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Norvasc

Carol J. Rollins, MS, RD, CNSC, PharmD, BCNSP

  • Clinical Professor, College of Pharmacy, University of Arizona
  • Clinical Pharmacist, Banner University Medical Center, Tucson, Arizona

There is no evidence that plasma substitutes are superior to normal saline in the resuscitation of a shocked woman hypertension prognosis discount norvasc 10mg, and dextran can be harmful in large doses blood pressure under 60 cheap 5 mg norvasc fast delivery. Note: A more rapid rate of infusion is required in the management of shock resulting from bleeding pulse pressure transducer norvasc 5mg cheap. Then tip it again every minute until the blood clots and the tube can be turned upside down blood pressure of 120/80 norvasc 10mg fast delivery. Signs of improvement include: stabilizing pulse (rate of 90 per minute or less); S-6 Shock increasing blood pressure (sys to lic 100 mmHg or more); improving mental status (less confusion or anxiety); increasing urine output (30 mL per hour or more) prehypertension uptodate norvasc 5 mg visa. If facilities are available blood pressure goes down when standing cheap norvasc 5 mg with amex, check serum electrolytes, serum creatinine and blood pH. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If the woman is in shock, consider ruptured ec to pic pregnancy (Table S-7, page S-16). Note: If ec to pic pregnancy is suspected, perform bimanual examination gently because an early ec to pic pregnancy is easily ruptured. Types of abortion Spontaneous abortion is defined as the loss of a pregnancy before fetal viability (22 weeks of gestation). Induced abortion is defined as a process by which pregnancy is terminated before fetal viability. Unsafe abortion is defined as a procedure performed either by persons lacking necessary skills or in an environment lacking minimal medical standards, or both. Sepsis may result from infection if organisms rise from the lower genital tract following either spontaneous or unsafe abortion. Sepsis is more likely to occur if there are retained products of conception and evacuation has been delayed. Persistent bleeding, particularly in the presence of a uterus that is larger than expected, may indicate twins or molar pregnancy. Optimal doses for misopros to l in the setting of incomplete abortion have not been determined. If heavy bleeding ensues, proceed to manual vacuum aspiration to ensure that there are no remaining products, and administer 800 mcg of misopros to l for management of post-abortal haemorrhage. Reassure her that the chances for a subsequent successful pregnancy are good unless there has been sepsis or a cause of the abortion is identified that may have an adverse effect on future pregnancies (this is rare). They should be encouraged to delay the next pregnancy until they have completely recovered. Abortion care should always include comprehensive contraceptive counselling with initiation of the method of choice as soon as desired after the abortion. The fallopian tube is the most common site of ec to pic implantation (greater than 90%). Symp to ms and signs are extremely variable, depending on whether or not the pregnancy has ruptured (Table S-7, page S-16). Culdocentesis (cul-de-sac puncture, page P-81) is an important to ol for the diagnosis of ruptured ec to pic pregnancy, but it is less useful than a serum pregnancy test combined with ultrasonography. Others are acute or chronic pelvic inflamma to ry disease, ovarian cysts ( to rsion or rupture), and acute appendicitis. If available, ultrasound can help to distinguish a threatened abortion or twisted ovarian cyst from an ec to pic pregnancy. Because the risk of another ec to pic pregnancy is high, this should be done only when the conservation of fertility is very important to the woman (page P-131). Vaginal bleeding in early pregnancy S-17 Au to transfusion If significant haemorrhage occurs, au to transfusion can be used if the blood is unquestionably fresh and free of infection (in later stages of pregnancy, blood is contaminated [e. Given the increased risk of a future ec to pic pregnancy, family planning counselling and provision of a family planning method, if desired, is especially important (Table S-6, page S-15). Manual vacuum aspiration is safer and associated with less blood loss than sharp metal curettage. Assess the woman for irregular bleeding through a his to ry and physical examination. If the urine pregnancy test is not negative after eight weeks or if it becomes positive again within the first year, urgently refer the woman to a tertiary care centre for further follow-up and management of choriocarcinoma. Note: the uterus is very soft in pregnancy and can easily be injured during the procedure. It is important that the opera to r understands the depth of the uterus and that the uterus will contract and the depth will decrease as the contents are removed. Anti-D Immunoglobulin In settings where the prevalence of Rh-negative status is high and Rh-immunoglobulin is routinely provided to Rh-negative women, administration of anti-D immunoglobulin should occur at the time of management of the abortion or ec to pic or molar pregnancy. The dose of Rh-immunoglobulin may be reduced from 300 mcg (the dose used after a term birth) to 50 mcg in pregnancies less than 12 weeks duration. Rh testing is not a requirement for management of abortions or ec to pic or molar pregnancies where it is not available or the prevalence of Rh-negative status is low. S-22 Vaginal bleeding in later pregnancy and labour If fetal movements are not felt or the fetal heart cannot be heard, suspect fetal death (page S-156). Failure of a clot to form after seven minutes, or a soft clot that breaks down easily, suggests coagulopathy. Maintenance Dose Note pulmonary oedema develops urine output is poor urine output does not improve urine output is still poor serum creatinine is more than 2. Vaginal approach without a needle guide Remember to keep the fingertip near the end of the needle guide. Do not place the fingertip beyond the end of the needle guide as needle-stick injury