Prevention and treatment of postpartum haemorrhage

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Click to edit Master title style<= /div>

Click to edit Master subtitle sty= le

05_XXX_MM‹#›&= #13;

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------=_NextPart_01C64D48.46DA3F10 Content-Location: file:///C:/F009C636/Postpartum_haemorrhage_Gulmezoglu_2006_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C64D48.46DA3F10 Content-Location: file:///C:/F009C636/Postpartum_haemorrhage_Gulmezoglu_2006_files/slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Prevention and treatment of postpartum haemorrhage - A. Metin Gülmez= oglu

05_XXX_MM1

Preven= tion and treatment of postpartum haemo= rrhage

A. Metin Gülmezoglu

UNDP/UNFPA/WHO/World Bank Special Pro= gramme of Resea= rch, Development and Research Training in Human Reproduction, Geneva, Switzerland = ;

Training in Reproductive Health Research
Geneva 2006=

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Africa

Asia

Latin America &= ; = The C= aribbean

Developed <= /span>Count= ries

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Metin Gülmez= oglu

05_XXX_MM3

PPH (controlled trials - bleeding >500 ml)

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Metin Gülmez= oglu

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Strategi= es to reduce postpartum blood loss=

Active management

–which uterotonic? <= /div>

Restrictive episiotomy

Retained placenta management

–

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What is active management?

Early cord clamping

Uterotonic&= #13;

Controlled = cord traction

<= span style=3D'visibility:hidden'> 3D"*"

Uterine massage

Variations = of each of the components common=

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Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Prevention and treatment of postpartum haemorrhage - A. Metin Gülmez= oglu

Oxytocin vs. syntometrine

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Metin Gülmez= oglu

05_XXX_MM3

Primary outcomes<= /span>

Secondary outcomes

–Measured blood loss ³ 500 mls.

–Blood transfusion <= /div>

–Manual removal of the placenta

–Late haemorrhage (after 1st hour) = ;

–Treatments for severe haemorrhage (hysterectomy, bimanual compression, = etc.)=

•= Measured blood l= oss ³ 1000 mls.

•= Additional utero= tonic

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05_XXX_MM3

Primary outcomes
Relative Risk=

* n=3D9214

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Misoprostol vs conventional injectable uterotonics

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Metin Gülmez= oglu

Misoprostol vs placebo

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Metin Gülmez= oglu

Umbilical vein injection for retained placenta

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Metin Gülmez= oglu

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Summary

= Active management reduces blood loss&= #13;

= Choice between oxytocin (10IU) and syntometrine involves trade-offs =

= Routine episiotomy should be abandone= d

= Retained placenta should be managed <= /span>actively

–Oxytocin +saline infusion is likely to reduce the likelihood of manual removal of the placenta

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Managem= ent of postpartum haemorrhage

Essential components

–treat shock

–ascertain the origin of bleeding and = treat accordingly

control lower tract bleeding

ensure uterine contraction

remove placenta

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Nonsurgical emerg= ency measures

= Uterine massage

= Uterotonics

–ergometrine IV, oxytocin infusion (20-40 IU)

–PGF2alpha IM or intramyometrial, intrauterine gemeprost pessaries

–misoprostol

= Compression of aorta against the sacr= al promontory

= Bimanual uterine compression

= Stretching the uterine arteries by el= evating the uterus

= Intrauterine balloon, condom

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Intrauterine pressure

–Packing

–Sengstaken-Blakemore tube

–Foley catheter with a large bulb

–Silicone water-filled balloon

Uterine artery embolization

Nonsurgical emerg= ency measures

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Misoprostol

3 trials (t= wo in S.Africa, one in The Gambia) 3D"*"

Promising but the effects on substantive outcomes unclear

<= span style=3D'visibility:hidden'> 3D"*"

<= span style=3D'visibility:hidden'> 3D"*"

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05_XXX_MM3

The effect of misoprosto= l on measured blood loss of 500 ml or more after enrolment

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Metin Gülmez= oglu

05_XXX_MM3

Misoprostol for R= x of PPH: Methods:

<= span lang=3DEN-GB style=3D'font-size:75%'>East London Hospital Complex, Tembisa= and Chris Hani Bara= gwanath Hospitals

= Routine active management of the thir= d stage

= Women with more than usual postpartum bleeding invi= ted to participate, and to sign informed consent

= All routine treatment given from a sp= ecial ‘Postpartum Haemorrhage Trolley’

= In addition, drew the next in a serie= s of randomised tre= atment packs containing either misoprostol 5 X 200mg or identical looking placebo

= Given 1 orally, 2 sublingually and 2 rectally.

