Dr James Down

• Consultant in Intensive care and Anaesthesia
• University College Hospital
• London

In m ost cases a reduced platelet count returns to norm al after the birth diet untuk gastritis akut imodium 2mg fast delivery, but a few patients who have severe pre-eclam psia com plain of upper abdom inal pain gastritis symptoms in dogs purchase imodium 2 mg amex, nausea or vom iting gastritis diet cure purchase discount imodium on line. Treatm ent consists of correcting the throm bocytopenia and delivering the fetus; system ic high-dose corticosteroids can shorten the recovery phase atrophic gastritis definition cheap 2 mg imodium visa. If the pre-eclam psia worsens the pregnancy m ust be term inated gastritis ultrasound generic imodium 2 mg without prescription, usually by caesarean section treating gastritis naturally discount imodium online mastercard. If there is tim e then prophylactic cortico-steroid therapy to enhance fetal lung m aturation should be considered. Care a the r birth the wom an needs to have close m onitoring of her blood pressure until it resolves. One-third of the wom en will have nonproteinuric hypertension in a subsequent pregnancy, but the rate of recurrence of severe pre-eclam psia is <5%. If severe pre-eclam psia presents before 34 weeks gestation a careful search for an underlying m edical disorder, such as renal disease, should be m ade. Eclam psia is characterized by convulsions and com a, which usually occur in patients who have severe preeclam psia or im m inent eclam psia, and in patients in whom gestational proteinuria has been superim posed on chronic hypertension. With better antenatal care and early recognition and treatm ent of pre-eclam psia and chronic hypertension, the incidence of eclam psia has fallen. In developed countries eclam psia occurs in 1: 2000 pregnant wom en, but in the developing countries the incidence is higher. She then passes into the clonic stage of the convulsion, when her body jerks uncontrollably, frothy saliva m ay ll her m outh and her breathing becom es stertorous. The convulsions occur in late pregnancy in 40% of cases, intrapartum in 30%, and a few hours after the birth in 30%. The patient is nursed on her side, with her head and shoulders raised, and a catheter is inserted into her bladder. The attending m idwives m ust: Magnesium reduces the risk of recurrent seizures by relieving vasospasm and inducing cerebral vascular dilatation. It increases the release of prostacyclin, im proving uterine blood ow, inhibits platelet activation and protects endothelial cells from injury. Magnesium sulphate m ay be given intravenously or by deep intram uscular injection (Box 14. The intravenous route is preferred, as intram uscular injections are painful and are followed, in 5% of cases, by deep abscess form ation. It is im portant that tendon re exes, respiratory rate (>16/m in) and urine output (>25 m L/h) are m onitored to detect m agnesium toxicity. Although uterine blood ow is increased in norm al pregnancy the increase is less in wom en who have essential hypertension, and the higher the blood pressure the less the increase. In 60% of affected wom en a rise in blood pressure occurs, and in 30% signi cant proteinuria (>300 m g/L) is detected. Essential hypertension with superim posed proteinuria is indistinguishable from severe pre-eclam psia. Me dical tre atme nt Once good control of the blood pressure and the convulsions has been obtained the pregnancy should be term inated. Depending on the period of the gestation, the health (alive or dead) of the fetus and its presentation, and on the condition of the cervix, delivery m ay be effected by caesarean section or labour m ay be induced using prostaglandins or by am niotomy. In m ost cases of eclam psia the induction of labour is followed rapidly by the birth of the infant. As postpartum haem orrhage m ay occur, prophylactic intravenous Syntocinon should be given on the birth of the infant. The patient should continue to be m onitored at least for the rst 4 days of the puerperium. Today few wom en in the developed countries should die from severe pre-eclam psia or from eclam psia. Diuretics should be avoided as these agents reduce plasm a volum e and uteroplacental blood ow. Most experience has been obtained using m ethyldopa, but it appears that -blockers such as atenolol and labetalol, and calcium channel blockers. It is im portant to rem em ber that the sm all physiological fall in blood pressure in the rst half of pregnancy m ay be exaggerated in wom en who have chronic hypertension, and som e cases m ay be m issed. Avo idance o pro ble ms the wom an should be seen m ore frequently during the antenatal period, the frequency depending on the severity of the hypertension. Her lifestyle should be checked, and if she is obese a reduction diet should be prescribed. If the fetus shows signs of growth restriction, biophysical tests for fetal well-being should be started (Chapter 20), and if conditions deteriorate induction of labour should be discussed with the patient. It is safer for the fetus to be born earlier rather than later, and the patient should not becom e postdate as the risk of perinatal loss increases. Close m onitoring of both renal and fetoplacental function is required and delivery by caesarean section needs only to be perform ed for obstetric indications. Most affected wom en have no im pairm ent of renal function, which is tracked by periodic serum creatinine m easurem ents. The burden on the heart reaches its m axim um at about the 28th week and continues into the puerperium. If a pregnant wom an has heart disease, the increased strain m ay affect her wellbeing. In 30% of cases a wom an has m itral valve disease; in 20%, ventricu lar septal defect; in 15%, atrial septal defect; in 15%, aortic stenosis; and in the rem ainder, other defects. Any suspicious signs, particularly a diastolic or loud systolic m urm ur, should lead to referral to a cardiologist. Factors that predispose to heart failure include anaem ia, infections (particularly urinary tract infections) and the developm ent of hypertension. Her daily activities should be evalu ated and changes suggested if this is appropriate. At each visit cardiac function is assessed by inquiring about breathlessness on exertion, or if she has a cough or orthopnoea. Many cardiologists place pregnant wom en in categories suggested by the New Y ork Heart Association, and the m anagem ent is planned according to this. He art ailure Should the wom an