Background: Postpartum haemorrhage (PPH) is the leading cause of maternal death worldwide. For every woman that dies, 20 or 30 more will experience morbidity. Severe PPH is increasing and is the leading cause of severe maternal morbidity in the UK. Rapid recognition of PPH is essential, but concealed bleeding, underestimation of blood loss and a failure to appreciate the physiological effects of blood loss, lead to delays in recognition and treatment. Experts believe that most deaths from PPH could be avoided by earlier diagnosis, but there is a lack of evidence on how to achieve this. Aims: To explore the experiences of those involved in evaluating blood loss during childbirth; and to develop and test a theory of blood loss evaluation and PPH recognition, as a prerequisite to developing strategies to support earlier diagnosis. Study Design: A sequential, exploratory mixed methods design was used. Methods: Qualitative methods included 8 focus groups and 19 one-to-one semi-structured interviews, conducted with 50 participants. These included: women and their birth partners (recruited from Liverpool Women's Hospital); and health professionals (midwives and obstetricians recruited from Saint Mary's Hospital, Manchester). A purposive sampling strategy was used to recruit women, who had experienced vaginal birth with or without PPH, and health professionals, with varying levels of experience in blood loss evaluation and PPH management. A snowball sampling strategy was used to recruit the birth partners of women participants. Phase one was completed from June to September 2014. All discussions were audio-recorded and transcribed verbatim. Data were managed using NVivo 10 qualitative data analysis software, which also supported the Framework approach to analysis and interpretation. Quantitative methods were used in phase two and involved 10 midwives and 11 obstetricians, recruited from Liverpool Women's Hospital, during February and March 2015. Two scenarios, one of fast and one of slow blood loss, were presented to the sample using clinical simulation with the NOELLE® childbirth simulator, in a pilot, randomised, cross-over study. Participants also completed three questions about the use of the NOELLE® mannequin for these types of scenarios. IBM SPSS Statistics version 23 software was used for quantitative data management and to estimate descriptive statistics. Numerical crossover data were copied into StatsDirect software, to perform the crossover analyses. Results: Women and birth partners were very perceptive to blood loss but felt ill-prepared for the reality of bleeding, with many experiencing negative emotional responses to both PPH and the lochia. Non-verbal communication from staff was used by women and their birth partners to interpret the seriousness of their blood loss. Health professionals: Recognition of PPH mainly occurs as an automatic response to the speed of blood flow. Volume of blood loss is often ascertained and used retrospectively after a PPH diagnosis, to validate the intuitive response and to guide and justify on-going decisions. This was confirmed by the simulation studies, where treatment was initiated at 100ml or less in all blood loss scenarios. Fast blood loss was more likely than slow blood loss to elicit a PPH response, despite volumes in the two groups being similar. Formal quantification of blood loss is not used routinely in practice. When it is used, values are often unofficially normalised to reflect health professionals' perceptions of the woman's clinical condition. Tools introduced to aid diagnosis, such as blood collection bags, routine weighing and the use of early warning scores, are not routinely used in the immediate post-birth period, especially if the woman and her blood loss are perceived to be normal. The tools are again used to validate intuitive feelings about blood loss and maternal condition. When they are used, the values are often modified if they contradict professional judgement. Conclusions: Women and birth partners want more information, open communication, and on-going support, to minimise the emotional impact of blood loss. For health professionals, the speed of blood loss is the crucial factor in PPH recognition rather than an accurate assessment of the volume of blood loss. The amount of visible blood is generally not initially interpreted as a volume, but is used to compare current blood losses to those previously witnessed. Experience therefore plays a crucial role in the decisions of whether blood loss is considered normal or excessive. Formal quantification of blood loss and regular recording of physiological observations do not occur routinely in the immediate post-birth period. Therefore, women with insidious blood loss can have delayed PPH diagnosis because they have a normal blood flow and exhibit minimal physiological changes, due to the compensatory mechanisms of shock. Often such women need to exhibit outward signs of physiological compromise, such as fainting or feeling unwell, before their physiological observations and blood loss are formally re-evaluated. Education of health professionals should highlight the common errors of judgement made during blood loss evaluation and provide feedback on cases of delayed recognition. Future research should examine normal postnatal bleeding in the hours following birth, and create visual aids for women to self-diagnose insidious blood loss. Training should focus on the skills of PPH recognition, particularly those with insidious blood loss and postnatal physiological assessments. Novel tools such as the shock index should be considered and evaluated as tools of assessment.

