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Hersh AR, Carroli G, Hofmeyr GJ, Garg B, Gülmezoglu M, Lumbiganon P, De Mucio B, Saleem S, Festin MPR, Mittal S, Rubio-Romero JA, Chipato T, Valencia C, Tolosa JE. Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes. Am J Obstet Gynecol 2024; 230:S1046-S1060.e1. [PMID: 38462248 DOI: 10.1016/j.ajog.2022.11.1298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 03/12/2024]
Abstract
The third stage of labor is defined as the time period between delivery of the fetus through delivery of the placenta. During a normal third stage, uterine contractions lead to separation and expulsion of the placenta from the uterus. Postpartum hemorrhage is a relatively common complication of the third stage of labor. Strategies have been studied to mitigate the risk of postpartum hemorrhage, leading to the widespread implementation of active management of the third stage of labor. Initially, active management of the third stage of labor consisted of a bundle of interventions including administration of a uterotonic agent, early cord clamping, controlled cord traction, and external uterine massage. However, the effectiveness of these interventions as a bundle has been questioned, leading to abandonment of some components in recent years. Despite this, upon review of selected international guidelines, we found that the term "active management of the third stage of labor" was still used, but recommendations for and against individual interventions were variable and not necessarily supported by current evidence. In this review, we: (1) examine the physiology of the third stage of labor, (2) present evidence related to interventions that prevent postpartum hemorrhage and promote maternal and neonatal health, (3) review current global guidelines and recommendations for practice, and (4) propose future areas of investigation. The interventions in this review include pharmacologic agents to prevent postpartum hemorrhage, cord clamping, cord milking, cord traction, cord drainage, early skin-to-skin contact, and nipple stimulation. Treatment of complications of the third stage of labor is outside of the scope of this review. We conclude that current evidence supports the use of effective pharmacologic postpartum hemorrhage prophylaxis, delayed cord clamping, early skin-to-skin contact, and controlled cord traction at delivery when feasible. The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine; oxytocin plus misoprostol; or carbetocin. After cesarean delivery, carbetocin or oxytocin as a bolus are the most effective regimens. There is inconsistent evidence regarding the use of tranexamic acid in addition to a uterotonic compared with a uterotonic alone for postpartum hemorrhage prevention after all deliveries. Because of differences in patient comorbidities, costs, and availability of resources and staff, decisions to use specific prevention strategies are dependent on patient- and system-level factors. We recommend that the term "active management of the third stage of labor" as a combined intervention no longer be used. Instead, we recommend that "third stage care" be adopted, which promotes the implementation of evidence-based interventions that incorporate practices that are safe and beneficial for both the woman and neonate.
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Affiliation(s)
- Alyssa R Hersh
- Oregon Health & Science University, Portland, OR; FUNDARED-MATERNA, Bogotá, Colombia.
| | | | - G Justus Hofmeyr
- University of Botswana, Gaborone, Botswana; University of the Witwatersrand, Johannesburg, Johannesburg, South Africa; Walter Sisulu University, Mthatha, South Africa
| | - Bharti Garg
- Oregon Health & Science University, Portland, OR
| | | | - Pisake Lumbiganon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bremen De Mucio
- Latin American Center for Perinatology, Women and Reproductive Health, Montevideo, Uruguay
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Mario Philip R Festin
- Department of Obstetrics and Gynecology, College of Medicine, University of the Philippines, Manila, Philippines
| | | | | | - Tsungai Chipato
- Faculty of Health Sciences, Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | - Catalina Valencia
- FUNDARED-MATERNA, Bogotá, Colombia; Medicina Fetal SAS, Medellin, Colombia
| | - Jorge E Tolosa
- Oregon Health & Science University, Portland, OR; FUNDARED-MATERNA, Bogotá, Colombia; St. Luke's University Health Network, Bethlehem, PA
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Chang H, Jung W, Ha J, Yu JY, Heo S, Lee GT, Park JE, Lee SU, Hwang SY, Yoon H, Cha WC, Shin TG, Kim T. EARLY PREDICTION OF UNEXPECTED LATENT SHOCK IN THE EMERGENCY DEPARTMENT USING VITAL SIGNS. Shock 2023; 60:373-378. [PMID: 37523617 PMCID: PMC10510834 DOI: 10.1097/shk.0000000000002181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/20/2023] [Accepted: 07/02/2023] [Indexed: 08/02/2023]
Abstract
ABSTRACT Objective/Introduction : Sequential vital-sign information and trends in vital signs are useful for predicting changes in patient state. This study aims to predict latent shock by observing sequential changes in patient vital signs. Methods : The dataset for this retrospective study contained a total of 93,194 emergency department (ED) visits from January 1, 2016, and December 31, 2020, and Medical Information Mart for Intensive Care (MIMIC)-IV-ED data. We further divided the data into training and validation datasets by random sampling without replacement at a 7:3 ratio. We carried out external validation with MIMIC-IV-ED. Our prediction model included logistic regression (LR), random forest (RF) classifier, a multilayer perceptron (MLP), and a recurrent neural network (RNN). To analyze the model performance, we used area under the receiver operating characteristic curve (AUROC). Results : Data of 89,250 visits of patients who met prespecified criteria were used to develop a latent-shock prediction model. Data of 142,250 patient visits from MIMIC-IV-ED satisfying the same inclusion criteria were used for external validation of the prediction model. The AUROC values of prediction for latent shock were 0.822, 0.841, 0.852, and 0.830 with RNN, MLP, RF, and LR methods, respectively, at 3 h before latent shock. This is higher than the shock index or adjusted shock index. Conclusion : We developed a latent shock prediction model based on 24 h of vital-sign sequence that changed with time and predicted the results by individual.
