Srdeční selhání patří mezi nejzávažnější zdravotní problémy současnosti. I přesto, že celoživotní riziko srdečního selhání je u mužů a žen podobné, existují výrazné rozdíly mezi oběma pohlavími. Muži jsou predisponováni k srdečnímu selhání se sníženou ejekční frakcí, zatímco u žen převažuje srdeční selhání se zachovanou ejekční frakcí (HFpEF). HFpEF je velmi heterogenní skupinou poruch a pochopení rozdílů mezi muži a ženy může přinést užitečné informace o možnostech prevence a léčby tohoto onemocnění. Například v etiologii a progresi HFpEF mohou hrát výraznou úlohu ženské pohlavní hormony, jmenovitě estradiol. Dalším faktorem může být fakt, že u žen může být cévní systém, a to především poruchy mikrocirkulace, predisponujícím faktorem k HFpEF. Proto včasný záchyt a léčba poruch periferní cirkulace může výrazně přispět i k prevenci HFpEF, především u žen.
Heart failure is one of the most serious problems of recent medicine. Despite the lifetime risk of heart failure is similar in men and women, significant sex differences were described. Men are more predisposed to heart failure with reduced ejection fraction, while women are predisposed to heart failure with preserved ejection fraction (HFpEF). HFpEF is a very heterogeneous group of disorders, and the research of sex differences might substantially improve preventive and treatment approaches. For example, female sex hormones, namely estradiol, might play prominent role in development and progression of HFpEF. Very common factor associated with HFpEF is vascular and microvascular system, which is more pronounced in women and might be cause and accelerating factor for HFpEF. Therefore, also early detection and manage- ment of disorders of vascular system might substantially add to prevention of HFpEF, especially in women.
Incidence idiopatických střevních zánětů (IBD) se stále zvyšuje. IBD jsou pro pacienta vysokou zátěží a stávají se významným socioekonomickým problémem. Správná a včasná diagnostika je rozhodující pro adekvátní léčbu, která by v nejlepším případě měla zabránit nebo alespoň minimalizovat riziko strukturálních změn v trávicí trubici, a tím zlepšit výhled nemocných s IBD.
The incidence of idiopathic bowel disease (IBD) is increasing. IBDs are a high patient burden and are becoming a significant socioeconomic problem. Correct and early diagnosis is crucial for adequate treatment, which in the best case should prevent or at least minimize the risk of structural changes in the digestive tract, thus improving the outlook of patients with IBD.
Patients with cardioembolic ischemic stroke are commonly prescribed direct oral anticoagulants (DOACs), such as dabigatran (a direct thrombin inhibitor) and factor Xa inhibitors (e.g., apixaban and rivaroxaban), or warfarin to reduce the risk of recurrent stroke. A major concern in anticoagulant therapy is the risk of intracerebral hemorrhage, which is associated with a high mortality rate. Cerebral microbleeds (MBs), small asymptomatic brain hemorrhages detectable by susceptibility-weighted imaging (SWI) on magnetic resonance imaging (MRI), are associated with increased hemorrhagic stroke risk. This study evaluated the incidence of new MBs during 1 year of anticoagulation therapy in patients after cardioembolic stroke. Patients indicated for anticoagulant therapy after cardioembolic stroke and monitored in the cerebrovascular outpatient clinic of our department underwent brain MRI at baseline and after 1 year of therapy. The occurrence of new MBs was assessed using SWI sequences. MBs were categorized based on location into 3 groups: deep (dMBs), lobar (lMBs), and infratentorial (iMBs). A total of 79 patients were included, 53 of whom were male (67.1%), with a median age of 71 years (IQR: 64-76). The majority of patients (n = 50, 63.3%) were treated with apixaban, 16 patients (20.3%) with dabigatran, and 13 patients (16.5%) with warfarin. Baseline MRI revealed MBs in 17 patients (21.5%), including dMBs in 2, lMBs in 16, and iMBs in 2 patients. Follow-up MRI showed new MBs in 8 patients (10.1%), with new dMBs in 1, lMBs in 5, and iMBs in 4 patients. No statistically significant differences were observed in MBs the incidence of new MBs between anticoagulant groups (P = .912). Over 1 year of anticoagulant therapy, new MBs were detected in 10.1% of patients, predominantly in lobar and infratentorial regions. No differences in the incidence of new MBs were identified between the different anticoagulant groups.