ABSTRACT Naturalistic Inquiry was used to explore, describe and discover the experiences and perceptions of men whose partners have been admitted to an Intensive Care Unit (ICU) immediately after childbirth. The sixteen men's experiences were explored using semi-structured open-ended questions. Data were analysed using thematic content analysis. The research questions driving this study were: • What are men's experiences and perceptions of the incidence and impact of their partners being admitted to ICU following the complications of childbirth? • What is the nature of the relationships and interactions that men have with healthcare professionals before, during and after their partner's ICU admission following the complications of childbirth? • What impact did the experience of their partners being admitted to ICU, following the complications of childbirth, have on the men's relationships with their partners, newborn child, and other children? • What impact did the experiences of their partners being admitted to ICU following the complications of childbirth have on their future life plans? During the time of their partners' obstetric crisis the men, in this study, were left isolated, alone and struggling. The current healthcare policy and practice for men with their partners in life-threatening situations intrapartum and immediately postpartum failed 16 families.

A retrospective review was made of the case records, angiograms and computed tomography (CT) relating to a total of 263 patients with subarachnoid haemorrhage (SAH) due to ruptured berry aneurysms who were admitted to the Department of Neurosurgery, Wentworth Hospital during the four years 1983-1986. The part of the thesis concerning vasospasm (VS) includes two independent studies on calcium blocker Nimodipine (NO) in the prevention and treatment of VS done by the author. The aim of the thesis is to analyse the management problems of aneurysmal SAH, and investigate factors influencing outcome in order to establish the best possible management policy. The results are discussed and related to the recent data from literature. The main factors influencing outcome were: clinical condition of the patient, the timing of admission and surgery, hypertension and hyperglycaemia on admission, presence of vasospasm and related CT appearance of a thick layer of blood or clot in subarachnoid haemorrhage (CT-Fisher 3). The systemic administration of the calcium blocker nimodipine did not reverse or prevent delayed vasospasm and caused serious adverse effects i.e. hypotension and hyperglycaemia. The results of the thesis suggest a change in management policy and timing of surgery should depend. on clinical condition of the patient on admission (Hunt & Hess grading)(HH I/II grade (HH as possible regardless of timing of admission and results of radiological investigations (CT, angiography). Early surgery (1-3 days) should be the aim of the effort including referral, transport and hospital organisation. III grade (HH surgery should be performed soon after day 10 post-SAH. Particular attention should be paid to the careful preparation and selection of patients for angiography. IV/V grade (HH in specialised units as s000n as possible, preferably neurological or neurosurgical wards, and operated on as soon as their grade improves or, in selected (by surgeon, radiologist and anaesthetist) cases by delayed surgery ( after day 10 post-SAH). / Thesis (M.Med.)-University of Natal, Durban, 1988.

Abstract Subarachnoid haemorrhage (SAH) is a life-threatened disease with poor outcome. It is usually caused by an intracranial aneurysm (IA) rupture and rapid diagnosis and treatment are of great importance. Computed tomography (CT) is a reliable method to detect the blood in the subarachnoid (SA) spaces. Digital subtraction angiography (DSA) offers dynamic and morphological information of a ruptured IA. The treatment options for excluding an aneurysm from the main circulation are neurosurgical clipping and endovascular procedures. The purpose of the present study was to evaluate the risk factors of acute hydrocephalus (HC) and the reliability to localize the ruptured aneurysm based on non-contrast CT. The aim was also to compare the effect of neurosurgical and endovascular treatment on the development of chronic HC, and evaluate the incidence and the risk factors of early rebleeding (<  30 days) after coiling. The data of 180 operated patients with a ruptured IA were checked. Two neuroradiologists separately located the IAs based on non-contrast CT. The analyses of blood amount and distribution was a reliable method for estimating the location of ruptured middle cerebral artery (MCA) aneurysms and anterior communicate artery (ACoA) aneurysms. Intracerebral haemorrhage (ICH) was a predictor for detecting the precise site. The results confirmed that intraventricular haemorrhage (IVH) was the most consistent single risk factor for the development of acute HC. Haemorrhage in the basal region and the large total blood amount in the SA spaces were strong predictors. The effect of early treatment modality for ruptured IAs on the development of chronic HC with 102 clipped and 107 coiled patients was compared. The treatment method used was not significantly associated with the occurrence of chronic HC or the need for shunt operation. The incidence and risk factors of early rebleeding after coiling were investigated in 194 consecutive acutely (within 3 days) coiled patients with ruptured IAs. The incidence of early rehaemorrhage was 3.6%. The presence of ICH at admission and poor clinical condition were significant predictors for rebleeding. An early rehaemorrhage appeared as an enlargement of the ICH in all of these patients. In conclusion, the non-contrast CT is a reliable method to detect the location of ruptured IA in patients with MCA and ACoA aneurysms. The risk factor for the development of acute HC is IVH. Other predictors are the total SA blood amount and blood in the basal regions. The treatment method used for acutely ruptured IA has no significant effect on the occurrence of chronic HC. The incidence of early rebleeding after coiling is low. The risk factors of rebleeding are the presence of ICH and poor clinical condition. Rehaemorrhage appears often as an enlargement of the ICH.

