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Clearly, this benefit must be weighed in opposition to different obstetric and medical dangers if present. If women on this scenario request a house confinement, this should be mentioned on an individual foundation. We counsel that ladies who take evening doses omit their dose the day before induction and these who take a morning dose omit their dose on the day of induction. Attention ought to be paid to general antithrombotic measures together with compression stockings, hydration, and mobility. A prolonged induction course of is more doubtless in primigravida and people with an unfavorable cervix firstly of the induction. Thus, the place potential, careful evaluation ought to be made to attempt to delay induction till the cervix is more favorable. Over 40 cases of vertebral canal hematoma were reported in the American literature from 1997 to 1998, from a 5-year statement period. However, subsequent European reports included solely two instances with vertebral canal hematoma. Incidence has been estimated at 1 in over 2 million in a European examine, but about 1 in 15 000 in American research. Other studies have advised that technical difficulties with needle, significantly epidural catheter, insertion, a number of insertion attempts or blood-stained tap[10] may also be related to elevated risk of hematoma (Table 15. This is primarily because of the superior nature of the block high quality but in addition as a outcome of the extra rapid velocity of onset, when compared with epidural anesthesia. Anesthetic Aspects One of the main anesthetic issues about the utilization of heparins within the peripartum interval is the risk of vertebral. The epidural catheter must be left in place till the drug levels have reached a secure trough (see Table 15. The time from drug administration to attaining surgical anesthesia with this methodology can take round an hour. The epidural area is positioned with a sixteen or 18 gauge Tuohy needle utilizing a lack of resistance method. A non-cutting spinal needle, of smaller gauge corresponding to 25, is then introduced by way of the Tuohy needle to pierce the dura and enter the subarachnoid house. Once this thinner spinal needle has been removed the epidural catheter can then be threaded through the Tuohy needle into the epidural space. Administration of lowered doses of native anesthetic into the subarachnoid area, with further doses administered via the epidural catheter, allows excellent management over the cardiovascular system. The presence of an epidural catheter also permits the anesthetist to provide further doses of anesthetic in instances of. This should be utilized often as part of antenatal planning and agreed between obstetric, anesthetic, and hematology groups. A scheme permitting neuraxial analgesia 8�10 hours following the administration of 2500 items and 12 hours following a dose of 5000 units of dalteparin, for example, could be acceptable (see Table 15. An evaluation based on previous anti-Xa ranges (if available) and on a risk�benefit evaluation for every affected person and situation is then needed. The administration of ladies with a need for therapeutic ranges of anticoagulation in the peripartum period entails balancing the necessity for persevering with anticoagulation to stop the risk of thrombosis associated with the underlying condition towards the dangers of excessive bleeding and difficulties with analgesia and anesthesia. This requires a cautious and individualized method and thorough forward planning by a multidisciplinary team (obstetrician, midwife, anesthetist, and hematologist), in full session with the patient (Table 15. This is particularly important for the small variety of ladies in whom the often really helpful short-term peripartum discount in level of anticoagulation may be considered unsafe. Subcutaneous prophylactic dose unfractionated heparin Catheter placement or removing >2�4 hours after injection Delay next dose till >2 hours after catheter insertion or >4 hours after removing B. Low-molecular-weight heparin Spinal or epidural catheter insertion: >8 hours after last injection � low dose >12 hours after last injection � intermediate dose >24 hours after last injection � full anticoagulation Removal epidural catheter: 12 hours after any dose Delay subsequent dose until >2 hours after catheter insertion or subarachnoid injection or >4 hours after catheter removal D. Fondaparinux Perform spinal or epidural: >36 hours after injection of low dose (2.