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Affiliation(s)
- Hansol Chang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Weon Jung
- Smart Health Lab, Research Institute of Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Juhyung Ha
- Department of Computer Science, Indiana University Bloomington, Bloomington, Indiana
| | - Jae Yong Yu
- Department of Biomedical System Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Sejin Heo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Gun Tak Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jong Eun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
- Smart Health Lab, Research Institute of Future Medicine, Samsung Medical Center, Seoul, South Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, South Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Taerim Kim
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
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Machine learning-based suggestion for critical interventions in the management of potentially severe conditioned patients in emergency department triage. Sci Rep 2022; 12:10537. [PMID: 35732641 PMCID: PMC9218081 DOI: 10.1038/s41598-022-14422-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/07/2022] [Indexed: 12/05/2022] Open
Abstract
Providing timely intervention to critically ill patients is a challenging task in emergency departments (ED). Our study aimed to predict early critical interventions (CrIs), which can be used as clinical recommendations. This retrospective observational study was conducted in the ED of a tertiary hospital located in a Korean metropolitan city. Patient who visited ED from January 1, 2016, to December 31, 2018, were included. Need of six CrIs were selected as prediction outcomes, namely, arterial line (A-line) insertion, oxygen therapy, high-flow nasal cannula (HFNC), intubation, Massive Transfusion Protocol (MTP), and inotropes and vasopressor. Extreme gradient boosting (XGBoost) prediction model was built by using only data available at the initial stage of ED. Overall, 137,883 patients were included in the study. The areas under the receiver operating characteristic curve for the prediction of A-line insertion was 0·913, oxygen therapy was 0.909, HFNC was 0.962, intubation was 0.945, MTP was 0.920, and inotropes or vasopressor administration was 0.899 in the XGBoost method. In addition, an increase in the need for CrIs was associated with worse ED outcomes. The CrIs model was integrated into the study site's electronic medical record and could be used to suggest early interventions for emergency physicians.
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Bento SF, Borovac-Pinheiro A, Tanaka EZ, Silveira C, Pacagnella RC. Understanding How Health Providers Identify Women with Postpartum Hemorrhage: A Qualitative Study. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:648-654. [PMID: 34670298 PMCID: PMC10183885 DOI: 10.1055/s-0041-1733997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To identify how health providers recognize postpartum hemorrhage early and the difficulties involved in it. METHODS An exploratory, descriptive study using a qualitative approach through a semi-structured interview technique. In total, 27 health professionals (nursing technicians, nurses, medical residents in Gynecology and Obstetrics, hired medical doctors, and medicine professors) working in a tertiary-level hospital of reference in women's health care in the State of São Paulo, Brazil, participated in the study through an invitation. After they accepted the invitation, they signed the free and informed consent form. All interviews were recorded and transcribed, and a thematic analysis was conducted. We found three analysis categories: a) perception of the severity: "there is something wrong with the women"; b) difficulties in the early diagnosis of postpartum hemorrhage; and c) the process to improve obstetrical care. RESULTS Caregivers believe teamwork and communication should be improved. Besides the visual estimation of blood loss, the nursing team is attentive to behavioral symptoms like irritability, while the medical staff follow protocols and look for objective signs, such as altered vital signs. CONCLUSION Besides the objective evaluations, the subjective perceptions of the providers are involved in the clinical judgement regarding the diagnosis of postpartum hemorrhage, and this should be included in a broader diagnosis strategy.
