F. Christopher Holsinger, MD, FACS

• Associate Professor, Department of Head and Neck Surgery
• Director, Program in Minimally Invasive and Endoscopic Head and Neck Surgery
• University of Texas MD Anderson Cancer Center
• Houston, Texas

This vague definition reflects the wide variations in clinical practice currently in operation treatment naive buy genuine oxybutynin online. Inefficient uterine activity is a failure of the uterus to function in a way that results in normal progression of labour medicine zyrtec cheap 5 mg oxybutynin with mastercard. Inco-ordinate uterine activity does not need to be specifically addressed if progress in labour is normal treatment quotes buy oxybutynin us. However medicine 4212 cheap oxybutynin 2.5 mg without prescription, it will not be appropriate to leave all women this long mueller sports medicine generic oxybutynin 5mg on line, and decisions must be taken in the context of full clinical assessment medications zopiclone purchase oxybutynin no prescription. Between 8 per cent of multiparae and 22 per cent of nulliparae will fail to respond to oxytocin and require delivery by caesarean section, although the majority of patients will deliver vaginally within this time with few risks of intrapartum injury [C]. It is important to recognize that as fetal compromise may result from augmentation of the forces, continuous monitoring of the fetus should be employed. The Royal College of Obstetricians and Gynaecologists audit standards suggest that caesarean section should not be performed for poor progress in nulliparae before a trial of oxytocin. However, it should be realized that this recommendation is not based on any evidence from randomized trials and situations exist in which this advice should not be followed. Once commenced, oxytocin should be titrated to provide a contraction frequency of four or five in 10 minutes, with each contraction lasting approximately 40 seconds. Such a regimen has been shown to be compatible with normal progress in labour (>1 cm/hour) with minimal adverse sequelae, as long as the appropriate action is taken if signs of maternal or fetal compromise develop. The frequency and duration of contractions may be assessed by either internal or external tocography; uterine tone and quantification of uterine activity can only be measured by internal tocography. Advocates of intrauterine pressure monitoring claim that uterine hyperstimulation can be identified earlier and, in patients with a previous caesarean section scar, that dehiscence can be diagnosed more promptly with a consequent improvement in neonatal outcome. However, a prospective randomized study failed to show an improvement in the obstetric outcome when an intrauterine pressure catheter was employed in an augmented labour when compared with an external tocograph [B]. They observed that an oxytocin infusion in conjunction with a strict diagnosis of labour, early amniotomy and oneto-one care resulted in a marked reduction in the rate of interventional deliveries. The Dublin team made every effort to ensure that it is understood that this strategy was not applicable to multiparae, though this message is often forgotten in other units. Active management is a package encompassing antenatal classes, one-to-one care, a strict diagnosis of labour, early amniotomy and oxytocin for slow progress and frequent vaginal assessment. The low rates of caesarean section achieved in Dublin has not been matched in other units. By contrast, the provision of continuous professional support in labour has been found to reduce both types of operative interventions, although the effect on the incidence of caesarean section was confined to those settings in which partners were excluded from the delivery room [A]. However, the dynamic nature of labour will continuously alter the dimensions of the presenting part through flexion, rotation and moulding in relation to the pelvis. Likewise, the shape of the pelvis undergoes subtle changes and is not simply a static bony conduit. The relative combinations of the passenger and the passages to the delay may therefore be difficult to evaluate. In cases of malposition, it is important to assess progress not only in terms of dilatation, but also in terms of rotation and descent. Therefore, accurate definition of position is very important when labour is not progressing Table 27. Although vaginal delivery may be possible if the head rotates during labour or with rotational forceps, in all but the most experienced hands, intervention by caesarean section is usually warranted. Contributory factors in absolute cephalo-pelvic disproportion Maternal causes Pelvic abnormalities Congenital these are rare and include the following (Table 27. Incorporation of the sacrum into the fifth lumbar vertebrae: this results in the sacral promontory being higher than usual, with an apparent lengthening of the sacrum and an increase in the angle of inclination. Protrusio acetabulae (the Otto pelvis): the acetabular heads protrude medially to distort the pelvic cavity and obstruct labour. In face presentations, a lower threshold for delivery by caesarean section is usually adopted, as avoidance of a difficult vaginal delivery is important. Bony abnormalities Soft tissue abnormalities Cervical fibroids Ovarian tumour Pelvic kidney Excessive fat Cervical cancer Hydrocephalus Iniencephaly Anencephaly Conjoined twins Table 27. Kyphoscoliosis combines these problems, and there may be additional maternal respiratory embarrassment. Pelvic fractures and disuse atrophy: direct pelvic trauma may result in a pelvis of any shape, which may or may not accommodate the passage of a fetus during childbirth. Rickets (vitamin D deficiency) may affect pelvic development in childhood, with a resultant narrowing of the pelvic inlet (sacral promontory pushed forward). This results in marked asynclitism of the presenting part and a significant risk of shoulder dystocia if the head is successfully delivered. Disuse atrophy may be the consequence of any primary pathology (poliomyelitis, spina bifida, tuberculosis, suppurative arthritis, etc. Caution must be taken with this line of management, especially in multiparae, and it should never be initiated in grande multiparae. In either case, if there is no change in the presentation over the time allotted, the delivery should be by caesarean section. The accoucheur should be aware that all malpresentations are more common preterm than at term. Therefore, they may not pose the same problems as the diameters of the fetal head are comparatively small. However, the same principles of management apply, and failure to progress should be dealt with in the safest manner (often by caesarean section). Problems with fetal abnormalities and maternal abnormalities (see lists above) must always be considered when a malpresentation is identified. Whatever the management of a poorly progressing labour, the possibility for a postpartum haemorrhage should always be anticipated by the attending team and managed accordingly. Soft tissue abnormalities Congenital abnormalities of the vagina are rarely a problem as the soft tissues will distort in the face of fetal descent and can often be pushed to one side, for example vaginal septum. Congenital or acquired strictures, on the other hand, may significantly impede descent and, because of the close proximity of the bladder anteriorly and the rectum posteriorly, delivery by caesarean section should be the treatment of choice. The mid-cavity of the pelvis measures only 12 by 12 cm in the average woman, and a brow is unlikely to negotiate its way through this passage unless it undergoes flexion to a vertex or extension to a face. Oxytocin augmentation during this phase does not result in an increase in the vaginal delivery rate, but rather a 10-fold increase in the incidence of caesarean delivery and a 3-fold increase in low Apgar