Roger Anthony Johns, M.D.
- Professor of Anesthesiology and Critical Care Medicine
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0014874/roger-johns
A threshold value of 135 mg/dL or 140 mg/dL can be used at the discretion of the provider depression joint definition asendin 50 mg without a prescription. Two abnormal values meeting or exceeding the values shown in Table 59-2 are required for the diagnosis depression elderly cheap 50 mg asendin with amex. From American College of Obstetricians and Gynecologists: Gestational diabetes mellitus. Maternal-Fetal Metabolism in Normal and Diabetic Pregnancy Significant changes in maternal metabolism occur during a normal pregnancy. For example, if a woman is healthy and lean before conception, there is an increased need to store adipose tissue in early pregnancy (to meet the increased energy demands of late gestation) and to develop insulin resistance in late gestation (to provide nutrients for the growing fetus). If a woman is obese before conception, there is little need to gain additional adipose tissue, but there is the requirement to provide nutrients for the fetal growth in late gestation. The alterations in insulin resistance affect endogenous glucose production (primarily hepatic glucose metabolism) and peripheral glucose metabolism, which takes place in skeletal muscle. In the lean pregnant woman with normal glucose tolerance, there is a significant 30% increase in basal hepatic glucose production by the third trimester of pregnancy. This is associated with a significant increase in basal or fasting insulin concentrations. In the postprandial state, increasing insulin concentrations enhance glucose uptake into skeletal muscle and adipose tissue and almost completely suppress hepatic glucose production. Although this is the case in lean women, obese women, even those with normal glucose tolerance, have a decreased ability for insulin to completely suppress hepatic glucose production in late pregnancy. Peripheral insulin resistance is defined as the decreased ability of insulin to affect glucose uptake primarily in skeletal muscle and to a lesser degree in adipose tissue. Various methods are used to assess insulin sensitivity in vivo, including mathematical models of fasting glucose and insulin modeling. Lean women usually have greater pregravid insulin sensitivity compared with overweight or obese women. These differences manifest before pregnancy, and when evaluated against the metabolic background of pregnancy, the relationships are similar in late pregnancy, albeit reduced by approximately 50% to 60%. The decreases in insulin sensitivity in late pregnancy are accompanied by an increase in insulin response. The insulin response to a glucose load increases approximately threefold compared with pregravid measures. If insulin sensitivity is estimated before conception or after delivery, there is a significant decrease in women who go 14 190 180 170 160 mg/min 150 140 130 120 110 100 90 Pregravid Early pregnancy Late pregnancy Glucose infusion rate (mg/kg. The increased glucose concentrations represent the inability of pancreatic beta cells to normalize glucose levels. The relationship between insulin sensitivity and insulin response has been characterized as a hyperbolic curve or, when multiplied, as the disposition index. Whether insulin resistance precedes beta cell defects or occurs concomitantly is not known with certainty. However, Buchanan proposed that insulin resistance causes beta cell dysfunction in susceptible individuals. The greatest increase was observed between 16 and 37 weeks, with a gradual decline thereafter. The action of insulin in target cells requires the orchestrated activation of complex molecular steps. The mechanisms responsible for pregnancy-induced insulin resistance have been characterized at the molecular level. In normal pregnancy, the ability of the insulin receptor to transduce an intracellular signal is diminished. The decreased receptor phosphorylation, which results in 25% less glucose transport activity, is not found in pregnant women with normal glucose tolerance. The insulin resistance of pregnancy is almost completely reversed shortly after delivery, consistent with the marked decrease in insulin requirements clinically in women managed on insulin. The term "metabolic inflammation" is applied to situations of lowgrade chronic inflammation observed in several metabolic disorders such as obesity and diabetes. Not only is it a storage depot for excess calories, but it also actively releases fatty acids and secretes a variety of adipocytokines. It proceeds from mild nonproliferative abnormalities, which are associated with increased vascular permeability; to moderate and severe nonproliferative diabetic retinopathy, which is characterized by vascular closure; to proliferative diabetic retinopathy, which is characterized by the growth of new blood