Best practice & research. Clinical obstetrics & gynaecology
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Healthy pregnancy is accompanied by changes in the haemostatic system which convert it into a hypercoagulable state vulnerable to a spectrum of disorders ranging from venous thromboembolism to disseminated intravascular coagulation (DIC). This latter is always a secondary phenomenon triggered by specific disorders such as abruptio placentae and amniotic fluid embolism due to release of thromboplastin intravascularly or endothelial damage resulting from pre-eclampsia and sepsis. In modern obstetric practice the most common cause is haemorrhagic shock with delay in resuscitation leading to endothelial damage. ⋯ Low-grade DIC, associated with pre-eclampsia, is monitored haematologically by serial platelet counts and serum fibrin degradation products (FDPs). Supportive measures and removal of the triggering mechanism are the key to successful management. Outcome depends primarily on our ability to deal with the trigger and not on direct attempts to correct the coagulation deficit.
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Best Pract Res Clin Obstet Gynaecol · Aug 2001
ReviewAnaesthesia and analgesia for the critically ill parturient.
Anaesthetic and analgesic techniques in the critically ill are determined largely by the nature of the presenting illness. The commonest conditions likely to present as life-threatening emergencies are pre-eclampsia, obstetric haemorrhage, cardiac disease and severe sepsis. Issues dictating choice of anaesthetic technique are the patient's ability to maintain her airway, coagulation status, intravascular volume and haemodynamic dependence upon sympathetic drive, and requirements for ventilatory support and intensive care. ⋯ Maternal survival takes priority, however, and occasionally general anaesthetic techniques must be used which lead to neonatal respiratory depression and requirement for ventilatory support. Anaesthesia itself is associated with known hazards. The risks of each technique must be balanced against possible benefits in the context of the presenting illness.
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Best Pract Res Clin Obstet Gynaecol · Jun 2001
ReviewSurgery for endometrial cancer: what type and by whom?
Endometrial cancer has far too long been regarded as a simple disease to treat. As such it has generally remained in the hands of the generalist obstetrician/gynaecologist. ⋯ However, consideration should be given to pelvic lymphadenectomy in high-risk cases. Surgery for high-risk endometrial cancer should be performed by gynaecological oncologists.
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Best Pract Res Clin Obstet Gynaecol · Apr 2001
Review Case ReportsGuidelines for an acceptable euthanasia procedure.
The Netherlands is one of the very few countries that has guidelines for the practice of euthanasia. Each year there are about 9700 explicit requests for euthanasia or physician-assisted suicide (EAS), of which approximately 3600 patients are agreed upon in The Netherlands. Other countries have criticized the Dutch policy concerning EAS. ⋯ Additionally, part of the criticism is based on the regulation of the euthanasia procedure in The Netherlands. This chapter describes the guidelines for the procedure for euthanasia in The Netherlands, and focuses on some of the practical problems and issues of euthanasia. Also, the current situation concerning euthanasia and physician-assisted suicide in The Netherlands is summarized and described.
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Gynaecological malignancies affect the respiratory system both directly and indirectly. Malignant pleural effusion is a poor prognostic factor: management options include repeated thoracentesis, chemical pleurodesis, symptomatic relief of dyspnoea with oxygen and morphine, and external drainage. Parenchymal metastases are typically multifocal and respond to chemotherapy, with a limited role for pulmonary metastatectomy. ⋯ Identification and treatment of gastroesophageal reflux, sinusitis, and asthma can improve many patients' coughs. Chest wall pain responds to local radiotherapy, nerve blocks or systemic analgesia. Case examples illustrate ways to address quality of life issues.