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Mamakou A. The role of midwife in postpartum hemorrhage. Eur J Midwifery 2021; 4:46. [PMID: 33537647 PMCID: PMC7839132 DOI: 10.18332/ejm/128271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/08/2020] [Indexed: 11/24/2022] Open
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Borovac-Pinheiro A, Priyadarshani P, Burke TF. A review of postpartum hemorrhage in low-income countries and implications for strengthening health systems. Int J Gynaecol Obstet 2021; 154:393-399. [PMID: 33529365 DOI: 10.1002/ijgo.13618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/13/2020] [Accepted: 01/21/2021] [Indexed: 11/09/2022]
Abstract
Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide. Disparities in PPH-associated survival between high and low-/middle-income countries reflect an imperative for low-resource countries to improve strategies for rapid diagnosis and treatment. A review of current PPH diagnosis, prevention, treatment, and access to care in low-income countries has been used to understand, extract, and report the challenges that public health systems face in trying to solve the marked global disparity in PPH outcomes. Improvement in PPH survival begins with holistic strengthening of each step along the continuum of care in health systems and should include performance feedback measures and quality-of-care research.
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Affiliation(s)
- Anderson Borovac-Pinheiro
- Global Health Innovation Lab, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Preeti Priyadarshani
- Global Health Innovation Lab, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Gorakhpur, India
| | - Thomas F Burke
- Global Health Innovation Lab, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard T, H. Chan School of Public Health, Boston, MA, USA
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Assessing and managing hypovolemic shock in puerperal women. Best Pract Res Clin Obstet Gynaecol 2019; 61:89-105. [DOI: 10.1016/j.bpobgyn.2019.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/20/2019] [Accepted: 05/20/2019] [Indexed: 12/17/2022]
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Scheepstra KWF, van Steijn ME, Dijksman LM, van Pampus MG. Post-traumatic stress disorder in women and their partners, following severe post-partum hemorrhage: A study protocol for a prospective cohort study. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1278840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Karel Willem Frank Scheepstra
- Department of Gynaecology, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1090 HM, 95500 Amsterdam, The Netherlands
- Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Minouk Esmée van Steijn
- Department of Gynaecology, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1090 HM, 95500 Amsterdam, The Netherlands
- Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Lea Magdalena Dijksman
- Department of Research and Epidemiology, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1090 HM, 95500 Amsterdam, The Netherlands
- Department of Research and Epidemiology, St. Antoniusziekenhuis, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Maria Gabriel van Pampus
- Department of Gynaecology, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1090 HM, 95500 Amsterdam, The Netherlands
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Borovac-Pinheiro A, Pacagnella RC, Morais SS, Cecatti JG. Standard reference values for the shock index during pregnancy. Int J Gynaecol Obstet 2016; 135:11-5. [DOI: 10.1016/j.ijgo.2016.03.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/02/2016] [Accepted: 05/31/2016] [Indexed: 10/21/2022]
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Sentilhes L, Merlot B, Madar H, Sztark F, Brun S, Deneux-Tharaux C. Postpartum haemorrhage: prevention and treatment. Expert Rev Hematol 2016; 9:1043-1061. [PMID: 27701915 DOI: 10.1080/17474086.2016.1245135] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) is one of the leading causes of maternal death and severe maternal morbidity worldwide and strategies to prevent and treat PPH vary among international authorities. Areas covered: This review seeks to provide a global overview of PPH (incidence, causes, risk factors), prevention (active management of the third stage of labor and prohemostatic agents), treatment (first, second and third-line measures to control PPH), by also underlining recommendations elaborated by international authorities and using algorithms. Expert commentary: When available, oxytocin is considered the drug of first choice for both prevention and treatment of PPH, while peripartum hysterectomy remains the ultimate life-saving procedure if pharmacological and resuscitation measures fail. Nevertheless, the level of evidence for preventing and treating PPH is globally low. The emergency nature of PPH makes randomized controlled trials (RCT) logistically difficult. Population-based observational studies should be encouraged as they can usefully strengthen the evidence base, particularly for components of PPH treatment that are difficult or impossible to assess through RCT.
