Optimal protocols for Ovulation induction (Assisted Reproductive technologies)Anu Test Tube Baby Centre
Presentation given in Tirupati, India in 2018 on Ovulation Induction for assisted reproductive technologies. Dealing with infertility using Intra uterine insemination (IUI) and In vitro fertilization (IVF)
Optimal protocols for Ovulation induction (Assisted Reproductive technologies)Anu Test Tube Baby Centre
Presentation given in Tirupati, India in 2018 on Ovulation Induction for assisted reproductive technologies. Dealing with infertility using Intra uterine insemination (IUI) and In vitro fertilization (IVF)
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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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.
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
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
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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
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.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
PPH
1. OBSTETRIC DRILLS –PPH
INDIA AUG 2016 6-11TH
HYDERABAD,CHENNAI,MUMBAI,KOLKATA,DELHI
&
LUCKNOW
IAN DONALD SCHOOL OF ULTRASOUND
&
LUPIN
6 DAYS 6 CITIES HANDS ON TRAINING
2. CONDUCTED BY
• ROBIN BURR(AUSTRALIA)
• SULLEN MILLER(USA)
• NARENDRA MALHOTRA
• SHEELA MANE
• JAIDEEP MALHOTRA
• ALKA KRIPLANI
• SADHNA GUPTA
JAYAM KANAN,ASHISH MUKERJEE,VP PAILEY,APARNA
SHARMA,SEEMA ,AMBUJA C.
7. Worldwide issue
Over 300,000 women and 2.7 million newborn babies die
each year in pregnancy and childbirth or soon afterwards,
the majority of them in Africa and South Asia.
Every minute of every day, somewhere in the world a woman
dies from complications related to pregnancy or childbirth.
99% of maternal deaths occur in the developing world
www.womenandchildrenfirst.org.uk/
10. MDG - GOAL 5: IMPROVE MATERNAL HEALTH
- Maternal mortality ratio (per 100,000 live births)
Initial
Value
Last
Value
2015
Target
Achieving
target in...
560.0 190.0 140.0 2021
11. Achieving Millennium Development Goal 5: is India serious?
Dileep Mavalankar, Kranti Vora, M Prakasamma
India - largest number of births per year (27 million) in the world.
Maternal mortality of about 300–500 per 100 000 births, about 75
000 to 150 000 maternal deaths occur every year in India.
• Absence of focus on emergency obstetric care
• Missing midwives
• Lack of management capacity in the health system
• No political will
• Absence of comprehensive maternal care services
Bulletin of the World Health Organization>Past issues>Volume 86: 2008>Volume 86, Number
4, April 2008, 241-320
12. MMR India over time
Year MMR
1990 556
1995 471
2000 374
2005 280
2010 215
2015 174
Source: WHO,UNICEF
, UNFP
A,W
orldBankGroupandUNPD
(MMEIG)- November 2015
15. Definitions
Primary PPH
> 500 ml (spontaneous delivery)
> 1000 ml (caesarean section)
Severe haemorrhage:
blood loss > 150 ml/min (within 20 min causing loss of more
than 50% of blood volume)
sudden blood loss > 1500-2000 ml (uterine atony; loss of 25-
35% of blood volume).
16. Causes of PPH: the 4 T’s
Tone: uterine atony, distended bladder.
Trauma: uterine, cervical, or vaginal injury.
Tissue: retained placenta or clots.
Thrombin: pre-existing or acquired coagulopathy.
