Wilbert S. Aronow, MD

• Department of Medicine
• Division of Cardiology
• New York Medical College
• Westchester Medical Center
• Valhalla, NY

If maternal sensitization of an Rh-negative woman to red blood cell antigens has occurred antibiotic resistance epidemic generic chloramphenicol 500 mg without prescription. The antibody screen is also essential for Rh-positive women because other blood group antigens bacteria del estomago helicobacter pylori generic 250 mg chloramphenicol with mastercard. B Syphilis test (venereal disease research laboratory) Syphilis involves several different stages antimicrobial and antifungal cheap 500 mg chloramphenicol free shipping, and the evaluation of each stage is important in assessing fetal risk antibiotic news best 500 mg chloramphenicol. A late abortion (after the fourth month of pregnancy) Identification of the High-Risk Pregnant Patient 51 3 treatment for dogs with fits order 500 mg chloramphenicol mastercard. A congenitally infected infant C Gonorrhea culture Screening may be either universal or selective, depending on the prevalence of the disease in the patient population. Intrauterine infection, with premature rupture of membranes and preterm delivery 2. Associated maternal arthritis, rash, or peripartum fever D Chlamydia testing Screening is recommended for all high-risk or symptomatic patients. The clinical course of rubella is no more severe or complicated in the pregnant woman than in the nonpregnant woman of comparable age. Maternal infection in the first trimester carries with it the greatest risk to the fetus. If a patient is diagnosed as having a rubella titer of less than 1:8, she should be immunized postpartum. The rubella vaccine is not given during pregnancy because it is a live attenuated vaccine. There have been no reported cases of congenital rubella from inadvertent administration of the vaccine to pregnant women. Microcytosis without anemia may represent a thalassemia and should also be investigated. A mild leukocytosis is normal in pregnancy; however, a grossly abnormal value needs to be evaluated. Asymptomatic bacteriuria predisposes the pregnant woman to the development of acute systemic pyelonephritis, which has serious complications for the mother and fetus and has been associated with premature labor and delivery. Systemic pyelonephritis develops in approximately 20% to 40% of pregnant women with untreated asymptomatic bacteriuria. Individualized counseling should be offered to patients to determine the best screening strategy and the need for further invasive testing in the form of chorionic villi sampling or genetic amniocentesis. First-trimester screening programs should be instituted to identify seropositive women (0. The neonates of women who test positive can then be treated with passive and active immunoprophylaxis. The rate of mother-to-infant transmission has been estimated to be 20% to 30%, regardless of maternal symptoms. Babies can be infected in utero, at the time of delivery, and postpartum via contaminated breast milk. N Hemoglobin electrophoresis this screen is indicated in all patients at the first prenatal visit. It will help in identifying hemoglobinopathies such as sickle cell disease that can increase the risk for poor obstetrical outcome. A Once an at-risk patient has been identified, a management plan is implemented to prevent adverse outcome; this plan may be empiric or schematic. The obstetrician decides on the specific management plan on a patient-by-patient basis. The obstetrician implements a specific, predetermined management scheme every time a risk factor is identified. Table 5­3 represents an example of a schematic risk factor management protocol on the basis of the past obstetric history. B To date, no studies compare empiric versus schematic risk factor management with regard to outcome, although a schematic approach is arguably more scientific. She delivered three healthy boys by vaginal delivery at ages 17, 23, and 27 years, respectively. She incurred a third-degree laceration after extension of a midline episiotomy upon delivery of her third boy. Her past medical history is unremarkable other than three to four asthma exacerbations every month. Her risk of which of the following is most increased in a subsequent pregnancy, as compared to her prior pregnancies A Asthma exacerbation B Fourth-degree laceration C Low-birth-weight infant D Twins E Uterine dysfunction 2. A 34-year-old primiparous woman is seeing you because she is considering a second pregnancy. She tells you she is afraid to get pregnant given the outcome of her first pregnancy. Had a second-trimester multiple marker screen been performed, which of the following results would have been helpful A 28-year-old woman, gravida 6, para 1, presents to your office because she tested positive on her home pregnancy test. She delivered a preterm infant with her very first pregnancy at the age of 17 years. Her subsequent pregnancies have been complicated by three miscarriages and an ectopic pregnancy. She denies any medical problems but admits contracting chlamydia during her late teens (which she sought treatment for). She delivered her first baby by cesarean section due to nonreassuring fetal heart rate pattern on the fetal monitor. Her second baby was also delivered by cesarean section because she did not want a trial of labor. You obtain operative records of her cesarean sections, which show a Pfannenstiel skin incision and low classical type of incision of the uterus. A Vaginal delivery is not recommended because the risk of uterine rupture approaches 8% B Vaginal delivery is recommended because the risk of uterine rupture is less than 1% C Vaginal delivery is not contraindicated with a history of two previous cesarean sections D Vaginal delivery is a possibility, but risk of rupture is between 0. Her past medical history is significant for two episodes of pyelonephritis with her first two pregnancies, as well as a partial bicornuate uterus. What in her history places her at greatest risk for preterm delivery with this pregnancy A Age B Delivery history C Therapeutic abortions D Pyelonephritis E Uterine anomaly 6. Her first pregnancy was complicated by delivery of a premature infant with respiratory problems. Her past medical history is remarkable for severe asthma (more than 20 exacerbations per week) for which she uses albuterol and steroid inhalers. Which of the following predisposes her to delivery of an infant with congenital anomalies A Weight B Liver disease C Diabetes mellitus D Hypertension E Intravenous drug history 56 Chapter 5-Answers and Explanations Answers and Explanations 1. Maternal age older than 35 years is a risk factor for multiple gestation, especially dizygotic. The effect of pregnancy on lung diseases is unpredictable; therefore, you cannot assume that her mild asthma will worsen. A third-degree laceration does not necessarily lead to a fourth-degree laceration in a subsequent pregnancy. Laceration degrees depend on obstetric factors, such as size of the baby and length of a midline episiotomy. Teenage pregnancies are at risk for delivery of low-birth-weight infants and uterine dysfunction. It is a screening test that can identify up to 80% of pregnancies with Down syndrome. The most important initial step in a patient with a history of an ectopic pregnancy and possible pelvic inflammatory disease history (history of chlamydial infection) who may be pregnant is to perform an obstetric ultrasound to rule out another ectopic pregnancy and to rule in an intrauterine pregnancy. In this patient who has regular cycles and is 12 days late, an intrauterine gestation should be visible on transvaginal ultrasound. Anticardiolipin antibodies may be helpful in the future along with other parameters if the patient is interested in delineating the cause of her recurrent spontaneous abortions. Chlamydia antibody levels are not necessary because you already know that the patient has had a chlamydial infection in the past. A classical uterine incision (vertical uterine incision through the muscular portion of the uterus) is a contraindication to a trial of labor and vaginal delivery with a subsequent pregnancy. Women with one previous cesarean section are candidates for a vaginal delivery with a subsequent pregnancy, especially if the reason for having the initial cesarean section is nonrepetitive. Currently, not enough data are available to establish the safety of a trial of labor with two or more previous transverse uterine scars. A history of two previous preterm deliveries is the strongest risk factor for spontaneous preterm delivery with a subsequent pregnancy. Premature birth is a risk factor with teenage pregnancies, not advanced maternal age pregnancies. Therapeutic abortions, pyelonephritis, and uterine anomalies are all significant risk factors for spontaneous preterm delivery. Pregestational diabetes may increase the risk of birth defects by a factor of three. The patient with diabetes should be counseled extensively with the aim of achieving good sugar control prior to conception in an attempt to reduce the number of birth defects. A previous history of intravenous drug use is not significant enough to contribute to congenital anomalies during a current pregnancy. Asthma, hypertension, and liver disease do not increase baseline