By W. Grobock. Marylhurst University.

Make a In the event of blood loss the maternal circulation is maintained brief assessment of the fundal height purchase mobic 15mg fast delivery, noting any significant uterine by diverting blood away from the uterus with only minimal change tenderness effective 7.5 mg mobic. A fundal height below the umbilicus suggests that if the to the patient vital signs cheap mobic 7.5mg on line. The pregnant patient may tolerate a loss fetus is delivered it is unlikely to survive. The introitus should then of up to 20% of their circulating volume without showing clinical be inspected for foetal parts, cord prolapse and significant bleeding. With continued blood loss and reduced ability to compensate due to limited cardiorespiratory reserve there will Box 28. This hypercoagulable state increases the risk of B Breathing deep vein thrombosis and pulmonary embolism. C Circulation D Disability E Exposure Uterus F Fundus / Foetus Uterine growth is the most important anatomical change and will clearly affect the presentation of abdominal disease and trauma. The most anterior presenting organ and therefore the most susceptible patient will often have hand-held maternity notes which may assist you in identifying potential problems. Gestation in weeks Estimated date of delivery Which hospital she is booked into Midwife or obstetric consultant care Complications in this pregnancy Nature of bleeding/pain/fluid loss/discharge Subjective assessment of foetal movements. It usually presents after 20 weeks, but can occur the practitioner has the requisite skills. The uterus should be palpated for tenderness, rigidity, contractions, • Severe pre-eclampsia is characterized by greatly elevated blood foetalpartsandmovements. Iftherehasbeenaspontaneousrupture pressure (>170/110 mmHg), proteinuria and one or more of of membranes the colour of the liquor should also be assessed for the following symptoms: severe headache, visual disturbance, blood or meconium staining. It generally occurs in the third Antenatal emergencies trimester, with 60% of cases reported in the intrapartum period Antepartum haemorrhage or within 48 hours after parturition. The incidence is higher Antepartum haemorrhage is vaginal bleeding after 24 completed in developing countries. The common causes are placental abruption lasting 90 seconds or less, but may be severe and recurrent. The result is Managementofseverepre-eclampsiaandeclampsiarequiresurgent bleeding from the maternal sinuses into the space between the transfer to an obstetric unit. Blood may remain concealed or left lateral position for transfer and oxygen applied if SpO2 <94%. Abruption Monitor the blood pressure en route and pre-alert the obstetric unit usually presents with severe abdominal pain and a hard, tender so that they can prepare drugs and/or theatre. Delay in presentation (up to 48 hours) is not uncommon shouldbemanagedinitiallywithbasicairwayadjucts(e. Further seizures can be prevented • Placenta praevia is when the placenta implants either completely by giving magnesium sulphate 4 g intravenously/intraosseously or partially across the cervical os. If magnesium sulphate is not available and the pregnancy because of intercourse or contractions the tearing of patient has recurrent or prolonged seizures consider parental or maternal blood vessels close to the cervical canal leads to blood rectal benzodiazepines. Emergency prehospital delivery Management of antepartum haemorrhage involves urgent Less than 1% of booked hospital deliveries are born before arrival at transfer to an obstetric unit. Neonatal consequences include a slightly higher perinatal access should be made en route and fluid resuscitation mortality rate (relative risk 5. Pre-eclampsia is a multisystem disorder consisting chiefly of elevated blood pressure (>140/90 mmHg), proteinuria with or First stage of labour The first stage of labour involves cervical effacement and dilatation to 10 cm. There will be an increase in frequency and intensity of Placental abruption Placenta previa contractions during this stage. Second stage of labour The second stage begins when the cervix is fully dilated and is completed with delivery of the baby. In the absence of a midwife able to perform a vaginal examination, the second stage will usually be recognized when the head becomes visible at the introitus (crowning). At this stage delivery is imminent and an emergency prehospital delivery should be prepared for. Allow the head to deliver with gentle support to the perineum Care of Special Groups: The Obstetric Patient 153 (a) (b) (c) Figure 28. Encouraging the mother to pant or breathe through her contractions at this stage will also help control the delivery of the head. If cord is seen around the neck it can be left alone as the body will usually deliver through the loops. The exaggerated Sim’s position should be used to transfer the patient with cord prolapse. The mother is laid on her left side with her head Third stage of labour flat and her buttocks elevated by pillows (Figure 28.

