FAMILY PLANNING AND PREGNANCY PREVENTION. GESTOSIS AND THEIR PREVENTION. BIRTHS OUTSIDE THE HOSPITAL. INJURIES, FIRST AID FOR INJURIES. INJURY PREVENTION AND COMPLICATIONS OF TRAUMA.
is the planning of when to have children, and the use of birth control and other techniques to implement such plans. Other techniques commonly used include sexuality education, prevention and management of sexually transmitted infections, pre-conception counseling and management, and infertility management.
Family planning is sometimes used in the wrong way also as a synonym for the use of birth control, though it often includes more. It is most usually applied to a female-male couple who wish to limit the number of children they have and/or to control the timing of pregnancy (also known as spacing children). Family planning may encompass sterilization, as well as abortion.
Family planning services are defined as "educational, comprehensive medical or social activities which enable individuals, including minors, to determine freely the number and spacing of their children and to select the
means by which this may be achieved."
Raising a child requires significant amounts of resources: time, social, financial, and environmental. Planning can help assure that resources are available.
Waiting until the mother is at least 18 years old before trying to have children improves maternal and child health. Also, if additional children are desired after a child is born, it is healthier for the mother and the child to wait at least 2 years after the previous birth before attempting to conceive (but not more than 5 years). After a miscarriage or abortion, it is healthier to wait at least 6 months.
Some families use modern medical advances in family planning. For example in surrogacy treatments a woman agrees to become pregnant and deliver a child for another couple or person.
In sperm donations, pregnancies are usually achieved using donated sperm by artificial insemination (either by ICI or IUI) and less commonly by in vitro fertilization (IVF), usually known in this context as ART but insemination may also be achieved by a donor having sexual intercourse with a woman for the sole purpose of initiating conception. This method is known as natural insemination, or NI.
There is generally a demand for sperm donors who have no genetic problems in their family, 20/20 eyesight, with excellent visual acuity, a college degree, and sometimes a value on a certain height and age.
Childbirth and prenatal
health care cost averaged $7,090 for normal delivery in the
Planning ahead has always been imperative in affecting the outcome of life-changing situations for everyone, which most certainly applies when it comes to pregnancy. Nearly fifty percent of the pregnancies nationwide each year is unplanned and the occurrence is far more prevalent among women under the age of 25 or with low income status. Lack of financial and emotional preparation often derives from unplanned parenthood that subsequently leads to a serious burden to the surrounding family members. Optional government aid became the only hope for many who are financially broken. Therefore, for women who are sexually active and have no intentions for parenthood, birth control pills offer a simple and effective deterrent to unplanned pregnancy that can adversely affect both family and society.
With assertions of overpopulation, there have been asertions that birth control is the answer. Birth control is techniques used to prevent unwanted pregnancy.
There are a range of contraceptive methods, each with unique advantages and disadvantages. Any of the widely recognized methods of birth control is much more effective than no method. Behavioral methods that include intercourse, such as withdrawal and calendar based methods have little up front cost and are readily available, but are less effective in typical use than most other methods. Long-acting reversible contraceptive methods, such as IUD and implant are highly effective and convenient, requiring little user action. When cost of failure is included, IUDs and vasectomy are much less costly than other methods.
The world's largest international source of funding for population and reproductive health programs is the United Nations Population Fund (UNFPA). The main goals of the International Conference on Population and Development Program of Action are:
Universal access to reproductive health services by 2015
Universal primary education and closing the gender gap in education by 2015
Reducing maternal mortality by 75% by 2015
Reducing infant mortality
Increasing life expectancy
Reducing HIV infection rates in persons aged 15–24 years by 25% in the most-affected countries by 2005, and by 25% globally by 2010
The World health organization (WHO) and World Bank estimate that $3.00 per person per year would provide basic family planning, maternal and neonatal health care to women in developing countries. This would include contraception, prenatal, delivery and post-natal care in addition to postpartum family planning and the promotion of condoms to prevent sexually transmitted infections.
Title X of the Public Health Service Act, is a US government program dedicated to providing family planning services for those in need. But funding for Title X as a percentage of total public funding to family planning client services has steadily declined from 44% of total expenditures in 1980 to 12% in 2006. Medicaid has increased from 20% to 71% in the same time. In 2006, Medicaid contributed $1.3 billion to public family planning.
Pregnancy can be a beautiful thing. But it can also be an inconvenient thing, a financially burdensome thing, a physically dangerous thing, an emotionally and politically charged thing, and a scandalous thing. This is why most women prefer to control their fertility: when pregnancy happens to them, they want it to be at its most beautiful.
There are many ways to deal with an unwanted pregnancy, but they fall into just three basic categories: prevent it, terminate it, or follow through with it. If you choose to carry an unplanned pregnancy to term, you have the additional option of giving the child to another family through the process of adoption. We will go over all these options here, starting with prevention, since it is the easiest and least traumatic way to control fertility.
Whatever your situation or your preference for handling it, bear in mind that I am not an expert or medical professional, just a good researcher. The purpose of this page is to provide a brief overview of all your options. If an option interests you, I encourage you to do further research and talk to a counselor or doctor before making a final decision.
Unintended pregnancies are those in which conception was not intended by the female sexual partner. Worldwide, 38% of pregnancies were unintended in 1999 (some 80 million unintended pregnancies in 1999). Unintended pregnancies are the primary cause of induced abortion, resulting in about 42 million induced abortions per year. Unintended pregnancy is also linked to higher rates of maternal and infant deaths.
The use of modern
contraceptive methods has greatly reduced the incidence of unintended
pregnancy, particularly in more developed countries. However the
Unintended pregnancies may arise within a committed relationship, such as marriage, as well as resulting from casual sexual activity, or as a result of rape.
· Not using contraception.
· Using contraception inconsistently or incorrectly.
· Contraceptive failure (the method was used correctly, but did not work.) Accounts for relatively small fraction of unintended pregnancies when modern highly effective contraceptives are used.
Reasons contraceptives might not have been used or been used incorrectly include:
· Coercion. Rape or involuntary sex which sometimes happens in the context of domestic violence. Unintended pregnancies are more likely to be associated with abuse than intended pregnancies. This may also include birth control sabotage - manipulation of someone's use of birth control to undermine efforts to prevent pregnancy.
· Lack of knowledge about sex and reproduction. Including erroneous beliefs.
· Lack of knowledge or experience with the contraceptive, or lack of motivation to use it correctly.
· Lack of planning or ambivalence about whether to have a child.
Unintended pregnancies result in poorer outcomes for the mother and for the child, if birth occurs. Unintended pregnancy precludes pre-conception counseling, and pre-conception care, and delays initiation of prenatal care. The great majority of abortions result from unintended pregnancies.
Results of unintended pregnancy include:
Prenatal care initiate later, and less adequate. Adversely affects health of woman and of child and less preparation for parenthood. Delay from unintended pregnancy is in addition to that from other risk factors for delay. Unwanted pregnancies have more delay than mistimed.
Unintended pregnancies preclude chance to resolve sexually transmitted diseases (STD) before pregnancy. Untreated STD in pregnant woman can result in premature delivery, infection in newborn or infant death.
Preclude use of genetic testing to help make decisions about whether to become pregnant.
Women with an unintended pregnancy are more likely to suffer depression during or after pregnancy.
Poorer maternal mental health
Increased risk of physical violence during pregnancy
Reduced likelihood of breastfeeding, resulting in less healthy children
Lower mother-child relationship quality (see also Maternal bond)
likely that mother smokes tobacco (about 30% more likely in the
Children whose births were unintended are:
Greater likelihood of low birth weight, particularly for unwanted pregnancies. In US eliminating all unwanted pregnancies would reduce rate of low birth weight by 7% for blacks, and 4% for whites, helping to decrease the large disparity in rates for whites vs. blacks. May be through increased risk preterm delivery.
infant mortality. If all sexually active couples in the
· likely to be less mentally and physically healthy during childhood,
· at higher risk of child abuse and neglect,
· less likely to succeed in school,
· more likely to live in poverty,
· more likely to need public assistance,
· more likely to have delinquent and criminal behavior.
Unintended pregnancies lead to higher rates of maternal morbidity, and threaten the economic viability of families.
Women with unintended pregnancies have less education and participate less in the workforce than women whose pregnancies are intended.
A woman who finds
herself pregnant may terminate the pregnancy by an abortion. A large proportion
of induced abortions worldwide are due to unwanted or mistimed pregnancy.
Unintended pregnancies result in about 42 million induced abortions per year
worldwide. In the
Abortion carries few health risks when performed in accordance with modern medical technique. It is far safer than child birth. However where safe abortions are not available, abortion can contribute significantly to maternal mortality and morbidity.
While decisions about abortion may cause some individuals psychological distress, some find a reduction in distress after abortion. There is no evidence of widespread psychological harm from abortion. Unwanted pregnancy and unwanted birth are also psychologically distressing, so considerations of psychological impact of abortion should be in comparison to potential harm from these stressors.
Some find abortion morally objectionable.
Over the six years between 1995 and 2000 there were an estimated 338 million pregnancies that were unintended and unwanted worldwide (28% of the total 1.2 billion pregnancies during that period). These unwanted pregnancies resulted in nearly 700,000 maternal deaths (approximately one-fifth of maternal deaths during that period). More than one-third of the deaths were from problems associated with pregnancy or childbirth, but the majority (64%) were from complications from unsafe or unsanitary abortion. Most of the deaths occurred in less developed parts of the world, where family planning and reproductive health services were less available.
Pre and postnatal depression contributes to increased risk of suicide among pregnant women and mothers. Suicide contributes to the rate of maternal mortality; where the rate of maternal deaths from physical causes is reduced by medically safe abortions and child delivery, the proportion from psychological problems can become more significant.
In cultures that practice honor killing, unintended pregnancy may increase the woman's chance of being killed.
Infants whose births were not wanted are more likely to die of infanticide. Unwanted children may also be abandoned, especially where social structures to handle adoption are not available. Unwanted children are sometimes put up for adoption.
Prevention includes comprehensive sexual education, availability of family planning services, including access to a range of effective birth control methods. Most unintended pregnancies result from not using contraception, many more result from using contraceptives inconsistently or incorrectly. Increasing use of long-acting reversible contraceptives (such as IUD and contraceptive implants) decreases the chance of unintended pregnancy by decreasing the chance of incorrect use. Method failure is relatively rare with modern, highly effective contraceptives, and is much more of an issue when such methods are unavailable, unaffordable, or not used.
Providing contraceptives and family planning services at low or no cost to the user helps prevent unintended pregnancies. Many of those at risk of unintended pregnancy have little income, so even though contraceptives are highly cost-effective, up front cost can be a barrier. Subsidized family planning services improve the health of the population and saves money for governments and health insurers by reducing medical, education and other costs to society.
Providing modern contraceptives to the 201 million women at risk of unintended pregnancy in developing countries who do not have access to contraception would cost an estimated US$3.9 billion per year. This expenditure would prevent an estimated 52 million unintended pregnancies annually, preventing 1.5 million maternal and child deaths annually, and reduce induced abortions by 64% (25 million per year). Reduced illness related to pregnancy would preserve 27 million healthy life years, at a cost of $144 per year of healthy life.
It is theorized that preventing unintended pregnancies could help break the cycle of poverty.
Affordable contraceptive services should form the basis for child abuse prevention. "The starting point for effective child abuse programming is pregnancy planning" US Surgeon General C. Everett Koop
Note: Numbers and rates are for detected pregnancies. A large proportion of pregnancies miscarry before the woman is aware of the pregnancy.
The global rate of unintended pregnancy was 55 per 1,000 women aged 15–44 in 2008, of which 26 per 1,000 ended in abortion. The rate of intended pregnancy was 79 per 1,000. The estimated 208 million pregnancies in 2008 resulted in 102 million intended births, 41 million induced abortions, 33 million unintended births, and 31 million miscarriages.
Globally, the proportion of married women practicing contraception increased from 54% in 1990 to 63% in 2003. The global rate of unintended pregnancy declined from 69 per 1,000 women in 1995. The decline was greatest in the more developed world.