malformation rate. A diagnostic test is one where a condition is identified with a "yes" or a "no" answer. Diagnostic tests are usually offered to those with a high risk for a disease, while those at low risk may opt for a screening test before pursuing diagnostic testing. The incidence of a condition, the sensitivity, specificity, and cost of a test and the risk of a procedure are among the factors that can influence the decision to pursue diagnostic versus screening tests. In pregnancy, patients are often stratified in to low- or high-risk categories to determine what type of testing they should be offered to ensure the best outcome of their pregnancy. While prenatal testing cannot identify every abnormality a fetus could have, prenatal testing is usually divided in to assessment of fetal structure and assessment for genetic abnormalities which may also entail structural abnormalities. A detailed history of the patient, including her age, ethnicity, prior family and obstetrical history (particularly a prior affected child), history of medical conditions, or drug exposures that may impact upon fetal development. Genetic counseling from trained counselors assesses the risks of having a child with a genetic condition or a congenital birth defect and assists the parents in making a decision regarding disease carrier state detection for parents or fetus, prenatal screening and diagnosis, options regarding pregnancy termination, contraception, adoption, and assisted reproductive techniques. Presence of ultrasound abnormalities will potentially increase the risk of chromosomal, syndromic, or structural abnormalities. Genetic screening tests will be reassuring if they predict low risk for a pregnancy while abnormal findings convey high-risk status and may lead to diagnostic testing. The baseline rate of congenital structural abnormalities is 2% to 3% for the general population (low risk). In general, invasive prenatal diagnostic tests are offered when the risk of having an affected pregnancy is greater than the risks of the procedure, specifically miscarriage. However, in the United States, all reproductive aged women can elect for amniocentesis if desired, including women at low risk for chromosomal abnormalities. While some genetic carrier screening tests are offered to the general population, such as cystic fibrosis, other may only be offered to those of select backgrounds, for example, Tay­Sachs testing in the Ashkenazi Jewish population. Previously, amniocentesis and diagnostic testing were reserved only for those with high risk for aneuploidy including those aged 35 years and more at delivery (Table 6­1). Several options for screening for aneuploidy are available and the decision to pursue a specific test is based upon gestational age and the ability to obtain the appropriate ultrasound measurements. This is commonly offered when patients enter prenatal care at 14 weeks or later and miss the earlier first-trimester window. Contingent sequential screen-if the first-trimester portion shows low risk, the patient will have completed her screening; if the first-trimester risk is elevated, invasive diagnostic testing will be recommended; if the first-trimester risk falls in an intermediate zone then the secondtrimester part of the screen is performed. Maternal serum marker screening is not as accurate for twins and is unavailable for triplets. It is difficult to know how much each fetus/placenta directly contributes to serum markers in maternal blood. Both parents should be tested ideally; and usually all mutations cannot be identified. Screening can be offered to all parents regardless of ethnicity, but should be offered when familial history is positive for cystic fibrosis and to all couples when both partners are of Caucasian, European, or Ashkenazi Jewish ancestry. The most common mutation is the -F508, which accounts for approximately 70% of mutations found in Caucasians. Most laboratories screen for 25 mutations, which account for more than 80% of mutations found in Caucasians; more than 90% mutations can be found in the Ashkenazi Jewish population. Hemoglobin A has two -chains and two -chains and makes up 95% of adult hemoglobin. Hemoglobin F has two -chains and two -chains and makes up the remainder of adult hemoglobin. All people of African descent should undergo carrier screening for sickle cell with a hemoglobin electrophoresis. In the deoxygenated state, hydrophobic bonds are formed, which cause red blood cell distortion, or sickling. Patients of Southeast Asian or Mediterranean descent should be offered carrier screening with a complete blood count. The carrier rate is 1 in 30 in Ashkenazi Jews and 1 in 300 in those of non-Jewish descent. Carrier screening should be offered if there is a positive familial history, to couples where both members are of Ashkenazi Jewish, French-Canadian, or Cajun descent, and in some cases when only one member is of high-risk descent. Canavan disease results from a deficiency of the aspartoacyclase enzyme affecting the central nervous system with developmental delay, hypotonia, seizures, resulting in early death. Familial dysautonomia leads to difficulties with feeding, sweating, blood pressure control, pain, and temperature insensitivity; the carrier rate is 1:32. Spinal muscular atrophy is a recessive condition that impacts the spinal motor neurons, leading to weakness and muscle atrophy.

Isoflavones are found in soya beans and chickpeas antimicrobial killing agent purchase chloramphenicol 500 mg on line, lignans particularly in oilseeds antibiotics and pregnancy buy cheap chloramphenicol on line. Herbal remedies include black cohosh antibiotic resistance worldwide order generic chloramphenicol online, kava kava antibiotics for acne flucloxacillin purchase chloramphenicol 500 mg on-line, evening primrose antibiotics for uti flagyl cheap chloramphenicol 500 mg visa, dong quai, gingko, ginseng and wild yam cream. Progesterone transdermal creams have not been proven to be effective for menopausal symptoms or skeletal protection, and are not protective of the endometrium. London: Royal Society of Medicine Press Ltd and British Menopause Society Publications Ltd, 2009. All pharmacological interventions except for parathyroid hormone and strontium ranelate act mainly by inhibiting bone resorption. Information on prevention in perimenopausal women or those with premature ovarian failure is scant. Bisphosphonates remain in bone for many years, may affect the fetal skeleton and are not advised in women desiring pregnancy. Expensive, they are reserved for severe osteoporosis in those unable to tolerate or unresponsive to other treatments. Given by subcutaneous injection every 6 months it reduces the risk of fractures in post-menopausal women with osteoporosis. It is most useful where oral bisphosphonates are contraindicated or with malabsorption. Calcium and vitamin D supplements are useful if insufficiency exists, especially in the elderly. However, the effects on fractures are contradictory, and in women whose the Menopause and Post-Reproductive Health 117 the Menopause at a Glance Definition Median age Perimenopause Features the last menstrual period 51 years. Mitotic division occurs as the zygote is swept toward the uterus by ciliary action and peristalsis. Tubal damage will impair movement and render tubal implantation and ectopic pregnancy more likely. The zygote normally enters the uterus on day 4, at the multicellular morula stage. Its outer layer becomes trophoblast, which will form the placenta, and from the sixth to twelfth day, this invades the endometrium to achieve implantation. Fifteen per cent of embryos are lost at this stage though this is too early to be considered a miscarriage. On the endometrial surface of the embryo, this villous system proliferates (chorion frondosum) and will ultimately form the surface area for nutrient transfer, in the cotyledons of the placenta. Spontaneous miscarriage Definition and epidemiology the fetus dies or delivers dead before 24 completed weeks of pregnancy. Types of miscarriage Threatened miscarriage: There is bleeding but the fetus is still alive, the uterus is the size expected from the dates and the os is closed. Incomplete miscarriage: Some fetal parts have been passed, but the os is usually open. Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed. Vaginal loss is usually offensive, the uterus is tender, but a fever can be absent. Missed miscarriage: the fetus has not developed or died in utero, but this is not recognized until bleeding occurs or ultrasound is performed. If there is doubt, the scan should be repeated a week later as non-viable pregnancies can be confused with a very early pregnancy, especially where the date of the last menstrual period is uncertain or periods irregular. Clinical features History: Bleeding is usual unless a missed miscarriage is found incidentally at ultrasound examination. Examination: Uterine size and the state of the cervical os are dependent on the type of miscarriage. This helps differentiate between ectopic and viable intrauterine pregnancies when no intrauterine gestation sac is visible on scan. Non-viable intrauterine pregnancy Management Admission is necessary if ectopic pregnancy is suspected, if the miscarriage is septic or there is heavy bleeding. Products of conception in the cervical os cause pain, bleeding and vasovagal shock and are removed via a speculum using polyp forceps. Intramuscular ergometrine will reduce bleeding by contracting the uterus, but is only used if the fetus is non-viable. If there is a fever, swabs for bacterial culture are taken and intravenous antibiotics are given. Expectant management can be continued as long as the woman is willing and there are no signs of infection. Medical management is with prostaglandin (oral, sublingual or vaginal) sometimes preceded by the oral antiprogesterone mifepristone. Evacuation is suitable if the woman prefers it, if there is heavy bleeding or signs of infection (performed under antibiotic cover). Risks of expectant and medical management include the need for surgical evacuation Ninety per cent of women in whom fetal heart activity is detected at 8 weeks will not miscarry. If infection becomes systemic, endotoxic shock occasionally ensues, with hypotension, renal failure, adult respiratory distress syndrome and disseminated intravascular coagulation. Counselling after miscarriage Patients should be told that the miscarriage was not the result of anything they did or did not do and could not have been prevented. Because miscarriage is so common, further investigation is usually reserved for women who have had three miscarriages. Parental karyotyping is therefore usual and translocations may be found leading to an increased proportion of chromosomally imbalanced sperm or oocytes, and therefore embryos. Referral to a clinical geneticist allows for full explanation of the findings and a discussion regarding karyotyping of other family members who may have inherited the same rearrangement. Anatomical factors: Uterine abnormalities are diagnosed with ultrasound (or hysterosalpingogram though this is more invasive). Many, however, are incidental findings and surgical treatment could lead to uterine weakness or adhesion formation. Legislation about abortion varies throughout the world, can vary within different states of an individual country and is illegal in some countries. The statutory grounds for termination of pregnancy in England are detailed in the box. However, abortions after 24 weeks are allowed if there is grave risk to the life of the woman, evidence of severe fetal abnormality or risk of grave physical and mental injury to the woman. Such later terminations are usually only performed where a fetal abnormality is present. Blood tests should be taken for haemoglobin, blood group and rhesus status and testing for haemoglobinopathies as indicated. Multiple surgical abortions are Disorders of Early Pregnancy 123 associated with an increased risk of subsequent preterm delivery (p. Psychological sequelae are common but may also reflect underlying problems before the termination. Promoting the knowledge of, and access to , effective contraception reduces the need for pregnancy termination. The thin-walled tube is unable to sustain trophoblastic invasion: it bleeds in to its lumen or may rupture, when intraperitoneal blood loss can be catastrophic. The ectopic can also be naturally aborted either within the tube or extruded through the fimbrial end. Aetiology Often no cause is evident, but any factor which damages the tube can cause the fertilized oocyte to be caught. Assisted conception and pelvic, particularly tubal, surgery are additional risks as is having had a previous ectopic and being a smoker. Abnormal vaginal bleeding, abdominal pain or collapse in any woman of reproductive age should all arouse suspicion and a urine pregnancy test should be performed. Increasing numbers of women are now diagnosed early and when asymptomatic, because of routine ultrasound. History: Usually, lower abdominal pain is followed by scanty, dark vaginal bleeding. The pain is variable in quality, often initially colicky as the tube tries to extrude the sac and then constant. Examination: Tachycardia suggests blood loss, and hypotension and collapse occur only in extremis. On pelvic examination, movement of the uterus may cause pain (cervical excitation) and either adnexum may be tender. The uterus is smaller than expected from the gestation and the cervical os is closed. Modern urine pregnancy tests are very sensitive and are positive even before the day of the missed period. Ultrasound (preferably transvaginal) does not always visualize an ectopic pregnancy. Caution is still required as, particularly with assisted conception, an intrauterine and an ectopic pregnancy can occasionally coexist (heterotopic pregnancy). Acute presentations If the patient is haemodynamically unstable expedient resuscitation and surgery is required. Laparoscopy may be suitable for experienced operators but laparotomy is often performed. If the contralateral tube appears normal then the subsequent intrauterine pregnancy rates are similar between salpingostomy or salpingectomy. They must have clear information on warning signs and be within easy access to the hospital treating them. Subacute presentations Hyperemesis gravidarum Definition and epidemiology Hyperemesis gravidarum is when nausea and vomiting in early pregnancy are so severe as to cause severe dehydration, weight loss or electrolyte disturbance. Surgical management: Laparoscopy is standard and is preferable to laparotomy because recovery is faster and subsequent fertility rates are equivalent or better. At laparoscopy, the ectopic is either removed from the tube (salpingostomy) or a salpingectomy is performed. Management Predisposing conditions, particularly urinary infection and multiple or molar pregnancy, are excluded. Psychological support is essential, particularly as many of these women have social or emotional problems. Gestational trophoblastic disease Definitions, pathology and epidemiology In this, trophoblastic tissue, which is the part of the blastocyst that normally invades the endometrium, proliferates in a more aggressive way than is normal. Proliferation can be localized and non-invasive: this is called a hydatidiform mole. Hydatidiform mole can be subdivided in to complete and partial mole based on genetic and histopathological features. A complete mole is entirely paternal in origin, usually when one sperm fertilizes an empty oocyte and undergoes mitosis. Complications Recurrence of molar pregnancy occurs in about 1 in 60 subsequent pregnancies. Low-risk patients receive methotrexate with folic acid, whereas higher risk patients receive combination chemotherapy. If a uterine septum is present this can be resected up to the fundus of the cavity. The complications of uterine perforation and fluid overload are unusual with experienced surgeons. Sterility is not ensured so sometimes a laparoscopic tubal sterilization is performed at the same time. Endometrial roller-ball diathermy, laser ablation or heating with an intrauterine hot balloon or microwave probe produce similar effects and may be safer but, because no specimen is produced, prior biopsies are essential. Endoscopy and endoscopic surgery Diagnostic hysteroscopy the uterine cavity is inspected with a rigid or flexible hysteroscope passed through the cervical canal. This can be performed without anaesthetic, or with a cervical local anaesthetic block or under general anaesthetic. Diagnostic laparoscopy the peritoneal cavity is insufflated with carbon dioxide after carefully passing a small hollow Veress needle through the abdominal wall. This enables a sharp trocar to be inserted through the umbilicus with less risk of damaging organs or major blood vessels. A laparoscope is then passed down the trocar to enable visualization of the pelvis. Hysteroscopic surgery An operating hysteroscope is used in which small instruments are passed down a parallel channel. Laparoscopic surgery Instruments to grasp or cut tissue are inserted through separate ports in the abdominal wall. The advantages are better visualization of tissues, less tissue handling, less infection, reduced hospital stay and faster postoperative recovery with less pain. Specific indications include malignancy (ovarian and endometrial, in conjunction with a full laparotomy), a very large or immobile uterus and when abdominal inspection is required. This reduces the risk of damaging the ureters or bladder since less extensive dissection is required. However, the patient will need to continue with regular cervical smears, so is inappropriate if there is a history of abnormal smears. Some will continue to have menstrual spotting from small amounts of endometrium remaining in the cervical canal. The specific indication is uterine prolapse, but absence of prolapse and moderate enlargement are not contraindications in experienced hands. A subtotal hysterectomy can be performed laparoscopically and the uterine body removed from the peritoneal cavity with a morcellator instrument. This is a diagnostic procedure and inferior to hysteroscopy because the cavity is not inspected. It is used to stage apparently early cervical carcinoma and is sufficient treatment for Stage 1a(i) disease. One end of the mesh is attached to the cervix and the other to the anterior longitudinal ligament over the sacrum. The theoretical advantages of this operation over hysterectomy, as well as preservation of fertility, are a stronger repair, with less risk of recurrent prolapse.

