By W. Milten. Barrington University. 2019.

With an increase in maternal plasma vol- important and each country will have a different screen- ume of up to 50% there is a physiological drop in the hae- ing strategy depending on the prevalence of these condi- moglobin (Hb) concentration during pregnancy order caverta. If the regional up to 12 weeks’ gestation or less than 105 g/L at 28 weeks sickle cell disease prevalence is high buy caverta 100 mg cheap, laboratory screen- signifies anaemia and warrants further investigation order caverta on line. If the regional sickle cell disease A low Hb (85–105g/L) may be associated with preterm prevalence is low, the initial screening should be based labour and low birthweight. Routine screening should be on the Family Origin Questionnaire; if this indicates high performed at the booking visit and at 28 weeks’ gesta- risk, then laboratory screening should be offered. While there are many causes of anaemia, including thalassaemia and sickle cell disease, iron deficiency Infection remains the commonest. Serum ferritin is the best way of assessing maternal iron stores and if found to be low, Maternal blood should be taken early in pregnancy and iron supplementation should be considered. Routine antibody screening women need to be managed by appropriate specialist should take place at booking in all women and again at teams. Routine screening for rubella ended in England in 28 weeks’ gestation irrespective of their rhesus D (RhD) April 2016, primarily because rubella infection levels in status. Following positive screening for syphilis, test- at 32 weeks depending on the dosage of anti‐D immuno- ing of a second specimen is required for confirmation. Consideration should also be given to Interpretation of results can be difficult and referral to offering partner testing, as anti‐D prophylaxis will not be specialist genitourinary medicine clinics is recom- necessary if the biological father is RhD negative. This will allow targeted anti‐D Asymptomatic bacteriuria occurs in approximately administration to women with RhD‐positive fetuses, 2–5% of pregnant women and when untreated is associ- which may result in cost savings and allow many women ated with pyelonephritis and preterm labour. Antenatal Care 53 Hypertensive disease about history of significant mental illness, previous psy- chiatric treatment or a family history of perinatal mental Chronic hypertension pre‐dates pregnancy or appears in health illness. If mental illness is suspected, further refer- the first 20 weeks, whereas pregnancy‐induced hyper- ral for assessment should be made. Good communica- tension develops in the pregnancy, resolves after delivery tion, particularly with primary care, is paramount. Pre‐eclampsia is defined as hypertension that is associated with proteinu- ria occurring after 20 weeks and resolving after birth. Pre‐eclampsia occurs in 2–10% of pregnancies and is Screening for fetal complications associated with both maternal and neonatal morbidity and mortality [11]. Risk factors include nulliparity, age Confirmation of fetal viability 40 years and above, family history of pre‐eclampsia, his- All women should be offered a ‘dating’ scan. In addition, a dating scan will improve the relia- absence of these, blood pressure measurement and urine bility of Down’s syndrome screening, diagnose multiple analysis for protein should be performed at each routine pregnancy and allow accurate determination of chorio- antenatal visit and mothers should be warned of the nicity and diagnose up to 80% of major fetal abnormali- advanced symptoms of pre‐eclampsia (frontal headache, ties. Women who present after 14 weeks’ gestation epigastric pain, vomiting and visual disturbances). However, there be offered serum screening between 15 and 20 weeks’ has been increasing evidence that ‘treating’ gestational gestation. The National Screening Committee further diabetes is more beneficial than expectant management refined these guidelines in 2010, stating that the detec- [12]. Consequently, the National Institute for Health and tion rate should be 90% for a screen‐positive rate of 2%. Women with risk factors should be tested for Unbiased, evidence‐based information must be given to gestational diabetes using the 2‐hour 75‐g oral glucose the woman at the beginning of the pregnancy so that she tolerance test. At booking, women should be asked mean the fetus has Down’s syndrome and to explain the 54 Normal Pregnancy options for further testing. A positive screen test does out the basis for the ultrasound screening service in not mean further testing is mandatory. Likewise, a England, describing what can and, importantly, what woman with a ‘screen‐negative’ result must understand cannot be achieved. While publicly funded healthcare systems and has a significant hearing the fetal heart may be reassuring, there is no evi- failure rate. Likewise there is women with high‐risk combined screening) would have no evidence to support the use of routine cardiotocogra- lower cost at the expense of lower detection rate. Physical examination detection rate would depend on the chosen cut‐off value of the abdomen by inspection and palpation will identify of risk (e. With either approximately 30% of small‐for‐gestational age fetuses strategy, the number of invasive procedures would be [16]. Measurement of the symphysis–fundal height in lower and hence there would be fewer miscarriages of centimetres starting at the uterine fundus and ending on healthy fetuses as a result of screening. Customized growth charts the identification of fetal structural abnormalities allows make adjustments for maternal height, weight, ethnicity the opportunity for in utero therapy, planning for deliv- and parity. However, there is no good‐quality evidence ery, for example when the fetus has major congenital that their use improves perinatal outcomes [4]. Follow‐up data are important for by week 24 of pregnancy and reduced fetal movements auditing the quality of the service. Written infor- fetal growth, amniotic fluid and umbilical artery Doppler mation should be given to women early in pregnancy assessment if there are additional risk factors for fetal explaining the nature and purpose of such scans, high- growth restriction or stillbirth. It is important to appreciate that the fetal anomaly scan is a screening Organization of antenatal care test which women should opt for rather than have as a routine part of antenatal care without appropriate coun- Antenatal care has been traditionally provided by a com- selling. The balance has ards and guidance for the mid‐trimester fetal anomaly depended on the perceived normality of the pregnancy scan; this was updated in 2015 [15]. However, pregnancy and childbirth is to a Antenatal Care 55 certain extent an unpredictable process. The frequency who move between hospitals so that caregivers would of antenatal visits and appropriate carer must be planned automatically be familiar with the style of the notes. If we carefully, allowing the opportunity for early detection of are to move to an electronic patient record, there must problems without becoming over‐intrusive. Frequency and timing of antenatal visits A meta‐analysis comparing pregnancy outcome in two groups of low‐risk women, one with community‐led There has been little change in how frequently women antenatal care (midwife and general practitioner) and are seen in pregnancy for the last 50 years. The first group had a lower rate ment recognized the large amount of information that of pregnancy‐induced hypertension and pre‐eclampsia, needs to be discussed at the beginning of pregnancy, par- which could reflect a lower incidence or lower detection ticularly with regard to screening tests. However, clear referral pathways need to be devel- ment needs to be early in pregnancy, certainly before oped that allow appropriate referral to specialists when 12 weeks if possible. This initial appointment should be either fetal or maternal problems are detected. A crucial aim is to identify usually provided by a number of different professionals those women who will require additional care during the often in different settings. A urine test should and prepared for labour, attend more antenatal classes, be sent for bacteriological screen and a dating ultrasound have fewer antenatal admissions to hospital and have scan arranged. While it Down’s syndrome screening, this too should be discussed would appear advantageous for women to be seen by the in detail and supplemented with written informa- same midwife throughout pregnancy and childbirth, tion. Ideally another follow‐up appointment should be there are practical and economic considerations that arranged before the screening tests need to be performed need to be taken into account. Nevertheless, where to allow further questions and to arrange a time for the possible, care should be provided by a small group of tests following maternal consent. The next appointment needs to be around 16 weeks’ gestation to discuss the results of the screening tests. In addition, information about antenatal classes should be Documentation of antenatal care given and a plan of action made for the timing and fre- the antenatal record needs to document clearly the care quency of future antenatal visits, including who should the woman has received from all those involved.