Special precautions Phosphorus-32 is excreted predominantly in the urine discount mobic 7.5mg amex, although some faecal excretion does occur 7.5 mg mobic amex. Patients should be advised to observe rigorous hygiene for the first two days after administration cheap mobic 7.5 mg without a prescription, to avoid contaminating others using the same toilet. Follow-up Haematological profiles should be obtained at monthly intervals to assess the response. Phosphorus-32 is generally reserved for patients who cannot be relied on to take hydroxyurea according to instructions, and for the elderly. The 32 increased risk of the development of acute myelogenous leukaemia in P treated patients should be taken into consideration during follow-up. Clinical benefits Radiation synovectomy, also known as synoviorthesis or synoviolysis, has become a well established method in the local therapy of inflammatory joint disorders. Many patients with chronic synovitis refractory to medical treatment respond to intra-articular radionuclide therapy. Primary treatment failures or relapses may be successfully treated by re-injection. Patients with less destructive radiographic changes, joint disease of shorter duration and localized disease tend to respond more favourably. Physiological basis The use of intra-articular radiocolloids to treat inflammatory arthritis was first reported as early as the 1950s using 198Au-colloid. The villi have a secretory function and determine the amount and content of the synovial fluid that lubricates the joint. In inflammatory arthritis and the rheumatoid variants, inflammatory changes develop that increase vascularity and result in synovial layer proliferation, lymphocytic infiltration, effusions, fibrosis and pannus formation. The goal of the technique is to destroy the diseased pannus and inflamed synovium by direct irradiation, with the expectation that, following destruction, the regenerated synovium will be free of disease. Histological changes include reduction of cellular infiltrations and, eventually, sclerosis of the synovium. In the last thirty years, several other radiocolloids have been developed using 90Y, 32P, 165 166 186 Dy, Ho and Re as radionuclides. Indications and contraindications The indications for radiosynovectomy are: —Rheumatoid arthritis (with persistent effusions); —Inflammatory joint diseases other than rheumatoid arthritis; —Pigmental villonodular synovitis; —Haemophilic joint disease; —Chronic pyrophosphate arthropathy; —Persistent effusion after knee prosthesis; —Baker’s cyst; —Activated arthropathy; —Polyarthrosis of finger joints. The absolute contraindications for radiosynovectomy are: —Pregnancy; —Continued breast feeding. The relative contraindications for radiosynovectomy are: —Periarticular sepsis; —Overlying cellulitis; —Bacteraemia; —An unstable joint; —Intra-articular fracture; —A septic joint. Patient selection Patients are eligible if there is inadequate relief after six months of conservative treatment with corticosteroids. Radiosynovectomy has been demon- strated to be successful only if a clear synovitis is indicated by three phase bone scintigraphy, especially in patients with arthrosis (or arthrosis– arthritis). Colloids Because of its deep tissue penetration, 90Y-colloid is suitable for the knee and in joints with greatly thickened synovium. For joints of intermediate size 186 (wrist, elbow, shoulder and hip) Re-colloid has been successfully used and for the smallest joints (phalanges) 169Er-colloid. Yttrium-90 has been bound to silicate, citrate and ferric hydroxide 90 compounds as colloids. Currently, it is most frequently used as Y-citrate, which ranges in particle size from 10 to 100 nm. Leakage estimates for 90Y- citrate range from 5 to 10% after 24 hours and from 15 to 25% after 4 days. Owing to its small particle size, and thus higher leakage, 198Au is no longer recommended. Dysprosium-165 macroaggregates 165 In order to reduce leakage from the synovial space, Dy-ferric hydroxide macroaggregates have been applied for joint therapy. The particle size averages 5 mm and the activity that does leak from the joint quickly decays 165 (with a half-life of Dy of 139 min), thus reducing