This anomaly is very rare but can be associated with other defects including on imperforate anus virus protection free download cheap 250 mg chloramphenicol with mastercard, coarctation of the aorta antimicrobial cleaner order discount chloramphenicol online, atrial septal defect antibiotic resistance newspaper article generic chloramphenicol 500 mg without a prescription, bicornuate uterus antibiotic macrobid cheap 500 mg chloramphenicol free shipping, and lumbar spine malformations antibiotics for urinary retention proven chloramphenicol 250 mg. The septum can also have a microperforation allowing egress of menstrual blood and presents as a shortened vagina with no visible cervix. Transverse vaginal septum presents as cyclic, sporadic, or chronic pelvic pain in the absence of menstruation. Physical examination can reveal a palpable pelvic pass if the obstruction is low in the vagina and there is a large hematocolpos, but genital examination does not usually reveal any bulge at the introitus as the obstruction is usually higher. Diagnosis is often delayed as pain symptoms in absence of menarche are usually attributed to causes other than gynecologic. Management involves surgical excision of the septum by vaginal approach, with anastomosis of upper and lower vaginal canals. A z-plasty technique is favored to avoid an annular stricture at the anastomosis site, and postoperative dilators are used to decrease stricture formation. Complete cervical agenesis can occur with a normal vagina or in conjunction with complete vaginal agenesis. Clinical manifestations include typically a presentation at the age of menarche with primary amenorrhea, and cyclic or even chronic pelvic pain. Development of pain is sooner to menarche than seen with transverse vaginal septum or imperforate hymen. Management has traditionally involved removal of uterus as attempts to preserve the uterus and fertility by creating a fistulous tract between the vagina and the uterus have been complicated by multiple surgeries to maintain patency of the connection, infection, and even death. Recently, however, surgical anastomosis of the vagina to the uterus has been performed with some success in selected individuals to preserve fertility. There is an absent or hypoplastic vagina and absent or abnormal müllerian structures. If there is functional endometrium within the remnant uterus, then the patient will have cyclic or chronic pain. Diagnosis is made by clinical examination showing normal breast, pubic and axillary hair development, and blind vagina. Many of these young females feel they are not "normal" and counseling can help overcome feelings of inadequacy. This can be accomplished by nonsurgical dilation techniques which is the preferred method. Surgical options include McIndoe technique using skin graft placed in a surgically created space between the bladder and rectum, Vecchietti procedure, or the Davidoff procedure. Creating a neovagina using a portion of sigmoid colon is less commonly recommended. As the body does not respond to androgens, these individuals are phenotypically female, but lack internal female reproductive structures. Examination reveals normal appearing external female genitalia, blind vagina, and absence or sparsity of pubic and axillary hair. Breast development is normal, as the androgens produced by the testes are aromatized to estrogens leading to breast development. The presentation can also be during childhood with testes present within inguinal hernias. The diagnosis should be considered in any young female presenting with inguinal hernia or labial mass. Some are advocating leaving the gonads in place and monitoring for development of gonadoblastoma, but this is not standard. Dosage is higher than for a postmenopausal woman to promote bone growth and secondary sexual characteristics. Fertility treatment is not possible as there are no oocytes, nor a uterus to carry a pregnancy. The female phenotype is similar to the patient with complete androgen insensitivity, but generally exhibits differing degrees of ambiguous genitalia axillary/ pubic hair at puberty. The male phenotype, exhibited in Reifenstein syndrome, is infertile and typically includes hypospadias and bifid scrotum. There is also a range of external genitalia from microphallus with a normal urethra, to the creation of a pseudovagina and lack of scrotal fusion. These males typically have gynecomastia and normal pubic and axillary hair but no chest or facial hair. However, some surgical procedure is often performed to modify the ambiguous genitalia to facilitate gender assignment. In the presence of this defective gene, gonads do not differentiate in to testes, and no testosterone or antimüllerian hormone is produced. Clinical manifestations include an externally female appearance, with nonfunctioning gonads. Therefore, girls often present with delayed puberty, both lack of menstruation and failure of secondary sex characteristics development, such as breast development. Diagnosis can be suspected in the setting of delayed puberty, with elevation in measured gonadotropins. This suggests that the pituitary is functioning normally, but the gonads are not responding. Hormonal supplementation for initiation of puberty with estrogen alone, followed by addition of progesterone to facilitate regular menstruation as uterus is present. Presentation is in adolescence or adulthood with hirsutism, irregular menstruation, or infertility. Diagnosis is made by measuring 17-hydroxyprogesterone which will be elevated due to the 21-hydroxylase deficiency. Neonates with ambiguous genitália must have serum electrolytes monitored for evidence of salt wasting, which can be life-threatening, and a karyotype. E 5-Alpha reductase deficiency is a disease in which the 5-alpha reductase enzyme is not present, and testosterone is not converted to dihydrotestosterone in peripheral tissues. Dihydrotestosterone is required in utero for normal development of male external genitalia. There is normal production of antimüllerian hormone, and therefore no development of müllerian duct structures occurs. Clinical manifestations range from the appearance of normal male external genitalia, normal female genitalia, or ambiguous genitalia. These infants are born with testes and wolffian duct structures, but can have the appearance of female primary sex characteristics. At puberty, these individuals can present with primary amenorrhea and may also have increased virilization, with testicular descent, and normal male-pattern hirsutism. Diagnosis is considered with the presentation of the above-mentioned constellation of clinical manifestations. There is usually a low or low-normal testosterone level, decreased levels of dihydrotestosterone, and a higher testosterone/dihydrotestosterone