+ All Categories
Home > Documents > Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Date post: 26-Mar-2015
Category:
Upload: leah-stokes
View: 236 times
Download: 0 times
Share this document with a friend
Popular Tags:
of 44 /44
Obstetric Obstetric Emergencies Emergencies Dr Mohamed Abdul Hakim Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Kotb,MBBCH,MSC,MD Anaesthesia & ICU Anaesthesia & ICU
Transcript
Page 1: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Obstetric EmergenciesObstetric Emergencies

Dr Mohamed Abdul Hakim Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Kotb,MBBCH,MSC,MD

Anaesthesia & ICUAnaesthesia & ICU

Page 2: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Obstetric emergenciesObstetric emergenciesMassive obstetric haemorrhageMassive obstetric haemorrhage

Non-haemorrhagic shock:Non-haemorrhagic shock:– Amniotic fluid embolismAmniotic fluid embolism– Acute uterine inversionAcute uterine inversion

Shoulder dystociaShoulder dystocia

EclampsiaEclampsia

Cord prolapseCord prolapseCardiac ArrestCardiac ArrestAnaphylaxisAnaphylaxisTRAUMATRAUMA

Page 3: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

BASIC PRINCIPLES FOR OBSTETRIC BASIC PRINCIPLES FOR OBSTETRIC EMERGENCIES.EMERGENCIES.

Physiological changes in pregnancy modify:Physiological changes in pregnancy modify:• Presentation of the problemPresentation of the problem• Normal physiological variablesNormal physiological variables• Response to treatmentResponse to treatment

Both mother & fetus are affected by the pathology & Both mother & fetus are affected by the pathology & subsequent treatment.subsequent treatment.

Mother’s welfare always takes precedence over fetal Mother’s welfare always takes precedence over fetal concerns ---concerns ---Fetal survival is usually dependant on optimal maternal Fetal survival is usually dependant on optimal maternal management.management.

Page 4: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.
Page 5: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

MASSIVE OBSTETRIC MASSIVE OBSTETRIC HAEMORRHAGEHAEMORRHAGE

Major contributor to maternal mortalityMajor contributor to maternal mortalityDefinitionDefinition– Blood loss requiring replacement of patient’s total blood Blood loss requiring replacement of patient’s total blood

volumevolume– Transfusion requiring > 10 u of blood in 24 hsTransfusion requiring > 10 u of blood in 24 hs– 50% replacement of blood vol. <3 hs period50% replacement of blood vol. <3 hs period

Difficult to estimate blood lossDifficult to estimate blood lossProblem of concealed bleedingProblem of concealed bleeding– UterusUterus– Broad lig.Broad lig.– Peritoneal cavityPeritoneal cavity

Page 6: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

RECOGNISING SIGNIFICANT RECOGNISING SIGNIFICANT BLOOD LOSSBLOOD LOSS

10 – 15%10 – 15%500-1000ml500-1000ml

Normal BPNormal BP

No signs.No signs.

15-25%15-25%1000-1500ml1000-1500ml

BP ~ 100mmHgBP ~ 100mmHg

Dizziness, Dizziness, tachycardiatachycardia

25-35%25-35%1500-2000ml.1500-2000ml.

BP ~ 70-80mmHg.BP ~ 70-80mmHg.

Restlessness,pallor, Restlessness,pallor, oliguria.oliguria.

35-45%35-45%2000-3000ml2000-3000ml

50-70mmHg50-70mmHg

Collapse, air hunger, Collapse, air hunger, anuriaanuria

Page 7: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Factors contributing to maternal Factors contributing to maternal death from catastrophic PPHdeath from catastrophic PPH

GeneralGeneralIncreased oxygen and Increased oxygen and cardiac output cardiac output requirements of requirements of pregnancy may hamper pregnancy may hamper adequate blood / volume adequate blood / volume replacementreplacement– Placental bed perfusion 600 Placental bed perfusion 600

mls/minmls/min

Blood loss Blood loss underestimatedunderestimatedDelayed or inadequate Delayed or inadequate managementmanagementInadequate resources / Inadequate resources / personnelpersonnel

