This document discusses post-partum hemorrhage (PPH), including its definition, causes, risk factors, prevention, and management. It describes:
1) PPH is defined as blood loss over 500ml within 24 hours of delivery. The main cause is uterine atony but can also be due to retained placenta or trauma.
2) Risk factors include previous c-section, large babies, and medical conditions like placenta previa. Prevention focuses on identifying risks antenatally and using oxytocics to manage the third stage of labor.
3) Initial management of PPH involves resuscitation, oxytocics, and identifying the cause. Further steps may include balloon
Prelabour Rupture of Membrane (PROM) by Sunil Kumar Dahasunil kumar daha
Please find the power point on Prelabour Rupture of Membrane (PROM). I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Prelabour Rupture of Membrane (PROM) by Sunil Kumar Dahasunil kumar daha
Please find the power point on Prelabour Rupture of Membrane (PROM). I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
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
Approach to maternal collapse and cardiac arrest.pptxKTD Priyadarshani
This is a case based discussion on approach to maternal collapse and cardiac arrest. It includes a detailed account on ERC ALS guideline on maternal cardiac arrest and post resuscitation care.
PPH Postpartum hemorrhage, affecter the delivery of fetus vaginal bleeding you can see with in 24 hours this primary PPH, secondary PPH will be up 28 of delivery.
complcations of third stage of labour, includes PPH, Inversion of uterus, retained placenta, placenta accreta, increta, percreta, amniotic fluid embolism
An investigation-of-fetal-growth-in-relation-to-pregnancy-characteristicsDr Max Mongelli
DM thesis by Dr Max Mongelli. "An Investigation of Fetal Growth in Relation to Maternal Characteristics", based on research carried out at the Perinatal Research and Monitoring Unit at the Queens' Medical Centre in Nottingham, UK. Some of this material formed the basis for the development of the customised fetal growth charts.
An investigation-of-fetal-growth-in-relation-to-pregnancy-characteristicsDr Max Mongelli
A PDF copy of the DM thesis "An Investigation of Fetal Growth in Relation to Maternal Characteristics", based on research carried out at the Perinatal Research and Monitoring Unit at the Queens' Medical Centre in Nottingham, UK. Some of this material formed the basis for the development of the customised fetal growth charts.
A brief description of the causes of death in pregnancy for non-medical people. Includes definitions, basic statistics, common causes and their prevention.
A basic presentation about bleeding in pregnancy for non-medical people. Includes links to organisations that work towards reducing maternal mortality world-wide.
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Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
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Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
the IUA Administrative Board and General Assembly meeting
Postpartum Hemorrhage
1. Max Mongelli
Clinical Associate Professor
Western Clinical School
University of Sydney
Nepean Hospital
Post-Partum Hemorrhage:
Management and
Complications
2. Third stage of labour
From delivery of the baby to delivery of the
placenta < 20minutes.
Cessation of umbilical artery pulsation,
placenta separates from uterine wall through
the decidua spongiosa and is delivered
Capillary haemorrhage and shearing effect
of uterine muscle.
3. Amount of blood loss depends on:
How quickly the placenta separates from
uterine wall.
How effectively the uterine muscle
contracts around the placental bed during
and after separation.
Intact coagulation system.
4. Active management
“Standard practice”
Administration of an oxytocic at the
delivery of the anterior shoulder/after the
baby has been delivered.