extraneous organ irradiation. Dose and route of administration It is assumed that intra-articular colloids are uniformly distributed over the joint surfaces. The most apparent problem is leakage from the joint space, primarily by lymphatic clearance, which depends largely on particle size. Leakage is reduced by a flushing injection of a long acting steroid (such as prednisolone acetate) after radiopharmaceutical injection. Biplanar radiographs with the joint positioned at the injection angle are mandatory to correlate palpable bone landmarks as a guide for needle placement. Following injection, the needle position is checked fluoroscopically using a few millilitres of contrast material. The joint is then manipulated through as full an arc as is possible of extension and flexion to distribute the particles throughout the joint space, following which it is splinted to minimize leakage. Early complications Early complications include: —Transient increase in pain; —Radiodermatitis at the injection site (best prevented by flushing with a steroid); —Septic arthritis; —Acute crystal synovitis; —Transient lymphoedaema. Long term complications Long term complications include: —Chromosomal aberrations in circulating lymphocytes; —Chronic myeloid leukaemia (a single case); —No cancers were found in any of the joints treated.

Chromosome Reciprocal translocation is an exchange of analysis of the parent with the family history 4 der(4) chromosomal material between two non- is a straight forward investigation which will homologous chromosomes resulting in the exclude chromosome translocations except same total number of chromosomes mobic 15mg on-line. A cryptic transloca- translocations are individually very rare generic 15 mg mobic amex, and tion cannot be identifed by conventional cyto- it is often diffcult to predict the likelihood of genetics; to date mobic 15 mg, this can only be diagnosed a fetus having an unbalanced karyotype as the using fuorescent in situ hybridization. If they would not consider having a It currently is recommended that all women cytogenetics as they are beyond the resolution pregnancy that might be affected and take folic acid prior to as well as after con- of the microscopes used. Spina bifda incidence has reduced Chromosome markers chromosomes for analysis have improved over since the recommendation of periconceptional available options are: the past 15 years; therefore, a karyotype may i. Avoid further pregnancy; folic acid and through the fortifcation of all Marker chromosomes are small extra parts of wheat products in some countries such as need to be repeated if it was performed many ii. In couples who have fected, it is unlikely to cause problems in a Preconceptional counseling considerations already had a baby with spina bifda it is rec- baby. Chromosome markers can potentially Preconceptional counseling is more preferable ommended that 5mg daily is taken rather than reduce fertility and lead to imprinting defects. Marker chromosomes are frequently identi- information gathering and molecular testing when considering a future pregnancy: Folic acid is also said to reduce the recurrence fed only in a proportion of cells (chromosome may take a prolonged length of time resulting risk of cleft lip and palate, and women with a mosaicism, i. Do they wish to investigate the possi- for cystic fbrosis mutations which account for Certain common disorders may be amena- more than 50% of this group17–19. They are common genetic diseases present in 1:500 men and is increasing in inci- with a high carrier frequency in specifc popu- dence for undetermined reasons. Accessing the target a proportion of men with azoospermia, but the population remains a challenge as on average cause of the infertility may then be passed on. The majority of myotonic dystrophy should be carefully coun- Marfan’s syndrome has a prevalence of improve during the pregnancy only to affected patients have mild learning diffcul- seled regarding their own health and the risk 1–5:10,000, the major physical features being deteriorate postnatally. Maternal age for frst pregnancy is increas- 21 span 10% more than the height, high arched festations and possibly leiomyomata