ratio. Those assigned to the male gender can be given exogenous dihydrotestosterone before puberty to increase the size of the penis. Psychological support is also important given the difficulties that can occur with specific gender identity. Estrogen replacement to promote puberty and breast development with subsequent addition of progestin to regulate menstruation. Estrogen dosing should be higher than postmenopausal woman to promote bone growth and secondary sexual characteristics. Pregnancy can be achieved with assisted reproductive technology and donor oocytes. There is typically a unilateral intra-abdominal testis, a streak gonad on the opposite side, and presence of müllerian structures. There is also a high risk of developing a gonadoblastoma, and as a result, removal of the gonads is recommended. Müllerian Anomalies and Disorders of Sexual Development 247 Study Questions for Chapter 21 Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. A Elevated serum testosterone B Vaginal agenesis, absent uterus C Scant/absent pubic hair, normal axillary hair D Gonads should be removed E Pregnancy possible with gestational carrier 2. A 15-year-old female is referred to you because of worsening dysmenorrhea, associated with nausea and vomiting. She has had such severe vomiting that she has not been able to go to school for the past 6 months and has forced out of the cheerleading squad because of her frequent absences. The rest of her medical history is notable for asthma, irritable bowel, and renal agenesis diagnosed during her fetal ultrasound. Her pediatrician has given her a diagnosis of "cyclic vomiting syndrome" and is treating her with antinausea medication and antidepressants and has referred her to a psychiatrist. Estrogen replacement needed to induce puberty, gonads do not need to be removed 5. Estrogen therapy needed to induce puberty, gonads need to be removed at diagnosis 6. Associated with blue bulging introitus with valsalva due to obstruction 248 Chapter 21-Answers and Explanations Answers and Explanations 1. The vagina and uterus are underdeveloped or absent, but the ovaries are not affected and are normal. Both the axillary and pubic hair are normal for a female as the androgen receptors are intact. Pregnancy is possible with a gestational carrier as the oocytes are normal and can be fertilized and transplanted in to a surrogate uterus. The gonads are testes and should be removed after puberty due to the increased risk of malignant transformation. There is no vagina or uterus because the testes did produce antimüllerian hormone during embryonic development. Pregnancy with gestational carrier is not possible as the testes do not function normally and do not produce sperm or contain oocytes. This young woman has increasingly severe dysmenorrhea, associated with nausea and vomiting and has a history of congenital renal agenesis. Uterus didelphys with obstructed hemivagina is less likely as she has not masses appreciated on abdominal examination. A karyotype is also not necessary as she has normal external genitalia and normal menstruation. Uterus didelphys is usually associated with a longitudinal vaginal septum and two vaginal canals. With tampon insertion in to one hemivagina, the other hemivagina is patent and therefore not occluded. Breast development will need to be induced with estrogen, but the ovaries do not need to be removed. Since malignant transformation can occur at any time, gonadectomy should be performed at time of diagnosis. To carry a pregnancy using donor oocytes, a uterus is necessary and nonfunctioning gonads would be present. Uterus didelphys with obstructed hemivagina is associated with right renal agenesis much more frequently than left. Transverse vaginal septum that is low needs to be distinguished from imperforate hymen as the surgical approach is different. Imperforate hymen just involves resection of hymenal tissue while transverse vaginal septum required resection of the septum with anastomosis of upper and lower vaginal canals. Cervical agenesis needs to be differentiated from high transverse vaginal septum as surgical resection of high vaginal septum is not associated with risk of infection as the cervix serves as a barrier to infection. With anastomosis of the vagina to the uterus, the protective barrier, the cervix, is not present and ascending infection from the vagina to the uterus and peritoneal cavity with subsequent death has been reported. Imperforate hymen is associated with primary amenorrhea with cyclic or chronic pelvic pain often associated with a mass. If there is a large hematocolpos present that extends down to the introitus, then a blue hue bulge of the distended hymenal tissue can be seen with valsalva. If not such blue bulging tissue is seen, then imperforate hymen may not be the diagnosis. Primary amenorrhea is the absence of menses by the age of 13 years in girls who do not show signs of developing secondary sexual characteristics, or by the age of 15 years in girls with normal development of secondary sexual characteristics. The age of work-up has decreased slightly over the past years due to a secular trend of earlier onset of menarche. Secondary amenorrhea is the cessation of menses for a period of 6 months or a three-cycle interval in women who have been menstruating regularly. B Normal menstrual cycle physiology requires interaction between the hypothalamus, pituitary gland, ovaries, and uterus. Granulosa cells produce progesterone during the luteal phase, resulting in luteinization of endometrial glands to their secretory form in preparation for a pregnancy. If pregnancy is not established, the corpus luteum regresses, progesterone support is withdrawn and menses ensues. It is defined as secondary amenorrhea with ovarian failure before 40 years of age. Fragile X premutation is associated with premature ovarian insufficiency and is caused by an increased number (55 to 200) of trinucleotide repeats on the X chromosome (2) Autoimmune disease: Typically autoimmune ovarian insufficiency is highly correlated with and can follow autoimmune adrenal insufficiency. The most common autoimmune disease seen with premature ovarian insufficiency is thyroid disease as it is the most common autoimmune disease. Other autoimmune diseases seen with autoimmune premature ovarian insufficiency include hyperparathyroidism, pernicious anemia, myasthenia gravis, and diabetes. The accumulated galactose metabolites is toxic to the ovary, and decreases the number of oogonia (5) Iatrogenic: Chemotherapy (especially alkylating agents) or pelvic radiation 2. This typically results from a chromosomal anomaly, the most common of which is 45,X. Patients with Y-bearing cell lines should undergo a gonadectomy as they are at increased risk of a germ cell malignancy.

