often inaccurate and a woman's ability to tolerate blood loss varies. For these reasons, PPH should be diagnosed based on any amount of blood loss that threatens hemodynamic stability. The natural mechanisms to stop uterine bleeding after birth include uterine contraction, apposition of the uterine walls, activation of coagulation and fibrinolysis pathways, and the muscle fibers of the uterus forming a "figure of eight" pattern. There is often a delay in PPH diagnosis due to physiological changes during pregnancy masking signs of hypovolemia, difficulty quantifying blood loss,
Postpartum hemorrhage (PPH) is defined as blood loss over 500 mL within 24 hours of delivery. The most common cause is an atonic uterus. Management involves a drill with logical steps: recognize PPH, alert team for help and monitoring, perform uterine massage, administer uterotonic drugs, and use bimanual compression or intrauterine balloon tamponade if bleeding persists. Surgical interventions like artery ligation or hysterectomy may be needed. The prognosis depends on blood loss amount.
Dr. Suguna R. Kumar discusses postpartum hemorrhage (PPH), which is the leading cause of maternal mortality in India. PPH is defined as blood loss over 500mL after a vaginal delivery or 1000mL after a cesarean section within 24 hours. Active management of the third stage of labor (AMTSL) including oxytocin administration after delivery, delayed cord clamping, and uterine massage has been shown to reduce PPH occurrences by 60% and need for further treatment by 80%. Management of PPH involves IV access, fluid resuscitation, uterotonic drugs like oxytocin and misoprostol, bimanual uterine compression, and potential surgical interventions if bleeding does not
The document discusses the medical management of postpartum haemorrhage, including definitions, risk factors, etiology, prevention through active management of the third stage of labor, general management principles, choice of uterotonic drugs and their doses and routes of administration, fluid resuscitation, blood product transfusion guidelines, and recommendations from WHO. Prevention of PPH primarily focuses on oxytocin administration and treatment involves oxytocin, carboprost, misoprostol or other uterotonics depending on availability and the clinical situation.
This document summarizes causes, risk factors, diagnosis, and management of postpartum hemorrhage (PPH). PPH is defined as blood loss of 500 ml or more within 24 hours of delivery. Common causes include uterine atony (70%), retained placenta, genital tract trauma, and bleeding disorders. Risk factors include previous uterine surgery, operative delivery, and bleeding abnormalities. Diagnosis involves estimating blood loss and identifying the cause. Management involves resuscitation, arresting the bleeding through uterotonic drugs, manual removal of retained placenta, repairing lacerations, and in severe cases, surgical procedures like hysterectomy.
This document summarizes postpartum hemorrhage, its risk factors, etiologies, pathophysiology, nursing interventions, and other potential postpartum complications including infection, emotional disorders, thrombophlebitis, and domestic violence. It discusses postpartum hemorrhage definitions and causes such as uterine atony, retained tissues, and genital tract trauma. It also outlines nursing assessments and treatments for various postpartum complications.
Informative presentation understanding postpartum hemorrhageAngela Smith
Postpartum hemorrhage (PPH) is excessive bleeding following childbirth, classified as minor (up to 1000ml blood loss), major (>1000ml blood loss), or primary PPH (>500ml blood loss); it affects 4.1% of women and risks are increased for multiples, grand multiparity, previous PPH, maternal age over 40, or obesity; medical treatments include oxytocin, misoprostol, methylergonovine, and balloon tamponade, while severe PPH may require hysterectomy or potentially cause death.
Obstetric emergency which can kill instantly !! - PPH presenting to ED, so what is the role of Emergency Dept ? The most basic presentation of Obstetric emergency and how to tackle it? Being an emergency physician, obstetrics is always challenging! Keep yourself updated with Obstetric emergency.
The document discusses postpartum hemorrhage (PPH), defined as blood loss greater than 500 ml within 24 hours of birth. PPH is a leading cause of maternal mortality, accounting for 30-38% of maternal deaths globally. Risk factors for PPH include prior hemorrhage, advanced maternal age, and prolonged labor. The majority of cases are due to uterine atony. Management involves active management of the third stage of labor with uterotonics like oxytocin, ergometrine, and misoprostol to prevent PPH. For treatment, initial steps are emptying the bladder, checking for complete placenta, massaging the uterus, and providing bimanual compression. Fluid res
Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide, accounting for 34% of deaths in developing countries. PPH is defined as blood loss of 500ml or more following a vaginal birth or 1000ml or more following a caesarean section. Early identification of at-risk patients and active management of the third stage of labour can help prevent PPH. Diagnosis involves communication, resuscitation with fluids and blood products, monitoring, and investigating the cause of bleeding. Treatment focuses on bimanual compression, uterotonic drugs, surgical haemostasis procedures if conservative measures fail, and consideration of recombinant factor VII.
The document provides an overview of postpartum hemorrhage (PPH) including its definition, risk factors, causes, prevention, and management. It discusses predicting patients at risk, preparing for potential hemorrhage, and treating PPH through evaluating tone, tissue, trauma, and thrombin (the 4 Ts). Uterine atony is identified as the leading cause, accounting for 80% of PPH cases. Early use of uterotonic medications and fluid resuscitation are emphasized as essential in management.
Postpartum haemorrhage (PPH) is commonly defined as a blood loss of 500 ml or more within 24 hours after birth.
It affects about 5% of all women giving birth around the world.Globally, nearly one quarter of all maternal deaths are associated with PPH. In most low-income countries, it is the main cause of maternal mortality.
The document discusses non-surgical management of postpartum hemorrhage (PPH). It outlines that PPH is a leading cause of maternal mortality, with causes including uterine atony, retained placenta, and coagulation disorders. Prevention focuses on risk identification and active management of the third stage of labor. Medical management includes uterotonics like oxytocin, carboprost, and misoprostol. Temporary measures like uterine packing, balloon tamponade, and embolization can control bleeding while arranging transfer for hysterectomy if needed.
Update management of postpartum haemorrhage.pdfAhmed Mowafy
Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide, responsible for over 80,000 deaths in 2015. PPH can be primary (within 24 hours of delivery) or secondary (within 12 weeks) and is classified by blood loss volume. The causes of PPH are commonly referred to as the "four Ts": tone (uterine atony), trauma, tissue (retained placenta), and thrombin (coagulopathies). Early recognition through monitoring vital signs and blood loss estimation is important. Treatment involves resuscitation, hemostatic measures like uterotonics to address the underlying cause, and consideration of surgical interventions if conservative options fail.
Postpartum haemorrhage (PPH) is defined as excessive bleeding after childbirth. It can occur within the first 24 hours (primary PPH) or between 24 hours and 12 weeks (secondary PPH). PPH is a leading cause of maternal mortality. Risk factors include previous PPH, multiple pregnancy, and prolonged labour. Prevention through optimal health and identifying risks is important. Management involves assessing blood loss, stopping bleeding, resuscitation, and fluid replacement.
This document provides information about managing postpartum hemorrhage (PPH) through drills and preparation. It discusses the key aspects of active management of the third stage of labor to prevent PPH and treating PPH if it occurs. It emphasizes the importance of being prepared through drills, having the necessary infrastructure, drugs, equipment, staff and teamwork in place. It outlines the steps of a PPH drill, including communication, team roles and maintaining situational awareness. It also provides information on assessing blood loss, signs of shock, and algorithms for PPH management.
PPH is a leading cause of maternal mortality. It can occur after vaginal or cesarean delivery. Uterine atony accounts for over 80% of cases. Initial management involves calling for help, uterine massage, IV access, rapid fluid resuscitation, and administration of uterotonic drugs like oxytocin, carboprost, and misoprostol. If bleeding continues, examination to check for lacerations or retained products is needed. Blood transfusion may be required based on Hb, platelets, fibrinogen levels. Secondary interventions include additional uterotonics, tamponade, or laparotomy for uncontrolled bleeding. Prompt recognition and treatment following protocols is key to reducing morbidity from PPH.
This document discusses postpartum haemorrhage (PPH), including its definition, causes, severity, risk factors, and management. PPH is a major cause of maternal mortality, accounting for 35% of deaths in Sarawak. It is defined as blood loss over 500mL within 24 hours or excessive bleeding from 24 hours to 6 weeks postpartum. Causes include uterine atony, retained placenta, trauma, and coagulation defects. Management involves recognition, resuscitation with fluids and blood, arresting the bleed through medications, uterine massage, and potential surgical interventions. Close monitoring of vitals and investigations is crucial, especially during the critical first hour after onset of PPH.
This document discusses the prevention and management of uterine atony, which is the leading cause of primary postpartum hemorrhage. It defines postpartum hemorrhage and describes risk factors. Prevention methods include active management of the third stage of labor and use of uterotonic drugs. Medical management includes uterotonic drugs, fluid resuscitation, blood products, and monitoring for disseminated intravascular coagulation. Surgical techniques like uterine packing, arterial ligation, and hysterectomy may be used if bleeding cannot be controlled medically.