Defective bladder contraction associated with spinal cord injury also results in poor bladder emptying order caverta with paypal. These conditions result in a significant volume of urine remaining in the bladder after voiding (“increased post-void residual”) buy 50mg caverta free shipping, which markedly increases the likelihood of infection best 100 mg caverta. Intrarenal obstruction caused by renal calculi, polycystic kidney disease, and sickle cell disease also increase the risk of renal infection. Proteus and other urea-splitting organisms can cause stone formation and can become entrapped within the stones. Another mechanical problem that increases the risk of upper tract disease is vesicoure-teral reflux (defective bladderureteral valves). Women have a short urethra, which increases the risk of bacteria entering the bladder. IgA and immunoglobulin G (IgG) antibodies against cell wall antigens have been described. The exact role of immunoglobulins in protecting against colonization and invasion of the urinary tract remains to be determined. Within 3– 4 days of catheterization, cystitis generally develops unless a sterile closed drainage system is used. Unfortunately, even the most sterile handling of the bladder catheter only delays the onset of infection. Once bacteria begin to actively grow in the bladder, they stimulate an acute inflammatory response. Over time, bacteria are capable of migrating up the ureters and reaching the kidney. Once bacteria enter the renal parenchyma, they are able to enter the bloodstream and cause septic shock. In young, sexually active women, Staphylococcus saprophyticus accounts for 5–15% of cases of cystitis. In patients who experience recurrent infections, have been instrumented, or have anatomic defects or renal stones, Enterobacter, Pseudomonas, and enterococci are more commonly cultured. Candida species are frequently encountered in hospitalized patients who are receiving broad-spectrum antibiotics and have a bladder catheter. Patients with structural abnormalities are more likely to have polymicrobial infections. Escherichia coli is the most frequent pathogen, followed by Klebsiella and Proteus. Staphylococcus saprophyticus causes 5–15% of cystitis cases in young, sexually active women. Nosocomial infections usually involve Enterobacter, Pseudomonas, enterococci, Candida, S. One week before admission (4 weeks after her honeymoon), she noted mild burning on urination. Two days before admission, she experienced fever associated with rigors and increasingly severe flank pain. The physical examination showed a blood pressure of 80/50 mmHg, a pulse of 125 per minute, and a temperature of 37. The remainder of her physical examination was normal, except for mild left costovertebral angle tenderness. Clinical Manifestations Patients with cystitis usually experience acute-onset dysuria (pain, tingling, or burning in the perineal area during or just after urination). In addition, patients need to urinate frequently, because inflammation of the bladder results in increasing suprapubic discomfort when the bladder is distended and may cause bladder spasms that interfere with bladder distension. Some patients note blood in the urine caused by inflammatory damage to the bladder wall. However, in addition to symptoms of cystitis, patients with pyelonephritis are more likely to experience fever and chills, costovertebral angle pain, nausea and vomiting, and hypotension. Patients with diabetes mellitus often experience subacute pyelonephritis that clinically mimics cystitis. Elderly patients have a higher probability of having upper-tract disease and a higher risk for developing bacteremia. Patients who have had symptoms for more than 7 days are also at increased risk for pyelonephritis. When antibiotic treatment for cystitis is delayed for this period, bacteria have time to migrate up the ureters and infect the kidneys. Cystitis symptoms include dysuria, urinary frequency, hematuria, suprapubic discomfort. Pyelonephritis symptoms include fever and chills, nausea and vomiting, tachycardia, hypotension, and costovertebral angle pain and tenderness, the disease is more likely to occur in a) diabetic patients (who often have only symptoms of cystitis), b) elderly patients (who may present with confusion or somnolence), or c) patients who have had cystitis symptoms for more than 7 days. Asymptomatic bacteriuria is defined as a positive culture with no symptoms, and usually without pyuria. Urethritis can be mistaken for cystitis; usual indicators are fewer than 5 10 bacteria on culture and a lack of suprapubic tenderness. Vaginitis can mimic cystitis; pelvic examination is a must if symptoms are associated with vaginal discharge. Another clinical condition (most commonly encountered in elderly women) is called asymptomatic bacteriuria. This form of bacteriuria does not need to be treated unless the patient is pregnant or a child is of preschool age. Treatment is recommended in pregnant women because these patients are at increased risk of developing pyelonephritis. In preschool children, asymptomatic bacteriuria can result in renal scarring and interfere with normal growth of the kidneys. Colony counts resulting from urine 5 culture are less than 10 organisms per milliliter (see “Diagnosis,” next), and the patient usually does not experience suprapubic pain or urinary frequency. Therefore, in a woman with symptoms suggestive of cystitis or urethritis accompanied by a vaginal discharge, a pelvic examination is warranted to exclude a pelvic infection. Patients with pyelonephritis often are febrile and may be hypotensive and have an elevated heart rate. Costovertebral angle or flank tenderness resulting from inflammation and swelling of the infected kidney may be noted. In elderly patients, pyelonephritis and gram-negative sepsis may lead to confusion and somnolence. Urinalysis and urine culture should therefore always be included in the workup for acute changes in the mental status of an elderly patient. Diagnosis A microscopic examination of urinary sediment should be performed for all patients (ure 9. The dipstick leukocyte esterase test is rapid, sensitive, and specific for detecting pyuria. Unspun urinary Gram stain is very helpful and should be performed in all patients with suspected pyelonephritis. The presence of one or more bacteria per oil 5 immersion field indicates more than 10 organisms per milliliter.