While these tumors often respond rapidly antibiotic used for lyme disease buy discount chloramphenicol 500 mg on line, recurrence is common and median survival is only about 4 years 5 infection control procedures chloramphenicol 500 mg buy fast delivery. Differential Diagnosis Frontonasal and frontoethmoidal cephaloceles: nasal glioma antibiotic resistance research funding buy chloramphenicol 500 mg without a prescription, dermoid antibiotic resistance understanding and responding to an emerging crisis cheap chloramphenicol uk, hemangioma Sphenoidal: nasopharyngeal tumors with skull base involvement Orbital: orbital neurofibromas Occipital: destructive tumors of the skull Teaching Points Cephalocele is a general term referring to extracranial extension of intracranial contents through defects in the bone and dura antibiotics groups discount chloramphenicol 500 mg visa. Cephaloceles can occur anywhere but common locations are frontoethmoidal, frontonasal, sphenoidal, occipital, and parietal. Management Surgical repair is often undertaken for obvious encephaloceles or those with mass effect or symptoms. Vascular imaging is occasionally needed for preoperative planning to avoid vascular injury during surgical repair. The cause is rarely established, but this entity can be the result of febrile seizures or encephalitis or can occur as the result of chronic seizures from another anatomic source. Management In persons whose seizures are refractory to medication, unilateral resection of the hippocampus and anterior temporal lobe is usually effective. T2-weighted images show a thin rim of hypointense material corresponding to the margins of the enhancing rim (arrowheads). The most common organisms are streptococci and anaerobes, but the most likely organism for any particular abscess depends on the source and host immune system. Clinical symptoms include headache, focal neurologic deficit, impaired cognition, and fever. Stereotactic drainage or surgical excision is generally needed for abscesses larger than 2. Differential Diagnosis Central neurocytoma Subependymal giant cell astrocytoma Choroid plexus papilloma/carcinoma Metastasis For subependymomas occurring in the fourth ventricle (a more common location), the differential includes ependymoma, choroid plexus papilloma/carcinoma, hemangioblastoma, and metastasis. Patient demographics provide an important diagnostic clue: subependymoma occurs primarily in older adults (50 to 60 years), with a male predominance. Symptoms may arise from ventricular obstruction (headache, nausea, obtundation) or neural compression (focal deficits). The most common locations are the inferior fourth ventricle (60%) and the lateral ventricle (35%, usually in the frontal horn and abutting the septum pellucidum). Management Asymptomatic lesions should be followed with serial imaging (due to potential growth and possibility of mixed subependymoma­ependymoma). Most cases result from fires, malfunctioning stoves and heaters, exhaust systems, and suicide attempts. Patients present with confusion, loss of consciousness, headache, and nausea/vomiting. Other areas that may be affected include the medial temporal lobes, insula, and cerebellar hemispheres. Some patients experience sudden neurologic deterioration and coma several weeks after the initial insult. This correlates with the development of T2-hyperintense signal abnormality in the deep white matter, representing acute demyelination. The etiology for this delayed response is unclear but is thought to be autoimmune-mediated. Treatment Despite treatment with high-concentration hyperbaric O2, most patients have permanent neurologic deficits. The magnetic resonance imaging appearances of the brain in acute carbon monoxide poisoning. There are two rim-enhancing cystic areas, the medial one having a fluid­fluid level consistent with hemorrhage. Differential Diagnosis Astrocytoma Ganglioglioma Dysembryoplastic neuroepithelial tumor Pleomorphic xanthoastrocytoma Teaching Points Oligodendrogliomas are slow-growing, infiltrative glial neoplasms that represent 5% to 20% of gliomas. The clinical presentation includes seizures (most common), headaches, and focal neurologic deficits. Common features include: T1-hypointense and T2-hyperintense signal Well-circumscribed margins (despite its infiltrative nature) Involvement of the cortex and subcortical white matter Variable enhancement +/- cystic and hemorrhagic components Unlike astrocytomas, contrast enhancement does not reliably differentiate low-grade oligodendrogliomas from anaplastic tumors. The loss of chromosomes 1p and 19q may be seen in up to 70% of oligodendrogliomas and is associated with an improved response to chemotherapy and a better prognosis. Management Surgical resection is the treatment of choice and may produce several years of disease-free survival. The typical age range is 5 to 12 years, although 30% of cases occur in patients 15 to 35 years old. Patients present with hydrocephalus or signs of brain-stem and cerebellar dysfunction. Imaging studies typically reveal a well-circumscribed mass adjacent to the cerebellar vermis. In contrast to medulloblastomas, ependymomas arise from the floor of the fourth ventricle, are more likely to have calcification and hemorrhage, and have a plastic growth pattern. Medulloblastomas often arise within the lateral cerebellar hemispheres when presenting in older patients. Areas with hypointensity on T2-weighted images and hyperintensity on T1-weighted images likely represent hemorrhage. Differential Diagnosis Leigh disease Kearns-Sayre syndrome Wilson disease Osmotic demyelination Creutzfeldt-Jakob disease Teaching Points Methanol is usually intentionally ingested as a suicide attempt or as a substitute for alcohol. It is found in many household products, including antifreeze and windshield wiper fluid. A latent period of 12 to 24 hours is seen as the methanol is metabolized to formaldehyde and formic acid, each of which is more toxic than methanol. Visual disturbances, secondary to optic nerve demyelination, are the most common symptom. Other findings may include extensive cerebral edema, cerebellar necrosis, and optic nerve necrosis. It has an affinity for alcohol dehydrogenase that is much greater than that of methanol, preventing methanol conversion to the more toxic metabolites. Other treatments include correction of metabolic imbalances and, in severe poisoning, hemodialysis. The margins of the cleft are lined by dysplastic/polymicrogyric gray matter (arrows). Differential Diagnosis Porencephaly Postoperative cavities and clefts Gray-matter heterotopia Teaching Points Schizencephaly is a disorder in which there is a cleft between the surface of the brain and the ventricle. Most cases are thought to be due to an early destructive insult occurring before neuronal migration. Later, when neuronal migration occurs from the germinal matrix, the cleft becomes lined with gray matter. Clinical severity is related to the extent and location of the cleft(s) and the associated malformations. In closed-lip schizencephaly, a "dimple" along the wall of the lateral ventricle may point to the abnormality. Schizencephaly is associated with other malformations, such as septo-optic dysplasia and corpus callosum anomalies. The lateral ventricles have a parallel configuration, and there is small bundle of white matter (bundle of Probst) running anteroposteriorly along the medial aspect of the lateral ventricles (arrowheads). On the coronal image, the configuration of the ventricles resembles a "Texas Longhorn. Azygous anterior cerebral arteries and midline venous anomalies (persistent falcine sinus) are occasionally seen. Management Evaluate imaging carefully for other brain anomalies and malformations. Prognosis and management depend on the presence of other associated abnormalities. Contrast-enhanced T1-weighted sagittal image of the cervical spine shows enhancing intramedullary masses within the spinal cord (black arrows). Contrast-enhanced T1-weighted sagittal image of the lumbar spine shows multiple small enhancing nodular masses along the cauda equina (arrows). Clinical presentation may be hearing loss, other cranial neuropathies, or extremity weakness and pain. Differential Diagnosis Neoplasms or cysts around aqueduct (pineal region tumors, tectal glioma, arachnoid cysts) Postinflammatory aqueductal gliosis after hemorrhage or infection Teaching Points Aqueductal stenosis is due to narrowing or occlusion of the aqueduct of Sylvius connecting the third and fourth ventricles. It is a common cause of congenital hydrocephalus, although it may present later in life, including in adulthood. Clinical signs and symptoms depend on severity and may include macrocephaly, bulging fontanelle in infants, headache, papilledema, and sixth nerve palsy. Sometimes communicating hydrocephalus too may present with a normal-sized fourth ventricle. Thin, high-resolution T2-weighted images may show obliteration of the aqueduct or small areas of web-like narrowing in the aqueduct. Carefully scrutinize the tectal plate and periaqueductal region to look for subtle masses, such as tectal glioma, that may mimic aqueductal stenosis. Management If left untreated, it will result in loss of brain substance over