R. Blaine Easley, MD

• Assistant Professor
• Department of Pediatrics, Anesthesiology
• and Critical Care
• Johns Hopkins Medical Institutes
• Baltimore, Maryland

Reproductive morbidity is used in a broader sense to include-(a) Obstetric morbidity treatment action campaign zyloprim 100 mg order on-line, (b) Gynecological morbidity and (c) Contraceptive morbidity medicine bobblehead fallout 4 cheap zyloprim 100 mg mastercard. The perinatal mortality rate is expressed in terms of such deaths per 1000 total births symptoms your having a boy order 300 mg zyloprim visa. The perinatal mortality rate closely reflects both the standards of medical care and effectiveness of social and public health measures treatment molluscum contagiosum generic 100 mg zyloprim amex. However medications made from plasma purchase 100 mg zyloprim amex, for international comparisons, only deaths of fetuses or infants weighing > 1000 g at birth should be included as in the developing countries many such deaths are under reported. Worldwide nearly four million newborns die within the first week of life and another three million are born dead. Perinatal deaths could be reduced by at least 50% worldwide if key interventions are applied for the newborn. The perinatal mortality is less than 10 per 1000 total births in the developed countries while it is much higher in the developing countries (60/1000 in India). The major health problem in the developing world arises from the synergistic effect of malnutrition, infection and unregulated fertility combined with lack of adequate obstetric care. The important causes of antepartum deaths are: (a) Chronic hypoxia (30%), (b) Pregnancy complications (30%), (c) Congenital malformations (15%), (d) Infection (5%) and (e) Unexplained (20%). Perinatal deaths increase due to hypoxia, intrauterine growth restriction, prematurity, congenital malformations and infection. Obstetric complications: (a) Antepartum hemorrhage particularly abruptio placenta is responsible for about 10% of perinatal deaths due to severe hypoxia, (b) Preeclampsia-eclampsia is associated with high perinatal loss either due to placental insu ciency or prematurity- spontaneous or induced (c) Rh isoimmunization (d) Cervical incompetence-Premature e acement and dilatation of cervix between 24 and 36 weeks is responsible for signi cant perinatal deaths from prematurity. Complications of labor: Dystocia from disproportion, malpresentation, abnormal uterine action, premature rupture of membranes may result in asphyxia, amnionitis and birth injuries contributing to perinatal deaths. Fetoplacental factors: Multiple pregnancy most often leads to preterm delivery and usual complications. Congenital malformation and chromosomal abnormalities are responsible for 15% of perinatal deaths, the lethal malformations are mostly related to nervous, cardiovascular or gastrointestinal system. Intrauterine growth restriction and low-birth-weight babies-Apart from preterm delivery, intrauterine nutritional de ciency may be responsible for such low weight babies which are more vulnerable to biochemical, neurological and respiratory complications resulting in high perinatal deaths of about 50% when the birth weight is less than 2 kg. Preterm labor and preterm rupture of the membranes are the known leading causes of prematurity. Unexplained: About 20% of stillbirths have no obvious fetal, placental, maternal or obstetric causes. As such, improvement of obstetric service only around delivery, will not minimize perinatal deaths appreciably. Simultaneous demographic and social changes help in reduction of perinatal mortality rate significantly. Termination of an a ected fetus is a positive step in reduction of deaths due to congenital malformations (see p. Chapter 38 Safe Motherhood, Epidemiology of Obstetrics 689 Detection and management of medical disorders in pregnancy: anemia, diabetes, infections and preeclampsia­eclampsia. Screening of high-risk patients those of poor socioeconomic status or high parity, extremes of age, and twins, etc. Skilled birth attendant - To minimize sepsis, at least three cleans are to be maintained (see p. Provision of referral neonatal service especially to look after the preterm babies. Continued study of perinatal mortality problems by demographic studies, regular clinically allied interdepartmental meetings and pathological research. Perinatal morbidity: It implies major illness of the neonate from birth to first 4 weeks of life. Important causes of morbidity are due to (a) Prematurity and low birth weight, (b) Birth asphyxia and birth trauma (c) Congenital malformations. Such deaths include antepartum deaths (macerated) and intrapartum deaths (fresh stillbirths). Stillbirths rate is the number of such deaths per 1000 total births (live and stillbirths) (Table 38. Causes: the causes of death within 7 days are almost always obstetrically related and as such stillbirths and neonatal deaths within 7 days are grouped together as perinatal deaths. However the progress fell short of the target in parts of South Asia and Subsaharan Africa. Beyond these strategic actions, good governance must also incorporate a human rights approach which includes accountability, participation, ownership, transparency, equity and non-discrimination. Lifetime risk of dying from pregnancy-related complications for a woman of developing country is 1 in 11, compared to 1 in 5000 in the industrialized country (see p. Maternal deaths are classi ed into- (a) Direct, (b) Indirect and (c) Fortuitous deaths (see p. Important causes of maternal deaths are: (i) Hemorrhage (20­25%) (ii) Hypertension (20­25%) (iii) Infection (15­20%) (iv) Unsafe abortion (10­13%) (v) Obstructed labor (8%) (vi) Anemia (15­20%) and (vii) Other indirect (viral hepatitis) causes (5­10%). Maternal Near Miss is a condition when a women who nearly died but survived from a severe health condition, during pregnancy, child birth or within 6 weeks of puerperium. Maternal morbidity (Obstetric morbidity) develops from any cause related to pregnancy, childbirth or puerperium. Nearly 15 more women su er from severe morbidity, when there is one maternal death. Important causes of stillbirths are: Birth asphyxia and trauma (30%), pregnancy complications (30%) and others (see p. Severe hypoxia in labor when associated with metabolic acidosis can cause fetal organ damage or fetal death. In between contractions the intraluminal pressure within the spiral artery (85 mm of Hg) is higher than the intramyometrial pressure (10 mm of Hg) to maintain the uteroplacental blood flow. During peak uterine contractions, myometrial pressure (120 mm of Hg) exceeds the arterial pressure (90 mm of Hg) causing temporary halting of O2 delivery to the fetus through the placenta. Depending upon the intensity and duration of contraction, fetal hypoxia may develop. Even in a normal labor, the baby is subjected to stress due to: (1) Uterine contractions temporarily curtailing the uteroplacental circulation. But in a compromised fetus and/or in a pathological state of labor, the fetal distress may appear abruptly. The term "Fetal distress" has been abandoned in favor of more appropriate term "Nonreassuring fetal status". The auscultation should be made for 60 sec particularly before and immediately following a uterine contraction. Pathogenesis: Hypoxia vagal response peristaltic activity and relaxation of the anal sphincter passage of meconium. The vicious circle is: Placental insufficiency oligohydramnios cord compression hypoxia thick meconium gasping breath meconium aspiration. Meconium staining of the liquor as observed following rupture of the membranes gives a crude idea of intrauterine fetal jeopardy. Intermittent auscultation is recommended to monitor the fetus for a woman in labor without any complications. The transducers are placed on the maternal abdomen, one over the fundus and the other at a site where the fetal heart sound is best audible. Frequency of uterine contractions and uterine pressure are recorded simultaneously by tocodynamometer. Intrauterine pressure could be simultaneously measured by passing a catheter inside the uterine cavity. Drawbacks: (i) Interpretation is affected by intra- and interobserver error (ii) Due to error of interpretation, cesarean section rate may be high (iii) Instruments are expensive and trained personnel are required to interpret a trace (iv) Mother has to be confined in bed. Absence of accelerations, reduced baseline variability of < 5 bpm for > 90 minutes denotes a hypoxic fetus. Decreased baseline variability may be due to fetal sleep, infection, hypoxia, anomalies or due to maternal medications. Variability is the reflex of normal cardiac behavior in response to sympathetic and parasympathetic nerve input. Baseline variability may be (a) absent, (b) minimal (< 5 bpm), (c) moderate (6-25 bpm) or (d) marked (> 25 bpm). Causes of late deceleration: (i) Placental pathology (postmaturity, hypertension, diabetes, placental abruption) (ii) Excessive uterine contractions (iii) Injudicious use of oxytocin (iv) Regional anesthesia (spinal of epidural). Decelerations are variable in all respect of size, shape, depth, duration and timing to the uterine contractions. It is thought to indicate cord compression and may disappear with the change in position of the patient. It is often associated with fetal anemia, fetomaternal hemorrhage, fetal hypoxia (acidosis). Fetal scalp stimulation by pinching with an Allis forceps or by gentle digital stroke is done before scalp blood pH test. In the high-risk patient, auscultation should be done at every 15 minutes in the first stage and at every 5 minutes in the second stage. In the low-risk group it may be done at an interval of 30 minutes in the first stage and at every 15 minutes in the second stage. Auscultation should be done for a period of 60 seconds after a uterine contraction. An illuminated plastic cone is inserted through the dilated cervix (4­5 cm) against the fetal head. Fetal Pulse Oximetry was initially used to determine fetal oxyhemoglobin saturation. Umbilical arterial cord (or neonatal) blood samples with pH < 7 and base deficit of > 2 mmol/L indicates profound metabolic acidemia and multiple organ dysfunction. Intrapartum umbilical artery Doppler study was poor to predict umbilical artery acidosis. It must be emphasized that hypoxia and acidosis is the ultimate result of the many causes of intrauterine fetal compromise. Because of this uncertainty about the diagnosis of fetal distress, terminologies used are "Reassuring" and "Nonreassuring". Nonreassuring fetal heart rate pattern is associated with fetal hypoxia, acidosis and therefore called fetal distress. Features to rule out metabolic acidosis are: (a) Presence of accelerations (b) Moderate variability and (c) scalp blood pH > 7. During hypoxia when O2 saturation falls below 40%, anaerobic glycolysis occurs, resulting in the accumulation of lactic acid and pyruvic acid leading to metabolic acidosis. H-ions first stimulate and then depress the sinoauricular node leading to tachycardia and bradycardia respectively. It also causes parasympathetic stimulation leading to hyperperistalsis and relaxation of the anal sphincter with passage of meconium. Decreased fetal oxygenation in labor hypoxia metabolic acidosis asphyxia organ damage/fetal death. During labor - common Uterine hyperstimulation following oxytocin for augmentation of labor Placental abruption Uterine rupture or scar dehiscence Cord prolapse Injudicious administration of oxytocin, analgesics and anesthetic agents Maternal hypotension ­ as in epidural analgesia B. Lateral positioning avoids compression of vena cava and aorta by the gravid uterus. Oxygen is administered (6-8 L/min) to the mother with face mask to improve fetal SaO2. Amnioinfusion is the process to increase the intrauterine uid volume with warm normal saline (500 mL). Indications are: (a) Oligohydramnios and cord compression (b) To dilute or to wash out meconium (c) To improve variable or prolonged decelerations (d) To reduce fetal gasping which is the result of hypoxia due to cord compression. Advantages: Reduces cord compression, meconium aspiration, and improves Apgar score. If the fetal heart rate pattern remains nonreassuring, further tests are performed to rule out metabolic acidosis. If acidosis is excluded labor is monitored with repeated testing (every 30 min) to exclude acidosis. If the fetus is acidemic urgent delivery by safest method (vaginal or abdominal) depending on the individual case. Persistence of nonreassuring pattern or presence of unusual or confusing pattern: these patients need immediate delivery. Thirty minutes has been accepted as the gold standard for decision to delivery interval in cases of confirmed fetal compromise. Loss of variability, loss of acceleration and presence of bradycardia indicate fetal compromise. Persistent hypoxia or presence of metabolic acidosis needs expeditious delivery of the baby to prevent organ damage. Circulatory inadequacy is due to a disparity between the circulating blood volume and the capacity of the circulatory bed. The net effect of this disparity is inadequate exchange of oxygen and carbon dioxide between the intraand extravascular compartments. The stagnation of carbon dioxide and other metabolites in the tissue leads to metabolic acidosis and cellular death. The flow of blood within the capillary bed is controlled by 2 sphincters ­ one at the arteriolar end and the other at the venular end. In addition to the tuft of capillaries, there is a direct communication between the arteriole and the venule and this communicating trunk bypasses the capillary bed. When the sphincters are closed, the metarteriole shunt operates to divert blood for supply to the vital organs, like brain, heart and kidney. Presence of endotoxin (lipopolysaccharide), in septic shock activates the leukocytes through complement system. These interfere with the function of a number of enzyme systems and increase capillary permeability. In presence of hypoxia, sepsis and acidosis, lysosomal enzymes which are cytotoxic, are released. Leukotrienes cause vasoconstriction, platelet activation and increased vascular permeability.

