This document discusses thromboprophylaxis in obstetrics and gynecology. It notes that venous thromboembolism is prevalent in hospitalized patients but often clinically silent. Screening recommendations are provided for various conditions like prior VTE and thrombophilia. Guidelines are presented for thromboprophylaxis in pregnancy, postpartum, and for various high risk procedures and cancers. Risk factors for VTE with oral contraceptives and hormone replacement therapy are reviewed. Management of thrombophilia and antiphospholipid syndrome are also covered.
Lecture by Dr Sujoy Dasgupta in BOGSCON 2015, the Annual Conference of Bengal Obstetric and Gynaecological Society, held at Hotel Novotel, Kolkata in January, 2015; where he had been invited as FACULTY to deliver his lecture
Lecture by Dr Sujoy Dasgupta in BOGSCON 2015, the Annual Conference of Bengal Obstetric and Gynaecological Society, held at Hotel Novotel, Kolkata in January, 2015; where he had been invited as FACULTY to deliver his lecture
Thromboprophylaxis in pregnancy and puerperiumManju Puri
This presentation is about thromboprophylaxis in pregnancy and puerperium and describes the risk assessment , indications, drugs to be used, when to start, for how long to continue.
review the evidence (RCT & meta-analyses) concerning the best practices in contemporary Recurrent Pregnancy Loss and Thrombophilia depending on Eshre guideline 2017 and other EBM sources.
Dr Abdullah Ansari
MBBS, MD Medicine
Aligarh Muslim University
The physiological changes in the liver during pregnancy
The possibilities of liver diseases
LFT in pregnancy
Intercurrent and pre-existing liver disease: viral hepatitis, autoimmune hepatitis, gall stones
Pregnancy associated liver disease: Hyperemesis Gravidarum, Acute cholestasis of pregnancy, Acute fatty liver of pregnancy, HELLP syndrome
Thromboprophylaxis in pregnancy and puerperiumManju Puri
This presentation is about thromboprophylaxis in pregnancy and puerperium and describes the risk assessment , indications, drugs to be used, when to start, for how long to continue.
review the evidence (RCT & meta-analyses) concerning the best practices in contemporary Recurrent Pregnancy Loss and Thrombophilia depending on Eshre guideline 2017 and other EBM sources.
Dr Abdullah Ansari
MBBS, MD Medicine
Aligarh Muslim University
The physiological changes in the liver during pregnancy
The possibilities of liver diseases
LFT in pregnancy
Intercurrent and pre-existing liver disease: viral hepatitis, autoimmune hepatitis, gall stones
Pregnancy associated liver disease: Hyperemesis Gravidarum, Acute cholestasis of pregnancy, Acute fatty liver of pregnancy, HELLP syndrome
The loss of pregnancy at any stage - devastating experience, both patient and physician.
Recurrent miscarriage is defined as the occurrence of three or more consecutive spontaneous abortion before 20wks of gestation.
Ectopic, molar and biochemical pregnancies not included.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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
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
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.
- 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
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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
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.
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.
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.
2. Rationale for Thromboprophylaxis
High prevalence of venous thromboembolism (VTE) in
hospitalised patients
Clinically silent nature of disease
Unprevented thrombi result in
- morbidity
- costs
- potential mortality (fatal PE)
3. PE: Facts & Figures
Annually: 20-30 cases / 100 000 population
30% mortality if untreated
40-80% fatal PE occur in Medical Patients
Commonest cause of in-patient mortality
Leading cause of maternal death
4. Thrombophilia
Thrombophilia is a term used to describe a lab
abnormality that increases the tendency to Venous
Thromboembolism.
It can be congenital or acquired
5. Causes of inherited thrombophilia
Definitely inherited Multifactorial
Antithrombin deficiency Elevated factor VIII
Protein C Deficiency
Protein S Deficiency hyperhomocysteinnemia
Factor V Leiden
Prothrombin 20210A mutation
Congenital Thrombophilia
7. Recommendations for Screening
Venous Thromboembolism
History of Thrombosis in first degree relative
Adverse pregnancy outcome
Who should be tested for Thrombophilia..?