scores. While no single aetiology is responsible for all cases, 70 per cent of nulliparae and 80 per cent of multiparae will respond to oxytocin in terms of improvement in the rate of cervical dilatation. Secondary arrest affects approximately 6 per cent of nulliparae and 2 per cent of multiparae, and may be defined as a cessation of cervical dilatation following a normal period of active-phase dilatation. Sixty per cent of nulliparae and 70 per cent of multiparae demonstrated an improvement in progress with oxytocin. Improved rates of cervical dilatation with oxytocin do not necessarily lead to improved outcomes for mothers and babies. By contrast, the provision of continuous professional support in labour reduces operative interventions and the need for pain relief, shortens labour and leads to infants being delivered in better condition. Prolonged labour is not a diagnosis; it is an abnormality that may be detected during parturition, and for which a cause must be identified before treatment is instigated. Delivery by caesarean section should not be regarded as a failure, but rather as an appropriate intervention after a full assessment. It is recommended that caesarean section should not be performed in nulliparae for delay in labour before oxytocin has been tried. Instrumental delivery may be challenging after correction of poor progress in labour and should only be performed by experienced practitioners. Partograms and nomograms of cervical dilatation in management of primigravid labour. Meconium is composed of swallowed amniotic fluid debris, bile pigment and the residue from intestinal secretions. It is a sterile, durable compound made up primarily of water (75 per cent), with mucous glycoproteins, lipids and proteases. Infants delivered through meconium-stained amniotic fluid are more likely to be depressed at birth and to require resuscitation and neonatal intensive care. The fetal bowel has little peristaltic action and the anal sphincter is contracted. It is thought that hypoxia and acidaemia cause the anal sphincter to relax, while at the same time increasing the production of motilin, which promotes peristalsis. Aspiration of meconium into the distal airways can occur either antenatally or postnatally, and in the majority of affected infants the exact timing is unclear. Production of fetal lung fluid is a continuous process, with a net movement of fluid out of the lung. During normal fetal breathing, lung fluid is not usually drawn into the distal airway. Passage of meconium is increasingly common in infants >37 weeks gestation Prevention of meconium aspiration syndrome 375 Aspiration is known to occur prior to delivery, as meconium has been found in the lungs of stillbirths and in infants delivered pre-labour by caesarean section without evidence of fetal distress. Perinatal inhalation can occur late in the second stage or immediately after delivery if the infant gasps or makes breathing movements while the oropharynx, nasopharynx or trachea contains meconiumstained liquor. Second, it acts as a chemical irritant causing pneumonitis, alveolar collapse and cell necrosis. The presence of organic material in the airway, although initially sterile, predisposes to secondary bacterial infection. Finally, meconium is known to inhibit the surface tension properties of surfactant at alveolar level, thus further increasing airway resistance. Perhaps this is not surprising, as neither the conditions for, nor the timing of, aspiration can be predicted. Maternal sedation It has been suggested that the administration of narcotics to labouring women will prevent fetal gasping in utero by suppressing fetal breathing. Moreover, the likely maternal and neonatal complications would preclude its use [E]. Intrapartum/postpartum management Oropharyngeal suctioning Suction of the oropharynx and nasopharynx before delivery of the shoulders and trunk was a well-established practice, used in the 1970s and 1980s. It seemed a reasonable assumption that suctioning in this way would minimize the amount of meconium in the upper airway and thus reduce the amount aspirated during the onset of respiration. This intervention was based on a non-randomized cohort study using historical controls and very small numbers. More recently, a large randomized controlled trial into the use of oropharyngeal and nasopharyngeal suctioning for meconiun before delivery of the shoulders showed no benefit for this practice. This has led to a number of antenatal, intrapartum and postnatal preventative therapies being explored, with varying degrees of success. Many of these remain controversial and have not been subjected to the scrutiny of randomized, controlled trials. Antenatal therapies Amnioinfusion this potential therapy was used in North America until recently. The rationale behind amnioinfusion is that by increasing the liquor volume, meconium will be diluted. In addition, in cases of oligohydramnios, the increased volume was felt to prevent cord compression, subsequent hypoxia, fetal gasping and passage of meconium. Methods advocated included thoracic compression, in which the thoracic cage of the infant was compressed by a healthcare professional in order to prevent respiration and subsequent aspiration of the contents of the upper airway, and cricoid pressure, in which external pressure is applied to the cricoid, thus preventing aspiration. This intervention was continued until a second resuscitator undertook oral and/or endotracheal suctioning. More recently, evidence has suggested a change in practice depending on whether or not an infant is deemed vigorous. A Cochrane Library meta-analysis suggests that routine intubation of vigorous term infants in order to aspirate the lungs should be abandoned [A]. Suctioning of the oropharynx may be beneficial, but endotracheal suctioning should be reserved for depressed or non-vigorous infants or those who deteriorate following initial assessment. The passage of an orogastric tube is likely to cause apnoea and/or bradycardia and is potentially harmful. Saline lavage is potentially harmful, as saline will displace endogenous surfactant, which could in turn worsen the respiratory illness. As air trapping is a feature of this condition, hyperinflation of the chest is common. Asphyxiated infants may be apnoeic, but exhibit identical physical signs once ventilated. An early chest x-ray will show widespread patchy infiltrates with areas of hyperinflation interspersed with areas of atelectasis and consolidation. In severe cases, the x-ray will show diffuse homogeneous opacification of the lung fields, reflecting the pneumonitis and interstitial oedema. It is no longer recommended that the oropharynx should be suctioned with delivery of the head and before delivery of the shoulders and body. Secretions should be cleared from the mouth and nose using a wide-bore suction catheter. Infants should receive appropriate neonatal intensive care support until the meconium is cleared and respiratory function returns to normal. Special attention should be paid to the treatment of respiratory failure, acid-base status and However, if an infant is not vigorous after birth (defined as depressed respirations, decreased muscle tone and/or heart rate <100 beats per minute): Direct endotracheal suctioning should be undertaken as soon as possible. Unless affected by coexisting asphyxia, many infants can be initially managed by administering humidified oxygen therapy via a headbox. Sedation with an opiate infusion is recommended in neonates who require ventilation as a result of meconium aspiration. Additionally, the use of muscle relaxants may be beneficial due to the need for high peak inspiratory pressures, to aid ventilatory management and reduce the risk of pneumothorax. For infants who remain hypoxic on conventional ventilation, high-frequency oscillatory ventilation is a useful alternative.