vessels on the retina and posterior surface of the vitreous. Second, the new blood vessels of proliferative diabetic retinopathy and contraction of the accompanying fibrous tissue can distort the retina and lead to tractional retinal detachment, producing severe and often irreversible vision loss. Third, the new blood vessels may bleed, adding the further complication of preretinal or vitreous hemorrhage. Although past studies suggested that rapid induction of glycemic control in early pregnancy stimulates retinal vascular proliferation,58 later investigations showed that the severity and duration of diabetes before pregnancy have a greater effect. However, progression was significantly greater in women who had had diabetes for more than 10 years (10% versus 0%). Four women required laser therapy during pregnancy, but none required laser subsequently. Baseline retinopathy status was the only independent risk factor that predicted progression of retinopathy. Screening for retinopathy by a qualified ophthalmologist is recommended before pregnancy and again during the first trimester for patients with pregestational diabetes because of the demonstrated effectiveness of laser photocoagulation therapy in arresting progression. Adapted from Standards of medical care in diabetes-2012, Diabetes Care 35(Suppl 1):S11-S63, 2012. However, use of this agent in pregnant women has been limited to case reports, several of which have documented miscarriage after intraocular injection. In the United States, diabetes is the leading cause of kidney failure, accounting for 44% of all new cases of kidney failure in 2008. Additional insults, such as repeated urinary tract infections, excessive glycogen deposition, glycosylation, and papillary necrosis, all hasten deterioration of renal function. The kidney is normal at the onset of diabetes, but within a few years glomerular basement membrane thickening can be identified. By 5 years, there is expansion of the glomerular mesangium, resulting in diffuse diabetic glomerulosclerosis. All patients with marked mesangial expansion exhibit proteinuria exceeding 400 mg in 24 hours. Categories of Diabetic Nephropathy Categories of diabetic nephropathy are distinguished by the level of urinary protein excretion. Table 59-3 shows normal values and the current clinical criteria for microalbuminuria and nephropathy. Screening for microalbuminuria can be performed by three methods: measurement of the albumin-tocreatinine ratio in a random spot collection; 24-hour urine collection with serum creatinine, allowing the simultaneous measurement of creatinine clearance; and timed (4-hour or overnight) collection. The first method is preferred because it is the easiest to carry out in an ambulatory setting and it provides adequately accurate information. Effect of Pregnancy on Progression of Nephropathy Although some clinicians discourage pregnancy in women with diabetic renal disease because of concerns about permanent 59 Diabetes in Pregnancy 997 renal deterioration as a result of the pregnancy, recent data consistently indicate that pregnancy does not measurably alter the time course of diabetic renal disease. Progression of diabetic nephropathy is closely related to the degree of glycemic control. To the extent that most women have better glycemic control during pregnancy, delay or slowing of renal function deterioration can be expected. A study of renal function for 4 years before and 4 years after pregnancy in 11 patients with diabetic nephropathy63 showed that the gradual rise in serum creatinine over that period was unaffected by the intervening pregnancy. Imbasciati and coworkers performed a longitudinal study of 58 women with chronic renal disease whose mean serum creatinine level was 6 mg/dL at the start and 6 mg/dL at the end of pregnancy. Although women with glomerular filtration rates slower than 40 mL/min and proteinuria greater than 1 g/day had increased risk of delivering a lowbirth-weight child, even those with worse values had similarly modest changes in renal function when after- and beforepregnancy indices were compared. In both groups, there was an increase in urinary albumin excretion during pregnancy (592 versus 119 mg/24 hr, respectively; P =. Rossing and colleagues66 evaluated the effect of pregnancy on deterioration of renal function in 93 women older than 20 years of age. They compared groups of never-pregnant and ever-pregnant women who received similar medical therapy and who had similar degrees of renal function at the start of the study. About 60% of births are premature, often because of uncontrollable hypertension, renal failure, or fetal growth failure. Among the 20% to 25% of pregnancies ending in live births, 40% of babies are severely growth restricted. A major practical problem with achieving a successful pregnancy outcome while on hemodialysis is proper maintenance of maternal vascular volume.