8. When to test for Thrombophilia..?
Factor V
Mutation
Factor II
Anytime
ATIII
Changes after Thrombosis
Changes after anti-coagulation
Protein C
Protein S
Factor VIII
Altered by pregnancy
OCP, warfarin
Acute Thrombosis
Delay Testing
It has to
be done
after
acute
Thrombo
sis
LA
ACL Antibodies
Can be done
9. Management
Thrombophilia Screen Positive
No prior VTE
Without Pregnancy
With Pregnancy POST PARTUM
OCP|HRT
No anticoagulation
after surgery – 4 weeks
Prophylaxis (AT) No antenatal anticoagulation
(0.3 to 1.2 %) except for AT
Risk is high (1 –
3%)Thromboprophyl
axis for
4 – 6 weeks
Avoid or with
caution
10. Management
Thrombophilia Screen Positive
prior VTE
Without Pregnancy
With Pregnancy POST PARTUM
OCP|HRT
Prolonged post-op
prophylaxis
Give Antenatal
Thromboprophylaxis
Thromboprophylaxis
Contraindicate
11. Criteria for APS
Vascular Thrombosis
Pregnancy Morbidity
– One or more unexplained loss of a morphologically
normal fetus at or > 10wks gestation
– One or more premature births of a morphologically
normal neonate at or <34 wks due to severe PE or
IUGR
– Three or more unexplained consecutive spontaneous
abortions < 10wks gestation
12. APS cont
Lab Criteria
ACL Antibodies
IgG
IgM
Anti Beta 2 glycoprotein Antibodies
IgG
IgM
LA Antibodies
Prolonged aPTT
Dilute Russels Viper venom time
KCT
Faliure to correct after mixing with normal plasma
13. Management of APAS
Without thrombosis or APO
Without SLE
With SLE
Without thrombosis with APO
With prior thrombosis
Avoid additional risk
Factors like OCP|HRT
Avoid additional risk
Factors like OCP|HRT
+
Thromboprophylaxis
for surgery/Pregnancy
Antenatal Thromboprophylaxis
Postpartunm Thromboprophylaxis
6 – 8 wks
Full anticoagulation during pregnancy
Life long warfarin
14. Case Scenarios
I. 26 yr old PRIMIGRAVIDA AT 33wks pregnancy
c/o
• LEG PAIN 4 Days
• SWELLING
1. What are the clinical signs . How reliable are they ?
2. What are investigations for objective evidence ?
3. Is D –dimer useful ?
15. 4. Will you ask for Thrombophilia screen | APLA..?
5. Treatment options
6. Labour & Delivery
16. GUIDELINES
1. SIGNS SYMP of DVT
START LMWH
OBJECTIVE TEST COMPRESSION DUPLEX
USG.
If still there is suspicion continue on LMWH
RPT scan after 1 week
ILIAC VEIN THROMBOSIS – MRI or CONTRAST
VENOGRAPHY for diagnosis.
17. 2. D-DIMER NOT USEFUL
Routinely evlevated in 3rd
Trimerster
POSTPARTUM
PIH
Low Level – No DVT
3. INITIAL Rx
LMWH is accepted as safe alternative to UFH
– Reduced risk of bleeding
– Heparin induced thrombocytosis is less than UFH
– Osteroporosis is less
18. 4. Therapeutic Dose
LMWH recent weight of patient
ENOXAPARIN 1mg/Kg twice daily (subcutenaously)
DALTEPARIN 100 units / Kg (subcutenaously)
No Oral anti-coagulants
5. Monitoring
– Only in extremes of body weight < 50 Kg or > 90kg
– Renal Impairment
– Recurrenct Thrombosis
– Anti Xa level 3hrs post injection 0.5 – 1.2 units / ml
CONT same dosage throughout pregnancy.
19. 6. Additional Therapy
– Leg Elevation
– Graduated Elastic Compression Stocking
– Mobilisation with stocking
6. Labour And Delivery
– Est Labour or Thinks is in labour to stop INJ
– Stop LMWH 24hrs prior to delivery
– REG ANAEST | ANALGESIA 24 hrs after last dose
– Thromboprophylactic dose can be given 3 hrs after
LSCS 4 hrs after removal of epidural catheter
– Epidural catheter not to be removed within 12 hrs after
last dose.
– Subcut – UFH should be stopped 12 hrs prior delivery
– IV - UFH 6 hrs prior to induction of labour.
21. II. 25 yr P2+0 underwent LSCS with ST 5 days back
admitted
Episode of convlusion (generalized) B.P Normal
H/O DVT in prev pregnancy Rx
Thrombophilia screen negative
No antenatal DVT prophylaxis
1. What are the issues in the patient ..?
2. Is it advisable to withhold antenatal DUT porphylaxis ..?
3. Would you recommend post natal prophylaxis..?
22. GUIDELINES
1. Antenatal Prophylaxis
– If DVT was not related to estrogen (surgery or Trauma) close
observation during pregnancy.
– If prev DVT is during pregnancy or ESTROGEN related
THROMBOPROPHYLAXSIS to be given in ANTENATAL PD
2. POSTNATAL prophylaxis
– Prev – VTE FULL THERAPEUTIC ANTI COAG
for 6 wks | 3 mths for prox DVT LPE
– LMWH | WARFARIN dosage same as ANTENATAL PD
– LMWH dosage same as in antinatal period
– No CONTRAIND to breast feeding
– WARFARIN only after 3rd
day of delivery
– Check INR 48hrs after starting WARFARIN maintain INR 2-3 &
CONT LMWH till INR is more than 2 for two successive days.
23. III. 33 yr G3 P 1 + 1 24 wks early onset PIH in last pregnancy
LSCS at 34 wks
Missed abortion at 12 wks
Lupus anticoagulant LA +ve
PIH in this pregnancy on antihypertensives.
