1. Postpartum haemorrhage (PPH) is defined as blood loss greater than 500 ml within 24 hours of delivery. It can be primary (within 24 hours) or secondary (24 hours to 12 weeks).
2. Causes of PPH include uterine atony, retained placenta, genital tract trauma, and coagulation disorders. Uterine atony accounts for 75-90% of cases.
3. Management involves communication, resuscitation, monitoring, arresting the bleeding. Resuscitation focuses on airway, breathing, circulation, transfusions and fluid resuscitation. Arresting bleeding uses uterotonics, tamponade, compression sutures,
This ppt is made by Mr. arkab khan pathan under guidance of Mrs. RAKHI GOAR. this ppt contain the detail and all the lecture notes of HEG.
THANK YOU.
Arkab khan
This ppt is made by Mr. arkab khan pathan under guidance of Mrs. RAKHI GOAR. this ppt contain the detail and all the lecture notes of HEG.
THANK YOU.
Arkab khan
Placenta previa is a condition in which the placenta lies very low in the uterus and covers all or part of the cervix. The cervix is the opening to the uterus that sits at the top of the vagina. Placenta previa happens in about 1 in 200 pregnancies.
Placenta praevia risk factors include a previous delivery, age older than 35 and a history of previous surgeries, such as a caesarean section (C-section) or uterine fibroid removal.
The main symptom is bright red vaginal bleeding without pain during the second-half of pregnancy. The condition can also cause severe bleeding before or during delivery.
Limited physical activity is recommended. A C-section is often required in severe cases.
This topic contains definition, incidence, types, causes, diagnosis, mechanism, management of occipito posterior position and deep transverse arrest and manual rotation of occipito posterior position
Cord prolapse is a frightening and life-threatening event that occurs in labor. Rapid identification and immediate appropriate response may well save the life of a neonate. Therefore, clinicians should be knowledgeable in its recognition and management.
Placenta previa is a condition in which the placenta lies very low in the uterus and covers all or part of the cervix. The cervix is the opening to the uterus that sits at the top of the vagina. Placenta previa happens in about 1 in 200 pregnancies.
Placenta praevia risk factors include a previous delivery, age older than 35 and a history of previous surgeries, such as a caesarean section (C-section) or uterine fibroid removal.
The main symptom is bright red vaginal bleeding without pain during the second-half of pregnancy. The condition can also cause severe bleeding before or during delivery.
Limited physical activity is recommended. A C-section is often required in severe cases.
This topic contains definition, incidence, types, causes, diagnosis, mechanism, management of occipito posterior position and deep transverse arrest and manual rotation of occipito posterior position
Cord prolapse is a frightening and life-threatening event that occurs in labor. Rapid identification and immediate appropriate response may well save the life of a neonate. Therefore, clinicians should be knowledgeable in its recognition and management.
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 use of algorithms & emergency boxes in obstetric emergencyWafaa Benjamin
obstetric hemorrhage Is the major cause of maternal mortality globally.
Substandard management identified as a contributor for maternal mortality in UK in 80% of the cases.
Is the major cause of mortality in Egypt ,according to the last Egyptian Maternal Mortality Report in 2001.
So we need to Work in a team, Do all needed steps, In the proper sequence of the steps,
competent emergency team should have Knowledge ,Skills , Attitude & exposed to regular Labor Ward drills.
Ready available Algorithms & Emergency Boxes are found to be helpful in emergency situations.
management of massive post par-tum hemorrhage is a very challenging & crucial.management with blood transfusions & drugs will reduce the mortality & morbidity.
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.
*I hope its help you all for preparation part 1 exam for MRCOG & MOG and your daily job.Good Luck May ALLAH bless our work and study,Good luck to all.dont forget to pray to ALLAH.if i wrong please correct me..process of learning..
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. Definition
• Loss of blood more than 500 ml from the
genital tract post delivery of a baby (WHO)
• Excessive PVB that cause haematocrit drop
more than 10% that require immediate
transfusion (ACOG)
3. • PRIMARY PPH
– Loss of 500 ml or more of blood from the
genital tract within 24 hours of the birth of
a baby
Minor : 500-1000 ml with no clinical shock
Major : > 1000 ml
• SECONDARY PPH
– Abnormal or excessive bleeding from the
birth canal between 24 hours and 12 weeks
postnatally
4.
