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By: E. Tjalf, M.B. B.CH., M.B.B.Ch., Ph.D.

Co-Director, Florida Atlantic University Charles E. Schmidt College of Medicine

Phenylephrine results in higher umbilical cord pH as ephedrine crosses the placenta and stimulates the fetal sympathetic system infection white blood cell count cheap 100 mg zithrocin visa, resulting in increased oxygen consumption with lactic acidosis treatment for dogs bite cheap zithrocin american express. In the supine position virus hunter island buy zithrocin 250 mg line, up to 15% of pregnant patients develop nausea, hypotension, and vomiting (supine hypotension syndrome). The supine position allows the gravid uterus to compress the inferior vena cava and aorta. Compression of the vena cava results in decreased venous return to the right atrium and subsequent decreased cardiac output. This decrease in venous return may be compensated by the sympathetic nervous system. Anesthetic drugs and techniques blunt the sympathetic response and prevent compensation. By tilting the patient to the left, the uterus is displaced off the vena cava and aorta. The uterus should be tilted to the left by placing a wedge underneath the right hip. There is vascular engorgement of the airway, resulting in possible edema of the oral and nasal pharynx, larynx, and trachea. Exacerbation of these changes may occur in patients with upper respiratory tract infections or preeclampsia. Manipulation, such as nasal intubation or the insertion of a nasogastric tube, may result in excessive bleeding. This decrease results in a reduction in blood pressure and in cardiac output with an increase in heart rate. Usually, the term parturient may compensate with activation of the sympathetic nervous system. In the supine position, cardiac output decreases typically 12% while blood pressure 20%. It is important to maintain left uterine displacement to avoid this supine hypotension syndrome. Aortocaval compression in pregnancy: the effect of changing the degree and direction of lateral tilt on maternal cardiac output. This decrease is a result of decreases in both residual and expiratory reserve volumes. Oxygen consumption increases by 20% due to increased metabolism and increased work of breathing. The parturient compensates for this increased oxygen consumption in two ways: (1) increased alveolar ventilation and (2) shifting the oxyhemoglobin dissociation curve to the right, thus facilitating unloading of oxygen at the cellular level. Total lung capacity is unchanged due to widening of the thoracic anteroposterior diameter. In going from nonpregnant to pregnant, the parturient experiences an increase in tidal volume, a decrease in expiratory reserve and residual volume, and no change in inspiratory reserve volume. After complete denitrogenation by breathing 100% oxygen, nonpregnant patients tolerate 9 minutes of apnea before oxygen saturation is less than 90%, whereas parturients may only tolerate 2 to 3 minutes. This increase results primarily from increased tidal volume and secondarily from a small increase in respiratory rate. Decreased serum bicarbonate from 26 mm Hg to 22 mm Hg through increased renal excretion results in a partially compensated respiratory alkalosis. The third trimester and labor are the time periods in which the parturient is at the greatest risk for regurgitation and aspiration of gastric contents during induction of general anesthesia or any other loss of consciousness. This displacement changes the angle of the gastroesophageal junction, decreasing competence of the gastroesophageal sphincter. Plasma volume increases 45% but the red cell mass increases only 20%, leading to the physiologic (dilutional) anemia of pregnancy. The increase in blood volume allows the parturient to tolerate the blood loss accompanying normal childbirth without hemodynamic consequences. The minimum alveolar concentration for inhaled anesthetics decreases up to 40% during pregnancy. The mechanism is unclear, although it may be related to progesterone (which has sedative activity) and endorphins. A concentration of an inhalation agent that may not produce loss of consciousness in nonpregnant patients may render pregnant women unconscious, placing the parturient at risk for aspiration.

Diseases

• Mesomelic dwarfism Nievergelt type
• Thyroid, renal and digital anomalies
• Shoulder and thorax deformity congenital heart disease
• Neuroaxonal dystrophy renal tubular acidosis
• Myopathy tubular aggregates
• Dysautonomia
• Scotoma
• Thyroid hormone plasma membrane transport defect
• Crouzonodermoskeletal syndrome
• Fanconi syndrome