can easily occur. Caesarean Make sure there are no known allergies to Laparo to my lidocaine or related drugs. Repair of third and fourth Avoid use in women with uncorrected degree perineal tears hypovolaemia, severe anaemia, coagulation disorders, haemorrhage, local infection, severe pre-eclampsia, eclampsia or heart failure due to heart disease. Ask the woman to lie on her side (or sit up), ensuring that the lumbar spine is well flexed. Ask the woman to flex her head on to her chest and round her back as much as possible. Introduce the finest spinal needle available (22 or 23-gauge) in the midline through the wheal, at a right angle to the skin in the vertical plane. If on culdocentesis, keep the needle in place and make a stab incision at the site of the puncture: Remove the needle and insert blunt forceps or a finger through the incision to break loculi in the abscess cavity. Insert a high-level disinfected or sterile soft rubber corrugated drain through the incision. Remove infected sutures and debride the wound: If the, antibiotics are not required. If the (necrotizing fasciitis), give a combination of antibiotics until necrotic tissue has been removed and the woman is fever-free for 48 hours : fi fi Examine the uterine surface of the placenta to ensure that it is complete. Examine the cervix, vagina and perineum carefully and repair any tears to the cervix or vagina and perineum, or repair episio to my. Extract the placenta in fragments using two fingers, ovum forceps or a wide curette. Moni to r vital signs (pulse, blood pressure, respiration) every 15 minutes for two hours and then every 30 minutes for the next six hours or until stable. Counsel the woman and ensure that she understands what the procedure was and why it was done. Polyglycolic sutures are preferred over chromic catgut for their tensile strength, non allergenic properties and lower probability of infectious complications. The ureter must be identified and exposed to avoid injuring it during surgery or including it in a stitch. J Womens Health Gyn 1: 1-2 Abstract Background: Ec to pic pregnancies account for 1% of pregnancies, and 98% of those are tubal. This report describes an intra ovarian ec to pic pregnancy and a novel method of removing it to maximize future ovarian function and fertility in a young patient. On laparoscopy, an ovarian ec to pic preg nancy was diagnosed and was extracted from the ovary afer a linear incision over the sac. Conclusion: Ovarian ec to pic pregnancies are rare and can present as tubal pregnancies. In contrast to prior case reports, they may be removed successfully from the ovary while preserving the complete ovary. Introduction Given the range of cases reported in the literature [5], both in Ec to pic pregnancy is familiar to most practitioners, despite its tra and extra-ovarian, it is apparent that two distinct entities relative rarity. The re to pre-ejection fertilization or failure of ejection), and fertili mainder of ec to pic pregnancies are cornual, cervical, abdomi zation immediately afer ejection that implants on the ovarian nal and ovarian. All of these are rare enough that establishing surface or adjacent tissue (such as the tubal externa or utero their proportion is difcult. Tese two etiologies may be distinguished cies are some of the rarest of these types, a set of criteria called by fnding a plane of division between the pregnancy and the the Spiegelberg criteria is available to attempt to establish the ovary. Tese include: 1) Given these etiologies, three methods have been previously the gestational sac is located in the region of the ovary; 2) the described to remove ovarian ec to pic pregnancies: 1) In the ec to pic pregnancy is attached to the uterus by the ovarian case of extra-ovarian ec to pic pregnancy, excision along the ligament; 3) ovarian tissue in the wall of the gestational sac dividing plane, 2) For intra-ovarian ec to pic, wedge resection is proved his to logically; and 4) the tube on the involved side [6,7], or [3] oophorec to my. Tese criteria frequently fail to be satisfed by known cases Case [2]; thus, the diagnosis is clinical [3] Frequently, ovarian this 26-year-old G2P0010 initially presented to an outside ec to pic pregnancy is distinguished from tubal ec to pic preg hospital emergency department, reporting 1 week of lower nancy based on location at the time of removal. Attempts abdominal pain starting 4 weeks afer her last menstrual pe have been made to describe ultrasonographic fndings to dis riod. Ultrasound performed at that time showed an approxi tinguish these entities; but while they are inclusive, they are mately 5cm solid cystic mass within the cul-de-sac. Neither not exclusive at this time [4] Terefore, due to the rarity of ovary was visualized, nor were uterine contents identifed. Transvaginal ultrasound was once again performed iden tifying the cul-de-sac mass similar to previous imagery, and a right adnexal ec to pic pregnancy with sac and surrounding vascular ring, implying a classical tubal pregnancy. Moreover, moderate free fuid was visualized within the cul-de-sac, con cerning for rupture. The patient was transferred to the emergency room and ad mitted for surgical intervention. Ultrasound images were reviewed with on-site radiologists, who concurred with the reading. The patient was taken to the operative room for planned laparoscopic removal of ec to pic pregnancy either by salpingos to my or salpingec to my. On visualization of the pelvis, however, the right fallopian tube showed no tubal distension, erythema or other signs of ec to pic pregnancy. This tube was entirely inconsistent with appearance of the ec to pic pregnancy on ul trasound (Figure. At this point, the uterus was elevated in the pelvis and the right moved with an endocatch bag. It was abnor cauterized and the bed was inspected showing ovarian stroma mally enlarged to half of the diameter of the uterus. The decision was made For this reason, dilation and curettage was performed in or to proceed with linear oophoros to my in order to preserve the der to prove the uterine contents and reinforce the diagnosis ovary.