Initiate hemodialysis Because ammonia is a byproduct of protein digestion treatment jiggers order 100 mg zyloprim free shipping, protein restriction should be the next step to help decrease ammonia production medicine zalim lotion buy zyloprim now. However symptoms 6 days post iui purchase zyloprim amex, there is substantial evidence to support protein restriction in cirrhosis treatment zinc poisoning zyloprim 100 mg buy without a prescription, and it does not appear to improve hepatic encephalopathy treatment cervical cancer buy discount zyloprim on-line. Because the patient has symptomatic hepatic encephalopathy, ammonia levels must be decreased rapidly. Hemodialysis can remove ammonia faster than lactulose or rifaximin (choices A and D). Even though ammonia is initially cleared by the liver, the liver enzymes do not suggest any hepatic insult (choice C). Ammonia is a byproduct of protein digestion and bacterial metabolism in the gut and acid management in the kidneys and a consequence of seizures or exercise in skeletal muscle; it is hepatically degraded into urea via the urea cycle. In acute elevations of ammonia, astrocytes rapidly metabolize it to glutamine, causing swelling from increasing intracellular osmolarity, releasing inflammatory cytokines, subsequent astrocyte apoptosis, and increasing lactic acid production from metabolism of pyruvate to lactic acid because of depletion of adenosine 5 triphosphate and nicotinamide adenine dinucleotide and paralysis of the Krebs cycle. Although most cases of hyperammonia secondary to urea cycle disorders are relevant in newborns, mild or partial deficiencies are asymptomatic through adulthood until specific stressors. Although family history is important, patients might not know their family history; therefore, important clues that could suggest a genetic disorder include a dietary history of veganism, psychiatric illness and prolonged flulike illness, and exacerbation of ammonia levels greater than 100 µmol/L in the setting of stressors such as stressors, change in diet, and recent corticosteroid use. If the glycine and glutamine levels are elevated, the citrulline level is checked. Treatment includes removal of ammonia, dietary protein withdrawal, reversal of catabolism from calorie supplementation and enzyme supplementation, and excess nitrogen scavenging methods. To reverse the catabolic state, dextrose, fluids, and intralipids should be administered. Priming dose on nitrogen scavengers include sodium phenylacetate and sodium benzoate 5. Cornstarch with thiamine Lactate is involved in oxidation, glucose metabolism, and cell signaling. Type B is further subcategorized into type B1 in which there is an underlying disease, type B2 in which there is a drug associated, and type B3 in which there is an inborn error of metabolism. The disorder also includes multiorgan dysfunction with development of liver adenomas, which can lead to hepatocellular carcinoma; bleeding diathesis secondary to platelet dysfunction with decreased adhesiveness and abnormal aggregation or von Willebrand-like defect; iron-deficiency anemia secondary to overexpression of hepcidin in adenomas and increases iron absorption; proximal renal tubular dysfunction, which can lead to renal failure; distal renal dysfunction with hypocitraturia and hypercalciuria, leading to nephrocalcinosis; polycystic ovaries with preserved fertility; neutropenia because of glucose critical for neutrophilic metabolic burst and fertility; neutropenia caused by glucose critical for neutrophilic metabolic burst; and a predisposition to gingivitis, mouth ulcers, upper respiratory infections, abscesses, and enterocolitis. The diagnosis is based on hypoglycemia, hyperuricemia, hypercholesterolemia, hypertriglyceridemia, lactic acidosis, genetic testing, and liver biopsy. Treatment consists of diet modification with avoidance of sucrose (fructose and glucose) and lactose (galactose) and use of cornstarch 1. Liver transplantation can improve hypoglycemia, but neutropenia and Crohn disease may still persist. Treatment includes citrate supplementation; hydration with or without thiazide to reduce hypercalciuria; low-dose angiotensin-converting enzyme inhibitors for early microalbuminuria (> 30 g/albumin/ mg creatinine); erythropoietin for glomerular filtration rate less than 50 mL/min/1. Lactate is used as an end goal for resuscitation and has prognostic implications in sepsis, asthma exacerbation, and diabetic ketoacidosis. However, the causes of elevated lactate are not mutually exclusive, and other etiologies should be further investigated despite having a primary diagnosis. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Provision of protein and energy in relation to measured requirements in intensive care patients. Prospective randomized trial to assess caloric and protein needs of critically ill, anuric, ventilated patients requiring continuous renal replacement therapy. Importance of early increase in intestinal permeability in critically ill patients. Canadian Critical Clinical Practice Guidelines Committee: Canadian Clinical Practice Guidelines for nutrition support in mechanical ventilated critically ill adult patients. Early enteral nutrition provided within 24 hours of injury or intensive care unit admission; significantly reduces mortality in critically ill patients: a meta-analysis of randomized controlled trials. Does enteral nutritional nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients Early enteral feeding compared with parenteral reduces postoperative septic complications. Parenteral vs enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Impaired gastrointestinal transit and its associated morbidity in the intensive care unit. Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective randomized trial. Duodenal versus gastric feeding in the medical intensive care unit patients: a prospective randomized clinical study. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Nutritional outcome and pneumonia in critical are patients randomized to gastric versus jejunal tube feedings. Nutritional and Metabolic Working Group of the Spanish Society of the Intensive Care Medicine and Coronary Units: multicenter, prospective, randomized single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. Prospective randomized controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Enteral Naloxone reduces gastric tube reflux and frequency of pneumonia in critical care patients during opioid analgesia. Metoclopramide for preventing pneumonia in critically ill patients receiving enteral tube feeding: a randomized controlled trial. Erythromycin vs metoclopramide for facilitating gastric emptying and tolerance to intragastric nutrition in critically ill patients. The effect of a polymeric enteral formula supplemented with a mixture of six fibres on normal human bowel function and colonic motility. Digestion and physiological properties of resistant starch I the human large bowel. Soluble fiber improves management of diarrhea in elderly patients receiving enteral nutrition. Gastrointestinal dysmotility is associated with altered gut flora and septic mortality in patients with severe systemic inflammatory response syndrome: a preliminary study. Reduction in diarrhea incidence by soluble fiber in patients receiving total or supplemental enteral nutrition. Effect of a fecal bulking agent on diarrhea during enteral feeding in the critically ill. Soluble fiber reduces the incidence of diarrhea in septic patients receiving total enteral nutrition: a prospective double blind randomized and controlled trial. Comparison of early enteral nutrition in severe acute pancreatitis with prebiotic fiber supplementation versus standard enteral solution: a prospective randomized double-blind study. Probiotic prophylaxis of ventilator-associated pneumonia: a blinded, randomized controlled trial. Effect of enteral nutrition and synbiotics on bacterial infection rates after pyloruspreserving pancreatoduodenectomy: a randomized, double blind trial. Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. Gastric versus duodenal feeding in patients with neurological disease: a pilot Study. Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. A randomized controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients. North American Summit on Aspiration in the Critically Ill Patient: consensus statement. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Can percutaneous endoscopic jejunostomy prevent gastroesophageal reflux in patients with preexisting esophagitis. Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial. Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients. Intermittent enteral feeding: the influence on respiratory and digestive tract colonization in mechanically ventilated intensive care unit patients. Comparison of continuous vs intermittent nasogastric enteral feeding in trauma patients: perceptions and practice. Erythromycin improves gastric emptying in critically ill patients intolerant of nasogastric feeding. Dutch Acute Pancreatitis Study Group: probiotic prophylaxis in predicted severe acute pancreatitis: a randomized, double-blind placebo controlled trial. Impact of the administration of probiotics on mortality in critically ill adult patients: a meta-analysis of randomized controlled trials. Influence of probiotics and fibre on the incidence of bacterial infections following major abdominal surgery-results of prospective trial. Early enteral supply of lactobacillus and fiber versus selective bowel decontamination: a controlled trial in liver transplant recipients. The effects of probiotics in early enteral nutrition on the outcomes of trauma: a metaanalysis of randomized controlled trials. Probiotics for the prevention of antibiotic-associated diarrhea and Clostridium difficile infection among hospitalized patients: systemic review and meta-analysis. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Short bowel syndrome: highlights of patient management, quality of life and survival. A prospective, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nutrition. Hypoenergetic nutrition support in hospitalized obese patients: a simplified method for clinical application. Effect of low calorie parenteral nutrition on the incidence and severity of hyperglycemia in surgical patients: a randomized controlled trial. Metabolic and nutritional support of critically ill patients: consensus and controversies. Classification of acute pancreatitis 2012: revision of the Atlanta Classification and definitions by international consensus. Prognostic value and agreement of achieving lactate clearance or central venous oxygen saturation goals during early sepsis resuscitation. Diagnosis and management of glycogen storage disease type I: a practice guideline of the American College of Medical Genetics and Genomics. Treatment of pyruvate carboxylase deficiency with high dose of citrate and aspartate. Gibbons created and successfully used the first heart­lung machine during an atrial septal defect repair. Four years later, silicone rubber membranes replaced the bubbler oxygenator, allowing the prolonged use of extracorporeal machines. These membranes serve as a gas­oxygen interface and thereby prevent severe hemolysis and plasma leakage. Deoxygenated blood is drained from right femoral vein with catheter tip ideally near right perihepatic inferior vena cava and oxygenated blood returned to right femoral artery. All parts are connected by tubing along with the intravascular cannula(s) on both ends. They are composed of long spirals that separate the gas phase from the blood phase. This design tolerates the high pressure generated by the pump and thus prevents circuit rupture. Short and wide cannulas are ideal for venous drainage because of reduced resistance. In the adult population, a flow of 50 to 80 mL/kg/min is usually sufficient to achieve adequate tissue oxygenation. The highly oxygenated infused blood returns to the systemic circulation, bypassing the pulmonary circulation. For this reason, measuring oxygenation in the right hand is typically performed (when the return cannula is in the femoral artery) as a surrogate to the oxygenation of the heart, coronary arteries, and brain given that the brachiocephalic and right subclavian arteries are closest to the heart. If the right hand displays insufficient oxygenation in the setting of lung disease, then the mixing point is distal to the brachiocephalic artery, and these vital organs (heart and brain) may be receiving insufficient oxygenation. Typically, the sweep gas consists of 100% O2 that flows at an equal rate to circuit blood flow rate (1:1). Most important, blood flow through a circuit is dependent on the size of the draining cannula. The circuit pressure is always negative before the pump and positive after the pump. The ideal anticoagulant would prevent clot formation in the circuit yet have minimal bleeding risk in native blood vessels. Clot-bound thrombin is relatively immune from the effects of heparin because the antithrombin site is occupied. The respiratory rate is set at 5 to 10 breaths/min with prolonged inspiratory times, commonly using an inverse inspiratory:expiratory (I:E) ratio. Drug adsorption to the circuit is increased for lipophilic drugs, such as midazolam and fentanyl. Therapeutic monitoring of drug concentrations is only available for certain medications (eg, vancomycin). Extracorporeal Life Support pain from prolonged bed rest and immobilization, devices, or procedures. A vital part of pain management includes assessment of pain using validated pain scales and scoring systems.