This treatment 1st 2nd degree burns order oxybutynin online pills, in turn premonitory symptoms order oxybutynin with american express, acts centrally to initiate further vasodilatation and a bradycardia medications jaundice discount oxybutynin online. These attacks usually resolve spontaneously medications with codeine buy generic oxybutynin, although it is advisable to position the patient flat and then elevate her legs to encourage central venous return and hence adequate filling of the heart [E] medicine for uti cheap oxybutynin online mastercard. Similar syncopal episodes may also be present in patients with cardiac disease symptoms 4 weeks oxybutynin 5 mg without a prescription, specifically those women who have arrhythmias or obstructive heart disease. Cardiac arrest Cardiac arrest during the postnatal period is usually associated with hypovolaemia, obstructive heart disease or complex congenital heart disease. However, with increasing maternal age at the time of delivery, ischaemic heart disease is now seen more commonly. Resuscitation of women who have had a cardiac arrest in pregnancy is usually complicated by the fact that, when supine, a gravid uterus will compress the inferior vena cava, decreasing venous return. Emptying the uterus, by delivering the fetus, will improve stroke volume by 60 per cent and is therefore mandatory if resuscitation has not been successful within 5 minutes [D]. Although this latter problem is not present in the immediate postpartum period, the uterus may still be of sufficient size to cause significant aortocaval compression and therefore resuscitation should be conducted with the patient on a left lateral tilt [D]. This results in an increased cardiac output of 25 per cent when compared to a supine patient. At this angle, it is possible to exert 80 per cent of the mechanical pressure on the chest that one would if the patient were flat. As a result of this study, the Cardiff Resuscitation Wedge was designed and manufactured. Management therefore consists of diagnosing and treating any reversible cause of the arrest, while simultaneously following the European Resuscitation Council Guidelines 2005 for Adult Advanced Life Support. Once a cardiac arrest has been diagnosed, a precordial thump may be administered by a trained healthcare professional, although its success rate is low if the arrest has already lasted longer than 30 seconds [D]. Basic life support should begin once the airway is secured, with chest compression at a rate of 100 per minute and a compression to ventilation ratio of 30:2. The most recent guidelines suggest that chest compression begins before rescue breaths are given as in these initial moments of a non-asphyxial cardiac arrest oxygenation of the blood is high, but delivery of oxygen to the myocardium and brain is poor. Chest compression is often performed suboptimally and the person leading the resuscitation needs to rotate the person performing chest compressions regularly, approximately every 2 minutes. Post-resuscitation care should include transfer of the patient to a critical care unit or coronary care unit [D]. Patients who are hypothermic should not be warmed and those who are pyrexial should receive antipyretics [C]. Amniotic fluid embolus Amniotic fluid embolism is rare, with estimates of the incidence varying between 1. This results in a biphasic model where initially patients develop pulmonary hypertension and hypoxia presenting as respiratory distress, central cyanosis and circulatory collapse, with survivors undergoing a resolution of the pulmonary hypertension and subsequent development of left ventricular failure. Diagnosis of the condition is suspected when patients suddenly collapse either in labour or shortly after delivery with signs of central cyanosis, although confirmation of the diagnosis can be made on examination of lung tissue at Table 41. Management of these patients revolves around the generic treatment of shock and coagulopathies, with the former often requiring the information provided by pulmonary artery wedge pressures to guide inotropic interventions [D]. Although high-dose hydrocortisone has been suggested as an appropriate treatment, no studies have examined this. The degree with which the fundus of the uterus inverts is variable, with the mildest form being dimpling of the fundus and the most severe being complete inversion, where the fundus of the uterus passes through the cervix. There is no agreement on the aetiology of this condition, although several factors appear to be associated with its occurrence. These include: Postpartum complications: maternal Uterine inversion Uterine inversion is a rare condition, occurring with an incidence of one in 10 000 pregnancies. Although maternal mismanagement of the third stage of labour, either by inappropriate traction during controlled cord traction or too rapid removal of the placenta during manual removal; 494 Postpartum collapse maternal age >25 years; a sudden rise in intra-abdominal pressure in the presence of a relaxed uterus; a fundally placed placenta with a short umbilical cord. This shock appears to be of neurogenic origin secondary to traction on structures adjacent to the uterus. The fundus of the uterus may be visible at the introitus; however, if not, it will be detected on vaginal examination. This latter examination is mandatory in all patients who appear to be shocked in the immediate postpartum period in the absence of visible blood loss [E]. Not only can this lead to the exclusion of a diagnosis of an inverted uterus, but a diagnosis of a supralevator haematoma will also be excluded. Treatment is based on the principles of managing a shocked patient and then replacing the uterus as soon as possible. If the diagnosis is made immediately, the uterus can often be replaced manually prior to the onset of shock. However, once the uterus has been inverted for only a few minutes, the tissues surrounding it constrict, preventing its replacement. In this circumstance, manual replacement may be possible using general anaesthesia [D]. At laparotomy, traction is placed on the round ligaments and an incision is made through the muscular ring in the posterior uterine wall. Continued manual pressure on the fundus from the vagina and traction of the round ligaments will allow replacement of the uterus, and the incision is closed [D]. In all these treatment options, it needs to be remembered that if the placenta is still attached it should not be removed until the uterus has been replaced, as the uterus will be unable to contract and constrict the placental bed blood vessels and therefore major haemorrhage may ensue [E]. In all the previously described management options, once the uterus is correctly sited, a Syntocinon infusion should be commenced to encourage contraction of the uterus [E]. It should be noted that a recurrence rate of approximately 30 per cent has been quoted in the literature, although recent figures are unavailable. Syntocinon may cause sudden hypotension and, in women who are supine and have recently haemorrhaged, can be sufficient to result in loss of consciousness. This situation should be managed as for any shocked patient, with the appropriate positioning of the woman, protection of the airway and the administration of oxygen and intravenous fluids. In the previous Confidential Enquiries into Maternal Mortality, it has been reiterated that Syntocinon should be used with