1. What are your recommendations ..?
2. Undergoes Rpt LSCS at 37 wks for severe PIH.
3. Develops BREATHLESSNESS on 2nd
Post Op day.
24. GUIDELINES
1. LUPUS ANTI-COAGULANT POSITIVE
– With APO she is a candidate for Antenatal
thromboprophylaxsis with LMWH
– Stop LMWH 24hrs prior to LSCS start 3hr post op
2. Start LMWH
– Clinical suspicion of acute PTE
– Chest X-Ray (ATELECTASIS LOBAR COLLAPSE)
NORMAL in > 50% of women PTE
– Compression Duplex Scan
– Both are normal
25. 3. IF SUSPICION IS HIGH
– Ventilation Perfusion Scan
– Computed Tomography Pulmonary ANGIOGRAPHY
3. CONT ANTI-COAGULANTS TILL PTE IS EXCLUDED
4. THROMBOPHILIA SCREEN PRIOR TO THERAPY IS
CONTROVERSIAL NOT RECOMMENDED
6. MASSIVE LIFE THREATHENING PE
– INTRAVENOUS UFH is drug of choice.
– Loading Dose 80 units / Kg followed by cont INFUSION
18 units / Kg / hour
– Check APTT 4 – 6 hrs after loading dose , 6hrs after any
dose change. Keep APTT 1.5 - 2.5 times control value.
27. I. Young married software professional wants to
postpone pregnancy – 1st
degree relative has VTE.
28. GUIDELINES
– Relative risk of VTE with OCP
However the absolute risk is small
5 | 100,000 - 15 | 100,000
25 | 100,000 ( with 3rd
GEN
PROGESTERONE)
– Combined OCP’s LNG | NORETHISTERONE
Lower risk of VTE than Desogestrol or Gestodene
29. Risk first four months after starting OCP with
duration of use , But still high compared to non users
VTE risk returned to normal within 3 mths of
discontinuation
Progestogen only PILL / INJ / LNG
Do Not risk of VTE
CERAZETTE does not risk.
No in risk with emergency contraception
30. Routine THROMBOPHILIA screen before OCP is not
recommended, Do it if 1 st
degree relative < 45 yrs had
VTE
31. II. 46 yr undergoes TAH with BSO
1. Do we require routine thromboprophylaxis..?
2. What are the risk factors which will prompt you for
routine peri-operative thromboprophylaxis..?
32. GUIDELINES
In gynaecological procedures less than thirty minutes
and for benign disease, the authors recommend
against the use of routine thromboprophylaxis.
In laparoscopic gynecologic procedures, in whom
additional risk factors are present, we recommend
the use of thromboprophylaxis with any of the
following; LMWH, LDUH, IPC
33. III. 40 Year patient with weight 35Kg with stage 3
ovarian carcinoma undergoes laparotomy with
ovarian debulking with sampling of paraaortic nodes
Justify why she needs thromboprophylaxis and for
how long ..?
34. GUIDELINES
Thromboprophylaxis should be given for all major
gynaecological surgery.
For major surgery in benign disease,LMWH less than
3400IU or LDUH 5000IU bid , or IPC till patient is
ambulant, are the recommendations.
In extensive surgery or for surgery for malignancy,
routine prophylaxis with once daily high dose LMWH
or LDUH 5000IU tid are recommended.
35. IV. Underwent TAH with BSO 3 mths back wants HRT
thrombophilia screen +ve
1. Does the risk of VTE with age ..?
2. Is there a risk of VTE with oral HRT ..?
3. Universal screen for thrombophilia or a good
personal & family history..?
4. Would you prescribe HRT for a woman with H/O
prev DVT if she is thrombophilia negative…?
5. Should we stop HRT before surgery…?
36. GUIDELINES
Incidence of VTE in post menopausal women is
double that of pre menopausal women
Incidence of VTE was 10.7% in HRT group 2.3 %
placebo group.
Presence of VTE in 1 st
or 2 nd
degree relative or
personal history of VTE should be obtained , No
universal screen for thrombophilia.
No HRT for prior DVT even if thrombophilia –ve
Best to avoid HRT especially in AT deficiency.
37. SERM carry same risk of thrombosis as conventional
HRT .
Need not routinely stop HRT before any surgery
provided LMWH prophylactic with or without stocking
is used.
38. Current Guidelines for Prosthetic Heart
Valve with Pregnancy
European & American college of cardiology / American Heart
Association.
WARFARIN upto 35 wks
FIRST TRIMESTER – No Warfarin
– High Risk Prev VTE
Old generation Medivalve
– UFH IV APTT 2-3 times control
– Low risk adjusted dose S/C UFH APTT 2-3 times control
UFH to replace WARFARIN after 36 wks
After delivery resume heparin 4-6 hrs later along with
WARFARIN