- MeSH
- Anticoagulants * adverse effects therapeutic use MeSH
- Cerebral Hemorrhage * chemically induced diagnostic imaging epidemiology MeSH
- Stroke * prevention & control MeSH
- Dabigatran adverse effects therapeutic use MeSH
- Incidence MeSH
- Middle Aged MeSH
- Humans MeSH
- Magnetic Resonance Imaging methods MeSH
- Pyrazoles adverse effects therapeutic use MeSH
- Pyridones adverse effects therapeutic use MeSH
- Secondary Prevention * methods MeSH
- Aged MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Observational Study MeSH
INTRODUCTION: Sexually transmitted infections (STIs) are an everlasting health issue globally. The military environment is recognised as a high-risk setting. Human papillomavirus (HPV), Chlamydia trachomatis and Neisseria gonorrhoeae are the most frequent STIs worldwide. This prospective cross-sectional pilot study focuses on the prevalence of selected STIs in the female population of the Czech Republic's Armed Forces. METHODS: C. trachomatis, N. gonorrhoeae and HPV detection and genotyping were performed between August 2020 and December 2022 in 141 women. Participants were divided into three groups according to their military status-recruits (n=72), active soldiers (n=25) and control civilian group (n=44). Cervical smear tests were performed, and data on STI risk factors were obtained through a questionnaire. RESULTS: A significant difference in the HPV prevalence between recruits (64.5 %) and both active soldiers (46.4 %) and civilians (47.3 %) was found when adjusted for age (p=0.007 and p=0.01, respectively). Lower age of coitarche (median 16; p=0.005) and smaller agglomeration origin (p=0.013) were reported for military recruits. No difference was proven in other researched risk factors. Associations between HPV detection and the higher number of sexual partners (p=0.013), early coitarche (p=0.016) and single marital status (p=0.002) across the groups were observed. Not a single case of N. gonorrhoeae was detected in any of the 141 participants. The prevalence of C. trachomatis did not differ significantly between the three evaluated groups-recruits, control civilian group, and active soldiers (5.6%, 2.3%, 0%, respectively; p=0.567). CONCLUSIONS: This pilot study showed a significantly higher HPV prevalence in female military recruits compared with both active military and civilian women. Recruits reported earlier coitarche which is a strong STI risk factor. Further study is needed to expand on the findings of this pilot study and generate data to support adjustment of STI preventive measures within the Czech Republic Armed Forces.
- MeSH
- Adult MeSH
- Humans MeSH
- Military Personnel * statistics & numerical data MeSH
- Pilot Projects MeSH
- Prevalence MeSH
- Prospective Studies MeSH
- Cross-Sectional Studies MeSH
- Surveys and Questionnaires MeSH
- Risk Factors MeSH
- Sexually Transmitted Diseases * epidemiology MeSH
- Check Tag
- Adult MeSH
- Humans MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Geographicals
- Czech Republic MeSH
Úvod: Onkologické skríningy sú kľúčové pre včasné odhalenie rakoviny a zvýšenie šancí na úspešnú liečbu. Sestry hrajú dôležitú rolu v edukácii pacientov a verejnosti o prevencii onkologických ochorení. Cieľ: Cieľom prieskumu bolo zistiť úroveň vedomostí študentov ošetrovateľstva o onkologických skríningových programoch na Slovensku. Metodika: Prieskum sa uskutočnil na Fakulte ošetrovateľstva a zdravotníckych odborných štúdií Slovenskej zdravotníckej univerzity v Bratislave od novembra 2023 do februára 2024. Prieskumná vzorka zahŕňala denných študentov bakalárskeho štúdia ošetrovateľstva, ktorí vyplnili dotazník zameraný na onkologické skríningové programy na Slovensku. Dotazník obsahoval 4 sociodemografické, 14 vedomostných a 2 osobnostné otázky. Prieskum bol dobrovoľný, anonymný a vyžadoval súhlas študenta. Výsledky boli vyhodnotené v absolútnych a relatívnych číslach. Výsledky: Prieskumu sa zúčastnilo 129 študentov (100 %), z toho 124 (96,12 %) žien a 5 (3,88 %) mužov. Najväčšiu skupinu tvorili študenti 1. ročníka v počte 58 (44,97 %). Priemerný počet získaných bodov bol 9,7 z maximálnych 14 bodov (min. 2, max. 14, SD: 3,4), čo predstavuje 69,73% úspešnosť vo vedomostných otázkach. Najvyššiu úspešnosť dosiahli študenti 3. ročníka (74 %). Najlepšie výsledky dosiahli študenti v odpovediach týkajúcich sa rakoviny krčka maternice (61 – 85 % správnych odpovedí), zatiaľ čo najnižšie výsledky pri otázkach o rakovine prsníka (24 – 65 % správnych odpovedí). Až 97,67 % študentov vyjadrilo záujem dozvedieť sa viac o prevencii v onkológii, pričom 62,79 % študentov sa domnieva, že by nedokázali edukovať pacienta v oblasti onkologickej prevencie. Záver: Vzhľadom na rastúcu incidenciu onkologických ochorení je dôležité zamerať sa na vzdelávanie študentov ošetrovateľstva v oblasti prevencie v onkológii, aby boli pripravení vykonávať edukačné intervencie a zvyšovať zdravotnú gramotnosť pacientov a širokej verejnosti.