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Breakage rates range from 1 to 8 per 100 episodes of vaginal intercourse (and somewhat higher for anal intercourse) buy caverta canada, and slippage rates range from 1% to 5% cheap caverta 100 mg mastercard. Condoms remain in good condition for up to 5 years unless exposed to ultraviolet light purchase caverta 50 mg without a prescription, excessive heat or humidity, ozone, or oils. Condom man- ufacturers regularly check samples of their products to make sure they meet national standards. When a condom breaks, or if there is reason to believe spillage or leakage occurred, a woman should contact a clinician preferably within 72 hours and no later than 120 hours. Couples who rely on condoms for contra- ception should be educated regarding emergency contraception, and an appropriate method should be kept available for self-medication. An important area of concen- tration is the teaching of the social skills required to ensure use by a reluctant partner. Barrier Methods of Contraception the Female Condom The female condom is a pouch made of polyurethane, which lines the vagina. The integrity of the female condom is maintained with up to eight multiple uses with washing, drying, and relubri- cating. Kost K, Singh S, Vaughan B, Trussell contraception: a Cochrane review, Hum J, Bankole A, Estimates of contraceptive Reprod 17:867, 2002. Keith L, Berger G, Moss W, Prevalence ted diseases in women: a comparison of gonorrhea among women using vari- of female-dependent methods and con- ous methods of contraception, Br J Vene- doms, Am J Pub Health 82:669, 1992. Psychoyos A, Creatsas G, Hassan E, diaphragms among couples in the Do- Spermicidal and antiviral properties minican Republic, Contraception 78:418, of cholic acid: contraceptive efficacy 2008. Centers for Disease Control and randomized trial, Obstet Gynecol 93:896, Prevention, Nonoxynol-9 spermicide 1999. Van Damme L, Ramjee G, Alary M, ceptive effectiveness and safety of five Vuylsteke B, Chandeying V, Rees H, nonoxynol-9 spermicides: a randomized Sirivongrangson P, Mukenge-Tshibaka trial, Obstet Gynecol 103:430, 2004. The risk of gonor- Female condom (Femidom): a clinical rhea transmission from infected women study of its use-effectiveness and patient to men, Am J Epidemiol 108:136, 1978. This method must take into account the viability of sperm in the female reproductive tract (2 to 7 days) and the lifespan of the ovum (1 to 3 days). The variability in the timing of ovulation is the reason why the period of abstinence must be relatively lengthy unless barrier methods are used during the fertile days. The period of maximal fertility begins 5 days before the day of ovulation and ends on the day of ovulation. Unsuccessful use can be predicted in couples who are unable to part with sexual spontaneity, women with irregular menses, dis- organized people who cannot keep good records, and women with chronic problems of vaginitis or cervicitis. The advantage of periodic abstinence as a method of contraception is the availability of this method regardless of 315 A Clinical Guide for Contraception economic status or the accessibility of other methods. Methods of Periodic Abstinence Tere are several specifc methods, and most teachers of periodic absti- nence advocate the incorporation of features from more than one method. The sophistication of these methods was made possible by the tremendous increase in the scientifc knowledge of the events in the human menstrual cycle. The time of ovulation (the fertile period) was identifed in the 1930s, but it was not until the 1960s with the advent of the radioimmunoassay that relatively precise timing of the various events became possible. The Rhythm or Calendar Method This method of periodic abstinence was based on the assumption that men- strual cycles were relatively constant, and therefore, the fertile period of the subsequent month could be predicted by the timing of the past cycle. The general rule is to record the length of six cycles, then estimate the beginning of the fertile period by subtracting 18 days from the length of the shortest cycle, and to estimate the end of the fertile period by sub- tracting 11 days from the length of the longest cycle. Tus, a woman with cycles varying from 26 to 32 days will practice periodic abstinence from the eighth day until the 21st day, a formidable requirement of 14 days of abstinence per cycle. Indeed, because of the normal variation in menstrual cycles, the average couple would practice periodic abstinence 16 days each month. This method has a pregnancy rate of about 40 per 100 woman-years, and therefore, it is not advocated without com- bining it with other techniques. However, the utilization of programmed electronic devices to record temperatures, keep track of cycles, and provide a signal to the patient during the fertile period can reduce pregnancy rates to 5 to 10 per 100 woman-years. The cer- vical mucus method is also called the ovulation method, the Billings method, the Creighton Model Fertility Care System, or the TwoDay method. Some recommend the addition of cervical palpation: frm and closed when infer- tile, sof, open, and moist when fertile. Not on consecutive days during the postmenstrual preovulatory period so that seminal fuid will not obscure observation of cervical mucus changes, although assessment in the evening afer intercourse that morning or the previous night should be reliable. Most women (95%) will have 4 to 12 days of observable secretions; thus, the method requires a lengthy period of abstinence for many women. Intercourse resumes the night of either the third day of a temperature shif or the fourth day afer the last day of sticky, wet mucus, whichever is later. Although this method is more complicated, the efcacy is slightly better, about 2 to 3 failures per 100 woman-years when practiced by experienced couples who follow all the rules. A study that compared the cervical mucus method with and without this device found a 2% failure rate with the monitor compared with a 12% rate without the monitor. CycleBeads, also devel- oped by the Institute for Reproductive Health of Georgetown University, are a string of color-coded beads used with the Standard Days method to moni- tor cycle days and lengths. Users of this method are advised that efcacy will be reduced even if only one menstrual cycle is out of the 26- to 32-day range, and to abandon the method if two cycles are out of the range. Resources It is too much to expect the average clinician to provide the