Worldwide, 38% of pregnancies were unintended in 1999 (some 80 million unintended pregnancies in 1999). In developed world an estimated 49% of pregnancies were unintended, 36% in the developing world.
pregnancy is more likely among the poor, who have less access to
contraceptives, less education about sexuality and family planning, and may
have fewer career opportunities. In the
US birth rates declined in the 1970s. Factors that are likely to have led to this decline include: The introduction of the birth control pill in 1960, and its subsequent rapid increase in popularity; the completion of legalization of contraceptives in the 1960s and early 1970s; the introduction of federal funding for family planning in the 1960s and Title X in 1970; and the legalization of abortion, which was completed in 1973. The decline in birth rate was associated with reductions in the number of children put up for adoption and reduction in the rate of neonaticide.
It is unclear to what extent legalization of abortion may have increased the availability of the procedure. It is estimated that before legalization about 1 million abortions were performed annually. Before legalization, aboriton was probably one of the most common criminal activities. Before legalization, an estimated 1,000 to 10,000 women died each year from complications of poorly preformed abortions. Legalization was followed by a decrease in pregnancy related deaths in young women, as well as decrease in hospital admissions for incomplete or septic abortions, conditions more common than induced abortion.
The infanticide rate during the first hour of life dropped from 1.41 per 100,000 during 1963 to 1972 to 0.44 per 100,000 for 1974 to 1983; the rate during the first month of life also declined, whereas the rate for older infants rose during this time.
The rate of unintended pregnancy declined significantly from 1987 until 1994, due to increased contraceptive use. Since then until 2001 the rate has remained relatively unchanged.
Among poor women, the rate of unintended pregnancy and unintended birth rose from 1994 to 2001, while it declined for the more affluent women (those >200% of federal poverty level). (Unintended pregnancy rose almost 30% and unintended births rose 50% for those below federal poverty level.) Contraceptive use had been increasing for years, but stopped in the 1990s, and began to decline among poorer women. Cuts in federal and state family planning programs may account for the decreased use of contraceptives and increase in unintended pregnancies.
Costs and potential savings
The public cost of unintended pregnancy is estimated to be about 11 billion dollars per year in short term medical costs. This includes costs of births, one year of infant medical care and costs of fetal loss. Preventing unintended pregnancy would save the public over 5 billion dollars per year in short term medical costs. Savings in long term costs and in other areas would be much larger. By another estimate, the direct medical costs of unintended pregnancies, not including infant medical care, was $5 billion in 2002.
the 800,000 teen pregnancies per year,
over 80% were unintended in 2001.
One-third of teen pregnancies result in abortion. In 2002, about 9% of women at risk for
unintended pregnancy were teenagers, but
about 20% of the unintended pregnancies in the
In the US it is estimated that 52% of unintended pregnancies result from couples not using contraception in the month the woman got pregnant, and 43% result from inconsistent or incorrect contraceptive use; only 5% result from contraceptive failure, according to a report from the Guttmacher Institute. Contraceptive use saved an estimated $19 billion in direct medical costs from unintended pregnancies in 2002.
2006, publicly funded family planning services (Title X, medicaid, and state
funds) helped women avoid 1.94 million unintended pregnancies, thus preventing
about 860,000 unintended births and 810,000 abortions. Without publicly funded family planning
services, the number of unintended pregnancies and abortions in the United
States would be nearly two-thirds higher among women overall and among teens;
the number of unintended pregnancies among poor women would nearly double The services provided at publicly funded
clinics saved the federal and state governments an estimated $5.1 billion in
unintended pregnancy in the
A longitudinal study in
1996 of over 4000 women in the
Early ways of preventing unwanted pregnancy included withdrawal and various alternatives to intercourse; they are difficult to use correctly and, while much better than no method, have high failure rates compared to modern methods. Various devices and medications thought to have spermicidal, contraceptive, abortifacient or similar properties were also used.
Abortions have been induced to prevent unwanted births since antiquity, abortion methods are described in some of the earliest medical texts. The degree of safety of early methods relative to the risks of child birth is unclear.
Infanticide (‘customary neonaticide’) or abandonment (sometimes in the form of exposure) are other traditional way of dealing with babies that were not wanted or that a family could not support. Opinions on the morality or desirability of the practices have changed through history.
Where modern contraceptives are not available, abortion has sometimes been used as a major way of preventing unwanted birth. For instance in much of Eastern Europe and the former Soviet republics in the 1980s, desired family size was small, but modern contraceptive methods were not readily available, so many couples relied on abortion, which was legal, safe, and readily accessible, to regulate births. In many cases, as contraceptives became more available the rate of unintended pregnancy and abortion dropped rapidly during the 1990s.
In the 19th and 20th century, the desired number of pregnancies has declined as reductions in infant and childhood mortality have increased the probability that children will reach adulthood. Other factors, such as level of education and economic opportunities for women, have also lead to reductions in the desired number of children. As the number of desired number of children decreases, couples spend more of their reproductive lives trying to avoid unintended pregnancies.
In society and culture
Unintended pregnancy can be an indicator of premarital sex, which may carry social stigma, result in persecution or honor killing. Sometimes, in order to prevent illegitimate children, forced marriages result. Such marriages typically have poorer outcomes than voluntary marriage.
In many industrialized nations there is increasing acceptance of premarital sex, single parenting, and children born outside wedlock.
Unintended pregnancy is common as a cause of stress or social stigma in fictional works. It plays a role in many portrayals of illegitimacy and teen pregnancy.
Types of Birth Control
Reversible Methods of Birth Control
Intrauterine Devices (IUDs)
Copper T IUD-An IUD is a small device that is shaped in the form of a “T.” Your doctor places it inside the uterus to prevent pregnancy. It can stay in your uterus for up to 10 years. This IUD is more than 99% effective at preventing pregnancy.
Levonorgestrel intrauterine system (IUS)-The IUS is a small T-shaped device like the IUD. It is placed inside the uterus by a doctor. It releases a small amount of progestin each day to keep you from getting pregnant. The IUS stays in your uterus for up to 5 years. The IUS is more than 99% effective at preventing pregnancy.
Oral contraceptives - Also called “the pill,” it contains the hormones estrogen and progestin. It is prescribed by a doctor. A pill is taken at the same time each day. If you are older than 35 years and smoke, have a history of blood clots or breast cancer, your doctor may advise you not to take the pill. The pill is 92–99% effective at preventing pregnancy.
Mini pill - Unlike the pill, the mini-pill only has one hormone, progestin, instead of both estrogen and progestin. It is prescribed by a doctor. It is taken at the same time each day. It is a good option for women who can’t take estrogen. They are 92–99% effective at preventing pregnancy.
Patch-This skin patch is
worn on the lower abdomen, buttocks, or upper body (but not on the breasts).
This method is prescribed by a doctor. It releases hormones progestin and
estrogen into the bloodstream. You put on a new patch once a week for three
weeks. During the fourth week, you do not wear a patch, so you can have a
menstrual period. The patch is 92–99% effective at preventing pregnancy, but it
appears to be less effective in women who weigh more than
Hormonal vaginal contraceptive ring - The ring releases the hormones progestin and estrogen. You place the ring inside your vagina. You wear the ring for three weeks, take it out for the week you have your period, and then put in a new ring. It is 92–99% effective at preventing pregnancy.
Injection or "shot". Women get shots of the hormone progestin in the buttocks or arm every three months from their doctor. It is 97–99% effective at preventing pregnancy.
Implant. The implant is a single, thin rod that is inserted under the skin of a women’s upper arm. The rod contains a progestin that is released into the body over 3 years. It is 99 percent effective at preventing pregnancy.
Emergency contraception - Emergency contraception is NOT a regular method of birth control. Emergency contraception can be used after no birth control was used during sex, or if the birth control method failed, such as if a condom broke.
Women can take emergency
contraceptive pills up to 5 days after unprotected sex, but the sooner the
pills are taken, the better they will work. There are three different types of
emergency contraceptive pills available in the
Another type of emergency contraception is having your doctor insert the Copper T IUD into your uterus within seven days of unprotected sex. This method is 99% effective at preventing pregnancy.
Male condom. Worn by the man, a male condom keeps sperm from getting into a woman’s body. Latex condoms, the most common type, help prevent pregnancy and HIV and other STDs as do the newer synthetic condoms. “Natural” or “lambskin” condoms also help prevent pregnancy, but may not provide protection against STDs, including HIV. Male condoms are 85–98% effective at preventing pregnancy. Condoms can only be used once, and are most effective when used consistently and correctly. You can buy condoms, KY jelly, or water-based lubricants at a drug store. Do not use oil-based lubricants such as massage oils, baby oil, lotions, or petroleum jelly with latex condoms. They will weaken the condom, causing it to tear or break.
Female condom. Worn by the woman, the female condom helps keeps sperm from getting into her body. It is packaged with a lubricant and is available at drug stores. It can be inserted up to eight hours before sexual intercourse. Female condoms are 79–95% effective at preventing pregnancy when used consistently and correctly, and may also help prevent STDs.
Diaphragm or cervical cap. Each of these barrier methods are placed inside the vagina to cover the cervix to block sperm. The diaphragm is shaped like a shallow cup. The cervical cap is a thimble-shaped cup. Before sexual intercourse, you insert them with spermicide to block or kill sperm. The diaphragm is 84–94% effective at preventing pregnancy. Visit your doctor for a proper fitting because diaphragms and cervical caps come in different sizes.
Spermicides - These products work by killing sperm and come in several forms-foam, gel, cream, film, suppository, or tablet. They are placed in the vagina no more than one hour before intercourse. You leave them in place at least six to eight hours after intercourse. You can use a spermicide in addition to a male condom, diaphragm, or cervical cap. Spermicides alone are about 71–82% effective at preventing pregnancy. They can be purchased in drug stores.
Fertility awareness and abstinence
Continuous abstinence - This method means not having vaginal intercourse at any time. It is the only 100% effective way to prevent pregnancy.
Natural family planning or fertility awareness - Understanding your monthly fertility pattern can help you plan to get pregnant or avoid getting pregnant. Your fertility pattern is the number of days in the month when you are fertile (able to get pregnant), days when you are infertile, and days when fertility is unlikely, but possible. If you have a regular menstrual cycle, you have about nine or more fertile days each month. If you do not want to get pregnant, you do not have sex on the days you are fertile, or you use a form of birth control on those days. These methods are 75–99% effective at preventing pregnancy.
Permanent Methods of Birth Control
These methods are meant for people who want a permanent method of birth control. In other words, they never want to have a child, or they do not want more children. The methods listed here are more than 99% effective at preventing pregnancy.
Female Sterilization – Tubal ligation or “tying tubes.” - A woman can have her fallopian tubes tied (or closed) so that sperm and eggs cannot meet for fertilization. The procedure can be done in a hospital or in an outpatient surgical center. You can go home the same day of the surgery and resume your normal activities within a few days. This method is effective immediately.
Transcervical Sterilization. A thin tube is used to thread a tiny device into each fallopian tube. It irritates the fallopian tubes and causes scar tissue to grow and permanently plug the tubes. It can take about three months for the scar tissue to grow, so use another form of birth control during this time. Return to your doctor for a test to see if scar tissue has fully blocked your fallopian tubes.
Male Sterilization . Vasectomy-This operation is done to keep a man’s sperm from going to his penis, so his ejaculate never has any sperm in it that can fertilize an egg. This operation is simpler than tying a woman’s tubes. The procedure is done at an outpatient surgical center. The man can go home the same day. Recovery time is less than one week. After the operation, a man visits his doctor for tests to count his sperm and to make sure the sperm count has dropped to zero; this takes about 12 weeks. Another form of birth control should be used until the man’s sperm count has dropped to zero
Gestosis of pregnant women include a number of pathological conditions that occur during pregnancy, complicating its course. There are early gestosis, usually occurring in the first trimester of pregnancy, and late gestosis, developing in the second half of pregnancy.
