Upper gastrointestinal bleeding (UGIB) is bleeding proximal to the ligament of Treitz (esophageal, gastric or duodenal source). More common than lower gastrointestinal bleeding (LGIB; approximately 70% of GIB). Most common cause is peptic ulcer disease. LGIB is bleeding distal to the ligament of Treitz. Lower gastrointestinal bleeding is less common than UGIB (approximately 30% of GIB). LGIB has lower mortality rate than UGIB. The most common cause is diverticular disease.

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

While great emergencies are fortunately rare and certainly devastating, the upside is that they are often accelerators of progress. Wars, pandemics, and emergencies have been catalysts for medical innovation out of necessity - a desperate attempt to compensate for the circumstances. They bend the trajectory of discovery in new directions and increase the rate at which certain medical discoveries are made. Chapter 16 is thus about how wars, outbreaks, and other emergencies influence the rate and direction of medical progress. It explores how both World Wars, the pandemic of 1918, and COVID-19 have altered the trajectory of discovery.

Haemorrhage is the leading global cause of maternal death. In the 1930s transfusion services were established in British cities, followed in 1946 by a national blood transfusion service. Drugs to cause uterine contraction were developed: ergometrine in the 1930s and oxytocin in the 1950s. In the 1930s obstetric flying squads were established, first in Bellshill and Newcastle, and in Birmingham by Hilda Lloyd, the first female RCOG president. They saved many lives but disappeared as home births fell. In the 1950s iron supplements were introduced into antenatal care to combat pre-existing anaemia. CEMD Reports highlighted the risk of vaginal examination in pregnancy. In the 1970s placental localisation by ultrasound became available. The Reports pointed out that intractable bleeding may need hysterectomy and the 1979-81 Report included the first guideline on emergency treatment of haemorrhage. Guidelines remain essential today, for example in planning care for women who refuse blood transfusion. Ectopic pregnancy can cause catastrophic bleeding in early pregnancy. The Reports showed that ethnic minorities are at higher risk and immediate surgery can be life-saving.

A 29-year-old primigravida with sickle cell anemia (SCA) is referred by her primary care provider to your tertiary center’s high-risk obstetrics unit for prenatal care of a sonographically confirmed single viable intrauterine pregnancy at 8+2 weeks’ gestation. She has no obstetric complaints.

CPB as well as surgical trauma have a significant impact on the usually well-balanced coagulation system. This often leads to bleeding complications, and interventions to restore this balance are frequently attempted perioperatively. The coagulation and inflammatory systems are so complex that restoration of homeostatic balance cannot be achieved by giving blood products alone. Major known causes of CPB associated coagulopathy are dilution, complex and variable platelet dysfunction, fibrinolysis, the effects of heparin and protamine, hypocalcemia, hypothermia, as well as activation of the coagulation system after contact with artificial surfaces and from tissue factor release from the endothelium in response to ischemia and reperfusion.

An understanding of the physiological role of blood and its role in the supply of oxygen to tissues is important for the perioperative care of the patient. A thorough approach to administration of blood components is vital in this setting. This chapter adresses the special properties of the red blood cells in promoting oxygen carriage, the methods of safe blood component transfusion, and consideration of the hazards of transfusion.

Key Learning Points

1. 1. Right blood, right patient, right time and right place is the key message for safe blood administration.

2. 2. Accidental transfusion of ABO-incompatible blood is classified as a ‘never event’.

3. 3. Most errors could be prevented by a final bedside check when performed correctly.

4. 4. Patient blood management has three pillars of focus to reduce unnecessary transfusions: recognition and treatment of anaemia, minimisation of bleeding and blood loss and optimisation of anaemia and transfusion thresholds.

5. 5. Unnecessary delays in transfusion can lead to death and major morbidity.