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Affiliation(s)
- Loïc Sentilhes
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Benjamin Merlot
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Hugo Madar
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - François Sztark
- b Department of Anesthesiology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Stéphanie Brun
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Catherine Deneux-Tharaux
- c INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics Sorbonne Paris Cité , Paris Descartes University , Paris , France
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Eckerdal P, Kollia N, Löfblad J, Hellgren C, Karlsson L, Högberg U, Wikström AK, Skalkidou A. Delineating the Association between Heavy Postpartum Haemorrhage and Postpartum Depression. PLoS One 2016; 11:e0144274. [PMID: 26807799 PMCID: PMC4726585 DOI: 10.1371/journal.pone.0144274] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/16/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To explore the association between postpartum haemorrhage (PPH) and postpartum depression (PPD), taking into account the role of postpartum anaemia, delivery experience and psychiatric history. METHODS A nested cohort study (n = 446), based on two population-based cohorts in Uppsala, Sweden. Exposed individuals were defined as having a bleeding of ≥1000 ml (n = 196) at delivery, and non-exposed individuals as having bleeding of <650 ml (n = 250). Logistic regression models with PPD symptoms (Edinburgh Postnatal Depression scale (EPDS) score ≥ 12) as the outcome variable and PPH, anaemia, experience of delivery, mood during pregnancy and other confounders as exposure variables were undertaken. Path analysis using Structural Equation Modeling was also conducted. RESULTS There was no association between PPH and PPD symptoms. A positive association was shown between anaemia at discharge from the maternity ward and the development of PPD symptoms, even after controlling for plausible confounders (OR = 2.29, 95%CI = 1.15-4.58). Path analysis revealed significant roles for anaemia at discharge, negative self-reported delivery experience, depressed mood during pregnancy and postpartum stressors in increasing the risk for PPD. CONCLUSION This study proposes important roles for postpartum anaemia, negative experience of delivery and mood during pregnancy in explaining the development of depressive symptoms after PPH.
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Affiliation(s)
- Patricia Eckerdal
- Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
| | - Natasa Kollia
- Department of Biostatistics, Harokopio University, Athens, Greece
| | - Johanna Löfblad
- Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
| | - Charlotte Hellgren
- Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
| | - Linnea Karlsson
- Department of Child Psychiatry, Turku University Hospital, Turku, Finland
- FinnBrain Birth Cohort Study, Turku Brain and Mind Centre, Institute of Clinical Medicine, University of Turku, Turku, Finland
| | - Ulf Högberg
- Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
| | - Anna-Karin Wikström
- Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
| | - Alkistis Skalkidou
- Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
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Penn AW, Beam NK, Azman H. Non-pneumatic anti-shock garment (NASG) as a first aid for preventing or reversing hypovolemic shock secondary to obstetric hemorrhage. Hippokratia 2015. [DOI: 10.1002/14651858.cd011700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Amy W Penn
- University of California, San Francisco; Global Health Sciences; 550 16th St 3rd Floor San Francisco California USA 94158
| | - Nancy K Beam
- UCSF School of Nursing; Family Health Care Nursing; 912 Cole Street, #223 San Francisco California USA 94117
| | - Hana Azman
- University of California, San Francisco; Global Health Sciences; 550 16th St 3rd Floor San Francisco California USA 94158
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Gupta A. A comparative study of methylergonovine and 15-methyl prostaglandin F2α in active management of third stage of labor. Obstet Gynecol Sci 2013; 56:301-6. [PMID: 24328019 PMCID: PMC3784129 DOI: 10.5468/ogs.2013.56.5.301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 04/04/2013] [Accepted: 04/04/2013] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Postpartum hemorrhage is most common cause of maternal mortality. Active management of third stage of labor minimizes the risk of postpartum hemorrhage. To compare the effect of methylergonovine and 15-methyl prostaglandin F2α (15-methyl PGF2α) in active management of third stage of labor. METHODS A randomized open labelled parallel study with 50 women in normal labor, 25 in each group were included. The drugs methylergonovine (0.2 mg) intravenous and 15-methyl PGF2α (250 µg) intramuscular were administered at the time of delivery of anterior shoulder. Main outcomes measured were amount of blood loss during the first four hours of delivery and objective measurement of hemoglobin and hematocrit levels before delivery and third day postpartum. RESULTS There was no statistically significant difference in the blood loss between the two groups at delivery (P = 0.130), at 1 hour of delivery (P = 0.453). The blood loss with 15-methyl PGF2α was significantly less as compared to that of blood loss with methylergonovine at four hours of delivery (P = 0.014) and the total, i.e., during first four hours, amount of blood loss was significantly less with 15-methyl PGF2α (P = 0.026). There was no statistically significant difference in the hemoglobin and hematocrit levels measured predelivery and postpartum third day between both the drugs. CONCLUSION Both the drugs were effective in controlling the amount of blood loss during the third stage of labor, 15-methyl PGF2α being more efficacious.