It may have less significant impact on the coagulation profile compared with other colloids and therefore may offer an advantage in the setting of hemorrhage depression test gratis buy asendin 50mg otc. The variety of blood product components available for transfusion is summarized in Table 71-10 depression definition in dsm iv purchase 50 mg asendin overnight delivery, along with their anticipated effects. Whole blood has not been separated into the various components and therefore offers an advantage because it contains clotting factors and platelets in addition to red blood cells. The major limitation to the use of whole blood is the inability to store the product beyond 24 hours. After 24 hours of extravascular storage, platelets and granulocytes are completely lost, and 2,3-diphosphoglycerate is depleted, significantly compromising the oxygen-carrying capacity of the red blood cell. Prolonged storage results in depletion of clotting factors and increasing levels of potassium and ammonia. Individual components are administered to address specific derangements according to clinical indications. The routine administration of clotting factors after every 4 to 6 units of packed red blood cells was previously thought not to improve outcomes. A single unit of packed red blood cells has a hematocrit of approximately 80% and increases the hemoglobin level by 1 g/ dL in a 70-kg individual. A patient with evidence of acute hemorrhage (>30% blood volume loss), a hemoglobin level between 6 and 10 g/dL with evidence of tachycardia and hypotension, or a hemoglobin level less than 6 g/dL should be considered a candidate for transfusion. Platelet counts equilibrate within 10 minutes and can be assessed immediately after completion of the transfusion. The goal is to correct clotting factor deficiencies and to achieve a post-transfusion serum fibrinogen level of approximately 100 mg/dL. Complications of Transfusion Complications resulting from blood component transfusion can vary from infections to immunologic responses. Minor transfusion reactions are relatively common occurrences and are not caused by hemolysis. Common clinical findings include low-grade fever, urticaria, and hives and result from exposure to incompatible platelet or white blood cell antigens. The use of leukocyte-poor packed red blood cells minimizes these types of reactions. Severe reactions after transfusion are usually a result of a hemolytic reaction from administration of an incompatible unit of blood. Administrative error is the culprit in most of these events, underscoring the need for accurate accounting of transfused units, particularly in an emergent situation. Treatment entails immediate discontinuation of the transfusion and supportive care. In approximately 3 minutes, a unit of blood with a hematocrit of 50% is generated. In one study comparing patients who received blood salvage and autotransfusion during cesarean section with those receiving allogeneic blood transfusions, no differences in the rates of infection, coagulation abnormalities, or respiratory problems were identified. This is accomplished by collecting blood from the patient preoperatively and placing it into special storage bags that can be obtained from the blood bank. Simultaneously, the patient is given crystalloid solution in a 3: 1 ratio, resulting in a dilutional effect that decreases the maternal hematocrit. Potential advantages include preservation of clotting factors and decreased likelihood of an allogeneic transfusion and therefore a decreased risk of infectious morbidity, alloimmunization, and immunologic complications. Supplemental oxygenation and elevation of the lower extremities are usually recommended in the setting of hemorrhage. For example, one of the most common causes of postpartum hemorrhage is uterine atony, which can be expected to respond to uterine massage and uterotonic agents as first-line therapy. Hemorrhage due to placenta accreta or previa requires a surgical intervention in the setting of hemorrhage. This includes any necessary surgical approach, appropriate replacement of blood products, and correction of severe acidosis, hypothermia, and hypocalcemia. Hemorrhage after a vaginal delivery should prompt a thorough evaluation for and repair of cervical or vaginal lacerations, particularly if an instrumented delivery was performed. If uterine atony fails to respond to uterine massage and uterotonic agents, evaluation for potential retained placental fragments should be performed. Ultrasound may be of assistance in this assessment process, particularly if uterine curettage is necessary. Intrauterine pressure packs to control life-threatening postpartum hemorrhage have been successful in some cases. If uterine hemorrhage after vaginal delivery fails to respond to the previous measures, exploratory laparotomy should be performed. If the bleeding is encountered at cesarean section, the same techniques for control of hemorrhage may be applied. Uterine artery ligation offers the advantage that the uterine arteries are readily accessible with uterine manipulation, and minimal or no vessel dissection is necessary. Hypogastric (internal iliac) artery ligation is more technically challenging, requiring dissection of the retroperitoneal space through the broad ligament. Bilateral ligation is usually necessary to achieve adequate reduction in pulse pressure. The surgeon must be familiar with pelvic vascular anatomy to avoid ureteral injury or inadvertent ligation of the common or exterior iliac artery, which will obstruct blood flow to the lower extremity. Identified risk factors include cesarean delivery, prior cesarean delivery, multiparity, and advancing maternal age. Although some case series have suggested that invasive placentation appears to be supplanting uterine atony as the leading indication for peripartum hysterectomy, these data suggest they may be equally common. Complications associated with emergency peripartum hysterectomy include excessive blood loss and need for blood product replacement, fever, wound infection, ureteral injury, thromboembolic events, cardiac arrest, and death. Selective pelvic artery embolization is increasingly used for the management of obstetric hemorrhage. Multiple case series have demonstrated success rates exceeding 90%, with minimal complications. The femoral artery is accessed, and diagnostic arteriography is performed with fluoroscopic imaging to localize the target arteries for embolization. Several options are available for arterial occlusion, including an absorbable gelatin sponge (Gelfoam) or another type of particulate material. Potential adverse results from the procedure include ischemia or tissue necrosis, infection, nephrotoxicity due to contrast medium, bleeding at the access site, and failure of the embolization. Of those requiring admission, 24% to 38% proceed to delivery during the hospitalization. El-Kady and colleagues published a large populationbased study of more than 10,000 trauma evaluations for pregnant women. As expected, the likelihood of abruption, uterine rupture, maternal death, and adverse neonatal outcomes, including fetal and neonatal death, was significantly higher for the group that delivered during the trauma admission. Women discharged undelivered after trauma had improved maternal outcomes compared with the delivered patients, but they remained at increased risk for preterm delivery, abruption, and need for blood products compared with uninjured controls. Three-point restraint seat belts are safe for pregnant women, and they decrease the risk of serious maternal injury and fetal loss. In one large series of 5352 injured pregnant women, minor trauma during the first or second trimester was found to be independently associated with fetal demise, with an adjusted odds ratio of 1. Detection of an abruption presents a challenge in the patient without vaginal bleeding. Abruption occurs in approximately 7% of patients after trauma, but the severity of the injury does not appear to correlate with the presence of an abruption or predict outcome. Most placental abruptions occur in patients after relatively minor trauma and without evidence of serious injury. Fetal mortality correlated with the estimated percentage of placental detachment, the location (retroplacental), and size (>60 mL) of hemorrhage. Assessment and stabilization of the airway, breathing, and circulation are the primary steps, followed by systematic evaluation for evidence of traumatic injuries. Rapid confirmation of gestational age and assessment of fetal well-being are necessary.