Early gestosis includes: vomiting in pregnancy (mild form), excessive vomiting and ptializm (salivation). Etiological factor of gestosis, according to many authors, is the failure of mechanisms to adapt to emerged pregnancy. Congenital and acquired deficiency of neuroendocrine regulation of adaptive responses (hypoxia, infection, intoxication, malnutrition in the antenatal period, hereditary factors) contribute to gestosis development, as well as presence of extragenital pathology in a woman (on the part of cardiovascular system - hypertension, hypotension, cardiac defects, endocrine disease - diabetes mellitus, hyper-and hypothyroidism, urinary tract disease - pyelonephritis, glomerulonephritis).
Early gestosis (vomiting during pregnancy) include vomiting, which is repeated several times during the day, accompanied by nausea, a decrease in appetite, change in taste and olfactory sensations. In accordance with the severity of the disease they distinguish:
• light form;
• moderate (moderate);
• excessive vomiting (severe).
Mild form corresponds to a phase of functional changes in nervous system (phase neuroses), the form of medium gravity - intoxication phase (phase toxicity), a severe form corresponds to a phase of dystrophy.
Late gestational toxicosis often occurs in the third trimester of pregnancy and is characterized by multiple organ failure. Late gestosis is manifested by three main symptoms - edema, proteinuria, arterial hypertension, at least - more severe symptoms (convulsions, coma, etc.). In modern obstetrics late gestosis is denoted as OPG-gestosis (under the name of three major symptoms). There are many classifications of late gestosis, but in practical obstetrics they distinguish 4 main clinical forms:
• hydrocephalus of pregnant;
• nephropathy (mild, moderate, severe);
We should also note pre-clinical stage of gestosis - pregestoz. All clinical forms of late gestosis are specific stages of a single pathological process.
Excess weight gain during pregnancy is one of early signs of pregnancy complications called gestosis, an evidence of initially hidden, and then, perhaps, obvious edema.
Hidden edema are
detected with regular measurement of body weight (weighing a patient) and
definition of diuresis. If weight gain exceeds 300-
Explicit, visible swelling differ in the degree of distribution:
• I degree - swelling of feet and legs;
• II degree - edema of the lower extremities and the anterior abdominal wall;
• III degree - generalized edema up to anasarca.
Nephropathy of pregnancy is divided into three levels:
mild (hypertension is not higher than 150/100 mm Hg. Art., swelling of feet not
higher than shins, proteinuria less than
moderate (blood pressure not higher than 175/115 mm Hg. Art., swelling extended
to the lower extremities and abdominal wall, proteinuria of
severe degree (blood pressure above 175/115 mm Hg. Art., Anasarca, proteinuria
Pre-eclampsia - a critical, but a reversible condition, which developed against the background of severe gestosis. In addition to the triad of symptoms of gestosis (OPG), a patient has a headache, nasal congestion, visual disturbances. These signs are regarded as cerebral circulation disorder.
Eclampsia - the most severe form of pregnancy problem called gestosis, which is characterized by seizures with loss of consciousness. The duration and number of seizures of eclampsia may be different. During a seizure there develop abnormalities of cerebral blood flow, bleeding in the brain and its membranes. Hemorrhages in internal organs are frequent. Hypoxia and metabolic disease are sharply increasing, there occurs acidosis. Renal function is rapidly deteriorating, oligouriya increases. Internal organs often have degenerative changes. Eclampsia is life-threatening for both mother and fetus.
The threat of termination and miscarriage
The most frequent complication of pregnancy is a threat of interruption and premature birth - one of the main perinatal cause of morbidity and mortality. The main reasons for threat of abortion and miscarriage are:
• infectious diseases of mother;
• complications related to pregnancy;
• traumatic injuries;
• iso serological incompatibility of blood between mother and fetus;
• developmental anomalies of female genitalia;
• neuroendocrine pathology;
• various non-communicable diseases of mother;
• chromosomal abnormalities.
There are genetic reasons for miscarriage. In presence of chromosomal aberrations of an embryo there develops the threat of interruption on early stages of pregnancy. Spontaneous miscarriage in this case can be regarded as a device, worked out in the process of evolution, resulting in the birth of children with deformities is quite rare.
Endocrine causes of miscarriage include hypovaria, hyperandrogenism of different genesis (adrenal, ovarian), thyroid dysfunction. The first place is occupied by mother’s infectious diseases. These are primarily latent infectious diseases such as chronic tonsillitis, urinary organs infections, listeriosis, toxoplasmosis, mycoplasma infection, chronic inflammatory diseases of genital organs and viral infections.
Under certain circumstances, there occurs an immunologic conflict in the mother-placenta-fetus, leading to the risk of abortion and spontaneous abortion.
Among malformations of the uterus as a cause of miscarriages most common are: bicornuate, saddle, unicorns uterus, intrauterine septum, doubling of the uterus, rudimentary uterus.
The reasons contributing to emergence of miscarriages also include genital infantilism, isthmic-cervical insufficiency, uterine myoma and extragenital diseases of mother.
Ptyalism in pregnancy, or excessive salivation, is
especially annoying for a small number of patients, sometimes approaching
At least 66 % of women experience nausea and 50 % emesis in the first trimester, with the frequency of these symptoms lessening as the second and third trimesters ensue. Classically, symptoms are predominantly present in the morning (“morning sickness”), but they may occur throughout the day and evening.
The genesis of pregnancy-induced nausea and vomiting is not clear. It may be that the hormonal changes of pregnancy are responsible. Chorionic gonadotropin, for instance, has been implicated on the basis that its levels are rather high at the same time that nausea and vomiting are most common.
Light, moderate and severe degrees of vomiting are distinguished.
Light degree of vomiting accompanying with 2-4 times per day episodes of vomiting after taking meals. general state of the woman is satisfactory, light tachycardia may be present.
Moderate degree of vomiting accompanying with 10 times and more per day episodes of vomiting which don’t from taking meals. Weight loss, ketosis, increased temperature are present.
Frequent small feedings and avoidance of foods that are unpleasant to the patient usually relieve symptoms to a manageable level. A variety of antiemetics can be prescribed if the above measures fail to provide adequate relief, but unfortunately, none is completely effective and all carry risks (Metoclopramide, Meclizine, Promethazine). Of historical interest is the compound medication Bendectin, a combination of the antihistamine doxylamine and vitamin B6 (pyrodoxine), which was reasonable effective as an antiemetic in pregnancy.
Severe degree of vomiting is also called as Hyperemesis gravidarum (intractable emesis during pregnancy) is a more severe form of nausea and vomiting, occurring in approximately 4 out of 1000 pregnancies (ccompanying with 10 times and more per day episodes of vomiting) .
Fortunately, hyperemesis gravidarum has become uncommon. This syndrome is defined as vomiting sufficiently pernicious to produce weight loss, dehydration, acidosis from starvation, alkalosis from loss of hydrochloric acid in vomitus, and hypokalemia. It appears to be related to high or rapidly rising serum levels of chorionic gonadotropin or estrogens. Goodwin and associates (1994) described significantly higher total as well as free b-subunits of chorionic gonadotropin concentrations in women with hyperemesis compared with asymptomatic controls. Hyperemesis may lead to transient hepatic dysfunction.
Dehydration is corrected as well as fluid and electrolyte deficits and acidosis or alkalosis. This requires appropriate amounts of sodium, potassium, chloride, lactate or bicarbonate, glucose, and water, all of which should be administered parenterally until vomiting has been controlled. Vomiting may be frequent and severe. Schwartz and Rossoff (1994) described a woman whose retching led to bilateral pneumothoraces and pneumomediastinum. A number of anti-emetics may be given to alleviate nausea and vomiting such as promethazine, prochlorperazine, and chlorpromazine. Nageotte and colleagues (1996) reported success with intravenous droperidol-diphenhydramine. For severe disease, metoclopramide may be given parenterally. This stimulates motility of the upper intestinal tract without stimulating gastric, biliary, or pancreatic secretions. Its anti-emetic properties apparently result from central antagonism of dopamine receptors. With persistent vomiting, appropriate steps should be taken to diagnose other diseases, such as gastroenteritis, cholecystitis, pancreatitis, hepatitis, peptic ulcer, pyelonephritis, and fatty liver of pregnancy.
In many instances, social and psychological factors contribute to the illness (Deuchar, 1995). With correction of these circumstances, the woman usually improves remarkably while hospitalized, only to relapse after discharge. Positive assistance with psychological and social problems is beneficial.
Godsey and Newman (1991) studied 140 women admitted for hyperemesis to the Medical University of South Carolina Hospital. In 27 percent of these women, multiple admissions were necessary. In some women with persistent and severe disease, parenteral nutrition is used (Levine and Esser, 1988). Enteral nutrition also has been successfully used after acute nausea and vomiting subside (Boyce, 1992).
firmed at surgery.
Rare forms of gestosis in pregnancy:
1. dermatosis gravidarum, clinic, diagnosis, treatment;
2. tetania gravidarum, clinic, diagnosis, treatment;
3. osteomalacia gravidarum, clinic, diagnosis, treatment;
4. acute fatty liver of pregnancy, clinic, diagnosis, differential diagnosis (viral hepatitis, cholestasis), treatment;
5. bronchial asthma of pregnancy, clinic, diagnosis, differential diagnosis, treatment.
Classification on pregnancy induced hypertension.
1. Hypertensive disorders during pregnancy.
2. Edema during pregnancy.
3. Proteinuria during pregnancy.
4. Mild preeclampsia.
5. Moderate preeclampsia.
6. Severe preeclampsia.
“Superimposed” hypertensive disorders develop on the underlying preexisting diseases, such as Diabetes Mellitus, Hypertensive disease, kidneys inflammatory diseases, thyroid and pulmonary dysfunction. They have such peculiarities as:
1. early beginning;
2. severe duration;
3. isolated symptoms only presenting (isolated proteinuria, edema, or hypertension);
4. presence of atypical clinical findings such as paresthesia, insomnia, hypersalivation.
Is defined as hypertension present before the twentieth week of gestation or beyond 6 weeks' postpartum.
Diagnosis of Coincidental (Chronic) Hypertension
All chronic hypertensive disorders, regardless of their cause, predispose to development of superimposed preeclampsia or eclampsia. These disorders can create difficult problems with diagnosis and management in women who are not seen until after midpregnancy. The diagnosis of coincidental or chronic underlying hypertension is suggested by (1) hypertension (140/90 mm Hg or greater) antecedent to pregnancy, (2) hypertension (140/90 mm Hg or greater) detected before 20 weeks (unless there is gestational trophoblastic disease), or (3) persistent hypertension long after delivery. Additional historical factors that help support the diagnosis are multiparity and hypertension complicating a previous pregnancy other than the first. There is also usually a strong family history.
The diagnosis of chronic hypertension may be difficult to make if the woman is not seen until the latter half of pregnancy. This is because blood pressure decreases during the second and early third trimesters in both normotensive and chronically hypertensive women. Thus, a woman with chronic vascular disease, who is seen for the first time at 20 weeks, will frequently have a normal blood pressure. During the third trimester, however, blood pressure returns to its former hypertensive level, presenting a diagnostic problem as to whether the hypertension is chronic or pregnancy induced.
Essential hypertension is the cause of underlying vascular disease in more than 90 percent of pregnant women. McCartney (1964) studied renal biopsies from women with “clinical preeclampsia,” and found chronic glomerulonephritis in 20 percent of nulliparas and in nearly 70 percent of multiparas. Fisher and co-workers (1969), however, did not confirm this high prevalence of chronic glomerulonephritis.
Chronic hypertension causes morbidity whether or not a woman is pregnant. Specifically, chronic hypertension may lead to premature cardiovascular deterioration, resulting in cardiac decompensation and/or cerebrovascular accidents. Intrinsic renal damage may also result from chronic hypertensive disease. More commonly in young women, hypertension develops as a consequence of underlying renal parenchymal disease. Dangers specific to pregnancy complicated by chronic hypertension include the risk of pregnancy-aggravated hypertension, which may develop in as many as 20 percent of these women. Additionally, the risk of abruptio placentae is increased substantively. Moreover, the fetus of the woman with chronic hypertension is at increased risk for growth restriction and death.