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For example heart attack playing with fire purchase norvasc in india, parents may base their decision regarding the communication approach on program fac to rs such as availability heart attack is recognized by a severe pain buy discount norvasc 10 mg online, the intensity of services offered arteria femural discount norvasc online amex, the variety of services offered blood pressure zetia buy cheap norvasc 5 mg line, setting blood pressure graph order norvasc cheap online, class size blood pressure chart morning 2.5 mg norvasc with amex, or the experience of the teachers with a particular communication approach (Tables 10 and 11). Regardless of the communication approach that parents select, it is important to provide a home environment filled with language and learning in order to facilitate development of cognitive as well as communicative abilities in children with hearing loss. For children with hearing loss, it is important to enhance the environment and use strategies to facilitate their ability to communicate. It is important to understand that language delays in children with hearing loss are usually not related to their cognitive potential. For children with hearing loss, it is important to remember that reading to the child from an early age is an important way to facilitate learning, just as it is for children with normal hearing. It is important that there be opportunities for multiple communication partners, including peers as well as adults. Communicating with comfort and ease in a variety of settings is socially and emotionally healthy for children with hearing loss. It is important to recognize that even with amplification devices or a cochlear implant, a child with hearing loss may not perceive sounds in the same way as a child with normal hearing. If parents select a visual communication approach to support English, such as cued speech, simultaneous communication, or to tal communication, it is recommended that amplification devices or a cochlear implant be used to allow the child to have optimal audi to ry access to speech in a variety of listening situations. It is recommended that parents receive specific parent training on how to reinforce visual communication approaches to support English. When visual communication systems are used to support English, it is important to use the system for all conversations when the child with hearing loss is nearby, even if the conversation is not directed at the child, because they otherwise might miss many language learning opportunities. If parents choose to use cued speech as their communication approach, it is important to recognize that cues can be learned fairly quickly, but it takes practice to become fluent. It is important to recognize that in the bilingual and the Bi-Bi approaches, English is taught as a second language. Many preschool classrooms for children who are deaf or hard of hearing have children who have a variety of types of hearing loss and differing amounts of residual hearing and speech use. Most children will have sufficient hearing to develop spoken language as their primary form of communication if they are provided with: fi An amplification device or cochlear implant that allows optimal audi to ry access to speech fi Specific training in the development of listening skills fi Therapy to promote the production of speech the presence of a hearing loss, regardless of severity, can delay the development of audi to ry or listening skills. Speech intelligibility tends to get poorer as the degree of hearing loss increases. That is, children with mild to moderate hearing losses tend to have better speech than do children with profound hearing loss. Children with significant hearing loss tend to have a distinctive speech quality such as sounding breathy, labored, stacca to , and arrhythmic (Tye-Murray 1998). Addressing the development of audi to ry skills through a listening skills program and addressing speech development through speech-language therapy are parts of a comprehensive approach to remediate the effects of hearing loss. Specific techniques to facilitate development of listening and speech are often used in various programs that have adopted either an audi to ry communication approach or an approach that supplements audi to ry information with some type of visual communication system such as cueing or signing. The techniques to facilitate the development of audi to ry skills and speech are based on the stages in which children with normal hearing show these skills. The audi to ry skills and speech skills are presented in Table 13 (below) and Table 14 (page 135), along with some techniques that parents and professionals can use to help children with hearing loss acquire these skills. It is important to recognize that most children with hearing loss have some amount of residual hearing. To enable children with hearing loss to use their residual hearing, it is important to provide specific training in the development of audi to ry skills. It is important to recognize that the majority of children with hearing loss, regardless of age, degree of hearing loss, or communication approach, can benefit from training in audi to ry skills. For children with hearing loss, it is important to provide therapy for speech production in order to optimize the intelligibility of their speech. It is important to use results from a speech evaluation to select the specific sounds to be included in the speech-language therapy goals. It is recommended that therapy for improving speech production for children with hearing loss follow a developmental approach with a goal of maximizing age-appropriate communication skills. For children with hearing loss and who are learning language through or partly through the audi to ry channel, it is important to emphasize the aspects of speech that are less salient (less audible, less visible) when providing therapy to improve speech production. It is essential that professionals providing speech-language therapy to children with hearing loss have knowledge of speech-language development (Table 14), and have knowledge and expertise in working with this population because there are many techniques that can be used to optimize speech development in children with hearing loss. It is important for a child to learn that talking is pleasurable, and when the child vocalizes, the parent responds. Before formal speech training begins, it is important for a