Early cord clamping and cutting
Controlled cord traction of the umbilical
cord
5. Expectant management
“Conservative” “Physiological”
Waiting for the umbilical cord to
pulsation
cease
Waiting for signs of placental separation
Allowing placenta to deliver spontaneously
Aided by gravity/nipple stimulation/breast
feeding
6. Active vs Expectant
Management
Reduced maternal blood loss
Reduced PPH rates (0.38, CI 0.32 to 0.46)
3rdShortening of stage of labour
(-9.77, CI –10.0 to –9.53)
Increased maternal nausea
(1.83, CI 1.51 to 2.23)
Increased vomiting and raised BP
(probably due to use of ergometrine)
Cochrane Database of Systematic Reviews 2000
8. Definition
Blood loss from the genital tract >500ml in
the first 24 hours following delivery
“normal blood loss” (Bonnar 2000)
- at vaginal delivery: 600ml
- at Caesarean section: 1000ml
9. PPH
Haemorrhage is the main cause of death in a
number of countries
At least 25% of maternal deaths worldwide
due to haemorrhage – the majority
postpartum haemorrhage
Vast majority in the developing world
3rdMost important complication of the
of labour
stage
10. Massive haemorrhage
>1500ml
Blood loss requiring replacement
patient’s total blood volume
of the
Transfusion >10 units blood within 24 hours
Replacement of 50% circulating blood
volume in <3hours
Loss of >150ml/minute
11. PPH rates
Depend on the definition used
KEMH >500ml 12%, >600ml 9.45%, >1000ml
5.5%
Similar rates in Australasian
Most of Australasia:
>500ml 8%,
tertiary institutions
>1000ml
>1500ml
>2000ml
4.27%,
1.83%,
0.6%
12. Maternal risks
Mortality
Triennial reports from UK 1985-96 show no
significant reduction in the number of deaths
haemorrhage (30 each triennia)
Majority due to substandard care
DELAY in - correction of hypovolaemia,
- diagnosis and treatment of defective
coagulation
- surgical control of bleeding
“TOO LITTLE TOO LATE”
from
13. Mortality
Developing countries PPH 125,000 deaths/yr
28% of maternal deaths
Risk 1 in 1000
Australia 1 in 100,000 deliveries die of PPH
Life threatening haemorrhage 1 in 1000 deliveries
Risk increases with increasing maternal age
especially >35 years
15. Morbidity
Injury to ureter and bladder
intervention
Sheehans syndrome
from surgical
permanent hypopituitarism caused by
avascular necrosis of the anterior
pituitary gland,
failure of lactation, amenorrhoea,
hypothyroidism and adrenocortical
insufficiency
16. Blood Changes in Pregnancy
Normal adult blood
eg 50kg 3.5L
volume 70ml/kg
60kg 4.2L
70kg 5.0L,
etc
The healthy pregnant woman has a blood
volume of 6-7L in late pregnancy
17. Blood Changes in Pregnancy
During pregnancy:
40% increase in blood vol
-increase in red cell mass
Lowering of haematocrit by 10%
Marked increase in fibrinogen
and factors VII,
VIII and X
18. Adaptation to blood loss
Blood loss <1000ml induces little or no
change in pulse or BP
Catecholamine – induced vasoconstriction
maintains perfusion of the maternal heart
and brain at the expense of diminished
utero-placental blood flow
Tachycardia may be absent in up to 25% of
cases with severe blood loss.
19. Haemorrhagic shock
and blood loss
Symptoms and
signs
Palpitations,
Blood volume
loss
10-15%
(500-1000ml)
BP Degree of
shock
CompensatedNormal
dizziness, HR incr
15-25%
(1000-1500ml)
Slight fall Weakness, sweating,
tachycardia
Mild
25-35%
(1500-2000ml)
35-45%
(2000-3000ml)
70-80mmHg Pallor Moderate
60-70mmHg Collapse, air hunger,
anuria
Severe
20. Disseminated Intravascular Coagulation
Depletion of fibrinogen, coagulation
circulating platelets
Haemostatic failure
Microvascular bleeding
Increased blood loss
Unlikely if platelet count is normal
factors and
21. Risk Factors for PPH (1)
Placenta praevia, especially
accreta/percreta/increta
Previous history of PPH
Previous history of retained
if associated with
placenta, Ashermans
syndrome, endometrial ablation
Hypertensive disorders
Manual removal of retained placenta
Refusal of blood transfusion
22. Risk Factors for PPH (2)
Maternal obesity
Large baby
APH/abruption
Multiple pregnancy
Previous PPH (recurrence rate 8-10%)
Operative delivery – Emergency CS
substantially increases the risk
23. Risk Factors for PPH (3)
Anaemia
Induction/augmentation
Instrumental delivery
of labour
(1st 2ndProlonged labour or stage)
Grand multiparity (>5)
Bleeding disorder (eg Von Willebrandt’s)
Use of anti-epileptic medications
24. Prevention of PPH:
Antenatal period
Identification and correction of anemia
pregnancy
in
Detection
Detection
Care plan
of sub-clinical bleeding disorders
of placenta accreta/percreta
for management of third stage if
risk factors detected
25. Prevention of PPH (2)
Oxytocic policy
Venous access, G+H, active management of
third stage, oxytocin infusion in those
identified as at risk
Senior obstetrician/anaesthetist at placenta
praevia CS
+/-gynae oncologist at placenta accreta CS
26. Management of PPH
Call for help
Resuscitate
Restore circulating blood volume
Identify and treat the cause
28. Volume replacement
Crystalloids
80% infused fluid leave the intravascular
AVOID DEXTROSE
O negative blood if torrential loss
Packed cells
4 units FFP for every 6 packed cells
Platelets/cryoprecipitate
Involve haematologist early on
Avoid colloids
space
30. Identify
Tone
and treat the cause
Bimanual compression,
oxytocics
Remove retained
placenta/membranes
Tissue
Trauma Repair genital tract tears
Thrombin Correct/prevent
coagulopathy
31. Uterine atony
Most common cause of PPH
Oxytocin infusion (as per local
Ergometrine IM
protocol)
Rectal misoprostol (up to 800mcg)
Rectal PGE2 (20 mg)
Intra-myometrial PG F2 alpha (250 mcg)
32. Examination under anaesthetic
Remove retained placental tissue ensuring
the uterus is empty
Detailed examination of cervix and vagina
to exclude and repair any lacerations
More oxytocics
Antibiotic cover
Medical – PgF2alpha
33. Case Scenario
You are the SR/consultant called to theatre.
