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12 - Post partum hemorrhage: Prevention, diagnosis, and management
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- By William F. Baker, Jr., M.D., F.A.C.P., Associate Clinical Professor of Medicine Center for Health Sciences, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA, USA, Thrombosis, Hemostasis and Special Hematology, Clinic, Kern Medical Center, Bakersfield, California, Joseph Mansour, M.D., Associate Professor Department of Obstetrics and Gynecology, Kern Medical Center, Bakersfield, California, USA, Arthur Fontaine, M.D., Chairman of Radiology, Mercy Hospital, Bakersfield, California, USA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
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- 20 April 2006, pp 361-441
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Summary
Introduction
Although childbirth is a wonderful and enjoyable experience by most, it still is an anatomically traumatic event, associated with tissue injury, vascular disruption and the potential for blood loss. All deliveries are accompanied by physiologic hemorrhage from the genital tract, and the abdominal soft tissue in cesarean section (Table 12.1). Post partum hemorrhage (PPH) is an obstetrical complication, which can transform a normal physiologic process of labor and delivery into a life-threatening emergency within minutes. A routine cesarean section can be complicated by massive hemorrhage. The healthy mother may quickly become a patient in the critical care unit, requiring all of the available skill and resources of physicians, nurses, the medical laboratory and the blood bank for survival. A thorough knowledge of the risk factors, preventive strategies, approach to diagnosis and management of PPH are required to properly care for women presenting for delivery. Once PPH is diagnosed, hospital facilities and/or referral centers, laboratories and blood banks must be readily available to provide the optimal chance for a successful outcome. The availability of blood replacement and modern critical care are major determinants of survival in women who develop post partum hemorrhagic shock. Mortality from PPH is strongly correlated with substandard care. Clearly, it is the problem of PPH that most vividly illustrates the difference, worldwide, between management of the puerperium in developed countries from that in underdeveloped countries.
7 - Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy
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- By William F. Baker, Jr., M.D., F.A.C.P.,, Associate Clinical Professor of Medicine Center for Health Sciences, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA, USA Thrombosis, Hemostasis, and Special Hematology Clinic, Kern Medical Center, Bakersfield, Eugene P. Frenkel, M.D., F.A.C.P.,, Professor of Medicine and Radiology Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas, USA, Rodger L. Bick, M.D., Ph.D., F.A.C.P., Clinical Professor of Medicine and Pathology, University of Texas Southwestern Medical Medical Center, Director: Dallas Thrombosis Hemostasis and Vascular Medicine Clinical Center, Dallas, Texas, USA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
- Print publication:
- 20 April 2006, pp 222-249
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Summary
Venous thromboembolism (VTE) represents a major cause of morbidity and mortality during pregnancy, complicating from 0.5 to 3.0 of every 1000 pregnancies. Pulmonary embolism (PE) has been the leading cause of maternal mortality in the United States and Great Britain for at least 20 years and complicates approximately 1 in 1,000 pregnancies. This represents a VTE risk of 3–4 times greater than age-matched non-pregnant controls. Diagnosing venous thromboembolism is challenging because clinical findings are often misleading. When evaluated with objective testing, as many as 75% of patients suspected of having venous thromboembolism are found to have an alternative diagnosis. This poses an even greater problem in the pregnant patient who experiences vasodilatation and intravascular volume expansion (20–25% increase) with associated lower extremity edema. The accuracy of many diagnostic tests used in the non-pregnant patient are either not useful at all or are potentially misleading. Diagnosis of VTE is critical since 24% of pregnant women with untreated deep vein thrombosis (DVT) develop PE, with a death rate of 15% to 30%. Proper diagnosis and treatment reduces the mortality rate of PE to 1%–3%. In addition, postphlebitic syndrome in the affected leg occurs nearly 80% of the time following DVT in pregnancy, compared to 30–40% in the non-pregnant patient. Although it is well recognized that the incidence of PE is greatly reduced with treatment for deep vein thrombosis (DVT), treatment is also problematic since anticoagulation regimens used in the non-pregnant patient may be highly teratogenic or in other ways hazardous to mother and/or fetus.