time. There is minimal hyperintense signal at this site on T2-weighted images, and there is no mass effect. On T2*-weighted imaging there is a corresponding focus of hypointense signal consistent with susceptibility-related signal loss Differential Diagnosis Pontine hemorrhage Metastasis Demyelinating disease Teaching Points Capillary telangiectasias represent circumscribed collections of dilated capillaries within normal cerebral parenchyma. They are an incidental finding (usually at autopsy) and generally produce no symptoms or hemorrhage. However, they may be found in association with cavernous malformations, developmental venous anomalies, or arteriovenous malformations. On heavily T2*-weighted (gradient echo) sequences the blood pool within the lesions may create marked hypointensity. The classic appearance (two thirds of cases) is a cystic mass with an enhancing mural nodule, usually within the cerebellar hemisphere. Patients present with hydrocephalus (fourth ventricular compression) and/or cerebellar signs. This distribution conforms to the border zone between the middle and anterior cerebral arterial territories. Differential Diagnosis Embolic infarction Lacunar infarction Vasculitis/vasculopathy Demyelination Teaching Points Border-zone infarcts arise from insufficient perfusion at the distal capillary beds between arterial systems. The most common cause is severe internal carotid artery stenosis or occlusion accompanied by systemic hypotension. Microembolization from cardiac surgery or unstable plaques can produce a similar appearance, possibly since microemboli can be poorly cleared in these areas. The positions of the arterial border zones vary with large vessel vascular anatomy. Cortical border zones are usually found anteriorly at the borders of the anterior and middle cerebral arteries and posteriorly at the junction of the anterior, middle, and posterior cerebral arteries. Internal border zones are present in the corona radiata (between lenticulostriate perforators and the superficial perforators from middle cerebral artery cortical branches) and centrum semiovale (between the superficial perforators of the anterior and middle cerebral arteries). Internal border zones have a characteristic anterior-posterior linear distribution that may be confluent or multifocal ("rosary bead" appearance). Management Head and neck vascular imaging is essential to identify a causative stenosis/occlusion that may be amenable to revascularization. Developmental delay, motor deficits, and sensorineural hearing loss are common manifestations. On the postcontrast T1-weighted image, there is a "leading edge" of enhancement along the periphery of the white matter area of signal abnormality (arrows). There are many different mutations and variants of adrenoleukodystrophy, the most common being classic X-linked disease. Clinical signs and symptoms include learning difficulties, behavioral problems, abnormal skin pigmentation, adrenal insufficiency, and disorders of gait, vision, and hearing commonly in preteen boys. Early in the disease, the abnormalities may be limited to the splenium of the corpus callosum. Metachromatic leukodystrophy produces demyelination that typically involves both anterior and posterior white matter. It often produces a "tigroid" appearance to the white matter and does not enhance. Neonatal hypoglycemia also has a posterior predominance and shows restricted diffusion but occurs in a different clinical setting and does not enhance. Sagittal T1- and T2-weighted images show syringohydromyelia in the cervical spinal cord (white arrows). Protrusion of the cerebellar tonsils in to the cervical spinal canal is asymptomatic in about half of patients. Many other clinical signs and symptoms have been described, including cranial nerve symptoms, ocular disturbances, hearing and vestibular symptoms, and gait disturbances, among others. Classic imaging findings are: Descent of the cerebellar tonsils below the foramen magnum by 5 mm or more Pointed configuration of the tonsils Crowding at the foramen magnum Other findings include a short clivus and syringohydromyelia in the cervical or thoracic spinal cord. Look for signs of increased intracranial pressure and intracranial hypotension, as they may manifest by acquired descent or herniation of the cerebellar tonsils. Management In symptomatic patients or in those with syringohydromyelia, surgical decompression is considered. Surgery includes suboccipital craniectomy +/- resection of the posterior arch of C1 and duraplasty to expand the dura at this level. International survey on the management of Chiari I malformation and syringomyelia. A small amount of subdural blood also layers along the posterior falx and left occipital lobe. Differential Diagnosis Acute or subacute subdural hematomas with cortical ischemic injury Teaching Points Head trauma is the most common cause of morbidity and mortality in abused children, especially in children under the age of 2 years.

Buy 500 mg chloramphenicol mastercard. How to Read and Interpret an Antibiogram.

Wound closure (1) the uterus is often exteriorized on to the anterior abdominal wall to massage the fundus polyquaternium 7 antimicrobial chloramphenicol 250 mg cheap, inspect the adnexa antibiotics you can drink on buy chloramphenicol canada, and facilitate visualization of the uterine incision for repair what antibiotics for sinus infection buy chloramphenicol with amex. Uterotonics are administered as indicated to facilitate contraction of the myometrium and promote hemostasis infection under fingernail 250 mg chloramphenicol visa. A vertical incision usually is closed in two or three layers because of the myometrial thickness of the upper segment antibiotic youtube order chloramphenicol 250 mg on line. E Complications Common postoperative complications include the following conditions: 1. Depending on the definition used, the incidence of endomyometritis after cesarean section may be as low as 5% or as high as 50%. Risk factors include lower socioeconomic status, prolonged labor, prolonged duration of ruptured membranes, and the number of vaginal examinations. Infection is polymicrobial and can include the following organisms: aerobic streptococci, anaerobic Gram-positive cocci, and aerobic and anaerobic Gram-negative bacilli. Use of prophylactic antibiotics at the time of the procedure decreases incidence of endomyometritis. With the use of modern, broad-spectrum antibiotics, the incidence of serious complications, including sepsis, pelvic abscess, and septic thrombophlebitis, is less than 2%. Urinary tract infections are the second most common infectious complication following cesarean delivery after endomyometritis. Practices that decrease risk include strict adherence to aseptic technique during catheter placement and minimizing duration of catheter drainage of the bladder. Risk factors include prolonged labor, ruptured membranes, amnionitis, meconium staining, morbid obesity, anemia, and diabetes mellitus. Common isolates include Staphylococcus aureus, Escherichia coli, Proteus mirabilis, Bacteroides sp. Prompt diagnosis and treatment decrease the risk of complicating pulmonary embolus to 4. Because of the risk of thromboembolic events in pregnancy and following major surgery, women undergoing cesarean section should receive mechanical and/or pharmacologic prophylaxis against deep venous thrombosis. Indications include uterine atony (43%), placenta accreta (30%), uterine rupture (13%), extension of a low transverse incision (10%), leiomyoma preventing uterine closure, and cervical cancer. The risk of rupture of previous cesarean scar varies with the location of the incision. Deterioration of the fetal heart rate tracing is usually the first sign of rupture, followed by severe abdominal pain and bleeding. Operative Obstetrics 127 F Vaginal birth after cesarean section Since the 1980s, previous cesarean section has not been a contraindication to subsequent labor and a vaginal birth. All women who are candidates should be counseled adequately and offered an attempt at vaginal birth or a repeat cesarean section. There is approximately a 60% rate of successful vaginal delivery after previous cesarean section. However, as many as 50% of women with previous cesarean section for cephalopelvic disproportion have a successful vaginal birth. Previous low transverse or low vertical cesarean section, with documentation of the uterine scar c. Informed consent regarding risks and benefits of repeat cesarean and vaginal birth d. It is made at the end of the second stage of labor just before delivery, when indicated. It increases the area of the outlet for the fetal head during delivery, particularly in assisted deliveries with forceps or the vacuum extractor. An episiotomy has been advocated in order to prevent major perineal lacerations, particularly at the time of operative vaginal delivery. However, there is no evidence to support this indication and there is evidence that episiotomy may be associated with an increased risk of lacerations of the anal sphincter or rectum. Prophylactic episiotomy has been advocated to prevent pelvic relaxation, although this too has never been demonstrated. Episiotomy has also been used in an effort to shorten