Clinical obstetrics and gynecology
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Obstetric hemorrhage remains the most important cause of maternal mortality worldwide, accounting for 30% of all direct maternal deaths. As the method of management depends on multiple concurrent and sequential evaluations of the patient's status, it is helpful to have an evaluation strategy prepared for when a postpartum hemorrhage is encountered to facilitate interventions. This review describes an etiology-based approach to the clinical evaluation of postpartum hemorrhage and a suggested systems process that allows both a timely and appropriate evaluation of the hemorrhaging mother.
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Placenta accreta is the abnormal adherence of the placenta to the uterine wall. Where placenta accreta is present, the failure of the placenta to separate normally from the uterus after delivery is accompanied by severe postpartum hemorrhage. ⋯ Management should take place in centers with special expertise. All obstetric units should have an obstetric hemorrhage protocol in place.
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Clin Obstet Gynecol · Mar 2010
ReviewThe use of recombinant activated FVII in postpartum hemorrhage.
Severe bleeding remains a leading cause of morbidity and mortality in obstetrics. The first-line standard treatment of massive postpartum hemorrhage (PPH) includes medical measures directed at improving uterine tone, replacement of lost intravascular volume, blood and coagulation factors, and surgical or invasive procedures. Recently, a number of case reports or case series have reported the successful "off-label" use of recombinant activated factor VII (rFVIIa) in PPH unresponsive to conventional treatments. ⋯ No randomized controlled trials have been conducted in this area. Currently, the literature data suggest that, at a median dose of 81.5 microg/kg, rFVIIa is effective in stopping or reducing bleeding in 85% of the cases. Finally, on the basis of the evidence from the literature and on own experience, we included some recommendations and an algorithm on the therapeutic role of rFVIIa in the management of PPH.
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Obstetrical emergencies require the rapid formation of a team with clear communication, strong leadership, and appropriate decision-making to ensure a positive patient outcome. Obstetric teams can improve their emergency response capability and efficiency through team and simulation training. Postpartum hemorrhage is an ideal model for team and simulation training, as postpartum hemorrhage requires a multidisciplinary team with the capability to produce a protocol-driven, rapid response. This article provides an overview of team and simulation training and focuses on applications within obstetrics, particularly preparation for postpartum hemorrhage.
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Disorders of coagulation are relatively uncommon as a sole cause of postpartum hemorrhage. Coagulation disturbances should be suspected in patients with a family history of such abnormalities and patients with a history of menorrhagia. Clinical circumstances may also suggest coagulation defect as a cause of postpartum hemorrhage. Diagnosis of a coagulation disorder often requires a high index of suspicion and should not be overlooked in the evaluation of obstetric hemorrhage.