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.
In settings with limited access to health care, misoprostol is an important intervention that could reduce maternal deaths both directly and through the more cost-effective use of health services. Misoprostol is, however, a powerful drug that needs to be used with care. Evidence-based information about the safest regimens should be widely disseminated so as to prevent its inappropriate use
In settings with limited access to health care, misoprostol is an important intervention that could reduce maternal deaths both directly and through the more cost-effective use of health services. Misoprostol is, however, a powerful drug that needs to be used with care. Evidence-based information about the safest regimens should be widely disseminated so as to prevent its inappropriate use
The second stage of labor begins when the cervix is completely dilated (open), and ends with the birth of your baby. Contractions push the baby down the birth canal, and you may feel intense pressure, similar to an urge to have a bowel movement. Your health care provider may ask you to push with each contraction.
It explains the mechanism of normal labour to medical and para-medical staff.It also puts light on principle movements underlying mechanism of normal labour with pictures.Thank You Like an share it to the maximum.
Retained placenta can be defined as lack of placental expulsion within 30 minutes of delivery of an infant. it is more common in preterm. Retained Placenta can lead to massive PPH and increase maternal morbidity and mortality.
The second stage of labor begins when the cervix is completely dilated (open), and ends with the birth of your baby. Contractions push the baby down the birth canal, and you may feel intense pressure, similar to an urge to have a bowel movement. Your health care provider may ask you to push with each contraction.
It explains the mechanism of normal labour to medical and para-medical staff.It also puts light on principle movements underlying mechanism of normal labour with pictures.Thank You Like an share it to the maximum.
Retained placenta can be defined as lack of placental expulsion within 30 minutes of delivery of an infant. it is more common in preterm. Retained Placenta can lead to massive PPH and increase maternal morbidity and mortality.
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.
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 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.
Neck pain, almost everyone of us would have definitely suffered with neck pain once in our lifetime. So what is your approach for patient with neck pain? Is it just a sprain or something serious? Know the red flags of neck pain, and learn to examine neck systematically.
Central Venous Catheterization without Ultrasound guidanceRunal Shah
In this modern era of USG, you will hardly attempt Central lines blindly. So when your USG machine breaks down, how will you resuscitate the patient? Know your basics about Central venous catheterization.
Initially in my lectures you can see that I have talked about Approach to Pain in abdomen, now we will learn what imaging should be done and why as per case to case basis. CT or USG or X-ray !!
The most challenging scenario you can ever face is resuscitation of pediatric population in your ED, high level of stress is involved, so going systematic will make your work easy. The new PALS guidelines by AHA is quoted d here.
Human insulin is a key drug to treat hyperglycemic conditions in ED, so how well we understand the most common Intravenous Insulin Protocol - "The Portland Protocol" !! Lets brush up a bit of most common Portland protocol which is used frequently in DKA and other hyperglycemic states in ED and the ICUs.
Stones of salivary gland - Sialolithiasis is an uncommon presentation in ED, but keeping high suspicion index while treating the cheek swelling patients will solve the problem.
The most common presenting complaint of Ophthalmology in Emergency dept. is Foreign body sensation, so just to recall the basics of Ophthalm in ED, read the following PPT.
Radiological evaluation of Lower Limb in acute ED setting !!Runal Shah
Radiological evaluation of Lower Limb in acute ED setting !!
How to evaluate lower limb injuries in ED by primary look out... How to assess simple bony injuries ! A simple radiological approach for ED physicians..
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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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
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2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- 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
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
3. Definitions
Quantitative :
– >= 500ml for vaginal delivery
– >= 750ml for LSCS
Significant Obstetric Hemorrhage (UK)
– >= 1500ml
Clinical :
– Bleeding in excess of physiological reserve
capacity of woman, evidenced by Tachycardia &
Hypotension
4. Incidence
6% of all live births in the world (WHO)
Responsible for up to 4% of maternal deaths
Worldwide >1.4 Lac women die every year
= 1 death every 4 min !!!
Associated mortality : Death due to PPH occurs
within 2 hours if no active intervention taken, as
compared to APH – 12 hours, Obstructed Labour –
2 days, Infection – 6 days !!!!!
5. Types of PPH
Primary PPH :
o Bleeding during the 3rd
stage labour or within 24 hrs after
childbirth.