17. Antenatal risk factors
• Polyhydramnios
• Multiple pregnancy
• Fibroids
• Past PPH
• Previous retained placenta
• Previous Caesarean Section/ uterine
surgery
• Placenta praevia/percreta/ increta
• APH
• High parity
• Maternal Age
• Obesity
• Drugs e.g. Nifedipine/MgSO4/
salbutamol
• Hypertensive disorders
• Pre-existing coagulation disorder
e.g. Von Willebrand’s
• Therapeutic anticoagulation
• Anaemia
18. Intrapartum risks
• Fetal demise in utero
• Abruption
• Induction/augmentation of
labour
• Prolonged labour
• Pyrexia
• Prolonged ruptured
membranes
• Instrumental delivery
• Episiotomy
• Retained
placenta/membranes
• Physiological third stage
• Drugs e.g. inhaled
anaesthetic agents
• Therapeutic anticoagulation/
DIC
19. Third stage of Labour
PPH ACTIVE EXPECTANT
>500 mls 5% 13%
>1000 mls 1% 3%
20. Active vs Expectant Management
Outcome Control Rate, % Relative Risk 95% CI* NNT † 95% CI
PPH of 500 mL 14 0.38 0.32-0.46 12 10-14
PPH of 1000 mL 2.6 0.33 0.21-0.51 55 42-91
Hemoglobin < 9 g/dL 6.1 0.4 0.29-0.55 27 20-40
Blood transfusion 2.3 0.44 0.22-0.53 67 48-111
Therapeutic 17 0.2 0.17-0.25 7 6-8
uterotonics
*CI: Confidence interval
† NNT: Number needed to treat
Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of
labour. Cochrane Database Syst Rev. 2000. CD000007.
22. The GOLDEN HOUR
• The first 60 minutes after the start of the PPH
• The greater the delay in starting resuscitation, the
lower the percentage of survivors
• However may not be true in trauma & too late in
PPH!
• FIRST 20 minutes?
24. Confidential enquiries (UK)
TOO LITTLE
Uterotonics
Fluid
Blood
Blood products
TOO LATE
Recognition
Reaction
Intervention
25. Drugs
• Oxytocin - 10U IM/IV
• Ergometrine - 500 mcg IV/IM
• Prostaglandins
• Carboprost – 250 mcg IM x8
• Misoprostol – 600 mg PO / 800 mg PR
• Carbetocin
26. Uterotonic Drugs
Drug Dosage Action Side Effects Caution
Oxytocin 10U IM/IV
Onset: 2-3 mins
Lasts: 10-15 mins
Minimal None
Ergometrine 500mcg IV/IM
Onset: 2-7 mins
Lasts: 2-4 hours
Nausea, vomiting,
headache,
hypertension
Hypertension
Carboprost 250mcg IM
Onset: 1-2 mins
Lasts: 15-20 mins
Vomiting,
diarrhoea,
bronchospasm
Brittle asthma
Misoprostol
800mcg SL/PR
600mcg PO
Onset: 3-5 mins
Peak: 20-30 mins
Lasts: <75 mins
Shivering, rise in
temperature
None
27. Misoprostol FIGO
• A single dose of misoprostol 600μg
orally for prevention
• One dose of misoprostol 800 μg
sublingually for treatment
• Administered immediately after
delivery of the newborn
• Contraindications - History of
allergy to misoprostol or other
prostaglandin
• FIGO 2012
28. Fluids
• Colloids vs Crystalloids
• Volume
• Warm
• Speed
• IV lines - Two large bore IV access –
Grey/Green (No. 16 or 18)
29. IV Access
Gauge Color Flow rate
16 Grey 180 mL/min
18 Green 80 mL/min
20 Pink 54 mL/min
22 Blue 31 mL/min
35. Visual Estimation of Blood Loss
• Caregivers consistently underestimate visible
blood loss by as much as 50%.
Razvi K, Chua S, Arulkumaran S, Ratnam SS. A comparison between visual estimation and
laboratory determination of blood loss during the third stage of labor. Aust N Z J Obstet
Gynaecol 1996;36:152–4
• Can be improved with training using visual aids
Bose P,Regan F,Paterson-Brown S. Improving the accuracy of estimated blood loss at
obstetric haemorrhage using clinical reconstructions. BJOG. 2006 Aug;113(8):919-24.