9 - Iron deficiency, folate, and vitamin B12 deficiency in pregnancy, obstetrics, and gynecology
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- By William F. Baker, Jr., M.D., F.A.C.P., Associate Clinical Professor of Medicine Center for Health Sciences, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA, USA Thrombosis, Hemostasis and Special Hematology Clinic, Kern Medical Center, Bakersfield, California, USA, Ray Lee, M.D., Associate Professor of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, Texas, USA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
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- 20 April 2006, pp 269-309
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Summary
Anemia is the single most common hematological problem faced by women. The most common anemia are iron deficiency anemia and folate deficiency megaloblastic anemia. Iron deficiency alone affects nearly 20% of the world's population. Approximately 51% of pregnant women are anemic. This includes a prevalence of 56% in developing countries and 18% in developed countries. Among these, 43% of women from developing countries and 12% of women from developed countries were already anemic, preconception. The WHO has estimated that considering all forms of anemia, from 16,800 to 28,000 women of reproductive age die annually from anemia, with the greatest risk in younger women. Of all anemias diagnosed during pregnancy, 75% are due to iron deficiency.
The systemic effects of anemia of any cause may result in significant morbidity. Deficiencies of iron, folate and vitamin B12 result in unique clinical consequences. These are manifested throughout life. The underlying etiologies of each deficiency state may be somewhat different pre-puberty, during the child bearing years and post menopause. During pregnancy, the adverse effects of iron, folate and vitamin B12 deficiency extend beyond the health of the mother to the developing fetus. This chapter is divided into two sections. The first reviews the most common type of anemia, iron deficiency. The second section examines the deficiencies of folate and vitamin B12. Because of the close interrelationship between folate, vitamin B12 and homocysteine in the methionine synthesis pathway, hyperhomocysteinemia is also discussed.
5 - Hereditary and acquired thrombophilia in pregnancy
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- By Rodger L. Bick, M.D., Ph.D., F.A.C.P., Professor of Medicine and Pathology, University of Texas Southwestern Medical Center; Director: Dallas Thrombosis Clinical Center, Dallas, Texas; Director: Pacific Thrombosis Clinical Center, Southern California, USA, William F. Baker, Jr., M.D., F.A.C.P., Associate Clinical Professor of Medicine, Center for Health Sciences, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA, USA, Thrombosis, Hemostasis, and Special Hematology Clinic, Kern Medical Center, Bakersfield; California Clinical Thrombosis Center, Bakersfield, California, USA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
- Print publication:
- 20 April 2006, pp 122-199
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Summary
Introduction
Thrombophilia in pregnancy represents a challenging problem for obstetricians, reproductive medicine specialists and hematologists. Normal pregnancy is known to be associated with an enhanced risk of deep vein thrombosis (DVT) and pulmonary embolus (PE). When combined with a thrombophilic disorder, this risk is significantly enhanced, usually considered to about 5–8-fold elevated in normal pregnant women, and addition of a thrombophilia, or other clinically significant risk factor, requires particular attention to avoid unnecessary fetal loss and maternal morbidity and mortality. Thrombophilia in obstetrics and pregnancy is known to be associated with not only enhanced risks of DVT and PE, but also recurrent miscarriage syndrome, infertility, stillborn births, eclampsia intrauterine growth retardation, pre-eclampsia, frank eclampsia, HELLP syndrome and abruption, with the additional usual thrombohemorrhagic complications, such as disseminated intravascular coagulation. Indeed many women with undiagnosed thrombophilia will experience their first clinical manifestation when pregnant – usually miscarriage or DVT with or without PE. In addition, many pregnancy patients who have had a prior DVT/PE harbor an undiagnosed thrombophilic disorder, thus emphasizing the importance of adequate investigation when a suggestive personal or family history warrants. This chapter summarizes (1) antithrombotic approaches to pregnant women with thrombophilia and other risk factors, and (2) the particular thrombophilias of concern to the obstetrician, reproductive medicine specialist and hematologist. In addition, treatment discussions and recommendations will be discussed in general and then, when necessary, for any particular disorder. It must be appreciated the clinical course of thrombophilic patients, particularly during pregnancy, is highly dynamic.