Background: Uncontrolled bleeding accounts for the majority of preventable deaths in the severely injured in both the civilian and military settings. Trauma induced coagulopathy (TIC) is now widely accepted as a major contributing factor to worsening bleeding in these patients. A quarter of severe trauma patients present with coagulopathy on admission and remain a group with high morbidity and mortality. Objectives: To describe the spectrum of coagulation profiles amongst severely injured patients presenting to an urban level-one trauma centre at Groote Schuur Hospital and to correlate these with blood product requirements, morbidity and mortality. Method: This is a retrospective study of all patients with complete baseline TEG coagulation parameters collected prior to randomization in the FIRST (Fluids In Resuscitation of Severe Trauma) trial between January 2007 and December 2009. Parameters recorded for this study included patient demographics, mechanism of injury, admission vital signs, lactate, base excess, coagulation studies PT, INR, TEG parameters, volume and type of fluids administered, volume of blood products administered, length of ICU stay, and major outcomes. Injury severity was categorized according to the Injury Severity Score (ISS) and New Injury Severity Score (NISS). Results: A total of 87 patients were included in this study, with a median ISS of 20 and 57.5% had a penetrating injury mechanism. Coagulopathy was highly prevalent in this cohort, of which a majority (69%) was diagnosed with hypercoagulopathy and 24% had a hypocoagulopathy status on admission. There was no difference in age, gender and amount 9 of pre-hospital fluids administered across the three groups (normal v/s hyper v/s hypo). Median volume of blood products was higher in the hypocoagulopathy group, although not statistically significant. Overall, 30-day mortality rate was 13%, with case fatalities occurring in only coagulopathic patients; hypercoagulopathy (15%) and hypocoagulopathy (10%). Conclusion: Trauma induced coagulopathy is not an infrequent diagnosis and remains a challenging clinical entity to manage in severely injured patients resulting in increased morbidity and mortality. Determining the coagulation profile using TEG at presentation in this group of patients may guide appropriate management guidelines in order to improve outcome. Hypercoagulable patients need to be recognised amongst the TIC patients as it results in different sequelae and impacts on clinical decision in the use of antifibrinolytic agents as compared to hypocoagulopathy.

Background and Objectives: Postpartum haemorrhage (PPH) and mother to child transmission (MTCT) of the Human Immune Deficiency Virus (HIV) are major threats to maternal and foetal health, especially in low and middle income countries. This thesis addressed two main objectives: 1) to investigate strategies for the prevention of PPH, with a focus on misoprostol; 2) to investigate strategies for prevention of mother to child transmission (PMTCT) of HIV, with a focus on the male partner. Methods: We employed a number of study designs including a cross sectional design, a retrospective chart review, and a systematic review which included Classical and Bayesian approaches of meta- analysis. Key methodological issues addressed include the use of propensity score matching methods to address channeling bias; comparison and combination of evidence from different sources; sensitivity analysis in health research; and methods for developing new tools for measurement in health research. Results and Conclusions: Our findings suggests that an oxytocin-misoprostol combination is better than the current standard of care of oxytocin-only which is recommended by the World Health Organisation for the prevention of PPH. Secondly, effectiveness data from well-designed observational studies may be used to inform clinical decisions on misoprostol in the prevention of PPH. Thirdly, using a new tool we have created, it is possible to objectively identify HIV positive women who lack the support of their male partners in adhering to PMTCT recommendations. / Background and Objectives: Postpartum haemorrhage (PPH) and mother to child transmission (MTCT) of the Human Immune Deficiency Virus (HIV) are major threats to maternal and foetal health, especially in low and middle income countries. This thesis addressed two main objectives: 1) to investigate strategies for the prevention of PPH, with a focus on misoprostol; 2) to investigate strategies for prevention of mother to child transmission (PMTCT) of HIV, with a focus on the male partner. Methods: We employed a number of study designs including a cross sectional design, a retrospective chart review, and a systematic review which included Classical and Bayesian approaches of meta- analysis. Key methodological issues addressed include the use of propensity score matching methods to address channeling bias; comparison and combination of evidence from different sources; sensitivity analysis in health research; and methods for developing new tools for measurement in health research. Results and Conclusions: Our findings suggests that an oxytocin-misoprostol combination is better than the current standard of care of oxytocin-only which is recommended by the World Health Organisation for the prevention of PPH. Secondly, effectiveness data from well-designed observational studies may be used to inform clinical decisions on misoprostol in the prevention of PPH. Thirdly, using a new tool we have created, it is possible to objectively identify HIV positive women who lack the support of their male partners in adhering to PMTCT recommendations. / Thesis / Doctor of Philosophy (PhD)