5. • Visual blood loss estimation often
underestimates
• More accurate method
– Blood collection drapes
– Weighing swabs
6. Estimated Blood
Pad 120 cc
Tampon 50 cc
Gauze 30 cc
Small Abdominal
Pack
250cc
Large Abdominal
Pack
450 cc
7. Haemorrhagic Shock
• Classification of haemorrhagic shock in
relation to clinical criteria and percentage of
total blood volume lost
• Total blood volume at term is approximately
100ml/kg
• Blood loss >40% of total blood volume
consider life-threatening
8. Class % bld.
loss
BP
(mmHg)
Sn & Sym
Compensated
Shock
10 - 15 normal Palp, dizzy, tachy
Mild 15 - 30 Slight fall Palp, Thirst, Tachy,
weak, sweaty
Moderate 30 - 35 70 - 80 Restless, pallor, oliguria
Severe 35 - 40 50 - 70 Pallor, cyanosis,
collapse
Profound 40 - 50 50 Collapse, air hunger,
anuria
9. Causes of PPH
•4 T
– Tone (abnormality of uterine contraction –
UTERINE ATONY)
– Tissue (retained products of conception)
– Trauma (of genital tract)
– Thrombin (abnormality of coagulation)
10. TONE (UTERINE ATONY)
• 75-90% of cases
• Uterine hyperdistension
– Macrosomic baby
– Multiple pregnancy
• Previous PPH
• High parity
• Precipitated or prolonged labour
15. THROMBIN
• Pyrexia in labour
• Placental abruption
• Pre-existing bleeding disorder like
haemophilia
• Patient on anti-coagulant
16. PREVENTION
• Identify the risk factors that may present
antenatally or intrapartum will help us to plan
the delivery
• However, most cases of PPH have no
identifiable risk factors
• Active management of 3rd
stage of labour
lowers maternal blood loss and reduce risk of
PPH
17. • Active management of 3rd
stage
– Use of uterotonic
– Uterine massage
– Control cord traction for delivery of placenta
18. • Prophylactic oxytocics should be given
routinely to all women
• As it reduce the risk of PPH by ≈60%
• Syntometrine (oxytocin + ergometrine)
may be used in absence of hypertension
19. • For cases with no risk factors and delivering
vaginally, give IM Oxytocin 5 iu or 10
iu
• For cases of Caesarean section, IV
Oxytocin 5 iu by slow infusion
20. • Syntometrine and Oxytocin have similar
efficacy in prevention of PPH
• However major difference in the side effect.
• Syntometrine : 5-fold increase of nausea,
vomiting, elevation of BP
22. • Misoprostol (600 mcg orally) may be used in
home-birth setting but not as effective as
oxytocin
• All women with previous Caesarean section
must be check for placental site and any
presence of placenta accreta
23. • Patient with placenta accreta that
diagnosed antenatally should be managed
by consultant (O&G, Anaest) at tertiary
centre
• Reduce the blood loss by leaving the
placenta in the uterus after delivery of the
baby by fundal classical uterine incision .
Followed by hysterectomy / treatment with
methotrexate.
24. • Role of prophylactic interventional radiology
in case of antenatally diagnosed placenta
accreata
–Balloon occlusion
–Embolization of pelvic arteries
• Studies done show the procedure have value
in control of primary PPH and secondary PPH
26. 1. COMMUNICATION
• Alert all relevant professionals
• For major PPH, activate
RED ALERT
– Call experienced Midwife
– Call Specialist
– Alert Consultant
27. – Call Anaesthetist (specialist)
– Alert Consultant clinical Haemotologist on
call
– Alert blood bank
– Call PPK for delivery of specimens / blood
– Alert one member of team to record the
events, fluid, drugs and vital sign
28. • Communicate with patient and the partner
with clear information of what happening
29. 2.
RESUSCITATION
• A B C
• The measurement for resuscitation depend
on condition and degree of shock
• Assess Airway and Breathing
– Give oxygen 10-15 L/min via face mask
regardless the maternal [O2]
– If airway is compromised due to impaired
conscious level, need to intubate with
anaesthetic assistance
30. • Evaluate Circulation
– 2 large-bore branula (14-16 gauge)
(Take blood for FBC, coagulation profile,
BUSE/Cr/LFT, Fibrinogen, GXM 4 units)
– Position flat, lateral tilt
– Keep patient warm
– Give crystalloid infusion (Hartmann)
• In Major PPH, add
– Tranfuse blood asap
31. – Until blood is available, total volume of 3.5 litres
crystalloid infuse up to 2 L of warmed crystalloid
Hartmann solution and/or colloid (1-2 L) as rapidly
as required if blood still not available.