Diagnosis of Pregnancy-aggravated Hypertension
Preexisting chronic hypertension worsens in some women, typically after 24 weeks. Such pregnancy-aggravated hypertension may be accompanied by proteinuria or pathological edema; the condition is then termed superimposed preeclampsia. Often, the onset of superimposed preeclampsia develops earlier in pregnancy than pure preeclampsia, and it tends to be quite severe and accompanied in many cases by fetal growth restriction.
The most common hazard faced by pregnant women with chronic hypertensive vascular disease is the superimposition of preeclampsia. The frequency of pregnancy-aggravated hypertension is difficult to specify precisely because the incidence varies with the diagnostic criteria employed. If the diagnosis is made only on the basis of (1) significant aggravation of the hypertension, (2) sustained proteinuria, and (3) generalized edema, the incidence will be relatively low because delivery is often accomplished before intense superimposed preeclampsia or eclampsia has developed. If, however, the diagnosis is made on the basis of a modest rise in blood pressure and minimal to modest proteinuria, the incidence will be much higher.
hypertension typically becomes manifest by a sudden rise in blood pressure that
almost always is complicated eventually by substantive proteinuria. Extreme
hypertension—systolic pressure greater than
The diagnosis requires documentation of chronic underlying hypertension. Pregnancy-aggravated hypertension is characterized by worsening hypertension, keeping in mind that both systolic and diastolic pressures normally rise as gestation increases.
Gestational hypertension - occurs after 20 weeks of pregnancy and doesn’t accompanies with proteinuria.
Hypertension - In pregnancy is generally defined as a diastolic blood pressure of
Preeclampsia - Is defined as the development of hypertension with proteinuria or edema (or both).
Differential diagnosis of chronic hypertension and preeclampsia
Onset of hypertension
Before pregnancy and in the first 20 weeks of gestation
After 20 weeks of gestation
Duration of hypertension
Constant, lasts during 3 months after delivery
It disappears after 6 weeks or 3 months after delivery
Presence of hypertensive disease in the parents, family
35-40 years old
20-25 years old
Spasm of vessels, hemorrhages
Vasospasm, edema of retina
1. Symptoms and signs
The pregnant woman is usually unaware of the two most important signs of preeclampsia—hypertension and proteinuria. By the time symptoms develop such as headache, visual disturbances, or epigastric pain, the disorder is almost always severe. Hence, the importance of prenatal care in the early detection and management of preeclampsia is obvious.
Hypertension in pregnancy is generally defined as a diastolic blood pressure of
Weight gain – a sudden increase in weight may precede the development of
preeclampsia. Weight increase of about much more than
sudden increase in weight may precede the development of preeclampsia, and
indeed, excessive weight gain in some women is the first sign. A weight
increase of about
3. Edema - peripheral edema is common in pregnancy, especially in the lower extremities; however, persistent edema unresponsive to resting in the supine position is not normal, especially, when it also involves the upper extremities and face
4. Headache - is unusual in milder cases but frequent in more severe disease. It is often frontal but may be occipital, and it is resistant to relief from ordinary analgesics.
5. Abdominal pain – epigactric or right upper quadrant pain often is a symptom of severe preeclampsia and may be indicated of imminent convulsions. It may be the result of stretching of the hepatic capsule, possibly by edema and hemorrhage. Tenderness over the liver should be presented.
6. Visual disturbances – a spectrum of visual disturbances, ranging from slight blurring of vision to scotomas to partial or complete blindness, may accompany preeclampsia. These develop as a result of vasospasm, ischemia, andpetechial hemorrhages within the occipital cortex.
7. Hyperreflexia should be presented. The patellar and achilles deep tendom reflexes should be carefully elicited and noted this symptom. The demonstration of clonus at the ankle is especially worrisome.
8. Any history of loss of consciousness or seizures, even in the patient with a known seizure disorder, may be significant.
Assessment for proteinuria, edema, weight, hyperreflexia, headache, visual disturbances, epigastric pain is obligatory daily.
Test or Procedure
Proteinuria is defined as 300 mg or more urinary protein during a 24-hour period or 30-100 mg per dL or more in at least two random urine specimens collected 6 hours or more apart
Hematocrit in complete blood count/every 2 days
It increasing may signify worsening vasocanstriction and decreased intravascular volume.
Platelet count/every 2 days
Thrombocytopenia and coagulopathy are associated with worsening PIH.
Coagulation profile (PT, PTT)
Fibrin split products
Liver function studies/ weekly
Hepatocellular dysfunction is associated with worsening PIH
Serum creatinine/twice weekly
Decreased renal function is associated with worsening PIH.
24-hour urine for creatinine clearance/twice weekly
24- hour for total protein/twice weekly
Serum uric acid/twice weekly
Ultrasound for fetal growth /every 2 weeks
To assess for pregnancy-associated hypertension effects on the fetus, intrauterine growth restriction.
Amniotic fluid volume
Fetal movement record/daily
Chronic fetal distress.
Biophysical profile/twice weekly
Nonstress test/twice weekly
Assessment of different stages of PIH severity
Diastolic blood pressure
90-99 mm Hg
100-109 mm Hg
> 110 mm Hg
Proteinuria in 24-hour collection
< 0.3 g
< 0.3 - 5 g
> 5 g
Diuresis per hour
> 50 ml
> 40 ml
< 40 ml
Presence of edema
In lower extremities
In lower extremities, and abdominal wall
Number of thrombocytes
80 - 150. 000
36 – 38
39 – 42
< 75 mkmol/L
75 – 120 mkmol/L
> 120 mkmol/L
< 4,5 mmol/L
4,5 – 8 mmol/L
> 8 mkmol/L
Preeclampsia is classified as severe if there is a blood pressure greater
than or equal to
Complications of preeclapsia:
Maternal – placenta abruption, cerebral hemorrhage, renal and liver insufficiency, disseminated intravascular coagulopathy, adrenal insufficiency, eclampsia.
Fetal – intrauterine growth retardation, fetal distress, intranatal fetal death, infant morbodity and mortality.
ECLAMPSIA is characterized typically by those same abnormalities as severe preeclampsia with the addition of convulsions that are precipitated by pregnancy-induced hypertension. The seizures are grand mal and may appear during pregnancy, during labor, or postpartum.
Treatment and prevention
The only known treatments for eclampsia or advancing pre-eclampsia are abortion or delivery, either by labor induction or Caesarean section. However, post-partum pre-eclampsia may occur up to six weeks following delivery even if symptoms were not present during the pregnancy. Post-partum pre-eclampsia is dangerous to the health of the mother since she may ignore or dismiss symptoms as simple post-delivery headaches and edema. Hypertension can sometimes be controlled with anti-hypertensive medication, but any effect this might have on the progress of the underlying disease is unknown.
Women with underlying inflammatory disorders such as chronic hypertension or autoimmune diseases would likely benefit from aggressive treatment of those conditions prior to conception, tamping down the overactive immune system.
Thrombophilias may be weakly linked to pre-eclampsia. There are no high quality studies to suggest that blood thinners will prevent pre-eclampsia in thrombophilic women.
In low-risk pregnancies the association between cigarette smoking and a reduced risk of pre-eclampsia has been consistent and reproducible across epidemiologic studies. High-risk pregnancies (those with pregestational diabetes, chronic hypertension, history of pre-eclampsia in a previous pregnancy, or multifetal gestation) showed no significant protective effect. The reason for this discrepancy is not definitively known; research supports speculation that the underlying pathology increases the risk of pre-eclampsia to such a degree that any measurable reduction of risk due to smoking is swamped. A study into the effects of smoking on the incidence of pre-eclampsia in African-American women found a significantly lower incidence of pre-eclampsia with higher measured levels of nicotine. When adjusted for age, parity, and medical comorbidities the association was still observable, but no longer significant. Medical authorities and anti-smoking advocates discourage smoking in general during pregnancy.
Antihypertensives may reduce maternal and fetal mortality among pregnancy patients with hypertension as compared to placebo according to a randomized controlled trial. Overall, after three weeks of treatment, MAP was lower in the isradipine group, but when compared with the placebo group, the difference in MAP did not have statistical significance. After treatment with isradipine, those patients with no proteinuria experienced a decrease of between 8.5 and 11.3 mmHg, whereas those with proteinuria experienced about only 1 mmHg difference in systolic blood pressure. Those treated with placebo in both groups did not experience much change in systolic blood pressure, regardless of proteinuria being present or not. Therefore, the authors concluded proteinuric patients may respond differently from nonproteinuric patients to this treatment, where the nonproteinuric patients responded the most to treatment with isradipine.
Labetolol or Nifedipine are often the antihypertensives of choice for eclampsia or pre-eclampsia according to the CHEST 2007 study, especially Labetolol as it has little placental transfer.
In some cases, women with pre-eclampsia or eclampsia
can be stabilized temporarily with magnesium sulfate intravenously to forestall
seizures while steroid injections are administered to promote fetal lung
maturation. Magnesium sulfate as a possible treatment was considered at least
as far back as 1955, but only in recent years did its use in the
Dietary and nutritional factors
The Farm (
Studies of protein/calorie supplementation have found no effect on pre-eclampsia rates, and dietary protein restriction does not appear to increase pre-eclampsia rates. No mechanism by which protein or calorie intake would affect either placentation or inflammation has been proposed.
Studies conducted on the effect of supplementation with antioxidants such as vitamin C and E found no change in pre-eclampsia rates. However, Drs. Padayatty and Levine with the NIH criticized the studies for overlooking several key factors that would have been important to the success of the supplementation.
Low levels of vitamin D may be a risk factor for pre-eclampsia, and calcium supplementation in women with low-calcium diets found no change in pre-eclampsia rates but did find a decrease in the rate of severe preeclamptic complications. Low selenium status is associated with higher incidence of pre-eclampsia. Some other vitamin may also play a role.
Aspirin supplementation is still being evaluated as to dosage, timing, and population and may provide a slight preventative benefit in some women; however, significant research has been done on aspirin and the results thus far are unimpressive.
There is insufficient evidence to recommend either exercise or bedrest as preventative measures.
Induction of paternal tolerance
Many studies have also suggested the importance of a woman's immunological tolerance to her baby's father, whose genes are present in the young fetus and its placenta and which may pose a challenge to her immune system. As the theory is further investigated, researchers are increasingly studying the importance of a woman's continued exposure to her partner's semen as early as several years before conception. One study published in the American Journal of Obstetrics and Gynecology involved several hundreds of women and found that "women with a short period of cohabitation (less than 4 months) who used barrier methods for contraception had a substantially elevated risk for the development of pre-eclampsia compared with women with more than 12 months of cohabitation before conception". However, the results from a study conducted in 2004 show that the theory is still not conclusive. In that study, the researchers found that after adjustment and stratification, the effect of barrier contraceptive use on the development of pre-eclampsia had disappeared, with both arms having identical rates of pre-eclampsia. Although the study has since been criticized for its subjective adjustment of data, it remains important because it demonstrates that there is still some contention over the degree to which failure of tolerance induction can be attributed to prior exposure to the partner's sperm.
Continued exposure to a partner's semen has a strong protective effect against pre-eclampsia, largely due to the absorption of several immune modulating factors present in seminal fluid.
Long periods of sexual cohabitation with the same partner fathering a woman's child significantly decreased her chances of suffering pre-eclampsia. As one early study described, "although pre-eclampsia is a disease of first pregnancies, the protective effect of multiparity is lost with change of partner". The study also concluded that although women with changing partners are strongly advised to use condoms to prevent sexually transmitted diseases, "a certain period of sperm exposure within a stable relation, when pregnancy is aimed for, is associated with protection against pre-eclampsia".
Several other studies have since investigated the strongly decreased incidence of pre-eclampsia in women who had received blood transfusions from their partner, those with long, preceding histories of sex without barrier contraceptives, and in women who had been regularly performing oral sex, with one study concluding "induction of allogeneic tolerance to the paternal human leukocyte antigen (HLA) molecules of the fetus may be crucial. Data collected strongly suggest that exposure, and especially oral exposure to soluble HLA from semen can lead to transplantation tolerance."