develop heart failure the principles of treatm ent are no different from those of nonpregnant wom en. Digoxin is given to control the heart rate and increase the tim e for blood ow into the left ventricle. There is no consensus as to whether wom en who are not in cardiac failure should be given prophylactic digoxin, but m ost experts agree that if the wom an is at risk of atrial brillation or has m itral heart disease and an enlarged left atrium, digoxin is indicated. During labour the patient should be nursed either on her side or well propped up, as com pression of the aorta in the supine position m ay cause m arked hypotension. If the wom an requires anaesthesia, an epidural blockade is the preferred choice as it decreases sym pathetic activity, and reduces both oxygen consum ption and vari ations in cardiac output. Delay in the second stage of labour should be recti ed by the use of forceps or vacuum extractor, but there is no need for prophylactic instrum ental delivery. The third stage is conducted in the sam e way as in noncardiac patients, and active m anagem ent using Syntocinon is safe, unless the wom an is in heart failure. The accoucheur should always bear in m ind that in general, wom en with cardiac disease tolerate postpartum haem orrhage poorly. The risks and m anagem ent of speci c cardiac conditions are sum m arized in Table 15. Class 1 the patient has no sym ptom s, although signs of cardiac dam age are present. Class 2 the wom an is com fortable at rest, but ordinary physical exertion usually causes fatigue, palpitations and, occasion ally, dyspnoea. She should then be closely m onitored for the rst few days, and additional support should be m ade available when she returns hom. Class 3 Less than ordinary physical exertion causes dyspnoea and fatigue, although the patient is com fortable when resting. Most wom en in this class should be adm itted to hospital for rest, but hom e conditions and responsibilities have to be assessed and help provided if needed. With good antenatal care the risk to the m other or fetus if the disease is m ild is not usually increased during the current pregnancy. Wom en with sig ni cant im pairm ent of cardiac function should be dis suaded from further pregnancies until the condition of the heart has been assessed and further treatm ent, including surgery, discussed. For a suspected deep vein throm bosis com pression duplex ultrasound should be undertaken. Regional anaesthesia is preferable to general anaesthesia if the wom an requires an operative delivery. A patient diagnosed with active tuberculosis in the rst half of pregnancy should be treated with isoniazid and etham butol. Diagnosis requires at least one of the clinical criteria and one of the laboratory criteria (see Box 15. Wom en who have suffered from clinical com plications should be screened and referred for specialist evaluation. All pregnant wom en should have a blood sam ple tested for the presence of anaem ia at the rst antenatal visit. During pregnancy, the plasm a volum e begins to increase by the sixth week of gestation, peaking at around 30 weeks, with a total extra volum e of 1. The red cell m ass also slowly increases, but proportion ately less than the plasm a volum. Iron requirem ents during pregnancy increase in response to fetal growth and developm ent and the increase in m aternal red cell m ass. Total iron requirem ents in norm al pregnancy have been estim ated as approxim ately 1300 m g/ day. Iron is absorbed predom inantly through the proxim al sm all intestine and is highly regulated. Body stores of folate m ay be rapidly exhausted and generally last less than 3 weeks. Undiagnosed m aternal vitam in B12 de ciency m ay result in irreversible neurological dam age to the breastfed in fant. Although m aternal vitam in B12 de ciency is un com m on, the m ajority of wom en with de cient B12 levels are asym ptom atic. Inadequate dietary iron intake and gastrointestinal blood loss (hookworm infestation) are the com m onest causes of iron de ciency. Prevalence rates for iron de ciency are increased am ong wom en from lower socioeconom ic groups, teenage m others, those eat ing predom inantly vegetarian or vegan diets, and wom en with closely spaced pregnancies. There is a paucity of evidence on whether the bene ts of treatm ent of otherwise healthy wom en with m ild iron de ciency anaem ia outweigh the adverse effects that include nausea and constipation for oral iron, venous throm bosis and allergic reactions for intravenous iron and pain and skin discolouration for intram uscular iron. Low dose oral iron supplem entation (20 m g) is as effec tive as high dose (80 m g) and has fewer side effects. Vita m in C aids absorption; coffee and tea reduce the am ount of available absorbable iron. Intram uscular iron is an alternative in rem ote settings where intravenous iron therapy cannot be accessed. Blood transfusion for the treatm ent of iron de ciency anaem ia should be avoided unless there is active bleeding or cardiovascular com prom ise. Deaths from haem orrhage would be dram atically reduced if all pregnant wom en could access a skilled birth attendant at the tim e of childbirth, and have access to quality em ergency obstetric care including a safe blood supply. They are autosom al recessive defects, and char acterized by reduced production of one or m ore of the chains of globin that m ake up haem oglobin. Carriers (who have only one affected globin locus) rem ain healthy throughout life. People who are hom ozygous or doubly heterozygous have haem oglobin disorders of varying clini cal severity. If a bone pain crisis occurs heparin should be given and the haem oglobin m easured every 2 hours; a fall of >2 g indicates the need for an exchange transfusion. The thalassaem ias m ay be either heterozygous, when they are sym ptom less, or hom ozygous, when they produce severe anaem ia. Because a signi cant num ber of wom en with thalassaem ia and other rarer haem oglobinopathies have norm al red cell indices, routine haem oglobin elec trophoresis should be offered to all previously unscreened pregnant wom en from com m unities at greater risk because of ethnicity. A pregnant wom an carrying the thalassaem ia trait has a 30% chance of becom ing anaem ic and a sim ilar chance of developing urinary tract infection. Thalassaem ia m ajor in the fetus can be detected in the rst quarter of pregnancy by chorionic villus sam pling. If the test is positive, term i nation of the pregnancy is an option for the parents.