Introduction: Cancer screenings are essential for the early detection of cancer and increasing the chances of successful treatment. Nurses play a crucial role in educating patients and the public about cancer prevention. Aim: The aim of the survey was to assess nursing students’ knowledge of cancer screening programs in Slovakia. Methodology: The survey was conducted at the Faculty of Nursing and Professional Health Studies of the Slovak Medical University in Bratislava from November 2023 to February 2024. The survey sample included full-time bachelor’s nursing students who completed a questionnaire focused on cancer screening programs in Slovakia. The questionnaire consisted of 4 sociodemographic, 14 knowledgebased, and 2 personal questions. Knowledge-based questions were evaluated, for which students could earn a maximum of 14 points. The student received 1 point for each correct answer, and for an incorrect answer or no answer, they received 0 points. Participation in the survey was voluntary, anonymous, and required the student’s consent. The results were evaluated in absolute and relative numbers. Results: A total of 129 students (100%) participated in the survey, including 124 women (96.12%) and 5 men (3.88%). The largest group consisted of first-year students, with 58 participants (44.97%). The average number of points obtained was 9.7 out of a maximum of 14 (min:. 2, max. 14, SD: 3.4), representing a 69.73% success rate in knowledge-based questions. The highest success rate was achieved by third-year students (74%). The best results were obtained in questions related to cervical cancer (61–85% correct answers), while the lowest results were observed in questions about breast cancer (24–65% correct answers). As many as 97.67% of students expressed interest in learning more about cancer prevention, while 62.79% believed they would not be able to educate a patient about cancer prevention. Conclusion: Given the increasing incidence of cancer diseases, it is crucial to focus on educating nursing students in cancer prevention to prepare them for providing educational interventions and enhancing the health literacy of patients and the general public.
Cardiovascular disease (CVD) is a leading cause of death worldwide. A key area of interest in CVD prevention is novel digital health technologies, primarily mobile health (mHealth) applications and wearable devices, that are rapidly transforming the methods of preventing and managing CVD. Studies have shown the success of smartphone applications, such as the RITMIA app (Heart SentinelTM, Parma, Italy), in successfully detecting atrial fibrillation (Afib) compared to a classic 12-lead electrocardiogram (ECG). mHealth devices should integrate these factors, based on artificial intelligence (AI) and driven by chatbots, to encourage patients to use technology through interactive, real-world, motivational, and timely feedback. Data from mHealth clinical research indicate improved medication adherence, weight control, and self-care among patients. This review highlights mHealth and wearable devices in CVD prevention, providing foresight into cardiovascular health conditions through continuous monitoring, early detection, and improved patient engagement. Additionally, it examines challenges, including ethical, regulatory, and accessibility issues, that need to be addressed before their widespread adoption. In the future, the priority must be integration with healthcare systems and equitable access. A thorough search was conducted using reputable databases such as Scopus, PubMed, and Google Scholar. Articles from 2015 to 2025, along with an article from 2002 published in reputable peer-reviewed journals, were analyzed and contextually used. We also refined our search terms and used high-quality English articles to achieve this.
- Publication type
- Journal Article MeSH
- Review MeSH
Optická koherentná tomografia (OCT) sa stala kľúčovým nástrojom v diferenciálnej diagnostike optických neuropatií (ON), najmä pri rozlíšení medzi glaukómovou a neglaukómovou ON. Správna diagnóza je základným faktorom pre efektívny manažment liečby a prevenciu progresívnej straty zraku. Zatiaľ čo glaukómová ON je charakteristická špecifickými štrukturálnymi zmenami v papile zrakového nervu a retinálnych vrstvách, neglaukómové neuropatie môžu byť spôsobené širokým spektrom iných príčin, vrátane zápalových, ischemických či kompresívnych procesov. OCT umožňuje vizualizovať jemné anatomické detaily terča zrakového nervu a sietnice, čo poskytuje cenné informácie na diferenciálnu diagnostiku. Dôležitosť spočíva v schopnosti lekára správne interpretovať tieto informácie a integrovať ich do celkového klinického obrazu pacienta. Tento prehľad sa zameriava na kľúčové znaky glaukómovej a neglaukómovej ON, ktoré môžu byť včas odhalené pomocou OCT a zdôrazňuje význam použitia tejto techniky v každodennej klinickej praxi.
Optical coherence tomography (OCT) has become a key tool in the differential diagnosis of optic neuropathies (ON), particularly in differentiating between glaucomatous and non-glaucomatous ON. Correct diagnosis is an essential factor for effective treatment management and prevention of progressive loss of vision. While glaucomatous ON is characterized by specific structural changes in the optic nerve head and retinal layers, non-glaucomatous neuropathies can be caused by a wide range of other causes, including inflammatory, ischemic or compressive processes. OCT allows visualization of the fine anatomical details of the optic nerve head and retina, providing valuable information for differential diagnosis. The importance lies in the physician’s ability to correctly interpret these images and integrate them into the patient’s overall clinical picture. This review focuses on the key features of glaucomatous and non-glaucomatous ON that can be detected early with OCT and highlights the importance of using this technique in everyday clinical practice.