More common
Atonic 90%
Traumatic 6%
Mixed
Coagulopathies (Von Willebrand’s disease)
Miscellaneous : anti-coagulant therapy
6. Types of PPH
Secondary PPH : (Delayed/ Late)
– Excessive bleeding from birth canal between 24 hours and
6 weeks after birth.
Retained product of conception
Puerperial sepsis
o Subinvolution of placental bed
o Puerperial inversion of uterus
o Placental polyp
o Ca.Cervix
o Rupture of vulval hematoma
o Uterine AV malformation
o Chorionic epithelioma
7. Risk factors (RCOG Guidelines)
Pre Conception
– Age >40, not multiparous
– Asian ethnicity
– BMI > 35 kg/m2
During pregnancy
– Anaemia (<9g/dl)
– Known placenta previa
– Suspected / proven placental abruption
– Multiple pregnancy
– Pre-eclampsia/ Gestational HT
– Induction of labour
8. Risk factors (RCOG Guidelines)
At delivery
– Caeserean section (elective/ emergency)
– Operative vaginal delivery
– Prolonged labour (>12hours)
– Birth weight > 4kg
– Medio-lateral episiotomy
– Retained placenta
– Pyrexia in labour
9. Clinical features
Signs of shock depend on :
-Amount of bleeding
-Pre delivery hemoglobin levels
Hypotension, tachycardia, cold clammy extremities
Clinical picture can change so rapidly from initial reversible
stage to later irreversible stage that unless timely action is
taken maternal death occurs within a short time.
10. Clinical features
Abdominal Examination :
Atonic PPH: Uterus is flabby & soft, may be overdistended
with clots
Full bladder may obscure finding
Uterus is larger than expected, squeezing it leads to gush
of clotted blood P/V.
Traumatic PPH: Uterus is contracted
Mixed
11. Vaginal examination
Atony :
Bleeding starts few minutes after delivery of fetus
Dark red in colour
Trauma :
Bleeding starts immediately after delivery of fetus
Is bright red in colour
12. Assessment of blood loss
Clinical :
‘The Golden Hour’ is the time at which resuscitation must
begin to achieve max survival before Metabolic Acidosis
sets in.
Rule of 30 :
30% blood loss – SBP fall by 30% - HR to increase by
30/min – RR > 30/min – Hb/HCT to drop by 30% - Urine
output fall < 30ml/hour
13. Assessment of blood loss
Visual Methods :
BRASSS-V method
Soaked pads
Gravimetric method : weighing sponges before & after
Acid-Hematin method (not done routinely)
Measurement of Isotope Cr51 tagged erythrocytes (for
research purpose)
Plasma volume changes – radioactive tracer
16. Prophylaxis
Ante-natal
– Improvement of health status (Rx of anemia and
malnutrition)
– Early detection of risk factors and regular ANC f/up
– Encouragement of institutional delivery
– Blood grouping and Rh typing
– Women with morbid adherent placenta (accreta) : Plan
elective CS with senior Obstetrician
17. Prophylaxis
Intra-natal
– Judicious use of sedatives and anesthetic agents
– Vigilant labour monitoring
– Prompt intervention in Prolonged labour, Obstructed labour
and Uterine inertia
– Active management of 3rd
stage Labour
Post-natal
– Close observation in 4th
stage of labour
– Examination of palcenta and membranes
– Exploration of genital tract for trauma
18. Management of
3rd
stage bleeding
Control the fundus, massage and make it hard
Inj Methergin 0.2mg IV
NS with Oxytocin 20 Units
Arrange for blood transfusion
Catheterise bladder
Placenta
Not Separated
Manual removal under GA
Placenta
Separated
Express Placenta out by CCT
Traumatic to be tackled by exploartion of genital tract
and sutures
19. Manual removal of placenta
Vaginal exploration under GA / Procedural sedation
to evaluate uterine cavity to remove placenta manually,
20. FLUID RESUSCITATION
2006 Guidelines from British Committee for
Standards in Haematology summarises main
therapeutic goals for Mx of massive blood loss is to
maintain:
– Hb > 8g/dl
– Platelet count > 75000/Cu.mm
– PT < 1.5 x mean control
– aPTT < 1.5 x mean control
– Fibrinogen > 1.0 gm/L
21. Transfusion Strategies
Initial resuscitation by IV fluids
It worsens existing coagulopathy and enhances
fibrinolysis !!