As the uterus grows acticoat 7 antimicrobial dressing buy zithrocin with mastercard, a certain amount of pulling and stretching of pelvic structures occurs antibiotic resistance definition generic zithrocin 100mg amex. Round ligament pain virus jokes purchase zithrocin now, which results from the stretching of the round ligaments that are attached to the top of the uterus on each side and the corresponding lateral pelvic wall, is common. Palpable uterine contractions (Braxton Hicks contractions) that are mild and irregular can begin during the second trimester. A low-lying placenta that causes bleeding at this stage usually moves away from the cervix as the uterus grows. Infants born at the end of the second trimester have an 80% to 90% chance of survival. When dilation or effacement of the cervix occurs, tocolytic agents are necessary to prevent delivery (see Chapter 15). Pain in the lower back and legs is often caused by pressure on muscles and nerves by the uterus and fetal head, which fills the pelvis at this time. Lightening is the descent of the fetal head to or even through the pelvic inlet due to the development of a well-formed lower uterine segment and a reduction in the volume of amniotic fluid. Motion (1) A decrease in fetal motion usually occurs because of the size of the fetus and lack of room within the uterus. However, some decreased fetal activity may indicate fetal compromise due to uteroplacental insufficiency. Bloody show, a discharge of a combination of blood and mucus caused by thinning and stretching of the cervix, is a sure sign of the approach of labor. Heavy bleeding suggests a more serious condition such as placenta previa (the placenta developing in the lower uterine segment and completely or partially covering the internal os, usually painless bleeding) or abruptio placentae (premature separation of the normally implanted placenta, usually painful bleeding) (see Chapter 9). Rupture of membranes is either a sudden gush or a slow leak of amniotic fluid that can happen at any time without warning. Brownish or greenish fluid may represent meconium staining of the fluid, the sign of a fetal bowel movement that may or may not represent fetal stress. At term, induction of labor is indicated if there is no labor within 6 to 24 hours of rupture or if there is any evidence of infection (chorioamnionitis). Contractions that occur at decreasing intervals with increasing intensity cause the progressive dilation and effacement of the cervix. A normal fetus weighs approximately 1,000 g (more than 2 lb) at 26 to 28 weeks, 2,500 g (5. Fetal lung maturity can be assessed by measuring surface-active lipid components of surfactant. Studies have shown that when the level of lecithin in amniotic fluid increases to at least twice that of sphingomyelin (at approximately 35 weeks), the risk of respiratory distress is very low. The presence of phosphatidylglycerol in the amniotic fluid provides even more definite assurance of lung maturity. This stress increases fetal cortisol secretion, which in turn accelerates fetal lung maturation. Administration of glucocorticoids to mothers between the 24th and 34th week of pregnancy effects an increase in the rate of maturation of the human fetal lung and is associated with a reduced rate of respiratory distress in their prematurely born infants. B Lie of the fetus is the relation of the long axis of the fetus to the long axis of the mother and is either longitudinal or transverse. In most labors (more than 99%) at term, the fetal head is either up or down in a longitudinal lie. This indicates an unstable situation that becomes either a longitudinal or transverse lie during the course of labor. C Fetal presentation is determined by the portion of the fetus that can be felt through the cervix. Cephalic presentations are classified according to the position of the fetal head in relation to the body of the fetus. The head is flexed so that the chin is in contact with the chest, and the occiput of the fetal head presents. The neck is extended sharply so that the occiput and the back of the fetus are touching, and the face is the presenting part. The fetal head is extended partially but converts in to a vertex or face presentation during labor. Breech presentations are classified according to the position of the legs and buttocks, which present first. In an incomplete breech, one hip is not flexed, and one foot or one knee lies below the breech.

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No parental permission is necessary to screen for violence in an adolescent or young female bacteria biology generic 250mg zithrocin free shipping. Children who witness violence are more likely to be perpetrators or victims of violence as adults not less likely antibiotics tired order zithrocin online now. If a woman is too intoxicated to give consent to sex treatment for dogs eye discharge cheap zithrocin 100 mg line, then there is sexual assault. In medicine, the law permeates, defines, and regulates the relationship between the physician and patient, the physician and hospital, and the physician and society. Moreover, legal issues dealing with access to medical care and consumer demands regarding health care are dominant in public policy discussions. Obstetrics and gynecology is at the cutting edge of these matters because the field involves the most critical aspects of life: conception, reproduction, and pregnancy. Thus, it is important for the student of medicine to understand, in a preliminary fashion, the legal issues that involve the practice of obstetrics and gynecology. B Elements of negligence A plaintiff must prove four elements of a case to be successful in a claim for medical negligence 1. In accordance with standards established or accepted by a reasonable fraction of the profession practicing in a given area b. As a reasonable physician, taking reasonable care of a patient and not taking unreasonable risks 2. A physician who fails to act in accordance with professional norms has departed from the standard of care and has committed a breach of the duty owed to the patient. Actual loss, injury, or damage must have occurred, although pain and suffering is a common accompaniment. C Recovery the patient or plaintiff must prove that it is more probable than not that the elements of negligence are satisfied (preponderance of evidence) to recover compensation for the damage incurred. The right to use contraception was the earliest right to reproductive freedom (Griswold v Connecticut, 1965). Most lawsuits regarding hormonal contraceptives are product liability cases against the manufacturer. The general rule is that a manufacturer must provide patients with a written warning of all untoward side effects. A physician must inform patients of the possible side effects and explain the alternative methods of contraception. C Sterilization this surgical procedure is undertaken for the express purpose of eliminating reproductive capacity. Counsel the patient that there is no guarantee of sterility; pregnancy occurs at a rate of 15 to 20 per 1,000 cases over 10 years, with ectopic pregnancy more frequent when pregnancy does occur f. A Consent and counseling for a prenatal genetic testing should include documentation of 1. Reproductive options Medicolegal Considerations in Obstetrics and Gynecology 493 6. Likely disease course of diagnosed condition Risks of test procedures Limitations of test procedures Length of time required to complete testing B An obstetrical provider is obligated to 1. Obtain detailed patient, family, and ethnic/racial histories to determine which prospective parents are at increased risk. The obstetrical provider does not have to obtain the information herself; she may refer the patient to a medical geneticist or genetic counselor for evaluation. Testing for cystic fibrosis should be discussed and offered at the preconceptional and/or prenatal visit. Prenatal multiple marker testing to determine the risk of neural tube defects and Down syndrome should be offered to all women, including those younger than 35 years of age.

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