- MeSH
- Diagnosis, Differential MeSH
- Glaucoma diagnostic imaging diagnosis MeSH
- Humans MeSH
- Optic Nerve Diseases * diagnostic imaging diagnosis MeSH
- Tomography, Optical Coherence MeSH
- Check Tag
- Humans MeSH
- Publication type
- Review MeSH
Anticipating clinical transitions in bipolar disorder (BD) is essential for the development of clinically actionable predictions. Our aim was to determine what is the earliest indicator of the onset of depressive symptoms in BD. We hypothesized that changes in activity would be the earliest indicator of future depressive symptoms. The study was a prospective, observational, contactless study. Participants were 127 outpatients with a primary diagnosis of BD, followed up for 12.6 (5.7) [(mean (SD)] months. They wore a smart ring continuously, which monitored their daily activity and sleep parameters. Participants were also asked to complete weekly self-ratings using the Patient Health Questionnaire (PHQ-9) and Altman Self-Rating Mania Scale (ASRS) scales. Primary outcome measures were depressive symptom onset detection metrics (i.e., accuracy, sensitivity, and specificity); and detection delay (in days), compared between self-rating scales and wearable data. Depressive symptoms were labeled as two or more consecutive weeks of total PHQ-9 > 10, and data-driven symptom onsets were detected using time-frequency spectral derivative spike detection (TF-SD2). Our results showed that day-to-day variability in the number of steps anticipated the onset of depressive symptoms 7.0 (9.0) (median (IQR)) days before they occurred, significantly earlier than the early prediction window provided by deep sleep duration (median (IQR), 4.0 (5.0) days; p <.05). Taken together, our results demonstrate that changes in activity were the earliest indicator of depressive symptoms in participants with BD. Transition to dynamic representations of behavioral phenomena in psychiatry may facilitate episode forecasting and individualized preventive interventions.
- Publication type
- Journal Article MeSH
At a population level, the European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter and Microbiota Study Group (EHMSG), and the European Society of Pathology (ESP) suggest endoscopic screening for gastric cancer (and precancerous conditions) in high-risk regions (age-standardized rate [ASR] > 20 per 100 000 person-years) every 2 to 3 years or, if cost-effectiveness has been proven, in intermediate risk regions (ASR 10-20 per 100 000 person-years) every 5 years, but not in low-risk regions (ASR < 10).ESGE/EHMSG/ESP recommend that irrespective of country of origin, individual gastric risk assessment and stratification of precancerous conditions is recommended for first-time gastroscopy. ESGE/EHMSG/ESP suggest that gastric cancer screening or surveillance in asymptomatic individuals over 80 should be discontinued or not started, and that patients' comorbidities should be considered when treatment of superficial lesions is planned.ESGE/EHMSG/ESP recommend that a high quality endoscopy including the use of virtual chromoendoscopy (VCE), after proper training, is performed for screening, diagnosis, and staging of precancerous conditions (atrophy and intestinal metaplasia) and lesions (dysplasia or cancer), as well as after endoscopic therapy. VCE should be used to guide the sampling site for biopsies in the case of suspected neoplastic lesions as well as to guide biopsies for diagnosis and staging of gastric precancerous conditions, with random biopsies to be taken in the absence of endoscopically suspected changes. When there is a suspected early gastric neoplastic lesion, it should be properly described (location, size, Paris classification, vascular and mucosal pattern), photodocumented, and two targeted biopsies taken.ESGE/EHMSG/ESP do not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection unless there are signs of deep submucosal invasion or if the lesion is not considered suitable for endoscopic resection.ESGE/EHMSG/ESP recommend endoscopic submucosal dissection (ESD) for differentiated gastric lesions clinically staged as dysplastic (low grade and high grade) or as intramucosal carcinoma (of any size if not ulcerated or ≤ 30 mm if ulcerated), with EMR being an alternative for Paris 0-IIa lesions of size ≤ 10 mm with low likelihood of malignancy.ESGE/EHMSG/ESP suggest that a decision about ESD can be considered for malignant lesions clinically staged as having minimal submucosal invasion if differentiated and ≤ 30 mm; or for malignant lesions clinically staged as intramucosal, undifferentiated and ≤ 20 mm; and in both cases with no ulcerative findings.ESGE/EHMSG/ESP recommends patient management based on the following histological risk after endoscopic resection: Curative/very low-risk resection (lymph node metastasis [LNM] risk < 0.5 %-1 %): en bloc R0 resection; dysplastic/pT1a, differentiated lesion, no lymphovascular invasion, independent of size if no ulceration and ≤ 30 mm if ulcerated. No further staging procedure or treatment is recommended.Curative/low-risk resection (LNM risk < 3 %): en bloc R0 resection; lesion with no lymphovascular invasion and: a) pT1b, invasion ≤ 500 μm, differentiated, size ≤ 30 mm; or b) pT1a, undifferentiated, size ≤ 20 mm and no ulceration. Staging should be completed, and further treatment is