Postpartum haemorrhage (PPH) is the leading cause of maternal death worldwide. In the developing countries, it is responsible for the death of about 125 000 women each year. Death from postpartum haemorrhage is eminently preventable. It is essential that first-line staff are able to prevent, make early diagnosis and provide prompt management of primary PPH. This article focuses on the prevention and management of primary PPH and highlights recent developments. Relevant current literature using the MEDLINE search strategy was examined.
Interstitial cystitis (IC) is a debilitating chronic inflammatory disorder of the bladder. It affects predominantly middle-aged Caucasian women. The diagnosis, made from the combination of symptoms, cystoscopic findings and bladder biopsies, is often delayed in the gynaecology setting because of a low index of suspicion. The pathophysiology is incompletely understood, although mast cell activation, altered bladder epithelial permeability and sensory afferent nerve up-regulation are thought to play key roles. Recent theories include the role of an antiproliferative factor. A wide assortment of therapies is available and many more are under trial. Until the causes and pathogenesis of IC are unraveled, mainstream medical treatment will remain palliative and cystectomy with urinary diversion, the only potential cure. In addition to our long experience on managing this disorder, we present a comprehensive review of the current thoughts on the aetiology and management of IC.
gestation, the intensity and frequency of contractions increased. At this time, atosiban tocolysis was administered. An initial bolus dose was followed by a continuous infusion, and maternal and fetal observations remained satisfactory. An antiseptic vaginal pack was also inserted in this case. Following a 48-hour infusion of atosiban, the woman's pains had settled completely. Gestation was now 25 weeks and again it was felt that, on an individual basis, this woman would benefit from a more prolonged infusion of tocolysis. Regular cardiotocographs remained reassuring.At 25 weeks and 5 days (1 week after starting tocolysis), spontaneous rupture of the membranes occurred and the atosiban infusion was discontinued. On vaginal examination, the breech was at the pelvic brim and a rim of cervix was present. It was felt that caesarean section would be the safest way to deliver this preterm fetus and the woman was counselled regarding the possible need for a classical uterine incision. Informed consent was obtained and general anaesthetic was administered. A lower-segment caesarean section was performed and a female infant weighing 745 g was delivered easily. No complications were associated with the procedure or the woman's postoperative course. As with the previous case study, this baby continues to do well in neonatal intensive care. DiscussionThese two cases show that, in selected cases of spontaneous preterm labour at very early gestation, there can be a benefit in prolonging the pregnancy with tocolysis. In addition, our cases show that, rather than limit the treatment to a 48-hour infusion to facilitate corticosteroid administration and/or in-utero transfer, in selected cases longer infusions can be administered to further improve outcome. However, this was made possible only by the favourable safety profile of atosiban, which allowed prolonged infusion, and may have contributed to the successful outcome (The Worldwide Atosiban versus Beta-agonists Study Group 2001). We have no doubt that the outcomes for the six babies in these two cases could have been very different had their deliveries occurred when they first presented in labour.
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