This document discusses postpartum hemorrhage (PPH), including risk factors, clinical findings, and management strategies. PPH is defined as blood loss of 1000cc or more within 24 hours of delivery, or blood loss accompanied by signs of hypovolemia. Estimated blood loss is often half of the actual amount. A 6% decrease in postpartum hematocrit indicates a clinically significant blood loss of over 1000cc for an average woman. Common causes of PPH include uterine atony, trauma, retained placental tissue, and coagulopathy. Risk factors, signs, and treatments are provided for each potential cause. Management may involve bimanual uterine massage, uterotonics, surgical repair, manual removal of
This document discusses postpartum haemorrhage (PPH), defined as blood loss greater than 500ml after a vaginal delivery or 1000ml after a cesarean section. It outlines prevention through risk identification and treatment protocols. Causes of PPH are explored through history and examination. Management is directed at the underlying cause and may include uterotonic drugs, tranexamic acid, uterine massage, and identifying uterine inversion. Knowledge of treatment protocols is assessed through sample cases. Recommended additional reading on diagnosis and management of PPH is provided.
PPH Drill Dr. Jyoti Bhaskar , Dr. Sharda Jain , Dr. Jyoti Agarwal Lifecare Centre
This document provides guidelines for managing postpartum haemorrhage (PPH). It emphasizes the need for immediate action, as death from PPH is usually rapid without treatment. The guidelines recommend following the principles of CALL, RESUSCITATE, MONITOR/INVESTIGATE, and STOP THE BLEEDING. First-line treatment includes uterotonics like oxytocin, ergometrine, and misoprostol. Other measures discussed include bimanual compression, condom catheter tamponade, and surgical techniques if conservative options fail. Early recognition, teamwork, and following standardized protocols are essential to optimize outcomes for mothers experiencing PPH.
Postpartum hemorrhage (PPH) is a leading cause of maternal mortality. All women who carry a pregnancy beyond 20 weeks are at risk. Estimates of blood loss are often inaccurate and a woman's ability to tolerate blood loss varies. For these reasons, PPH should be diagnosed based on any amount of blood loss that threatens hemodynamic stability. The natural mechanisms to stop uterine bleeding after birth include uterine contraction, apposition of the uterine walls, activation of coagulation and fibrinolysis pathways, and the muscle fibers of the uterus forming a "figure of eight" pattern. There is often a delay in PPH diagnosis due to physiological changes during pregnancy masking signs of hypovolemia, difficulty quantifying blood loss,
Postpartum hemorrhage (PPH) is defined as blood loss over 500 mL within 24 hours of delivery. The most common cause is an atonic uterus. Management involves a drill with logical steps: recognize PPH, alert team for help and monitoring, perform uterine massage, administer uterotonic drugs, and use bimanual compression or intrauterine balloon tamponade if bleeding persists. Surgical interventions like artery ligation or hysterectomy may be needed. The prognosis depends on blood loss amount.
Dr. Suguna R. Kumar discusses postpartum hemorrhage (PPH), which is the leading cause of maternal mortality in India. PPH is defined as blood loss over 500mL after a vaginal delivery or 1000mL after a cesarean section within 24 hours. Active management of the third stage of labor (AMTSL) including oxytocin administration after delivery, delayed cord clamping, and uterine massage has been shown to reduce PPH occurrences by 60% and need for further treatment by 80%. Management of PPH involves IV access, fluid resuscitation, uterotonic drugs like oxytocin and misoprostol, bimanual uterine compression, and potential surgical interventions if bleeding does not
The document discusses the medical management of postpartum haemorrhage, including definitions, risk factors, etiology, prevention through active management of the third stage of labor, general management principles, choice of uterotonic drugs and their doses and routes of administration, fluid resuscitation, blood product transfusion guidelines, and recommendations from WHO. Prevention of PPH primarily focuses on oxytocin administration and treatment involves oxytocin, carboprost, misoprostol or other uterotonics depending on availability and the clinical situation.
This document summarizes causes, risk factors, diagnosis, and management of postpartum hemorrhage (PPH). PPH is defined as blood loss of 500 ml or more within 24 hours of delivery. Common causes include uterine atony (70%), retained placenta, genital tract trauma, and bleeding disorders. Risk factors include previous uterine surgery, operative delivery, and bleeding abnormalities. Diagnosis involves estimating blood loss and identifying the cause. Management involves resuscitation, arresting the bleeding through uterotonic drugs, manual removal of retained placenta, repairing lacerations, and in severe cases, surgical procedures like hysterectomy.
This document summarizes postpartum hemorrhage, its risk factors, etiologies, pathophysiology, nursing interventions, and other potential postpartum complications including infection, emotional disorders, thrombophlebitis, and domestic violence. It discusses postpartum hemorrhage definitions and causes such as uterine atony, retained tissues, and genital tract trauma. It also outlines nursing assessments and treatments for various postpartum complications.
Informative presentation understanding postpartum hemorrhageAngela Smith
Postpartum hemorrhage (PPH) is excessive bleeding following childbirth, classified as minor (up to 1000ml blood loss), major (>1000ml blood loss), or primary PPH (>500ml blood loss); it affects 4.1% of women and risks are increased for multiples, grand multiparity, previous PPH, maternal age over 40, or obesity; medical treatments include oxytocin, misoprostol, methylergonovine, and balloon tamponade, while severe PPH may require hysterectomy or potentially cause death.
Obstetric emergency which can kill instantly !! - PPH presenting to ED, so what is the role of Emergency Dept ? The most basic presentation of Obstetric emergency and how to tackle it? Being an emergency physician, obstetrics is always challenging! Keep yourself updated with Obstetric emergency.
The document discusses postpartum hemorrhage (PPH), defined as blood loss greater than 500 ml within 24 hours of birth. PPH is a leading cause of maternal mortality, accounting for 30-38% of maternal deaths globally. Risk factors for PPH include prior hemorrhage, advanced maternal age, and prolonged labor. The majority of cases are due to uterine atony. Management involves active management of the third stage of labor with uterotonics like oxytocin, ergometrine, and misoprostol to prevent PPH. For treatment, initial steps are emptying the bladder, checking for complete placenta, massaging the uterus, and providing bimanual compression. Fluid res
Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide, accounting for 34% of deaths in developing countries. PPH is defined as blood loss of 500ml or more following a vaginal birth or 1000ml or more following a caesarean section. Early identification of at-risk patients and active management of the third stage of labour can help prevent PPH. Diagnosis involves communication, resuscitation with fluids and blood products, monitoring, and investigating the cause of bleeding. Treatment focuses on bimanual compression, uterotonic drugs, surgical haemostasis procedures if conservative measures fail, and consideration of recombinant factor VII.
The document provides an overview of postpartum hemorrhage (PPH) including its definition, risk factors, causes, prevention, and management. It discusses predicting patients at risk, preparing for potential hemorrhage, and treating PPH through evaluating tone, tissue, trauma, and thrombin (the 4 Ts). Uterine atony is identified as the leading cause, accounting for 80% of PPH cases. Early use of uterotonic medications and fluid resuscitation are emphasized as essential in management.
Postpartum haemorrhage (PPH) is commonly defined as a blood loss of 500 ml or more within 24 hours after birth.
It affects about 5% of all women giving birth around the world.Globally, nearly one quarter of all maternal deaths are associated with PPH. In most low-income countries, it is the main cause of maternal mortality.
The document discusses non-surgical management of postpartum hemorrhage (PPH). It outlines that PPH is a leading cause of maternal mortality, with causes including uterine atony, retained placenta, and coagulation disorders. Prevention focuses on risk identification and active management of the third stage of labor. Medical management includes uterotonics like oxytocin, carboprost, and misoprostol. Temporary measures like uterine packing, balloon tamponade, and embolization can control bleeding while arranging transfer for hysterectomy if needed.
Update management of postpartum haemorrhage.pdfAhmed Mowafy
Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide, responsible for over 80,000 deaths in 2015. PPH can be primary (within 24 hours of delivery) or secondary (within 12 weeks) and is classified by blood loss volume. The causes of PPH are commonly referred to as the "four Ts": tone (uterine atony), trauma, tissue (retained placenta), and thrombin (coagulopathies). Early recognition through monitoring vital signs and blood loss estimation is important. Treatment involves resuscitation, hemostatic measures like uterotonics to address the underlying cause, and consideration of surgical interventions if conservative options fail.
Postpartum haemorrhage (PPH) is defined as excessive bleeding after childbirth. It can occur within the first 24 hours (primary PPH) or between 24 hours and 12 weeks (secondary PPH). PPH is a leading cause of maternal mortality. Risk factors include previous PPH, multiple pregnancy, and prolonged labour. Prevention through optimal health and identifying risks is important. Management involves assessing blood loss, stopping bleeding, resuscitation, and fluid replacement.
Blood loss of >/ 500 ml within 24 hours of vaginal birth or 1000 ml after caesarean section or any blood loss sufficient to compromise haemodynamic instability
MINOR PPH- 500- 1000ml blood loss
MAJOR PPH- > 1000ml Blood loss
MASSIVE PPH- >2000ml Blood loss
This document provides information on preparing for and managing obstetric hemorrhage. Some key points:
- Severe bleeding is a leading cause of maternal death worldwide, with rapid blood loss occurring within 24 hours of delivery in many cases.
- Non-pharmacological measures for postpartum hemorrhage include uterine massage, uterine tamponade, compression sutures, and ligation of internal iliac or uterine arteries. Pharmacological options include oxytocin, ergometrine, carboprost, and tranexamic acid.