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Answer: D Pheochromocytoma is a tumor of chromaffin cells that secrete catecholamines. In 90% of instances pheochromocytomas are discovered within the adrenal medulla, however they may even be found in other tissues derived from neural crest cells (paraganglia of the sympathetic chain, carotid body, genitourinary system, brain). Chromaffin cells seem malignant upon microscopic examination, however the tumor is considered benign in 90% of circumstances (no metastases) and is curable if accurately identified and properly handled. Learning objective: Describer the triad of symptoms that strongly recommend the diagnosis of pheochromocytoma. By activating 1 (and to a lesser extent 2) receptors in the heart catecholamines improve myocardial contractility, conduction, excitability, frequency, and oxygen consumption. Catecholamines produce a prompt enhance within the metabolic price (likely as a result of cutaneous vasoconstriction and increased muscular activity) and then a delayed enhance probably due to oxidation of lactate within the liver. The sudden launch of catecholamines causes a pointy improve of blood strain, which is the most likely cause of the extreme headache in these patients. Learning goal: Identify the drug that may set off paroxysmal signs in a patient with from pheochromocytoma. It is a part of some over-the-counter preparations used as nasal decongestants. The drug acts, at least partially, by releasing catecholamines from postganglionic sympathetic terminals. In pheochromocytoma, catecholamine shops inside sympathetic nerve endings are elevated because the catecholamines produced by the tumor are, in part, taken up by the sympathetic terminals. Therefore the intake of a drugs containing pseudoephedrine can trigger a paroxysmal episode in a affected person with pheochromocytoma. The drug may counteract, not trigger, some signs of pheochromocytoma (tachycardia). Atropine might set off some symptoms of pheochromocytoma (tachycardia), but could counteract different signs (sweating). Answer: C Paroxysmal attacks of headache, sweating, and tachycardia are so widespread that the shortage of all three would virtually exclude the diagnosis of pheochromocytoma. Other widespread signs include tachypnea, angina, nausea and vomiting, epigastric pain, paresthesias, constipation, and a sense of impending doom. Epinephrine, norepinephrine, and dopamine are secreted by the adrenal medulla, and a lot of the signs of pheochromocytoma are as a end result of the exces- 313 35 Pheochromocytoma E Prazosin is an 1-adrenoceptor antagonist. The drug may counteract, not trigger, some signs of pheochromocytoma (hypertension). The drug might trigger some symptoms of pheochromocytoma (tachycardia) but may counteract different symptoms (headache). Learning objective: Explain why a calcium channel blocker is normally not fully effective in reducing the hypertension of a patient affected by pheochromocytoma. A A optimistic family history for myocardial infarction is known to be a major risk issue for cardiovascular disease however not for pheochromocytoma. D A optimistic family history for lymphoma could be a threat issue for blood cancers however not for pheochromocytoma. Learning goal: Explain the rationale for chest pain in a patient with pheochromocytoma. Even if only one out of 1,000 hypertensive patients prove to be affected by this illness, pheochromocytoma should always be suspected in patients with hypertension, and this diagnosis should be excluded only after appropriate investigation. Nifedipine is a calcium channel blocker that, at therapeutic doses, blocks solely L-type calcium channels on the graceful muscle membrane. By reducing calcium entry the drug provokes a vasodilation, mainly on the arterioles. Therefore it antagonizes the vasoconstricting action of catecholamines by performing on receptors totally different from these activated by catecholamines. In conclusion, it may be outlined as a functional antagonist of norepinephrine and epinephrine. A common rule in pharmacology is that a functional antagonist is much less efficient than a pharmacological antagonist, typically. Answer: B Catecholamine-induced tachycardia requires an elevated quantity of oxygen, but, in spite of coronary vasodilation, oxygen demand is higher than oxygen supply, inflicting a relative heart ischemia. A Catecholamines trigger coronary vasodilation, not vasoconstriction, as a result of the center depends totally on metabolic mechanisms to adapt the caliber of its coronary vessels to the need of oxygen. D Only extremely excessive tachycardia can improve pulmonary artery pressure, because of the increased left diastolic quantity.