Haematological malignancies and their treatment lead to prolonged periods of severe thrombocytopenia (platelet count ≤ 50 x 10⁹/l). Despite the use of prophylactic platelet transfusions, haemorrhage remains an important complication during this thrombocytopenic period. Within a 30 day period up to 70% of patients have clinically significant haemorrhage (World Health Organization (WHO) grade 2 or above bleeding) and up to 10% have severe or life-threatening haemorrhage (WHO grade 3 or 4 bleeding). Hence our current management of these patients to prevent haemorrhage is sub-optimal. The aim of this thesis was to identify clinical and laboratory factors that may predict the risk of haemorrhage in patients with haematological malignancies and severe thrombocytopenia. This was achieved via several different study designs and assessed the effect of clinical and laboratory factors on any or clinically significant haemorrhage and their effect on intracranial haemorrhage. This thesis has demonstrated that there is no consensus on how bleeding is assessed and graded in this patient group. Also it showed that the absolute immature platelet number may be a better alternative to the total platelet count to guide administration of platelet transfusions. Female sex, a previous history of a fungal infection, a high C-reactive protein, a high white cell count, a low platelet count, anaemia, impaired renal function, and recent clinically significant haemorrhage were all found to be independent risk factors for haemorrhage. Patients who were in complete remission from their haematological malignancy had a much lower risk of bleeding.

No description available.

The trace elements zinc and copper are essential components of many enzymes, some of which are of importance for the development and function of the central nervous system. Deficiency of the metals has been shown to lead to malformations and to the loss of myelin in animals. Earlier reports of zinc concentrations in the cerebrospinal fluid are few and the results variable. In multiple sclerosis and in epilepsy therapy with phenytoin there are varying reports of changes in serum concentrations of zinc and copper. A method was developed for the determination of zinc in cerebrospinal fluid by flame atomic absorption spectrophotometry utilizing a pulse nebulizer technique. Zinc and copper in serum were determined by flame atomic absorption spectrophotometry with conti nous aspiration. The normal concentrations of zinc in cerebrospi nal fluid was 0.16_+0.03 micromoles per litre (mean +_ S.D.). The zinc concentrations were correlated with protein and albumin concentrations in the cerebrospinal fluid but not with the serum zinc levels. In the patients with increased protein concentrations in the cerebrospinal fluid or with subarachnoid haemorrhage increased zinc levels were found. In 50 patients with multiple sclerosis lower serum concentrations of zinc were found compared to age and sex matched controls. In younger patients low serum levels of copper were also observed. There was no correlation between zinc and protein parameters in the cerebrospinal fluid of multiple sclerosis patients. In untreated epileptic males low serum zinc concentrations were observed. During the first 72 hours of phenytoin therapy increased serum concentrations of zinc and copper were found. during long-term therapy with phenytoin alone or in combination with other antiepileptic drugs there was an increased serum concentration of copper and ceruloplasmin but no change in zinc concentration compared with controls. / <p>Diss. Umeå, Umeå universitet, 1982, härtill 4 uppsatser</p> / digitalisering@umu