Bladder must be emptied beforehand and preferably the bowel too treatment hyponatremia quality 300 mg zyloprim, as the full bladder and the loaded bowel may raise the level of the fundus of the uterus medications during childbirth generic zyloprim 300 mg online. The uterus is to be centralized and with a measuring tape treatment plan for depression purchase zyloprim 100 mg without prescription, the fundal height is measured above the symphysis pubis medications you cant crush discount 100 mg zyloprim overnight delivery. During the first 24 hours medicine to treat uti purchase zyloprim 100 mg with visa, the level remains constant; thereafter, there is 170 Textbook of Obstetrics a steady decrease in height by 1. The rate of involution thereafter slows down until by 6 weeks, the uterus becomes almost normal in size. Sometimes, the involution may be continued in women who are lactating so that the uterus may be smaller in size - superinvolution. The mucosa remains delicate for the first few weeks and submucous venous congestion persists even longer. Rugae partially reappear at 3rd week but never to the same degree as in prepregnant state. Hymen is lacerated and is represented by nodular tags - the carunculae myrtiformes. Broad ligaments and round ligaments require considerable time to recover from the stretching and laxation. Pelvic floor and pelvic fascia take a long time to involute from the stretching effect during parturition. Color: Depending upon the variation of the color of the discharge, it is named as: (1) lochia rubra (red) 1­4 days, (2) lochia serosa (5­9 days) - the color is yellowish or pink or pale brownish, (3) lochia alba - (pale white) - 10­15 days. Composition: Lochia rubra consists of blood, shreds of fetal membranes and decidua, vernix caseosa, lanugo and meconium. The presence of bacteria is not pathognomonic unless associated with clinical signs of sepsis. Lochia alba contains plenty of decidual cells, leukocytes, mucus, cholesterin crystals, fatty and granular epithelial cells and microorganisms. Amount: the average amount of discharge for the first 5­6 days is estimated to be 250 mL. The red lochia may persist for longer duration especially in women who get up from the bed for the first time in later period. The discharge may be scanty, especially following premature labors or may be excessive in twin delivery or hydramnios. Clinical importance: the character of the lochial discharge gives useful information about the abnormal puerperal state. The vulval pads are to be inspected daily to get information of: Odor: If malodorous-indicates infection. Color: Persistence of red color beyond the normal limit signi es subinvolution or retained bits of conceptus. Duration: Duration of the lochia alba beyond 3 weeks suggests local genital lesion. On the 3rd day, there may be slight rise of temperature due to breast engorgement which should not last for more than 24 hours. However, genitourinary tract infection should be excluded if there is rise of temperature. The common urinary problems are: overdistention, incomplete emptying and presence of residual urine. Only "clean catch" sample of urine should be collected and sent for examination and contamination with lochia should be avoided. Constipation is a common problem for the following reasons: delayed gastrointestinal motility, mild ileus following delivery, together with perineal discomfort. The amount of loss depends on the amount retained during pregnancy, dehydration during labor and blood loss during delivery. Cardiac output rises soon after delivery to about 80% above the prelabor value but slowly returns to normal within 1 week. Leukocytosis to the extent of 25,000/mm3 occurs following delivery probably in response to stress of labor. Platelet count decreases soon after the separation of the placenta but secondary elevation occurs, with increase in platelet adhesiveness between 4 and 10 days. A hypercoagulable state persists for 48 hours postpartum and fibrinolytic activity is enhanced in first 4 days. The increase in fibrinolytic activity after delivery acts as a protective mechanism. If woman does not breastfeed her baby, menstruation returns by 12th week following delivery in 80% of cases. In nonlactating mothers, ovulation may occur as early as 4 weeks and in lactating mothers about 10 weeks after delivery. Duration of anovulation depends upon the frequency (>8/24 hours), intensity and duration of breastfeeding. The physiological basis of anovulation and amenorrhea is due to elevated levels of serum prolactin associated with suckling. In lactating mothers the mechanism of amenorrhea and anovulation are depicted schematically below. Women who is exclusively breastfeeding, the 172 Textbook of Obstetrics contraceptive protection is about 98% up to 6 months of postpartum. However, ovulation may precede the first menstrual period in about one-third and it is possible for the patient to become pregnant before she menstruates following her confinement. Nonlactating mother should use contraceptive measures in 3rd postpartum week and the lactating mother in 3rd postpartum month. Women on thyroid medications should get their thyroid function checked to readjust the drugs. The secretion from the breasts called colostrum, which starts during pregnancy becomes more abundant during the period. It has got a higher specific gravity; a high protein, vitamin A, sodium and chloride content but has got lower carbohydrate, fat and potassium than the breast milk (Table 14. Colostrum and milk contains immunologic components such as immunoglobulin A (IgA), complements, macrophages, lymphocytes, lactoferrin and other enzymes (lactoperoxidase). Microscopically: It contains fat globules, colostrum corpuscles and acinar epithelial cells. The colostrum corpuscles are large polynuclear leukocytes, oval or round in shape containing numerous fat globules. The physiological basis of lactation is divided into four phases: (a) Preparation of breasts (mammogenesis). Mammogenesis: Pregnancy is associated with remarkable growth of both ductal and lobuloalveolar systems. An intact nerve supply is not essential for the growth of mammary glands during pregnancy. Inspite of a high prolactin level during pregnancy, milk secretion is kept in abeyance. When the estrogen and progesterone are withdrawn following