[醫如往常] Senior Clerkship Day 28: Ob/Gyn Management of post-partum hemorrhage; 水中分娩; Immature teratoma

林醫師 Management of post-partum hemorrhage
產婦死亡率7/100,000
------------
>500cc, NSD
>1000cc, cesarean
------------
Primary within 24h
Secondary within 12 days
------------
Signs
Tachycardia>120
Hematocrit>10%
------------
Etiology
History of PPH
Tone
• Myoma
• Too long
• Too fast
• Polyparity, macrosomia
• Infection
Trauma
• Retroperitoneal bleeding
• Uterine rupture
• Cesarean
• Uterine inversion
Tissue
• Placenta accrete
• Placenta previa
Thrombin
• Severe preeclampsia
• HEELP syndrome
------------
Most mortality within 4 hours
AMTSL, Active management of third stage labor
• Early cord cutting
• Uterotonic agents
• Oxytocin, hypotension
• Ergometrine, hypertension
• Misoprostol, 塞anus, tremor, drug fever (pyrexia)
• Carbetocin,  cash $2000 效果很好, hypotension




------------
Uterine artery, IIA ligation
• 先放ureter catheter, 確定位置
B lynch suture
Square suture
• 1,0 absorbable line
Hymen suture
Trans arterial embolization
Rupture repair
pRBC, FFP, Platelets
Cryoprecipitate, vWF; Von Willebrand factor
Subtotal hysrectomy
------------
En caul delivery


------------
Sheehan's syndrome


------------
水中分娩
黃醫師 惠欣婦幼診所


樂得兒產房LDR 一天約五千多元
------------
------------
不要用按摩浴缸
水質要控制
 1960 Dr. Igor Charkovsky
------------
Dive reflex


------------
產球
繩子可以拉
護理找沒生過的


------------
嬰兒按摩
嬰兒游泳


------------
防水胎心音監視器


------------
R1 張/ Attending 陳醫師
Immature teratoma


------------
Pregnancy ovarian immature teratoma
0.7%


Grade 1 不太會復發，不用做化療
------------
第二孕期做化療相對安全
第一孕期會有10%異常
------------
Pubmed發表bias
週數大， 第二孕期
治療相對積極


------------
ACGME 六大核心能力
1. 病人照護 (Patient care)
2. 醫學知識 (Medical knowledge)
3. 從工作中學習及成長 (Practice-based learning and improving)
4. 人際及溝通技能 (Interpersonal and communication skills)
5. 制度下的臨床工作 (System-based practice)
6. 專業素養 (Professionalism)
------------
Dysgerminoma
Grade 1: 15%復發
復發後再化療, 可治療90%病人


------------