The reason for this is that the trial of vaginal delivery is term inated by caesarean section in one- fth of all cases gastritis zunge discount imodium online mastercard, 0 gastritis diet ������ imodium 2 mg low cost. If an elective caesarean section is chosen gastritis diet ������ purchase cheapest imodium and imodium, the m aturity of the fetus m ust be established so that the operation is perform ed when the gestation period is greater than 38 weeks diet for hemorrhagic gastritis purchase discount imodium, to obtain the lowest neonatal respiratory m orbidity gastritis diet of the stars purchase genuine imodium on-line. Before attem pting the version the doctor m ust be sure that the pelvis has norm al dim ensions and that the placenta is not praevia high protein diet gastritis discount imodium 2mg on line. If the fetal heart rate falls below 90 bpm during the version, the attem pt is abandoned. Short-term bradycardia occurs in 20% but delivery by em ergency caesarean section, because of persistent bradycardia, is required in only 0. They include rupture of the m em branes, cord entanglem ent around a lim b of the fetus, and the onset of prem ature labour. There is insuf cient evidence to support m oxibustion (burning of Artemisia vulgaris to stim ulate acupuncture point lateral to the sm all toe), acupuncture alone or m aternal postural positioning, to effect conversion of the breech to a cephalic presentation. It m ay nd use in cases of the delayed birth of a second twin which is lying transversely in the uterus, but in m ost cases caesarean section is safer. In this case the head is perforated with a perforator and the uid allowed to drain, m aking the fetus easier to deliver. The breech is m obilized and the version attem pted by lifting it with one hand and pushing the fetal head down with the other. The fetal heart rate is either m onitored continuously or every 2 m inutes during, and for 30 m inutes 214 Chapter 25 the epidem iology of obstetrics began to fall. In the period before the m id-1930s it was about 500 per 100,000; by the m id-1980s, in m any industrialized countries it had fallen to fewer than 10 per 100,000 m aternities. The initial fall was due to the control of infections by better obstetric care and the introduction of antibiotics. The second factor was that m ost wom en availed them selves of good-quality antenatal care, which enabled com plications to be detected early and treatm ent to be offered, usually in well-equipped hospitals staffed by trained m edical attendants. Blood becam e increasingly and quickly available from blood banks, which considerably reduced the deaths due to haem orrhage. Sociological changes have also occurred in the past 60 years: fewer wom en now have m ore than three children, and m ost have their pregnancies before the age of 35. There has been a sm all rise in the m aternal m ortality rates in som e developed countries in the last decade. Whether this is due to wom en with m edical conditions that previously precluded pregnancy having children, increasing m aternal age, the rise in obesity or better ascertainm ent of cases is not clear. In sub-Saharan Africa it averages 600 per 100,000 live births; in south Asia, 500 per 100,000 births; in southeast Asia and Latin Am erica 300 per 100,000 live births. The reasons for these high rates are: frequent pregnancies, with short intervals between them; the resort to unsafe abortion perform ed in unhygienic surroundings; a relative lack of prenatal care and a lack of the perception of its value by poorly educated and poorly inform ed wom en; a lack of access to skilled m edical help; and a lack of governm ent support to m ake changes to the status, education and em powerm ent of wom en. The death of a wom an in pregnancy or childbirth is one of the greatest tragedies that can happen to a fam ily. The m aternal m ortality ratio is the num ber of direct and indirect m aternal deaths per 100,000 m aternities. In m ost developed countries the m aternal death rate rem ained about the sam e from 1850 to 1934, when it 215 Fundam entals of Obstetrics and Gynaecology Box25. In these reports the causes of and contributing factors to the deaths are analyzed and suggestions are m ade that m ight prevent such deaths occurring. This m ay be due to underreporting in earlier years, but em phasizes that there is no room for com placency in m odern m aternity units in the developed world. The m ajor contributing factors to suboptim al care are poor liaison between healthcare professionals, failure to appreciate the severity of the condition, and wrong diagnosis. Maternal deaths can be reduced further, particularly those associated with haem orrhage, anaesthesia, ectopic gestation, sepsis and pulm onary em bolism. Am ong wom en whose body m ass index was 35 or m ore, 10% had a stillbirth or a neonatal death. The accurate determ ination of the speci c factors leading to the neonatal death enables health professionals to identify correctable problem s. The principal causes of perinatal deaths in Victoria, Australia in 2011 are shown in Table 25. Multiple pregnancy carries a signi cantly greater risk of perinatal loss; stillbirths 22. From the Expert Case Review in Victoria, Australia of stillbirths the four m ost frequent contributing factors were m isinterpretation of or undue reliance on tests, delay or lack of specialist consultation in high-risk pregnancies, inadequate fetal m onitoring in labour and delivery by caesarean section being too late. For neonatal deaths the two m ost frequent factors were inadequate resuscitation and inadequate paediatric m anagem ent. When she realizes that her baby has died the expectant m other is distressed and concerned that the dead fetus, if it rem ains in her uterus, will decay and cause infection. Medical problem s are unlikely, at least in the 218 Chapter 2 5 the epidem iology of obstetrics T able 25. After this tim e, dissem inated intravascular coagulation and hypo brinogenaem ia m ay arise, with potentially serious consequences to the wom an. They should be reassured that the dead fetus, if left in the uterus, will not cause any harm in the following 3 weeks, and that usually labour will start during this tim. The m anagem ent of the labour should be discussed with her and she should be assured that she will be given analgesics to reduce or elim inate the pain of childbirth. If she and her partner wish to view and hold the fetus after delivery they should be m ade aware that it m ay be m acerated, depending on when the death occurred. If spontaneous labour has not started 3 weeks after the diagnosis, or if the wom an chooses im m ediate treatm ent, labour is induced by prostaglandin E2 vaginal pessaries or gel, as described on page 203. If the wom an chooses to await the spontaneous onset of labour, frequent blood checks should be m ade by observing the clotting tim e of the blood or by estim ating brinogen levels. The m ore m ature the fetus or neonate at the tim e of death the greater the grief reaction. This reaction is reduced if the parents touch and hold the infant for as long as they wish; if keepsakes are available, including a lock of hair and a photograph; and if a health professional is readily available if the parents want m ore inform ation. Inve stig atio ns the basic investigations to determ ine the cause of death that should be offered are listed in Box 25. An autopsy should be offered, as the reason