generally not necessary, but a multidisciplinary discussion is required. Local-risk resection (very low risk of LNM but increased risk of local persistence/recurrence): Piecemeal resection or tumor-positive horizontal margin of a lesion otherwise meeting curative/very low-risk criteria (or meeting low-risk criteria provided that there is no submucosal invasive tumor at the resection margin in the case of piecemeal resection or tumor-positive horizontal margin for pT1b lesions [invasion ≤ 500 μm; well-differentiated; size ≤ 30 mm, and VM0]). Endoscopic surveillance/re-treatment is recommended rather than other additional treatment. High-risk resection (noncurative): Any lesion with any of the following: (a) a positive vertical margin (if carcinoma) or lymphovascular invasion or deep submucosal invasion (> 500 μm from the muscularis mucosae); (b) poorly differentiated lesions if ulceration or size > 20 mm; (c) pT1b differentiated lesions with submucosal invasion ≤ 500 μm with size > 30 mm; or (d) intramucosal ulcerative lesion with size > 30 mm. Complete staging and strong consideration for additional treatments (surgery) in multidisciplinary discussion.ESGE/EHMSG/ESP suggest the use of validated endoscopic classifications of atrophy (e. g. Kimura-Takemoto) or intestinal metaplasia (e. g. endoscopic grading of gastric intestinal metaplasia [EGGIM]) to endoscopically stage precancerous conditions and stratify the risk for gastric cancer.ESGE/EHMSG/ESP recommend that biopsies should be taken from at least two topographic sites (2 biopsies from the antrum/incisura and 2 from the corpus, guided by VCE) in two separate, clearly labeled vials. Additional biopsy from the incisura is optional.ESGE/EHMSG/ESP recommend that patients with extensive endoscopic changes (Kimura C3 + or EGGIM 5 +) or advanced histological stages of atrophic gastritis (severe atrophic changes or intestinal metaplasia, or changes in both antrum and corpus, operative link on gastritis assessment/operative link on gastric intestinal metaplasia [OLGA/OLGIM] III/IV) should be followed up with high quality endoscopy every 3 years, irrespective of the individual's country of origin.ESGE/EHMSG/ESP recommend that no surveillance is proposed for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history, incomplete intestinal metaplasia, persistent H. pylori infection). This group constitutes most individuals found in clinical practice.ESGE/EHMSG/ESP recommend H. pylori eradication for patients with precancerous conditions and after endoscopic or surgical therapy.ESGE/EHMSG/ESP recommend that patients should be advised to stop smoking and low-dose daily aspirin use may be considered for the prevention of gastric cancer in selected individuals with high risk for cardiovascular events.
- MeSH
- Biopsy MeSH
- Early Detection of Cancer * methods standards MeSH
- Gastroscopy * standards MeSH
- Risk Assessment MeSH
- Helicobacter Infections complications MeSH
- Humans MeSH
- Stomach Neoplasms * pathology diagnosis therapy MeSH
- Precancerous Conditions * pathology diagnosis therapy MeSH
- Societies, Medical MeSH
- Gastric Mucosa pathology diagnostic imaging MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Practice Guideline MeSH
- Geographicals
- Europe MeSH
Autoři jsou uváděni v abecedním pořadí, podíl jednotlivých autorů je uveden na konci práce. Souhrn doporučení Preventivní opatření a postupy Doporučujeme, aby v průběhu porodu u žen s rizikovými faktory pro PPH byla sledována krevní ztráta s využitím kalibrovaných kolektorů krve nebo jejich ekvivalentů. (Dobrá klinická praxe) Doporučujeme, aby ženy se závažnými rizikovými faktory pro PŽOK (např. placenta acrreta spectrum nebo hematologické poruchy vyžadující konziliární hematologickou péči) rodily v perinatologickém centru intenzivní péče nebo v perinatologickém centru intermediární péče. (Dobrá klinická praxe) Doporučujeme u pacientek s vysokým rizikem PŽOK v přiměřeném časovém předstihu před porodem formulování plánu péče za účasti multidisciplinárního týmu. (Dobrá klinická praxe) Doporučujeme léčbu anemie antepartálně. Těhotným ženám by měly být podávány preparáty železa, pokud hladina hemoglobinu klesne v I. trimestru < 110 g/l nebo < 105 g/l ve 28. týdnu těhotenství. (Dobrá klinická praxe) Navrhujeme zvážit parenterální podání železa u žen se sideropenickou anemií, nereagující na suplementaci železa perorální cestou. Příčina anemie by měla být zjištěna co nejdříve po ukončení těhotenství. (Slabé doporučení) Pokud se dítě dobře adaptuje, nedoporučujeme dřívější podvaz pupečníku než za 1 min. (Silné doporučení) Doporučujeme pro snížení rizika rozvoje PPH a PŽOK u všech vaginálních porodů profylaktické podání uterotonik ve III. době porodní po porodu dítěte a po podvazu pupečníku. Lékem první volby je oxytocin. (Silné doporučení) Pokud nebyla aktivně vedena III. doba porodní, navrhujeme pro zkrácení trvání III. doby porodní a pro snížení krevní ztráty u vaginálního porodu zvážit provedení masáže dělohy a řízenou trakci za pupečník, provádí-li ji kvalifikovaná osoba. (Slabé doporučení) Doporučujeme podání uterotonik k prevenci rozvoje PPH u žen po vybavení dítěte císařským řezem a po podvazu pupečníku. (Silné doporučení) Navrhujeme zvážit u žen se zvýšeným rizikem PŽOK podání carbetocinu. (Slabé doporučení) Doporučujeme u žen se zvýšeným rizikem PŽOK