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At the conclusion of surgery depression symptoms withdrawal order discount asendin line, it is prudent to remove the endotracheal tube while anesthesia is still sufficient to suppress hyperreactive airway reflexes anxiety 30000 50 mg asendin sale, a technique referred to as "deep extubation. Intraoperatively, bronchospasm is often due to factors other than asthma (Table 9-6). Treatment with bronchodilator drugs should not be instituted until causes of wheezing such as mechanical obstruction of the breathing circuit, the airway, or the endotracheal tube are considered. Bronchospasm resulting from asthma may respond to deepening of the anesthetic with a volatile agent. If bronchospasm persists despite 2-agonist therapy and deep general anesthesia, corticosteroid administration may be necessary. It must be recognized that several hours may pass before the therapeutic effects of corticosteroids become apparent. Emergency surgery in the asthmatic patient introduces a conflict between protection of the airway in someone at risk of aspiration and the possibility of triggering bronchospasm. In addition, there may be insufficient time to optimize bronchodilator therapy before surgery. As expiratory airflow obstruction increases in severity, tachypnea and a prolonged expiratory phase are evident. Patients with predominantly chronic bronchitis have a chronic productive cough, whereas patients with predominantly emphysema report dyspnea. Transient periods of sputum discoloration occur in association with respiratory tract infection. Slowing of expiratory airflow and gas trapping behind prematurely closed airways are responsible for the increase in residual volume. Hyperlucency due to arterial vascular deficiency in the lung periphery and hyperinflation (flattening of the diaphragm with loss of its normal domed appearance and a very vertical cardiac silhouette) suggest the diagnosis of emphysema. Smoking cessation causes the symptoms of chronic bronchitis to diminish or entirely disappear, and it eliminates the accelerated loss of lung function observed in those who continue to smoke. Long-term oxygen administration (home oxygen therapy) is recommended if the Pao2 is less than 55 mm Hg, the hematocrit is more than 55%, or there is evidence of cor pulmonale. The goal of supplemental oxygen administration is to achieve a Pao2 between 60 and 80 mm Hg. This goal can usually be accomplished by delivering oxygen through a nasal cannula at 2 L/min. Ultimately, the flow rate of oxygen is titrated as needed according to arterial blood gas or pulse oximetry measurements. Relief of arterial hypoxemia with supplemental oxygen administration is more effective than any known drug therapy in decreasing pulmonary vascular resistance and pulmonary hypertension and in preventing erythrocytosis. They may thus improve exercise tolerance, despite the fact that there is little improvement in spirometric measurements. An additional benefit of 2-agonists may be fewer infections, since these drugs decrease the adhesion of bacteria such as Haemophilus influenzae to airway epithelial cells. Intermittent administration of broad-spectrum antibiotics is indicated for acute episodes of increased dyspnea associated with excessive or purulent sputum production. Diuretic therapy may be considered for patients with cor pulmonale and right ventricular failure with peripheral edema. Diuretic-induced chloride depletion may produce a hypochloremic metabolic alkalosis that depresses the ventilatory drive and may aggravate chronic carbon dioxide retention. Surgical removal of these overdistended areas allows more normal areas of the lung to expand and improves not only lung function but quality of life. The proposed mechanisms for improvement in lung function after this surgery include (1) an increase in elastic recoil, which increases expiratory airflow; (2) a decrease in the degree of hyperinflation, which results in improved diaphragmatic and chest wall mechanics; and (3) a decrease in the inhomogeneity of regional ventilation and perfusion, which results in improved alveolar gas exchange and increased effectiveness of ventilation. Currently research is under way to examine nonsurgical approaches for achieving benefits similar to those provided by lung volume reduction surgery. Management of anesthesia for lung volume reduction surgery includes use of a double-lumen endobronchial tube to permit lung separation, avoidance of nitrous oxide, and avoidance of excessive positive airway pressure. Monitoring of central venous pressure as a guide to fluid management is unreliable in this situation. A history of poor exercise tolerance, chronic cough, or unexplained dyspnea combined with diminished breath sounds, wheezing, and a prolonged expiratory phase predicts an increased risk of postoperative pulmonary complications. The