for the death is changed by the autopsy ndings in up to 25% of cases. The ndings can have signi cant im plications for counselling and for the m anagem ent of another pregnancy. Nonspeci c stim uli, such as pain, cold and light, also lead to stim ulation of breathing. In m ost infants the rst breathing efforts occur within 30 seconds of birth and are forceful enough to overcom e the high resistance of the liquid in the airways and to in ate the lungs. In im m ature 221 Fundam entals of Obstetrics and Gynaecology Ligamentum arteriosum Fossa ovalis Ligamentum venosum Ligamentum teres Lateral umbilical ligaments. The lungs expand with the rst breath and the pulm onary vascular resistance falls abruptly. As the infant breathes, the oxygen tension in the blood rises and the m uscular walls of the ductus contract, the passage of blood through it ceasing. Because of the changes in pressure between the two atria, the foram en ovale closes. With the closure of the ductus venosus, the foram en ovale and the ductus arteriosus, the adult pattern of circulation of the blood is established. The liver can ef ciently convert glucose into glycogen and vice versa, but som e of its enzym atic functions are im m ature. Most of the glycogen stored in the liver is laid down in the last 8 weeks of intra-uterine life. Glucose from glycogen and the m etabolism of ketone bodies contribute signi cantly to the energy needs of the rst few days of life. Preterm and growth restricted babies have sm aller liver glycogen stores and m ay develop hypoglycaem ia. After a few days the neonate obtains energy from food and by oxidizing fats stored in adipose tissue. The m ost im portant step in resuscitation is to initiate ventilation with interm ittent positive-pressure respiration; current evidence suggests that ventilation using air (21% oxygen) should be the initial step for term babies, with oxygen being added only if hypoxia persists despite adequate ventilation. A 5-m inute Apgar of <6 should be followed by m easurem ents of arterial blood gases and pH, and treatm ent given to adjust the ndings if necessary. Infants who have required advanced resuscitation or have prolonged cardiorespiratory depression should be closely observed in a special care nursery until it is clear that they have recovered or need continuing specialist care. A m ature infant will have laid down fat in brown adipose tissue and can utilize this for heat production without shivering. Because of the instability of tem perature control, neonates should be wrapped properly in cold environm ents, but in hot environm ents too m uch wrapping should be avoided. These conditions have been m entioned when discussing the at-risk fetus in pregnancy and labour (see Chapter 20). If severe fetal hypoxia develops in pregnancy, the fetus m ay die in utero or m ay be born with acidaem ia and hypercapnia as well as hypoxia (asphyxia). The severity of cardiorespiratory and neurological depression around the tim e of birth can be assessed by the Apgar scoring system (Table 26. In all cases, the injury m ust be explained to the parents and the treatm ent and prognosis discussed. The oedem atous swelling and bruising is subcutaneous and can cover a large area of scalp. Treatm ent is not required; the swelling of the caput disappears rapidly and the bruising within a few days. Ce phalhae mato ma Cephalhaem atom as m ay occur after a spontaneous vaginal delivery or following traum a from the obstetric forceps or the ventouse. The periosteum is sheared from the underlying parietal bone and subperiosteal haem orrhage occurs. The swelling is lim ited to the outline of the bone; initially it is tense, subsequently it is uctuant and the rim m ay calcify. Subapo ne uro tic (subg ale al) hae mo rrhag e Subaponeurotic haem orrhage, while rare, occurs m ost com m only after a traum atic vacuum extraction (see 224 Chapter 2 6 the newborn infant dif cult delivery. It should be looked for after any dif cult delivery as, unless treated by stretching the m uscle, perm anent shortening m ay result. Occasionally the bleeding is very rapid and life-threatening and requires urgent blood transfusion. Frequent observation for diffuse head swelling following vacuum extraction is m andatory. Intracranial hae mo rrhag e Intracranial haem orrhage m ay be subarachnoid, subdural or intraventricular. Subarachnoid haem orrhage is com m on and m ay cause irritability and even convulsions over the rst 2 days; it rarely has longstanding effects. Subdural haem orrhage can follow the m isapplication of forceps; in severe cases the infant m ay be shocked and show little response to resuscitation. Intraventricular haem orrhage is found m ost often in preterm infants; it is diagnosed by ultrasound exam inations, which should be perform ed routinely on very preterm infants. Surfactant assists the stability of the lung after birth and lowers the surface tension in the alveoli, ensuring a norm al residual volum e of air and the capacity for gas exchange. In the absence of surfactant, the alveoli becom e airless at the end of each breath and their ability to expand against the forces of surface tension is decreased, leading to poor oxygen exchange. Facial palsy Facial palsy is a lower m otor neuron disorder with paresis or paralysis of the facial nerve and inability to close the eye on the affected side. Brachial palsie s these are due to nerve dam age, usually following dif culty delivering a shoulder or the aftercom ing head of a breech. In m ost cases the nerve sheath is torn and the nerve is com pressed by haem orrhage and oedem a, but its integrity is preserved. The infant has a paralyzed arm, with wrist drop and accid paralysis of the hand m uscles. Nerve injuries are best referred to neurology or plastic surgery clinics that specialize in their m anagem ent. Aspiration of m econium causes a chem ical pneum onitis that can be life-threatening. They m ay also occur following a breech extraction, and in addition the fem ur m ay be dam aged. Investigations to exclude infection should be perform ed in all babies in which the respiratory distress is not clearly transient. The signs of neonatal infection m ay be nonspeci c, with lethargy, poor tem perature control (including hypotherm ia as well as fever), poor feeding, vom iting and/or com prom ised perfusion. Any infant suspected of having infection requires a blood culture, blood picture exam ination and possibly nonspeci c infection m arker. C-reactive protein); if the diagnosis rem ains unclear collection of a urine specim en (by suprapubic aspiration), a chest X-ray and a lum bar puncture to exclude m eningitis should be perform ed. Treatm ent consists of giving the appropriate antibiotic, depending on local bacterial sensitivities and experience. Early treatm ent is of the utm ost im portance to m inim ize the risk of death or long-term sequelae. Care m ust be taken to prevent cross-infection by ensuring that the staff practise infection control m easures, especially hand hygiene. When the diagnosis has been established the doctor should talk with the parents, explaining the m alform ation and the prognosis calm ly and sym pathetically. They m ay express anger and guilt, questioning whether anything they did or did not do during the pregnancy caused the m alform ation. Hydrocephalus can be diagnosed in the second half of pregnancy by ultrasound scanning, but m ay only be noticed when delivery is dif cult.