podstupujících císařský řez jednorázové podání kyseliny tranexamové (TXA). Klinická poznámka: Použití TXA před provedením císařského řezu není explicitně uvedeno v SPC přípravku. Recentní metaanalýza uvádí nejčastější dávkování 1 g i.v. (Silné doporučení) Organizace poskytování péče Doporučujeme, aby každé zdravotnické zařízení, kde je gynekologicko-porodnické pracoviště, mělo pro situace PŽOK vypracováno řízený dokument definující organizační a odborný postup. (Dobrá klinická praxe) Doporučujeme, aby řízený dokument (tj. krizový plán) jednoznačně vymezoval organizační a odborné role jednotlivých členů krizového týmu při vzniku PŽOK (nelékařský personál, porodník, anesteziolog, hematolog apod.) a definoval minimální rozsah vybavení pracoviště pro zajištění péče o pacientky s PŽOK. (Dobrá klinická praxe) Doporučujeme pravidelný simulační trénink krizové situace PŽOK celým krizovým týmem s následným debrífinkem nebo jeho formalizovaným ekvivalentem. (Dobrá klinická praxe) Doporučujeme na každém pracovišti definování indikátorů kvality diagnostiky a léčby PŽOK a jejich formalizované vyhodnocování v pravidelných intervalech, nejméně jednou ročně. (Dobrá klinická praxe) Diagnostický a léčebný postup při PŽOK Při nálezu hypotonie nebo atonie dělohy doporučujeme používat strukturovaný stupňovitý postup. (Dobrá klinická praxe) Na pracovištích s dostupností endovaskulárních intervencí navrhujeme u stavů PŽOK z důvodu hypotonie nebo atonie dělohy zvážit preferenční využití radiologických intervenčních metod (selektivní embolizace pánevních tepen), pokud to aktuální klinický kontext umožňuje. (Slabé doporučení) U všech stavů rozvoje PPH doporučujeme provedení tzv. předtransfuzního vyšetření. Pro posouzení aktuálního stavu koagulace jsou (kromě standardních laboratorních vyšetření) preferovány metody tzv. point-of-care-testing, zejména viskoelastické metody. (Dobrá klinická praxe) Každé porodnické pracoviště by mělo mít ve spolupráci s transfuzním oddělením a ústavní lékárnou trvale dostatečnou zásobu transfuzních přípravků a krevních derivátů pro jejich bezprostřední dostupnost v režimu 24/7. Doporučujeme u stavů rozvoje PŽOK zajistit iniciálně dostupnost čtyř transfuzních jednotek plazmy (preferována je tzv. solvent/detergent ošetřená plazma), čtyř transfuzních jednotek erytrocytů a 6 g fibrinogenu. Za minimální zásobu fibrinogenu považujeme 8 g fibrinogenu a dostupnost dalších 8 g do 1 hod. (Dobrá klinická praxe) Doporučujeme u všech pacientek s PPH zahájit okamžitou tekutinovou resuscitaci. Pro zahájení tekutinové resuscitace doporučujeme použití balancovaných roztoků krystaloidů. (Silné doporučení) Navrhujeme zvážit použití syntetických koloidních roztoků s obsahem želatiny při nedosažení nebo nedosahování hemodynamických cílů tekutinové resuscitace použitím krystaloidních roztoků a při trvající potřebě tekutin. (Slabé doporučení) Do doby dosažení kontroly zdroje krvácení doporučujeme u pacientek s PŽOK usilovat o dosažení hodnoty systolického krevního tlaku v pásmu 80–90 mmHg. (Silné doporučení) Doporučujeme u PŽOK použít vazopresory co nejdříve při nemožnosti dosažení cílových hodnot arteriálního krevního tlaku probíhající tekutinovou resuscitací. (Silné doporučení) V diagnostice a léčbě koagulopatie u PŽOK nereagujícího na standardní léčebné postupy doporučujeme spolupráci s hematologem. (Dobrá klinická praxe) K identifikaci typu koagulační poruchy u PŽOK, k její monitoraci a pro cílenou léčbu poruchy hemostázy doporučujeme kromě výše uvedených skupinových laboratorních vyšetření (minimálně KO, aPTT, fibrinogen) používat i viskoelastické metody (ROTEM, TEG). (Silné doporučení) K dosažení/obnovení účinnosti endogenních hemostatických mechanismů a léčebných postupů podpory koagulace doporučujeme maximální možnou korekci hypotermie, acidózy a hladiny ionizovaného kalcia. (Silné doporučení) Doporučujeme časné zahájení všech dostupných postupů k prevenci hypotermie a udržení nebo dosažení normotermie. (Silné doporučení) Doporučujeme monitorovat a udržovat hladinu ionizovaného kalcia v normálním referenčním rozmezí při podávání transfuzních přípravků. Ke korekci byl měl být přednostně podáván chlorid vápenatý. (Silné doporučení) Substituci fibrinogenu doporučujeme u pacientek s PPH při poklesu jeho hladiny < 2 g/l a/nebo při nálezu jeho funkčního deficitu zjištěném viskoelastickými metodami a/nebo při odůvodněném klinickém předpokladu deficitu fibrinogenu i bez znalosti jeho hladin. Jako úvodní dávku u PŽOK doporučujeme podání minimálně 4 g fibrinogenu. (Silné doporučení) Doporučujeme podat kyselinu tranexamovou (TXA) v úvodní dávce 1 g i.v. co nejdříve po vzniku PŽOK. Identická dávka může být opakována (nejdříve po 30 min), pokud krvácení pokračuje a je-li současně prokázána hyperfibrinolýza a/nebo je-li v aktuálním klinickém kontextu hyperfibrinolýza vysoce pravděpodobná. (Silné doporučení) Po dosažení kontroly krvácení další podání TXA u pacientek s PŽOK nedoporučujeme. (Silné doporučení) Doporučujeme podání plazmy v dávce 15–20 ml/kg u stavů PPH, kde je předpoklad koagulopatie jiné etiologie, než je nedostatek fibrinogenu a/nebo jsou přítomny abnormální výsledky koagulačních vyšetření, a kdy jejich výsledky neumožní identifikovat spolehlivě převažující mechanizmus koagulační poruchy a její cílenou korekci. (Silné doporučení) Doporučujeme podání faktorů protrombinového komplexu (PCC) u pacientek s PŽOK, kde je laboratorně prokázán deficit faktorů v PCC obsažených. Rutinní podávání PCC u pacientek s PŽOK nedoporučujeme. (Silné doporučení) Navrhujeme zvážit podání rFVIIa v době před rozhodnutím o endovaskulární nebo chirurgické intervenci. (Slabé doporučení) Doporučujeme u pacientek s PŽOK podávání erytrocytárních transfuzních přípravků k dosažení cílové hodnoty hemoglobinu v pásmu 70–80 g/l. (Silné doporučení) Doporučujeme u pacientek s PŽOK podávání trombocytů k dosažení cílové hodnoty minimálně 50 × 109/l a/nebo při předpokladu či průkazu poruchy jejich funkce. (Silné doporučení) Nedoporučujeme rutinní měření hladin antitrombinu III u pacientek s PŽOK. (Silné doporučení) Nedoporučujeme rutinní substituci antitrombinu III u pacientek s PŽOK. (Silné doporučení) Doporučujeme zahájit farmakologickou profylaxi trombembolické nemoci co nejdříve po dosažení kontroly zdroje PPH. Mechanickou tromboprofylaxi (intermitentní pneumatická komprese anebo elastické punčochy) doporučujeme zahájit neprodleně, jakmile to klinický stav dovolí. (Silné doporučení)
Summary of recommendations Preventive measures and procedures We recommend monitoring of blood loss in women with risk factors for PPH during labor using calibrated blood collectors or their equivalents. (Good Clinical Practice) We recommend that women with significant risk factors for PPH (e.g., placenta acrreta spectrum or hematologic disorders requiring consultative hematologic care) deliver in a perinatal intensive care center or perinatal intermediate care center. (Good Clinical Practice) We recommend formulating a plan of care in collaboration with a multidisciplinary team at a reasonable time prior to delivery for patients at high risk of PPH. (Good Clinical Practice) We recommend treating anemia antepartally. Pregnant women should be given iron supplements if the haemoglobin level falls to < 110 g/L in the 1st trimester or < 105 g/L at 28 weeks of pregnancy. (Good Clinical Practice) We suggest considering parenteral iron administration in women with sideropenic anemia unresponsive to oral iron supplementation. The cause of anemia should be identified as soon as possible after termination of pregnancy. (Weak recommendation) If the baby adapts well, we do not recommend cord ligation in less than 1 min. (Strong recommendation) In all vaginal deliveries, we recommend prophylactic administration of uterotonics in the third postpartum period after the delivery of the baby and cord ligation to reduce the risk of PPH. The first-choice drug is oxytocin. (Strong recommendation) If the third stage of labor has not been actively managed, we suggest that uterine massage and controlled umbilical cord traction be considered to shorten the duration of the third stage of labor and to reduce blood loss during vaginal delivery, if performed by a qualified healthcare professional. (Weak recommendation) We recommend the administration of uterotonics to prevent the development of PPH in women after the delivery of a child by caesarean section and umbilical cord ligation. (Strong recommendation) We suggest considering carbetocin administration in women at increased risk of PPH. (Weak recommendation) We recommend a single-dose administration of tranexamic acid (TXA) in women at increased risk of PPH undergoing a caesarean section. Clinical note: The use of TXA prior to the caesarean section is not explicitly stated in the product's SPC. A recent meta-analysis states the most common dosage to be 1 g i.v. (Strong recommendation) Organization of care We recommend that every health care facility with an OB/GYN unit should have the PPH management protocol (guided document is not specific or really used at all, I am not sure if my suggestion is sufficient) defining the organizational and professional procedure for PPH situations. (Good Clinical Practice) We recommend that the PPH management protocol (i.e. the crisis action plan) should clearly define the organizational and professional roles of the individual members of the crisis team in the event of PPH (non-medical staff), obstetrician, anesthetist, hematologist, etc.) and define the minimum scope of equipment for the care of patients with PPH. (Good Clinical Practice) We recommend regular simulation training of PPH crisis by the entire crisis team with a subsequent debriefing or its formalized equivalent. (Good Clinical Practice) We recommend defining quality indicators for the diagnosis and treatment of PPH and their formalized evaluation at regular intervals, at least once a year. (Good Clinical Practice) Diagnostic and treatment procedure at PPH When hypotonia or atony of the uterus is found, we recommend using a structured procedure. (Good Clinical Practice) At departments with an option of endovascular interventions, we suggest considering the preferential use of radiological interventional methods (selective pelvic artery embolization) in cases of PPH due to uterine hypotonia or atony, if the current clinical context allows it. (Weak recommendation) For all stages of PPH development, we recommend a pre-transfusion examination. In addition to standard laboratory tests, point-of-care-testing methods, especially viscoelastic methods, are preferred to assess the current coagulation status. (Good Clinical Practice) Each obstetric unit should ensure a sufficient