delivery, prolactin begins its milk secretory activity in previously fully developed mammary glands. Prolactin, insulin, growth hormone and glucocorticoids are the important hormones in this stage. Discharge of milk from the mammary glands depends not only on the suction exerted by the baby during suckling but also on the contractile mechanism which expresses the milk from the alveoli into the ducts. Oxytocin (e erent arc via blood) is liberated from the posterior pituitary, produces contraction of the myoepithelial cells of the alveoli and the ducts containing the milk. A sensation of rise of pressure in the breasts by milk experienced by the mother at the beginning of sucking is called "draught" is can also be produced by injection of oxytocin. For maintenance of e ective and continuous lactation, frequency of suckling (>8/24 hours) is essential. Ductal and alveolar distension due to failure of milk transfer (suckling) is a cause of lactation failure. Milk pressure reduces the rate of production and hence periodic breastfeeding is necessary. For this purpose a store of about 5 kg of fat during pregnancy is essential to make up any nutritional de cit during lactation. Following delivery important steps are: (i) to put the baby to the breast at 2­3 hours interval from the 1st day, (ii) plenty of fluids to drink and (iii) to avoid breast engorgement. Sulpiride (dopamine antagonist), domperidone has also been found effective by increasing prolactin levels. Lactation suppression: It may be needed for women who cannot breastfeed for personal or medical reasons. Lactation is suppressed when the baby is born dead or dies in the neonatal period or if breastfeeding is contraindicated. Methods commonly used are: (i) to stop breastfeeding, (ii) to avoid pumping or milk expression, (iii) to wear breast support, (iv) ice packs to prevent engorgement, (v) analgesics (aspirin) to relieve pain and (vi) a tight compression bandage is applied for 2­3 days. Medical methods of suppression with estrogen, androgen or bromocriptine is not advised. The side effects of bromocriptine are: hypotension, rebound secretion, seizures, myocardial infarction and puerperal stroke. Breast milk for premature infant is beneficial by many ways (psychological, nutritional and immunological). Metabolic disturbances like azotemia, hyperaminoacidemia and metabolic acidosis are less with breast milk compared to formula. There are methods for collection (manual expression or electric pumps), and milk preservation. Usually the first feeling of mother is the sense of happiness and relief, with the birth of a healthy baby. After a good resting period, the patient becomes fresh and can breastfeed the baby or moves out of bed to go to the toilet. Advantages are: (1) provides a sense of well-being, (2) bladder complications and constipation are less, (3) facilitates uterine drainage and hastens involution of the uterus and (4) lessens puerperal venous thrombosis and embolism. Following an uncomplicated delivery, climbing stairs, lifting objects, daily household work and cooking may be resumed. If adequate supervision by trained health visitors is provided, there is no harm in early discharge. Most women are discharged fit and healthy after 2 days of spontaneous vaginal delivery with proper education and instructions. Some need prolonged hospitalization due to morbidities (infections of urinary tract, or the perineal wound, pain, or breastfeeding problems). If the patient is lactating, high calories, adequate protein, fat, plenty of fluids, minerals and vitamins are to be given (see p. At times, the patient fails to pass urine and the causes are - (1) unaccustomed position and (2) reflex pain from the perineal injuries. Catheterization is also indicated in case of incomplete emptying of the bladder evidenced by the presence of residual urine of more than 60 mL. The underlying principle of the bladder care is to ensure adequate drainage of urine so that infection and cystitis are avoided. If necessary, mild laxative such as isabgol husk two teaspoons may be given at bed time. If there is any discomfort, such as after pain or painful piles or engorged breasts, they should be dealt with adequate analgesics (Ibuprofen). The perineal wound should be dressed with spirit and antiseptic powder after each act of micturition and defecation or at least twice a day. When the perineal pain is persistent, a vaginal and rectal examination is done to detect any hematoma, wound gaping or infection. Nipple soreness is avoided by frequent short feedings rather than the prolonged feeding, keeping the nipples clear and dry. This not only establishes the mother-child relationship but the mother is conversant with the art of baby care so that she can take full care of the baby while at home. Liberal use of local antiseptics, aseptic measures during perineal wound dressing, use of clean bed linen and clothings are positive steps. Clean surroundings and limited number of visitors could be of help in reducing nosocomial infection. Mandatory postponement of pregnancy for at least 2 months following vaccination can be easily achieved. Presence of blood clots or bits of after births lead to hypertonic contractions of the uterus in an attempt to expel them out. Pain on the perineum: Never forget to examine the perineum when analgesic is given to relieve pain. Correction of anemia: Majority of the women in the tropics remain in an anemic state following delivery. Supplementary iron therapy (ferrous sulfate 200 mg) is to be given daily for a minimum period of 4­6 weeks. This also includes the correct principle of lifting and working positions during day-to-day activities. Advantages gained thereby are: (1) to minimize the risk of puerperal venous thrombosis by promoting arterial circulation and preventing venous stasis, (2) to prevent backache and (3) to prevent genital prolapse and stress incontinence of urine. The common exercises prescribed are: (a) To tone up the pelvic floor muscles: the patient is asked to contract the pelvic muscles in a manner to withhold the act of defecation or urination and then to relax. The abdominal muscles are contracted and relaxed alternately and the process is to be repeated several times a day. Sexual activity may be resumed (after 6 weeks) when the perineum is comfortable and bleeding has stopped.