46. BRASSS-V Drape™
• Placed under woman
• Two ties around waist
• Blood drains into
calibrated pouch
Kodkany BS, Derman RJ, Goudar SS, et al. Initiating a
novel therapy in preventing postpartum hemorrhage in
rural India: a joint collaboration between the United
States and India. Int J Fertil Women Med 2004;49:91–6
47. Kelly’s Pad
• The patient sits on this
device
• The pad funnels the
blood into a collection
container which has a
marked line at 500 mL
• This device is washable
and can be sterilized
48. Blood Mat
•20” x 20”
•= 500mls
photo: Pathfinder staff/Bangladesh
50. PPH and shock
Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock
500-1000 mL (10-15%) Normal
Palpitations, tachycardia,
dizziness
Compensated
1000-1500 mL (15-25%) Slight fall (80-100 mm Hg)
Weakness, tachycardia,
sweating
Mild
1500-2000 mL (25-35%) Moderate fall (70-80 mm Hg)
Restlessness, pallor,
oliguria
Moderate
2000-3000 mL (35-50%) Marked fall (50-70 mm Hg)
Collapse, air hunger,
anuria
Severe
51. Monitoring: MEWS
• Observation of vital signs are an integral part of care
• There is a potential for any woman to be at risk of
physiological deterioration and this cannot always be
predicted.
• There is poor recognition of deterioration in condition.
• Regular recording and documentation of vital signs will aid
recognition of any change in a woman’s condition
• The use of EWS chart prompts early referral to an appropriate
practitioner, who can undertake a full review, order
appropriate investigations, resuscitate and treat as required
53. MEOWS Chart
• All women whose clinical condition requires close
observation; admitted early pregnancy, antenatal or
postnatal
• All post operative cases – in recovery and following
transfer from theatre
• Any woman giving cause for concern (medical or
obstetric causes)
• During/Following APH/PPH/Eclampsia
• Suspected infection e.g. Prolonged SROM
• High-risk women in delivery suite (not in labour)
54.
55.
56.
57.
58. The Value of MEWS charts
• 676 consecutive obstetric admissions
• 200 patient (30%) triggered and 86 patients (13%) had morbidity
• haemorrhage (43%)
• hypertensive disease of pregnancy (31%)
• suspected infection (20%)
• 89% sensitive (95% CI 81–95%)
• 79% specific (95% CI 76–82%)
• positive predictive value 39% (95% CI 32–46%)
• negative predictive value of 98% (95% CI 96–99%)
61. Rationale for an Obstetric HDU
• Modified early warning scoring systems improve the
detection of life threatening illness.
• It is the subsequent management that will alter the
outcome.
62. Other drivers for change
CEMACH 1988 - 90
“properly equipped, staffed and supervised high dependency
area in every consultant obstetric unit”
SAFER CHILDBIRTH - 2007
“all obstetric units should be able to provide some high
dependency care”
1 in 100 deliveries
63. Advantages of an Obstetric HDU
• Concurrent availability of obstetric and critical care
management
• Awareness of physiology and pathology of the maternity
patient
• Fetal monitoring in antenatal patients
• Avoiding hazards of transfer
• Keeping mum and baby together
• Improved continuity of antenatal and postnatal care
64. Disadvantages of an Obstetric HDU
• Skill levels of Midwives/Obstetric Nurses
• Skill levels of Junior doctors
• Anaesthetic support
• Location
• Equipment
• ICU outreach
65. Levels of Care
• Level 0 - normal ward care
• Level 1 - needing more observation
Critical Care:
• Level 2 - support of one organ
• Basic respiratory &/or cardiovascular support
• Level 3 - advanced support
• Advanced respiratory support alone
• Support of 2 or more organs
Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011
66.
67. Graduated response to deterioration
Low-score group: (EWS =3)
o Increased frequency of observations and the midwife in charge alerted.
Medium-score group: (EWS =4, 5)
o Urgent call to team with primary medical responsibility for the patient.
o Simultaneous call to personnel with core competences for acute illness.
High-score group: (EWS ≥ 6)
o Emergency call to team with critical care competences and maternity team.
o There should be an immediate response.
68. Admissions to HDU
• Obstetric Indications
– Eclampsia
– Sepsis
– Severe pre-eclampsia
– Severe asthma
– Major haemorrhage
– Diabetic ketoacidosis
– Thromboembolism
– HELLP syndrome
– Puerperal sepsis
• Non-obstetric indications
– Transfer from ICU
– Other surgical procedures or complications
– related to surgical condition
– Pneumonia/ respiratory embarrassment
– Hypertension
– Renal impairment
– Thyrotoxicosis
– Cardiac or neurological co-morbidity
– Morbid obesity (BMI >40kg/m2) with
comorbidities.
