Best practice & research. Clinical obstetrics & gynaecology
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Hypertensive disorders of pregnancy are one of the leading causes of peripartum morbidity and mortality globally. Hypertensive disease in pregnancy is associated with a spectrum of severity, ranging from mild pregnancy-induced hypertension to eclampsia. Although most cases of pre-eclampsia may be managed successfully, severe pre-eclampsia is a life-threatening multisystem disease associated with eclampsia, HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome, acute kidney injury, pulmonary oedema, placental abruption and intrauterine foetal death. ⋯ In addition to anti-hypertensive agents, close attention should be given to regular clinical examination, assessment of fluid balance, neurologic status and monitoring of other vital signs. Magnesium sulphate should be considered early to prevent seizures. Delivery of the baby is the definitive management of severe pre-eclampsia.
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Best Pract Res Clin Obstet Gynaecol · Dec 2013
ReviewProvision of critical care services for the obstetric population.
Management of the peripartum patient is a challenging aspect of critical care that requires consideration of both the physiological changes associated with pregnancy as well as the well-being of the foetus. In the UK, for every maternal death, approximately 118 near-miss events or severe acute maternal morbidities (SAMMs) occur. While a dedicated anaesthetic cover is usually provided on larger labour wards in the UK and US, a close communication with intensive care and other medical specialties must still be maintained. ⋯ The countries with the highest maternal mortality rates have the lowest number of ICU beds per capita. In under-resourced countries, patients admitted to ICUs tend to have higher illness severity scores, suggesting delayed admission to the ICU. The appropriate training of midwives is essential for successful HDUs located within labour wards.
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Best Pract Res Clin Obstet Gynaecol · Oct 2013
Surgery in elderly people: preoperative, operative and postoperative care to assist healing.
Surgery for elderly women is likely to increase steadily as the population of elderly people increases globally. Although increasing age increases perioperative morbidity and mortality, the functional age and physiologic reserve rather than chronological age is more important in preventing complications. Preparation for surgery, with special attention to functional capacity and activity, mental status, and existing comorbid conditions, can improve outcomes. ⋯ Of particular note is the enhanced effect of narcotic medications in elderly people, which affects intraoperative and postoperative management of pain. Prevention of postoperative delirium is accomplished through preoperative and postoperative planning. Discharge planning, particularly for frail elderly people, must start before surgery.
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Best Pract Res Clin Obstet Gynaecol · Aug 2013
ReviewReducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies.
Poor teamwork results in preventable morbidity and mortality for mothers and babies. Suboptimal communication and lack of leadership cost not only lives but also money that is diverted from clinical care to insurance and litigation. ⋯ Recent research has identified the problems and solutions, including the best way to train maternity teams to make a palpable difference. We describe simple yet evidence-based methods to improve teams and leaders.
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Sepsis is a major cause of maternal mortality and morbidity worldwide. In the UK, sepsis is now the leading cause of direct maternal deaths. ⋯ The challenge in the management of maternal sepsis is the translation of the vast knowledge gained from sequential confidential enquiries into maternal death and research findings, into clinical practice, to ensure an improvement in patient quality of care and maternal mortality and morbidity. In this chapter, I give an overview of the management of the risks of sepsis, and discuss implementation strategies that may reduce these risks.