- For severe hemorrhage, measures such as hysterectomy, arterial embolization, factor VIIa, or cell salvage may be needed. Initial
Antepartum haemorrage by dr alka mukherjee AND dr apurva mukherjee nagpur m.s...alka mukherjee
A number of clinical and epidemiological studies have identified predisposing risk factors for placental abruption. The most predictive is abruption in a previous pregnancy. risk factors for placental abruption include: pre-eclampsia, fetal growth restriction, non-vertex presentations, polyhydramnios, advanced maternal age, multiparity, low body mass index (BMI), pregnancy following assisted reproductive techniques, intrauterine infection, premature rupture of membranes, abdominal trauma (both accidental and resulting from domestic violence), smoking and drug misuse (cocaine and amphetamines) during pregnancy. First trimester bleeding increases the risk of abruption later in the pregnancy
Maternal thrombophilias have been associated with placental abruption
Risk factors for placenta PRAVIA - Previous placenta praevia , Previous caesarean sections , 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
In view of the known associations between placental abruption and tobacco use, cocaine and amphetamine misuse, women should be advised and encouraged to modify these risk factors. No evidence was identified that specifically investigated smoking cessation and APH. A Cochrane review concluded that smoking cessation programmes in pregnancy reduce the proportion of women who continue to smoke, and reduce low birthweight and preterm birth. The pooled trials have inadequate power to detect reductions in perinatal mortality or very low birthweight and did not specifically analyse rates of APH. It is considered good practice to avoid vaginal and rectal examinations in women with placenta praevia, and to advise these women to avoid penetrative sexual intercourse.
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
Postpartum hemorrhge final دراسات عليا.pptxabdelnaser5
This document provides an update on new technologies for managing postpartum haemorrhage (PPH). It discusses challenges in PPH management and definitions. Risk factors and types of PPH are outlined. New methods for accurately estimating blood loss are presented, including the BRASSS-V drape. Causes and clinical manifestations of PPH are described. Diagnosis involves assessing the 4 T's: Tone, Tissue, Trauma, Thrombin. Conservative and surgical management options are discussed, as well as complications of PPH. Newer techniques like uterine tamponade balloons and compression sutures aim to control bleeding without hysterectomy.
Postpartum haemorrhage (PPH) is defined as blood loss greater than 500 mL following vaginal delivery or 1000 mL following cesarean delivery. The main causes of PPH are uterine atony, retained placental fragments or blood clots, genital tract trauma, and coagulation disorders. Risk factors include uterine fibroids, multiple pregnancy, and polyhydramnios. Clinical signs include lightheadedness, fatigue, and dropping blood pressure and pulse as blood loss exceeds 1500 mL. Treatment involves uterine massage, IV fluids and oxytocics, emptying the bladder, repairing lacerations, and blood transfusions. Prevention strategies include active management of the third stage of labor and careful examination of the
approach to urosepsis/sepsis/septic shock.
general approach to sepsis, severe sepsis, septic shock according to the latest guidelines. SCG2016/ EGDT2018/EUA2020
This case highlights the importance of early recognition and prompt management of postpartum haemorrhage. Some key points:
1. Risk factors for uterine atony include prolonged labour, operative delivery like ventouse which can cause trauma and lead to atony.
2. Common causes of uterine atony are failure of the uterus to contract adequately after delivery of the placenta due to factors like overdistension, infections, retained products of conception.
3. Management of uterine atony involves emptying the uterus, bimanual compression, medical treatment with uterotonics like oxytocics and prostaglandins, and if bleeding persists surgical interventions like balloon tamponade, compression sutures or hysterectomy may be
Hypertensive crisis in pregnancy by dr alka mukherjee dr apurva mukherjee nag...alka mukherjee
Hypertension affects 10% of pregnancies, many with underlying chronic hypertension, and approximately 1–2% will undergo a hypertensive crisis at some point during their lives. Hypertensive crisis includes hypertensive urgency and emergency; the American College of Obstetricians and Gynecologists describes a hypertensive emergency in pregnancy as persistent (lasting 15 min or more), acute-onset, severe hypertension, defined as systolic BP greater than 160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia. Pregnancy may be complicated by hypertensive crisis, with lower blood pressure threshold for end-organ damage than non-pregnant patients. Maternal assessment should include a thorough history. Fetal assessment should include heart rate tracing, ultrasound for growth and amniotic assessment, and Doppler evaluation if growth restriction is suspected. Initial management of hypertensive emergency (systolic BP >160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia) generally includes the rapid reduction of blood pressure through the use of intravenous antihypertensive medications, with goal systolic blood pressure between 140 mmHg and 150 mmHg and diastolic pressure between 90 mmHg and 100 mmHg. First-line intravenous drugs include labetalol and hydralazine, but other agents may be used, including esmolol, nicardipine, nifedipine, and, as a last resort, sodium nitroprusside. Among patients with hypertensive urgency, slower blood pressure reduction can be provided with oral agents. The objective of this article is to review the current understanding, diagnosis, and management of hypertensive crisis during pregnancy and the postpartum period.
This document discusses massive obstetric hemorrhage (MOH), including its definition, causes, incidence, impact on maternal health, clinical presentation, management, and prognosis. Some key points:
- MOH is a leading cause of maternal death worldwide and in sub-Saharan Africa. It is defined as blood loss greater than 1500ml or a decrease in hemoglobin of more than 4g/dl.
- Common causes of MOH include uterine atony, genital tract trauma, and retained placenta. Early diagnosis and treatment with uterotonics, fluid resuscitation, blood transfusions, and potential interventions like hysterectomy can help manage MOH.
- Outcomes are better when treatment
Anaesthetic management of obstetric emergenciesVidhi Gajjar
This document discusses the anesthetic management of obstetric emergencies such as major obstetric hemorrhage and fetal compromise. It covers the challenges in managing obstetric hemorrhage including difficulty in estimating blood loss and early diagnosis of shock due to masking of signs by normal pregnancy physiology. The management approach "ORDER" is outlined which includes organization, resuscitation, defective coagulation, evaluation of response, and remedying the cause of bleeding. General anesthesia techniques for cesarean sections in hemorrhage emphasize rapid sequence induction, cricoid pressure, and hemodynamic support through fluid resuscitation and blood product transfusion to maintain coagulation.
Postpartum hemorrhage (PPH) is excessive bleeding after childbirth, defined as blood loss over 500 ml for vaginal births or 1000 ml for C-sections. The main causes of PPH are uterine atony (failure of the uterus to contract), retained placenta, and trauma to the genital tract. Management involves bimanual uterine massage, uterotonic drugs, vaginal packing, balloon tamponade, and in severe cases surgical interventions like B-Lynch sutures or hysterectomy.
Postpartum haemorrhage (PPH) is a major cause of maternal mortality. It can be primary (within 24 hours of delivery) or secondary (24+ hours after delivery). Primary PPH is mainly due to uterine atony or trauma during delivery. Diagnosis involves assessing blood loss and vital signs. Management focuses on uterine massage/contraction, blood transfusion, repairing lacerations, and rarely hysterectomy. Prevention strategies include active management of the third stage of labour and treating prenatal anemia.
Primary postpartum hemorrhage is a leading cause of maternal mortality. This presentation defines PPH as blood loss exceeding 500mL after vaginal delivery or 1000mL after c-section within 24 hours of delivery. The main causes are uterine atony, retained placenta or clots, genital tract trauma, and coagulopathy. Risk factors include previous c-sections, multiple gestation, and medical disorders. Prevention focuses on active management of the third stage of labor and treatment involves addressing the underlying cause, fluid resuscitation, blood transfusion, and potentially hysterectomy for uncontrolled bleeding.
This document discusses postpartum hemorrhage (PPH), defined as blood loss of 1000 mL or more after childbirth. It outlines ways to prevent and manage PPH, including active management of the third stage of labor, identifying risk factors, and following the "Four Ts" approach to determine the cause of bleeding (tone, trauma, tissue, thrombin). Initial treatments include uterotonic drugs, bimanual uterine massage, and blood transfusions. More severe cases may require interventions like uterine balloon tamponade, compression sutures, arterial embolization, or hysterectomy. Massive bleeding requires activating a massive transfusion protocol with predetermined blood product ratios.
Complications of 3rd stage Prof.Salah.pdfSalahRoshdy2
This document discusses complications of the third stage of labor, with a focus on postpartum hemorrhage (PPH). It defines PPH, reviews risk factors, and discusses the physiology of hemorrhage. Primary causes of PPH include uterine atony, trauma, and coagulation defects. The document outlines prevention strategies like proper labor management and being prepared. Initial management of PPH focuses on ABCs, IV access, fluids, examining for causes, and treating uterine atony with uterotonic drugs and massage. Blood replacement is indicated for significant blood loss.
Seminar on Management of pelvic hemorrhage.pptxmenkirtegegne
This document outlines a seminar on the management of pelvic hemorrhage. It discusses evaluating and preparing patients preoperatively through blood transfusions and iron therapy. Intraoperatively, techniques include applying pressure, identifying bleeding sites, and developing avascular spaces. The major sites of bleeding in the pelvis are also reviewed.
