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  SPECIFICATION
SEVERE ACUTE MATERNAL MORBIDITY (pb)2011
Author: ARULMOZHI RAMARAJAN
ISBN: 9789350254820
Year: 2011
Publisher: JAYPEE BROTHERS MEDICAL PUBLISHERS PVT LTD.
Category: OBSTETRICS & GYNAECOLOGY
Edition: 1
Format: Paperback
Language: English
Pages: 215
 ABOUT THE TITLE
Nothing hurts more than seeing healthy and happy women suffer or die because of pregnancy related complications that are so very preventable. Nothing brings more satisfaction than saving a mother from such complication. This book is all about the complications of pregnancy that every student and practitioners of obstetrics has seen and known the purpose of this book is to provide a quick and comprehensive what to do, how to go about guidance to the reader who is looking for answers to specific questions in specific situations.

by: Arulmozhi Ramarajan
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 TABLE OF CONTENTS
PART I: ISSUES IN THE MANAGEMENT OF NEAR MISS IN OBSTETRICS
1. An Introduction to Near Miss in Obstetrics 3
PK Sekharan
Defi nitions 4
Methods of Identifying Severe Maternal Morbidity 4
Clinical Criteria Related to a Specifi c Disease Entity 4
Mortality Index 6
2. Essential Obstetric Care 9
Latha Venkataram, Anbukkani Subbian
Essential Obstetric Care 9
Level Source of Evidence 16
3. Sociocultural and Economic Issues in SAMM 19
Arulmozhi Ramarajan
Case Scenario 19
Too Soon to Marry, Too Soon to Carry 20
Unwed Mothers 20
Sex Selective Abortions 20
Mistrust and Minimal Use of Family Planning Services 21
Poverty and Low Social Class 21
Ill Health and Infections 21
Infl uence of Sociocultural Matt ers on Maternal Health 22
Case Scenario 22
Steps Towards Safer Motherhood 24
The National Rural Health Mission 25
4 Critical Care in Obstetrics 29
Pankaj Desai, Shobhana Mohandas
Identify the Patient Requiring Critical Care 29
Principles of Management 30
Clinical Monitoring 30
Mental Status 30
Heart Rate 30
Blood Pressure 30
Respiration 30
Urine Output 30
Electronic Monitoring and Invasive Hemodynamic Monitoring 30
xxiv Severe Acute Maternal Morbidity
Blood Investigations 31
Respiratory Support in the Critically Ill 32
Hemorrhagic Shock 33
Septic Shock 34
Pre-Eclamptic Toxemia 35
5. The Obstetric High-Dependency Unit (HDU) 37
Arulmozhi Ramarajan
Levels of Care and the Concept of High-Dependency Unit 37
Standard Maternity Ward 37
Intensive Care Unit 37
Obstetric High-Dependency Unit 38
Message 40
6. Audit in Obstetric Near-Miss Situations 41
Arulmozhi Ramarajan
What is Audit? 41
What is Clinical Audit? 41
Clinical Audit in Obstetric Near-Miss Situations 41
Stage 1: Identifying the Problem or Issue 42
Stage 2: Sett ing Criteria and Standards 42
Stage 3: Observing Practice and Data Collection 42
Stage 4: Comparing Performance with Criteria and Standards 42
Stage 5: Implementing Change 43
Who Should Conduct Clinical Audits? 43
7. Communication in Near-Miss Situations 45
Susheela Rani BS
Communication 45
Communication in an Emergency 46
Communication—Who and How? 47
Communication—Clear and Complete 47
Communication—Clear, Complete and Writt en Legibly 48
Communication that is Best Avoided 48
Communication within the Team 48
Communication with the Referring Doctor 48
Communication when Referring a Patient 49
8. Medicolegal Issues and Litigation in Obstetric Morbidities 51
Arulmozhi Ramarajan, Sunitha
Medicolegal Issues 51
Perspective of the Judicial Authorities 51
The Informed Consent 52
Legal Redress 52
An Aff ected Party can Seek Legal Redress through Three Routes 52
Maternal Morbidity Related Litigations 52