value of routine preoperative pulmonary function testing remains controversial. The results of pulmonary function tests and arterial blood gas analysis can be useful for predicting pulmonary function following lung resection, but they do not reliably predict the likelihood of postoperative pulmonary complications after nonthoracic surgery. Clinical findings (smoking, diffuse wheezing, productive cough) are more predictive of pulmonary complications than spirometric results. Patients with mild pulmonary disease undergoing peripheral surgery do not require pulmonary function tests. Pulmonary function tests should be viewed as a management tool to optimize preoperative pulmonary function but not as a means to predict risk. Indications for a preoperative pulmonary evaluation (which may include consultation with a pulmonologist and/or performance of pulmonary function tests) typically include (1) hypoxemia on room air or the need for home oxygen therapy without a known cause, (2) a bicarbonate concentration of more than 33 mEq/L or Pco2 of more than 50 mm Hg in a patient whose pulmonary disease has not been previously evaluated, (3) a history of respiratory failure resulting from a problem that still exists, (4) severe shortness of breath attributed to respiratory disease, (5) planned pneumonectomy, (6) difficulty in assessing pulmonary function by clinical signs, (7) the need to distinguish among potential causes of significant respiratory compromise, (8) the need to determine the response to bronchodilators, and (9) suspected pulmonary hypertension. Right ventricular function should be carefully assessed by clinical examination and echocardiography in patients with advanced pulmonary disease. Ventilatory function is quantified under static conditions by measuring lung volumes and under dynamic conditions by measuring flow rates. In assessing lung function, expiratory flow rates can be plotted against lung volumes to produce flow-volume curves. When flow rates during inspiration are added to these curves, flow-volume loops are obtained. Once forced expiration begins, the peak flow rate is achieved rapidly and flow rate then falls in a linear fashion as the lung volume decreases to residual volume. During maximal inspiration from residual volume to total lung capacity, the inspiratory flow is most rapid at the midpoint of inspiration, so that the inspiratory curve is U-shaped. Patient coming for noncardiothoracic surgery Evaluate for: Patient risk factors Procedural risk factors Lab-related factors (albumin 3. Obesity and mild to moderate asthma have not been shown to be independent risk factors. Strategies to decrease the incidence of postoperative pulmonary complications include preoperative, intraoperative, and postoperative interventions (Table 9-10). These times of exposure to general anesthesia and/or surgery offer a window of opportunity for a smoking cessation intervention by a health care provider or other individual. The intervention can be carried out at the surgical clinic or anesthetic preadmission testing clinic, via phone calls by nurses or health care workers, or in a letter indicating the risks of postoperative complications caused by continued smoking. Recent evidence shows that the earlier the intervention before surgery, the more effective it is in reducing the postoperative complications and maintaining abstinence. It recommends systematically identifying all tobacco users who come in contact with the health care system to urge and help them to quit smoking. The American Society of Anesthesiologists also has a Stop Smoking Initiative and provides resources to help practitioners encourage smoking cessation. Among smokers, predictive factors for the development of pulmonary complications are a lower diffusing capacity than predicted and a smoking history of more than 60 pack-years. Those who have smoked more than 60 pack-years have double the risk of any pulmonary complication and triple the risk of pneumonia compared with those who have smoked less than 60 pack-years. Smoking cessation causes the symptoms of chronic bronchitis to diminish or disappear and eliminates the accelerated loss of lung function observed in those who continue to smoke. Anesthesiologists who practice pain medicine also have the opportunity to encourage smoking cessation in their patients. Among adults with chronic pain, smoking is associated with higher levels of pain, greater levels of depression and anxiety, worse physical functioning, and use of larger amounts of prescription opioids. The adverse effects of carbon monoxide on oxygen-carrying capacity and of nicotine on the cardiovascular system are short-lived. The elimination half-life of carbon monoxide is approximately 4 to 6 hours when breathing room air. Within 12 hours after cessation of smoking the Pao2 at which hemoglobin is 50% saturated with oxygen (P50) increases from 22.