Other studies have investigated the roles of semen in the female reproductive tracts of mice, showing that "insemination elicits inflammatory changes in female reproductive tissues" concluding that the changes "likely lead to immunological priming to paternal antigens or influence pregnancy outcomes". A similar series of studies confirmed the importance of immune modulation in female mice through the absorption of specific immune factors in semen, including TGF-Beta, lack of which is also being investigated as a cause of miscarriage in women and infertility in men.
According to the theory, the fetus and placenta both contain "foreign" proteins from paternal genes, but regular, preceding and coincident exposure to the father's semen may promote immune acceptance and subsequent implantation, a process which is significantly supported by as many as 93 currently identified immune regulating factors in seminal fluid.
Having already noted the importance of a woman's immunological tolerance to her baby's paternal genes, several Dutch reproductive biologists decided to take their research a step further. Consistent with the fact that human immune systems tolerate things better when they enter the body via the mouth, the Dutch researchers conducted a series of studies that confirmed a surprisingly strong correlation between a diminished incidence of pre-eclampsia and a woman's practice of oral sex, and noted that the protective effects were strongest if she swallowed her partner's semen. The researchers concluded that while any exposure to a partner's semen during sexual activity appears to decrease a woman's chances for the various immunological disorders that can occur during pregnancy, immunological tolerance could be most quickly established through oral introduction and gastrointestinal absorption of semen. Recognizing that some of the studies potentially included the presence of confounding factors, such as the possibility that women who regularly perform oral sex and swallow semen also engage in more frequent intercourse, the researchers also noted that, either way, "the data still overwhelmingly supports the main theory" behind all their studies-that repeated exposure to semen establishes the maternal immunological tolerance necessary for a safe and successful pregnancy.
A team from the
Prevention and treatment of pregnancy induced hypertension
Prophylaxis and Early Treatment
Because women are usually asymptomatic and seldom notice the signs of incipient preeclampsia, its early detection demands careful observation at appropriate intervals, especially in women known to be predisposed to preeclampsia. Major predisposing factors are (1) nulliparity, (2) familial history of preeclampsia–eclampsia, (3) multiple fetuses, (4) diabetes, (5) chronic vascular disease, (6) renal disease, (7) hydatidiform mole, and (8) fetal hydrops.
Rapid weight gain any time during the latter half of pregnancy, or an upward trend in diastolic blood pressure, even while still in the normal range, is worrisome. Every woman should be examined at least weekly during the last month of pregnancy and every 2 weeks during the previous 2 months. At these visits, weight and blood pressure measurements are made. All women should be advised to report immediately any symptoms or signs of preeclampsia, such as headache, visual disturbances, epigastric distress, and puffiness of hands or face. The reporting of any such symptoms calls for an immediate examination to confirm or exclude preeclampsia.
Natriuretic drugs, such as chlorothiazide and its congeners, have been overused severely in the past. Although diuretics have been alleged to prevent preeclampsia, Collins and colleagues (1985) reviewed results of nine studies of more than 7000 women and concluded that perinatal mortality was not improved when diuretics were given. Furthermore, thiazides can induce serious sodium and potassium depletion, hemorrhagic pancreatitis, and severe neonatal thrombocytopenia. The failure of natriuretic drugs to prevent preeclampsia raises serious doubt about the efficacy of rigid dietary sodium restriction.
Wallenburg and co-workers (1986) reported their experiences with either 60 mg of aspirin or placebo to angiotensin-sensitive primigravid women at 28 weeks. The reduced incidence of preeclampsia in the treated group was attributed to selective suppression of thromboxane synthesis by platelets and sparing of endothelial prostacyclin production. In a group of high-risk women with prior bad pregnancy outcomes due to hypertension and placental insufficiency, Beaufils and colleagues (1985) reported that early prophylactic treatment with dipyridamole and aspirin reduced recurrences. Benigni and colleagues (1989) and Schiff and associates (1989) also reported salutary effects in high-risk women.
Spitz and colleagues (1988) reported that most angiotensin-sensitive women at high risk for developing preeclampsia could be rendered refractory to angiotensin by a 1-week course of daily 81-mg aspirin.
They confirmed that low-dose aspirin significantly decreased thromboxane synthesis. Prostacyclin and prostaglandin E2 synthesis were also decreased 20 to 30 percent by therapy. These same investigators reported that approximately 20 percent of angiotensin-sensitive pregnant women given low-dose aspirin did not become refractory to angiotensin, and all such women developed preeclampsia (Brown and associates, 1990). The nonresponders to low-dose aspirin had a significant fall in thromboxane levels, but they also had significant declines in prostacyclin and prostaglandin E2 levels.
Low-dose aspirin was not effective for women who already had mild pregnancy-induced hypertension (Schiff and associates, 1990); however, women with moderate hypertension improved. Magness and colleagues (1991) observed that less than 20 percent of women with early-onset pregnancy-induced hypertension failed to become normotensive with hospitalization. In the 20 percent who remained hypertensive after hospitalization, low-dose aspirin allowed prolongation of pregnancy compared with controls.
Low-dose aspirin may be effective in some women in preventing the development of pregnancy-induced hypertension and fetal growth restriction (Imperiale and Petrulis, 1991). Hauth and co-workers (1993) randomized 604 nulliparas to 60 mg aspirin or placebo beginning at 24 weeks. Only 1.7 percent of aspirin-treated women developed preeclampsia versus 5.6 percent of controls (P < 0.01). Studies from the National Institutes of Health sponsored Maternal–Fetal Medicine Network showed that aspirin prophylaxis significantly decreased preeclampsia to 4.6 percent compared with 6.3 percent in nontreated controls (Sibai and colleagues, 1993). Overall, perinatal outcome was not improved, and women who took aspirin had significantly more placental abruptions, although Hauth and colleagues (1995) concluded that these abruptions were of no clinical importance.
a study by the Royal College of Obstetricians and Gynecologists (CLASP, 1994),
it was concluded that low-dose aspirin was ineffective to prevent preeclampsia.
Similarly, the ECPPA Collaborative Group (1996), in a study from 12 Brazilian
teaching hospitals, concluded that low-dose aspirin did not decrease the
incidence of proteinuric preeclampsia in 1009 women randomized to aspirin or
placebo. Both of these groups of investigators used Korotkoff IV sound for
diastolic pressure, and this may overestimate diastolic pressure by 7 to
Currently, the salutary effects of low-dose aspirin therapy remain to be proven for most groups of women. The prevailing opinion is that normal women should not be treated, but selective treatment for certain high-risk groups is acceptable (Cunningham and Gant, 1989; Hauth and Cunningham, 1995; Royal College of Obstetricians and Gynecologists, 1996; Zuspan and Samuels, 1993).
Low-dose aspirin therapy appears to be safe for the fetus. Although most clinical trials have resulted in no apparent maternal risks, Brown and colleagues (1990) noted a rapid clinical deterioration if therapy was stopped suddenly.
The basic management objectives for any pregnancy complicated by pregnancy-induced hypertension are:
1. Termination of the pregnancy with the least possible trauma to the mother and the fetus.
2. Birth of the infant who subsequently thrives
3. Complete restoration of the health of the mother.
Hospitalization is considered for women with pregnancy-induced hypertension if there is a persistent or worsened elevation in blood pressure or development of proteinuria. With hospitalization, a systematic study should be instituted that includes the following:
2. Admittance weight and every day thereafter.
3. Admittance analysis for proteinuria and at least every 2 days thereafter.
4. Blood pressure readings with an appropriate-size cuff every 4 hours, except between midnight and morning, unless the midnight pressure has increased.
5. Measurements of plasma creatinine, hematocrit, platelets, and serum liver enzymes, the frequency to be determined by the severity of hypertension.
6. Frequent evaluation of fetal size and amnionic fluid volume by the same experienced examiner and by serial sonography if remote from term.
If these observations lead to a diagnosis of severe preeclampsia, further management is the same as described for eclampsia.
Reduced physical activity throughout much of the day is beneficial. Ample, but not excessive, protein and calories should be included in the diet. Sodium and fluid intakes should not be limited or forced. Sedatives or tranquilizers have been used routinely by some; we do not recommend them. Further management depends upon (1) severity of preeclampsia, (2) duration of gestation; and (3) condition of the cervix. Fortunately, many cases prove to be sufficiently mild and near enough to term that they can be managed conservatively until labor commences spontaneously or until the cervix becomes favorable for labor induction. Complete abatement of all signs and symptoms, however, is uncommon until after delivery. Almost certainly, the underlying disease persists until after delivery!
1. Bed rest. Preferably with as much of the time as possible spent in a lateral decubitus position. In this position, cardiac function and uterine blood flow are maximized and maternal blood pressures in most cases are normalized. This improves uteroplacental function, allowing normal fetal growth and metabolism. ambulatory treatment has no place in the management of PIH; bed-rest throughout the greater part of the day is essential.
2. Sedative drugs for normalization of status of central nervous system:
1.Droperidol – 2 ml IM, Seduxen – 2 ml IM. These drugs should be combined with Droperidol – 0,25 % - 2ml IM or IV
3. Antihypertensive therapy eliminates vasospasm of macro- and microcirculation.
Antihypertensive drugs used in pregnancy:
1. spasmolytic agents – No-spani 2 % - 2-4 ml intramuscularly, Papaverine hydrochloride – 2 % - 2-4 ml IM, Plathyphillinum – 0,2 % - 2, 0 – twice a day, Dibasol – 1 % 2-4 ml IM or IV, Euphyllinum – 2,4 % 10, 0 IV;
2. Nifedipine – calcium-channel blocker – in the dose 10 mg po q 4-8 hours;
3. Labetalol – a- and b- adrenergic blockers – in the dose 20-50 mg IV q 3-6 hours;
4. Methyldopa – false neurotransmission, central nervous system effect;
5. Thiazide – decreased plasma volume and cardiac output.
If diastolic pressure is
Hydralazine is given intravenously whenever the diastolic blood pressure is
administered has proven remarkably effective, and importantly, cerebral
hemorrhage has been avoided. At
The tendency to give a larger initial dose of hydralazine when the blood pressure is higher must be avoided. Figure 31–19 shows the mean arterial blood pressure responses to 5-mg hydralazine bolus doses. The response to even 5- to 10-mg doses cannot be predicted by the level of hypertension; thus we always give 5 mg as the initial dose. Hydralazine was injected more frequently than recommended in the protocol, and blood pressure decreased in less than 1 hour from 240–270/130–150 mm Hg to 110/80 mm Hg. Ominous fetal heart rate decelerations were evident when the pressure fell to 110/80 mm Hg, and the decelerations persisted until maternal blood pressure increased.
4. Magnesium Sulfate is used to arrest and prevent the convulsions of eclampsia without producing generalized central nervous system depression in either mother or the fetus. Magnesium sulfate may be given intramuscularly in the dose 25 % -5, 0 2-3 times a day or by continuos intravenous infusion in the dose 8 % - 200, 0 ml. It has spasmolytic, sedative, hypotensive and anticonvulsant effects.
Frequent evaluations of the patient's patellar reflex and respiration (> 14 respiratory act in a minute) are necessary to monitor for manifestations of toxic serum magnesium concentrations. In addition, because magnesium sulfate is excreted solely from the kidney, maintenance of urine output at > 30 ml/hr will avoid accumulation of the drug. Reversal of the effects of excessive magnesium concentrations is accomplished by the slow intravenous administration of 10% calcium gluconate along with oxygen supplementation and cardiorespiratory support if needed.