------=_NextPart_01C64D48.46DA3F10 Content-Location: file:///C:/F009C636/Postpartum_haemorrhage_Gulmezoglu_2006_files/master24_image036.png Content-Transfer-Encoding: base64 Content-Type: image/png iVBORw0KGgoAAAANSUhEUgAAAA8AAABUAQMAAABnUf89AAAAAXNSR0ICQMB9xQAAAAZQTFRFAAAA AABmAbZ9ogAAAAF0Uk5TAEDm2GYAAAAJcEhZcwAACDYAAAg0Ab6QHjwAAAAZdEVYdFNvZnR3YXJl AE1pY3Jvc29mdCBPZmZpY2V/7TVxAAAAKElEQVQY02NgGGSAiYGBjYGBFcwGMhgZGNgx2HDADlOJ yYCw4QgbAAAZ5gBqq+VzAQAAAABJRU5ErkJggk== ------=_NextPart_01C64D48.46DA3F10 Content-Location: file:///C:/F009C636/Postpartum_haemorrhage_Gulmezoglu_2006_files/slide0033.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Prevention and treatment of postpartum haemorrhage - A. Metin Gülmez= oglu

05_XXX_MM3

Results: Misoprostol vs placebo

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Metin Gülmez= oglu

05_XXX_MM3

Review: all misoprostol in 3rd stage trials with = maternal deaths

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FdpYADg7SRn046VoUUUAFFFFABRRRQAUUUUAFFFFABRRRQAUUUUAFFFFABRRRQAUUUUAFFFFABRR RQAUUUUAf//Z ------=_NextPart_01C64D48.46DA3F10 Content-Location: file:///C:/F009C636/Postpartum_haemorrhage_Gulmezoglu_2006_files/slide0020.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Prevention and treatment of postpartum haemorrhage - A. Metin Gülmez= oglu

05_XXX_MM3

Surgical measures=

Exploration under g/a

<= span style=3D'font-size:88%'> 3D"*"

Removal of retained products of conception

Internal iliac artery ligation

Stepwise uterine and ovarian artery ligation

Vaginal uterine artery ligation <= /span>

Uterine repair or hysterectomy

Full-thickness uterine suture<= /span>

------=_NextPart_01C64D48.46DA3F10 Content-Location: file:///C:/F009C636/Postpartum_haemorrhage_Gulmezoglu_2006_files/master24_image041.png Content-Transfer-Encoding: base64 Content-Type: image/png iVBORw0KGgoAAAANSUhEUgAAAA8AAABUAQMAAABnUf89AAAAAXNSR0ICQMB9xQAAAAZQTFRFAAAA AABmAbZ9ogAAAAF0Uk5TAEDm2GYAAAAJcEhZcwAACDYAAAg0Ab6QHjwAAAAZdEVYdFNvZnR3YXJl AE1pY3Jvc29mdCBPZmZpY2V/7TVxAAAAKElEQVQY02NgGEyAnYGBiYGBjYGBFcwFMhjBgmhsZPWs OBgQNhxhAwAc6ABxFLCmtgAAAABJRU5ErkJggk== ------=_NextPart_01C64D48.46DA3F10 Content-Location: file:///C:/F009C636/Postpartum_haemorrhage_Gulmezoglu_2006_files/slide0023.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Prevention and treatment of postpartum haemorrhage - A. Metin Gülmez= oglu

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Summary

Misoprostol= is promising but should be evalua= ted in well-conducted trials with appro= priate power. 3D"*"

Other methods have not = been evaluated rigorously.

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= Definition (500, 1000 ml) =

= Visual estimation <= /div>

–Underestimates blood loss

–More with increased blood loss

= Measurement

–Several methods exist with varying precision and practicality

–WHO protocol for measurement of blood loss used in the Misoprostol Trial

Assessment of b= lood loss after delivery

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‹header›

‹date/time›

Click to edit Master text styles

Second level

Third level

Fourth level

Fifth level

‹footer›

‹#›

237 women with clinically diagnos= ed PPH who had received all the conventional treatment, were aske= d to participate. Those who agreed received in addition to routine treatment, 5 tablets, 1 orally 2 sublingually and 2 rectally. Neither the women nor= the caregivers knew which were misoprostol and which were placeb= o.

