Be ready the basics are changing !!!
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Transcript of Be ready the basics are changing !!!
Be ready !!!The basics are changing
Dr/ Mahmoud Abdel-AleemAssistant Professor of Obstetrics and
Gynecology
• Human mind is always scrutinizing and searching for new information.
• Science is always changing and evolving.– Meticulous research is being done.– More new types of research.– Better assessment methods.
What do we need to discuss?
Major changes in our basic practice involving common day-to day problems
• For guidelines developers: adopt the recent change to be up-to-date.
• For academics: lecture preparation• For specialists: application and standardization of
new knowledge and practice.• For postgraduate students: preparation for an exam• For undergraduate students: preparation for an
exam• For researchers: for conducting and publishing
research.
Selected Hot Topics• Pregnancy:
– Pre-eclampsia.– Diabetes mellitus during pregnancy.
• Normal labour– First stage.– Second stage.– Third stage.
• Venous Thromboembolism during pregnancy and labour.
• Gynecology: Abnormal uterine bleeding.
Common.Practical.
Recent Major changes.
Why important?
Increasing incidence
Contribution to
prematurity
Less than optimal care
Contribution to near-miss
cases
Contribution to maternal
mortality
• ACOG Task Force on Hypertension in Pregnancy.• A 99-page report. • Published on November 2013.• Inclusive of the diagnosis and management of
preeclampsia.• Culmination of two years of hard work by
the 16-member ACOG task force.
Classification
• Pre-eclampsia / Eclampsia• Chronic HT.• Chronic HT with superimposed PE.• Gestational HT.
A changing paradigm !!!
• The problem is that many patients with preeclampsia don't have enough proteinuria to meet the former criteria, so their diagnosis and treatment are delayed.
Starting by definitionNow Was
No longer requires the detection of proteinuria.
Persistent HT that develops during pregnancy or during the postpartum period that is associated with:Proteinuria
ORNew development of thrombocytopenia.hepatic or renal dysfunction.Pulmonary edema.Signs of brain trouble such as seizures and/or visual disturbances.
Hypertension
Plus
Proteinuria
Next: typesNow Was
PreeclampsiaPreeclampsia with severe features.
Mildsevere
Preeclampsia is a dynamic disease:We don’t know
When or at Which rate
or in Whom it will change from mild to severe
Hypertension
• As it is; no change• 140/90 mmHg or more on 2 readings 6 hours
apart at bed rest unless anti-HT drugs were given.
• 160/110 mmHg or more on single reading at bed rest unless anti-HT drugs were given.
Proteinuria
• Proteinuria: 300 mg/protein in a 24-hr urine collection.
• A protein/creatinine 0.3
• Dipstick is not recommended because of wide variability. It is only to be used if other methods aren’t available. Proteinuria 1+ = diagnosis.
• Massive proteinuria > 5gm. Not to be used.
Protein dipstick grading
DesignationApprox. amount
Concentration[6] Daily[7]
Trace 5–20 mg/dL
1+ 30 mg/dL Less than 0.5 g/day
2+ 100 mg/dL 0.5–1 g/day
3+ 300 mg/dL 1–2 g/day
4+ More than 300 mg/dL More than 2 g/day
Then: treatmentNow Was Prophylactic magnesium sulphate is used in:BP 160/110 or more.BP 140/90-159/109 PLUS symptoms.
Prophylactic Magnesium sulphate was used in Severe PE with symptoms
Termination is at:37 weeks: no severe features34 weeks: associated severe features
Termination is at:38 weeks: mild cases34 weeks: severe cases
Last of All: Prevention of PE
• Vitamin C: no role• Vitamin E: no role.• Calcium:– Normal takers: no role.– Low takers: reduces the severity of PE.
• Aspirin: 60-80 mg/day.– Low risk: no value– High risk: slight decrease in PE and adverse
perinatal outcome.
Take home message
• Don’t wait proteinuria to diagnose PE. • On diagnosis of new onset HT: do platelet
count, liver enzymes, serum creatinine, ask for visual symptoms.
• There is no method to predict, to prevent PE. The only way to help women is early diagnosis and early treatment.
• Use low dose aspirin only in high risk women.
Why important?
High incidence
Contribution to anemia
Lowering the effective
woman load weight in society
Contribution to increasing
surgical interventions
Contribution to low
quality of life
• The Federation Internationale de Gynecologie et d’Obstetrique (FIGO)
• Date: November 2010.• The causes of AUB in the reproductive years. • A collaborative, international group consisting
of reproductive clinicians, haematologists, basic scientists.
• The group had representation from six continents
Definitions adopted
• Acute AUB: an episode of bleeding in a woman of reproductive age, who is not pregnant, that is of sufficient quantity to require immediate intervention to prevent further blood loss.
• Chronic AUB: bleeding from the uterus that is abnormal in frequency, duration and/or volume and has been present for the majority of the previous six months.
• Inter-menstrual bleeding (IMB): bleeding between clearly defined cyclic and predictable menses and includes random episodes as well as predictable episodes occurring at the same time each month.
Take home message II
• The PALM-COEIN system is readily applicable.
• Let us try to use the new classification system for abnormal uterine bleeding as regards the norms, definitions, classification.
Do we have to follow the changes ?
• We should be in accordance with changes as the scientific society is now “A small village”.
• Although the changes may look both few and little, they are of great value in defining, standardizing, diagnosing and treating diseases.
• We were already following older recommendations, and once they change, we have to apply the changes especially if these are simple and not sophisticated.