SpecificSpecificFailure to anticipate Failure to anticipate coagulopathycoagulopathyPET, abruption, sepsis, PET, abruption, sepsis, IUFD, IUFD, AFE.AFE.Abnormal placentationAbnormal placentationPlacenta praevia / accretaPlacenta praevia / accretaJehovah’s witness**Jehovah’s witness**

Page 8: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Mechanism of DICMechanism of DIC1) intravascular infusion of thromboplastic 1) intravascular infusion of thromboplastic substances that initiate the extrinsic substances that initiate the extrinsic coagulation systemcoagulation system– placental abruption, IUFDplacental abruption, IUFD

2) conditions associated with endothelial 2) conditions associated with endothelial cell damage, which activates both the cell damage, which activates both the extrinsic and intrinsic coagulation systemsextrinsic and intrinsic coagulation systems– eclampsia/ PETeclampsia/ PET

3) indirect effects of other disease, such as 3) indirect effects of other disease, such as G- sepsis, AFE etcG- sepsis, AFE etc

Page 9: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Preventative Management PPHPreventative Management PPH Detect and treat antenatal anaemia Detect and treat antenatal anaemia Active Management of Third StageActive Management of Third Stage

Administration of a prophylactic oxytocin Administration of a prophylactic oxytocin Early cord clamping Early cord clamping Controlled cord traction of the umbilical cord. Controlled cord traction of the umbilical cord.

Advantage of active management = reduction in the Advantage of active management = reduction in the incidence of PPH by 40%incidence of PPH by 40%

IV access plus collect blood for grouping IV access plus collect blood for grouping and cross matching if assessed as at risk. and cross matching if assessed as at risk.

Page 10: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Available from Royal Women’s Hospital, Carlton, Clinical Practice Guidelines: http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3333

Page 11: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Management PrinciplesManagement Principles

OrganisationOrganisationrestoration of blood volumerestoration of blood volumecorrection of coagulopathycorrection of coagulopathyevaluating response to treatmentevaluating response to treatment

monitoring PR, BP, CVP, ABG, UOPmonitoring PR, BP, CVP, ABG, UOPIf resuscitation is adequate P & BP should return If resuscitation is adequate P & BP should return to normalto normal

treat the causetreat the causeabruptionabruptionplacenta praeviaplacenta praeviauterine ruptureuterine ruptureplacenta accretaplacenta accreta

Page 12: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Available from Royal Women’s Hospital, Carlton, Clinical Practice Guidelines: http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3333

Page 13: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

NON-HAEMORRHAGIC NON-HAEMORRHAGIC OBSTETRIC SHOCKOBSTETRIC SHOCK

Uncommon but responsible for Uncommon but responsible for majority of maternal deaths in majority of maternal deaths in developed countries.developed countries.

-Amniotic fluid embolus-Amniotic fluid embolus

-Acute uterine inversion-Acute uterine inversion

Page 14: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Amniotic Fluid EmbolismAmniotic Fluid Embolism

– Passage of amniotic fluid debris into maternal circulation

– Obstructs pulmonary circulation

– Cardio-respiratory arrest

Page 15: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

AMNIOTIC FLUID EMBOLISMAMNIOTIC FLUID EMBOLISM

Clinical featuresClinical features– Multiparous womenMultiparous women– Precipitous labourPrecipitous labour– Presence of intact membranesPresence of intact membranes– Sudden dyspneaSudden dyspnea– HypotensionHypotension– Seizure activity not uncommonSeizure activity not uncommon– If survive initial insultIf survive initial insult

70% suffer non-cardiogenic pulmonary oedema70% suffer non-cardiogenic pulmonary oedema