Similar to Massive obstetric haemorrhage by dr alka mukherjee dr apurva mukherjee nagpur m.s. india (20)
Management of anaemia in pregnancy BY DR ALKA MUKHERJEE DR APURVA MUKHERJEE N...alka mukherjee
Prenatal vitamins typically contain iron. Taking a prenatal vitamin that contains iron can help prevent and treat iron deficiency anemia during pregnancy. In some cases, your health care provider might recommend a separate iron supplement. During pregnancy, you need 27 milligrams of iron a day.
Good nutrition also can prevent iron deficiency anemia during pregnancy. Dietary sources of iron include lean red meat, poultry and fish. Other options include iron-fortified breakfast cereals, prune juice, dried beans and peas.
The iron from animal products, such as meat, is most easily absorbed. To enhance the absorption of iron from plant sources and supplements, pair them with a food or drink high in vitamin C — such as orange juice, tomato juice or strawberries. If you take iron supplements with orange juice, avoid the calcium-fortified variety. Although calcium is an essential nutrient during pregnancy, calcium can decrease iron absorption.
How is iron deficiency anemia during pregnancy treated?
If you are taking a prenatal vitamin that contains iron and you are anemic, your health care provider might recommend testing to determine other possible causes. In some cases, you might need to see a doctor who specializes in treating blood disorders (hematologist). If the cause is iron deficiency, additional supplemental iron might be suggested. If you have a history of gastric bypass or small bowel surgery or are unable to tolerate oral iron, you might need intravenous iron administration. Oral iron is recommended as the first line treatment, with repeated checking of Hb at 2 to 3 weeks after starting treatment to assess compliance, correct administration and response to treatmentOnce Hb reaches the normal range, it is recommended that iron replacement should continue for three months and until at least six weeks postpartumIntravenous (IV) iron is recommended for women who could not tolerate or respond to oral iron, and for those with moderately severe to severe anemia (Hb ≤ 90 g/LHb be measured within 24 to 48 hours after delivery in women with blood loss more than 500 mL, those with uncorrected anemia detected during pregnancy or those with symptoms suggestive of anemia postnatallyOral iron is recommended for women with Hb <100 g/L postpartum, who are hemodynamically stable, asymptomatic or mild symptomatic
Anemia signs and symptoms include:
• Fatigue
• Weakness
• Pale or yellowish skin
• Irregular heartbeats
• Shortness of breath
• Dizziness or lightheadedness
• Chest pain
• Cold hands and feet
• Headache
Keep in mind, however, that symptoms of anemia are often similar to general pregnancy symptoms. Regardless of whether or not you have symptoms, you'll have blood tests to screen for anemia during pregnancy. If you're concerned about your level of fatigue or any other symptoms, talk to your health care provider.
Secondary amenorrhoea by dr alka mukherjee dr apurva mukherjeealka mukherjee
The first step in the evaluation of any patient with secondary amenorrhea is a urine pregnancy test. Every contraceptive method has a failure rate, and anyone who is menstruating is potentially fertile, regardless of age. [5][6]
If the pregnancy test is negative, consider the clinical picture: hirsutism, acne, and a long history of infrequent and irregular menses suggest polycystic ovarian syndrome. By the Rotterdam criteria, a patient may be diagnosed with PCOS if she has two of the following: clinical or chemical hyperandrogenism, oligo- or amenorrhea, or polycystic ovaries on ultrasound. So if a patient has evidence of hirsutism and oligo- or amenorrhea, she can be diagnosed with PCOS without further laboratory testing or imaging.
If history and physical exam are not consistent with PCOS, a TSH should be ordered. Both hyper- and hypothyroidism can lead to menstrual dysfunction.
If TSH is normal, check a serum prolactin. Elevated serum prolactin suggests prolactinoma.
Early pregnancy loss by dr alka mukherjee dr apurva mukherjee nagpur ms indiaalka mukherjee
Early pregnancy loss, or loss of an intrauterine pregnancy within the first trimester, is encountered commonly in clinical practice. Obstetricians and gynecologists should understand the use of various diagnostic tools to differentiate between viable and nonviable pregnancies and offer the full range of therapeutic options to patients, including expectant, medical, and surgical management.
Early pregnancy loss is defined as a nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart activity within the first 12 6/7 weeks of gestation 1. In the first trimester, the terms miscarriage, spontaneous abortion, and early pregnancy loss are used interchangeably, and there is no consensus on terminology in the literature.
Pprom by dr alka mukherjee dr apurva mukherjee nagpur indiaalka mukherjee
Preterm premature rupture of the membranes (PPROM) is a pregnancy complication. In this condition, the sac (amniotic membrane) surrounding your baby breaks (ruptures) before week 37 of pregnancy. Once the sac breaks, you have an increased risk for infection. You also have a higher chance of having your baby born early.
In most cases of PPROM, the cause is not known.
These things may increase risk:
• Having a preterm birth in a previous pregnancy
• Having an infection in your reproductive system
• Vaginal bleeding during pregnancy
• Smoking during pregnancy
Symptoms can occur a bit differently in each pregnancy. They can include:
• A sudden gush of fluid from your vagina
• Leaking of fluid from your vagina
• A feeling of wetness in your vagina or underwear
Call your healthcare provider right away if you have these symptoms.
The symptoms of this health problem may be similar to symptoms of other conditions. See your healthcare provider for a diagnosis.
Diagnosis
• pH (acid-base) balance testing. The pH balance of amniotic fluid is different from vaginal fluid and urine. Your healthcare provider will put the fluid on a test strip to check the balance.
• Looking at a sample under a microscope. When amniotic fluid is dry, it has a fern-like pattern.
• ultrasound exam. This is done to check the amount of amniotic fluid around baby.
Public education on breast cancer hindi by dr alka mukherjee nagpur ms i...alka mukherjee
Abnormal lump — Breast cancer can be discovered when a lump or other change in the breast or armpit is found by a woman herself or by her healthcare provider. In addition to a lump, other abnormal changes may include dimpling of the skin, a change in the size or shape of one breast, retraction (pulling in) of the nipple when it previously pointed outward, or a discoloration of the skin of the breast not related to infection or skin conditions such as psoriasis or eczema.Mammogram — A mammogram is a very low-dose X-ray of the breast. The breast tissue is compressed for the X-ray, which decreases the thickness of the tissue and holds the breast in position, so the radiologist can find abnormalities more accurately. Each breast is compressed between two panels and X-rayed from two directions (top-down and side-to-side) to make sure all the tissue is examined. Mammograms are currently the best screening modality to detect breast cancer. Some mammograms capture images digitally, offering better clarity, the ability to adjust the image, and a decreased likelihood that the woman will need to return on a different day for repeat pictures.
Cancer cervix awareness in hindi by dr alka mukherjee nagpur ms indiaalka mukherjee
Cervical cancer occurs when the cells in the cervix grow abnormally or out of control. The cervix is part of the female reproductive system. The exact cause of cervical cancer is unknown. Certain strains of the human papillomavirus (HPV), a sexually transmitted disease, cause the majority of cervical cancer.
A new vaccine is available to prevent infection against the two types of HPV that are responsible for the majority of cervical cancer cases and the two types of HPV that are responsible for the majority of genital wart cases. A pap smear test is a preventive measure that can detect precancerous or cancerous cells. Precancerous cells are 100% curable.
Telehealth medico legal aspects by dr alka mukherjee nagpur ms indiaalka mukherjee
The term telehealth includes a broad range of technologies and services to provide patient care and improve the healthcare delivery system as a whole. Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services. According to the World Health Organization, telehealth includes, “Surveillance, health promotion and public health functions.”
Telemedicine involves the use of electronic communications and software to provide clinical services to patients without an in-person visit. Telemedicine technology is frequently used for follow-up visits, management of chronic conditions, medication management, specialist consultation and a host of other clinical services that can be provided remotely via secure video and audio connections.
Evolution and current practices in emergency contraceptives BY DR ALKA MUKHER...alka mukherjee
This document provides information on emergency contraceptives, including their evolution and current practices. It discusses various emergency contraceptive methods such as the Yuzpe regimen, levonorgestrel pills, mifepristone, copper IUDs, and the recently approved ulipristal acetate. It summarizes the mechanisms of action, effectiveness, appropriate timing, side effects, limitations and safety considerations of the different emergency contraceptive options. The document concludes that emergency contraception can effectively reduce unintended pregnancies and abortions if provided correctly and in a timely manner after unprotected intercourse.