Dilatation and curettage requires more cervical dilatation and is associated with a significantly higher complication rate gastritis diet �� cheap imodium 2mg with amex, including uterine injury gastritis olive oil cheap imodium 2 mg with mastercard, and a higher incidence of retained products of conception and adverse future reproductive outcome (Henshaw and Templeton 1993) gastritis diet zone discount imodium online american express. Vacuum aspiration can be performed under either local paracervical block or general anaesthesia gastritis newborn order generic imodium on-line. Some evidence suggests that the use of general anaesthesia increases the risk of the procedure gastritis treatment probiotics 2mg imodium amex. Preoperative treatment with a cervical priming agent has been shown to reduce the risk of haemorrhage and genital tract trauma associated with vacuum aspiration gastritis upper left abdominal pain imodium 2 mg on line. Pretreatment of the cervix adds to the cost of the procedure and may be difficult to organize when abortion is performed as a day case. As cervical trauma is more common in women under the age of 17 years and uterine perforation is associated with increasing parity and increasing gestation, efforts to arrange cervical ripening should be concentrated on young women (aged <18 years), highly parous women and those presenting at a gestation of greater than 10 weeks. A curette of up to 10 mm internal diameter is passed through the cervix, and the contents of the uterus are aspirated using negative pressure created by a pump. It is advisable to use the smallest diameter curette which is adequate for the gestation; most gynaecologists use an 8 mm curette at 8 weeks, 10 mm at 10 weeks, etc. Failure is more likely to occur before 7 weeks of gestation when it is possible to miss the fetus with the curette. For this reason, medical methods or a rigorous protocol for early surgical abortion are recommended. The mortality from vacuum aspiration in the first trimester is less than approximately one in 100,000; considerably less than the maternal mortality from continuing pregnancy. Mifepristone is a synthetic steroid which blocks the action of progesterone by binding to its receptor. When mifepristone is used alone, complete abortion only occurs in approximately 60% of pregnancies. The antiprogesterone itself stimulates some uterine contractility, but mainly works by greatly enhancing the sensitivity of the myometrium to the tocolytic effect of prostaglandins. Offered the choice of method, approximately 30% of women in Scotland prefer medical abortion. Women often choose the medical method because it avoids an anaesthetic in most cases, and because they feel more in control of the situation. The incidence of serious complications is probably similar to that associated with surgical abortion, but because 95% of women need neither anaesthesia nor instrumentation of the uterus, large randomized trials may eventually show medical abortion to be safer. Not all women are suitable for medical abortion; the contraindications are shown in Box 29. The fetus is usually passed within 4 h of prostaglandin administration, and this is accompanied by bleeding and pain. The bleeding is usually described as being like a very heavy period, although rarely (<1%) there may be very heavy bleeding requiring resuscitation. Prostaglandin synthetase inhibitors, such as aspirin or mefanamic acid, should be avoided for obvious reasons. A few women will abort at home in response to mifepristone with variable amounts of bleeding and discomfort. The total amount of blood lost is similar to that occurring at the time of vacuum aspiration. All women should be given an appointment for follow-up approximately 2 weeks after administration of the prostaglandin. This visit is absolutely essential for those (approximately 30%) who have not passed an identifiable fetus and/or placental tissue while in hospital. The risk of fetal malformation following mifepristone alone or in combination with prostaglandins is not known. Women should be clearly advised that medical abortion is a two-stage procedure, and that it is not possible to have a change of heart after taking mifepristone and before prostaglandin administration. Women who seem even remotely uncertain about abortion should certainly not be offered the medical method. In the event of failed medical abortion and therefore ongoing pregnancy, the patient must be strongly advised to have vacuum aspiration, although babies born to the few women who have chosen to continue with the pregnancy after medical abortion has failed have been normal. Most women find the procedure painful and distressing, and require opiate analgesia. Evacuation of the uterus is necessary in approximately 30% of women who retain all or part of the placenta. Abortion beyond 18 weeks of gestation is rare and is usually for pregnancies complicated by severe fetal malformation. Particularly distressing for both the mother and the staff, these late abortions are often effectively managed with vaginal prostaglandins in combination with mifepristone, with intra-amniotic urea or fetal intracardiac injection of potassium to minimize the chance of a live birth. Follow-up Anti-D immunoglobulin should be given to all nonsensitized Rhesus-D-negative women following any therapeutic abortion. Written advice about possible post-treatment symptoms, particularly those associated with infection, together with advice about what action to take should be given to patients before discharge home. All women should receive contraceptive advice and, if appropriate, supplies before going home. Ovulation can return within 20 days following abortion, and contraception should be started at the time of abortion if possible. All should be given a follow-up appointment within 2 weeks, either with the clinic which carried out the abortion or with a suitable alternative doctor. At follow-up, a pelvic examination should confirm complete abortion and the absence of infection. Discussion should include contraceptive advice and postabortion counselling, if required. However, a randomized trial of women between 9 and 13 weeks of gestation to either medical or surgical abortion found completed abortion rates to be comparable (Ashok et al 2002). Although late-first-trimester abortion remains an extremely safe procedure, blood loss and other complications increase as gestation advances. It is important, therefore, to refer the woman for abortion promptly after the decision to terminate the pregnancy has been made. Although maternal mortality is, fortunately, extremely rare following abortion, the incidence of major complications, haemorrhage, thromboembolism, operative trauma (uterine perforation and cervical trauma) and infection is approximately 2%. While many are done because of fetal malformation, it is often the women who are least able to cope with an unwanted pregnancy, particularly the very young, who first present at this time. It is possible to induce abortion at this stage of pregnancy