the second stage of labor or effect rapid delivery if there is evidence of fetal compromise. Disadvantage: possible occurrence of inadvertent incision or extension in to the anal sphincter and rectum. It is important to recognize and repair this complication during repair of the episiotomy to prevent rectovaginal fistula 2. This incision is made at a 45-degree angle to the hymenal ring; it extends lateral and posterior. B Incidence the incidence of operative vaginal delivery is approximately 5% to 10% of vaginal deliveries. C Indications An operative vaginal delivery is performed to shorten the second stage of labor with certain maternal or fetal indications. Nonreassuring fetal status based on heart rate pattern, auscultation, lack of response to scalp stimulation, or scalp pH 2. Prolonged second stage of labor secondary to malposition, deflexion, or asynclitism (lateral deflection) of the fetal head. Nulliparous patient: more than 3 hours with a regional anesthetic or more than 2 hours without regional anesthesia b. Multiparous patient: more than 2 hours with a regional anesthetic or more than 1 hour without regional anesthesia 3. Certain maternal illnesses (such as heart disease or pulmonary compromise), which make avoidance of voluntary maternal expulsive efforts. Poor voluntary expulsion efforts because of exhaustion, analgesia, or neuromuscular disease D Prerequisites for instrumental delivery 1. The position and station must be known, and the head must be engaged (0 station; see Chapter 10). Head that cannot be advanced with ordinary traction when using forceps or the vacuum extractor 4. To be categorized as an outlet forceps delivery, the following criteria must be satisfied: a. Sagittal suture is in the anteroposterior diameter or right or left occiput anterior or posterior position. In a low forceps delivery, the leading point of the fetal skull has descended to at least 2 station (out of 5), but has not reached the pelvic floor. The design of the blades provides standard cephalic and pelvic curves; that is, they conform to the shape of the fetal head and to the vaginal canal, respectively. Each matching part of the forceps has three parts: the blade, the shank, and the handle. These forceps are used primarily for traction when there is to be little or no rotation. H Vacuum extractors There are two types of vacuum extractors, based on the type of cup used for application to the fetal head. This device consists of a metal cup (40 to 60 mm in diameter) that is applied to the fetal scalp. This device, which is more widely used in the United States, consists of a flexible silastic cup that is applied to the fetal head. Maternal complications include lacerations of the cervix, vagina, and perineum; episiotomy extensions; and associated hemorrhage. Scalp abrasions or lacerations are the most common injury associated with vacuum extraction. Cephalohematoma (separation of the fetal scalp from underlying structures) occurs in 0. Cervical insufficiency is characterized by gradual, progressive, painless dilation of the cervix, usually leading to spontaneous pregnancy loss in the second trimester. Although the incidence is difficult to determine due to imprecise definitions, it is thought that only a minority of the second-trimester losses are due to cervical insufficiency. Acquired causes primarily result from obstetric or gynecologic trauma to the cervix. Congenital causes may include Mullerian anomalies or exposure to diethylstilbestrol exposure in utero. There is an ongoing debate about the potential benefit of universal or targeted ultrasound screening for cervical length and the subsequent use of cerclage for those women found to have a shortened cervix. There is evidence suggesting a decreased rate of the third-trimester preterm delivery with this approach. B Techniques Cervical cerclage involves placing an encircling suture around the cervical os using a heavy, nonabsorbable suture or Mersilene tape. In the more complicated of the two vaginal procedures, the suture is almost completely buried beneath the vaginal mucosa at the level of the internal os. It can be left in place for subsequent pregnancies if a cesarean section is performed. This procedure requires dissection of the bladder and is associated with an increased blood loss compared with a McDonald cerclage. It involves less trauma to the cervix and less blood loss than the Shirodkar procedure. This is an uncommon, semipermanent procedure used in women with a short or amputated cervix or in those in whom a vaginal cerclage has failed. C Timing Cerclage is usually performed between the 12 and 16 weeks of gestation but can be performed as late as the 24 weeks of gestation. Fetal viability and the absence of anomalies should be documented before performing the procedure. D Effectiveness the success rate of cerclage varies tremendously on the basis of the population and the inclusion criteria. The best data on the efficacy of cerclage show a benefit only for those women with the worst pregnancy history. Except in women with a strong history consistent with cervical insufficiency, the benefit of cerclage has not been proven. Cervical dystocia with failure to dilate, requiring a cesarean birth, occurs in 2% to 5% of cases. Early, elective cerclages have a low rate (1%) of infection; cerclage placement with dilation of the cervix has a much higher risk (30%) of infection. A Spontaneous abortion is expulsion of the products of conception without medical or mechanical intervention. Spontaneous loss occurs in at least 15% of clinically recognized pregnancies; the risk increases directly with maternal age, advancing paternal age, minority race, increasing gravidity, and history of previous spontaneous losses. Chromosomal abnormalities are the most common reason for the first-trimester losses, occurring at a 60% frequency. Most chromosomal abnormalities are sporadic defects; in a small percentage of cases, one of the parents carries a balanced translocation. Autosomal trisomies are the most common anomaly, followed by 45,X0 monosomy (the most common single anomaly seen in abortuses), triploidy, tetraploidy, translocations, and mosaicism. Inevitable abortion: this includes bleeding, cramping, or rupture of the membranes associated with dilation of the cervix. This type of pregnancy loss occurs when there has been partial but incomplete expulsion of the products of conception from the uterine cavity. Depending on the clinical circumstances and patient preference, management can be expectant (with eventual spontaneous passage of remaining tissue) or the woman can undergo medical or surgical emptying of the uterus. This occurs when a previously diagnosed intrauterine pregnancy is completely expelled from the uterus. Death of the fetus or embryo may occur without the onset of labor or the passage of tissue for a prolonged period. Legal abortion is one of the most frequently performed surgical procedures in the United States. Therapeutic abortions are terminations of pregnancy that are performed when maternal risk is associated with continuation of the pregnancy or fetal abnormalities are associated with genetic, chromosomal, or structural defects. Techniques used effectively to empty the uterus of the products of conception fall under the categories of surgical evacuation or medical management. Suction curettage is the most common method of pregnancy termination in this country. This technique is the preferred method of termination at 13 or more weeks of gestation. A final sharp curettage may also be performed in an effort to ensure complete emptying of the uterus. Evaluation to ensure removal of major fetal parts is an important component of this procedure. Simultaneous ultrasound monitoring can be helpful to decrease risk to the mother and ensure complete evacuation of the uterus. Medical means of inducing abortion include extrauterine and intrauterine administration of abortifacients, such as prostaglandins, hypertonic saline, and oxytocin. Common side effects include fever, nausea and vomiting, diarrhea, and uterine hyperstimulation. Laminaria to facilitate cervical dilation is useful to shorten the length of induction. By interacting with prostaglandin receptors, misoprostol causes the cervix to soften and the uterus to contract, resulting in the expulsion of the uterine contents. Because of severe cramping, it is usually given with pain medication (narcotic) and antiemetics. The success rate is 75% to 85% when administered in the first 9 weeks of pregnancy.

References

• Shulman HM, Kleiner D, Lee SJ, et al. Histopathologic diagnosis of chronic graftversus- host disease: National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: II. Pathology Working Group Report. Biol Blood Marrow Transplant. 2006;12:31-47.
• Bondarenko S: Laparoscopic extravesical transverse ureteral reimplantation in children with obstructive megaureter, J Pediatr Urol 9(4):437n441, 2013.
• Shin EK, Moon W, Park SJ, et al. Congenital absence of the splenic artery and splenic vein accompanied with a duodenal ulcer and deformity. World J Gastroenterol 2009;15:1401.
• Svensson E, Eisensmith RC, Dworniczak B, et al. Two missense mutations causing mild hyperphenylalaninemia associated with DNA haplotype 12.