Role of TEG (Thromboelastography) and ROTEM
(Rotational Thromboelastometry) :
– To examine clot formation and dissolution in whole blood &
identify reduction in clot strength in 5-10 min
– To predict need of massive transfusion with accuracy of
71%
22. FFP :Platelets :PRBC = 1 :1 :1
PRBC
– When blood loss exceeds > 30% of blood volume
– Post partum Hb to maintain > 8 gm/dl
– HCT can be normal/high in PPH as resulting plasma loss,
clinical evaluation is must
Platelet Transfusion
– May be required in Thrombocytopenia or paltelet
dysfunction
– Plt > 50,000 is usually adequate for Vaginal delivery, C-
section or epidural anaesthesia
– Prophylactic Platelet transfusion if <20,000 before vaginal
delivery or <50,000 before C-section
23. Fresh Frozen Plasma (FFP)
– Only to be used in massive hemorrhage or to replace
single inherited clotting factor deficiency (mostly factor V)
– FFP + Platelets to be used for multifactor deficiency
associated with severe bleeding and/or DIC
– Indication : aPTT & PT > 1.5 x of reference value,
Fibrinogen < 0.8 gm/L
– Each FFP unit is ~ 200ml, contains 0.4 gm Fibrinogen and
all clotting factors
– Therapeutic dose : 10-15 ml/kg body weight
– ABO compatible to be used
24. Role of Tranexemic Acid
• Role in Obstetrical hemorrhage is still under
evaluation.
• A French Study* reported that use of TXA
– Decreased median blood loss (173 vs. 221 ml)
– Decreased likelihood of stopping bleeding within 30 min
(63% vs. 46%)
– Less chances of progressing to severe PPH (27 vs. 37
women)
– In women undergoing Vaginal Delivery, similar results
found with C-Section also but used along with Oxytocin
28. Management – Uterotonic Rx
Oxytocin
– MoA : myometrial contraction through Oxytocin receptors
and voltage gated Ca++ channel
– Duration : 20 min
– Onset : 3-4 min
– Dose : 20 units in 500ml NS iv rapid infusion / 10 units im
– S/E : Uterine rupture, Hypotension, Water retention –
Hyponatremia, confusion, coma, convulsion, CCF, Death !!
– Strict I/O charting required
29. Ergot derivatives – Methergin
– MoA : Direct action on myometrium to contract
– Onset : 1.5 min (iv), 7 min (im), 10 min (oral)
– Duration : 3 hours
– Dose : 0.2 mg iv/ im
– If bleeding is not controlled, dose can be repeated after 2-
4 hours, but not more than total 4 dose to be given.
– S/E : N&V, Hypertension
– C/I : IHD, HT (Pre-eclampsia)
30. Prostaglandins (Life saving drug to arrest PPH)
PG E1 – Misoprostol
– 1ST
line PR, 2nd
line SL
– 200 mcg tab, max 1000 mcg
– S/E : Fever, Tachycardia
15 Methyl PG F2alpha – Carboprost
– 1st
line im, 2nd
line Intra-myometrial
– Dose : 0.25 mg, can be repeated every 15-90 min
– Max 8 doses can be given
– S/E : N&V&D, chills
– C/I : Asthma, Active cardiac, renal, liver disease
33. Secondary PPH
1st
and foremost USG
Principles
– Assess amount of blood loss and REPLACE
– To find out cause and rectify it
– Supportive therapy :
• Blood transfusion, if necessary
• Inj Methergin 0.2 mg iv / im
• Antibiotics
– Conservative therapy : admit and observe x 24 hours
34. Secondary PPH
Active treatment
– Explore the Uterus under GA
– Gentle Curettage (!!Perforation!!)
– Inj Methergin 0.2 mg iv/im
– Send curettings for HPE
– LAPAROTOMY
35. Thank you …
Ref :
Current progress in Obstetrics & Gynaecology
Modern Obstetrics by Ajit Virkud 2/e
Williams Obstetrics 24/e
Practical Guide to High-Risk Pregnancy and Delivery by Fernando Arias 3/e
Practical Obstetrics Problems by Ian Donald 6/e
Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7/e
D.C.DUTTA'S TEXTBOOK OF OBSTETRICS 6/e