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Personal history: Contraceptive practice prior to pregnancy medicine for yeast infection 100 mg zyloprim with mastercard, smoking or alcohol habits are to be enquired medicine to stop diarrhea generic zyloprim 300 mg buy on line. Previous history of blood transfusion medications hyperkalemia buy zyloprim 300 mg low cost, corticosteroid therapy symptoms bladder cancer purchase zyloprim in india, any drug allergy and immunization against tetanus or prophylactic administration of anti-D immunoglobulin are to be enquired medications causing tinnitus purchase zyloprim with amex. Nutrition: Good/average/poor Height: Short stature is likely to be associated with a small pelvis. Thus, in primigravidae, the height is to be measured to screen out the short stature. Repeated weight checking in subsequent visit should preferably be done in the same weighing machine. Pallor: the sites to be noted are lower palpebral conjunctiva, dorsum of the tongue and nail beds. Jaundice: the sites to be noted are bulbar conjunctiva, under surface of the tongue, hard palate and skin. Tongue, teeth, gums and tonsils: Evidences of malnutrition are evident from glossitis and stomatitis. Evidence of any source of infection in the mouth is to be eradicated least there be a chance of autogenous infection in puerperium. Slight physiological enlargement of the thyroid gland occurs during pregnancy in 50% of cases. The sites for evidence of edema are over the medial malleolus and anterior surface of the lower one-third of the tibia. Causes of edema in pregnancy: (1) Physiological (2) Preeclampsia (3) Anemia and hypoproteinemia (4) Cardiac failure (5) Nephrotic syndrome. Dependent edema is physiological in pregnancy but generalized edema (anasarca) or facial edema can be a first sign of disease. Physiological edema: the cause of physiological edema is due to increased venous pressure of the inferior extremities by the gravid uterus pressing on the common iliac veins. The features of the physiological edema are: (1) slight degree (ankle edema), usually confined to one leg, more on the right, (2) unassociated with any other features of preeclampsia or proteinuria, (3) disappears on rest alone, (4) other pathologies of cardiac, renal and hematological are absent. Systemic examination: Heart, Lungs, Liver and Spleen: Breasts: Examination of the breasts helps to note the presence of pregnancy changes but also to note the nipples (cracked or depressed) and skin condition of the areola. The purpose is to correct the abnormality; if any, so that there will be no difficulty in breastfeeding immediately following delivery. Vaginal: Examination is done in the antenatal clinic when the patient attends the clinic for the first time before 12 weeks. It is done: (1) to diagnose the pregnancy, (2) to corroborate the size of the uterus with the period of amenorrhea and (3) to exclude any pelvic pathology. Internal examination is, however, omitted in cases with previous history of miscarriage, occasional vaginal bleeding in present pregnancy. Steps of vaginal examination: Vaginal examination is done in the antenatal clinic. The patient must empty her bladder prior to examination and is placed in the dorsal position with the thighs flexed along with the buttocks placed on the foot-end of the table. Hands are washed with soap and a sterile glove is put on the examining hand (usually right). Inspection: By separating the labia-using the left two fingers (thumb and index), the character of the vaginal discharge, if any, is noted. Speculum examination: this should be done prior to bimanual examination, especially when the smear for exfoliative cytology or vaginal swab is to be taken. The cervix and the vault of the vagina are inspected with the help of good light source placed behind. Cervical smear for exfoliative cytology or a vaginal swab from the upper vagina, in presence of discharge, may be taken. Bimanual: Two fingers (index and middle) of the right hand are introduced deep into the vagina while separating the labia by left hand. Gentle and systematic examinations are to be done to note: (1) Cervix: consistency, direction and any pathology. Early pregnancy is the best time to correlate accurately uterine size and duration of gestation. If signi cant proteinuria is found, "clean catch" specimen of midstream urine is collected for culture and sensitivity test. To collect the midstream urine, the patient is advised to clean the vulva and to collect the urine in a clean container during the middle of the act of urination. Presence of nitrites and/or leukocyte esterase by dipstick indicates urinary tract infection (p. Cervical cytology study by Papanicolaou stain has become a routine in many clinics. Booking (18­20 weeks) scan has got advantages in addition to first trimester scan: (i) detailed fetal anatomy survey and to detect any structural abnormality including cardiac, (ii) placental localization. Ultrasound examination is performed as a routine at 18­20 weeks though doubt remains about its absolute benefit. Repetition of the investigations: (1) Hemoglobin estimation is repeated at 28th and 36th week. Ideally, this should be more flexible depending on the need and the convenience of patient. Objectives: (A) To assess: (1) fetal well-being, (2) lie, presentation, position and number of fetuses, (3) anemia, preeclampsia, amniotic fluid volume and fetal growth, (4) to organize specialist antenatal clinics for patients with problems like cardiac disease and diabetes. History: To note: (1) appearance of any new symptom (headache, dysuria), (2) date of quickening. Examination: General: In each visit, the following are checked and recorded: (1) weight, (2) pallor, (3) edema legs, (4) blood pressure. Abdominal examination: Inspection: Abdominal enlargement, pregnancy marks-linea nigra, striae, surgical scars (midline or suprapubic). Vaginal examination: Vaginal examination in the later months of pregnancy (beyond 37 weeks) with an idea to assess the pelvis is not informative. Pelvic assessment is best done with the onset of labor or just before induction of labor. Methods of vaginal examination for assessment of the pelvis and test for cephalopelvic disproportion are described in Chapter 24. Ongoing assessment and counseling is important as prenatal care has an educational opportunity. The woman should be informed about the list of warning signs so that she can contact the hospital or avail the nearby health-care facilities in time (see below). During pregnancy, there is increased calorie requirement due to increased growth of the maternal tissues, fetus, placenta and increased basal metabolic rate. The increased calorie requirement is to the extent of 300 over the nonpregnancy state