Screening for gestational diabetes an update by dr alka mukherjee nagpur ms i...alka mukherjee
Gestational Diabetes Mellitus (GDM) is defined as any glucose intolerance with the onset or first recognition during pregnancy. This definition helps for diagnosis of unrecognized pre-existing Diabetes also. Hyperglycemia in pregnancy is associated with adverse maternal and prenatal outcome. It is important to screen, diagnose and treat Hyperglycemia in pregnancy to prevent an adverse outcome. There is no international consensus regarding timing of screening method and the optimal cut-off points for diagnosis and intervention of GDM. DIPSI recommends non-fasting Oral Glucose Tolerance Test (OGTT) with 75g of glucose with a cut-off of ≥ 140 mg/dl after 2-hours, whereas WHO (1999) recommends a fasting OGTT after 75g glucose with a cut-off plasma glucose of ≥ 140 mg/dl after 2-hour. The recommendations by ADA/IADPSG for screening women at risk of diabetes is as follows, for first and subsequent trimester at 24-28 weeks a criteria of diagnosis of GDM is made by 75 g OGTT and fasting 5.1mmol/l, 1 hour 10.0mmol/l, 2 hour 8.5mmol/l by universal glucose tolerance testing. Critics of these criteria state that it causes over diagnosis of GDM and unnecessary interventions, the controversy however continues. The ACOG still prefer a 2 step procedure, GCT with 50g glucose non-fasting if value > 7.8mmol/l followed by 3-hour OGTT for confirmation of diagnosis. In conclusion based on Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study as mild degree of dysglycemia are associated with adverse outcome and high prevalence of Type II DM to have international consensus It recommends IADPSG criteria, though controversy exists. The IADPSG criteria is the only outcome based criteria, it has the ability to diagnose and treat GDM earlier, thereby reducing the fetal and maternal complications associated with GDM. This one step method has an advantage of simplicity in execution, more patient friendly, accurate in diagnosis and close to international consensus. Keeping in the mind the diversity and variability of Indian population, judging international criteria may not be conclusive, thus further comparative studies are required on different diagnostic criteria in relation to adverse pregnancy outcomes
Hague convention for inter country adoption by dr alka mukherjee nagpur ms indiaalka mukherjee
The Hague Convention on the Protection of Children and Co-operation in Respect of Intercountry Adoption (Convention) is an international agreement to safeguard intercountry adoptions. Concluded on May 29, 1993 in The Hague, the Netherlands, the Convention establishes international standards of practices for intercountry adoptions. The United States signed the Convention in 1994, and the Convention entered into force for the United States on April 1, 2008The Convention applies to all adoptions by U.S. citizens habitually resident in the United States of children habitually resident in any country outside of the United States that is a party to the Convention (Convention countries). Adopting a child from a Convention country is similar in many ways to adopting a child from a country not party to the Convention. However, there are some key differences. In particular, those seeking to adopt may receive greater protections if they adopt from a Convention country.
The Convention requires that countries who are party to it establish a Central Authority to be the authoritative source of information and point of contact in that country. The Department of State is the U.S. Central Authorityfor the Convention.
The Convention aims to prevent the abduction, sale of, or trafficking in children, and it works to ensure that intercountry adoptions are in the best interests of children.
The Convention recognizes intercountry adoption as a means of offering the advantage of a permanent home to a child when a suitable family has not been found in the child's country of origin. It enables intercountry adoption to take place when, among other steps:
1. The child has been deemed eligible for adoption by the child's country of origin; and
2. Due consideration has been given to finding an adoption placement for the child in its country of origin.
The role of judiciary & the legal procedure in an adoption case by dr alka mu...alka mukherjee
Central Adoption Resource Authority (CARA) is the nodal agency to monitor and regulate in-country and intra-country adoption and is a part of Ministry of Women and child care.
Following are the certain essential conditions in order to be eligible to adopt a child:
• The procedure for adoption is different in case of Indian citizen, NRI or a foreign citizen and a child can be adopted by any of the three.
• Irrespective of their gender or marital status, any person is eligible to adopt.
• Provided that a couple is adopting a child, they should have completed two years of stable marriage and both should agree for the adoption.
• 25 years should be the minimum age difference between the child and the adoptive parents.
WHEN CAN A CHILD BE ELIGIBLE TO BE ADOPTED?
• Any orphan, surrendered or abandoned child is legally declared free for adoption by the child welfare committee as per the guidelines of the Central Government of India.
• A child without a legal parent or a guardian or the parents are not capable of taking care of the child anymore is said to be an orphan.
• When a child is deserted or unaccompanied by parents or a guardian and the child welfare committee has declared the child to be abandoned, a child is considered to be abandoned.
• Renounce on account of physical, social and emotional factors that are beyond the control of parents or the guardian is called a surrendered child as declared by the child welfare committee.
• In case of adoption, a child requires to be “legally free”. A child is considered to be legally free if even after trying their level best the police fails to find the true parent or guardian of the child.
WHAT ARE THE NORMAL CONDITIONS TO BE FULFILLED BY PARENTS?
• The adoptive parents need to be mentally, physically and emotionally stable.
• The adoptive parents should be financially stable.
• The adoptive parents should not be suffering from any life- threatening diseases.
• Apart from cases of special needs children, couples with three or more kids are not allowed for adoption.
• A single female is allowed to adopt a child of any gender but a single male is not allowed to adopt a girl child.
• The maximum age limit of a single parents should be 55 years.
Laws , rules & regulations governing adoptions in india by dr alka mukherjee ...alka mukherjee
ADOPTION IN INDIA
The custom and practice of adoption in India dates back to the ancient times. Although the act of adoption remains the same, the objective with which this act is carried out has differed. It usually ranged from the humanitarian motive of caring and bringing up a neglected or destitute child, to a natural desire for a kid as an object of affection, a caretaker in old age, and an heir after death.[iii]
But since adoption comes under the ambit of personal laws, there has not been a scope in the Indian scenario to incorporate a uniform law among the different communities which consist of this melting pot. Hence, this law is governed by various personal laws of different religions.
Adoption is not permitted in the personal laws of Muslims, Christians, Parsis and Jews in India. Hence they usually opt for guardianship of a child through the Guardians and Wards Act, 1890.
Indian citizens who are Hindus, Jains, Sikhs, or Buddhists are allowed to formally adopt a child. The adoption is under the Hindu Adoption and Maintenance Act of 1956 that was enacted in India as a part of the Hindu Code Bills. It brought about a few reforms that liberalized the institution of adoption.
Tuberculosis in prenancy by dr alka mukherjee dr apurva mukherjee nagpur ms i...alka mukherjee
Prevention of Tuberculosis
The BCG vaccine has been incorporated into the National immunization policy of many countries, especially the high burden countries, thereby conferring active immunity from childhood. Nonimmune women travelling to tuberculosis endemic countries should also be vaccinated. It must, however, be noted that the vaccine is contraindicated in pregnancy [72].
The prevention, however, goes beyond this as it is essentially a disease of poverty. Improved living condition is, therefore, encouraged with good ventilation, while overcrowding should be avoided. Improvement in nutritional status is another important aspect of the prevention.
Pregnant women living with HIV are at higher risk for TB, which can adversely influence maternal and perinatal outcomes [73]. As much as 1.1 million people were diagnosed with the co-infection in 2009 alone [2]. Primary prevention of HIV/AIDS is, therefore, another major step in the prevention of tuberculosis in pregnancy. Screening of all pregnant women living with HIV for active tuberculosis is recommended even in the absence of overt clinical signs of the disease.
Isoniazid preventive therapy (IPT) is another innovation of the World Health Organisation that is aimed at reducing the infection in HIV positive pregnant women based on evidence and experience and it has been concluded that pregnancy should not be a contraindication to receiving IPT. However, patient's individualisation and rational clinical judgement is required for decisions such as the best time to provide IPT to pregnant women
Torch infections during pregnancy by dr alka mukherjee nagpur ms indiaalka mukherjee
TORCH Syndrome refers to infection of a developing fetus or newborn by any of a group of infectious agents. "TORCH" is an acronym meaning (T)oxoplasmosis, (O)ther Agents, (R)ubella (also known as German Measles), (C)ytomegalovirus, and (H)erpes Simplex. Infection with any of these agents (i.e., Toxoplasma gondii, rubella virus, cytomegalovirus, herpes simplex viruses) may cause a constellation of similar symptoms in affected newborns. These may include fever; difficulties feeding; small areas of bleeding under the skin, causing the appearance of small reddish or purplish spots; enlargement of the liver and spleen (hepatosplenomegaly); yellowish discoloration of the skin, whites of the eyes, and mucous membranes (jaundice); hearing impairment; abnormalities of the eyes; and/or other symptoms and findings. Each infectious agent may also result in additional abnormalities that may be variable, depending upon a number of factors (e.g., stage of fetal development
How to develope your personality by dr alka mukherjee nagpur ms indiaalka mukherjee
Personality is what makes a person a unique person, and it is recognizable soon after birth. A child's personality has several components: temperament, environment, and character. Temperament is the set of genetically determined traits that determine the child's approach to the world and how the child learns about the world. There are no genes that specify personality traits, but some genes do control the development of the nervous system, which in turn controls behavior.
A second component of personality comes from adaptive patterns related to a child's specific environment. Most psychologists agree that these two factors—temperament and environment—influence the development of a person's personality the most. Temperament, with its dependence on genetic factors, is sometimes referred to as "nature," while the environmental factors are called "nurture."
While there is still controversy as to which factor ranks higher in affecting personality development, all experts agree that high-quality parenting plays a critical role in the development of a child's personality. When parents understand how their child responds to certain situations, they can anticipate issues that might be problematic for their child. They can prepare the child for the situation or in some cases they may avoid a potentially difficult situation altogether. Parents who know how to adapt their parenting approach to the particular temperament of their child can best provide guidance and ensure the successful development of their child's personality.