The maximal dose of
magnesium during a day in the case of severe preeclampsia is 50-80 ml (12,5 –
Sheme of magnesium administration in the case of severe preeclampsia and eclampsia:
administration of Magnesium Sulfate - 12 ml 25 % during 5 minutes. At the same
time – intramuscularly administration of 4,5 –
3) administer 4-
5. Normalization of blood reology because of hemoconcentration – Trental, Curantil, Komplamin.
6. Limited intravenous fluid therapy under control of blood volume, hematocrit, 24-hours diuresis. Primarily lactated Ringer’s containing 5 % dextrose – should be given at a rate of 60-125 ml per hour (not faster) unless there is unusual fluid loss from vomiting, diarrhea, or, more likely, excessive blood loss at delivery. Oliguria is common in severe preeclampsia and eclampsia, making it tempting to administer intravenous fluids more vigorously. However, the infusion of large volumes of fluid enhances the maldistribution of extracellular fluid and in that way increases the risk of pulmonary and cerebral edema.
Lactated Ringer solution is administered routinely at the rate of 60 mL/hr to no more than 125 mL/hr unless there was unusual fluid loss from vomiting, diarrhea, or diaphoresis, or more likely, excessive blood loss at delivery. Oliguria, common in cases of severe preeclampsia and eclampsia, coupled with the knowledge that maternal blood volume is very likely constricted compared with normal pregnancy, make it tempting to administer intravenous fluids more vigorously. The rationale for controlled, conservative fluid administration is that the typical eclamptic woman already has excessive extracellular fluid that is inappropriately distributed between the intravascular and extravascular spaces of the extracellular fluid compartment. Infusion of large fluid volumes could and does enhance the maldistribution of extracellular fluid and thereby appreciably increases the risk of pulmonary and cerebral edema (Benedetti and Quilligan, 1980b; Gedekoh and associates, 1981; Sibai and co-workers, 1987b).
For the patient with worsening preeclampsia or the patient who has severe preeclampsia or eclampsia, stabilization with magnesium sulfate, antihypertensive therapy as indicated, monitoring for maternal and fetal well-being, and delivery by induction or cesarean section are required. A 24-hour delay in delivery allow steroid administration to enhance fetal pulmonary maturity may be indicated in some cases.
7. Avoidance of Diuretics and Hyperosmotic Agents. Potent diuretics further compromise placental perfusion, because their immediate effects include further intravascular volume depletion, which most often is already reduced compared with normal pregnancy. Therefore, diuretics are not used to lower blood pressure, so as not to enhance the intensity of the maternal hemoconcentration and its adverse effects on the mother and fetus (Zondervan and associates, 1988).
Once delivery is accomplished, in almost all cases of severe preeclampsia and eclampsia there is a spontaneous diuresis that usually begins within 24 hours and results in the disappearance of excessive extravascular extracellular fluid over the next 3 to 4 days..
With infusion of hyperosmotic agents, the potential exists for an appreciable intravascular influx of fluid and, in turn, subsequent escape of intravascular fluid in the form of edema into vital organs, especially the lungs and brain. Moreover, an oncotically active agent that leaks through capillaries into lungs and brain promotes accumulation of edema at these sites. Most importantly, a sustained beneficial effect from their use has not been demonstrated. For all of these reasons, hyperosmotic agents have not been administered, and use of furosemide or similar drugs has been limited to the rare instances in which pulmonary edema was identified or strongly suspected.
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Resuscitation of a trauma patient often involves multiple management procedures.
Trauma can be classified by the affected area of the body (percentages of total incidence):
-Head injury (30%)
-Chest trauma (20%)
-Abdominal trauma (10%)
-Extremity trauma (2%)
-Spinal cord injury
-Genitourinary system trauma
-Soft tissue injury
They may also be classified by the type of force applied to the body, such as blunt trauma versus penetrating trauma.
An injury is damage to body. It is a general term that refers to harm caused by accidents, falls, blows, burns, weapons and more. Injuries can happen at work or play, indoors or outdoors, driving a car or walking across the street.
Common injuries include:
-Sprains and strains
A fracture is a break or crack in a bone that can be caused by an accident, fall, or blow.
Signs and Symptoms of a Fracture
-Pain at or around the site of the fracture.
-Tenderness (pain on gentle pressure) over the area. Do not press hard.
-Swelling over the area with discoloration.
-Loss of normal movements of the affected part.
-Deformity of the limb may be caused. The limb may lose its normal shape and there may be apparent shortening of the limb.
-If, as in the leg bone, the break is just under the skin, the irregular outline of the bone can be felt easily.
-When one end of the broken bone moves against the other, a crackling sound may be heard. This is called crepitus (grating). This should never be elicited by the person giving First Aid.
-Unnatural movements may be felt at the site of the fracture. This too should never be elicited by the First-Aid provider.
-In addition the victim may himself say that he heard the snap of the bone. It is important to compare the injured limb with the normal limb while making an assessment.
- direct force - a blow that breaks the bone at the point of impact
- indirect force - when the bone breaks at some distance from the point of impact,e.g. where a fall on an outstretched hand results in a fracture of the collarbone
- abnormal muscular contraction - a sudden contraction of a muscle may result in a fracture,e.g. an elderly person snapping the keecap after tripping and trying to prevent a fall.
- bleeding -
fractures of large bones may result in considerable loss of blood, e.g. a
fractured thigh results in the loss of 1 or
- damage to surrounding tissues and blood vessels
- possibly shock.
Types of Fractures
Closed or simple fracture. The bone is broken, but the skin is not lacerated.
Open or compound fracture. The fracture in which the fractured bone penetrates the skin. The bone may or may not be visible in the wound.
Transverse fracture. The fracture is at right angles to the long axis of the bone.
Greenstick fracture. Fracture on one side of the bone, causing a bend on the other side of the bone. This type of fracture is typical for little children
Comminuted fracture. A fracture that results in three or more bone fragments.
1. SEEK MEDICAL ATTENTION IMMEDIATELY. Call for EMS, or transport victim to emergency room after immobilizing affected area. Wait for EMS and DO NOT attempt to transport victim if you suspect head, back, or neck injury; if there's a visible deformity of bone; or if the victim cannot be splinted or transported without causing more pain.
2. Suspect back or neck injury if victim is unconscious or has head injury, neck pain, or tingling in arms or legs. If neck or back injury suspected, DO NOT move victim unless necessary to save victim's life. See back or neck injury.
3. Immobilize and support affected bone in position found. DO NOT try to push protruding bone back into body or let victim move or use affected area.
4. Control any bleeding through direct pressure, but DO NOT elevate affected area. See bleeding, external.
5. If bone is protruding, cover with clean cloth once bleeding is controlled.’
6. Observe for shock (see shock). DO NOT give victim anything to eat or drink.
7. Immobilize injured area, and, if no open wound present, apply ice pack wrapped in clean cloth.
Apply ice pack to affected
area and cover with cloth.
Immobilizing Fractured Bone:
1. Check for sensation, warmth, and color of toes or fingers below suspected break.
2. Place padded splint under area of suspected break:
Use belts or neckties to bind splint to arm but do not bind
on top of the break
- Use board, rolled newspaper or magazines, broomstick, or rolled blanket for splint.
-Wrap splint in cloth or towels for padding.
-Bind splint to limb using neckties, cloth, belts, or rope. DO NOT bind directly over break.
3. Recheck often for sensation, warmth, and coloring. If fingers or toes turn blue or swell, loosen binding.
4. For arm or shoulder injury, place splinted arm in sling, with hand above elbow level. Bind arm to victim's body by wrapping towel or cloth over sling and around upper arm and chest; tie towel or cloth under victim's opposite arm.
Create a sling for arm injuries using whatever
cloth you can find.
The aims of First Aid are:
- to prevent further damage
- to reduce pain
- to make the patient feel comfortable
- to get medical aid as soon as possible
- Fractures often occur along with other injuries. So the rescuer must assess for other injuries and decide which of them requires care on priority. Heavy bleeding is more urgent and requires higher priority care over a fracture.
- If there is no danger to life then temporary attention to the fracture is often sufficient.
- Handle the patient very gently. Avoid all unnecessary movement.
- Treat for shock if present.
- If the broken ends of the bones show out, do not wash the wound or apply antiseptics to the end of the bone.
- Do not handle the fracture unnecessarily.
- Never attempt to reduce the fracture or to bring the bones to the normal position.
- Stabilise and support the injured part so that no movement is possible. This stops further injury and helps to control the bleeding.
- Immobilise the fracture area and the joints on both sides of the fracture site (above and below) by using bandages or by using splints wherever available. It is essential that the rescuer be familiar with the use of bandages and splints.
A: Using Bandages
Usually it is enough to use the other (uninjured) limb or the body of the victim as the splint. The upper limb can be supported by the body, and the lower limb by the other limb provided that also is not fractured. Most fractures except those of the forearm can be immobilised in this manner:
Do not apply bandage over the area of the fracture.
The bandaging should be firm so that there is no movement of the fractured ends but should not be too tight as blood circulation to the affected area could be reduced. If there is further swelling of the injured area, the bandage may be too tight and therefore may need to be loosened.
Always place padding material between the ankles, knees and other hollows if they have to be tied together so that when the limbs are bound together they are comfortable and steady.
If the patient is lying down, the bandage should be passed through the natural hollows like the neck, the lower part of the trunk, knees, just above the ankles etc., so that the patient’s body is not jarred.
Always tie the knots on the sound side.
B: Using Splints
Splints are used only when necessary expertise is there.
A splint is a rigid piece of wood or plastic material or metal applied to a fractured limb to prevent movement of the broken bone.
Reasonably wide splints are better than narrow ones.
Splints should be long enough so that the joints above and below the fractured bones can be made immobile.
The splints should be well padded with cotton or cloth so as to fit snugly and softly on the injured limb.
Splints are best applied over the clothing.
In an emergency, splints can be improvised using a walking stick, an umbrella, a piece of wood, a book or even a firmly folded newspaper.
Use of splints becomes obligatory only when both legs or both thigh bones are broken.
Fractures involving the back (vertebral column) require special care. In such cases, the victim should not be allowed to get up. Further, movement must be avoided as much as possible and emergency medical help must be sought.
People who have severe trauma frequently require specialized physicians and equipment. Designated trauma centers have improved outcomes compared to non designated centers.The transfer directly to a trauma center is associated with improved outcomes compared to transfer to a non trauma center.
Stabilization and transportation
In the prehospital setting the use of stabilization techniques improve the chances of a person surviving the transport to the nearest trauma-equipped hospital. After ensuring their own safety and taking isolation precautions, a primary survey is performed, consisting of checking and treating airway, breathing, and circulation (called the ABC's) then an assessment of the level of consciousness. To prevent further injury, unnecessary movement of the spine is minimized by securing the neck with a cervical collar, and the back with a long spine board with head supports, or other medical transport device such as a Kendrick extrication device, before moving the person.
Rapid transportation of those who are severely injured is associated with improved outcomes.Unless the person is in imminent danger of death, first responders will typically "load and go," transporting to the nearest appropriate facility. Helicopter EMS transport reduces mortality compared to ground based transport in adult trauma patients. In the prehospital environment, the availability of advanced life support does not improve outcomes for major trauma, when compared with basic life support. The evidence is also inconclusive with respect to support for prehospital intravenous fluid resuscitation and some evidence has found it may be harmful.
People who have suffered trauma may require specialized care, including surgery. Outcomes are better if this occurs as quickly as possible thus the so called golden hour of trauma. This is not a strict deadline, but recognizes that many deaths which can be prevented by appropriate care occurring in a relatively short time after injury.
Community-based trauma referral systems seek to decrease overall injury-related morbidity and mortality and years of life lost within a population by ensuring the provision of optimal care during both the acute and late phases of injury. The care of acutely injured people is a public health issue that involves bystanders and community members, health care professionals, and health care systems. It encompasses prehospital assessment and care by emergency medical services personnel, emergency department assessment, treatment, and stabilization, and in-hospital care among all age groups. An established trauma system network is also an important component of community disaster preparedness, facilitating the care of victims of natural disasters or terrorist attacks. In those with cardiac arrest due to trauma cardiopulmonary resuscitation (CPR) is considered futile but still recommended.