ARDSARDS

Page 16: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

AMNIOTIC FLUID EMBOLISMAMNIOTIC FLUID EMBOLISM

DiagnosisDiagnosis– Consider in all obstetric patients with Consider in all obstetric patients with

sudden collapse.sudden collapse.– DifferentialDifferential

PTEPTE

Septic shockSeptic shock

MIMI

Aspiration pneumoniaAspiration pneumonia

Allergy to drugAllergy to drug

Page 17: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

ManagementManagement

Secure airwaySecure airway

treat cardiovascular collapsetreat cardiovascular collapse

central venous linecentral venous line

acute left ventricular failure: digoxinacute left ventricular failure: digoxin

dopaminedopamine

correct coagulopathycorrect coagulopathy

treat metabolic/electrolyte treat metabolic/electrolyte abnormalitiesabnormalities

Page 18: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Acute Uterine InversionAcute Uterine Inversion

Most commonly arises from Most commonly arises from mismanaged 3mismanaged 3rdrd stage stage

Page 19: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.
Page 20: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

PresentationPresentation

Sudden collapse in 3Sudden collapse in 3rdrd stage stage

Degree of shock inconsistent with Degree of shock inconsistent with blood lossblood loss

Shock is neurogenic in natureShock is neurogenic in natureTraction on infundibular pelvic ligamentTraction on infundibular pelvic ligament

May be no palpable fundusMay be no palpable fundus

Mass in vagina/introitusMass in vagina/introitus

Page 21: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

ManagementManagement

Avoid mismanagement of 3Avoid mismanagement of 3rdrd stage of stage of labourlabour

Once occursOnce occurs– Anti-shock measuresAnti-shock measures– If placenta still attached remove after If placenta still attached remove after

uterus is replaceduterus is replaced– Manual replacement of uterusManual replacement of uterus– O’Sullivans hydrostatic pressureO’Sullivans hydrostatic pressure– Surgical correctionSurgical correction

Page 22: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Shoulder DystociaShoulder Dystocia

Page 23: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Erb’s palsy

Page 24: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

‘‘It all comes,’ said Pooh crossly, ‘of not It all comes,’ said Pooh crossly, ‘of not having front doors big enough’having front doors big enough’

Page 25: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

‘‘It all comes’, said Rabbit It all comes’, said Rabbit sternly, ‘of eating too much’sternly, ‘of eating too much’

Page 26: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.
Page 27: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Risk FactorsRisk FactorsMacrosomia (>4kg)Macrosomia (>4kg)– maternal diabetesmaternal diabetes– post datespost dates– maternal obesitymaternal obesity– high maternal wgt high maternal wgt

gain in pregnancygain in pregnancy– advanced maternal advanced maternal

ageage– previous large infantprevious large infant– previous shoulder previous shoulder

dystociadystocia

IntrapartumIntrapartum– protracted late active protracted late active

phasephase– prolonged 2nd stageprolonged 2nd stage– delay in head descent delay in head descent

in 2nd stagein 2nd stage– mid-pelvic operative mid-pelvic operative

deliverydelivery

The combination of macrosomia and delay in 2nd stage predicts 35% of shoulder dystocia

Page 28: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

EclampsiaEclampsia

1/15001/1500

Page 29: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

ComplicationsComplications

Cerebrovascular injuryCerebrovascular injury

pulmonary oedemapulmonary oedema

coagulopathycoagulopathy

maternal/fetal deathmaternal/fetal death

HELLP syndromeHELLP syndrome

Page 30: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

PresentationPresentation

Hypertension, hyperreflexia, clonus, Hypertension, hyperreflexia, clonus, headache, visual changes, seizureheadache, visual changes, seizure

20% have diastolic BP<90, normal 20% have diastolic BP<90, normal reflexes, and urinary protein <2+reflexes, and urinary protein <2+

70% of deaths due to intracerebral 70% of deaths due to intracerebral haemorrhagehaemorrhage

Page 31: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Management Management