After dependence is established anxiety low blood pressure order cheap asendin online, the success rates for recovery are not encouraging; 70% of abusers relapse within 6 weeks of nonmedication rehabilitation efforts anxiety cat generic 50 mg asendin overnight delivery. A more intensive focus on this population would offer the possibility of primary prevention of neonatal complications encountered as a result of maternal opiate abuse. Women who are currently abusing heroin or prescription opioids and choose to breastfeed may expose their infants to levels of opioids that are sufficient to cause tremors, restlessness, vomiting, poor feeding, or addiction. In contrast, women who are in opioid-agonist treatment with methadone or buprenorphine should be encouraged to breastfeed, because methadone and buprenorphine concentrations in breast milk are low. For doses of methadone between 50 and 105 mg/day, the neonatal dose is less than 0. For women who are concerned that the cessation of breastfeeding may precipitate narcotic withdrawal in the infant, a period of weaning is appropriate to avoid that outcome. Other adverse outcomes are attributed to drugseeking behaviors, concomitant smoking, and inadequate nutrition, all of which are common in this population. There do not appear to be adverse consequences to tapered opiate withdrawal in pregnancy,146 although miscarriage, preterm birth, meconium passage, stillbirth, and elevated epinephrine and norepinephrine levels have been reported. One study compared various detoxification regimens in pregnant, opioid-dependent patients with methadone maintenance. It has many favorable qualities: high bioavailability, long half-life, low cost, convenient (daily) dosing, and slow onset of withdrawal syndrome. It has been used for more than 40 years for the treatment of opiate addiction151 and has demonstrated benefits of deterring high-risk behaviors, reducing incarceration, and diminishing the spread of infectious disease. Methadone maintenance therapy for addiction is available in the United States through federally funded opiate maintenance programs. In this setting, patients are dosed daily and participate in counseling and drug screening according to the regulations of the facility. Methadone maintenance programs are not widely available, and transportation issues and the need for daily compliance are often obstacles to participation. Despite these challenges, the benefits of methadone maintenance have been demonstrated in pregnant women. Methadone maintenance has been associated with earlier and more compliant prenatal care, improved nutrition and weight gain, fewer children in foster care, and improved enrollment in substance abuse treatment and recovery programs. The model of opiate maintenance in pregnancy is one of harm reduction rather than abstinence. Because of physiologic adaptations to pregnancy, split dosing is sometimes recommended. Buprenorphine disassociates slowly from the receptor, can displace circulating opiates, and is unlikely to be displaced by other competing opiates. A ceiling effect for the benefit of buprenorphine is thought to exist, and additional dosing beyond 24 to 32 mg/day may not achieve any additional benefits. The autonomic withdrawal associated with buprenorphine is less significant than with other opiates. Buprenorphine shares favorable qualities with methadone, such as decreased drug craving with daily dosing, and it has the additional benefit of being prescribed by specifically certified physicians rather than federally funded clinics. This promotes improved patient autonomy and broader availability of opiate maintenance. In pregnancy, buprenorphine alone is favored over the buprenorphine-naloxone combination product because data about the combination product are lacking in pregnancy and because of concerns about the possibility that naloxone may produce maternal and fetal hormonal changes. However, if the combination of buprenorphine and naloxone is injected or snorted, it will precipitate withdrawal in opioid-dependent individuals. We routinely use the combination drug in our clinics, and recent preliminary findings indicate no significant adverse maternal or neonatal outcomes related to the use of the combination product. There have been numerous comparisons of methadone and buprenorphine for the treatment of opioid dependence in pregnant women. This study has led to increased use of buprenorphine to treat opiate dependence in pregnancy. A review of the literature comparing methadone and buprenorphine supported several conclusions. Third, the long-term effects of buprenorphine and methadone require further study. Treatment ceases when the neonate has been free of signs of withdrawal for 24 to 48 hours. Because effective implies that the mother is free of illicit drugs, elimination of drug craving is a key component of therapy. The difficulty of dosing methadone during pregnancy is that pregnancy-associated somatic complaints. The physiology of pregnancy leads to decreased absorption, increased volume of distribution, rapid elimination, and higher clearance of the drug, all of which may mandate higher doses as gestational age advances. Cocaine in powder or salt form is highly water soluble, making it easy to dissolve for injection and facilitating transport across mucous membranes when it is inhaled. The free-base form is not water soluble and has a much lower melting point; smoking is the preferred mode of use for this form. The norepinephrine release related to euphoria augments the norepinephrine reuptake mechanism and contributes further to vasoconstriction. Biologic testing for cocaine measures its metabolite benzoylecgonine, which is present in urine for 2 to 4 days after exposure. Physicians practicing in the 1980s have anecdotal experience with women who presented with hypertension, abdominal pain, and nonreassuring fetal status, prompting delivery due to cocaineinduced abruption. This pathophysiology has been demonstrated in animal models, in which cocaine administration induces a hypertensive response and reduction in uterine blood flow lasting 15 minutes. Women who are determined to be cocaine users during pregnancy warrant a comprehensive cardiac workup, including