The primary outcome was measured blood loss above 500ml after enrolment. There was a non-significant trend to f= ewer in the misoprostol group,occurring in 6 women who received misoprostol versus 11 who received placebo.

Other outcomes tended to favour the placebo group, but apart from the side-effects of pyrexia and shivering, were also not statistically significant. All 5 women who had hysterectomy or die= d, were in the misoprostol group.

Based on this information, how many are of the opinion that misoprostol <= span style=3D'font-family:"Times New Roman";mso-ascii-font-family:"Times New Ro= man"'>should be used to treat PPH?

How many feel that there is still a need for randomised trials of misoprostol = for the treatment of PPH?

(Why do you think so?)

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FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('

' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr= row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; 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charset="windows-1252" Prevention and treatment of postpartum haemorrhage - A. Metin Gülmez= oglu ------=_NextPart_01C64D48.46DA3F10 Content-Location: file:///C:/F009C636/Postpartum_haemorrhage_Gulmezoglu_2006_files/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252"

1	Prevention and t= reatment of postpartum haemorrhage A. Metin Gülmezoglu UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development= and Research Training in Human Reproduction, Geneva, Switzerland Training in Reproductive Health Research Geneva 2006
2	Africa
3	PPH (controlled = trials - bleeding >500 ml)
4	Strategies to re= duce postpartum blood loss Active management which uterotonic? Restrictive episiotomy Retained placenta management
5	What is active management? Early cord clamping Uterotonic Controlled cord traction Uterine massage Variations of each of the components common
6
7	Oxytocin vs. syntometrine
8
9	Primary outcomes= Secondary outcomes Measured blood loss ³= 500 mls. Blood transfusion Manual removal of the placenta Late haemorrhage (after 1st hour) Treatments for severe haemorrhage (hysterectomy, bimanual compressi= on, etc.)
10	Primary outcome= s Relative Risk
11	Misoprostol vs conventional injectable uterotonics
12	Misoprostol vs = placebo
13	Restricted epis= iotomy
14	Umbilical vein injection for retained placenta
15	Summary Active management reduces blood loss Choice between oxytocin (10IU) and syntometrine involves trade-offs<= /li> Routine episiotomy should be abandoned Retained placenta should be managed actively Oxytocin +saline infusion is likely to reduce the likelihood of man= ual removal of the placenta
16	Management of postpartum haemorrhage Essential components treat shock ascertain the origin of bleeding and treat accordingly control lower tract bleeding ensure uterine contraction remove placenta
17	Nonsurgical eme= rgency measures Uterine massage Uterotonics ergometrine IV, oxytocin infusion (20-40 IU) PGF2alpha IM or intramyometrial, intrauterine gemeprost pessaries misoprostol Compression of aorta against the sacral promontory Bimanual uterine compression Stretching the uterine arteries by elevating the uterus Intrauterine balloon, condom
18	Nonsurgical eme= rgency measures Intrauterine pressure Packing Sengstaken-Blakemore tube Foley catheter with a large bulb Silicone water-filled balloon Uterine artery embolization
19	Misoprostol= 3 trials (two in S.Africa, one in The Gambia) Promising but the effects on substantive outcomes unclear
20	The effect of misoprostol on measured blood loss of 500 ml or more after enrolment<= /font>
21	Misoprostol for= Rx of PPH: Methods: East London Hospital Complex, Tembisa and Chris Hani Baragwanath Hospitals Routine active management of the third stage Women with more than usual postpartum bleeding invited to participat= e, and to sign informed consent All routine treatment given from a special ‘Postpartum Haemorrhage Trolley’ In addition, drew the next in a series of randomised treatment packs containing either misoprostol 5 X 200mg or identical looking placebo Given 1 orally, 2 sublingually and 2 rectally.
22	Results: Misoprostol vs placebo
23	Review: all mis= oprostol in 3^rd stage trials with maternal deaths
24	Surgical measur= es Exploration under g/a Removal of retained products of conception Internal iliac artery ligation Stepwise uterine and ovarian artery ligation Vaginal uterine artery ligation Uterine repair or hysterectomy Full-thickness uterine suture
25	Summary Misoprostol is promising but should be evaluated in well-conducted trials with appropriate power. Other methods have not been evaluated rigorously.
26	Assessment of b= lood loss after delivery Definition (500, 1000 ml) Visual estimation Underestimates blood loss More with increased blood loss Measurement Several methods exist with varying precision and practicality WHO protocol for measurement of blood loss used in the Misoprostol Trial

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