either medically or surgically. It may be necessary to dilate the cervix up to a diameter of 20 mm before the fetal parts can be extracted. D&E is a safe procedure in skilled hands, but if complications such as haemorrhage and perforation of the uterus are to be avoided, surgeons should be adequately trained. Up to 5% of women undergoing first-trimester medical abortion will require surgical evacuation of the uterus within the first month. The incidence of incomplete abortion and ongoing pregnancy after vacuum aspiration rises as the gestation increases. References the occurrence of bleeding at 2 weeks after a medical or surgical abortion is not, in itself, an indication to evacuate the uterus. Ultrasound scans often show residual trophoblastic tissue even in women who have stopped bleeding. Although an ultrasound scan of the uterus and the measurement of human chorionic gonadotrophin in plasma may be helpful in diagnosing an ongoing pregnancy, the decision to evacuate the uterus should be made on clinical grounds. The majority of women with an incomplete or missed abortion will pass the residual tissue with time if they are prepared to be patient. The belief that all women with an incomplete abortion had a high risk of intrauterine infection until the uterus was evacuated probably stemmed from the time when illegal abortion was common. Late complications There are very few late complications from abortion if women have been counselled carefully. Psychological sequelae Many women feel tearful and emotional for a few days following the abortion. However, many studies have demonstrated a significant improvement in psychological well-being by 3 months post abortion compared with before abortion (Adler et al 1990, 1992). Reviewers of existing literature have concluded that adverse psychiatric outcomes are observed in a minority of women following abortion, which are most often (although not exclusively) an exacerbation of morbidity predating the procedure, and that women denied abortion often experience significant ongoing resentment (Dagg 1991, Thorp et al 2002). Lack of a supportive partner, ambivalence regarding their decision or membership of a cultural group that forbids abortion are, unsurprisingly, risk factors for adverse psychological sequelae. Minor complications Some 10% of women undergoing abortion present to their general practitioner during the 3 weeks following the procedure with a variety of complaints related to the abortion. Lower abdominal pain, vaginal bleeding and passage of clots or trophoblastic tissue are relatively common and usually only require reassurance. Established pelvic inflammatory disease with pyrexia, abdominal pain and offensive vaginal discharge occurs in approximately 1% of women whatever method of abortion is used. Infertility Postabortion infection is a significant cause of tubal disease and infertility following illegal abortion. However, with modern methods performed under optimal conditions, the incidence of infection is very low, particularly where preoperative screening and treatment of infection are routine. Cervical and vaginal lacerations Lacerations to the vagina and cervix are rare, and the risk of the latter can be reduced by pretreatment of the cervix in selected cases, as discussed earlier. Subsequent pregnancy Although damage to the cervix or perforation of the uterus can predispose to cervical incompetence, preterm delivery and/or uterine rupture, there is no significant increase in adverse outcome of any subsequent pregnancy. Lack of contraceptive use continues to be a major problem in many developing countries. Antihormones, particularly antigestogens, show great promise for the development of new contraceptives. There are a variety of ways of inducing therapeutic abortion, and women should be offered a choice of method within the context of a high-quality service which meets national standards. Akerlund M, Rode A, Westergaard J 1993 Comparative profiles of reliability, cycle control and side effects of two oral contraceptive formulations containing 437 29 Fertility control Collaborative Group on Hormonal Factors in Breast Cancer 1996 Breast cancer and hormonal contraceptives: collaborative re-analysis of individual data on 53,297 women with breast cancer and 100,239 women without breast cancer from 54 epidemiological studies. Committee on Safety of Medicines 2006 Updated Prescribing Advice on the Effect of Depo-Provera Contraception on Bone. Duffy S, Marsh F, Rogerson L et al 2005 Female sterilization, a cohort controlled comparative study of Essure versus laparoscopic sterilization. Gbolade B, Ellis S, Murby B, Randall S, Kirkman R 1998 Bone density in long term users of depot medroxyprogesterone acetate. Glasier A 2002 Implantable contraceptives for women, effectiveness, discontinuation rates, return of fertility and outcome of pregnancies. International Collaboration of Epidemiological Studies on Cervical Cancer 2007 Cervical cancer and hormonal contraceptives: collaborative reanalysis of data from 16573 women with and 33509 women without cervical cancer from 24 epidemiological studies. Lakha F, Glasier A 2006 Unintended pregnancy and the use of emergency contraception among a large cohort of women attending for antenatal care or abortion in Scotland. Perez A, Labbok M, Queenan J 1992 Clinical study of the lactational amenorrhoea method for family planning. Collaborative Review of Sterilization Working Group 1996 the risk of pregnancy after tubal sterilization: findings from the U. Collaborative Review of Sterilization 1997 the risk of ectopic pregnancy after tubal sterilization. Royal College of Obstetricians and Gynaecologists 1999 the Management of Menorrhagia in Secondary Care. Royal College of Obstetricians and Gynaecologists 2004a Male and Female Sterilisation. Royal College of Obstetricians and Gynaecologists 2004b the Care of Women Requesting Abortion. Task Force on Postovulatory Methods of Fertility Regulation 1999 Comparison of three single doses of mifepristone as emergency contraception: a randomised trial. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception 1995 Effect of different progestagens in low oestrogen oral contraceptives on venous thromboembolic disease. World Health Organization Scientific Group 1998 Cardiovascular Disease and Steroid Hormone Contraception. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception 1998 Cardiovascular disease and use of oral and injectable progestogen-only contraceptives and combined injectable contraceptives. It is an integral part of every human being and it is up to every individual to deal with their own sexuality in whichever way they choose. Although so fundamental to human existence, scientific documentation of sexuality is relatively recent. Historically, there was a persistent refusal to recognize that women could enjoy sex. At the beginning of the 20th Century, Havelock Ellis, an English doctor, gave scientific voice to the idea that sexual activity was important in its own right, not just as a means of procreation.

