Best practice & research. Clinical obstetrics & gynaecology
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Best Pract Res Clin Obstet Gynaecol · Oct 2009
ReviewUrgent care in gynaecology: resuscitation and management of sepsis and acute blood loss.
Sepsis and/or acute blood loss can be encoutered as an emergency condition in gynaecology, especially in women with ectopic pregnancy/miscarriage, acute pelvic inflammatory disease (PID)/tuboovarian abscesses, post-puerperal sepsis/haemorrhage and even in postoperative scenarios. If underestimated or suboptimally treated, both can lead to an inadequate tissue perfusion (defined as shock) and the development of multi-organ failure. Morbidity and mortality after development of one of the shock syndromes (septic or haemorrhagic) correlates directly with the duration and severity of the malperfusion. ⋯ In septic shock, hypotension is primarily treated with fluid administration and eventually vasopressors, if required, in order to improve the circulation. Timely administration of antibiotics, control of infectious foci, appropriate use of corticoids and recombinant human activated protein C, tight glucose control, prophylaxis of deep vein thrombosis and stress ulcer prevention complete the therapy of septic shock. In haemorrhagic shock, the treatment primarily involves controlling haemorrhage, reversal of possible coagulopathy and administration of sufficient volumes of fluids and blood products to restore normal tissue perfusion.
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Nausea and vomiting occur in up to 80% of normal pregnancies. Hyperemesis gravidarum, resulting in dehydration and ketonuria, is a more severe, disabling and potentially life threatening condition affecting up to 1.5% of pregnancies. ⋯ There are good safety data to support the use of antihistamines, phenothiazines and metoclopromide in hyperemesis gravidarum, though trials of efficacy are lacking and there is little evidence on which to chose the optimum therapy. This review discusses the diagnosis and management of hyperemesis gravidarum and the prevention, recognition and treatment of the serious complications of Wernicke encephalopathy, osmotic demyelination syndrome and thromboembolism.
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Miscarriage is the most common serious pregnancy complication affecting approximately 30% of biochemical pregnancies and 11-20% of clinically recognised pregnancies. The diagnosis of miscarriage is made most commonly by trans-vaginal ultrasound (TVS) assessment. Evidence-based criteria should be employed for the diagnosis of delayed and incomplete miscarriage. ⋯ Prediction of the diagnosis of miscarriage using maternal history and ultrasound features may be helpful in counselling women towards likely pregnancy outcome and planning appropriate further assessment. Use of three-dimensional ultrasound has not improved diagnosis of miscarriage. After a diagnosis of miscarriage, half the women undergo significant psychological effects, which may last for up to 12 months.
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The management of the unconscious pregnant patient encompasses many aspects of obstetrics and critical care. It is not uncommon to have to manage such a patient, therefore one needs to be well prepared. There is a spectrum of altered consciousness, brain death being the most extreme. ⋯ A multidisciplinary approach would be prudent. The intermediate and long-term management should also involve the family. The issues of perimortem and somatic support for foetal maturity are also discussed.
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Best Pract Res Clin Obstet Gynaecol · Jun 2009
Severe acute maternal morbidity in high-income countries.
Maternal mortality in high income countries has become low in recent years and therefore analysis of severe acute maternal morbidity has been added to confidential enquiries into the causes of maternal deaths. The major drawback at the moment is the lack of universal definitions of severe acute maternal morbidity. ⋯ Audit is the instrument to analyse whether substandard care factors are present. Guidelines and protocols to provide obstetric critical care may be improved from audit findings and skills and drills training put in place.