Traditionally, high volume intravenous fluids were given in people with hemodynamic instability due to trauma. This is still appropriate for those with isolated extremity, thermal or head injuries. The current evidence however supports limiting the use of fluids for penetrating thorax and abdominal injuries allowing mild hypotension to persist (known as permissive hypotension). Targets include a mean arterial pressure of 60 mmHg, a systolic blood pressure of 70-90 mmHg, or until their adequate mentation and peripheral pulses.
As no intravenous fluids used for initial resuscitation has been shown to be superior to warmed Lactated Ringer's solution it continues to be the solution of choice.
When you approach the scene of an accident or emergency, follow the DRABC Action Plan:
- to you
- to other
- to the casualty
make sure that no one also gets hurt. You will not be able to help if you are also a casualty
only proceed if it is safe to do so.
- is the casualty conscious?
Turning an unconscious casualty on the side to clear and open the airway
Clearing the airway
1. With the casualty supported on the side, tilt the head backwards and slightly down.
2. Open the mouth and clear any foreign objects. Only remove dentures if loose or broken.
Opening the airway
1. Place one hand high on the casualty's forehead.
2. Support the chin with the other hand.
3. Gently tilt the head backwards.
4. Lift the jaw and open the casualty's mouth slightly.
- look for the chest rising and falling.
- listen for the sound of breathing
- feel woth your cheek
EAR (mouth-to-mouth resuscitation)
1. Knee beside the casualty.
2. Keep the casualty's head tilted back.
3. Pinch the casualty's nostrils with your fingers or seal with your cheek.
4. Lift the jaw forward with your other hand.
5. Take a deep breath and open your mouth wide.
6. Place your mouth firmly over the casualty's mouth making an airtight seal.
7. Breathe into the casualty's mouth.
8. Remove your mouth and turn your head to observe the chest fall and listen or feel for exhaled air.
9. If the chest does not rise and fall , check head tilt position first , then check for and clear foreign objects in the airway.
10. Give 5 full breaths in 10 seconds , then check the carotid (neck) pulse for 5 seconds. If pulse is present, continue EAR at the rate of 15 breaths per minute.
· feel the pulse at the neck (carotid pulse)
· if pulse is present , continue EAR at the rate of 15 breaths per minute. Check breathing and the pulse after 1 minute, then after every 2 minutes
· if pulse is not present, commence CPR (cardiopulmonary resuscitation)
· check breathing and the pulse after 1 minute , then after every2 minutes. If the pulse returns, continue EAR. If breathing returns , turn the casualty to a stable side position. Check for and manage shock, bleeding and other injuries
· seek medical aid.
If a casualty is not breathing and has no pulse , you should try to give cardiopulmonary resuscitation. However, even if performed expertly , you may not be successfully in saving the casualty's life. Success depends on the cause of the injury or illness, how quickly you are able to respond, and how quickly you are able to respond, and how quickly expert medical aid arrives.
After managing life-threatening problems turn the casualty to a stable side position. Remember that you must call medical aid as soon as possible, You should then undertake an orderly assessment of the casualty, looking for any bleeding , then other injuries such as burns and fractures. Note any tenderness, swelling, wounds or deformity.
Examine the casualty in the following order :
· head and neck
· chest (including shoulders)
· abdomen (including hip bone)
· upper limbs
· lower limbs
General rules for fracture management:
· control bleeding and cover all wounds
· check for fractures - open, closed or complicated
· ask the casualty not to move the injured part
· immobilize fractures with slings, bandages or splints to prevent movement at the joints above and below the fracture
· watch for signs of loss of circulation to the foot or hand
· move the casualty only if there is danger to you or the casualty
· handle gently
· observe casualty carefully and manage shock if necessary
· seek medical aid
· DO NOT move the person unless the broken bone is stable.
· DO NOT move a person with an injured hip, pelvis, or upper leg unless it is absolutely necessary. If you must move the person, pull the person to safety by his clothes (such as by the shoulders of a shirt, a belt, or pant-legs).
· DO NOT move a person who has a possible spine injury.
· DO NOT attempt to straighten a bone or change its position unless blood circulation appears hampered.
· DO NOT try to reposition a suspected spine injury.
· DO NOT test a bone's ability to move.
· Wear protective gear while skiing, biking, roller blading, and participating in contact sports. This includes helmets, elbow pads, knee pads, and shin pads.
· Create a safe home for young children. Gate stairways and keep windows closed.
· Teach children how to be safe and look out for themselves.
· Supervise children carefully. There is no substitute for supervision, no matter how safe the environment or situation appears to be.
· Prevent falls by not standing on chairs, counter tops, or other unstable objects. Remove throw rugs and electrical cords from floor surfaces. Use handrails on staircases and non-skid mats in bathtubs. These steps are especially important for the elderly.
Fractured upper arm
Symptoms and signs
If the injury is closed to, or involves the elbow:
· lay the casualty down, supporting the injured area
· check the pulse at the wrist and the color of the hand and finger
· gently place the injured limb on supporting material by the side of the body. Do not bend the elbow
· immobilize the arm firmly to the body with broad bandages
· tie bandages in front on the uninjured side
· check the pulse
· seek medical aid.
If the injury is not close to the elbow:
· apply a collar and cuff sling
· do not support under the elbow. Allow the elbow to hang freely
· place soft padding between the elbow area and the chest
· immobilize the arm with two broad bandages (or narrow ones for a small person): - one above the fracture, over the arm and surround the chest . - the other below the fracture
· tie off the bandages in front on the uninjured side
· check the pulse
· Seek medical aid.
Symptoms and signs
If fracture is not near the elbow:
1. immobilize the limb firmly to a splint which extents from the elbow to the finger. Bandage:
- above the fracture, below the elbow
- below the fracture
- at the wrist / hand
2. apply an arm sling
3 . seek medical aid
4 . check pulse and color of finger.
If the fracture is near the elbow :
1. immobilize the arm in the position found
2. check the pulse
3. seek medical aid urgently.
This x-ray shows broken (fractured) forearm bones (radius and ulna)
Fracture Of The Hands And The Fingers
Symptoms and signs
Finger or thumb fractures
Symptoms and signs
Fracture Neck Of The Thigh Bone
Symptoms and signs
· severe pain at the site of the injury
· loss of power
· tenderness at the site of the injury
· possibly a rotation of the foot of the injured leg
· possible shortening of the injured leg
· cover open wounds
· place padding between legs
· gently bring uninjured limb to the injured limb
· apply a figure-of-eight bandage around the knees and tie on the uninjured side
· seek medical aid.
If expert assistance is likely to be delayed:
1 . DRABC
2 . cover open wounds
3 . gently bring uninjured limb to the normal position
4 . place a well padded splint between the legs
5 . place one hand under the heel and the other around the toes of the injured limb
6 . gently draw down to apply traction to the foot, while rotating the leg to a position as nearly normal as possible against the splint
7 . apply a narrow figure-of-eight bandage around the ankles and feet
8 . pass bandages under:
- the thighs above the fracture
- the thighs below the fracture
- both knees
- between the knee and the ankles
9 . tie on the uninjured side
10 . check the circulation of both limbs ( note the color and temperature of the skin and feet).
Symptoms and signs
· pain in the area of the hip, thigh or knee when moving the limb
· loss of power
· tenderness over the hip
· outward rotation of the foot of the injured leg
· shortening of the injured leg
· bruising ( seen later ).
· if the casualty has been lying on the ground for a long period of time, manage any scalds to the skin from urine and faeces
· reassure the casualty comfortable
· place padding between legs and under tender spots
· apply a figure-of-eight bandage at the ankle and a broad bandage at the knees
· seek medical aid.
Symptoms and signs
· pain over kneecap, aggravated by movement
· loss of power at the knee
· inability to straighten the leg
· tenderness and swelling over the kneecap
· sometimes a gap can be felt at the front of the knee
· sometimes the displaced kneecap can be felt.
1 . DRABC
2 . lay the casualty on the back with head and shoulders raised
3 . raise the leg about 30 centimentres and support it in the most comfortable position
4 . do not attempt to straighten the knee
5 . if the limb can be splinted without increasing discomfort, then
- apply a pressure bandage around the knee ( figure-of-eight crepe or conforming bandage )
- apply a splint along the back of the limb from buttock to beyond the heel
- ensure that the splint is adequately padded, particularly under the natural hollows of the knee and ankle
- secure the limb to the splint by a figure-of-eight bandage around the thigh, and broad bandage around the lower leg
- seek medical aid.
Fracture Lower Leg
Symptoms and signs
· inability to walk
· shortening of injured leg
· rotation of foot of injured leg
· protruding bone
· control bleeding and cover wounds
· place padding between the legs
· bring the uninjured limb to the injured limb
· steady and support the injured limb
· apply a figure-of-eight bandage around the ankle and feet
· apply a broad bandage the knees, and tie on the uninjured side.
If expert assistance is delayed :
· control bleeding and cover wounds
· lace a well padded splint between the legs, from the thighs to the ankles
· pad between the thighs, knees and ankles
· apply a figure-of-eight bandage around the ankles and feet
· apply a broad bandage around the thighs, at the knees, above and below the fracture
· seek medical aid.
Fracture Feet And Toes
Symptoms and signs
This fracture may be mistaken for a sprain, particularly if no deformity is present.
Symptoms and signs
If no deformity is present :
If deformity is present :
A dislocation is a separation of two bones where they meet at a joint. (Joints are areas where two bones come together.) A dislocated bone is no longer in its normal position, which may result in damage to ligaments, nerves, and blood vessels.
Dislocations are usually caused by a sudden impact to the joint. This usually occurs following a blow, fall, or other trauma.
A dislocated joint may be:
Radial dislocation may be caused by a sudden pull on a child's arm or hand. For first aid, immobilize the arm and take the child to the doctor's office or emergency room.
1. Call emergency before you begin treating someone who may have a dislocation, especially if the accident causing the injury may be life-threatening.
2. If there has been a serious injury, check the person's airway, breathing, and circulation. If necessary, begin rescue breathing, CPR, or bleeding control.
3. Do not move the person if you think that the head, back, or leg has been injured. Keep the person still. Provide reassurance.
4. If the skin is broken, take steps to prevent infection. Do not blow on the wound. Rinse the area gently to remove obvious dirt, but do not scrub or probe. Cover the area with sterile dressings before immobilizing the injury.
5. Splint or sling the injury in the position in which you found it. Do not move the joint. Be sure to immobilize the area above and below the injured joint.
6. Check the person's blood circulation around the injury by pressing firmly on the skin in the affected area. It should blanch white, then regain color within a couple of seconds. Avoid this step if the skin has been broken, to reduce the risk of infection.
7. Apply ice packs to ease pain and swelling.
8. Take steps to prevent
shock. Unless there is a head, leg, or back injury, lay the victim flat,
elevate the feet about
Preventing injuries in children:
Preventing dislocations in adults:
For all age groups:
A sprain is an injury to the ligaments around a joint. Ligaments are strong, flexible fibers that hold bones together. When a ligament is stretched too far or tears, the joint will become painful and swell.
Sprains are caused when a joint is forced to move into an unnatural position. For example, "twisting" one's ankle causes a sprain to the ligaments around the ankle.
Symptoms of a sprain include:
The ankle joint connects the foot with the leg. The ankle joint allows the foot to move upward and downward and in an inward and outward motion. Muscles, tendons, and ligaments surround the ankle providing the stability the ankle joint needs for walking and running.
Aspirin, ibuprofen, or other pain relievers can help. DO NOT give aspirin to children.
Keep pressure off the injured area until the pain goes away. This usually takes 7-10 days for mild sprains and several weeks for severe ones. Your doctor may recommend crutches. Physical therapy will help you regain motion and strength of the injured area.
Minor injuries like sprains may be treated at home if broken bones are not suspected. The acronym RICE is helpful in remembering how to treat minor injuries: "R" stands for rest, "I" is for ice, "C" is for compression, and "E" is for elevation. Pain and swelling should decrease within 48 hours, and gentle movement may be beneficial, but pressure should not be put on a sprained joint until pain is completely gone (one to several weeks).
Keep the affected area elevated and the victim at rest.
Use an ice pack or cold compress to combat pain and swelling.