Syndromes

• Observe posted signs that may warn of danger from jellyfish or other hazardous marine life.
• Your overall health
• Vaginal discharge
• Vitamin D intoxication
• Fainting or feeling light-headed
• Skin-colored bumps are the size of a grain of sand
• Heart-lung transplant, if medicines do not work

Plant sterols and stanols reduce the absorption of cholesterol from the gut gastritis nuts purchase imodium 2mg otc, and therefore reduce serum concentrations of cholesterol gastritis cancer imodium 2 mg without a prescription. They are incorporated into a variety of foods such as spreads gastritis diet 600 buy imodium online from canada, yogurts and drinks gastritis diet questions imodium 2mg low price. Omega-3 fatty acids include the plant-derived -linolenic acid (18:3n-3) gastritis diet ������ discount imodium 2 mg without a prescription, and the fish-oil-derived eicosapentaenoic acid (20:5n-3) and docoshexaenoic acid (22:6n-3) gastritis symptoms in tamil cheap 2 mg imodium with mastercard. They are found in a wide variety of fruit and vegetables such as grapes, berries, apples, chocolate, teas, kale and hot peppers. Animal and in-vitro studies suggest that flavonoids may have a role in preventing cancer and neurodegenerative disease. Dietary fibre consists of plant substances that resist hydrolysis by digestive enzymes in the small bowel, and is an extremely complex group of substances. Fibre can be classified according to its solubility and fermentability by bacteria: a soluble fibre is readily fermentable by colonic bacteria, and an insoluble fibre is only slowly fermentable. These actions lead to potentially beneficial effects in the gastrointestinal tract and systemically, such as lowering serum cholesterol and improving glycaemic control. The importance of diet is such that the American Heart Association recommends that `Women should consume a diet rich in fruits and vegetables; choose wholegrain, highfibre foods; consume fish, especially oily fish, at least twice a week; limit intake of saturated fat to <10% of energy, and if possible to <7%, cholesterol to <300 mg/day, alcohol intake to no more than 1 drink per day, and sodium intake to <2. A systematic review found that no conclusions regarding the effectiveness of exercise as a treatment for 415 28 Menopause vasomotor menopausal symptoms could be made due to a lack of trials (Daley et al 2007). A Cochrane review found that fast walking improved bone density effectively in the spine and the hip, whereas weight-bearing exercises were associated with increases in bone density of the spine but not the hip (Bonaiuti et al 2003). Exercise regimens can be very helpful in the management of established osteoporosis, and represent a component of falls prevention programmes. They are also used in the treatment of women with mixed incontinence, and less commonly for urge incontinence. Systematic reviews support the view that pelvic floor muscle training and bladder training should be included in first-line conservative management programmes for women with stress, urge or mixed urinary incontinence (Shamliyan et al 2008). Botanicals the evidence from clinical trials on the benefit of botanicals on menopausal symptoms is limited and conflicting. Studies may use different products which are not chemically consistent, making comparison difficult. Also, the stability of individual chemicals may vary and may depend on the type of packaging. Herbs may contain many chemical compounds, the individual and combined effects of which are unknown. A major concern is use without consulting a health professional, leading to interaction with standard pharmacopeia with potentially fatal consequences. Severe adverse reactions, including renal and liver failure and cancer, have been reported. Some have been found to be contaminated or to contain unlabelled ingredients such as conventional medicines (steroids) or banned substances. Herbal remedies need to be used with caution in women with a contraindication to oestrogen, as some botanicals have oestrogenic properties. Thus, they should not be used by women with a hormonedependent condition such as breast cancer or endometriosis. Phytoestrogens are plant substances that have effects similar to those of oestrogens. With regard to menopausal symptoms, the evidence from randomized placebo-controlled trials in Western populations is conflicting for soy and derivatives of red clover (Lethaby et al 2007). Similarly, debate also surrounds the effects on lipoproteins, endothelial function, blood pressure, cognition and the endometrium. Further well-designed randomized trials are needed to determine the role and safety of phytoestrogen supplements in perimenopausal and postmenopausal women and those who have survived cancer. Actaea racemosa (black cohosh) is a herbaceous perennial plant native to North America, used widely to alleviate menopausal symptoms. There is no consensus regarding whether non-oestrogenic or oestrogenic actions are involved in the mechanisms by which it relieves hot flushes. One small placebo-controlled, randomized trial showed it to be ineffective for the treatment of hot flushes. It was not found to be superior to placebo in a randomized trial, but may be effective when combined with other herbs. Ginkgo biloba (gingko) is widely used but there is little evidence that it improves menopausal symptoms. Piper methysticum (kava kava) may be an effective symptomatic treatment for anxiety, but the data about menopausal 416 Premature ovarian failure symptoms are conflicting. Concern about liver damage has led regulatory authorities to suspend or withdraw kava kava. Data with regard to the menopause are scant, and well-designed adequately powered studies are required. In contrast, menopause implies permanent cessation of ovarian activity and menstruation, and infertility. With regard to an age cutoff, premature menopause should ideally be defined as menopause that occurs at an age more than two standard deviations below the mean estimated for the reference population. In the absence of reliable estimates of age of natural menopause in developing countries, the age of 40 years is often used as an arbitrary limit below which the menopause is said to be premature. In the developed world, however, an age of 45 years should be taken as the cut-off point. He then pursued the concepts of minimum dose and succession (the curative action of certain preparations seemed to be stronger at some of the lower doses, particularly when shaken vigorously). In the absence of a non-invasive test to differentiate between follicular depletion or dysfunction, the only alternative is ovarian biopsy. The validity of single biopsies has been questioned, with pregnancies occurring despite histological lack of follicles in the biopsy material. Some studies have shown benefits on the skeleton, cognition, well-being, libido and vagina. One licensed gel is available in Europe; however, it is indicated for local use on the breast but not for systemic therapy. Progesterone creams have been