necessary instruction and support for these methods. The local afliate of the Planned Parenthood Federation of America can direct a clinician to a community program. The following resources can be contacted for advice, charts, and teaching plans: The Couple to Couple League Foundation http://www. Periodic abstinence is associated with good efcacy when used correctly and consistently, but the method is very unforgiving of imperfect use. A multicenter trial in the 1970s of the cervical mucus method in the United States documented over a 2-year period of time, a method failure rate of 1. Better rates have been reported with newer methods that emphasize patient teaching and provide techniques to assess and record the window of fertility. Concerns A lingering concern is that because of periodic abstinence, inadvertent fertilization could occur with aged gametes. Is pregnancy from aged gametes more likely to result in birth defects, spontaneous miscarriages, and chromosomal abnormalities? No diferences have been noted in the frequency of monosomic or trisomic abnormalities in relation to the timing of conception; however, conceptions A Clinical Guide for Contraception with postovulatory aged ova appear to be at increased risk of polyploidy. Evidence supports the idea that the further away from the time of highest fertility fertilization occurs, the more likely a male child will be conceived. Use of periodic absti- nence is possible during lactation, but scrupulous attention is required to detect impending ovulation. With typical practice of the method, the preg- nancy rate is about the same as with diaphragm and spermicides. The problem of a long period of abstinence can be overcome by using a barrier method and/or spermicides during the fertile period. If withdrawal before ejaculation occurs with every instance of intercourse, a failure rate over a year of only 4% can be achieved. A lack of respect for withdrawal as a contraceptive method can be attrib- uted to two factors: an understandable preference for modern methods and a belief that preejaculate fuid contains sperm.

Hemodialysis should also be strongly considered when patients demonstrate any impairment in the level of consciousness purchase caverta online from canada, rather than waiting for unresponsiveness or coma [93] buy cheap caverta 50mg online. Acidemia and temperature greater than 38°C are associated with high mortality [46] and should also be considered potential indications for hemodialysis purchase caverta once a day, particularly if the patient is resistant to bicarbonate and fluid therapy. Similarly, patients with moderate poisoning who have liver dysfunction and, hence, impaired ability to eliminate salicylate may also benefit from hemodialysis. A high salicylate level is often cited as a stand-alone indication for hemodialysis but recommendations vary widely, with cutoffs ranging from 40 to 200 mg per dL (100 mg per dL being the most common) for acute ingestions and 60 to 80 mg per dL for chronic exposures [98]. A recent international multidisciplinary group “recommended” extracorporeal treatment when concentrations exceed 100 mg per dL, and “suggested” it for concentrations over 90 mg per dL, based on “very weak” evidence [93]. In one study [43], salicylate levels in fatal cases ranged from 34 to 193 mg per dL and in another [45], some patients died with drug levels in the therapeutic range. Instead, the severity of poisoning is determined by clinical findings, which reflect tissue drug concentration, and do not necessarily correspond to blood levels, especially when acidemia is present [96]. Moreover, a serum salicylate concentration should be interpreted in the context of a simultaneous measurement of serum pH. Hence, hemodialysis is appropriate for patients with high drug levels who have severe clinical toxicity (particularly acidemia), but it may not be necessary in those without such manifestations [46]. Conversely, patients with low salicylate levels, particularly those with significant underlying cardiorespiratory disease, should be treated with hemodialysis if they exhibit clinical or laboratory manifestations of severe toxicity. Because of delays inherent in the turnaround time for measuring salicylate and in preparing for hemodialysis, the projected clinical course should also be considered. Waiting for the salicylate level to reach some predetermined level before initiating hemodialysis in patients who are severely poisoned or deteriorating despite other treatments is ill-advised. Hemodialysis should be performed for at least 4 to 6 hours, and salicylate concentrations are below 20 mg per dL [93]. Failure to adequately correct fluid deficits prior to initiating hemodialysis can result in disastrous consequences. Uncorrected or occult hypovolemia can result in cardiovascular decompensation with hemodynamic instability, and even cardiac arrest, when dialysis is started because of the acute decrease in intravascular volume that can occur at the beginning of dialysis. This complication can be prevented or minimized by ensuring adequate volume resuscitation, and priming the tubing and pump with saline (rather than blood) prior to initiating dialysis. Oral administration of glycine or N-glycylglycine has been used in overdose patients to promote drug clearance [23,101]. Because the conjugation of salicylic acid with glycine to form salicyluric acid becomes saturated and glycine levels decrease in overdose patients, supplemental glycine can enhance the formation and excretion of this metabolite. To date, clinical experience with this therapy is limited, its comparative efficacy is unknown, and the side effects of nausea and vomiting with glycine have been problematic. Doses used ranged from 8 g dissolved in water initially, followed by 4 g every 4 hours for 16 hours, to 20 g followed by 10 g every 2 hours for 10 hours for glycine. The dose for N- glycylglycine was 8 g dissolved in water followed by 2 to 4 g every 2 hours for 16 hours. However, airway protection and mechanical ventilation, fluid resuscitation, anticonvulsants for seizures, bicarbonate for acidosis, and blood products for gastrointestinal tract bleeding may occasionally be required. Renal function should be monitored carefully in patients with abnormal urinalysis, underlying renal disease, or advanced age. Liver function tests should be followed in patients with severe phenylbutazone and piroxicam poisoning [66]. Gastrointestinal decontamination with activated charcoal should be considered for patients who present soon