– May require DIVC regime
• FFP : 4 units for every 4 units of Pack Cells or PT/APTT >
1.5 x normal
• Platelet concentration : if Plt < 50 x 109
/L
• Cryoprecipitate : if fibrinogen < 1g/L
32. • Aim to restore the both blood volume and
oxygen-carrying capacity
• Volume replacement must be undertaken on
the basis that blood loss is often grossly
underestimated
33. • The therapeutic goals of management of
massive blood loss is to maintain
– Hb > 8 g/dL
– Plt count > 75 x 109
/L
– PT < 1.5 x mean control
– APTT < 1.5 x mean control
– Fibrinogen > 1.0 g/L
2006 Guideline of British Committee for Standards in Haematology
34. • Role of recombinant factor VIIa therapy
(rFVIIa)
– Used in treatment of haemophilia
– Used in reducing the bleeding in PPH
– In life-threatening PPH and in consultation with a
haematologist, rFVIIa is used as an adjuvant
therapy
– Dose 90 mcg/kg
35. • Role of anti fibrinolytic drugs – there is role of
management of obstetric hemorrhage.
36. 3. MONITORING &
INVESTIGATION
• Take blood as mentioned
• Monitor BP/PR every 15 minute is Minor PPH
• Continous BP/PR/RR in Major PPH (using
oximeter, cardiac monitoring, automated BP
recording)
• Put Foley catheter to monitor urine output
37. • In certain cases, consider arterial line
monitoring by experienced staff
• Transfer to ICU or HDW once bleeding is
controlled
• Documentation of fluid balance, blood, blood
products and procedure
• Central line by senior skilled-anaesthetist may
required
38. • Recommendation for central line and arterial
line for pressure monitoring when CVS is
compromised by haemorrhage or heart
disease
39. Anaesthetic management
• Anaeshetist needs to asses woman quickly , to initiate or
continue resuscitation to restore intravascular volume and
provide adequate anaesthesia.
• Presence of cardiovascular instability is a relative
contraindication to regional anaesthesia.
• Blockage of sympathetic system can potentially lead to
worsening hypotension due to hemorrhage.
• General anaesthesia is more appropriate when there is
continuing bleeding and the cardiovascular instability.
• Ventilator with high oxygen concentrations may be needed
40. 4. ARREST THE
BLEEDING
• Depends on the cause of the massive bleeding
• Common cause – Uterine Atony
– Mechanical
– Pharmacological
– Surgical
43. Pharmacology
• Repeat IM Syntocinon or Syntometrine
• IV Pitocin 40 units in 500 ml Hartmann’s
solution, run at 125ml/hr
• IM Carboprost (Haemabate®) 0.25mg, may
repeated at interval not less than 15 min to a
maximum 8 doses (contraindicated in Asthma)
44. • Intramyometrial of Carboprost 0.25-0.5mg
• Misoprostol 1000 mcg rectally or cervagem
per rectally
45. TABLE 1 Drug Used to Manage Postpartum Hemorrhage
OXYTOCIN
(PITOCIN)
METHYLERGO
NOVINE(METH
ERGINE)
PROSTAGLAND
IN F2α
(PROSTIN/15M;
HEMABATE)
Action Contraction of
uterus; decreases
bleeding
Contraction of
uterus
Contraction of
uterus
Side
effect
Infrequent; water
intoxication;
nausea and
vomiting
Hypertension,
nausea,
vomiting, headache
Headache, nausea,
vomiting, fever
Contrain
dications
None forPPH Hypertension,
cardiac disease
Asthma,
hypersensitivity
46. Dosage;
route
10-40 U/L diluted in
lactated Ringer's solution
or normal saline at 125-
200mU/min IV or 10-20
U IM
0.2 mg IM every 2-4 hr
up to 5 doses; 0.2 mg IV
only for emergency
0.25 mg IM or
intramyometrially every
15 min up to 8 doses
Nursing
consideratio
ns
Continue to monitor
vaginal bleeding and
uterine tone
Check blood pressure
before giving and do not
give if >140/90 mm Hg;
continue monitoring
vaginal bleeding and
uterine tone
Continue to monitor
vaginal bleeding and
uterine tone
47. Surgery
• If fail pharmacological
• Depends on the clinical circumstances and
available expertise
• First line is Balloon Tamponade
– Various types of hydrostatic balloon catheter
– Foley catheter, Bakri balloon, Sengstaken-
Blakemore oesophageal catheter and a
condom catheter
48.