69. Minimum equipment requirements
o Piped oxygen
o Suction equipment
o Resuscitation equipment including ready access to defibrillator
o Pulse oximeter
o Non-invasive blood pressure monitor
o ECG waveform monitor
o Calf compression device
o Invasive haemodynamic monitoring
o Level 1 fluid infuser
70.
71. Transfers out of HDU
• Failure of more than one organ system
• Disease requiring the expertise of specialist medical teams e.g.
• Renal failure, other than the impairment associated with preeclampsia
• Hepatic failure
• Respiratory disease especially that requiring ventilatory support
• Cardiac disease, pre-existing or of recent onset
• Neurological conditions
• Endocrine disease including diabetes mellitus
• Non-obstetric surgical problems
72. Transfer of care
• Guidelines
• Clear plan
• Timing of transfer
• Continuity of care
• Structured formal handovers
• summary of critical care stay
• a monitoring plan detailing the frequency of observations
• An plan for ongoing treatment
• physical and rehabilitation needs
• psychological and emotional needs
• specific communication or language needs
73. Discharges to ward
• Patient haemodynamically stable, no further continuous
intravenous medication or frequent blood tests required
• No invasive monitoring required
• No active bleeding
• No supplementary oxygen required
• Patient mobilized
74. ISBAR tool
Identification: identify yourself and your role to the person you are
communicating with in the communication.
Situation: describe the specific situation about a particular patient,
including name, consultant, patient location, vital signs, resuscitation
status and any specific concerns.
Background: communicate the patient’s background, including date of
admission, diagnosis, current medications, allergies, laboratory results,
progress during the admission and other relevant information.
Assessment: this involves critical assessment of the situation, clinical
impression and detailed expression of concerns.
Recommendation: this includes the management plan, suggestions for
care, detail of investigation requests and expected time frame.
75.
76. UK Obstetric HDU
• Admissions rose from 2.67% to 5.01%
• Massive obstetric haemorrhage is now the most common
reason for admission.
• Invasive monitoring in 30%
• Two-thirds of neonates (66.3%) stayed with their critically ill
mothers in the high dependency unit.
• Transfer to the intensive care unit was needed in 1.4 per
1000 deliveries conducted.
77.
78. Indian Obstetric HDU
• Admission rate - 9.4%
• Severe P.I.H with complications - 26%,
• Placenta praevia APH - 3.14%,
• Abruptio placenta - 5.7%,
• P.P.H - 14%,
• P.R.O.M with sepsis - 8%
• Medical complications in pregnancy - 24.2%
• HDU mortality rate was 3.7% (69.2% were preventable deaths)
82. When to transfer the patient with PPH?
From PHC to First Referral unit: Clinical assessment
Class I / Retained placenta / Traumatic PPH
From Nursing home with OT to Hospital with HDU & ICU:
Uncontrolled Class II
From Labor room to OT:
Class II / Retained placenta / Traumatic PPH
(Do not wait till Class III & IV)
PPH Module 2014
83. Prerequisites for Transfer
Informed consent
Anti shock Garment (NASG)
