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Whats amtsl
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AMTSL active management third stage labor obstetrics
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AMTSL stands for Active Management of the Third Stage of Labour.
What is AMTSL?
The third stage of labour is the period from delivery of the baby to delivery of the placenta. AMTSL is a bundle of interventions applied during this stage to reduce the risk of postpartum haemorrhage (PPH), which it reduces by approximately 60–70%.
The Three Components of AMTSL
| Component | Details |
|---|---|
| 1. Uterotonic drug | Oxytocin (10 IU IM/IV) is the drug of choice, given immediately after delivery of the baby. Misoprostol is used where oxytocin is unavailable. |
| 2. Controlled cord traction (CCT) | Gentle, sustained traction on the clamped umbilical cord while applying counter-pressure just above the symphysis pubis (Brandt–Andrews manoeuvre), once signs of placental separation appear. |
| 3. Uterine massage | Fundal massage after placental delivery to maintain uterine tone. |
Signs of Placental Separation (to watch for before CCT)
- Uterus becomes firmer and rises in the abdomen
- Umbilical cord lengthens by 5–10 cm
- Sudden gush of blood
These signs normally appear within 5–10 minutes of birth. Beyond 18 minutes, PPH risk rises significantly — it is up to six times more likely after 30 minutes.
Why It Matters
- WHO recommends AMTSL for all births as the primary strategy to prevent PPH
- Attempting placental delivery before separation is contraindicated
- Oxytocin should not be given before placental delivery, as it can trap placental fragments or mask an undetected twin
(ROSEN's Emergency Medicine, p. 3412; Active management of the third stage of labour, PMC2647525)
Whats pph
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postpartum hemorrhage PPH definition causes management
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PPH stands for Postpartum Haemorrhage — excessive bleeding after childbirth. It is a leading cause of maternal mortality worldwide.
Definition
Excessive blood loss in the postpartum period, defined as:
- A 10% drop in haematocrit, OR
- Need for packed red blood cell transfusion, OR
- Blood loss generating symptoms of hypovolaemia
Note: Pregnancy increases plasma volume by ~40% and RBC volume by ~25%, so PPH can be masked — the first sign may just be a mild rise in pulse. Up to 30% blood volume loss can occur before blood pressure drops.
Types
| Type | Timing | Common Causes |
|---|---|---|
| Primary PPH | Within first 24 hours of delivery | Uterine atony, lacerations, retained placenta, coagulopathy |
| Secondary PPH | 24 hours to 6 weeks postpartum | Subinvolution of the placental site, retained tissue, uterogenital infection |
The "4 Ts" — Causes
| T | Cause | Frequency |
|---|---|---|
| Tone | Uterine atony (most common) | 70–80% |
| Tissue | Retained placental fragments / placenta accreta | ~10% |
| Trauma | Cervical, vaginal, perineal lacerations; uterine rupture/inversion | ~20% |
| Thrombin | Coagulopathy (hereditary or acquired) | Uncommon |
Management (stepwise)
- Resuscitation — IV access, IV fluids (Lactated Ringer's), blood transfusion if needed
- Identify the source — examine for lacerations, retained placenta, uterine atony; use ultrasound to detect retained fragments
- Uterotonics for atony:
- Oxytocin 20–30 units in 1L fluid (avoid IV bolus — can cause hypotension)
- Methylergonovine / Ergonovine 0.2 mg IM (avoid IV — risk of hypertension/CNS vasospasm)
- Carboprost (PGF2α) 250 µg IM — use cautiously in asthma/cardiovascular disease
- Misoprostol 800–1000 µg rectally/transvaginally if above fail
- Bimanual uterine compression — fist in anterior fornix, compress fundus from above
- Tamponade — Bakri balloon or uterine gauze packing
- Surgical — B-Lynch sutures, uterine/hypogastric artery ligation, selective pelvic embolisation
- Hysterectomy — last resort for refractory cases
Risk Factors for Uterine Atony (most common cause)
Pre-eclampsia · prolonged labour · multiparity · fetal macrosomia · multifetal pregnancy · retained placenta · uterine infection · prolonged use of uterotonics or tocolytics
Connection to AMTSL: AMTSL (which you asked about earlier) is specifically designed to prevent PPH by shortening the third stage of labour and ensuring the uterus contracts effectively.