after a significant ingestion, defined as greater than ten therapeutic doses in adults and more than five adult doses in children [60,61]. Although charcoal hemoperfusion has been used to treat a patient with severe phenylbutazone poisoning who had impaired renal and hepatic function [64], extracorporeal elimination measures are unlikely to be effective because of the high-protein binding and rapid intrinsic elimination of these agents. Multiple-dose charcoal therapy enhances the elimination of therapeutic doses of phenylbutazone by 30% [102] and may be similarly effective for other agents, but the clinical benefit of such therapy after overdose is likely to be limited. Romsing J, Walther-Larsen S: Peri-operative use of nonsteroidal anti- inflammatory drugs in children: analgesic efficacy and bleeding. Drummond R, Kadri N, St-Cyr J: Delayed salicylate toxicity following enteric-coated acetylsalicylic acid overdose: a case report and review of the literature. Rauschka H, Aboul-Enein F, Bauer J, et al: Acute white matter damage in lethal salicylate intoxication. Kent K, Ganetsky M, Cohen J, et al: Non-fatal ventricular dysrhythmias associated with severe salicylate toxicity. Osterloh J, Cunningham W, Dixon A, et al: Biochemical relationships between Reye’s and Reye’s-like metabolic and toxicological syndromes. Johnson D, Eppler J, Giesbrecht E, et al: Effect of multiple-dose activated charcoal on the clearance of high-dose intravenous aspirin in a porcine model. Gren J, Woolf A: Hypermagnesemia associated with catharsis in a salicylate-intoxicated patient with anorexia nervosa. Sweeney K, Chapron D, Brandt L, et al: Toxic interaction between acetazolamide and salicylate: case reports and a pharmacokinetic explanation. Muhlebach S, Steger P, Conen D, et al: Successful therapy of salicylate poisoning using glycine and activated charcoal. The chronic use of all sedative- hypnotics can result in physical tolerance, addiction, misuse, and withdrawal syndromes on abrupt cessation of therapy. This results in an increase in the frequency of chloride channel opening, with a resultant increase in chloride flux and hyperpolarization. Peak serum concentration commonly results within 3 hours post-ingestion; intramuscular absorption varies from agent to agent but can be erratic and delayed. Duration of action is dependent on the lipophilicity of each compound: the more lipophilic, the shorter the duration of action. A retrospective review of 1,239 overdoses from one medical examiner’s office revealed only two deaths solely related to diazepam overdose [4]. Complications such as pulmonary aspiration, hypoxic cardiac arrest, and acute lung injury are also possible, but are more likely to occur in mixed sedative ingestions. Diagnostic Evaluation Recommended laboratory studies include serum electrolytes, creatinine, and glucose. As a result, it is important to know what screening immunoassay a laboratory uses for urine drug screening, as this will list which agents can and cannot be detected. Airway management should precede all interventions, and intubation is indicated if the patient cannot adequately maintain spontaneous ventilation or protect the airway. Flumazenil may precipitate an abrupt withdrawal syndrome with potential for seizures in these patients. Flumazenil is especially contraindicated in patients with electrocardiographic evidence of sodium channel blockade (e. Flumazenil has been suggested as a diagnostic tool for undifferentiated coma and after iatrogenic toxicity. The aim of therapy is to give enough to have the patient moderately drowsy and easily aroused and not to have the patient awake, alert, and keen to self-discharge from hospital. However, as recently as 2011, barbiturates were still in the top 20 most common classes of drugs associated with fatality in the United States [11]. The recommendation that pentobarbital is a good drug for euthanasia in pro-euthanasia resources may also be leading to an increase in self-poisonings with barbiturates obtained illicitly for this purpose [12]. When parenterally administered, they have rapid onset with less than 1-hour duration of effect; their predominant role is for induction of anesthesia.

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Administering a dose before and after gastric lavage is more effective than giving one only after lavage purchase 100 mg caverta fast delivery. The interval between administration of toxin and activated charcoal also has a significant effect on the in vivo efficacy of charcoal discount caverta express. As this interval increases generic caverta 100 mg without prescription, the ability of activated charcoal to prevent chemical absorption decreases. In controlled studies using doses of activated charcoal many times greater than those of toxin, charcoal decreased chemical absorption an average of 71% (range 10% to 100%) when it was given within 5 minutes, 52% (range 17% to 75%) when given at 30 minutes, and 38%, 34%, 21%, 29%, and 14% when given at 1, 2, 3, 4, and 6 hours, respectively [47]. The ability of activated charcoal to prevent the absorption of a toxin in vivo generally correlates with its ability to absorb that chemical in vitro [55]. Conversely, the absorption of some toxins that are relatively adherent to activated charcoal in vitro (ethanol, ipecac, and N- acetylcysteine) is not significantly inhibited in vivo. The presence of food in the stomach appears to enhance the efficacy of activated charcoal in preventing the absorption of ingested agents, possibly by slowing gastric emptying. Coingested antacids, cathartics, chocolate, ethanol, and excipients have variable but relatively minor or no effect on its efficacy. Premixed product containers should be thoroughly agitated to resuspend sedimented charcoal before use. Activated charcoal can be given orally to awake patients or by gastric tube to comatose or uncooperative patients. Because of volume constraints, the maximum single dose is generally limited to 1 to 2 g per kg of body weight. The main disadvantages are its dark color (significantly impairs bronchoscopy if aspirated), and low or reversible binding of some chemicals. It can also prevent the enteral absorption and enhance elimination of drugs administered for therapeutic purposes. Aspiration of activated charcoal along with gastric contents can result in large and small airway obstruction, pneumonitis, and death [56,57]. Although there are no absolute contraindications, activated charcoal is not recommended for ingestions of acids, alkali, and hydrocarbons