Check availability of bed in the referral hospital
Referral documents
Indwelling catheter with Urosac
Vaginal pack in traumatic PPH
Tamponade in atonic PPH
Record presence of Pack/Tamponade – Do not remove until
destination PPH Module 2014
85. O
Nn
as
ta
ra
l O
ns
xf
y
e
gren on flow
Two IV lines (#16/18) with fluid on flow
Nurse or Doctor & Patient’s able attendant
to accompany
PPH Module 2014
86. NASG: Updates on Clinical Trial Results,
Implementation Trials, Cost Effectiveness, and
Global Guidelines
Professor Suellen Miller,
University of California, San Francisco
Dept. Obs/Gyn & Reproductive Sciences
Director, Safe Motherhood Program
89. Where in India?
Pathfinder, Raksha Project, 2007-2012
Tamil Nadu, Rajasthan, Bijar, Orrissa, Maharashtra,Assam, Agra
Pathfinder and World Health Partners in UP
Dr. Narendar Malhotra, Rainbow Hospitals
Dr. Sheela Mane, throughout India
90. Clinical Trials: Tertiary Level
5 peer-reviewed studies: 4 pre-post design, 1 (India) contemporaneous use
3,651 women: Severe OH (>1000 mL) with clinical sxs of shock
1614 (45.3%), standard care, 1947, 54.7% standard care + NASG
Sub-analysis of Severe Shock
(1227 MAP < 60 mm HG, 594, std care; 633, 51.6% std care + NASG)
Meta-analytic Techniques to pool all data
91. Outcomes: NASG Tertiary Level
•LifeWrap significantly reduced mortality 48% RR: 0.52 (95% CI 0.36-0.77)
Pileggi-Castro C; Nogueira-Pileggi V; Tuncalp O; Oladapo OT; Vogel JP; Souza JP.
Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage
: a systematic review. (2015) Reproductive Health; 12:28.
92. Clinical Trials: Primary Level
Zambia and Zimbabwe, 2007-2012
880 women transported from PHCs, midwifery directed, no blood/surgery
Clinics randomized to standard care vs. standard care plus NASG before transport for hypovolemic
shock
38 clinics, 5 tertiary facilities
OUTCOMES: Mortality and Time to Recovery of Shock
Similar in magnitude of effect and trend of the Tertiary Facilities
Non-pneumatic Anti-Shock Garment (NASG), a First-Aid Device to Decrease Maternal Mortality from Obstetric
Hemorrhage: A Cluster Randomized Trial. Miller, S; Bergel, EF; El Ayadi, A; Gibbons, L; Butrick, E; Magwali, T;
Mkumba, G; Kaseba, C; My Huong, NT; Geissler, JD; Merialdi, M.(2013) PLOS ONE; 8(10): e76477.
93. Pragmatic Trial/Implementation Science: 334 PHCs
Rural Tanzania
Baseline: all hemorrhage >500 mL
Endline: Severe hemorrhage only, >1000 mL or signs of hypovolemia
*P < 0.01
94. Cost-Effective Analyses
• Comparison of CEA at Tertiary Level, 1442 women
• Egypt: Cost BENEFICIAL, save health system $10,000/1000 women with
shock
• Nigeria, Zambia, Zimbabwe: Extremely COST EFFECTIVE
Cost-effectiveness of the non-pneumatic anti-shock garment (NASG): evidence from a cluster randomized controlled trial in Zambia and Zimbabwe. Downing J; El
Ayadi A; Miller S; Butrick E; Mkumba G; Magwali T; Kaseba-Sata C; Kahn JG. (2015) BMC; 15:37.
Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage: A Cost-Effectiveness Analysis in Egypt and Nigeria. Sutherland,
T; Downing, J; Miller, S; Bishai, DM; Butrick, E; Fathalla, MF; Mourad-Youssif, M; Ojengbede, O; Nsima, D; Kahn, JG. (2013) PLOS ONE; 8(4):e62282.