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These receptors bind and internalize the transferrin�iron complex by way of the process of receptor-mediated endocytosis. The ferric iron is then launched, lowered to ferrous iron, and used for hemoglobin synthesis or stored as ferritin. In the liver an identical course of stores iron as ferritin, making that organ the most ample iron store. Answer: C Hematologic response to oral iron therapy is usually seen in 2 to 3 weeks with 1 to 2 g/dL improve in hemoglobin. However, iron therapy should be continued for three to 6 months to exchange iron shops. Answer: B Gastrointestinal adverse results are extraordinarily frequent (up to 30%) with oral iron administration. These embody a metallic taste, flatulence, stomach cramps, constipation, diarrhea, nausea, and vomiting. These results are often dose-related and could be overcome by reducing the dose and taking the drug with meals. Recently he had noted an elevated daily drowsiness, an increased tenseness and girth of his abdomen, and a yellow color on his skin and eyes. The affected person had an extended history of alcohol abuse, with multiple hospital admissions for alcoholic gastritis and alcohol withdrawal. He reported that, regardless of his disease, he was unable to stop drinking and sometimes drank three or four glasses of whisky virtually daily. Physical examination revealed an afebrile and cachectic male in moderate distress. Vital signs were as follows: blood stress 100/50 mm Hg, pulse a hundred and ten bpm, respiration 22/min. Palpation of the abdomen revealed that his liver measured 14 cm within the midclavicular line, and his spleen was palpable 3 cm beneath the left costal margin. A analysis of superior alcoholic cirrhosis was made, and an acceptable therapy was began, which included the next medication: spironolactone, furosemide, meropenem, propranolol, and lactulose. Which of the following morphological changes within the liver best characterizes this disorder Liver cirrhosis is related to the unique anatomical construction of the liver the place the venous blood of the portal vein is blended with the arterial blood of the hepatic artery. Alcoholic cirrhosis consists of greater than 50% of liver cirrhosis in the developed world. Which of the next disorders is most probably the second most prevalent cause of cirrhosis in the developed world, and the first one worldwide An elevated level of which of the following hormones is believed to be a cause of those signs Which of the next lab results finest signifies an impairment in a selected synthetic function of U. This outcome means that the patient more than likely suffered from which of the following issues Which of the next pathological conditions was most probably the principle goal of U. Which of the next renal transport methods was most probably blocked by furosemide Which of the following steps in the turnover of bacterial cell walls is specifically inhibited by meropenem Connection of two amino sugar chains by peptide bridges 230 Answers and Explanations sixteen. The drug was given primarily to prevent or counteract which of the next of his disorders Hypoalbuminemia mobile hyperplasia that produces regenerating nodules surrounded by fibrotic tissue, and arterial progress. Regenerating nodules typically lack lobular group, and cirrhosis may be subdivided into micronodular and macronodular, according to nodule dimension.

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Similar appearance to a broad-based exostosis, however not angulated away from the joint and no medullary continuity. Lateral radiograph of the tibia/fibula demonstrating a small focal lucent lesion within the mid-left fibula cortex with surrounding sclerosis. Femoral neck is the most typical location (also usually tibia, humerus, arms, ft and spine). There is a second peak between 70 and eighty years of age as a result of malignant transformation of Paget disease. Frontal radiograph of the left knee demonstrating an ill-defined lytic/sclerotic lesion within the metaphyseal region of the proximal tibia. There is an association with other congenital abnormalities: spinal dysraphism, sacral agenesis, hydronephrosis, imperforate anus and gastroschisis. It is a well-defined lucency lying within the long axis of the bone and marginated by a skinny sclerotic rim. Frontal radiograph of the left shoulder demonstrating a lucent expansile lesion with a narrow zone of transition centred on the metadiaphyseal region. Periostitis (non-aggressive appearance) of the underlying bone indicates bone involvement. An amoeboma is a mass of granulation tissue that mimics most cancers and causes an irregular luminal stricture. The drawback is a ring of pancreatic tissue encircling the duodenum secondary to the irregular migration of the ventral pancreas. It may end in duodenal obstruction, often at the second part of the duodenum. It is often associated with congenital abnormalities together with Down syndrome, tetralogy of Fallot, duodenal atresia and imperforate anus. Findings to counsel perforation: fluid collection adjacent to the appendix, gas bubbles close to the appendix and lack of visualisation of the submucosal layer. Note-in patients >50 years of age, consider appendix mucocele (can be benign or malignant); wall calcification is specific but not sensitive for this. Inflammatory causes: Zollinger�Ellison syndrome, eosinophilic enteritis, Crohn illness, sarcoidosis, Helicobacter pylori, Menetrier illness. Areae gastricae and rugae are seen within the oedema up to the ulcer crater (otherwise, malignancy is suggested). Phytobezoars are most common-they are balls of partly digested fibre and vegetable matter. A partialthickness tear (Mallory�Weiss syndrome) is associated with blood-tinged vomiting and chest ache. Widening of the mediastinum could accompany the development of mediastinitis or mediastinal haematoma. Frontal chest radiograph demonstrating massive quantity pneumomediastinum and subcutaneous emphysema with a left pleural effusion. Mechanical causes of large bowel obstruction are commonly malignancy, diverticulitis and volvulus. There is dysmotility and atonia initially, then plaque-like filling defects reflecting ulceration and thickened mucosal folds. It is especially seen in the immunosuppressed and likewise in sufferers with scleroderma and achalasia. Linear, longitudinally oriented filling defects (plaques of necrotic debris and fungal colonies). It largely originates within the distal small bowel, exterior the intestine lumen, and infrequently causes symptoms in itself. Carcinoid syndrome is a scientific entity comprising flushing, wheezing and diarrhoea within the presence of lung and liver metastases. Patients with long-term coeliac disease could present with an acute ulcerative form of the disease referred to as ulcerative jejuno-ileitis. Extramural vascular invasion-associated with a considerably decreased disease-free survival time. Effect of the circumferential resection margin on survival following rectal most cancers surgery.