electrocardiography and echocardiography, and an anesthesia consultation before delivery. This effect has particular significance in obstetrics, because -blockade with labetalol is commonly used for hypertension. Labor and delivery personnel should know that hydralazine, not labetalol, is the drug of choice for treatment of hypertension in pregnant women exposed to cocaine. Infants exposed to cocaine through breast milk ingestion may have increased heart rate and blood pressure, choking, and vomiting; they often show increased irritability and agitation. The vasoconstrictive properties of cocaine can have a wide range of fetal effects. There have been numerous reports of congenital malformations attributed to prenatal cocaine exposure, but the current literature suggests that these outcomes were overreported during the early years of the crack and cocaine epidemic because of publication bias for positive findings. In rodent studies of cocaine exposure during pregnancy that employed intraperitoneal injection, cocaine did not increase the incidence of congenital malformations, but it did decrease maternal and fetal weight. Subcutaneously administered cocaine was associated with ophthalmologic, skeletal, and urogenital tract abnormalities. Urogenital abnormalities were the most commonly confirmed anomalies in the population-based Atlanta Birth Defects CaseControl Study by the Centers for Disease Control and Prevention. Maternal cocaine use was defined as reported use at any time from 1 month before pregnancy through the first 3 months of pregnancy. Exposure was documented by self-report or identification of cocaine metabolites in the meconium of the neonate. The incidence of congenital malformations was not increased in the cocaine-exposed group. Many such studies did not control for confounding variables such as maternal age, parity, socioeconomic status, and concomitant alcohol and cigarette exposure, suggesting that the risk attributed to cocaine was perhaps inappropriately estimated. The Knowledge Synthesis Group on Determinants of Low Birth Weight and Preterm Births examined the effect of cocaine use during pregnancy by metaanalysis. The initial 1985 report184 described 23 67 Substance Abuse in Pregnancy 1143 cocaine-exposed infants who demonstrated depression of interactive behavior and poor organizational response to environmental stimuli on the Brazelton Neonatal Behavioral Assessment Scale. This small study, heavily promoted by lay media, raised concerns about a "generation of crack babies. In a longitudinal study that compared 154 pregnant crack or cocaine users and 154 controls matched for race, parity, socioeconomic status, and type of prenatal care, infants who were exposed to tobacco and cocaine or marijuana had fewer alert periods and less alert responsiveness. In the acute withdrawal phase, no medication has proved effective in treating cocaine withdrawal, and hospitalization is rarely indicated on medical grounds. Despite this national trend, methamphetamine abuse remains a significant problem in some areas.
The early use of acyclovir was associated with an improved hospital course after the fifth day and a lower mean temperature depression symptoms vertigo purchase 50mg asendin overnight delivery, lower respiratory rate depression symptoms in cats discount 50mg asendin, and improved oxygenation. Among 312 pregnancies, there was no increase in the number of birth defects and no consistent pattern of congenital abnormalities. The program of universal childhood vaccination against varicella in the United States has resulted in a sharp decline in the rate of death from varicella. A study75 assessed the risk of congenital varicella syndrome and other birth defects in offspring of women who inadvertently received varicella vaccine during pregnancy or within 3 months of conception. Fifty-eight women received their first dose of varicella vaccine during the first or second trimester. Among the prospective reports of live births, five congenital anomalies were identified in the susceptible cohort or the sample population as a whole. The investigator suggested that although the numbers in the study were small, the results should provide some reassurance to health care providers and women with inadvertent exposure before or during pregnancy. Epidemiologic information shows differences between men and women in prevalence of infection, rate of progression from infection to disease, incidence of clinical disease, and mortality resulting from tuberculosis. Case-notification rates from countries with a high prevalence of tuberculosis suggest that it may be less common among women. From 1985 through 1991, reported cases of tuberculosis increased by 18%, representing approximately 39,000 more cases than expected had the previous downward trend continued. Many centers advocate directly observed therapy in the treatment of multidrug-resistant disease. Only one patient began retreatment during pregnancy because her organism was susceptible to three antituberculosis drugs that were considered nontoxic to the fetus. Despite concern about teratogenicity of the second-line antituberculosis medications, careful timing of treatment initiation resulted in clinical cure for the mothers, regardless of some complications because of chronic tuberculosis or therapy. If anergy is suspected, control antigens such as candidal, mumps, or tetanus toxoid should be used. The onset of the recent tuberculosis epidemic stimulated the need for rapid diagnostic tests using molecular biology methods to detect M. The risk of progression to active disease is highest in the first 2 years of conversion. It is important to prevent the onset of active disease while minimizing maternal and fetal risk. However, monthly monitoring of liver function tests may prevent this adverse outcome. The finding of acid-fast bacilli in earlymorning sputum specimens confirms the diagnosis of pulmonary tuberculosis. At least three early-morning sputum samples should be examined for the presence of acid-fast bacilli. If sputum cannot be produced, sputum induction, gastric washings, or diagnostic bronchoscopy may be indicated. However, compared with control women, the 21 women with tubercular