96. NASG (Life Wrap)
It applies pressure on the legs & abdomen
Blood returns to vital organs curbing internal bleed
Stabilizes BP until patient reaches appropriate hospital
Easy to apply
Application time takes < 60 seconds in trained hands
PPH Module 2014
97. How does NASG work?
It is a First Aid
Controls bleeding through direct pressure
Auto transfusion of blood in upward direction
Ball in abdominal segment applies focused pressure to uterus
Circumferential pressure on lower half of the body reduces the
total vascular space
Vital organs get increased blood supply & oxygenation
Stabilization of patient during transport
PPH Module 2014
98. How does NASG work?
In shock, the brain, heart and lungs are deprived of oxygen
because blood accumulates in the lower abdomen and legs
in addition to blood loss from the vagina during obstetric
hemorrhage
The NASG applies circumferential counter pressure which
reverses shock
• By returning blood to the vital organs
• Decreasing blood flow in the compressed areas
• Decreasing blood loss
PPH Module 2014
99. NASG’s Unique Role in Obstetric
Hemorrhage and Hypovolemic Shock
Used with hemorrhage therapies, uterotonics, massage, vaginal
procedures, even surgeries
Does not compete with other approaches: Not an either or situation, first-
aid device that buys time
A technology that can be used when patient with uterine atony does not
respond to uterotonics
AND
Effective for ALL obstetric hemorrhage: rupture, lacerations, ectopic
Only technology that reverses shock, until blood transfusions
Can be used with balloon tamponade to reverse shock
100. About NASG
NASG is light weight (1500 G)
Compression suit made of Neoprene
Five segments enclosing ankle, thigh, calves, pelvis & abdomen
Velcro fastenings to keep garment tight
A small foam ball in the abdominal segment applies pressure on the uterus
Markings on the sections show how to apply
PPH Module 2014
101. About NASG
Correct tight application supplies 20 to 40 mm Hg of circumferential
pressure to lower body effectively reversing hypovolemic shock
Can be easily packed back into carry bag
PPH Module 2014
103. Applying NASG
Step 1:
Place NASG under the woman with the top at the level of lowest rib
Close segment 1 tightly around ankle on both sides
Snap it until you hear a sharp sound
Step 2:
Close segment 2 around calf muscle
Leave the knee joint free
PPH Module 2014
104. Step
A
3p
: plying NASG
Apply segment 3 around the thighs
Step 4:
Apply segment 4 all around the woman with the lower edge at the level of pubic
bone
PPH Module 2014
105. Applying NASG
Step 5:
Place segment 5 with pressure ball directly over umbilicus
Close the NSAG using segment 6
Only one person should close segment 4 & 5
Should not be too tight to
restrict breathing
PPH Module 2014
106. Applying NASG
Step 6:
Ensure patient is breathing normally after the application
In case of uterine atony administer uterotonics & massage the
uterus without removing the NASG
NASG is flexible enough to allow the massaging
PPH Module 2014
107. Vaginal Procedures with NASG in situ
Pelvic examination
Lithotomy position
Repair of episiotomy / Perineal tear / Vaginal
laceration / Cervical tear
MRP
Bimanual compression
D&C / D&E / MVA
PPH Module 2014
108. Surgery with NASG in situ
Laparotomy (Keep segments 1,2&3 in situ and open pelvic &
abdominal segments 4,5&6 just prior to incision)
Steep Trendelenberg position
Operate quickly
Replace segment 4, 5 & 6 after procedure
PPH Module 2014
110. When to remove NASG?
Patient must be stable for 2 hours
Bleeding <50 ml/hr
Pulse <100 BPM
Systolic BP 90-100 mm Hg
Hb >7G%
Patient conscious & aware
PPH Module 2014
111. How to remove NASG?
Remove segment 1 & wait for 15 mts
Check pulse & BP
If pulse rate increases >20 BPM or BP falls by 20 mm Hg: Reapply segment 1
If vitals stable remove segment 2
Follow same principles till removal of segment 6
PPH Module 2014
112. Do not remove NASG before all vital signs are
restored
Early removal of NASG can be dangerous or even
fatal
PPH Module 2014
113. If B
CP
af
ua
tl
l
is
onb
y20 mm Hg or Pulse increases by 20 BPM after removal
of any segment, rapidly replace all segments
Consider need for crystalloids / Blood
If recurrent bleeding, determine source & arrest
PPH Module 2014
114. Storing NASG
Clean NASG with running water & disinfectant and dry
Keep folded NASG in a clear plastic bag
Store NASG in a place where it is visible & accessible
Always store at the same place
Ensure every one knows place of storage
Storage place should be displayed prominently
The referral center must send a replacement NASG after receiving the
patient
PPH Module 2014
115. Relative contraindications
Cardiac failure
Pre existing Mitral stenosis / Pulmonary edema
Advanced pregnancy with live fetus (APH)
Abdominal evisceration
Open pelvic fracture
PPH Module 2014
116. Principles to be observed
One person alone can apply NASG
Two persons needed when patient is unconscious
Urine output should be measured
Ensure airway protection & Prevent aspiration
Ensure one on one nursing care
PPH Module 2014
117. Advantages of NASG
50-78% Reduction in blood loss
50-55% Reduction in Maternal Mortality & related Morbidity
WHO includes NASG in recommendations
Cost effective
Reusable
PPH Module 2014
118. World Scenario 2013
Used in 16 Countries
UK & USA
Remote Rural areas
Jehova’s witness
Zambia &
Zimbabwe
Peri urban
centers
Tamil Nadu
All levels
Ambulance
#108
PPH Module 2014
121. FIGO Guidelines
1. Non-pneumatic anti-shock garment to stabilize women with hypovolemic
shock secondary to obstetric hemorrhage☆ FIGO Safe Motherhood and
Newborn Health Committee (2014)
http://dx.doi.org/10.1016/j.ijgo.2014.10.014
2. FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage
in low-resource settings, FIGO Safe Motherhood and Newborn Health
(SMNH) Committee, International Journal of Gynecology and Obstetrics 117
(2012) 108–118, doi:10.1016/j.ijgo.2012.03.001
122.