that are poorly absorbed and have low systemic toxicity (low-viscosity petroleum distillates and turpentine) [47,48,54]. Gastric lavage can directly remove ingested chemicals from the stomach and thereby prevent their absorption [45]. As with activated charcoal, the efficacy of gastric lavage decreases as the time between ingestion and treatment increases. In animal studies and in simulated overdoses in human volunteers, gastric lavage decreased chemical absorption an average of 42% (range 29% to 90%) when performed within 20 minutes of chemical administration, 26% (13% to 38%) when performed at 30 minutes, and 17% (8% to 32%) when performed at 60 minutes [45]. Efficacy is enhanced if activated charcoal is given before and after lavage, but not if it is only given afterward [43]. Gastric lavage is performed by first aspirating stomach contents and then repetitively instilling and withdrawing fluid through a large orogastric tube. It appears to be most effective if the patient is placed in a left lateral decubitus Trendelenburg position. The simplest, quickest, and least expensive method to use is a funnel connected to the lavage tube, raising it 2 to 3 feet above the level of the stomach when administering fluid and lowering it 2 to 3 feet below the stomach to allow drainage [59]. Recommended amounts range from 60 to 800 mL for adults and up to 10 mL per kg of body weight for children [45]. Although endotracheal intubation does not completely prevent aspiration during gastric lavage, it is recommended to reduce the risk of aspiration, facilitate other investigations and for the patient’s predicted clinical course [45]. As in experimental studies, the clinical efficacy of gastric lavage decreases as the time between overdose and initiation of treatment increases. The efficacy of gastric lavage increases in cases of toxin induced gastroparesis or decreased intestinal motility. Although there are no absolute contraindications to gastric lavage, its use for corrosive and hydrocarbon ingestions is not recommended [45,57]. Gastric lavage should be reserved for large ingestions of liquid acid or alkali and for agents that can cause systemic toxicity (heavy metals, hydrazine), and only if it can be performed within 1 to 2 hours of exposure. Because lavage may increase the risk of pulmonary aspiration after hydrocarbon ingestion, it should only be considered for large ingestions of agents that have systemic toxicity (camphor, halogenated and aromatic derivatives, and those that contain heavy metals or pesticides) and in conjunction with the advice of a poison center. Although syrup of ipecac is simple to use, and was once widely available for home administration, it is less effective than activated charcoal in preventing chemical absorption in experimental studies and has more contraindications [42]. Vomiting exposes patients to aspiration risks and may preclude the administration of activated charcoal or other oral antidotes. Whole-bowel irrigation refers to the enteral administration of large volumes of an electrolyte solution. In experimental studies, whole-bowel irrigation decreased chemical absorption by about 70% (range, 67% to 73%) when initiated 1 hour after simulated overdose of ampicillin, paraquat, and sustained-release formulations of aspirin and lithium and 4 hours after a supratherapeutic dose of enteric-coated aspirin [60–62]. Whole-bowel irrigation solutions have been found both to enhance [63,64] and to interfere [60,62] with the in vitro adsorptive capacity of activated charcoal. Whole-bowel irrigation is performed by administering a solution of electrolytes and polyethylene glycol by nasogastric tube at a rate of 0. The combination of charcoal followed by whole-bowel irrigation was more effective than whole-bowel irrigation alone [61,62]. Although no controlled studies addressing efficacy in overdose patients have been performed, it may be useful for ingestions of enteric-coated or sustained-release pharmaceuticals, foreign bodies (bezoars, button batteries, drug packets, and lead paint chips), and agents that are poorly adsorbed by activated charcoal (iron and other metals), and for patients with extremely large ingestions or delayed presentations [47,64–70]. Potential complications of whole-bowel irrigation include regurgitation and aspiration of gastric contents and abdominal distension with cramping [47,61]. Disadvantages of whole-bowel irrigation are that it is unpleasant, labor intensive, and time-consuming. Gastric endoscopy, using baskets or snares to grasp or break up particulate chemicals, can be used to remove foreign bodies (button batteries that break apart or fail to pass beyond the pylorus) and gastric pill bezoars (see “Absorption” section). Endoscopy should never be used for the removal of drug packets, because it may cause rupture and lethal toxicity. Surgery should also be considered when endoscopic removal is unsuccessful or impossible because of the location of the toxin or foreign body [71]. In animal and human volunteer studies, cathartics have variable but clinically insignificant effects on chemical absorption [44]. Their effect on the efficacy of activated charcoal is also minimal and clinically insignificant [73,74]. The administration of water, milk, or other drinkable liquids is now recommended as a primary treatment only for corrosive ingestions. The volume of fluid should not exceed 5 mL per kg, because larger amounts may induce vomiting and cause further esophageal exposure. It may facilitate the dissolution of solid chemicals, increase the amount of chemical in solution, and stimulate gastric emptying, thereby enhancing chemical absorption. Selective antidotes act by competing with chemicals for target sites or metabolic pathways, by binding and neutralizing them, by promoting their metabolic detoxification, and by antagonizing their autonomic effects via activation or inhibition of opposing neuronal pathways (see Table 97. Nonselective antidotes act by correcting metabolic derangements or enhancing nonmetabolic toxin elimination. Specific indications, contraindications, dosing, and potential complications are discussed in the following chapters. All enhanced elimination procedures are associated with potential complications, and some require specialized equipment and expertise. In general, invasive elimination procedures should be reserved for patients with severe poisoning and/or those who deteriorate or fail to improve despite aggressive supportive care, antidotal therapy, and noninvasive methods of toxin removal.