49. • The intervention describe as the
‘tamponade test’
• A ‘positive test’ : able to control PPH
following inflation of the balloon,
indicate that laparotomy is not required
• A ‘negative test’ : continued bleeding
following inflation of the balloon,
indication to proceed to laparotomy
50. • No evidence of how long the balloon
tamponade should be left in place
• Most cases, 4-6 hours of tamponade is
adequate to achieve haemostasis
• Should be remove during daytime hours
with presence of appropriate senior
staff as further intervention may be
necessary
52. – Hayman suture, describe in 2002 with
modified compressive suture which does
not require hysterotomy
– Vertical compression sutures
• Effective technique to controlling severe
PPH and reducing the need for
hysterectomy
• Cx : pyometria, partial uterine necrosis
53. • Bilateral ligation of uterine arteries
• Bilateral ligation of internal iliac arteries
• Selective arterial embolization
• Hysterectomy
– Need second consultant to involved in
decision of hysterectomy
54. 4. ARREST THE BLEEDING
• Case of RETAINED PLACENTA
– empty bladder, attempt CCT
– If fail, proceed with Manual Removal of
Placenta (MRP) either under sedation or GA
– Take consent
– If under sedation, give IV Pethidine 25-50mg
stat, IV Midazolam 2.5-5.0 mg stat
– Continous SPO2 monitoring, Litothomy position
55. - IV Ampicillin 1g stat, IV Flagyl 500 mg stat
- Fully gown, mask, long-sleeve glove
- Introduce one hand into vagina along the cord
56. - Other hand grasp the fundal of uterus and the hand just
now move through the cervix to the intrauterine cavity
- Detaching the placenta by sideways slicing movement
of the fingers
57. - Once able to detach the placenta part from the
intrauterine wall, grasp the placenta and bring out in
piece
- Then recheck again inside the uterus for any remnant
part of placenta
58. 4. ARREST THE BLEEDING
• Management of Genital Tract Trauma
– Suture the cervical / vaginal wall tear
– May need vaginal packing
– Cover with broad spectrum antibiotic
60. • Ix : FBC, CRP, high & low vaginal swabs, blood
culture if pyrexia
• Pelvic ultrasound, help in presence of POC
• Treatment :
– Antibiotic : Ampicillin and Metronidazole
– Uterotonics
– If continuing bleeding, may need balloon
tamponade or ERPOC
61. Flow Chart of Mx of Major
PPH
Major obstetric haemorrhage
Blood loss > 2000 ml
Continuing major obstetric
haemorrhage or clinical shock
62. Call for help
Senior midwife/obstetrician and
anaesthetist
Alert haematologist
Alert blood transfusion laboratory
Alert consultant obstetrician on-call
64. Monitoring and investigations
14-g cannulae x 2
FBC, coagulation, U&Es, LFTs
Crossmatch (4 units, FFP, PLT,
cryoprecipitate)
ECG, oximeter
Foley catheter
Hb bedside testing
Blood products
Consider central and arterial lines
Commence record chart
Weigh all swabs and estimate blood loss
Medical treatment
Bimanual uterine compression
Empty bladder
Oxytocin 5 iu x 2
Ergometrine 500 mcg
Oxytocin infusion (40 u in 500 ml)
Carboprost 250 mcg IM every 15
minutes up to 8 times
Carboprost (intramyometrial) 0.5 mg
Misoprostol 1000 micrograms rectally
65. Theatre
Is the uterus contracted?
Examination under anaesthesia
Has any clotting abnormality been
corrected?
Intrauterine balloon tamponade
Brace suture
Consider interventional radiology
66. Surgery
Bilateral uterine artery ligation
Bilateral internal iliac ligation
Hysterectomy (second consultant)
Uterine artery embolisation
Consider monitor
at HDU or ICU