of the counseling is strongly recommended. The patient may wish to undergo inva- ness in pregnancy that is rare in younger complications are lens dislocation and dissect- sive prenatal diagnosis in view of the approxi- women, such as coronary artery disease. There may be no previous family Marfan’s syndrome may be identifed in the These rarely cause fetal/neonatal compromise All autosomal dominant diseases that affect history of the disease. Two genes have been fetus on ultrasound but normally this is the and disappear over the frst year of life but one parent have a 50:50 chance of being passed on to the fetus. The majority are inher- Ehlers Danlos syndrome type I however, many women may be taking beta- Many women with successfully repaired con- ited as an autosomal dominant trait, and the blockers and a few will have implantable car- genital heart disease are now becoming preg- penetrance is highly variable. Conotruncal and careful assessment needs to be undertaken are not given to affected women as they may Respiratory disease cardiac defects are the commonest type of prior to pregnancy. All couples where larly carefully monitored, and anticoagulation may make patients more vulnerable to arrhyth- Cystic fbrosis one parent is affected should be offered either may be required. It is advisable that the partner tion, may become hypocalcemia if the mother and beyond the scope of this chapter, includ- it is a diffcult diagnosis to confrm in the is tested for cystic fbrosis. Referral to a cardiologist spe- mutations in the northern European popula- Cardiomyopathy cializing in inherited cardiac disease is advis- tion, 90% can be screened. Valproic acid embryopathy: report Phenylketonuria Increased osteopenia may occur during the Periconceptional counseling in of two siblings with further expansion of the postnatal period. Spinal anesthesia is unlikely to be contra- normal antenatal services and equally impor- Neurology 2005;64:961–5 phenylalanine diet needs to be followed pre- indicated but may be technically challenging. It Systemic lupus erythematosus Growth until puberty after in utero exposure syndrome may have partial expression in a girl, is a urea cycle defect resulting in hyperam- to coumarins. Treatment consists of Diabetes mellitus (diabetic embryopathy) a baby, and family discussions and involvement 2008;11:324–30 a low protein diet and arginine supplementa- Diabetes mellitus is the most common chronic of social services are entirely appropriate. The partner tions der(13;14): frequencies of reproductive ceptional counseling for diabetic mothers is may also have learning diffculties and details outcomes and infertility in 101 pedigrees. Am J Women with skeletal dysplasia are not at well recognized and does not need to be reiter- of the cause of his problems may also need to Med Genet A 2008;146A:2611–6 high risk during pregnancy, and no par- ated in this chapter (see Chapters 5 and 32). When published their frst reports regarding the these environmental conditions change rap- association between reduced fetal growth idly, the fetus who later becomes an adult is and a number of conditions occurring later in exposed to a different environment than the life. At the beginning of Low birth weight obviously may serve as an the 21st century, Bateson and Barker pub- indicator of a disrupted intrauterine environ- lished their ‘developmental plasticity theory’5. This indicates that small morbidity in offspring, one should try to look well as by changing the secretion of several been recognized for decades and thoroughly Indian babies have small abdominal viscera into the assumed mechanism by which this investigated, as noted above. This may affect fetal ing frst and second trimester of pregnancy) ity, and that low maternal intake of B12 but to illustrate how cell differentiation (i. Such fndings highlight onstrated that maternal diet during preg- fnding is now thought to be an indicator of 8 (diabetes and osteoporosis) in adult life. It draws upon its genetic milieu the offspring, although sharing the same coat- mother, such as fetal gender or ethnic back- folate14,15 may be associated with increased for continued development and growth.