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These could be helpful to help you decide whether a scan is pre- or post-contrast. Differentiating tumour recurrence from radiotherapy damage could be challenging (see Table 6. The anterior cerebral artery may be compressed with herniation, which may cause ischaemia/infarction. Look for an effaced ambient/ suprasellar cistern and contralateral ventricular dilatation. This is a uncommon tumour of childhood (consider as a differential for medulloblastoma). Expect effacement of the standard contour of the fourth ventricle, exophytic development into the basal cisterns. May spread alongside the white matter tracts and cross the midline to ventricles and leptomeninges. Chemotherapy and radiotherapy may cause a transient increase within the lesion dimension; this denotes a response. The look has a differential that features glioblastoma multiforme, lymphoma and multiple sclerosis. There is a small, enhancing mural nodule (arrow), mass effect (midline shift) and hydrocephalus with dilatation of the temporal horns. They sometimes current with seizures and focal neurology; nevertheless, lung most cancers and melanoma metastases are sometimes silent. It is the most typical intracranial tumour in childhood and is closely associated to neurofibromatosis type 1 (20% of those sufferers endure from it). It develops from embryonic neuroepithelial cells that will originate within the germinal matrix. The diagnosis is recommended by the mix of affected person age, location, dense calcification and contrast enhancement. Presents with hydrocephalus (obstruction on the foramen of Monro), optic nerve palsy and hypothalamic signs. A suprasellar mass in a child or adolescent should be considered to be a craniopharyngioma until proven otherwise. Calcium in the choroid plexus in these aged <10 years is abnormal-suggests papilloma. Well-defined, multi-lobulated (cauliflower) mass associated with the choroid plexus. The look is consistent with a dermoid cyst and ruptured dermoid cyst, respectively. Low-density (due to fat content) lesion extra generally within the midline, parasellar/ sella area. Note: A spinal wire tumour in an adult is most probably to be an ependymoma (most on the conus/filum terminale). More frequent in boys <2 years of age, it presents with precocious puberty, seizures, developmental delay and hyperactivity. It is the most common extra-axial mass with peak incidence between 50 and 60 years of age (rare in children, until neurofibromatosis sort 2). It is extra common in ladies and hormone sensitive, so could enlarge throughout pregnancy. There is crowding of the white matter and mass impact (compression of the brainstem), but no oedema. Heterogeneous enhancement, haemorrhage, cystic look, rapid growth or bone erosion counsel malignancy. With or without embolisation of feeding vessels (usually a branch of the center meningeal artery, so the angiogram contains the exterior carotid artery). A calcified pineal at <10 years of age or >1 cm of calcium in an grownup recommend tumour. They usually current with hydrocephalus due to compression of the cerebral aqueduct. It causes a sudden onset of a headache and commonly presents with cranial nerve palsies. Coronal and sagittal T1 pre- and post-contrast magnetic resonance imaging is the gold commonplace for imaging the pituitary. Note that adenoma is indistinguishable from pituitary carcinoma by imaging alone (carcinoma could be very rare).