during second half of pregnancy. Excessive weight gain increases antepartum and intrapartum complications including fetal macrosomia. In terms of figures, the daily requirement during pregnancy and lactation is given in Table 10. The diet should consist in addition to the principal food at least half liter, if not, 1 liter of milk (1 liter of milk contains about 1 g of calcium), plenty of green vegetables and fruits. At least, half of the total protein should be first class containing all the amino acids and majority of the fat should be animal type which contains vitamins A and D. Dietetic advice should be given with due consideration to the socioeconomic condition, food habits and taste of the individual. The instruction about diet should be reasonable and realistic to individual women. Chapter 10 Antenatal Care, Preconceptional Counseling and Care 113 Supplementary nutritional therapy: As previously mentioned, there is negative iron balance during pregnancy and the dietetic iron is not enough to meet the daily requirement especially in the second half of the pregnancy. Thus, supplementary iron therapy is needed for all pregnant mothers from 16 weeks onwards. Above 10 g% of hemoglobin, 1 tablet of ferrous sulfate (Fersolate) containing 60 mg of elemental iron is enough. The dose should be proportionately increased with lower hemoglobin level to 2­3 tablets a day. As the essential vitamins are either lacking in the foods or are destroyed during cooking, supplementary vitamins are to be given daily from 20th week onwards (Table 10. However, excessive and strenuous work should be avoided especially in the first trimester and the last 4 weeks. Recreational exercise (prenatal exercise class) is permitted as long as she feels comfortable. However, on an average, the patient should be in bed for about 10 hours (8 hours at night and 2 hours at noon), especially in the last 6 weeks. Regular bowel movement may be facilitated by regulation of diet taking plenty of fluids, vegetables and milk or prescribing stool softeners at bedtime. Bathing: the patient should take daily bath but be careful against slipping in the bathroom due to imbalance. High heel shoes should better be avoided in advanced pregnancy when the center of balance alters. This will facilitate extraction or filling of the caries tooth, if required, comfortably in the second trimester. Care of the breasts: Breast engorgement may cause discomfort during late pregnancy. Release of prostaglandins and oxytocin with coitus may cause uterine contractions. Women with increased risk of miscarriage or preterm labor should avoid coitus if they feel such increased uterine activity. Travel: Travel by vehicles having jerks is better to be avoided, especially in first trimester and the last 6 weeks. Air travel is contraindicated in cases with placenta previa, preeclampsia, severe anemia and sickle cell disease. Prolonged sitting in a car or aeroplane should be avoided due to the risk of venous stasis and thromboembolism. Smoking and alcohol: In view of the fact that smoking is injurious to health, it is better to stop smoking not only during pregnancy but even thereafter. Similarly, alcohol consumption is to be drastically curtailed or avoided, so as to prevent fetal maldevelopment or growth restriction (see p. In the developing countries, immunization in pregnancy is a routine for tetanus; others are given when epidemic occurs or traveling to an endemic zone or for traveling overseas. Live virus vaccines (rubella, measles, mumps, varicella, yellow fever) are contraindicated. However in certain circumstances, risk or benefit assessment should be made before making decision. Drugs: Almost all the drugs given to mother will cross the placenta to reach the fetus. Possibility of pregnancy should be kept in mind while prescribing drugs to any woman of reproductive age (see p. She is instructed to report to the physician even at an early date if some untoward symptoms arise such as intense headache, disturbed sleep with restlessness, urinary troubles, epigastric pain, vomiting and scanty urination. She is advised to come to hospital for consideration of admission in the following circumstances: Painful uterine contractions at interval of about 10 minutes or earlier and continued for at least 1 hour-suggestive of onset of labor. Sudden gush of watery uid per vaginam-suggestive of premature rupture of the membranes. They usually appear following the first or second missed period and subside by the end of first trimester. Physiological changes that contribute to backache are: joint ligament laxity (relaxin, estrogen), weight gain, hyperlordosis and anterior tilt of the pelvis. Other factors may be faulty posture and high heel shoes, muscular spasm, urinary infection or constipation. Improvement of posture, well-fitted pelvic girdle belt which corrects the lumbar lordosis during walking and rest in hard bed often relieve the symptom. Massaging the back muscles, analgesics and rest relieve the pain due to muscle spasm. Atonicity of the gut due to the effect of progesterone, diminished physical activity and pressure of the gravid uterus on the pelvic colon are the possible explanations. Leg cramps: It may be due to deficiency of diffusible serum calcium or elevation of serum phosphorus. Supplementary calcium therapy in tablet or syrup after the principal meals may be effective. Massaging the leg, application of local heat and intake of vitamin B1 (30 mg) daily may be effective. Acidity and heartburn: Heartburn is common in pregnancy due to relaxation of the esophageal sphincter. Patient is advised to avoid over eating and not to go to bed immediately after the meal. Hiatus hernia which is common during the pregnancy can also produce heartburn, especially when the patient is in lying down position. Sleeping in semi-reclining position with high pillows relieves the symptoms of hiatus hernia. Chapter 10 Antenatal Care, Preconceptional Counseling and Care 115 Varicose veins: Varicose veins in the legs and vulva (varicosities) or rectum (hemorrhoids) may appear for the first time or aggravate during pregnancy, usually in the later months. For leg varicosities, elastic crepe bandage during movements and elevation of the limbs during rest can give symptomatic relief. Hemorrhoids: It may cause annoying complications like bleeding or may get prolapsed. Regular use of laxative to keep the bowel soft, local application of hydrocortisone ointment and replacement of the piles if prolapsed are essential. Surgical treatment is better to be withheld as the condition sharply improves following delivery. Carpal tunnel syndrome (10%): Woman presents with pain and numbness in the thumb, index and the middle finger.

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