involvement of other extrapulmonary sites had higher rates of antenatal hospitalization (24% versus 2%; P <. There were no congenital abnormalities, and pregnancy outcomes for the treated individuals were good. Untreated tuberculosis has been associated with higher morbidity and mortality rates among pregnant women. The management of the gravida with multidrug-resistant tuberculosis should be individualized. The patient should be counseled about the small risk of teratogenicity and should understand that the risk of postpartum transmission of tuberculosis to the infant may be higher among those born to patients with drug-resistant tuberculosis. In patients with active disease at the time of delivery, separation of the mother and newborn should be accomplished to prevent infection of the newborn. However, if the infant is concurrently taking oral antituberculous therapy, excessive drug levels may be reached in the neonate, and breastfeeding should be avoided. Proper screening and therapy will lead to a good outcome for the mother and infant in most cases. Insight into the pathogenesis of asthma has changed with the recognition that airway inflammation occurs in almost all cases. The medical management for asthma emphasizes treatment of airway inflammation to decrease airway responsiveness and prevent asthma symptoms. The common alternative diagnosis is dyspnea of pregnancy, which is not associated with cough, wheezing, chest tightness, or airway obstruction. Other potential diagnoses include cough due to reflux or postnasal drip, bronchitis, laryngeal dysfunction, hyperventilation, pulmonary edema, and pulmonary embolism. In a small study, exhaled nitric oxide was significantly reduced among pregnant women with asthma compared with healthy pregnant controls. Skin tests are not generally recommended during pregnancy because skin testing with potent antigens may be associated with systemic reactions. Current asthma control should be assessed according to the frequency and severity of symptoms, including interference with sleep and normal activity, the frequency of use of rescue therapy, the history of exacerbations requiring the use of systemic corticosteroids, and the results of pulmonary function tests. Patients who have asthma that is well controlled and who are not receiving controller medications can be classified as having intermittent rather than persistent asthma. Using the Juniper Quality of Life Questionnaire, asthma-specific quality of life in early pregnancy was found to be related to subsequent asthma morbidity but not to perinatal outcomes. In a large, prospective study of pregnant women, those Asthma in Pregnancy Asthma may be the most common potentially serious medical condition to complicate pregnancy. In a large, prospective study, 23% improved and 30% became worse during pregnancy. These prospective studies tended to find fewer significant adverse associations, possibly because of better asthma surveillance and active asthma management. In addition, women who enroll in research studies tend to be more compliant and better motivated than the general public. Also, the failure to find more adverse outcomes among women with severe asthma may be a function of the relatively small numbers and the resulting lack of statistical power. Nonetheless, these prospective studies are reassuring in their consensus of good pregnancy outcomes among women with asthma. These findings do not contradict the possibility that suboptimal control of asthma during pregnancy is associated with increased risk to the mother or baby. Other goals include achievement of minimal or no maternal symptoms day or night, minimal or no exacerbations, no limitations of activities, maintenance of normal or near-normal pulmonary function, minimal use of short-acting 2-agonists, and minimal or no adverse effects from medications. Consultation or comanagement with an asthma specialist is appropriate for evaluation of the role of allergy and irritants, complete pulmonary function studies, or evaluation of the medication plan if there are complications in achieving the goals of therapy or if the patient has severe asthma. A team approach is helpful if more than one clinician is managing the asthma and the pregnancy. The effective management of asthma during pregnancy relies on four integral components: objective assessment, trigger avoidance, patient education, and pharmacologic therapy. Objective Measures for Assessment and Monitoring Subjective measures of lung function by the patient or physician provide insensitive and inaccurate assessments of airway hyperresponsiveness, airway inflammation, and asthma severity. The green zone is more than 80% of the personal best, the yellow zone is between 50% and 80%, and the red zone is less than 50%. Avoiding or Controlling Asthma Triggers Limiting adverse environmental exposures during pregnancy is important for controlling asthma. Irritants and allergens that provoke acute symptoms also increase airway inflammation and hyper-responsiveness. Avoiding or controlling such triggers can reduce asthma symptoms, airway hyper-responsiveness, and the need for medical therapy. Other common nonimmunologic triggers include tobacco smoke, strong odors, air pollutants, food additives such as sulfites, and certain drugs, including aspirin and -blockers. For some patients, exercise-induced asthma can be avoided with inhalation of albuterol 10 to 30 minutes before exercise. Specific measures for avoiding asthma triggers include removing carpeting, using an allergen-impermeable mattress and pillow covers, weekly washing of bedding in hot water, avoiding tobacco smoke, inhibiting mite and mold growth by reducing humidity, and leaving the house when it is being vacuumed. Allergic women should at least keep furry pets out of the bedroom; ideal animal dander control involves removing the pet from the home. Cockroaches can be controlled by poison baits or bait traps and eliminating exposed food or garbage. The use of allergen immunotherapy, or "allergy shots," has been shown to be effective in improving asthma in allergic patients.
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References
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