care in such situations. Ergometrine, which is usually administered along with Syntocinon, is a powerful smooth muscle constrictor and is contraindicated in women with severe hypertension, as it may precipitate a hypertensive crisis and haemorrhagic cerebrovascular accident. In women with inadequate analgesia, infiltration of the perineum with a local anaesthetic is mandatory prior to surgical repair of the perineum. Lidocaine, the most widely used local anaesthetic for this purpose, is ideally suited, with an onset and duration of action after infiltration of 5 minutes and 1 hour, respectively (maximum plasma concentrations occur at 25 minutes). Overdosage usually presents as lightheadedness, sedation, paraesthesia, twitching and convulsions. However, if the drug is administered intravenously, it may result in the precipitation of cardiac arrhythmias and cardiac arrest. This is one of the reversible causes of cardiac arrest and should be managed according to the guidelines described by the European Resuscitation Council [E]. This latter variable can be altered by the administration of a vasoconstrictors to the local anaesthetic. The recommended maximum dose of lidocaine is 200 mg (500 mg, if administered with adrenaline). However, this situation is complicated by the fact that most local anaesthetics are labelled in percentage solutions and hence professionals need to understand how much lidocaine there is in a specified percentage solution. Although any drugs may be There are few randomized, controlled trials of the management of acute postpartum collapse. There are, however, internationally accepted evidencebased guidelines for adult resuscitation. Local anaesthetic solutions are labelled in per cent and can easily be converted into milligrams. Local and national guidelines are essential for the management of these conditions. The influence of gestational age on the maternal cardiovascular response to posture and exercise. A statement from the Advanced Life Support Working Group (1) and approved by the Executive Committee of the European Resuscitation Council. Postpartum haemorrhage is subclassified as follows: Primary postpartum haemorrhage is defined as the loss of 500 mL of blood from the genital tract following, but within the first 24 hours of, the delivery of the baby. A caveat is added in that if the blood loss is <500 mL, but is sufficient to cause hypovolaemic shock in the patient, this is also classified as a primary postpartum haemorrhage. A new definition of massive postpartum haemorrhage has been introduced, being the loss of greater than 1000, 1500 or 2500 mL of blood. Owing to the relatively low risks of blood loss below these levels, this is thought to be of greater clinical relevance. The incidence of this complication is being used in some units as an indicator of the standard of maternity care and is being promoted by the Royal College of Obstetricians and Gynaecologists as one of their clinical indicators on the maternity scorecard. It should be noted that the new Confidential Enquiry into maternal deaths will be published in 2010. Although significant morbidity will be associated with this condition, other data concerning its incidence are limited. However, the risk of mortality from postpartum haemorrhage was calculated to be 0. Management 497 Uterine atony may have many causes, including retained placental fragments, and is associated with prolonged labour, multiple pregnancies, polyhydramnios, instrumental deliveries and grand multiparity. These rarer causes retain a significant level of importance because of their relative over-representation among severe cases of haemorrhage. The major aetiological factors associated with secondary postpartum haemorrhage are retained placental fragments and endometritis. Although for many years clinical teaching has been that fluid replacement by colloid is superior to the use of a crystalloid, examination of randomized, controlled trials in patients with hypovolaemia has failed to show any benefit with the preferential use of colloids [A]. In this early stage of resuscitation, it is important to obtain blood for a full blood count, clotting studies and group and cross-matching. Such women include those in the risk categories mentioned above, as well as women who have had a previous postpartum haemorrhage, who have a risk of recurrence of approximately 25 per cent. Examination of the placenta post-delivery should identify a proportion of women who have retained placental fragments and who will require manual removal of the placenta. Significant postpartum haemorrhage is an obstetric emergency that requires a multi-disciplinary team for optimum management [E]. This is difficult, as it is well recognized that both obstetricians and midwives are poor at accurately estimating blood loss at the time of delivery. This can be further confounded by the ability of fit young women to maintain their blood pressure, either with or without a tachycardia, until they have lost approximately 15 per cent of their blood volume. Regardless of the aetiology, the management should revolve around maintaining an adequate intravascular volume and treating the underlying cause, in this case stopping the haemorrhage. Although administration of blood components should be guided by haematological results, as described above, this should not be delayed until the patient is moribund, as successive Confidential Enquiries into maternal mortalities have identified delay in transfusion as a significant contributor to maternal mortality [D]. Specific management strategies Uterine atony can be managed pharmacologically or by a combination of pharmacological and surgical intervention. If the placenta is thought to be complete, the uterus is clinically atonic and there are no significant signs of genital tract trauma, an examination in theatre may be avoided by the administration of ergometrine followed by a Syntocinon infusion. Although the former has significant side effects, including nausea, vomiting and hypertension, its tonic action on the uterine muscle is a valuable adjunct to therapy with Syntocinon alone. However, caution is necessary in patients with pre-eclampsia, who may suffer episodes of severe hypertension following the administration of ergometrine. Should these efforts fail to control the bleeding, examination of the genital tract needs to be performed with adequate lighting and patient analgesia. This usually means examination in an operating theatre with the patient Postpartum complications: maternal Resuscitation Immediate management will involve resuscitation of the hypovolaemic patient with the siting of two large-bore (16 G) intravenous cannulae, fluid administration, the application of facial oxygen, and examination to determine the 498 Postpartum haemorrhage having a regional or general anaesthetic. If the bleeding is significant, this examination should not be delayed in order to obtain blood results; if the anaesthetist is concerned about the risks of siting a regional anaesthetic in the presence of a possible coagulopathy or hypotension, then immediate resuscitation should be followed by the administration of a general anaesthetic [E]. Examination under anaesthesia should include examination of the vagina, cervix and, in the case of continued bleeding, exploration of the uterine cavity digitally to identify and remove any retained fragments of the placenta. If the uterine cavity is explored