Finally, the third component of personality is character—the set of emotional, cognitive, and behavioral patterns learned from experience that determines how a person thinks, feels, and behaves. A person's character continues to evolve throughout life, although much depends on inborn traits and early experiences. Character is also dependent on a person's moral development .
Personality by dr alka mukherjee nagpur ms indiaalka mukherjee
The word personality itself stems from the Latin word persona, which refers to a theatrical mask worn by performers in order to either project different roles or disguise their identities.
At its most basic, personality is the characteristic patterns of thoughts, feelings, and behaviors that make a person unique. It is believed that personality arises from within the individual and remains fairly consistent throughout life.
While there are many different definitions of personality, most focus on the pattern of behaviors and characteristics that can help predict and explain a person's behavior.
Explanations for personality can focus on a variety of influences, ranging from genetic explanations for personality traits to the role of the environment and experience in shaping an individual's personality.
Qualitative blood loss in obstetric hemorrhage by dr alka mukherjee indiaalka mukherjee
• Quantitative methods of measuring obstetric blood loss have been shown to be more accurate than visual estimation in determining obstetric blood loss.
• Studies that have compared visual estimation to quantitative measurement have found that visual estimation is more likely to underestimate the actual blood loss when volumes are high and overestimate when volumes are low.
• Although quantitative measurement is more accurate than visual estimation for identifying obstetric blood loss, the effectiveness of quantitative blood loss measurement on clinical outcomes has not been demonstrated.
• Implementation of quantitative assessment of blood loss includes the following two items: 1) use of direct measurement of obstetric blood loss (quantitative blood loss) and 2) protocols for collecting and reporting a cumulative record of blood loss postdelivery.
Dysmenorrhea and related disorders by dr alka mukherjee dr apurva mukherjee n...alka mukherjee
Dysmenorrhea is a common symptom secondary to various gynecological disorders, but it is also represented in most women as a primary form of disease. Pain associated with dysmenorrhea is caused by hypersecretion of prostaglandins and an increased uterine contractility. The primary dysmenorrhea is quite frequent in young women and remains with a good prognosis, even though it is associated with low quality of life. The secondary forms of dysmenorrhea are associated with endometriosis and adenomyosis and may represent the key symptom. The diagnosis is suspected on the basis of the clinical history and the physical examination and can be confirmed by ultrasound, which is very useful to exclude some secondary causes of dysmenorrhea, such as endometriosis and adenomyosis. The treatment options include non-steroidal anti-inflammatory drugs alone or combined with oral contraceptives or progestins.
Dyspareunia & vulvodynia by dr alka mukherjee dr apurva mukherjee nagpur m.s....alka mukherjee
This document discusses dyspareunia (recurring pain during sexual intercourse) and vulvodynia (chronic genital pain). It describes the causes, symptoms, diagnosis, and treatment options. Dyspareunia and vulvodynia can have physical and psychological causes, and treatment may involve medications, physical therapy, cognitive behavioral therapy, and sometimes surgery. A multidisciplinary approach is often needed to properly diagnose and address the underlying causes of genital pain.
Chronic pelvic pain by dr alka mukherjee dr apurva mukherjee nagpur m.s. indiaalka mukherjee
Chronic pelvic pain in women is defined as persistent, noncyclic pain perceived to be in structures related to the pelvis and lasting more than six months. Often no specific etiology can be identified, and it can be conceptualized as a chronic regional pain syndrome or functional somatic pain syndrome. It is typically associated with other functional somatic pain syndromes (e.g., irritable bowel syndrome, nonspecific chronic fatigue syndrome) and mental health disorders (e.g., posttraumatic stress disorder, depression). Diagnosis is based on findings from the history and physical examination. Pelvic ultrasonography is indicated to rule out anatomic abnormalities. Referral for diagnostic evaluation of endometriosis by laparoscopy is usually indicated in severe cases. Curative treatment is elusive, and evidence-based therapies are limited. Patient engagement in a biopsychosocial approach is recommended, with treatment of any identifiable disease process such as endometriosis, interstitial cystitis/painful bladder syndrome, and comorbid depression. Potentially beneficial medications include depot medroxyprogesterone, gabapentin, nonsteroidal anti-inflammatory drugs, and gonadotropin-releasing hormone agonists with add-back hormone therapy. Pelvic floor physical therapy may be helpful. Behavioral therapy is an integral part of treatment. In select cases, neuromodulation of sacral nerves may be appropriate. Hysterectomy may be considered as a last resort if pain seems to be of uterine origin, although significant improvement occurs in only about one-half of cases. Chronic pelvic pain should be managed with a collaborative, patient-centered approach.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
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In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
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2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
Director of Mukherjee Multispecialty Hospital
Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
Hon.Secretary AMWN (2018-2021)
Hon.Secretary ISOPARB (2019-2021)
Life member, IMA, NOGS, NARCHI, AMWN & Menopause Society,
India, Indian medico-legal & ethics association(IMLEA), ISOPRB,
HUMAN RIGHTS
Founder Member of South Rapid Action Group, Nagpur.
On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
Winner of NOGS GOLD MEDAL – 2017-18
Winner of BEST COUPLE AWARD in Social
Work - 2014
APPRECIATION Award IMA - MS
Past Position
Organizing joint secretary ENDO-GYN 2019
Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019
3. KEY FACTS
• Definition Blood loss of over 2000 ml (or > 30% of blood
volume) is defined as massive obstetric hemorrhage (MOH).
• There is a tendency to underestimate rather than over
estimate the actual blood loss.
4. TYPES
• Massive obstetric haemorrhage can occur
• Antepartum (placenta praevia, placental abruption and
placenta accreta) or
• Postpartum period (postpartum haemorrhage (PPH) due to
uterine atonia, genital tract trauma, retained placenta and
membranes or coagulopathy).
• Rare obstetric disorders such as amniotic fluid embolism
(afe) or acute inversion of uterus may also present with
massive obstetric haemorrhage.
5.
6. INCIDENCE
• Antepartum haemorrhage (APH) : 3-5% of all pregnancies
a) Placenta praevia - 1/3th cases
b) Placental abruption – ¼ th cases
• Postpartum haemorrhage occurs in 2–10% of deliveries but
• Major obstetric haemorrhage - 3.7–5/1000 maternities.
• It is estimated that every year about 600 000 to 800 000
women die during childbirth around the world.
• In the developing world, PPH occurs in about 1 in 1000
deliveries.
7.
8. • The eighth report of the confidential enquiries into maternal
deaths in the UK has listed PPH as the third most common
direct cause of maternal mortality
• Massive blood loss leads to sudden and rapid cardiovascular
decompensation and coagulopathy.
• Three delays have been identified as the causes of maternal
deaths due to massive obstetric haemorrhage:
• Delay in seeking medical care,
• Delay in reaching healthcare facilities and
• Delay in receiving appropriate care in a healthcare
institution.
9. • Involvement of a multidisciplinary team of
I. Anaesthetists,
II. Haematologists and
III. Intensivists is essential to improve outcome
•
• Special Massive Haemorrhage Protocols such as 'Code Blue'
should be in place for the effective, multidisciplinary
management of massive obstetric haemorrhage.
10. KEY IMPLICATIONS
• Massive obstetric haemorrhage causes significant maternal
morbidity and mortality as well as many ‘near misses.
Antepartum haemorrhage due to placental abruption and
intrapartum haemorrhage due to uterine rupture are
associated with increased perinatal mortality.
• Moreover, massive obstetric haemorrhage due to placenta
praevia may result in fetal complications secondary to
prematurity as well as severe maternal hypovolumia and
hypotension.
11. RECOGNISE MASSIVE OBSTETRIC
HAEMORRHAGE (REVEALED AND CONCEALED)
• Visible blood loss > 2 litres
• On-going bleeding (>150 ml/minute)
• Loss of > 30% of blood volume as assessed by visible blood
loss or
• Rule of 30 :
• (rise in pulse > 30/minute,
• Drop in SBP by 30 mm hg,
• Increased respiratory rate > 30 /minute,
• A drop in haematocrit (packed cell volume) by 30%
• Shock index (pulse rate / systolic blood pressure) > 0.9
12. ENSURE IMMEDIATE RESUSCITATION
• Lower the head end of the bed and left lateral tilt (antepartum)
• Ensure adequate oxygenation - 15 litres of oxygen by mask
• Two large intravenous cannulae (14 G) Rapid infusion of
crystalloids 2 litres, colloids 1 litre to maintain blood volume
• Group specific o negative blood or uncross matched group specific
blood if haemodynamically unstable, whilst awaiting cross
matched blood
• Correct coagulopathy (platelets and 4 units of fresh frozen plasma
for every 6 units of blood transfusion)
• Send for urgent investigations: full blood count, urea and
electrolytes, clotting profile
• Commence monitoring - blood pressure, pulse, respiration,
oxygen saturation, urine output, ECG (if available)
• Consider arterial blood gases and central venous pressure
monitoring
13. IDENTITY AND MANAGE SPECIFIC CAUSE OF
MASSIVE OBSTETRIC HAEMORRHAGE
Antepartum
1. Placental abruption
• Expedite delivery , whilst correcting hypovolumia and
coagulation abonormalities.