How to Avoid Medicolegal Problems? 53
PART II: OBSTETRIC HEMORRHAGE
9. Antepartum Hemorrhage 57
Arulmozhi Ramarajan, Susheela Rani BS
Placenta Previa 57
Early Diagnosis and Expectant Management 57
During Expectant Management 59
Vaginal Delivery 60
Cesarean Section 60
Abruptio Placentae 62
Key Points in APH 64
Advice 64
10. Postpartum Hemorrhage 65
Sheela V Mane, Arulmozhi Ramarajan
Practical Issues in Postpartum Hemorrhage 65
Predisposing Factors and Causes 66
Management of Postpartum Hemorrhage 66
Begin Basic Monitoring and Support 66
Att empt a Quick Assessment on the Cause of Hemorrhage 66
Replace Lost Blood Volume 67
Start Blood Transfusion at the Earliest, to Prevent Dilutional Coagulopathy or ‘Washout Phenomenon’ 67
Clinical Assessment of Blood Loss 68
Prevention of Postpartum Hemorrhage at Vaginal Delivery 69
Active Management of the Third Stage of Labor (AMTSL) 69
Systematic Review of Eff ects of AMTSL Components 70
Prevention of Postpartum Hemorrhage at Cesarean Delivery 71
Management of Postpartum Hemorrhage at Vaginal Delivery 71
Uterotonics 71
How to Do Condom Tamponade? 71
How to Do Bimanual Compression of the Uterus? 72
How to Give Aortic Compression? 72
Management of Postpartum Hemorrhage at Cesarean Delivery 73
Newer Developments in the Management of Postpartum Hemorrhage 73
PPH: Key Recommendations 75
Further Measures to Prevent Postpartum Hemorrhage 76
11. Case Scenarios in Postpartum Hemorrhage 79
Arulmozhi Ramarajan, Sheela V Mane
Case 1. Atonic Postpartum Hemorrhage Following Normal Delivery 79
Case 2. Traumatic Postpartum Hemorrhage from an Episiotomy 80
Case 3. PPH Following Repeat LSCS: Inferior Epigastric Vessel Rupture 80
Case 4. Postpartum Hemorrhage in Placenta Previa—Obstetric Hysterectomy 81
Case 5. Atonic Postpartum Hemorrhage in Twin Gestation: Condom Tamponade 82
Case 6. Placenta Previa—Postpartum Hemorrhage on Table 83
Case 7. A Case of Disseminated Intravascular Coagulation 84
Case 8. Massive Hemorrhage during Lower Segment Cesarean Section 84
12. Serious Hazards of Transfusion 87
C Shivaram
Incorrect Blood Component Transfusion 88
Acute Transfusion Reactions 88
Delayed Transfusion Reactions 89
Post-Transfusion Purpura 89
Transfusion-Related Acute Lung Injury (TRALI) 90
Etiology of TRALI 90
Diagnosis of TRALI 90
Post-Transfusion GVHD 91
PART III: HYPERTENSION AND ECLAMPSIA
13. Complications of Severe Pre-eclampsia 97
Prakash K Mehta
Systemic Derangements 97
1. Cardiovascular 97
2. Hematologic 98
3. Renal 98
4. Hepatic 98
5. Central Nervous System 98
Complications 98
Eclampsia 98
HELLP Syndrome 98
Hematological Complications 98
Hepatic Complications 99
Antepartum Hemorrhage 100
Cardiovascular Dysfunction 100
Pulmonary Problems 101
Neurological Complications 102
Renal Complications 105
Gastrointestinal Complications 107
Musculoskeletal Complications 107
Fetal Complications 107
Mortality/Morbidity 107
Complications due to Drugs 108
Long Term Eff ects 108
Prevention of Complications 109
14. Case Situations in Pregnancy-Induced Hypertension (PIH) 111
Prakash K Mehta
Case 1. Eclampsia in All its Floridity 111
Case 2. Multiple Complications—Eclampsia/HELLP/DIC/Oliguria/PRES/Pancreatitis 112
15. Eclampsia 115
Gomathy Narayanan
A Case of Eclampsia 115
Investigations 115
Discussion 116
Prevention and Treatment of Convulsions with Magsulf 117
Magnesium Toxicity .117
Commonly Used Antihypertensive Drugs in Severe Pre-Eclampsia and Eclampsia 117
Maternal Complications 117
16. The Eclampsia Drill 119
BSOG RCOG Workgroup
Aims 119
Severe Pre-eclampsia/Imminent Eclampsia 119
Management of Eclampsia 119
Eclampsia Kit 119