digitally, this should be covered by the administration of a broad-spectrum antibiotic. At this time, if no other cause for the haemorrhage has been identified, administration of prostaglandin analogues, either intramuscularly (if carboprost is available) or rectally (if only misoprostol or gemeprost is available), is advisable. Bimanual compression of the uterus may also need to be performed at this stage; this decreases blood loss partly because of the fact that it puts the uterine arteries under tension. If these pharmacological and basic surgical steps have not achieved haemostasis, the uterus can be packed by either a traditional technique using gauze9 or, as has more recently Table 42. Indeed, the provisional data on the use of balloon insufflation using a Rusch urological balloon appear very encouraging, although there are problems related to when and by how much the balloon should be deflated. At that time, either unilateral or bilateral uterine artery ligation can be performed, with success rates reported of more than 90 per cent [D]. The suture should be placed approximately 2 cm above the point where an incision for a lower segment caesarean section would be, thus ligating the ascending branch of the uterine artery and avoiding inclusion of the ureter in the suture. Arterial ligation has been modified into a series of stepwise procedures producing uterine devascularization. This technique, described in Egypt, involves five steps: unilateral ligation of the uterine artery at the level of the lower segment; bilateral ligation of the uterine artery at the level of the lower segment; low ligation of the uterine artery after mobilization of the bladder; unilateral ovarian vessel ligation; and bilateral ovarian vessel ligation [D]. Although ligation of the internal iliac arteries has been well described in the literature, it requires a high level of surgical skill and is reported as avoiding hysterectomy in only 50 per cent of cases. After all these levels of uterine devascularization, subsequent menstruation and successful pregnancies have been reported. The use of compression sutures of the uterus has been reported from Switzerland and the United Kingdom,15,16 although their exact role in the treatment of postpartum haemorrhage has yet to be established.

Breastfeeding should be encouraged; no deficiency in the let down reflex has been observed symptoms schizophrenia cheap oxybutynin, even in patients with high cervical lesions medicine for stomach pain buy oxybutynin 5 mg overnight delivery. Acknowledgement 123 Myotonic dystrophy is an autosomal dominant condition medicine qhs buy oxybutynin 5 mg on line, affected individuals having one normal and one abnormal allele symptoms ulcer stomach order oxybutynin with visa. Quite how severely affected the child will be is difficult to predict with any degree of accuracy symptoms dengue fever buy oxybutynin american express. A woman with moderate to severe disease herself is likely to have a significantly expanded mutation already symptoms ptsd cheap 5 mg oxybutynin. If this is inherited by the fetus, further expansion is likely and the neonate will be born with severe congenital myotonic dystrophy. Preterm delivery is more common, and severe hypotonia and respiratory difficulties are evident at birth. Talipes and facial diplegia may be present and survival beyond the neonatal period is followed by significant developmental delay in most cases. A woman with minimal or absent disease (and therefore a shorter expansion) has a risk of approximately one in ten that her child will be severely affected. This reflects the greater likelihood that she has an inherently unstable mutation. Inheritance and further expansion of the mutated allele can be detected by molecular testing carried out on placental biopsy material, although precise analysis of expansion size and prediction of outcome can still be difficult. Epilepsy and pregnancy: a prospective study of seizure control in relation to free and total plasma concentrations of carbamazepine and phenytoin. Population based, prospective study of the care of women with epilepsy in pregnancy. Pregnancy is associated with a lower risk of onset and a better prognosis in multiple sclerosis. Oestrogen is probably responsible for cutaneous vascular changes such as an increase in spider naevi, palmar erythema and even the occurrence of head and neck haemangiomas. Oedema is almost universal, and venous varicosities of the legs, vulva and rectum often become more prominent or appear for the first time. Striae gravidarum are pinkish purple linear markings on the lower abdomen and breast, which later fade to white and usually persist after pregnancy is over as depressed, irregular bands. Postpartum alopecia, however, is a recognized phenomenon that is usually mild and transient. As with all preexisting maternal conditions, one must consider the effect both the disease and its therapies will have on the pregnancy, the labour, the fetus and the neonate. Conversely, the pregnancy may influence the course and nature of the condition itself. The effect of pregnancy on atopic dermatitis (atopic eczema) and psoriasis is unpredictable. A generalized pustular psoriasis may occur in pregnancy (see below) and is more common in women with previous psoriasis. Sebum secretion increases in pregnancy and may be responsible for the common deterioration of acne during pregnancy. The pregnancy-associated suppression of cell-mediated immunity is thought to cause the often marked increase in human papilloma virus warty lesions (condylomata acuminata). Skin disorders occurring as part of multisystem disease (connective tissue disease, infections and malignancies) are considered in the appropriate chapters. It is worth remembering, however, that the skin manifestation of these disorders may be the initial presentation of these conditions. Hyperpigmentation may occur of the nipples and areolae, axillae, linea alba Dermatoses precipitated by pregnancy 125 obstruct the vagina. Impact of pre-existing skin diseases on the pregnancy itself is usually minimal in the absence of any multisystem involvement (clearly, connective tissue disorders and infections with skin involvement are quite different). Conditions affecting the abdominal wall may interfere with abdominal delivery and delay wound healing. Vulval problems may similarly affect vaginal delivery and the healing of tears and episiotomies. A rare condition called X-linked ichthyosis is associated with steroid sulphatase deficiency and this in turn is said to delay the onset of labour, increasing the need for induction for prolonged pregnancy. Certain skin conditions have a genetic component and the offspring may be at risk of the condition themselves. One of the most important factors to consider is the potential impact that dermatological drugs and therapies may have on a pregnancy. Isotretinoin is especially harmful, causing central nervous system, craniofacial and cardiovascular abnormalities in as many as 50 per cent of exposed pregnancies. A number of these medications may linger in body tissues for many months after treatment has ended. Great care must be taken that women undergoing such therapies are made aware of the vital role of reliable contraception, which may need to be continued long after the treatment has stopped. It should be noted that these drugs may also carry potential harm through an effect on the male gametes. Men