123. Partnership for Distribution in LMIC/EMEC/UN
•United Nations Commission on Life Saving Commodities for Women and
Children’s Health
• CHAI
• UCSF/Safe Motherhood Program
• BlueFuzion: UNGM (United Nations Global Marketplace)
• Higher Quality, Lower Price, Increased Reusability
• $0.30 /use
• $42.00/garment and Wash/Reuse Cycles ~ 140 times
127. Safety
> 10,000 documented cases
NO REPORTS of any safety issues
NO INCREASE of side effects minor or major due to use of NASG
Used now routinely in Africa/Asia/
South America
Large-Scale, Pragmatic
“operations research”
in Tanzania, East Timor, and others
128. Conclusions
•Statistically significant decreases in time to return to normal Shock Index in quasi-experimental and
RCTs
•At the TERTIARY LEVEL~ 58% significant reduction in MORTALITY across several quasi-experimental
studies
•Randomized Trial at PHC/Earlier Application: 64% reduction in mortality, ns
•Cost Effective or Cost-Beneficial
•On WHO and FIGO GUIDELINES, UN Marketplace Vendor/NASG, AICOG:
•In 10,000 cases carefully documented, there were no adverse events related to NASG use: SAFE
•Now in use in over 33 countries globally
133. . . . the most common and severe type of obstetric
enigma to the present day
haemmorrhage, is still an
obstetrician
as it is sudden,
often unpredicted,
assessed subjectively
and can be catastrophic.
The clinical picture changes so rapidly that unless timely
action is taken maternal death occurs within a short period.
POST PARTUM HAEMORRHAGE
134. Identify PPH Risk Factors
• Pre-eclampsia
• Nulliparity
• Multiple gestation
• Previous post-partum haemorrhage
• Previous caesarean section
• 60% have no risk factors
• Prolonged 1st & 2nd stage
• Prolonged active third stage (>30 min)
• Arrest of descent
• Episiotomy
• Lacerations: cervical, vaginal, perineal
• Assisted birth
• Use of oxytocics
Ante-natal
Intra-partum
135. Be Ready for it all the time l
Drill is a practice and
anticipation
& task allotment to tackle emergencies
Fire drill/earth quake drill etc etc
PPH drill should be taught , practised and rehearsed in obstetric set up so that every one is prepared for the
emergency and know what to do
147. GOES UNDER THE
BUTTOCK OF MOTHER
RINGS-A string from each go around the buttock
to be tied together suprapubically for double fixing
REUSABLE TYPE BLOOD COLLECTOR PAN
(DEBDAS)
178. Balloon Tamponade
•A balloon (inflated with saline/water) exerts pressure to stop bleeding from within the
uterus in 5-15 mins.
•Is very effective (≥85%) when uterotonics fail. Can prevent need for laparotomy and
hysterectomy. (Reported success rates for the control and
management of PPH with uterine tamponade are quite high and
range between 70-100%.)
•Easy to use
•Can effectively be used in low resource settings
189. WHO RECOMMENDATIONS
1- Uterotonics Play a central role in treatment
2-uterine massage is advised
3- initial crystalloids recommended
4--use of Tx in refractory trauma bleeding
5-intrauterine balloon in refractory bleeding and when uterotonic not available
6-Bimanual uterine compression
7 external aortic compression
use of non pneumaticanti shock garments as temporizing measures
8 still not controlled then Uterine aa embolization should b considered
9 Despite all if not controlled then surgical intervention should b done without delay