(Tintinalli's Emergency Medicine, p. 2129–2137; Creasy & Resnik's Maternal-Fetal Medicine, p. 948)
Whats pih
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PIH pregnancy induced hypertension definition classification management
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PIH stands for Pregnancy-Induced Hypertension — high blood pressure that develops as a result of pregnancy. It is an older umbrella term; modern guidelines (ACOG/NIH) now prefer the broader term Hypertensive Disorders of Pregnancy (HDP).
Definition
Blood pressure ≥ 140/90 mmHg measured on at least two occasions, ≥ 4 hours apart, arising during pregnancy (after 20 weeks).
Normal BP in pregnancy is actually lower than baseline — systolic 92–114 mmHg / diastolic 46–66 mmHg in early pregnancy. BP rising above 130/80 mmHg at any point is considered abnormal.
Classification (ACOG/NIH)
| Category | Key Features |
|---|---|
| Gestational Hypertension | New-onset BP ≥140/90 after 20 weeks, no proteinuria, resolves by 12 weeks postpartum |
| Preeclampsia | New-onset HTN after 20 weeks + proteinuria (>300 mg/24 h) ± end-organ dysfunction |
| Eclampsia | Preeclampsia + seizures |
| Chronic Hypertension | HTN before 20 weeks or diagnosed before pregnancy, persists >6 weeks postpartum |
| Superimposed Preeclampsia | Chronic hypertension + new onset proteinuria or worsening end-organ damage |
Severity Classification
| Grade | SBP | DBP |
|---|---|---|
| Mild | 140–149 | 90–99 mmHg |
| Moderate | 150–159 | 100–109 mmHg |
| Severe | ≥ 160 | ≥ 110 mmHg |
Pathophysiology (Preeclampsia)
- Placenta-derived factors impair vascular integrity and endothelial function
- Leads to: peripheral oedema, renal dysfunction (proteinuria), hepatic dysfunction
- Severe cases: seizures (eclampsia), HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets)
Fetal Risks
Foetal growth restriction (FGR) · placental abruption · preterm birth · foetal distress · foetal death (in severe/untreated cases). Women with chronic HTN have ~20% risk of developing superimposed preeclampsia.
Management
Drug Treatment
| Drug | Use | Notes |
|---|---|---|
| α-Methyldopa | Oral, chronic HTN in pregnancy | First-line, long safety record |
| Labetalol | Oral or IV (20 mg IV, escalate) | Safe, used for acute and chronic |
| Nifedipine | Oral (30 mg daily) | Ca²⁺ channel blocker, safe |
| Hydralazine | IV/IM (5–10 mg) | Acute severe HTN |
| Magnesium sulfate | IV infusion | Seizure prevention in severe preeclampsia/eclampsia |
Drugs to AVOID in pregnancy: ACE inhibitors, Angiotensin receptor blockers (ARBs) — clear evidence of adverse foetal effects.
Thresholds for Starting Treatment
- Diastolic BP > 105 mmHg, OR
- Systolic BP > 160 mmHg
Definitive Treatment
- Delivery of the baby — the only cure for preeclampsia/eclampsia
- If fetus is preterm: hospitalisation + pharmacotherapy to allow further maturation in utero
- ~20% of eclamptic seizures occur >48 hours after delivery → continue Mg sulfate postpartum in high-risk women
Key connection: PIH/preeclampsia is a major risk factor for PPH (which you asked about earlier), and women with chronic HTN have higher maternal and foetal morbidity.
(Creasy & Resnik's Maternal-Fetal Medicine, p. 5983–5993; Goodman & Gilman's Pharmacological Basis of Therapeutics; Textbook of Family Medicine 9e, p. 490)
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