• • Goals:Goals:– – Stabilization of the mother/seizure controlStabilization of the mother/seizure control• • MgSO4 therapy: 4-6 g over 20 min MgSO4 therapy: 4-6 g over 20 min

followed byfollowed byinfusion of 1-3 g/hr, ORinfusion of 1-3 g/hr, OR• • Thiopental or diazepam followed by Thiopental or diazepam followed by

MgSO4MgSO4infusioninfusion– – Airway managementAirway management– – Avoiding aspirationAvoiding aspiration

Page 32: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Prolapsed CordProlapsed Cord

1/500 deliveries

Most occur during ARM

Page 33: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

PresentationPresentation

Cord visible outside the introitusCord visible outside the introitus

CTG abnormalities appearCTG abnormalities appear– variable decelerationsvariable decelerations– fetal bradycardiafetal bradycardia

Note: fetal or maternal injury due to Note: fetal or maternal injury due to hasty interventionhasty intervention

Page 34: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

ManagementManagementKeep cord warm - replacing in vagina Keep cord warm - replacing in vagina may helpmay helpKeep pressure off cord by gloved Keep pressure off cord by gloved hand in vagina lifting fetal part off the hand in vagina lifting fetal part off the cordcord

Positioning,Maternal OPositioning,Maternal O22, IV access, IV accessIf fetus is alive, operative delivery - If fetus is alive, operative delivery - CS if not able to deliver vaginallyCS if not able to deliver vaginallyIf fetus is dead, vaginal delivery if If fetus is dead, vaginal delivery if presentation allowspresentation allows

Page 35: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

AnaphylaxisAnaphylaxisvasodilatation, smooth muscle contraction, vasodilatation, smooth muscle contraction, glandular secretion, increased capillary glandular secretion, increased capillary permeabilitypermeabilityManagementManagement: : – oxygenoxygen– colloidcolloid– bronchodilator bronchodilator – adrenaline (despite Ux stimulatory effect)adrenaline (despite Ux stimulatory effect)– anti-histamine (if angioneurotic oedema)anti-histamine (if angioneurotic oedema)– steroid (for refractory bronchospasm)steroid (for refractory bronchospasm)

Page 36: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Maternal cardiac emergencyMaternal cardiac emergency

Acute:Acute:– AMIAMI– Tocolytic therapyTocolytic therapy– Aortic dissecting aneurysmAortic dissecting aneurysm– Peripartum cardiomyopathyPeripartum cardiomyopathy: :

1 in 50000, 50% progress to end-stage 1 in 50000, 50% progress to end-stage heart failure (heart Tx), 50% recurrence.heart failure (heart Tx), 50% recurrence.Suspect if acute SOB, chest pain, abN Suspect if acute SOB, chest pain, abN ECG, signs LVF/RVFECG, signs LVF/RVF

– Traumatic myocardial contusionTraumatic myocardial contusion: ie: : ie: MCAMCA

Page 37: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Drug OverdoseDrug OverdoseIllicit drugsIllicit drugs: heroin, cocaine and : heroin, cocaine and amphetamines (these 2 can cause amphetamines (these 2 can cause hypertension, ^ C.O., decrease Uterine blood hypertension, ^ C.O., decrease Uterine blood flow, APH, cerebral haemorrhage, convulsions, flow, APH, cerebral haemorrhage, convulsions, arrhythmias).arrhythmias).Drug overdoseDrug overdoseDrug errorDrug errorAnaphylaxisAnaphylaxisHypermagnesaemiaHypermagnesaemia::– wide QRS on ECG, 5-6mmol/l lose tendon reflexwide QRS on ECG, 5-6mmol/l lose tendon reflex– resp. paralysis, SA and AV node blockresp. paralysis, SA and AV node block– cardiac arrest. cardiac arrest.

TreatmentTreatment: CaGluconate 10% 10ml slow IV: CaGluconate 10% 10ml slow IV

Page 38: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

CARDIO-PULMONARY ARRESTCARDIO-PULMONARY ARRESTCardiac arrest rare in pregnancy (1 in 30000 Cardiac arrest rare in pregnancy (1 in 30000 deliveries)deliveries)

Usually associated with particular obstetric Usually associated with particular obstetric complications like amniotic fluid embolism, drug complications like amniotic fluid embolism, drug toxicity from Magnesium sulphate & local toxicity from Magnesium sulphate & local anesthetics.anesthetics.