Further Management of Eclampsia 119
Anticonvulsants 119
Investigations 120
Fluid Management 121
Delivery 121
Shift ing to Tertiary Care Center 121
PART IV: SEPSIS
17. Sepsis in Relation to Abortions 127
Susheela Rani BS
The Providers 128
The Procedure 128
Septic Abortion 128
Uncomplicated Sepsis 128
Severe Sepsis 129
Multiple Organ Dysfunction Syndrome 129
Septic Shock 129
Diagnosis 129
Antimicrobial Treatment 130
Indications for Surgery 130
Surgical Management of Septic Abortion 130
Supportive Care 131
Prevention of Septic Abortion 131
Advantages of Medical Method of Abortion 132
Strategies to Reduce Unsafe Abortions 133
18. Puerperal Sepsis 135
Shobha N Gudi
Puerperal Sepsis 135
Incidence 135
Predisposing Factors 135
Bacteriology 136
Pathogenesis 136
Clinical Presentation 136
Diff erential Diagnosis of Puerperal Fever 137
Investigations 137
Treatment 137
Management of Puerperal Septic Shock 138
Complications of Puerperal and Postabortal Sepsis 138
Septic Pelvic Thrombophlebitis 139
Toxic Shock Syndrome 139
Tetanus 139
Prevention of Infection 139
Prevention during Cesarean Section 140
Other Factors in Sepsis 140
PART V: OBSTRUCTED LABOR
19. Dysfunctional Labor 143
Arulmozhi Ramarajan
Common Causes of Dysfunctional Labor 145
Use of Oxytocin 146
Case Situations of Dysfunctional Labor 147
Case 1. Prolonged Labor, CPD 147
Case 2. Rupture Uterus in Trial of Labor aft er Cesarean (TOLAC) 148
Case 3: Shoulder Dystocia 149
Case 4. Undiagnosed Breech 150
Case 5: Instrumental Delivery 150
Practice Recommendations .151
20. Obstetric Drills 153
BSOG RCOG Workgroup
The Partogram 153
Details are Recorded on the Partogram 153
Purpose of the Partogram 155
Forceps and Ventouse 156
Shoulder Dystocia 156
Risk Factors 156
Management 157
Vaginal Breech Delivery 158
Prerequisites for Att empting Vaginal Breech Delivery 158
Situations where Breech Delivery should not be Att empted 158
21. Rupture of the Uterus 161
Narayanan R
Etiology 161
Classifi cation 161
Incidence 161
Clinical Presentation 162
Diff erential Diagnosis 163
Site of Rupture 163
Complications 163
Mortality 163
Case Scenarios 163
Case 1 163
Case 2 164
22. Cesarean Section 167
Jaya Narendra
Causes for SAMM in Cesarean Section 167
Causes for Severe Bleeding .168
Case History 1 168
Placenta Previa and Abnormal Placental Invasion (API) 168
Cesarean Delivery of a Very Preterm Fetus 174
Case History 2 175
Case History 3 175
Case History 4 178
Cesarean Hysterectomy 179
Common Indications for Emergency Hysterectomy 179
Surgical Considerations and Technique 179
A Total or Subtotal Hysterectomy 179
PART VI: BOLT FROM THE BLUE
23. Amniotic Fluid Embolism 185
RK Saxena, GS Sandhu
Pathophysiology 185
Clinical Presentation 186
Case 1 186
Case 2 187
Clinical Indicators of Severe Acute Maternal Morbidity 190
Diff erential Diagnosis 190
Key Investigations 190
Treatment 190
24. Thromboembolism in Pregnancy 197
Prathima Reddy
Case 1 197
Case 2 198
Pathophysiology 198
Incidence 198
Sequelae 199
Risk Factors 199
Prevention 199
Clinical Features 200
Diagnosis 200
Management 201
25. Anesthetic Near-Misses in Obstetrics 205
Sunitha
Challenges 205
Common Obstetric Presentations 206
Obstetric Anesthesia Cases 206
Case 1: Emergency Lower Segment Cesarean Section 206
Case 2: Traumatic Postpartum Hemorrhage on Table 207
Case 3: Supine Hypotension Syndrome 207
Case 4: Cardiac Arrest following Subarachnoid Block 207
Case 5: Amniotic Fluid Embolism at Cesarean Section 208
Labor Analgesia (LA) 210
Case 6: Labor Analgesia—Post-dural Puncture Headache 211
General Anesthesia 211
Index 213
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