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Affiliation(s)
- Anshu Gupta
- Department of Pharmacology, MMIMSR, Ambala, India
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Matsunaga S, Seki H, Ono Y, Matsumura H, Murayama Y, Takai Y, Saito M, Takeda S, Maeda H. A retrospective analysis of transfusion management for obstetric hemorrhage in a Japanese obstetric center. ISRN OBSTETRICS AND GYNECOLOGY 2012; 2012:854064. [PMID: 22462007 PMCID: PMC3302117 DOI: 10.5402/2012/854064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 10/24/2011] [Indexed: 11/23/2022]
Abstract
Background. Since cryoprecipitate, fibrinogen concentrate, or recombinant activated factor VII is not approved by public medical insurance in Japan, we retrospectively assessed blood product usage in patients with obstetric hemorrhage at our tertiary obstetric center. Material and Methods. 220 patients with obstetric hemorrhagic disorders who underwent blood product transfusion in our institution during a 5-year period were reviewed for the types and volumes of blood products transfused. Results. There was a significant positive correlation (P< 0.001) between the volume of RCC (red blood cell concentrate) transfused and that of FFP (fresh frozen plasma), irrespective of underlying obstetric disorders. The median of FFP to RCC ratio in each patient was 1.3-1.4, when 6 or more units of RCC were transfused. Conclusions. In transfusion for massive obstetric hemorrhage in terms of appropriate supplementation of coagulation factors, the transfusion of RCC : FFP = 1 : 1.3-1.4 may be desirable.
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Affiliation(s)
- Shigetaka Matsunaga
- Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
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RATH WERNERH. Postpartum hemorrhage - update on problems of definitions and diagnosis*. Acta Obstet Gynecol Scand 2011; 90:421-8. [DOI: 10.1111/j.1600-0412.2011.01107.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pérez Solaz A, Ferrandis Comes R, Llau Pitarch JV, Alcántara Noalles MJ, Abengochea Cotaina A, Barberá Alacreu M, Belda Nácher FJ. [Obstetric bleeding: an update]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:224-235. [PMID: 20499801 DOI: 10.1016/s0034-9356(10)70209-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Massive bleeding in obstetrics still ranks among the most frequent causes of maternal morbidity and mortality worldwide. The most frequent type is primary postpartum hemorrhage, which is usually the result of an atonic uterus. The clinical priorities are to assure hemodynamic stability and to correct coagulation abnormalities. If pharmacologic treatment cannot achieve these goals, invasive methods such as interventional vascular radiology or artery ligation must be used. Hysterectomy is the last resort when the previous methods fail. For the best prognosis, in terms of preventing death, maintaining maternal fertility and minimizing morbidity, every maternity ward should have a well-defined multidisciplinary protocol that facilitates diagnosis and immediate treatment.
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Miller S, Fathalla MMF, Youssif MM, Turan J, Camlin C, Al-Hussaini TK, Butrick E, Meyer C. A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt. Int J Gynaecol Obstet 2010; 109:20-4. [PMID: 20096836 DOI: 10.1016/j.ijgo.2009.11.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 11/04/2009] [Accepted: 12/10/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the impact of the non-pneumatic anti-shock garment (NASG) on maternal outcome following severe obstetric hemorrhage. METHODS A non-randomized pre-intervention/intervention study was conducted in 2 tertiary hospitals in Egypt from June 2006 to May 2008. Women with obstetric hemorrhage (estimated blood loss >or=1000 mL and/or >or=1 sign of shock [systolic blood pressure <100 mm Hg or pulse >100 beats per minute]) were treated with either a standardized protocol (pre-intervention) or a standardized protocol plus the NASG (intervention). The primary outcome was extreme adverse outcome (EAO), combining maternal mortality and severe morbidity (cardiac, respiratory, renal, or cerebral dysfunction). Secondary outcomes were measured blood loss, urine output, emergency hysterectomy, and (individually) mortality or morbidity. Analyses were performed to examine independent association of the NASG with EAO. RESULTS Mean measured blood loss decreased from 379 mL pre-intervention to 253 mL in the intervention group (P<0.01). In a multiple logistic regression model, the NASG was associated with reduced odds of EAO (odds ratio 0.38; 95% confidence interval, 0.17-0.85). CONCLUSION The NASG, in addition to standardized protocols at tertiary facilities for obstetric hemorrhage and shock, resulted in lower measured blood loss and reduced EAO.
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Affiliation(s)
- Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94105, USA.