Thesis (MCurr)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Intraventricular haemorrhage is associated with neurological morbidity and mortality in low birth weight infants. In spite of improvements in treatment to reduce the incidence of the haemorrhage, the condition continues to remain a major cause of long term morbidity in low birth weight infants. The evidence from the literature has shown that low birth weight infants might benefit from delayed cord clamping particularly in reducing the risk of intraventricular haemorrhage and its neurological consequences. The primary objective of this review was to assess the effects of delayed versus early cord clamping on intraventricular haemorrhage amongst low birth weight infants. The secondary objectives were to evaluate the effects of delayed versus early cord clamping on the Apgar scores, hyperbilirubinaemia and polycythaemia in infants. The following electronic databases were searched: CINAHL, MEDLINE (searched via PubMed) and Cochrane Central Register of Controlled Trials (CENTRAL). Other information was gathered from the reference lists of retrieved articles and relevant experts. The selection criteria entailed all randomised controlled trials comparing delayed versus early cord clamping following birth in infants with low birth weight. Two reviewers independently extracted the data and assessed the quality of the trials. Disagreements on studies for inclusion were resolved by discussion with the third reviewer. The review included five randomised controlled trials with 215 participants. The risk of intraventricular haemorrhage was significantly reduced in the delayed compared with early cord clamping (RR0.52, 95% CI 0.33 to 0.82, P=0.005). No statistically significant difference was shown between delayed versus early cord clamping for the risk of hyperbilirubinaemia (RR O.48, 95% CI -0.43 to 1.39, P=0.30). There was no data available for other comparisons: Polycythaemia and Apgar scores. There is growing evidence that delayed cord clamping might benefit low birth weight infants. In the included studies, delayed cord clamping for at least 30 seconds appear to have a potential in reducing the risk of intraventricular haemorrhage. The results of this review should however be interpreted with caution due to a limited number of studies with the absence of clinically important secondary outcomes in the included trials. Further research is required on large scale randomised controlled trials. / AFRIKAANSE OPSOMMING: Intraventrikulêre bloeding word geassosieer met neurologiese morbiditeit en mortaliteit in suigelinge met ’n lae geboortegewig. Ten spyte van die verbetering in die behandeling om die gevalle van bloeding te verminder, duur die toestand voort as ’n belangrike oorsaak van langtermyn morbiditeit in lae gewig geboortes. Bewyse uit die literatuur toon dat suigelinge met ’n lae geboortegewig voordeel mag trek uit vertraagde afklemming, veral deur die vermindering van die risiko van intraventrikulêre bloeding en die neurologiese gevolge daarvan. Die primêre doelwit van hierdie navorsing was om die effek van vertraagde, versus vroeë afklemming op intraventrikulêre bloeding onder suigelinge met ’n lae geboortegewig te bepaal. Die sekondêre doelwit is om die effekte van vertraagde, versus vroeë afklemming op die Apgar uitslae, hiperbilirubinaemia en polisitaemia by suigelinge te evalueer. Die volgende elektroniese databasisse is nagegaan: CINAHL, MEDLINE (soektog via PubMed); Cochrane Central Register of Controlled Trials (CENTRAL). Ander inligting is verkry uit die bronnelyste van nagevorsde artikels en van relevante deskundiges. Die seleksie kriteria behels alle ewekansige beheerde toetsing, insluitende toekomstige studies wat vertraagde, versus vroeë afklemming vergelyk by suigelinge met ’n lae geboortegewig. Twee resensente het onafhanklik data geneem en die kwalititeit van die toetse bepaal. Verskille oor insluiting van navorsing, is met ’n derde resensent deur middel van bespreking opgelos. Die navorsing het vyf ewekansige beheerde steekproewe met 215 deelnemers ingesluit. Die risiko van intraventrikulêre bloeding is beduidend verminder in die vertraagde gevalle, in teenstelling met vroeë afklemming (RR0.52, 95% CI 0.33 tot 0.82, P=0.005). Geen statistiese beduidende verskil is bewys tussen vertraagde teenoor vroeë afklemming ten opsigte van hiperbilirubinaemia nie (RR 0.48, 95% CI – 0.43 tot 1.39, P=0.30). Daar was geen data beskikbaar vir ander vergelykings nie: Polisytaemia en Apgar uitslae. Daar is groeiende bewyse dat vertraagde afklemming lae geboortegewig suigelinge mag beïnvloed. Dit wil in die ingeslote studies voor kom dat vertraagde afklemming van ten minste 30 sekondes die potensiaal het om die risiko van intraventrikulêre bloeding te verminder. Die uitslae van hierdie beskouing sal nietemin met omsigtigheid geïnterpreteer moet word, weens die beperkte aantal studies met die afwesigheid van klinies belangrike sekondêre uitkomste in die ingeslote proewe. Verdere navorsing word benodig op grootskaalse ewekansige beheerde proewe.