who have used griseofulvin, for example, are advised against fathering offspring within six months of treatment ending. Emollients, dithranol, coal tar and topical corticosteroids are safe in pregnancy, as is chlorpheniramine. Acne, erythema multiforme, erythema nodosum and generalized pustular psoriasis form the first group. Erythema multiforme and erythema nodosum are both caused by a multitude of other aetiological factors, which must be excluded before it is possible to attribute the onset to pregnancy alone. Generalized pustular psoriasis describes a superficial sterile eruption occurring on the background of widespread erythema, which is associated with fever, systemic upset and hypocalcaemia (with tetany) in the more severe cases. It carries significant perinatal mortality and is more common in those with a history of plaque psoriasis. A clinically identical condition called impetigo herpetiformis was previously thought to be a pregnancy-specific dermatosis, but the two are now considered the same condition. Pregnancy appears to be one of a number of triggers for generalized pustular psoriasis. This leaves four reasonably well-defined dermatoses found only in pregnancy (see Table 6. Acknowledgement 127 A diagnosis can usually be made on clinical grounds alone; however, pemphigoid gestationis can be confused with polymorphic eruption of pregnancy if there are no vesicles present. The two conditions are easily distinguished by immunofluorescence studies of skin biopsies. Pemphigoid gestationis is characterized by C3 deposition along the epidermal/dermal junction. Immunoglobulin G (IgG) deposition is usually another feature, the target protein being a 180 kDa component of hemidesmosomes. Although this may represent biased reporting of poor outcomes, extra surveillance would seem warranted in these pregnancies [E]. The author and editors acknowledge the contribution of Alec McEwan to the chapter on this topic in the previous edition of the book. Caring for women with childbearing potential taking teratogenic dermatologic drugs. Clearly the problem is increasing, and maternity services must have local guidelines and action plans in place to manage it. There is a tendency to focus attention on the medical aspects of substance abuse in pregnancy. Although these drugs may involve actual harm to the pregnancy, the associated social and health problems are as important, if not more so. Throughout this chapter it will become clear that separating the two is very difficult, and the contributions made firstly by the drugs themselves and secondly by the socio-economic environment are almost impossible to disentangle. The following discussion therefore does not tackle each drug independently, but aims to explore their individual contributions to each problem encountered in the pregnancy. Better study design is often associated with negative results or a diminution in the harm reported. There is little doubt, however, that drug use during pregnancy is linked to poorer outcomes. A recent cross-sectional audit of health records in a London specialist perinatal addictions outreach service reported a total of 167 pregnant substance-using women referred between 2002 and 2005. It prevents the reuptake of neurotransmitters (adrenaline, noradrenaline, dopamine) at nerve terminals, causing an exaggerated response to these chemical messengers. Increased motor activity, tremors, convulsions, tachycardia, generalized vasoconstriction, hypertension and hyperpyrexia may result. The sense of euphoria occurs as a result of dopamine accumulation within the mesolimbic system. Use of cocaine with alcohol results in a more powerful vasoconstrictor called cocaethylene. It is vital for obstetricians to have an understanding of these problems, as they may present in the antenatal clinic or as emergencies on the labour suite. These compounds have a wide diversity of physical functions, but are intimately linked with pain perception and mood control. Acute maternal effects Drug abuse is associated with a wide range of health problems, which may present acutely to various different healthcare professionals. Overdose Excess alcohol intake causes ataxia, confusion, stupor and eventually coma. Cocaine, amphetamines and ecstasy cause tachycardia, hypertension and hyperthermia and predispose to cardiac arrhythmias, myocardial infarction, seizures and stroke. The potential for diagnostic confusion with fulminating pre-eclampsia and eclampsia is clear. Amphetamines Amphetamines similarly enhance the dopaminergic neurotransmitter system. It causes accumulation of synaptic serotonin and dopamine, but direct axonal damage and serotonin depletion can occur with prolonged use. Withdrawal Withdrawal from the physically addictive substances may also present acutely. Alcohol withdrawal may result in blackouts, tremor, hallucinations, delirium and seizures. Pyrexia, nausea and vomiting, diarrhoea and abdominal pain, tachycardia and hypertension are also common. They differ somewhat in their actions due to differing lipid solubilities, routes of intake, metabolic pathways and different ratios of stimulant and depressant effects. Infections Drug abuse is often associated with poor diet, poor hygiene and generalized immunosuppression. Intravenous substance use predisposes to endocarditis, hepatitis and septicaemia (which may be fungal). Aspiration pneumonitis, subdural haematomata and rhabdomyolysis with acute renal failure are further examples of acute complications of substance abuse. Poor venous access is common in intravenous substance users and this may cause difficulty during emergency situations (drug induced or pregnancy related). Femoral nerve neuropathy may result from frequent trauma during injection into the femoral vein. Obstructive and restrictive pulmonary lesions may occur, as can pulmonary hypertension. Alcohol consumption is closely related to smoking and caffeine use (coffee drinking), both of which have stronger causative relationships with miscarriage. This association is not, on the whole, confirmed in European and Australian studies, where greater effort has been made to control for confounding factors. There is no good evidence to suggest that the other substances discussed in this chapter cause miscarriage. Teratogenicity the only confirmed teratogen amongst this group of substances is alcohol. Although plausible biological explanations exist for why substances of abuse might cause these problems, the exact contribution from the drugs themselves is very difficult to isolate from the confounding factors such as smoking, poor nutrition and general health, lack of antenatal care and low socioeconomic status. Most attention has been paid to the effect of alcohol on miscarriage rates, and large quantities have been shown to have abortive properties in animal experiments. These figures are altered by socioeconomic status, general health, smoking and possibly ethnicity, which all act as confounding factors. Obstetric problems 131 the relationship between benzodiazepine use in the first trimester and congenital anomalies, most notably cleft lip and palate, has been examined many times. The cohort studies could not significantly link benzodiazepine use with any fetal abnormalities. The casecontrol studies, however, gave a 3-fold increase in risk for all major anomalies and an odds ratio of 1. They suggest detailed scanning for those pregnancies exposed in the first trimester.