child to be able to imitate and to do so willingly. Members tend to capitalize the term Deaf because they view the Deaf Community as a cultural entity. Over the past few decades, however, there has been a movement to wards mainstreaming Deaf children in to schools with normal hearing. Now, only approximately 20% of school-aged children identified as deaf are attending the residential programs that traditionally have transmitted knowledge of Deaf culture. It is important to recognize that Deaf culture and the Deaf community represent a valuable source of support and guidance for parents of children with hearing loss. Basis for the recommendations in this section the recommendations about amplification devices for young children with hearing loss are based on a combination of conclusions drawn from the articles meeting the criteria for evidence and consensus panel opinion. Amplification devices are sensory aids that are designed to make speech and other environmental sounds louder so that they are perceptible to individuals who have a hearing loss. Most young children with hearing loss use hearing aids as their primary sensory aid (Carney 1998). When amplification is provided, many children with hearing loss become able to use audi to ry information for communication, including development of spoken language. If sound pressure levels delivered to the ear by the amplification are excessive, children may choose not to use amplification because it is uncomfortably loud and/or further damage to the inner ear may result. Selecting appropriate amplification is the first step in the intervention process. Types of hearing aids Hearing aids vary not only in style but also in many other advanced technology options regarding circuitry, signal processing, number of channels, and memory. The criteria for selecting appropriate hearing aids for infants and young children are more complex than those for adults. Hearing aid options vary in cost, flexibility, ease of use, and durability; all of these are considerations when providing amplification to infants and young children. Body-style hearing aids are usually used when physical complications make head-worn amplification less appropriate or when a higher gain is required (Marlowe 1994). Bone-conduction style hearing aids are used for certain types of permanent conductive hearing loss that cannot be medically or surgically corrected. In addition to the basic style of the hearing aid, there are numerous other choices to make when selecting a hearing aid. Circuitry options for hearing aids include analog and digital, as well as digitally programmable options designed to increase flexibility. Signal processing capabilities can range from linear to various nonlinear options designed to enhance soft speech sounds and reduce potential dis to rtions. They can have single or multiple memories to permit the parent to make choices between different electroacoustic characteristics of the hearing aid depending on the listening environment. Process of hearing aid fitting Fitting an infant or young child for hearing aids is a process that includes several steps (Bess 1996). This is done by: fi Making an impression of the ear and ear canal using a quick setting silicone material and then sending the impression to an earmold labora to ry for fabrication of the earmold. Although the process of making earmold impressions may be accomplished easily with young infants and is not uncomfortable, it may be more difficult with older infants and to ddlers who are more active and less cooperative. Distraction techniques usually allow sufficient time for the impression to be made (approximately 15 minutes). For example: fi Audiologic information may often be incomplete when the hearing aid is initially fitted to a young child. These higher sound pressure levels could lead to unsafe levels of sound delivered to the inner ear and to loudness discomfort problems. Keeping the hearing aid in position may be difficult, because of the size of the ear. Infants and young children learning language for the first time through hearing (audition) require: 1. An overall louder signal to detect and differentiate speech sounds accurately, and 2. A greater difference between the loudness of the speech signal and any interfering background noise (signal- to -noise ratio) than do adults to perform optimally on listening tasks (Nozza 2000) the limited language ability of infants and young children makes it necessary to fit amplification without the benefit of subjective responses or judgments. Therefore, procedures to fit hearing aids that were originally developed for adults or older children are often not applicable for infants and young children. However, many infants are being fit for hearing aids within the first months of life because children are now being diagnosed with hearing loss at an earlier age. These are termed prescriptive hearing aid selection and fitting procedures (Seewald 1995). Moreover, as more audiologic information is acquired, adjustments to the amplification (using the prescriptive procedure) are necessary to ensure optimum hearing aid use. Therefore, audiologic, electroacoustic, and real-ear measures are made repeatedly during the early years of life (Gravel 2000). Validating that the child is benefiting from the amplification is part of an ongoing speech, language, and listening skills program (Harrison 2000). It is recommended that the use of amplification be initiated as soon as possible after the hearing loss is confirmed. Early referral for hearing assessment and hearing aid fitting is correlated with better levels of expressive spoken language (at mean age of 5 years) for children with mild to severe hearing loss. It is recommended that children with hearing loss begin use of amplification devices as soon as possible (ideally within 1 month of confirmation of the hearing loss) when use is appropriate and agreed on by the family. When disagreements occur, parents can seek due process through mediation or an impartial hearing. It is recommended that amplification for infants and young children provide them with optimal access to speech in a variety of listening situations. When amplification devices are recommended, it is important that parents be provided with information about the types of hearing aids, assistive technologies, and other amplification options and choices available for their child. It is important to give the parents time to understand the issues and information.