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Laparoscopic excision of endometriosis: a 65 Stepniewska A order caverta overnight, Pomini P order generic caverta canada, Scioscia M order generic caverta pills, Mereu L, Ruffo randomized, placebo‐controlled trial. Fertil Steril 55 Vercellini P, Pietropaolo G, De Giorgi O, Daguati R, 2006;86:283–290. Long‐term adjuvant therapy Clinical and covariate phenotype data collection in for the prevention of postoperative endometrioma endometriosis research. Fluid biospecimen collection, processing, and storage 60 Vercellini P, Giussy B, Somigliana E, Bianchi S, Abbiati in endometriosis research. World Tissue collection, processing, and storage in Endometriosis Research Foundation Endometriosis endometriosis research. N Engl J Med report from the 2011 World Congress of Endometriosis 2010;362:2389–2398. Pain management is complex physical, biochemical, emotional and social therefore a vital component and may reduce chronicity. Somatic pain is usually sharp and unilateral In most instances the diagnosis is derived from clini- whereas visceral pain is duller, aching, bilateral or local- cal history rather than relying upon examination and ized to the midline. Overall, pain relief, though paramount, is not the sufficient severity to cause functional disability or lead to only goal of treatment. It is recognized that in England it can take several years for a patient’s persistent Clinical history is an integral part of management as it chronic pain condition to be recognized and even longer not only helps to find the possible cause or predisposing before management is provided in a secondary care set- factor but also helps in understanding the impact on ting [6]. The intensity of dys- ated with a well‐described disease process requires that menorrhoea can sometimes warn of the possibility of Dewhurst’s Textbook of Obstetrics & Gynaecology, Ninth Edition. There are also specific question- Mechanical: uterine retroversion, adhesions naires available from the International Pelvic Pain Functional: pelvic congestion, irritable bowel syndrome Society (https://pelvicpain. One should also explore the temporal relationship of pain with events like labour and delivery, which could Examination have damaged the pelvic floor, or surgery which could have caused adhesions or nerve damage leading to pain. Observing how a patient walks into the consulting A history of subfertility hints at a diagnosis of endome- room can provide a clue to the diagnosis. Abdominal wall pain has been pro- good outcomes following (inappropriate) gynaecological posed as a defining new test, where there is abdominal referral and investigation [10]. The women with abdominal Abdominal bloating in association with acute exacerba- wall pain were more likely to require opioids or tions of pain is indicative, but needs to be distinguished pain adjuvants than women without it (P = 0. Urinary frequency and urgency, but palpation, abdomino‐pelvic masses may be noted. It is most importantly exacerbation of pain associated with a useful to ask the patient to point to the area of maximum full bladder, may indicate the presence of interstitial cys- pain and encircle the area where the pain spreads. The titis, a neurogenic inflammatory condition of the bladder diagnosis is confirmed by infiltration of local anaesthetic associated with chronic pain. Vulval erythema may sug- ● A detailed comprehensive clinical history should dif- gest infection, whilst thinning is suggestive of lichen ferentiate between gynaecological and non‐gynaeco- sclerosus. The presence ● Cyclical pelvic pain is likely to be associated with of vulval or lower limb varicosities is associated with endometriosis. The uterus should be palpated for ● Laparoscopy is not recommended as a first‐line size, mobility and tenderness. Culture swabs to exclude sexually trans- psychotherapy was effective in terms of pain scores mitted infections such as Chlamydia are useful. Venography scores, useful in identifying uterine or adnexal pathology and symptom and examination scores, mood and sexual has been shown to be an effective means of providing function were improved to a greater extent 1 year after reassurance [17,18]. The aims are to give a No improvement in pain scores was seen in women diagnosis but also to provide ‘one‐stop’ treatment for taking the selective serotonin reuptake inhibitor sertra- endometriosis and adhesions where these are identi- line compared with placebo. This approach is cost‐effective for endometriosis perception’ showed a small improvement in the sertra- treatment, as the expense of a second procedure or line arm, while the ‘role functioning–emotional’ subscale hormonal treatment is obviated [19]. However, these studies have been small and there are no randomized controlled trials to suggest Adhesiolysis that this technique should be implemented into routine Intraperitoneal adhesions can form de novo or following practice. Each surgeon defines adhesions on an individual basis contingent on the sur- Other treatments geon’s own experience and capability. This treatment There is no definite relationship between adhesions and approach has already shown promise in a pilot study on pain. A large Dutch trial randomizing both perceived to originate from and it is therefore reasona- men and women to adhesiolysis or no treatment found ble to consider these treatment options for all women no difference between the groups. Medical options such as antidepressant and possible difference in those undergoing adhesiolysis with anticonvulsant drugs are well tolerated and could there- dense vascular adhesions but the sample size was small fore be started by a gynaecologist or primary care phy- for conclusive results [33]. Other more novel or invasive therapies are likely examining the efficacy of adhesiolysis for the treatment to require referral to a pain management team. However, of chronic pain showed that the benefit of intervention it is important that gynaecologists are aware that such varied from 16 to 88%, with the majority of studies options exist so that referral can be considered for reporting pain relief in more than 50% of cases. However, patients who are refractory to standard treatments there was a high risk of bias in most of the studies [34,35]. Unfortunately, the current evi- ported by only limited evidence and their use should per- dence lacks rigour and the available trials are frequently haps not be continued [36,37]. There is no internal iliac veins can be technically successful in generally accepted, well‐defined criteria for diagnosing 98–100%. It is predominantly observed in multiparous women improvement in pelvic pain frequency, dysmenorrhoea of reproductive age, suggesting a mechanical and/or hor- and dyspareunia lasting up to 5 years [43] (s 54. However, as there are significant methodological pelvic pain that radiates to the upper thighs and is aggra- flaws with most of these studies, there is an urgent need vated by prolonged standing and walking. Pelvic vein incompetence is thought to be a possible being conducted and the results are awaited. Taylor in 1949 first described how incom- this procedure should not be routinely implemented in petent and distended pelvic veins might cause symptoms clinical practice. There is some evidence to tentatively support this hypothesis, as there are data to suggest that women with pelvic vein incompetence experience more lower abdominal and pelvic pain than age‐matched women with varicose veins or healthy controls [41]. Botulinum toxin A inhibits the release of acetylcholine from cholinergic nerve terminals, preventing the activation of muscle con- Myofascial pain traction and causing transient hypotonia and muscle weakness. It also provides long‐term analgesia by ret- Myofascial pain usually arises from a trigger point, rograde axonal spread and blockade of neurotransmit- which is formed due to a metabolic crisis within the ter release from spinal cord. A comprehensive clinical history lization has not been evaluated and should not be and thorough examination can provide a diagnosis in routinely performed until clinical trials have been many women. Some women are ● Myofascial pain arises from trigger points and can be relieved by the fact that there is no sinister pathology and treated with local anaesthesia, corticosteroids or botu- do not want further investigations and treatment, linum toxin. A multidisciplinary team approach should evaluate such cases, especially in liaison with a chronic pain team. Patterns of diagnosis and gynecologic patients with pelvic pain, as detected by referral in women consulting for chronic pelvic pain in intravesical potassium sensitivity. The psychological and physical benefits of postsurgical abdominal and pelvic pain. Relationship of sexual and physical abuse to pain and 18 Guerriero S, Condous G, van den Bosch T et al.