Syndromes

• Terrorism or mass disaster
• Your lung on this side will be deflated so that air will not move in and out of it during surgery. This makes it easier for the surgeon to operate on the lung.
• Stools that are pale or clay colored, foul smelling, have mucus, or that float
• Abdominal cramps
• Blood type problems (Rh and ABO)
• One or more small tubes in a vein (IV line) to give fluids and medicines.
• Niemann-Pick disease
• Fluid within the retina
• History of cancer

The cost medicine 512 order cheap oxybutynin on line, success rate medications japan travel buy genuine oxybutynin line, complications and benefits must be assessed in every case individually treatment of uti safe 5 mg oxybutynin. In centres where appropriate expertise is available symptoms walking pneumonia cheap oxybutynin 5 mg line, it may be considered as a treatment option medicine hat mall discount oxybutynin 2.5 mg otc. Once tubal surgery is being contemplated medicine 3d printing buy oxybutynin visa, careful assessment of the tubes and pelvis with hysterosalpingography and laparoscopy should be carried out [E]. Laparoscopic surgery is less costly and offers less morbidity, more technical advantages and a marginally better pregnancy rate. If the tubes remain patent, ovulation should be assessed and perhaps a short period of ovulation induction could be tried. The key issues here are to present the couple with all the available facts and to involve them in the decision-making process. Selective salpingography and tubal cannulation these procedures can be carried out under image intensification or at hysteroscopy. These methods were originally developed for diagnostic purposes, but were subsequently proven to be useful in treating proximal tubal damage, for which surgery yielded disappointing success rates. The outcome of these procedures in terms of regaining tubal patency is immediately known. Management of anovulatory infertility A number of therapeutic interventions for the induction of ovulation are available. Patients with ovarian failure and resistant ovary syndrome will not respond to ovulation induction and should be offered oocyte donation [C]. Normalization of body weight in underweight and obese patients can help to regain ovulation without the need for medical intervention [B]. Additionally, women undergoing treatment with clomifene citrate should be offered ultrasound monitoring during at least the first cycle of treatment to ensure that they receive a dose that minimizes the risk of multiple pregnancy. Although pregnancies resulted, the operation (performed by laparotomy) led to complications, including tubal damage and adhesion formation, and fell into disrepute. Ovarian drilling involves focal local destruction of the ovarian stroma with laser or diathermy, applied laparoscopically. Ovarian drilling achieves equivalent ovulation and pregnancy rates to medical ovulation induction. On the other hand, the long-term advantages and risks of ovarian drilling require further assessment. Destroying ovarian tissue inevitably leads to destruction of primordial follicles and reduction of the ovarian reserve. These anxieties have partially been resolved by studies that demonstrate that a good therapeutic response can be achieved by minimal application of energy and after reduction of the number of diathermy burns to 4 per ovary. Management of endometriosis-related infertility this depends on the severity of the condition and the presence of any other infertility factors. Medical treatment of minimal and mild endometriosis does not enhance fertility in infertile women and should not be offered [A]. Women with minimal or mild endometriosis who undergo laparoscopy should be offered surgical ablation or resection of endometriosis plus laparoscopic adhesiolysis because this improves the chance of pregnancy [A]. As many infertile patients will undergo diagnostic laparoscopy, diathermy to endometriosis can be delivered at the same session, alleviating the need for a further anaesthetic. Women with moderate or severe endometriosis should be offered surgical treatment because it improves the chance of pregnancy [B]. Assisted reproduction has lent itself to treating endometriosis-related infertility. Approximately 60 per cent of couples with unexplained secondary infertility (diagnosed after one year) achieve a pregnancy within three years of conservative management [C]. Management of uterine factor infertility Congenital defects, leiomyomas and intrauterine adhesions and polyps are the only treatable uterine factors. Myomectomy can be carried out either laparoscopically or by laparotomy with similar postoperative pregnancy rates [A]. Entry into the uterine cavity should be avoided if possible, and adhesion barriers Reproductive medicine Management of unexplained infertility the lack of an identifiable reason for infertility in this category makes the treatment empirical. Conservative management, ovulation induction with or without intrauterine 610 Female infertility and microsurgical technique should be used to reduce the risk of post-operative adhesions. The risk of a scar rupture during pregnancy is less if the endometrial cavity remains intact at myomectomy [D], although some fibroids cannot be removed without breach of the cavity. Submucous fibroids can successfully be resected hysteroscopically, depending on the size of the fibroid and its degree of protrusion into the uterine cavity. The risk of tubal damage with this procedure is minimal, but there is a risk of haemorrhage, uterine perforation and endometrial scarring leading to intrauterine adhesions. Hysteroscopic division of intrauterine adhesions and excision of polyps are usually straightforward, with low morbidity. There is no evidence that thorough physical examination of every patient is necessary. The post-coital test is of limited value with regard to discriminating between couples achieving and not achieving a pregnancy. Drug treatment is ineffective in the treatment of endometriosis-related infertility. Around 9 per cent of couples are affected by infertility and half of them seek help. Delaying starting a family until later life does not only reduce fertility, but also increases the risk of miscarriage. Careful history taking is a very important starting point to the investigation of infertility. The mid-luteal phase is approximately 7 days from the next menstrual cycle, which is important when measuring serum progesterone levels for ovulation detection. Combining laparoscopy and dye test with electrocoagulation of minimal and mild endometriosis adds a therapeutic dimension to a diagnostic procedure. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. The pathogenesis of testicular dysfunction is poorly understood, with no obvious predisposing factors being identifiable in more than 50 per cent of cases. Mumps orchitis and severe epididymo-orchitis are the main inflammatory causes of testicular damage [D]. In other words, any man with motile normal spermatozoa in his ejaculate should be credited with some degree of fertility. Women undergoing donor insemination treatment have a higher probability of pregnancy if they are partners of azoospermic men than if they are partners of oligozoospermic men. This reflects that a degree of compensation can exist between the female and male partners. Accordingly, in most circumstances, it is easier to define male fertility than infertility. There are many causes of male infertility, although primary testicular disorders are most commonly responsible. Obstructive male infertility Obstruction can occur at any level of the male reproductive tract from the rete testis and the epididymis to the vas deferens. Congenital absence of the vas is also fairly common, being the cause of azoospermia in approximately 10 per cent of cases [D]. Bilateral congenital absence of the vas is seen in carriers of genes for cystic fibrosis [C], and pre-treatment screening of both partners is essential to avoid the possibility of cystic fibrosis in the offspring. The more common conditions seen in this category include hypogonadotrophic hypogonadism, thyroid and adrenal disease [D]. Although rare, these conditions should be diagnosed, as their treatment is straightforward and can restore fertility. Hyperprolactinaemia in men can lead to impotence, but has little effect on sperm production [C]. Autoimmune causes Approximately 12 per cent of men have anti-sperm antibodies [C]. This can lead to decreased sperm motility and may impede the binding of the spermatozoon to the zona pellucida of the oocyte, hindering fertilization. Low levels of antisperm antibodies are not thought to have a significant impact on fertility [D]. The reason why some men develop antisperm antibodies is not known, although damage to the testis following trauma and surgery can be found in many cases. It occurs in both fertile and infertile men, although the incidence seems to be higher among infertile men [C]. Increased testicular temperature (which is unfavourable for spermatogenesis) has been suggested as a mechanism of action in these cases, but surgical or radiological correction of the disorder is not thought to improve the chances of conception [A]. Ejaculatory disorders Retrograde ejaculation, in which sperm enter the bladder rather than the penile urethra at ejaculation, can follow from neurological disorders, diabetes or bladder neck or prostate surgery. Failure of ejaculation due to neurological disorders, medication or psychological difficulties is a rare cause of male infertility. Drugs Drugs taken for medicinal and recreational purposes can affect sperm production and/or function. Alcohol, cigarettes, opiates and marijuana can suppress spermatogenesis and affect sperm function [D]. Anabolic steroids, antifungal drugs, sulfasalazine, corticosteroids and other classes of drugs also affect spermatogenesis. Other drugs, including antidepressants, sedatives and antihypertensives, can lead to male infertility by causing erectile dysfunction. A normal result can provide a degree of reassurance to the male partner, and erectile and ejaculatory problems can usually be excluded by a sensitively taken medical history. If the seminal parameters are abnormal, further investigations should be instigated. It is important to elicit from the history any of the causes of male infertility mentioned above. This should be followed by examination of genital development, the testicles, the epididymis and the vas deferens. Any of the aforementioned reversible causes can usually be corrected, and advice regarding smoking, alcohol and substance abuse should be given. Testicular cooling by wearing boxer shorts or taking cold baths is probably of little value, although occupational exposure to extreme heat should be avoided. Evidence for the extent of the effects of environmental toxins on male fertility is lacking. Although epidemiological studies have demonstrated a decline in sperm quality in the developed world, it is difficult to extrapolate from this population-based data to individual cases. However, it seems sensible to advise the avoidance of excessive heat and exposure to chemicals such as paints, organic solvents, lead-based products and pesticides in oligospermic/asthenospermic subfertile men. Semen analysis the value of a diagnostic test depends on its sensitivity (ability to identify disease), specificity (ability to identify normality) and reproducibility (obtaining similar results each time the test is carried out). The wide overlap of the results of the various components of a semen analysis between fertile and infertile men reduces the sensitivity and specificity of routine semen analysis as a test of infertility. Dilatation occurs when valves within the veins along the spermatic cord obstruct normal blood flow, causing a back flow of blood. The test assesses several measures of sperm quality, some of which are more sensitive in identifying infertile men than others. Several population-based studies have produced statistical correlation between the different semen parameters and fertility potential in men. These include biochemical analysis of the seminal fluid and detection of anti-sperm antibodies. Biochemical analysis of the seminal fluid can provide information about the prostate, seminal vesicles and epididymis. Zinc, fructose, carnitine and acid phosphatase have all been studied, but are not thought to impart useful diagnostic or prognostic information. Other tests Unexplained severe sperm abnormality including azoospermia merits further investigation. The objectives of such tests are to identify whether azoospermia is due to a primary testicular disorder or an outflow obstruction. Karyotyping and cystic fibrosis gene screening are necessary if a chromosomal abnormality is suspected or to assess the carrier status for cystic fibrosis genes in patients with congenital absence of the vas. Sperm function tests the functions of the sperm in vivo are to negotiate the cervical mucus, reach the ampullary part of the Fallopian tube in Table 52. Data from assisted reproduction suggest that fertilization rates drop if sperm morphology falls below 15% of the normal forms. The objectives of the general examination are to assess the level of masculinization and to detect any stigmata of chromosomal abnormality, inguinal hernia or relevant surgical scars, gynaecomastia or evidence of systemic illnesses. The genital examination should include assessment of the testes, epididymis and vas deferens and detection of any scrotal swellings or varicocele. If the history suggests penile or prostatic problems, it is advisable to refer for a urological opinion. The examination should be carried out in standing and supine positions in a warm private room. The testicular axis, volume and consistency should be assessed with a Prader orchiometer to measure the testicular volume.

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