Junior registar has a patient who has lost
1500ml has done EUA, given oxytocics
including PgF2alpha and the patient is
continuing to bleed.
What are you going to do?
35. Laparotomy
Uterine haemostatic suture
B Lynch suture
Modified B Lynch
Arterial ligation
Bilateral internal artery ligation
Bilateral uterine/ovarian artery
ligation
Hysterectomy
Total
Subtotal
36. Technique
70mm round bodied No.2 CCG
3cm from the right lower edge and 3cm
from the right lateral border of the incision
Thread through into the uterine cavity and
emerge the needle 3cm above the incision
Pass the CCG over the fundus 3-4cm from
the right cornual border
37. Technique
Feed CCG posteriorly and vertically.
Enter uterine cavity posteriorly at same site
as superior anterior entry point
Pull CCG under moderate tension, assistant
applies manual compression
Pass suture horizontally to emerge on
posterior wall at the same level but on the
left posterior side of the uterus
38. Technique
Suture knot using two or three throws whilst
assistant maintains bimanual compression
Close the lower transverse incision in the
uterus
39. B Lynch suture
Advantages
Effective control of haemorrhage
Conservation of the uterus for fertility
Avoidance of more
(hysterectomy) and
morbidity
Relatively simple
Disadvantage:
-paralytic ileus
radical procedure
its potential
40. Hayman compression sutures
Does not require a lower uterine incision
Uses 1-vicryl x 4
Bladder has to be reflected down
Simpler than B-Lynch
43. SOS – Bakri Balloon Tamponade
The indications for use:
Temporary management of lower uterine
segment bleeding.
Indicated in about one third of all PPH
cases.
45. Sengstaken-Blakemore Balloon Tamponade
Esophageal balloon inflated to 250 ml with
normal saline
Prophylactic antibiotics
Prevented major surgery in more than 70%
of cases
May help reduce bleeding if transfer is
required.
46. Balloon Tamponade with Condoms
The idea was first introduced by Professor Sayeba Akhter
(Dhaka, Bangladesh) to save the life of a woman who had
severe jaundice with intractable PPH.
Condom is inflated with isotonic saline of 250 – 500 ml
(sometime >500 ml – 1 L)
When the bleeding is reduced considerably, further
inflation is stopped. then outer end of the catheter is
folded and fixed to the thigh.
To keep the inflated balloon within the uterus, the post
vagina is packed with sterile pack
47. Uterine Artery Ligation -
“O’ Leary Stitch”
Requires downward bladder reflection
risk of ureteric injury.
to reduce
Bilateral ligation effective in 90% of cases
High ligature may be required.
Low risk of long-term complications
48. Interventional Radiology
Percutaneous transcatheter embolisation
Must be performed before uterine artery
ligation
Performed under fluoroscopic guidance
Gelfoam is the preferred agent
Angiographic occlusion balloon catheters
Success rate 95-97%
Useful for vulvovaginal hematomas
49. Interventional Radiology:
Disadvantages
There may be a significant delay before
personnel and equipment are in place
Not widely available
Contraindicated if coagulopathy is present
Minimal data on subsequent pregnancy
outcomes
51. Case scenario
You are a GP obstetrician delivering a low
risk woman in a country hospital.
You are delivering the placenta and note
that her BP has suddenly fallen to 80/40,
pulse
What
What
40. She is bleeding profusely
do you do?
is your differential diagnosis?
52. Concealed PPH
If hypovolaemic……..and no overt
consider
Broad ligament haematoma
bleeding
Ischiorectal fossa haemorrhage/haematoma
Paravaginal haematoma
Intra abdominal bleeding
Previous uterine scar – uterine rupture
Rupture of vascular aneurysms
Liver/spleen rupture
53. Conclusions
Relevance of PPH worldwide
Increasing incidence of PPH
Prophylaxis
Don’t forget the basics
Good luck!