A teenager must be assured that a discussion about sexuality and con- traception will be strictly confdential buy caverta 100 mg visa. One reason European countries are able to provide better contraceptive services to adolescents is the guarantee by law of complete confdentiality (other reasons are dissemination of information via public media and dis- tribution of contraceptives through free or low-cost services) cheap caverta online amex. A Clinical Guide for Contraception Successful use of contraception (continuation) requires teenager involvement purchase 50mg caverta otc, not just passive listening. It is a good practice to see all patients frst in an ofce setting prior to examination, and this is especially true with adolescents. It is helpful to sit next to a patient; avoid the formality (and obsta- cle) of a desk between clinician and patient. A teenager should be asked about success in school, family life, and behaviors indicative of risk taking. A good way to introduce the subject of contraception is to ask an ado- lescent when he or she would like to have children. Contraceptive use is a private matter, and therefore, instruction comes from the clinician, not from peers. Be very concrete; demonstrate the use of pill packages, the skin patch, the vaginal ring, foam aerosols, and condom application. This seems like oversimplifcation, but clinicians working with adolescents have found that this approach is both necessary and appreci- ated by their young patients. If possible, family involvement that results in improved emotional support of a teenager is worthwhile because it is associ- ated with better contraceptive behavior. A clinician may be the only resource for information and guidance, but clinicians must give the right signals to adolescents and must initiate communication. No matter what the chief complaint, any interaction with an adolescent is an opportunity to discuss sexuality and contraception. Useful Web Sites for Adolescents and Clinicians Center for Young Women’s Health, Children’s Hospital, Boston: http://youngwomenshealth. This is a good match; adolescents are at highest risk for unwanted pregnancies and are at lowest risk for complications. But teenagers do have concerns regarding oral contraception, citing most ofen a fear of cancer, concern with impact on future fertility, and problems with weight gain and acne. We believe it is appropriate to state that there is no defnitive evidence demonstrating a link between breast cancer and oral contraception, as discussed in Chapter 2. Cervical cancer, especially adenocarcinoma, continues to be a concern (Chapter 2), although confounding factors have been difcult to control. Tere is no evidence that early use of oral contra- ception has any inhibiting impact on growth or any adverse efects on the reproductive tract. With great confdence, a clinician can tell adolescents that there is no impact on future fertility with the use of oral contracep- tion. It is worth emphasizing repeatedly to adolescents that studies with low- dose oral contraception,40–47 even studies in adolescents,40 do not indicate a problem of weight gain, and that acne is usually improved. A Clinical Guide for Contraception Adolescents are very receptive to hearing about the benefcial impact of oral contraception on menstrual problems: cramps, bleeding, and iron- defciency anemia. Relief of dysmenorrhea in teenagers has been documented to be associated with better and more consistent use of oral contraceptives. Currently, approximately 35% of people in the United States who have not obtained a high school diploma are smokers, but only 12% of those with higher education. It is important to note that smoking appears to have a greater adverse efect on women compared to men. However, because the actual incidence of cardiovascular events is so low at a young age, the real risk is very, very low for young women. This recommendation also applies to all women using nicotine-containing products as an aid to stop smoking. Other conditions with which oral contraception is acceptable include cystic fbrosis, sickle cell disease, or inactive, stable, moderate systemic lupus erythematosus with a low risk for thrombosis. Unfortunately, the failure rate of oral contraceptives among adolescents is higher compared with all typical users. Education and support Clinical Guidelines for Contraception at Different Ages: Early and Late are necessary to maximize efcacy and continuation. Serial monogamy is usual among younger women, and this ofen is associated with episodic use of contraception. With oral contraception, it is helpful to instruct the adolescent that the minor side efects diminish in frequency with use, and therefore, there is an advantage to staying on the oral contraceptive. It is also good advice to tell teenagers to continue taking oral contraceptives for at least 2 months afer “breaking up” with a boyfriend, because by then a new relationship is likely to have begun. One reason the average teenager waits months to a year afer initiating sexual activity before seeking contraception is fear about the pelvic exam. Tus, letting teenagers know that the pelvic exam can be delayed until the third or sixth month or even later will encourage them to seek contraceptive advice. We advocate the elimination of pelvic and breast examinations as a require- ment for teenagers to obtain contraceptives. However, the contraceptive patch (Ortho- Evra) and the vaginal ring (NuvaRing) have an important advantage. The problem, then, is achieving sufcient educa- tion and motivation without the intervention of clinicians. We believe this is a social problem, not a medical problem, and we are strongly supportive of public education eforts in schools and the media to accomplish this impor- tant public and individual health objective. The female condom provides a young woman with a female-controlled method, but its expense and complexity are obstacles for teenagers. Ado- lescents are not comfortable with body interventions, and the insertion before coitus is too willful an act for most teens. Vaginal Nonsteroid Contraceptives The creams, foams, suppositories, and jellies are not ideal for adolescents. Tey require proper timing before coitus, careful placement, and consistent use to achieve good efcacy, approaching that of hormonal methods or con- doms. Long-Acting Methods for Adolescents Although long-acting methods are an excellent answer for continuation problems, the many minor side efects present difcult problems for teenag- ers. Acne, weight change, and irregular bleeding are more common among implant and injectable users compared with oral contraception (however, the diferences are not great). In addition, the cost and the surgical proce- dure with implants are major difculties for adolescents. The contraceptive use of depot-medroxyprogesterone acetate is asso- ciated with the short-term loss of bone, as discussed in Chapter 6. Almost all of the bone mass in the hip and the vertebral bodies will be accumulated in young women by age 18, and the years immediately following menarche A Clinical Guide for Contraception are especially important. A 7-year prospective cohort study demonstrated unequivocally that bone is regained, almost 100% within 2 years afer depot- medroxyprogesterone acetate is discontinued in both the lumbar spine and the hip. Food and Drug Administration indicated a concern for the bone loss associated with depot-medroxyprogesterone acetate and warned that this method should not be used longer than 2 years unless it was the only option. The degree of bone loss and the evidence that the bone loss is regained, plus the similarity to the benign bone loss associated with lacta- tion, all argue that the use and duration of use of depot-medroxyprogester- one acetate should not be limited by this concern and that measurement of bone density or treatment with supplemental estrogen or bisphosphonates is not indicated (and would infuence and complicate compliance).

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