The following steps may lower your risk of a sprain:
A strain is when a muscle becomes overstretched and tears. This painful injury, also called a "pulled muscle," can be caused by an accident, improper use of a muscle, or overuse of a muscle.
A strain may be caused by:
Symptoms of a strain can include:
The brain is a soft and delicate organ. A hard blow to the head can injure the brain or spinal cord even when there are no visible signs of trauma to the scalp or face. That’s why all head injuries are considered serious and you should consult with your doctor or nearest hospital emergency department.
Two types of head injury
Head injuries are classified as:
Open – with bleeding wounds to the face or head
Closed – no visible signs of injury to the face or head.
The symptoms of a head injury can occur immediately or develop slowly over several hours or days. Even if the skull is not fractured, the brain can bang against the inside of the skull and be bruised. The head may look fine, but complications could result from bleeding or swelling inside the skull.
In any serious head trauma, always assume the spinal cord is also injured.
Some head injuries result in prolonged or nonreversible brain damage. This can occur as a result of bleeding inside the brain or forces that damage the brain directly. More serious head injuries may cause the following symptoms:
· Check the person's airway, breathing, and circulation. If necessary, begin rescue breathing and CPR.
· If the person's breathing and heart rate are normal but the person is unconscious, treat as if there is a spinal injury. Stabilize the head and neck by placing your hands on both sides of the person's head, keeping the head in line with the spine and preventing movement. Wait for medical help.
· Stop any bleeding by firmly pressing a clean cloth on the wound. If the injury is serious, be careful not to move the person's head. If blood soaks through the cloth, do NOT remove it. Place another cloth over the first one.
· If you suspect a skull fracture, do NOT apply direct pressure to the bleeding site, and do NOT remove any debris from the wound. Cover the wound with sterile gauze dressing.
· If the person is vomiting, roll the head, neck, and body as one unit to prevent choking. This still protects the spine, which you must always assume is injured in the case of a head injury. (Children often vomit once after a head injury. This may not be a problem, but call a doctor for further guidance.)
· Apply ice packs to swollen areas.
For a mild head injury, no specific treatment may be needed. However, closely watch the person for any concerning symptoms over the next 24 hours. The symptoms of a serious head injury can be delayed. While the person is sleeping, wake him or her every 2 to 3 hours and ask simple questions to check alertness, such as "What is your name?"
If a child begins to play or run immediately after getting a bump on the head, serious injury is unlikely. However, as with anyone with a head injury, closely watch the child for 24 hours after the incident.
Over-the-counter pain medicine, such as acetaminophen, may be used for a mild headache. Do NOT take aspirin, ibuprofen, or other anti-inflammatory medications because they can increase the risk of bleeding.
Do NOT wash a head wound that is deep or bleeding a lot.
Do NOT remove any object sticking out of a wound.
Do NOT move the person unless absolutely necessary.
Do NOT shake the person if he or she seems dazed.
Do NOT remove a helmet if you suspect a serious head injury.
Do NOT pick up a fallen child with any sign of head injury.
Do NOT drink alcohol within 48 hours of a serious head injury.
Always use safety equipment during activities that could result in head injury. These include seat belts, bicycle or motorcycle helmets, and hard hats.
Obey traffic signals when riding a bicycle. Be predictable so that other drivers will be able to determine your course.
Be visible. Do NOT ride a bicycle at night unless you wear bright, reflective clothing and have proper headlamps and flashers.
Use age-appropriate car seats or boosters for babies and young children.
Make sure that children have a safe area in which to play.
Supervise children of any age.
Do NOT drink and drive, and do NOT allow yourself to be driven by someone whom you know or suspect has been drinking alcohol or is otherwise impaired.
The spinal cord contains the nerves that carry messages between your brain and body. The cord passes through your neck and back. A spinal cord injury is very serious because it can cause loss of movement (paralysis) below the site of the injury.
A spinal cord injury may be caused by:
· Bullet or stab wound
· Traumatic injury to the face, neck, head, chest, or back (for example, a car accident)
· Diving accident
· Electric shock
· Extreme twisting of the middle of the body
· Landing on the head during a sports injury
· Fall from a great height
Symptoms of a spinal cord injury may include:
· Head that is in an unusual position
· Numbness or tingling that spreads down an arm or leg
· Difficulty walking
· Paralysis (loss of movement) of arms or legs
· No bladder or bowel control
· Shock (pale, clammy skin; bluish lips and fingernails; acting dazed or semiconscious)
· Lack of alertness (unconsciousness)
· Stiff neck, headache, or neck pain
Never move anyone who you think may have a spinal injury, unless it is absolutely necessary. For example, if you need to get the person out of a burning car.
Keep the person absolutely still and safe until medical help arrives.
· Call the local emergency number
· Hold the person's head and neck in the position in which they were found. DO NOT try to straighten the neck. Do not allow the neck to bend or twist.
· Do not allow the person to get up and walk unassisted.
If the person is not alert or responding to you:
· Check the person's breathing and circulation. If necessary, begin rescue breathing and CPR.
· DO NOT tilt the head back when doing CPR. Instead, place your fingers on the jaw on each side of the head. Lift the jaw forward.
Do not roll the person over unless the person is vomiting or choking on blood, or you need to check for breathing. If you need to roll the person over:
· Two people are needed.
· One person should be located at the person's head; the other at the person's side.
· Keep the person's head, neck, and back in line with each other while you roll him or her onto one side.
To roll an injured person two people are needed. One person is stationed at the head and the other at the victim's side. The person on the side places one hand on the victim's shoulder and the other on the victim's thigh area. The person at the victim's head stabilizes the head and neck so that the head and neck does not bend, move, or twist in any direction.
· DO NOT bend, twist, or lift the person's head or body.
· DO NOT attempt to move the person before medical help arrives unless it is absolutely necessary.
· DO NOT remove a helmet if a spinal injury is suspected.
The following may lower your risk of spinal injury:
CHEST AND ABDOMINAL INJURIES
Injuries to the chest and abdomen can be difficult to recognize and treat, and many injuries can go unnoticed until they become very serious. The muscle and bones that serve to protect vital organs can also mask their injuries - or at worst contribute to them. It is important for the rescuer to consider injuries that lie beneath the skin.
In addition, the different organs react in different ways when subjected to trauma. Hollow organs (such as the bladder) tend to rupture, releasing their contents into the surrounding space. Solid organs (such as the liver) tend to tear instead, often bleeding at a slow enough rate to be overlooked.
CLOSED CHEST INJURIES
Chest injuries can be inherently serious, as this area of the body houses many critical organs, such as the heart, lungs, and many blood vessels. Most chest trauma injuries should receive professional medical attention. Always call for an ambulance for any potentially serious chest injury.
A common result of trauma to the chest is damage to the victim's rib cage. The curved shape of the rib cage helps to deflect the force of some injuries, but damage to cartilage or the ribs themselves can still result. While a single broken rib can be very painful for the patient, a number of broken ribs can lead to other complications. A victim with broken ribs may take very shallow breaths without even noticing it, as their body tries to prevent the pain with taking a full breath.
The third to tenth ribs tend to be injured most frequently because they have limited protection. Fracture of the first and second ribs, which are protected by the clavicle, scapula, humerus, and chest musculature, indicates a high-energy mechanism of injury and is associated with a high risk for vascular injury. Lower rib fractures may be associated with concurrent spleen, liver, and kidney injuries.
When do rib fractures tend to heal?
Callus starts to form at the fracture site within 10-14 days after injury. The ribs typically heal within 3-6 weeks unless comminuted fractures or major displacement is present.
When many adjoining ribs are broken in different places, a portion of the rib cage can move in the opposite direction the chest should. This is known as a "flail" segment, and can make breathing very painful and less effective.
OPEN CHEST WOUNDS
An open pneumothorax or sucking chest wound - the chest wall has been penetrated.
Making a flutter valve
Get some sort of plastic that is bigger than the wound. Ideas: credit card or similar, Ziploc bag, some first aid kits will have a ready-to-use valve. Tape the plastic patch over the wound on only 3 sides. The 4th side is left open, allowing blood to drain and air to escape. This opening should be at the bottom (as determined by the victim’s position). When the casualty inhales, the bag will be sucked in, but when the casualty exhales, the air will exit through the untaped side.
If a trauma injury has caused the victim's internal organs to protrude outside the abdominal wall, do not push them back in. Doing so will only cause greater complications - remember that preventing further injury is one of the aims of first aid.
Instead, have the person lie flat with their knees bent and cover the organs with a moist, sterile dressing composed of material that will not stick to the affected organs. Normally a special dressing, ABD Pad (Army Battle Dressing) or trauma dressing is used. Gauze can stick if it is dry - be careful to keep normal gauze moist if you do use it. Paper products like paper towel or toilet paper must never be used, as they will turn to pulp, causing major complications. Do not allow the victim to eat or drink, though they may complain of extreme hunger or thirst. Call an ambulance, treat for shock, and monitor ABCs until the emergency medical team arrives.
If the abdominal injury does not cause an open wound, have the person lie flat with their knees bent and treat for shock until EMS arrives.
The human body conducts electricity very well. That means, electricity passes very easily throughout the body. Direct contact with electrical current can be deadly. While some electrical burns look minor, there still may be serious internal damage, especially to the heart, muscles, or brain.
Electric current can cause injury in three ways:
· Cardiac arrest due to the electrical effect on the heart
· Muscle, nerve, and tissue destruction from a current passing through the body
· Thermal burns from contact with the electrical source
· Accidental contact with exposed parts of electrical appliances or wiring
· Flashing of electric arcs from high-voltage power lines
· Machinery or occupational-related exposures
· Young children biting or chewing on electrical cords, or poking metal objects into an electrical outlet
Symptoms depend on many things, including the type and strength of voltate, how long you were in contact with the electricity, how it moved through your body, and your overall health.
Symptoms may include:
· Changes in alertness (consciousness)
· Broken bones
· Heart attack
· Problems with swallowing, vision, or hearing
· Irregular heartbeat
· Muscle spasms and pain
· Numbness or tingling
· Breathing problems or lung failure
· Skin burns
1. If you can do so safely, turn off the electrical current. Unplug the cord, remove the fuse from the fuse box, or turn off the circuit breakers. Simply turning off an appliance may NOT stop the flow of electricity. Do NOT attempt to rescue a person near active high-voltage lines.
2. Call your local emergency number.
3. If the current can't be turned off, use a non-conducting object, such as a broom, chair, rug, or rubber doormat to push the person away from the source of the current. Do not use a wet or metal object. If possible, stand on something dry and that doesn't conduct electricity, such as a rubber mat or folded newspapers.
4. Once the person is away from the source of electricity, check the person's airway, breathing, and pulse. If either has stopped or seems dangerously slow or shallow, start first aid (cardiopulmonary resuscitation)
5. If the person has a burn, remove any clothing that comes off easily, and rinse the burned area in cool running water until the pain subsides. Give first aid for burns.
6. If the person is faint, pale, or shows other signs of shock, lay him or her down, with the head slightly lower than the trunk of the body and the legs elevated, and cover him or her with a warm blanket or a coat.
7. Stay with the person until medical help arrives.
8. Electrical injury is frequently associated with explosions or falls that can cause additional severe injuries. You may not be able to notice all of them. Do not move the person's head or neck if the spine may be injured.
Stay at least
Do NOT touch the person with your bare hands if they are still in contact with the source of electricity
Do NOT apply ice, butter, ointments, medications, fluffy cotton dressings, or adhesive bandages to a burn
Do NOT remove dead skin or break blisters if the person has been burned
After the power is shut off, do NOT move the person unless there is a risk of fire or explosion
· Avoid electrical hazards at home and at work. Always follow manufacturer's safety instructions when using electrical appliances
· Avoid using electrical appliances while showering or wet
· Keep children away from electrical devices, especially those that are plugged in
· Keep electrical cords out of children's reach
· Never touch electrical appliances while touching faucets or cold water pipes
· Teach children about the dangers of electricity
· Use child safety plugs in all outlets