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So-Osman C, Cicilia J, Brand A, Schipperus M, Berning B, Scherjon S. Triggers and appropriateness of red blood cell transfusions in the postpartum patientâa retrospective audit. Vox Sang 2010; 98:65-9. [DOI: 10.1111/j.1423-0410.2009.01231.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Weisbrod AB, Sheppard FR, Chernofsky MR, Blankenship CL, Gage F, Wind G, Elster EA, Liston WA. Emergent management of postpartum hemorrhage for the general and acute care surgeon. World J Emerg Surg 2009; 4:43. [PMID: 19939251 PMCID: PMC2788527 DOI: 10.1186/1749-7922-4-43] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Accepted: 11/25/2009] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage is one of the rare occasions when a general or acute care surgeon may be emergently called to labor and delivery, a situation in which time is limited and the stakes high. Unfortunately, there is generally a paucity of exposure and information available to surgeons regarding this topic: obstetric training is rarely found in contemporary surgical residency curricula and is omitted nearly completely from general and acute care surgery literature and continuing medical education. METHODS The purpose of this manuscript is to serve as a topic specific review for surgeons and to present a surgeon oriented management algorithm. Medline and Ovid databases were utilized in a comprehensive literature review regarding the management of postpartum hemorrhage and a management algorithm for surgeons developed based upon a collaborative panel of general, acute care, trauma and obstetrical surgeons' review of the literature and expert opinion. RESULTS A stepwise approach for surgeons of the medical and surgical interventions utilized to manage and treat postpartum hemorrhage is presented and organized into a basic algorithm. CONCLUSION The manuscript should promote and facilitate a more educated, systematic and effective surgeon response and participation in the management of postpartum hemorrhage.
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Affiliation(s)
| | - Forest R Sheppard
- Department of Surgery, National Naval Medical Center, Bethesda, MD, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
- Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD, USA
| | - Mildred R Chernofsky
- Department of Obstetrics and Gynecology, Walter Reed Army Medical Center, Washington, DC, USA
| | | | - Frederick Gage
- Department of Surgery, National Naval Medical Center, Bethesda, MD, USA
- Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD, USA
| | - Gary Wind
- Department of Surgery, National Naval Medical Center, Bethesda, MD, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Eric A Elster
- Department of Surgery, National Naval Medical Center, Bethesda, MD, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
- Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD, USA
| | - William A Liston
- Department of Surgery, National Naval Medical Center, Bethesda, MD, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
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Bayrak S, Pehli˙vanogˇlu B, Balkanci ZD, Őzyürek H, Aksoy Y, Ati˙lla P, Cakar AN. The effects of transient systemic hypotension on renal oxidative status, morphology and plasma nitric oxide levels in pregnant rats. J Matern Fetal Neonatal Med 2009; 22:528-36. [DOI: 10.1080/14767050902822229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
OBJECTIVE To describe the management of severe postpartum hemorrhage. MATERIAL AND METHODS Prospective observational study from July 2005 to November 2007 in women who were admitted to the recovery unit of a tertiary referral hospital due to postpartum hemorrhage. We analyzed incidence, prevalence, morbidity, mortality, and associated risk factors. RESULTS The study included 21,726 deliveries (124 with severe bleeding). Postpartum hemorrhage was more common after an instrumental delivery (odds ratio [OR], 4.54) and after a cesarean delivery (OR, 2.86). The risk factors identified in the study population were multiple gestation pregnancy and fetal death. One patient died due to disseminated intravascular coagulation. The main causes of bleeding were uterine atony (45.2%) followed by vaginal tearing (26.6%). Treatment was provided using packed red blood cells in 96.8% of the patients, fibrinogen in 49.2%, prothrombin complex in 7.25% and activated factor VII in 3.2%. Selective arterial embolization was performed in 10.5% of the cases (success rate, 84.6%) and hysterectomy was required in 13.7%. The main complications were need for postoperative mechanical ventilation (11.3%), myocardial ischemia (4%), pulmonary edema (4.8%), acute renal failure (8.9%), ventricular fibrillation (0.8%), and death (0.8%). CONCLUSIONS The incidence of severe postpartum hemorrhage in patients treated at our hospital is low, as is the mortality rate. Use of fibrinogen is common and provides good results. Angiographic embolization is very effective, though the percentage of hysterectomies is still high. Multiple gestation pregnancy and fetal death are associated risk factors.