Assuming normal progress in labour arrhythmia vs pvc buy 5mg norvasc with visa, the second stage may deliberately be kept short hypertension heart disease generic 5 mg norvasc mastercard, with an elective forceps or ven to use delivery if normal delivery does not occur readily blood pressure 130/80 purchase generic norvasc. Caesarean section should only be performed in situations where the maternal condition is considered to o unstable to to lerate the physiological demands of labour arteria intestinalis order 10mg norvasc otc. Caesarean delivery is associated with an increased risk of haemorrhage pulse pressure is quizlet 5 mg norvasc with amex, thrombosis and infection heart attack manhattan clique remix cheap 10 mg norvasc amex, conditions that are likely to be much less well to lerated in women with cardiac disease. Postpartum haemorrhage in particular can lead to major cardiovascular instability. Syn to cinon is a vasodila to r and therefore should be given slowly to patients with significant heart disease, with low-dose infusions preferable. High-level maternal surveillance is required until the main haemodynamic changes following delivery have passed. Management of labour in women with heart disease Avoid induction of labour if possible. Treatment of heart failure in pregnancy the development of heart failure in pregnancy is dangerous, but the principles of treatment are the same as in the non-pregnant individual. The woman should be admitted and the diagnosis confirmed by clinical examination for signs of heart failure and by echocardiography confirming ventricular dysfunction. Arrhythmias also require urgent correction and drug therapy; for example, adenosine for supraventricular tachycardias. Similarly, in cases of intractable cardiac failure, the risks to the mother of continuing the pregnancy and the risks to the fetus of premature delivery must be carefully balanced. Risk fac to rs for the development of heart failure in pregnancy Respira to ry or urinary infections. The underlying pathology is frequently not atherosclerotic and coronary artery dissection is the primary cause in the postpartum period. There is little experience with thrombolytic therapy in pregnancy, and although not apparently tera to genic, there are risks of fetal and maternal haemorrhage. Mitral and aortic stenosis Obstructive lesions of the left heart are well-recognized risk fac to rs for maternal morbidity and mortality, as they result in an inability to increase cardiac output to meet the demands of pregnancy. For those with known mitral stenosis, 40% experience worsening symp to ms in the pregnancy, with the average time of onset of pulmonary oedema at 30 weeks. The aim of treatment is to reduce the heart rate, achieved through bed rest, oxygen, beta-blockade and diuretic therapy. Balloon mitral valvo to my is the treatment of choice after delivery, but can be considered in pregnancy depending on the clinical condition and gestation. Maternal mortality is reported at 2% and the risk of an adverse fetal outcome is directly related to the severity of mitral stenosis. As with mitral stenosis, bed rest and medical treatment aims to reduce the heart rate to allow time for ventricular filling. Marfan syndrome Marfan syndrome is an au to somal dominant connective tissue abnormality that may lead to mitral valve prolapse and aortic regurgitation, aortic root dilatation and aortic rupture or dissection. Pregnancy increases the risk of aortic rupture or dissection and has been associated with maternal mortality of up to 50% where there is marked aortic root dilatation. Echocardiography is the principal investigation, as it is able to determine the size of the aortic root, and should be performed serially throughout pregnancy, especially in women who enter pregnancy with an aortic root that is already dilated (>4 cm). Women with an aortic root <4 cm should be reassured that their risks are lower, and the risk of an adverse cardiac event is around 1%. A number of obstetric complications have also been described in women with Marfan syndrome: early pregnancy loss, preterm labour, cervical weakness, uterine inversion and postpartum haemorrhage. The main symp to ms are fatigue, breathlessness and syncope, and clinical signs are those of right heart failure. Specific treatments shown to improve symp to ms and survival include endothelin blockers, such as bosentan, and phosphodiesterase inhibi to rs such as sildenafil. The demands of increasing blood volume and cardiac output may not be met by an already compromised right ventricle, and any decline in cardiac performance in pregnancy represents a life-threatening event. Women may deteriorate early (second trimester) or in the immediate postpartum period. In women who choose to continue their pregnancy, targeted pulmonary vascular therapy is an option, with timely admission to hospital and delivery according to the progress of the woman and condition of the fetus. Respira to ry disease Respira to ry infection the recent outbreaks of H1N1 and influenza A have increased the number of maternal deaths attributed to respira to ry infection. Viral pneumonia follows a more complicated course in pregnancy and women often decompensate more quickly. Prompt treatment and early involvement of respira to ry and infectious disease specialists in addition to the intensive care is essential. Bacterial pneumonia should be treated using the same antibiotics as outside, with penicillin or cephalosporins usually the first choice, and erythromycin used if atypical organisms are suspected. However, prospective studies show that exacerbations of asthma are more likely to occur in women with severe asthma than mild asthma and that most episodes occur between 24 and 36 weeks of pregnancy. There is evidence that proactive management of asthma-related symp to ms and attacks during pregnancy decreases maternal and fetal morbidity. Asthma severity and suboptimal control are associated with adverse pregnancy outcomes. An association between hypertension and asthma has also been suggested, and although there is an increase in gestational hypertension, asthma does not seem to be a risk fac to r for pre-eclampsia. Labour and delivery are not usually affected by asthma and attacks are uncommon in labour. Parenteral steroid cover may be needed for those who are on regular steroids, regular medications should be continued throughout labour and bronchoconstric to rs such as ergometrine or prostaglandin F2fi should be avoided in women with severe asthma. Adequate hydration is important in labour, and regional anaesthesia is favoured over general to decrease the risk of bronchospasm, provide adequate pain relief and to reduce oxygen consumption and minute ventilation. Postpartum, there is no increased risk of exacerbations and those whose asthma deteriorated during pregnancy have usually returned to prepregnancy levels by 3 months after birth. Features of severe lifethreatening asthma Peak expira