stock of blood products and blood derivatives for their immediate availability 24/7 in collaboration with the transfusion department and the inpatient pharmacy. In case of PPH development, we recommend securing initial availability of 4 units of plasma (solvent/detergent-treated plasma is preferred), 4 units of erythrocytes and 6 g of fibrinogen. We consider 8 g to be a minimum supply of fibrinogen and additional 8 g should be available within 1 h. (Good Clinical Practice) We recommend the initiation of immediate fluid resuscitation in all patients with PPH. We recommend the use of balanced crystalloid solutions to initiate fluid resuscitation. (Strong recommendation) We propose considering the use of synthetic colloid solutions containing gelatin when hemodynamic goals of fluid resuscitation have not been achieved or are not being achieved using crystalloid solutions and when a fluid deficit persists. (Weak recommendation) Until the source of bleeding is controlled, we recommend aiming for a systolic blood pressure in a range of 80–90 mmHg in patients with PPH. (Strong recommendation) We recommend the use of vasopressors as soon as possible in PPH when target arterial blood pressure values cannot be reached by ongoing fluid resuscitation. (Strong recommendation) We recommend cooperation with a hematologist in the diagnosis and treatment of coagulopathy in PPH unresponsive to standard therapies. (Good Clinical Practice) In addition to the above-mentioned panel laboratory tests (at least KO, aPTT, fibrinogen), we also recommend using viscoelastic methods (ROTEM, TEG) to identify the type of coagulation disorder in PPH, to monitor it and for targeted treatment of hemostasis disorders. (Strong recommendation) To achieve/restore the efficacy of endogenous hemostatic mechanisms and coagulation support therapies, we recommend the maximum possible correction of hypothermia, acidosis and ionized calcium levels. (Strong recommendation) Early initiation of all available procedures to prevent hypothermia and maintain or achieve normothermia is recommended. (Strong recommendation) It is recommended monitoring and maintaining ionized calcium levels within the normal range when administering transfusion products. Preferably, calcium chloride should be administered for correction. (Strong recommendation) Fibrinogen replacement is recommended in patients with PPH when fibrinogen levels fall to < 2 g/L and/or when there is a functional fibrinogen deficiency detected by viscoelastic methods and/or when there is a reasonable clinical assumption of fibrinogen deficiency even without knowledge of fibrinogen levels. We recommend a minimum of 4 g of fibrinogen as an initial dose in PPH. (Strong recommendation) It is recommended to administer tranexamic acid (TXA) at an initial dose of 1 g i.v. as soon as possible after the onset of PPH. An identical dose may be repeated (after 30 min at the earliest) if bleeding continues and if hyperfibrinolysis is demonstrated and/or if hyperfibrinolysis is highly likely in the current clinical context. (Strong recommendation) We do not recommend further administration of TXA in patients with PPH after bleeding control has been achieved. (Strong recommendation) We recommend administration of plasma at a dose of 15–20 mL/kg in PPH conditions where coagulopathy of a different etiology than fibrinogen deficiency is suspected and/or abnormal coagulation test results are present, and where the results do not reliably identify the predominant mechanism of the coagulation disorder and its targeted correction. (Strong recommendation) We recommend the administration of prothrombin complex factors (PCC) in patients with PPH where there is a laboratory evidence of a deficiency of PCC factors. We do not recommend routine administration of PCC in patients with PPH. (Strong recommendation) We suggest considering administration of rFVIIa before making a decision on an endovascular or a surgical intervention. (Weak recommendation) In patients with PPH, we recommend administration of erythrocyte blood products to achieve a target hemoglobin value in the range 70–80 g/L. (Strong recommendation) In patients with PPH, we recommend platelet administration to achieve a target value of at least 50 × 109/L and/or when platelet function impairment is suspected or demonstrated. (Strong recommendation) We do not recommend routine measurement of antithrombin III levels in patients with PPH. (Strong recommendation) We do not recommend routine antithrombin III replacement in patients with PPH. (Strong recommendation) We recommend initiating pharmacological prophylaxis for thromboembolic disease as soon as possible after control of the source of PPH is achieved. We recommend initiating mechanical thromboprophylaxis (intermittent pneumatic compression or elastic stockings) as soon as the clinical condition permits. (Strong recommendation)
- Keywords
- profylaxe uterotoniky, peripartální krvácení, tlakové a podlatkové nitroděložní prostředky, hemostatické nitroděložní prostředky, viskoelastické metody, krizový management,
- MeSH
- Uterine Hemorrhage * diagnosis therapy MeSH
- Factor VIIa MeSH
- Hemorrhage diagnosis therapy MeSH
- Humans MeSH
- Peripartum Period MeSH
- Pregnancy MeSH
- Check Tag
- Humans MeSH
- Pregnancy MeSH
- Female MeSH
- Publication type
- Practice Guideline MeSH