• Emergency caeasrean section , if evidence of fetal
compromise and if the mother is haemodynamically stable.
2. Placenta praecia
• Expedite delivery after correcting hypovolumia and
cogulation abnormalities Gases and central venous pressure
monitoring
14. • Intrapartum:
1. Uterine rupture/ supra-levator broad ligament haematoma :
- Urgent laparotomy to control bleeding
- Consider pelvic arterial embolisation pre – or postsurgey , if
patient is stable.
2. Uterine trauma during caearean section - surgical
haemostasis +/- peripartum hysterctomy
3. Rapid onest of coagulopathy due to amniotic fluid embolism
- Urgent intensive care for ventilation and inotropic support
with correction of coagluation abnormalities.
15. • Postpartum
• Postpartum haemorrhage due to :
A. Uterine atony , uterine truma , coagulopthy , retained
placenta and membranes
B. Manage as per the Algorithm HAEMOSTASIS
• Acute uterine inversion
1. Immediate manual reposition of the fundus of the uterus
2. Use of O sullvan’s hydrostatic method.
C. Bleeding due to bleeding diathesis Correct the underlying
disorder (e.g platelets)
16. IMMEDIATE IMPLICATIONS
a. Hypovolumia, hypoxaemia and cardiac arrest.
b. Blood transfusion and effects of multiple blood transfusions
induding transfusion reactions, risk of infections and
transfusion associated acute lung injury (TRALI).
c. Acute renal failure.
d. Pulmonary oedema.
e. Coagulopathy
f. Risk of peripartum hysterectomy.
g. Intensive care treatment.
17. LONG-TERM IMPLICATIONS
• Psychological sequelae - delayed bonding with baby, post-
traumatic stress disorder.
• Sheehan's syndrome (pituitary necrosis and failure due to
massive obstetric haemorrhage leading to
panhypopituitarism).
• Impaired future fertility.
• Long – term anaemia.
18. • H - Ask for Help and hands on uterus(uterine massage)
• A - Assess (ABC) and resuscitate (crystalloids 21. colloids TI, oxygen by mask (15
l/min)
• E - Establish aetiology (atonic traumatic, coqulopathy or trauma), ensure
availability of Nood and administe ecbolics (drugs that contact the uterus -
Oxytocin ergometrine of Syntoneinne intramuscularly)
• M - Massage uterus
• O - Oxytocin infusion/prostaglandins - IVIM/per rectal (second line medications
to contract the uterus)
• S - Shift to theatre-3000 pressure or on anti - shock garment/bimanual
compression as appropriate
• T - Tamponade balloon/uterine packing - alter exclusion of tissue and trauma
• A - Apply compression sutures - B-Lynch/ modified
• S – systematic pelvic devascularisation - uterine/ovarian/ Quadruple internal ilac
• I - Interventional radiology and, if appropriate uterine artery embolisation
• S- Subtotal abdominal hysterectomy.
20. INTRAPARTUM
• Amniotic fluid embolism (AFE) with coagulopathy.
• Uterine rupture secondary to previous uterine scar or grand
multiparity, especially with injudicious use of oxytocin.
• Surgical complications (extension of uterine angular tear
during caesarean section).
22. KEY POINTERS TO MASSIVE OBSTETRIC
HAEMORRHAGE
• Visible blood loss 2 litres.
• Ongoing bleeding (150 ml/minute).
• Loss of > 30% of blood volume as assessed by visible blood loss
(estimated blood loss or EBL expressed as the percentage of
estimated blood volume = EBL/100 ml/kg).
• Rule of 30' (Rise in pulse 30/min, drop in systolic blood pressure
by 30 mmHg, increased respiratory rate > 30/minute, a drop in
haematocrit (packed cell volume) by 30%) which is suggestive of
at least 30% loss of blood volume.
• Shock index (pulse rate/systolic blood pressure) > 0.9. Normal
shock index is between 0.5-0.7 as the pulse rate is less than
systolic blood pressure. Tense, tender abdomen with evidence of
intrauterine death (massive placental abruption)
23. KEY ACTIONS: MASSIVE OBSTETRIC
HAEMORRHAGE PRIOR TO DELIVERY
• Placental abruption - premature separation of a normally
situated placenta.
• Maternal risks include haemorrhage secondary to
accumulation of blood in the retro-placental space after
separation of placenta as well as, in severe cases, bleeding
into the uterine cavity as well as within the myometrial
fibres.
• Activation of the extrinsic pathway of coagulation results in
disseminated intravascular coagulation
• Fetal risks include hypoxic cerebral injury as well as
intrauterine death.
25. CLINICAL PRESENTATION
1. Vaginal bleeding that is associated with abdominal pain or
discomfort - ('revealed' bleeding)
2. blood con accumulate behind the separated placenta and hence,
mo bleeding may be noted - (concealed haemorrhage)
3. Rarely, it may be 'mixed' (a combination of the above).
• On examination, the patient may be pale and may be in constant
pain.
• Abdominal examination may confirm a very tense, lender 'woody
hard' uterus (especially in a concealed haemorrhage),
• In severe cases of placental abruption –
the fetal heart rate may be absent
patient may show signs of coagulopathy.
Observed blood loss may be out of proportion to the clinical
condition and this may point to a mixed' haemorrhage.
26. MANAGEMENT
• Immediate management -
i. Active resuscitation to ensure a patent airway, breathing
and maintaining circulation with intravenous fluids, blood
and blood products as well as correction of coagulopathy.
ii. Left lateral tilt
iii. Administration of high flow oxygen (15 l/minute) at the
outset.
iv. A multidisciplinary input involving haematologists and
anaesthetists is essential.
v. Delivery should be planned once the patient is
haemodynamically stable.
vi. Emergency caesarean section may be considered for fetal
reasons (i.e. Evidence of fetal compromise).
27. • If intrauterine death is diagnosed, delivery should be
expedited by performing artificial rupture of membranes
(ARM) and commencement of oxytocin infusion.
• Postpartum haemorrhage should be anticipated due to
coagulopathy as well as Couvelaire uterus (presence of
blood within the myometrial fibres results in their
disruption, leading to uterine apoplexy).
28. PLACENTA PRACVIA
• Placenta Previa to the extension of the placenta wholly or
partially to the lower uterine segment.
• Massive obstetric haemorrhage ensues as the progressive uptake
of the lower segment with advancing gestation leads to
separation of the placenta, resulting from bleeding from the
placental attachment. Such bleeding is therefore maternal with
no direct effect on the fetus.
• latrogenic preterm delivery in the 'maternal interest as well as
effects of prolonged maternal hypotension may result in
detrimental effects on the fetus.
• Paucity of muscle fibres and hence the inability of the lower
segment to contract and retract after birth increases the risk of
atonic postpartum haemorrhage.
29. CLINICAL FEATURES
a. 'Painless, causeless and recurrent' vaginal bleeding typical
of placenta praevia.
b. 'Non-engaged' presenting part or abnormal lie or
presentation with a soft non- tender uterus - clinch the
diagnosis.
c. Uterine tenderness may be rarely present as placenta
praevia if associated with co-existing abruption in 10 % of
cases.
d. Ultrasound examination - confirm the diagnosis and
e. A digital vaginal examination should be avoided in all cases
of massive antepartum haemorrhage prior to excluding the
diagnosis of placera praevia.
30. MANAGEMENT
• Initial management involves active resuscitation
• vaginal birth is not possible in major degree placenta
praevia. - emergency caesarean section should be
performed by an experienced operator, once the woman is
stabilised.
• Postpartum haemorrhage should be anticipated and
managed effectively (the lower uterine segment has fewer
muscle fibres and hence is not effective in controlling
bleeding from the placental site).
31. MASSIVE OBSTETRIC HAEMORRHAGE:
POSTPARTUM
• As massive atonic postpartum haemorrhage is a
major cause of maternal morbidity worldwide
Management Algorithm
“HAEMOSTASIS” in detail.
32.
33.
34. H - ASK FOR HELP AND HANDS ON THE
ABDOMEN (UTERINE MASSAGE)
• Alert all members of the (including the haematologist and
the hospital porter in case of an emergency through the
hospitals board (e.g. 'Code blue' protocol).
• A multidisciplinary approach
• Monitoring and management of fluid, electrolytes &
coagulation parameters
• Uterine massage should be commenced early (as 80% of
postpartum haemorrhages occur secondary to uterine
atony)
35. A- ASSESS (VITAL PARAMETERS, BLOOD LOSS)
AND RESUSCITATE
• The woman should be positioned flat and resuscitation should begin
with administration of high-flow oxygen (10-15 l/min) via a face mask
regardless of her oxygen Saturation.
• Body temperature should be maintained.
• Two large-bore cannulae (preferably 14 gauge) should he inserted in
either arm and Hartmann's or normal saline infusion should be
commenced.
• Up to 2 litres of Crystalloids may be infused rapidly over 1-2 hours for
initial stabilisation, Colloids like gelatin (Haemacel) or hydroxyethyl
starch (1-2 litres) may also be needed to achieve haemodynamic
stability.