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He was additionally instructed to come back to the clinic every 2 months for routine follow-up. Given the response to date, no modifications had been required, and the current regimen was confirmed. The antiretroviral remedy was modified, discontinuing emtricitabine and tenofovir and including raltegravir. He admitted he had just lately disregarded the antiviral therapy because he felt quite nicely. He complained of a low-grade fever, fatigue, cough with blood-streaked sputum, and extreme evening sweating over the past month. He also complained of floating spots, gentle flashes, and issue with far vision. A native miconazole therapy and later an oral fluconazole therapy was prescribed to deal with F. Which of the next sets of blood cells represents the principle target of this virus Both medicine more than likely act by inhibiting which of the following enzymes or virion action Which of the next steps of the viral growth cycle is specifically inhibited by emtricitabine and tenofovir Which of the following is a uncommon however life-threatening opposed effect that may be caused by emtricitabine and tenofovir Which of the following steps of the viral cycle is specifically inhibited by this drug combination Which of the next was most likely the main reason for the affiliation of ritonavir with the opposite antiretroviral medication The synthesis of which of the following mycobacterial cell parts was most likely inhibited by this drug Which of the next statements greatest explains why ethambutol was added to the therapeutic routine The addition of this vitamin was carried out to forestall which of the following drug-induced opposed results Transpeptidase 204 AnswersandExplanations Answers and Explanations Learning goal: Explain the mechanism of action of azoles. Answer: E Both miconazole and fluconazole belong to the antifungal azole subclass. The inhibition impairs the exercise of a P-450-dependent lanosterol demethylase that converts lanosterol to ergosterol. The ultimate effect is an inhibition of ergosterol synthesis in fungal cells, which results in disruption of the fungal cell membrane. The final effect could additionally be fungicidal or fungistatic, relying on the organism and on drug focus. The specificity of azole drugs outcomes from their greater affinity for fungal than for mammalian cytochrome P-450 enzymes. A Inhibition of conversion of squalene to lanosterol would be the mechanism of motion of terbinafine. B Formation of artificial pores within the fungal membrane would be the mechanism of motion of amphotericin B. In otherwise healthy, immunocompetent individuals, the appearance of opportunistic infections, corresponding to oral candidiasis, is rare. Learning objective: Identify the antiviral drug class that includes both emtricitabine and tenofovir. A Candidiasis is included within the sickness record when it includes both the esophagus, bronchi, trachea, or lungs. Answer: C Reverse transcriptase inhibitors are thought-about the primary assist of antiretroviral remedy and are generally utilized in mixture with other courses of brokers like protease inhibitors or integrase strand switch inhibitors.

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Because of this, the drug is approved only through a carefully restricted program. D Epidermal growth factor receptors are blocked by trastuzumab, a monoclonal antibody used to deal with breast cancer. E Vascular endothelial progress factor is blocked by bevacizumab, a monoclonal antibody used to deal with lung and colon cancers. He additionally denied any abrupt sensation that urination was imminent, but he lately observed he started voiding several occasions through the night time. Medical historical past of the affected person indicated that 3 years in the past he suffered from renal colic due to a small calculus obstructing the ureter. Physical examination on admission confirmed a well-developed and nourished white male (weight 72 kg) who looked his age and was in no acute distress. Vital indicators had been as follows: blood stress 158/92 mm Hg, coronary heart fee seventy six bpm, respirations 12/min and common. Pain was elicited by a brisk percussion on the costovertebral angles of both sides, just below the twelfth rib. The right kidney was enlarged with a number of small cysts scattered all through the cortex and the medulla. Computed tomographic scan the renal computed tomogram was in settlement with the renal ultrasonogram. The liver tomogram disclosed some small cysts disseminated all through the parenchyma. The insulin-dextrose remedy was repeated, and three days later, the serum K+ degree was 5. Which of the next pairs of serum values are the most effective indicators of his disease Which of the following would be more than likely the acid�base dysfunction of this patient Which of the following statements best explains the first cause for this therapy Which of the following is the most likely molecular mechanism of each medication leading to this reduction Which of the following pairs of antihypertensive medicine could be appropriate for the management of blood strain on this affected person This toxicity is primarily as a end result of the impairment of renal synthesis of which of the next pairs of endogenous compounds Creatinine is derived from creatine and phosphocreatine, main constituents of muscle. The ability to focus the urine declines early and causes compulsory polyuria, which is especially related to the lower of tubule operate. If the tubular perform were normal the kidney would excrete solely 1/100 of that filtrate, particularly 331 mL of urine daily. This lower may also play a job within the pathogenesis of metabolic acidosis in sufferers with superior kidney illness. Answer: D In the kidney potassium excretion is determined by the sum of three processes: the rate of potassium filtration the speed of potassium reabsorption by the proximal tubule (about 65%) and by the loop of Henle (about 25%) the rate of potassium secretion by the distal and collecting tubules. Changes in potassium secretion in these websites account for many of the daily variation in potassium excretion. Mechanisms involved on this course of embody Increased aldosterone ranges Polyuria, which promotes higher distal tubule move charges A more adverse luminal electrical potential brought on by the elevated 6. The kidney carefully regulates magnesium excretion by changing tubular reabsorption. Moreover, decreased extracellular fluid calcium focus leads to a lower in magnesium excretion. For that reason, administration of calcium is normally accompanied by different therapies that actually help decrease serum potassium levels.