advocated for the treatment of menopausal symptoms and skeletal protection. However, at present, insufficient published data show that transdermal progesterone has a positive effect on vasomotor symptoms or the skeleton. There is also no consistent evidence that transdermal progesterone creams can prevent mitotic activity or induce secretory change in an oestrogen-primed endometrium. Thus, it should not be used for endometrial protection in women using systemic oestrogen. Bilateral oophorectomy or surgical menopause this results in an immediate menopause which may be intensely symptomatic. The implications of this procedure require detailed discussion with the patient in view of the increased morbidity and mortality in those who cannot, or will not, take oestrogen replacement. Hysterectomy without oophorectomy/uterine artery embolization Both procedures can diminish ovarian reserve and lead to ovarian failure. Diagnosis may be difficult in women where the procedures have made them amenorrhoeic. Infection Tuberculosis and mumps are infections that have been implicated most commonly. These patients experienced ovarian failure at an early age, often before the second decade of life. Mean life expectancy in women with menopause before the age of 40 years is 2 years shorter than that in women with menopause after the age of 55 years. Management Patients must be provided with adequate information about the condition, its implications on long-term health, use of oestrogen replacement and fertility (Pitkin et al 2007). In those who have not had an oophorectomy, the return of spontaneous ovarian activity and the possibility of spontaneous pregnancy must be explained. Women who do not wish to have children need to consider using an effective form of contraception. Techniques to conserve ovarian tissue or oocytes before cancer therapy should help with maintenance of fertility. There is no evidence to support the efficacy or safety of the use of non-oestrogen-based treatments, such as bisphosphonates, strontium ranelate or raloxifene, in these women. Some patients report reduced libido or sexual function despite apparently adequate doses of oestrogen replace- Chemotherapy and radiotherapy the likelihood of ovarian failure after chemotherapy or radiotherapy depends on the agent used, dosage levels, interval between treatments and, particularly, the age of the patient, which probably reflects the age-related progressive natural decline in the oocyte pool. The prepubertal ovary is relatively resistant to the effects of chemotherapeutic alkylating agents. Fertility and contraception It is important to ascertain whether or not the woman wishes to have children. Recent advances in oocyte preservation have improved livebirth rates following freezing of mature eggs. Cryopreservation of ovarian tissue is still largely experimental, although pregnancies have been reported. This technique would be an option for prepubertal girls in whom ovulation induction is not possible. The menopause is the permanent cessation of menstruation resulting from loss of ovarian follicular activity, and occurs in the early 50s. Thus, chronic diseases affecting postreproductive health spanning over several decades are major public health issues. There are no effective alternatives to oestrogen with longterm safety data for vasomotor symptoms. The increase in risk of breast cancer is approximately equivalent to the increase in relative risk of breast cancer associated with each year the menopause is delayed after 50 years of age. In non-hysterectomized women, progestogen is added to oestrogen to reduce the risk of endometrial cancer. Non-hormonal treatments for osteoporosis, such as bisphosphonates and strontium ranelate, have mainly been studied in women over 60 years of age at increased risk of the disease. Data for younger women are limited, and these treatments should not be used in women contemplating pregnancy since the effects on the developing fetal skeleton and the long-term consequences are unknown. The evidence that complementary and alternative therapies are effective is poor, and there are concerns about safety and interactions with standard pharmacopoeia. Basson R, Berman J, Burnett A et al 2000 Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. Beral V; Million Women Study Collaborators, Bull D, Green J, Reeves G 2007 Ovarian cancer and hormone replacement therapy in the Million Women Study. Bjelakovic G, Nikolova D, Gluud L, Simonetti R, Gluud C 2008 Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Bonaiuti D, Shea B, Iovine R et al 2003 Exercise for preventing and treating osteoporosis in postmenopausal women. Daley A, MacArthur C, Mutrie N, StokesLampard H 2007 Exercise for vasomotor menopausal symptoms. Million Women Study Collaborators 2003 Breast cancer and hormone-replacement therapy in the Million Women Study. Shapiro S 2007 Recent epidemiological evidence relevant to the clinical management of the menopause. Liu B, Beral V, Balkwill A et al 2008 Gallbladder disease and use of transdermal versus oral hormone replacement therapy in postmenopausal women: prospective 420 References World Health Organization 1994 Scientific Group on Research on the Menopause in the 1990s. Writing Group on Osteoporosis for the British Menopause Society Council 2007 Prevention and treatment of osteoporosis in women. Writing Group for the British Menopause Society Council 2008 Non-estrogenbased treatments for menopausal symptoms. They should be able to advise women of the method most appropriate for their individual circumstances, and to deal with the side-effects which lead to referral to a gynaecologist. Over the last 40 years, there has been a significant increase in the use of contraception worldwide. In 2008, it was estimated that up to 62% of all married women of reproductive age or their partners were using contraception. However, the prevalence of contraceptive use remains low in many less developed countries; only 13% of couples use contraception in some African countries. It has been estimated that some 120 million women in developing/restructuring countries who do not wish to become pregnant are unable, for a variety of reasons, to use contraception (Ross and Winfrey 2002). In Great Britain, 88% of sexually active women who wish to avoid pregnancy use a method of contraception (Office for National Statistics 2007/8). Usage is lower among adolescents (56%), women over 45 years of age (69%) and less well-educated women (65%). Worldwide, between 8 and 30 million unplanned pregnancies per year are the result of contraceptive failure. Scotland has an abortion rate which is one of the lowest in countries in which abortion is legal, yet for every six babies born, one pregnancy is terminated. In some of the less developed parts of the world, breast feeding is still the most important method of birth spacing. Increased uptake of contraceptive implants and injections may reduce unintended pregnancies among sexually active teenagers.

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