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Fetal outcomes of critically ill pregnant women admitted to the intensive care unit for nonobstetric causes. Crit Care Med 2008; 36:2746-51. [PMID: 18828192 DOI: 10.1097/ccm.0b013e318186b615] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The outcome of the fetus in critically ill mothers has been briefly reported as a part of descriptive studies focusing on maternal risk factors for admission to the intensive care unit. We evaluated the risk factors for adverse fetal outcomes in critically ill pregnant women admitted to the intensive care unit for nonobstetrical reasons. DESIGN Retrospective cohort study of all critically ill pregnant patients >18 yr; admitted to four (medical, surgical, trauma, and mixed medical-surgical) intensive care units at the Mayo Clinic in Rochester, MN; during the period of January 1995 to December 2005. Only pregnant women admitted to the intensive care unit in the antepartum period for nonobstetrical indications were included. Main predictors for fetal outcomes included: maternal comorbidities, obstetrical history, intensive care unit interventions, and intensive care unit complications. Fetal outcomes were defined as spontaneous abortions, neonatal mortality, fetal deaths, admission to the neonatal intensive care unit, neonatal intensive care unit length of stay, and neonatal intensive care unit complications. RESULTS A total of 153 adult women (>18 yr) with a diagnosis of pregnancy were admitted to the intensive care unit, of whom 93 pregnant women met the inclusion criteria. Median maternal age was 26 yr (interquartile range 22-33) and median gestational age was 25 wk (interquartile range 8-33). The median maternal Acute Physiologic and Chronic Health Evaluation III score was 27 (interquartile range 17-38). There were 32 fetal losses; 18 were spontaneous abortions and 14 were fetal deaths. Ten neonates required neonatal intensive care unit admission, five for respiratory distress syndrome; and only one neonate died. The median neonatal intensive care unit length of stay was 34 days (interquartile range 15-87). After multivariable logistic regression analysis, the risk factors associated with fetal loss were: presence of maternal shock, odds ratio 6.85 (95% confidence interval 1.16-58, p = 0.04); maternal transfusion of blood products, odds ratio 7.24 (95% confidence interval 1.4-49, p = 0.02); and gestational age, odds ratio 1.2 for every gestational week below 37 wk (95% confidence interval 1.1-1.3, p < 0.001). CONCLUSIONS Nonobstetrical critical illness in pregnant women significantly affects fetal and neonatal outcomes. Maternal shock, maternal requirement of allogenic blood product transfusion and lower gestational age were associated with an increased risk of fetal loss.
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[Spontaneous intra-abdominal bleeding in twin pregnancy--case report]. SRP ARK CELOK LEK 2008; 136:299-301. [PMID: 18792631 DOI: 10.2298/sarh0806299b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Spontaneous rupture of utero-ovarian vessels is a rare cause of haemoperitoneum in pregnancy, leading to significant maternal and foetal morbidity and mortality. Aetiopathogenesis of this condition is still unclear. Establishing clinical diagnosis of this condition is difficult, but very important. Clinical symptoms are nonspecific, and the diagnosis is usually made at laparotomy. CASE OUTLINE We report a case of spontaneous haematoperitoneum in the third trimester of twin pregnancy. Differential diagnosis included uterine rupture and placental abruption. Due to the deteriorated condition of the patient, it was decided to perform laparotomy which established the diagnosis of ruptured venous varices on the posterior uterine wall. Delivery was performed by caesarean section. The postoperative period was uneventful. CONCLUSION The clinical presentation of spontaneous rupture of utero-ovarian blood vessels is not specific and clinical examination and ultrasonographic scanning may be insufficient for diagnosis. Once the diagnosis of spontaneous haematoperitoneum in pregnancy is established, emergency laparotomy is indicated. Following caesarean delivery, it is necessary to establish surgical haemostasis. There are some authors who suggest leaving the pregnancy intact in cases when the foetus is not viable, although one must have in mind the possibility of recurrent bleeding. The safety of this procedure requires further investigation. It is necessary to have in mind the possibility of blood vessel rupture in all cases of abdominal pain and hypotension of unknown origin during pregnancy.
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Abstract
Morbid adherent placenta (MAP), also known as placenta accreta, increta or percreta, is one of the main causes of maternal morbidity and mortality. Its incidence has noticeably increased in the last few decades, a fact directly related to the increase in caesarean sections. There is a close relation between iterative caesarean sections and MAP. This connection is of vital importance, since caesarean rates have risen worldwide, especially in the countries where there is the possibility of caesarean section on demand.
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Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG 2006; 113:919-24. [PMID: 16907938 DOI: 10.1111/j.1471-0528.2006.01018.x] [Citation(s) in RCA: 237] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Following the results of the Confidential Enquiries into Maternal Deaths report, which claims two maternal deaths annually in the UK from postpartum haemorrhage, our aim was to assess the accuracy of 'visual estimation of blood loss' and produce suitable pictorial and written algorithms to aid in the recognition and management of massive obstetric haemorrhage. DESIGN Observational study to determine discrepancy between actual blood loss (ABL) and estimated blood loss (EBL). SETTING Teaching hospital. POPULATION Hundred and three obstetricians, anaesthetists, midwives, nurses and healthcare assistants. METHODS Clinical scenarios were reproduced in the form of 12 Objective Structured Clinical Examination (OSCE) style stations augmented with known volumes of whole blood. Individual staff estimated the blood loss visually and recorded their results. Digital photographs were used to produce a pictorial 'algorithm' suitable for use as a teaching tool in labour ward. MAIN OUTCOME MEASURES Areas of greatest discrepancy between EBL and ABL. RESULTS Significant underestimation of the ABL occurred in 5 of the 12 OSCE stations: 500-ml (50-cm diameter) floor spill, 1000-ml (75-cm diameter) floor spill, 1500-ml (100-cm diameter) floor spill, 350-ml capacity of soaked 45- x 45-cm large swab and the 2-l vaginal postpartum haemorrhage on bed/floor. CONCLUSIONS Accurate visual estimation of blood loss is known to facilitate timely resuscitation, minimising the risk of disseminated intravascular coagulation and reducing the severity of haemorrhagic shock. Participation in clinical reconstructions may encourage early diagnosis and prompt treatment of postpartum haemorrhage. Written and pictorial guidelines may help all staff working in labour wards.