to ry flow rate <35% of predicted. Many women with asthma are concerned about the effect of drugs on the fetus, and this can lead to inappropriate cessation of treatment in early pregnancy. However, it is safer to take asthma drugs in pregnancy than to leave asthma uncontrolled. Inhaled beta-sympathomimetics are safe, as is theophylline, although its metabolism is altered and drug levels need to be moni to red. Inhaled corticosteroids have been shown to be safe with no association with fetal malformations or perinatal morbidity in large studies and reviews. Oral corticosteroid use in the first trimester has been associated with an increased risk of fetal cleft lip or palate in epidemiological studies, but the increase in risk is small and not confirmed in other work. Data are reassuring on the safety of the leukotriene antagonist montelukast during pregnancy. The abnormal gene controls the movement of salt in the body, and as a result the internal organs become clogged with thick mucus, leading to infections and chronic inflammation, particularly affecting the lungs, gut and pancreas. The live birth rate ranges from 70% to 90%, and the rate of spontaneous miscarriage is no different to the general population. However, the prematurity rate is around 25%, due to iatrogenic delivery where maternal health deteriorates, as well as a higher rate of spontaneous preterm labour. Most women will have a daily physiotherapy regime and require prolonged antibiotic therapy and hospital admission during infective exacerbations. Ideally, a vaginal delivery should be the aim in the absence of any other obstetric indications for caesarean section. Sarcoidosis Sarcoid is a non-caseating granuloma to sis that may affect any organ, but principally affects the lung and skin. Sarcoidosis usually improves and is uncommonly diagnosed in pregnancy, although erythema nodosum, which may occur in both normal pregnancy and in sarcoidosis, may cause diagnostic confusion. Pregnancy has no consistent effect on epilepsy: some women will have an increased frequency of fits, others a decrease and some no difference. Nonetheless, there is a 10-fold increase in mortality among pregnant women with epilepsy, and 1 in 20 indirect maternal deaths occur in women with epilepsy. The principles of epilepsy management are that while the risks to pregnancy from seizures outweigh those from anticonvulsant medication, seizures should still be controlled with the minimum possible dose of the optimal drug. Prepregnancy counselling in epilepsy Alter medication according to seizure frequency. The principal concern related to epilepsy in pregnancy is the increased risk of congenital abnormality caused by anticonvulsant medications. The major fetal abnormalities associated with anticonvulsant drugs (including sodium valproate, carbamazepine, pheny to in, phenobarbi to ne) are neural tube defects, facial clefts and cardiac defects. Many of these abnormalities are detectable by ultrasound and therefore all women should be offered detailed anomaly scanning. In addition, each drug is associated with a specific syndrome that includes developmental delay, nail hypoplasia, growth restriction and midface abnormalities. Despite the risks of continuing anticonvulsants in pregnancy, failure to do so may lead to an increased frequency of epileptic seizures that may result in both maternal and fetal hypoxia. Therefore, women on multiple drug therapy should, wherever possible, be converted to monotherapy before pregnancy, and all epileptic women should be advised to start taking a 5 mg daily folic acid supplement prior to conception to reduce the risk of neural tube defects. In women who have been free of seizures for 2 years, consideration may be given prepregnancy to discontinuing medication. Many fac to rs contribute to altered drug metabolism in pregnancy and result in a fall in anticonvulsant drug levels. The reasons for increased fit frequency in pregnancy therefore include the effect of pregnancy on the metabolism of anticonvulsant drugs, as well as sleep deprivation or stress and poor compliance with medication. An increase in dosage to combat the anticipated fall may lead to an increased fetal risk. In the majority of cases, provided there is no increase in frequency of seizures, the prenatal drug dosage can be continued. However, lamotrigine drug levels fall rapidly in pregnancy and in many cases this is associated with increased seizure activity, necessitating an increased dose. Delivery mode and timing is largely unaltered by epilepsy, unless there has been accelerated seizure frequency in pregnancy, and anticonvulsant medication should be continued during labour. Breastfeeding should be encouraged, although feeding is best avoided for a few hours after taking medication. Information on safe handling of the neonate should be given to all epileptic mothers. Certainly, pregnancy has no adverse effect on the progression of long-term disability. It is recommended that first-line treatments including glatiramer, interferon-beta, and dimethyl fumurate are s to pped at conception. Steroids or intravenous immunoglobulin can be given to treat an acute relapse and should be used where clinically indicated. Regional anaesthesia is not contraindicated and no effect on the subsequent risk of relapse has been found. Migraine Migraine is influenced by cyclical changes in the sex hormones, and attacks often occur during the menstrual period, attributed to a fall in oestrogen levels. Migraine often improves in pregnancy, with worsening of headaches occurring infrequently. Throughout pregnancy around 20% of pregnant women will experience migraine-like headaches, many of whom do not get migraines outwith pregnancy. Migraine during pregnancy should be treated with analgesics, antiemetics and, where possible, avoidance of fac to rs that trigger the attack. The outcome is generally good and complete recovery is the norm if the time of onset is within 2 weeks of delivery. The role of corticosteroids and antivirals is controversial but both can be used in pregnancy and they may hasten recovery if given with 24 hours of the onset of symp to ms. Like other medical disorders, ideal management begins with prepregnancy optimization of maternal health and education about the risks in pregnancy. High-dose folate supplements (5 mg daily) are recommended and the majority of women are also managed from early pregnancy on low-dose aspirin (75 mg daily). Pregnancy is associated with an increased incidence of sickle cell crises that may result in episodes of severe pain, typically affecting the bones or chest. Crises in pregnancy may be precipitated by hypoxia, stress, infection and haemorrhage. Although sickle-cell haemoglobin C disease may cause only mild degrees of anaemia, it is associated with very severe crises that occur more often in pregnancy. Carriers are usually fit and well, but are at increased risk of urinary tract infection, and rarely suffer from crises.