Hypothyroidism Hypothyroidism is defined as the insufficient production of thyroid hor- mone buy 15mg mobic mastercard. Secondary hypothyroidism as a result of dysfunction of hypothala- mic and pituitary hormone secretion are much less common but should be suspected in a patient with a history suggestive of Sheehan syndrome or with symptoms or signs of a tumor in the region of the sella discount 7.5mg mobic fast delivery. Ninety-five percent of cases of hypothyroidism are caused by primary thyroid gland failure generic mobic 7.5mg amex, resulting in insufficient thyroid hormone production. In the United States, the most common cause of hypothyroidism is lymphocytic (Hashimoto) thyroiditis, in which cytotoxic antibodies are produced, which leads to thyroid atrophy and fibrosis. The next most common cause is surgi- cal or radioactive iodine treatment for hyperthyroidism, or Graves disease. Worldwide, iodine deficiency is the most common cause of goitrous (enlarged thyroid) hypothyroidism, but in the United States, this is rare. Elderly individuals may be suspected of having dementia or depression when the cause is really hypothyroidism. In general, symptoms of fatigue, weight gain, muscle cramping, cold intolerance, hair thinning, menstrual changes, or carpal tunnel syndrome are common and should prompt an investigation of thyroid function. These patients present with dull facies, swollen eyes, and doughy extremities from the accumulation of hydrophilic polysaccharides in the dermis, sparse hair, and a thickened tongue. They may have an enlarged heart, nonmechanical intestinal obstruction (ileus), and a delayed relaxation phase of their deep tendon reflexes. Without treatment, they may become stu- porous and hypothermic, especially if challenged with an intercurrent illness. This is a life-threatening emergency with a high mortality, even when man- aged aggressively with intravenous levothyroxine. An easy way to remember this is by like vector analysis: when T4 and T3 uptake both are high, the patient really is hyperthyroid; when they both are low, the patient is hypothyroid. However, when they vary in opposite directions, for example, high T4 with low T3 uptake, they “cancel each other out,” that is, it is a protein-binding abnormality as described above. Patients may be asymptomatic or report the vague and subtle symptoms of hypothyroidism, such as fatigue. Thyroid hormone replacement can be prescribed in an attempt to relieve symptoms or possibly to reduce cardiovascular risk. The overwhelming majority of patients with hypothyroidism can be treated with once-daily dosing of synthetic levothyroxine, which is biochem- ically identical to the natural hormone. Levothyroxine is relatively inexpen- sive, has a long half-life (6-7 days), allowing once-daily dosing, and gives a predictable response. Older thyroid preparations, such as desiccated thyroid extract, are available but are not favored because they have a high content of T3, which is rapidly absorbed and can produce tachyarrhythmias, and the T4 content is less predictable. In older patients and in those with known car- diovascular disease, dosing should start at a low level, such as 25 to 50 μg/d, and increased at similar increments once every 4 to 6 weeks to an average dose of 1. Overly rapid replacement with the sud- den increase in metabolic rate can overwhelm the coronary or cardiac reserve. Depending on the cause of hypothyroidism and the amount of residual gland function, individual patient needs will vary widely. She denies excess dieting, although she does work out with her team 3 hours daily. She has been reading about her diagnosis on the Internet and wants to try desiccated thyroid extract instead of the medicine you gave her. On examination, she weighs 175 lb, her heart rate is 64 bpm at rest, and her blood pres- sure is normal. Tell her that this delay in resolution of symptoms is normal and schedule a follow-up visit with her in 2 months. Hashimoto thyroiditis is the most common cause of hypothy- roidism with goiter in the United States. It is most commonly found in middle-aged women, although it can be seen in all age groups. Patients can present with a rubbery, nontender goiter that may have “scalloped” borders. Iodine deficiency is exceedingly uncommon in the United States because of iodized salt. Patients with thyroid cancer usually are euthyroid and have a history of head and neck irradiation. Several different autoantibodies directed toward components of the thyroid gland will be present in the patient’s serum; however, of these, antithyroperoxidase antibody almost always is detectable (also called antimicrosomal antibody). On thyroid biopsy, lymphocytic infiltra- tion and fibrosis of the gland are pathognomonic. The presence of these autoantibodies predicts progressive gland failure and the need for hormone replacement.