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Affiliation(s)
- P Bose
- Department of Obstetrics and Gynaecology, Queen Charlotte's Hospital, London, UK. Email
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Fowler SJ. Provision for major obstetric haemorrhage: an Australian and New Zealand survey and review. Anaesth Intensive Care 2006; 33:784-93. [PMID: 16398386 DOI: 10.1177/0310057x0503300614] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Obstetric haemorrhage is a leading cause of maternal death and the most common contributor to serious obstetric morbidity. Maternal mortality audit data suggest that appropriate preparation and good emergency management leads to improved outcome. The aim of this study was to assess facilities relevant to major obstetric haemorrhage management in all units in Australia and New Zealand that offer operative obstetric services. The questionnaire was divided into ten sections: demographics, facilities, staffing, policies and guidelines, drugs, procedures, equipment, point of care testing, availability of O negative blood and free comments. Responses were received from 240 (76.4%) of the 314 hospitals surveyed (187 public and 53 private). One hundred and nine units (45%) had fewer than 500 deliveries per year Distances to referral facilities were frequently very large. Of the 90 hospitals (38.1%) without an onsite blood bank, 12 did not have a supply of blood for emergencies. Half of all units (n=121) had on-site intensive care or high dependency facilities and 72.9% (n=175) had an on-site cardiac arrest team. Only 58.8% of units (n=141) had a written haemorrhage protocol. Findings are presented in the context of other literature, including evidence-based guidelines. Haemorrhage responds well to appropriate treatment, although careful preparation and anticipation of problems is required. In our region geographical factors and different systems of healthcare complicate provision of obstetric services. Where facilities are limited, women should be offered antenatal transfer to a larger centre.
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Affiliation(s)
- S J Fowler
- Department of Anaesthesia, Wellington Hospital, Wellington, New Zealand
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Abstract
This article thoroughly updates the authors' previous review of nutritional assessment and support during pregnancy. After briefly reviewing nutrient metabolism and requirements, the authors discuss the nutritional assessment of the pregnant woman and review the nutritional support principles in hyperemesis gravidarum and other conditions that can compromise the nutritional health of mother or fetus.
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Affiliation(s)
- Elie Hamaoui
- Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA.
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Abstract
Blood substitutes are solutions intended to replace transfusion of banked red blood cells. Several variations of products based on either hemoglobin (animal or human) or perfluorocarbon emulsions are in advanced stages of clinical development. The need for such products is pressing as shortages of banked blood worsen and awareness of the dangers of blood transfusion increases. Animal and human studies with these cell-free oxygen carriers have led to new concepts of how oxygen is delivered to tissue and how the microcirculation is regulated. Although development of products is exciting and timely, understanding how they function to perfuse and oxygenate tissue could be at least as important. Because cell-free oxygen carriers will perfuse every organ of the body, their effects are far-reaching, and the transition from the laboratory to the bedside can be expected to be slow and deliberate. Comparison of oxygen carriers with more traditional starch-based products provides new insight into the interaction of oxygen transport, microvascular perfusion, and blood volume expansion.
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Abstract
Postpartum haemorrhage remains in the top five causes of maternal deaths in both developed and developing countries. Persistent blood loss of more than 1000 ml should prompt predetermined measures to achieve resuscitation and haemostasis. A protocol including guidelines is given and volume replacement is discussed. The range of medical and surgical interventions that may be considered for the modern management of major haemorrhage unresponsive to oxytocin and ergometrine are presented. The review discusses in depth the use of misoprostol, recombinant activated factor VII, the uterine tamponade procedures, artery ligation, and uterine haemostatic suturing techniques. It also evaluates the place of interventional radiology and hysterectomy in modern obstetrics.
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Affiliation(s)
- H A Mousa
- University Department of Obstetrics & Gynaecology, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK
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