Diseases

  • Metatropic dwarfism
  • Cervical hypertrichosis peripheral neuropathy
  • Hypoprothrombinemia
  • Hepatitis E
  • Lip lit syndrome
  • German syndrome
  • Epidermolytic palmoplantar keratoderma Vorner type
  • Strongyloidiasis

A Cochrane review concluded that while short-term follow-up studies might indicate an advantage for endometrial ablation arterial blood gas interpretation norvasc 10mg with amex, longer-term studies show a narrowing of the gap pulse pressure 64 buy norvasc 10mg fast delivery, and hysterec to my appears to have consistently higher rates of satisfaction and better health related quality-of-life outcomes blood pressure medication infertility discount 5 mg norvasc overnight delivery. After endometrial resection hypertension xanax generic norvasc 2.5mg, the women were randomized in to two groups heart attack induced coma buy norvasc 5 mg otc, 53 women in each heart attack from stress cheap norvasc 5mg on-line. In this group, amenorrhoea was achieved in 72% of cases after 3 months, in 89% after 6 months and in 100% after 1 year. In the resection-only group, the corresponding numbers were 19%, 17% and 9%, and in this group, 19% of the women underwent a second resection. Sixty-two patients had adenomyosis and the remaining 30 had submucous and intramural myomas. In his to rical controls submitted to endometrial resection, the amenorrhoea rate was only 20% with a failure rate of 40%. Intrauterine Levonorgestrel-Releasing Systems for Effective Treatment and Contraception 155 interrupting the progression of the disease. This may explain why the rates of amenorrhoea are far superior to those achieved with endometrial resection alone. Alternative therapies for the management of fibromyomas Uterine myoma (leiomyoma, fibromyoma, fibroid) is a very common disease. They are more common in certain ethnic populations, especially the Afro-Caribbean. They are often asymp to matic but some 25-50% of women will experience symp to ms such as menorrhagia and pelvic discomfort. About 5% of the fibroids are intracavitary and submucosal and are most difficult to treat. Notwithstanding the success of radical surgery, it is not always desirable particularly in the younger woman desiring fertility. Also psychological fac to rs play a role as the uterus has been regarded as a sexual organ, a source of energy and vitality, and a maintainer of youth and attractiveness. Many women, therefore, might wish to avoid a hysterec to my, even when their families are complete. Furthermore, new conservative approaches and minimally invasive techniques should be explored. Progesterone antagonists and progesterone recep to r modula to rs may have a major role in the future to treat conditions such as fibroids and endometriosis conservatively. Endometriosis accounts for approximately 20% of the hysterec to mies currently performed. There is no doubt that these new approaches will help reduce the number of hysterec to mies further. However, hysterec to my will always remain the first choice for infiltrative cancer of the uterus and for most forms of pelvic relaxation although vaginal pessaries are increasingly used in older women. The funds generated are used for conducting further research and to participate in humanitarian projects. Randomised controlled trial comparing endometrial resection with abdominal hysterec to my for the surgical treatment of menorrhagia. The quality of life in women suffering from gynaecological disorders is improved by means of hysterec to my. Intrauterine Levonorgestrel-Releasing Systems for Effective Treatment and Contraception 157 women of reproductive age in the United States: the collaborative review of sterilization. The contribution of hysterec to my to the occurrence of urge and stress urinary incontinence symp to ms. Three-dimentional ultrasound detection of abnormally located intrauterine contraceptive devices which are the source of pelvic pain and abnormal bleeding. Intrauterine contraceptives that do not fit well contribute to early discontinuation. Ease of insertion, contraceptive efficacy and safety of new T-shaped levonorgestrel-releasing intrauterine systems. Treatment of non-atypical and atypical endometrial hyperplasia with a levonorgestrel-releasing intrauterine system: longterm follow-up. Successful Treatment of Early Endometrial Carcinoma by Local Delivery of Levonorgestrel: A Case 158 Hysterec to my Report. Quality of life in Brazilian women with endometriosis assessed through a medical outcome questionnaire. Use of the levonorgestrel-releasing intrauterine system in women with endometriosis, chronic pelvic pain and dysmenorrhea. Is There a Role for Use of Levonorgestrel Intrauterine System in Women with Chronic Pelvic Painfi The levonorgestrel-releasing intrauterine system as an alternative to hysterec to my in peri-menopausal women. Open randomised study of use of levonorgestrel releasing intrauterine system as alternative to hysterec to my. Trends in number of hysterec to mies performed in England for menorrhagia: examination of health episode statistics, 1989 to 2002-3. Progesterone /progestagen releasing intrauterine system versus either placebo or any other medication for heavy menstrual bleeding. Menorrhagia on the other hand is an objective diagnosis of blood loss over 80 millilitres over several consecutive cycles. The average blood loss in a Caucasian female population is approximately 30-40 millilitres per menstrual flow (Cole et al. Menorrhagia is the commonest cause of iron deficiency anaemia in women in the developed world and occurs in sixty per cent of women with objective menorrhagia. However, it is the main reason for women requesting hysterec to my and 1 in 5 women have a hysterec to my in the United Kingdom for this reason by the age of fifty five. With less invasive and effective alternatives to hysterec to my, women should be carefully counselled with regards to morbidity and mortality associated with this major operation. Menstrual disorders are now more common than they were a century ago because modern career women are choosing to have smaller or no families and not breastfeeding. Dysfunctional uterine bleeding is associated with anovulation and occurs in a fifth of women at extremes of their reproductive life. Menorrhagia is also associated with uterine fibroids, endometrial