Page 39: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Technique for external cardiac massage:Technique for external cardiac massage: External cardiac massage in non-obstetric patient External cardiac massage in non-obstetric patient

provides 30% cardiac output.provides 30% cardiac output. After 20 weeks reduced further due to veno-caval After 20 weeks reduced further due to veno-caval

compression.compression. Relief of aorto-caval compression part of BLS:Relief of aorto-caval compression part of BLS: left lateral tilt --- decreased efficacy of compressionsleft lateral tilt --- decreased efficacy of compressions wedge 27wedge 2700 angle allows 80% of maximal force to be angle allows 80% of maximal force to be

dissipateddissipated rescuer’s thigh as wedge.rescuer’s thigh as wedge.

Sodium bicarbonate controversial as it leads to fetal Sodium bicarbonate controversial as it leads to fetal acidosis but pH has to be kept above 7.30 to prevent acidosis but pH has to be kept above 7.30 to prevent uterine vasoconstriction.uterine vasoconstriction.

International Liaison Committee on Resuscitation International Liaison Committee on Resuscitation (ILCOR) (ILCOR) “ “ if there is no response to ALS, peri-mortem caesarean if there is no response to ALS, peri-mortem caesarean delivery should be made within 5 minutes of arrest”delivery should be made within 5 minutes of arrest”

Page 40: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

TRAUMATRAUMAOccurs in 6-7% of all pregnancies.Occurs in 6-7% of all pregnancies.

Hospital admissions only 0.3- 0.4 % of all Hospital admissions only 0.3- 0.4 % of all pregnancies.pregnancies.

1% of all trauma cases are pregnant.1% of all trauma cases are pregnant.

Maternal deaths associated most commonly Maternal deaths associated most commonly with head injuries & severe hemorrhage.with head injuries & severe hemorrhage.

Fetal deaths associated with placental Fetal deaths associated with placental abruption & maternal death.abruption & maternal death.

Page 41: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

ManagementManagementInitial resuscitation should follow normal plan of Initial resuscitation should follow normal plan of ABC.ABC.

Hypotension may not be present until 35% or Hypotension may not be present until 35% or more blood volume is lost.more blood volume is lost.

Aorto-caval compression releaseAorto-caval compression release

Rule out pelvic fractures, uterine injury & retro-Rule out pelvic fractures, uterine injury & retro-peritoneal hemorrhageperitoneal hemorrhage

Fetal monitoring with cardio-tocographic monitor Fetal monitoring with cardio-tocographic monitor

Rh immunoglobulin – within 72 hours.Rh immunoglobulin – within 72 hours.

Radiation hazards: Radiation hazards: 11stst trimester >5 rads trimester >5 rads

Chest x-ray < 5 radsChest x-ray < 5 rads

Pelvic film <1 radsPelvic film <1 rads

Abdomino-pelvic CT scan 5-10 radsAbdomino-pelvic CT scan 5-10 rads

Page 42: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

BURNSBURNSIncreased levels of prostaglandins predispose to Increased levels of prostaglandins predispose to pre-term labour.pre-term labour.

Replacement of fluids vis-à-vis increased volumes Replacement of fluids vis-à-vis increased volumes in pregnancy.in pregnancy.

Inhalational injury- hypoxia & carbon monoxide Inhalational injury- hypoxia & carbon monoxide poisoningpoisoning

Infections- prophylactic antibiotics controversialInfections- prophylactic antibiotics controversial

Topical Povodine iodine- affects fetal thyroid Topical Povodine iodine- affects fetal thyroid functionsfunctions

Page 43: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.
Page 44: Obstetric Emergencies Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Anaesthesia & ICU.

Recommended