• Pulse, blood pressure and respiration should be recorded every 15 min
utes. Additional monitoring includes pulse oximetry and indwelling
urinary catheter for hourly urine out put. A central venous pressure
(CVP) and an arterial line should be considered in cases of severe PPH
36. ESTABLISH AETIOLOGY; ENSURE AVAILABILITY OF BLOOD,
ECBOLICS (BOLUS OF OXYTOCIN, SYNTOMETRINE,
ERGOMETRINE)
• The cause of massive postpartum haemorrhage- identify -
(4Ts: tone, tissue, trauma and thrombin)
• The uterus should be examined for contraction and
retraction; it may also be worthwhile to check for free fluid
in the abdomen, if the history suggests trauma (previous
caesarean section, difficult instrumental delivery) or if the
patient's condition is worse than what would be expected
based on the estimated blood loss.
• Exclude any trauma to the genital tract and to ensure
completeness of the placenta and membranes
37. ECBOLICS
• Once atonic uterus has been identified as the cause of PPH,
measures should be taken to ensure uterine contraction and
retraction
• Syntocinon (5 units) should be administered intramuscularly
and
• If bleeding persists, syntometrine (combination of oxytocin 5
U and ergometrine 0.5 mg) or
• Ergometrine (0.5 mg) should be administered with in severe
preeclampsia)
38.
39. ENSURE AVAILABILITY OF BLOOD AND BLOOD
PRODUCTS
• Replacement of the circulating blood volume with
crystalloids and colloids should be followed by restoration of
the oxygen-carrying capacity of the blood and correction of
any derangements in coagulation.
• The aim of blood and fluids should be to replenish the
previous loss in the first hour followed by maintenance
fluids to replace continuing loss and maintain normal vital
parameters.
• If coagulopathy is suspected, the haematologist should be
involved and fresh frozen plasma (FFP), cryoprecipitate and
platelets administered as required.
40. • In massive obstetric blood loss, rapid infusion of FFP may be
required to replace clotting factors other than platelets.
• With every 6 units of blood transfusion, 1 litre of FFP should
be administered.
• Maintain the platelet count above 50 000 by infusing
platelet concentrates when indicated.
• Cryoprecipitate may also be needed if the patient develops
disseminated intravascular coagulation (DIC) and her
fibrinogen drops to less than 1 g/dl (10 g/l).
41. MASSAGE THE UTERUS
• Uterine massage helps stimulate uterine contraction and
retraction and should be commenced very early. It may act
synergistically with the uterotonic drugs.
• Compression of aorta - to gain temporary control of bleeding
by applying the fist directly in the midline, just above the
umbilicus and the uterus with the heel of the hand pressing
down on the aorta.
• In a low-resource setting, anti-shock garments may also be
used if available, during transfer to operating theatre or to
another referral centre.
42. OXYTOCIN INFUSION PROSTAGLANDINS
• Syntocinon 40 units added to 500 ml of normal saline and
infused at a rate of 125 ml/hour
• Avoid fluid overload, as fatal pulmonary and cerebral
oedema with convulsions may occur secondary to dilutional
hyponatraemia.
• An indwelling transurethral catheter – MUST
• Monitoring urine output – MUST, it also helps to keep the
bladder empty and promote uterine contractions.
43. a. Prostaglandins - (15-methyl prostaglandin 2 alpha) 250
microgm intramuscularly, once every 15 minutes for a
maximum of eight doses (2 mg).
b. Rectal misoprostol (600-1000 ug) - low cost & easier
storage.
c. Tranexamic acid (starting dose of 1-4 g followed by 1 g 8 –
hourly ) may be considered for PPH if administration of
uterotonics has failed to stop the bleeding, or it is thought
that the bleeding may be partly due to trauma.
44. S-SHIFT TO THEATRE
• If the patient continues to bleed despite initial management
(i.e 'HAEMO) it is best to transfer her to the theatre (for
'STASIS).
• Theatre provides an environment suitable for continuous
monitoring and resuscitation and facilitates an examination
to exclude any retained placental tissue or membranes.
• A bimanual compression can be carried out at this stage to
squeeze the uterus between the abdominal and vaginal
hands.
45. T-TAMPONADE BALLOON
• Uterine tamponade with a balloon is easy to perform and takes
only a few minutes.
• It arrests the bleeding and may prevent coagulopathy due to mas
sive blood loss and the need for further surgical procedures.
1. Sengstaken-Blakemore oesophageal catheter (SBOC)
2. the Rusch urological hydrostatic balloon
3. Bakri balloon
• Usually a volume of about 300 to 400 ml may be required to exert
the desired counter-pressure to stop bleeding from the uterine
sinuses. If the tamponade arrests the bleeding (i.e. positive), the
chances of the patient requiring any further surgical intervention
are remote.
• ‘Tamponade test' has a positive predictive value of 87% for the
successful management of PPH
46. APPLY COMPRESSION SUTURES
• The patients parity should be considered prior to attempting
conservative surgical measure.
• This will help avoid too little being done too late
• It is prudent to discuss with the anaesthetist regarding the
ability to withstand continued bleeding, whilst conservative
surgical measures are attempted.
• This is vital in developing countries where the patient might
have lost a significant amount of blood by the time she
reaches the referral center .
• In such situations, radical measures such as total or subtotal
hysterectomy to save the patient’s life
47. • Conservative surgical measures include
compression sutures which include classical B
– Lynch or vertical or horizontal brace sutures
using a delayed absorbable suture material.
48. SYSTEMATIC PELVIC DEVASCULARISATION
• If the compression sutures fail - ligation of blood vessels supplying
the uterus
• These include ligation of both uterine arteries , followed by tubal
branches of both ovarian arteries proximal to the ovarian
ligament (called the 'quadruple ligation').
• Uterine artery ligation is straightforward once the uterovesical
fold of peritoneum is incised and the bladder is reflected down. A
window is made in the broad ligament just lateral to the uterine
vessels and the needle is passed through this opening.
• Medially, the needle is passed through the lower uterine
myometrium, about 2 cm from the lateral margin, thus getting a
good bite and then the sutures are tied. The same procedure is
repeated on the other side.
49. • Internal iliac artery ligation is an option if bleeding persists.
• This requires an experienced surgeon who is familiar with the
anatomy of the lateral pelvic wall.
• Bilateral internal iliac artery ligation has been found to reduce the
pulse pressure by up to 85% in arteries distal to the ligation.
• This translates to an acute reduction in the blood flow by about
50% in the distal vessels.
• Success rate - 40% and 75% and invaluable for avoiding a
hysterectomy.
• Potential complication include haematoma formation in the
lateral pelvic wall, injury to the ureters, laceration of the iliac
vein and accidental ligation of the external iliac artery.
• Ligation of the main trunk of the internal iliac artery .may result in
intermittent claudication of the gluteal " muscles due to
ischaemia. Examining the femoral pulse prior to completely
ligating the internal iliac artery vital.
50. INTERVENTIONAL RADIOLOGY
• In women who are not acutely compromised or bleeding
severely, interventional radiology can be considered. The
success rates may be as high as 85-95% and the entire
procedure may take about 1 hour.
• Uterine artery embolization helps to avoid radical
procedures and preserve future fertility.
• Complications - vessel perforation, haematoma, infection
and tissue necrosis.
51. SUBTOTAL OR TOTAL ABDOMINAL
HYSTERECTOMY
• If the bleeding is predominantly from the lower segment (as in
PPH following a major degree placenta praevia)
- Total abdominal hysterectomy
- Subtotal hysterectomy may be performed if the bleeding mainly
from the upper segment & the cause is ‘unresponsive uterine
atony, lower morbidity and mortality rates and requires less time
to perform.
• Due to the anatomical changes of pregnancy - important to
exercise utmost care to prevent visceral trauma, especially of the
bladder and ureters.
• It is also important to clamp the ovarian ligament medially to
avoid non-intentional or inadvertent oophorectomy.
52. POSTOPERATIVE CARE
• Women with massive obstetric haemorrhage often need
multi-organ support.
• Hence, transfer to an intensive care unit or high dependency
unit should be considered for monitoring.
• Thromboprophylaxis should be considered once the
coagulation parameters return to normal.
53. COMPLETE THE '3 E' AFTER EVERY OBSTETRIC
EMERGENCY
A. Examine - for heart rate, blood pressure, uterine
contractility, vaginal bleeding and monitor urine output.
Replenish lost fluid, blood and blood products adequately
B. Explain the delivery events possible reasons, complications
and future plan of care to the patient (I e. debrief).
C. Escalate - incident reporting form and to senior colleagues as
well as to the team to identify learning points to
continuously improve patient care
54. KEY PITFALLS
• Failure to accurately estimate blood loss and involve senior
and multidisciplinary input.
Too little done too late
• Too little estimation of blood loss,
• Too little fluid replacement,
• Too little ecbolics,
• Too little replacement of blood and clotting factors,
• Too late referral or involvement of multidisciplinary team
• Too late laparotomy and surgical haemostasis.
55. KEY PEARLS
• Young fit women may maintain their blood pressure until
significant blood loss occurs
• Systematic management of massive obstetric haemorrhage
with the use of algorithms with multidisciplinary input will
help save lives.
• Use of 'Shock index' and 'Rule of 30 may help in estimating
actual blood loss, when the vital signs are maintained
despite significant blood loss