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The Role of Fibrinogen Observational research present that a fibrinogen degree of 1� 1. Fibrinogen under three g/L and particularly beneath 2 g/L is associated with progression of bleeding, elevated red blood cell and blood element requirement, and the necessity for invasive procedures. A double-blind randomized controlled trial has proven that pre-emptive infusion of 2 g fibrinogen concentrate in girls. Similar outcomes have been reported for cryoprecipitate and fibrinogen concentrate[34]. Two swimming pools of cryoprecipitate enhance the fibrinogen stage by about 1 g/L within the average girl, though it will differ relying on consumption. Increasing the fibrinogen degree by 1 g/L requires about 60 mg/kg fibrinogen concentrate[35]. Other Hemostatic Agents Tranexamic Acid Tranexamic acid reduces bleeding and transfusion requirement in huge hemorrhage secondary to a variety of non-obstetric causes[43]. A double-blind randomized management trial of tranexamic acid versus placebo at elective cesarean section reported reduced blood loss[47]. Monitored administration of fibrinogen focus has led to a fall in blood product usage however the outcomes of trials are required earlier than suggestions on its routine use may be made. Venous thromboprophylaxis should be began as soon as possible as quickly as Case Studies Case Study 1 A fit and properly 18-year-old primigravida had a forceps delivery in theater beneath spinal block with a 700-mL measured blood loss. In the restoration room, she had a small bleed of 300 mL after which 60 minutes later was famous to be hypotensive and tachycardic and a further 1000 mL blood loss from uterine atony famous. She returned to theater and had a small piece of residual placenta removed underneath the residual spinal block. Case Study 2 A multiparous lady with a earlier history of placental abruption was admitted to the delivery suite complaining of stomach pain. Fetal distress was noted on the cardiotocograph and a decision for quick cesarean part underneath common anesthetic was made. Fibrin-based clot formation as an early and speedy biomarker for progression of postpartum hemorrhage: a potential study. Disseminated intravascular coagulation in obstetric problems and its acute hematological management. Guidance for diagnosis and remedy of disseminated intravascular coagulation from harmonization of the. Pathogenesis and management of peripartum coagulopathic calamities (disseminated intravascular coagulation and amniotic fluid embolism). Platelet count and transfuion necessities throughout moderate or severe postpartum haemorrhage. Association between fibrinogen stage and severity of postpartum hemorrhage: Secondary analysis of a potential trial. Early fibrinogen as a predictor of pink cell necessities throughout postpartum hemorrhage. Predictive components of advanced interventional procedures in a multicenter severe postpartum hemorrhage examine. Predictive elements for failure of pelvic arterial embolization for postpartum hemorrhage. Hemostatic monitoring throughout postpartum hemorrhage and implications for management. The use of fibrinogen focus to right hypofibrinogenemia rapidly throughout obstetric hemorrhage. Thromboelastography, thromboelastometry, and standard coagulation tests within the diagnosis and prediction of postpartum hemorrhage. Point-of-care testing of coagulation and fibrinolytic standing during postpartum hemorrhage: Developing a thrombelastography�-guided transfusion algorithm. Bedside evaluation of fibrinogen degree in postpartum hemorrhage by thrombelastometry.

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