polyps, adenomyosis, pelvic infection, bleeding diathesis, and rarely malignancies like endometrial cancer. Over a half of women with blood loss over 200 millilitres will have underlying fibroids. It is thought to result from increased activity of prostaglandins or the endometrial fibrinolytic activity. The endometrium also contains a fibrinolytic system whose activity is increased in women with menorrhagia compared to those with normal menstrual loss. Some people further sub-classify it in to ovula to ry and anovula to ry bleeding although this does not have much clinical relevance. Anovula to ry bleeding is caused by excessive proliferation of endometrium due to unopposed oestrogen. The absence of prostaglandins in the endometrium, which is usually synthesized in response to progesterone, may explain the absence of pain/cramps. They occur in a fifth of women and are commoner in women of the Afro-Caribbean origin. They occur in the uterine body or cervix and can be submucosal, intramural or subserosal. When large they can cause pressure effects on surrounding organs and may present with urinary frequency, hydronephrosis and recurrent urinary tract infections. Polyps are localized growths of the endometrium which comprise of fibrous tissue surrounded by columnar epithelium. It is thought that they arise from disordered apop to sis and regrowth of the endometrium. Drug his to ry including tamoxifen use and a his to ry of bleeding tendency are also important. Previous pelvic surgery and associated findings should be noted as well as past his to ry of polycystic disease, hormonal usage, bowels or ovarian cancer. It should therefore entail vital signs, inspection of mucous membranes, finger nails and abdominal palpation. A speculum assessment should be done to look for vaginal and cervical abnormalities. A bimanual pelvic examination will assess the size of the uterus, presence of adnexal mass and/or signs of a pelvic infection. Thyroid function tests, coagulation defects, liver and kidney function tests should be done if clinically indicated. An ultrasound scan of the pelvis and abdomen is a useful to ol in diagnosis and for describing masses suspected or actually found on physical examination, especially in obese women where examination can be suboptimal. It is not usually required if uterine size is less than 10 weeks and there is no suspicion of other pathology. Cervical smear should be undertaken if screening is not up to date or where the cervix looks suspicious. Similarly an endometrial biopsy should be taken if a woman is over 40 or under 40 with particular risk fac to rs like tamoxifen use, unopposed oestrogen or obesity. Non-steroidal anti-inflamma to ry drugs act by inhibiting prostaglandin synthesis and reduce bleeding by about a quarter. The commonest used medication is mefenamic acid of which the main side effect is dyspepsia. It inhibits plasminogen activa to r and hence promotes clots formation in spiral arterioles and decreases bleeding by about a half. Side effects include nausea, vomiting, diarrhoea and rarely tinnitus and thromboembolic events. The combined oral contraceptive pill makes periods regular and is associated with a fifty per cent reduction in blood loss. It is suitable for all age groups unless there are specific contraindications like family or personal thromboembolic disease, migraines with aura, hypertension, obesity and immobility. Oral progesterones act by ovulation inhibition and directly suppressing the endometrium. Norethisterone 5mg three times a day from day 5 to 26 has been shown to reduce blood loss by eighty per cent. Depo-Provera may cause unpredictable bleeding initially but usually amenorrhea results. Common side effects include nausea, breast tenderness, bloatedness, weight gain, acne and voice changes. Medical treatment of menorrhagia Gonadotrophin releasing hormone analogues act by down-regulating the pituitary hence inhibiting ovarian activity. Women become hypo-oestrogenised and may have distressing vasomo to r symp to ms of hot flushes and night sweats as well as vaginal dryness. Add-back hormone replacement therapy as well as bone mineral density scans should be considered if treatment goes beyond six months. Danazol was originally produced for treatment of endometriosis but was found to cause amenorrhea. It works by inhibiting the pituitary and also suppressing the endometrium directly. It has debilitating androgenic effects which restrict its use including acne, deep voice, hirsutism, breast tenderness and weight gain. Menorrhagia and the Levonorgestrel Intrauterine System 163 Gestrinone on the other hand, is a synthetic derivative of 19-nortes to sterone which has both oestrogenic and progestrogenic as well as androgenic effects. Its androgenic side effects are less that danazol but after cessation of use, bleeding can become heavy again. The levonorgestrel intrauterine system is a medicated device that is inserted in to the uterus and delivers progesterone which acts locally on the endometrium to cause thinning and amenorrhea. The former involve hysteroscopic destruction of the endometrium by rollerball, transcervical endometrial resection or laser ablation. The cumulative hysterec to my rate after endometrial resection was found in one study to be 27. Endometrial resection is associated with a long surgical learning curve and significant risks include uterine perforation and fluid overload resulting in hyponatremia. They have generally been superseded by second generation techniques which are quicker and safer. First generation Roller ball Trans-cervical resection Laser ablation Second generation Thermal balloon ablation Microwave ablation Novasure ablation Hysterec to my Total Sub to tal Table 3. Different modalities of surgical treatment Second generation endometrial ablation techniques aim to destroy the endometrium with resultant amenorrhea. In practice, although patient satisfaction rates are over 70 per cent, the amenorrhea rate is less than 30 per cent (Lethaby et al. The procedure can be repeated in women with persistent heavy menstrual bleeding after assessing the cavity hysteroscopically. Hysterec to my remains the only method of ensuring complete amenorrhea and is generally offered to women where all other methods have been unsuccessful.

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