Best practice & research. Clinical obstetrics & gynaecology
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Best Pract Res Clin Obstet Gynaecol · Oct 2020
ReviewManagement of viral hepatitis A, C, D and E in pregnancy.
Viral hepatitis can cause significant maternal and neonatal morbidity and mortality. Hepatitis A and E mainly present as acute hepatitis during pregnancy, while hepatitis C and D are usually found as chronic infection in pregnant women. ⋯ New treatments of hepatitis C and E require further evaluation for use in pregnancy. This review summarizes the prevalence, clinical manifestations, maternal, foetal and neonatal effects, and the management of hepatitis A, C, D and E viral infection during pregnancy.
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Best Pract Res Clin Obstet Gynaecol · Jan 2020
ReviewThe Irish Journey: Removing the shackles of abortion restrictions in Ireland.
In May 2018, the Irish electorate voted to remove from the Constitution one of the most restrictive abortion bans in the world. This referendum followed 35 years of legal cases, human rights advocacy, feminist activism and governmental and parliamentary processes. ⋯ The new law, enacted in 2018, provides for access to abortion on a woman's request up to 12 weeks of pregnancy and in situations of risk to the life or of serious harm to the health of the pregnant woman and fatal foetal anomaly thereafter. Abortion is now broadly accessible in Ireland; however, continued advocacy is needed to ensure that the state meets international human rights standards and that access to abortion care and abortion rights is fully secured within the law.
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Best Pract Res Clin Obstet Gynaecol · Nov 2019
ReviewTranexamic acid for post-partum haemorrhage: What, who and when.
Tranexamic acid reduces bleeding by inhibiting the breakdown of blood clots. It is cost-effective and heat-stable with a long shelf life. In the WOMAN trial, tranexamic acid reduced deaths due to bleeding with no increase in thromboembolic events. ⋯ Urgent treatment is critical because women with post-partum haemorrhage bleed to death quickly, and tranexamic acid is most effective when given early. Evidence suggests there is no benefit when the drug is given more than 3 h after bleeding onset. Alternative routes of administration and use of tranexamic acid in the prevention of post-partum haemorrhage are research priorities.
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The prothrombotic state during pregnancy protects against coagulopathy. Fibrinogen is of key importance with concentrations of 4-6 g/l in parturients preventing the majority of women with postpartum haemorrhage developing hypofibrinogenaemia. However, plasma levels below 2 g/l are strongly predictive of bleed progression and should be maintained above this. ⋯ Formulaic blood product administration results in unnecessary treatment for the majority. Reduced morbidity with viscoelastometry-guided blood product administration has been demonstrated with observational studies but not with randomised controlled trials. Further studies are needed to assess the optimal treatment threshold and outcome benefits from targeted fibrinogen replacement.
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Every six minutes, a mother dies from post-partum haemorrhage (PPH) in low- and middle-income countries, often in the prime of her life and often leaving behind a young family. To prevent PPH, the routine administration of a uterus-contracting ('uterotonic') agent is a standard practice across the world. Oxytocin is the standard uterotonic agent recommended for this purpose, and is recommended for all women giving birth. ⋯ However, because carbetocin costs 20 times more than oxytocin and is not widely available yet, oxytocin remains the mainstay for prevention of PPH. However, this may change as WHO has signed a memorandum of understanding with the manufacturer to provide carbetocin for the public sector of LMIC at a similar price level to that of oxytocin. Currently, carbetocin is being registered in 90 low- and middle-income countries to be made available and improve access to this life-saving uterotonic agent.