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A 36-year-old para 1 woman with a previous caesarean section for failure to progress at 7 cm was admitted at 40 + 10 weeks’ gestation for induction of labour discount ethambutol 400mg on line antibiotic resistance game. A nulliparous woman had a trial of instrumental delivery in theatre for failure to progress in the second stage of labour discount ethambutol 600 mg online broken dog's tail treatment. She sustained a fourth-degree tear with 1 cm of the anal mucosa torn during the forceps delivery cheap 600mg ethambutol mastercard antibiotic 5440. You performed forceps delivery in one of the labour ward rooms for prolonged second stage of labour and maternal exhaustion. You have diagnosed shoulder dystocia, delivered the baby in good condition with simple maneuvers. Later during the parent debriefng, you were asked about the risk of recurrence in the future. You have confrmed that she is now fully dilated with a mento-anterior face presentation at spines. A nulliparous woman at 40 + 2 gestation was admitted in spontaneous labour and progressed satisfactorily to full dilatation 2 hours ago. On reassessment there is no change in the descent with the vertex at −1 station, the position is occipitoanterior with absent membranes, no caput or moulding. You have just performed a trial of forceps in theatre and diagnosed shoulder dystocia. Your team arrived for help; McRoberts manoeuvre and suprapubic pressure were not successful. A 38-year-old, para 3 woman with gestational diabetes and pre-eclampsia was induced at 38 weeks’ gestation for polyhydramnios and a big baby. Mento-vertical is the longest diameter at 13 cm, longer than any of the pelvic diameters. This is diagnosed when anterior fontanelle, supraorbital ridges and nose are palpable on vaginal examination. Presentation Presenting diameter Diameter (cm) Flexed vertex Suboccipito-bregmatic 9. Women should not enter water (a birthing pool or bath) within 2 hours of opioid administration or if they feel drowsy. One randomised controlled study demonstrated a 30%–40% reduction in labour pain, shorter frst stage of labour, less epidural requirement and fewer caesarean sections following the implementation of a birthing ball exercise programme in labour. A Cochrane systematic review (n = 5218) supported adopting an upright position during labour and has shown a reduction in analgesic requirements, shorter frst stage of labour of 1 hour 20 minutes, shorter second stage of labour, reduction in caesarean sections, instrumental delivery rates and episiotomies, but it has also shown an increase in blood loss. Diamorphine injection has prolonged delivery by 82 minutes, but there were no signifcant diferences in neonatal adverse outcomes with either analgesic. Its use is contraindicated if morphine or pethidine were given in the previous 4 hours. Continuous monitoring of maternal oxygen saturation is mandatory during its use due to its association with respiratory depression and cardiorespiratory arrest (<1 in 2200). Recovery from local anaesthetic–induced cardiac arrest may take more than an hour. Propofol is not a suitable substitute for lipid emulsion, and lignocaine should not be used as an anti-arrhythmic therapy. An intravenous bolus injection of 20% lipid emulsion (Intralipid is the most commonly used brand name) at 1. If cardiovascular stability has not been restored or there is deterioration of adequate circulation, repeat two more boluses of intravenous 20% lipid emulsion 5 minutes apart (maximum of three boluses including the frst one). Intravenous infusion can be doubled at 30 mL/kg/h afer 5 minutes of bolus if cardiovascular stability has not been restored or deterioration of adequate circulation occurs. Infusion can be continued until stable or maximum dose of lipid emulsion was given. Mediolateral episiotomy should be considered in instrumental deliveries and where episiotomy is indicated, the mediolateral technique is recommended, with careful attention to ensure that the angle is 60° away from the midline when the perineum is distended. No diferences were seen in the incidence of frst- or second-degree perineal tears or third- or fourth-degree perineal trauma with the perineal massage. Sagittal suture is in the anterior-posterior diameter or right or lef occiput anterior or posterior position (rotation does not exceed 45°). Low-cavity delivery is when the leading point of the foetal skull is at or lower than the +2 station, but not on the pelvic foor.

The principal cause of hypotonic contraction is excessive loss of sodium through the kidneys order ethambutol overnight delivery virus jamie lee curtis. This may occur because of diuretic therapy buy ethambutol once a day antibiotic bactrim, chronic renal insufficiency ethambutol 800 mg fast delivery antibiotic 400mg, or lack of aldosterone (the adrenocortical hormone that promotes renal retention of sodium). Treatment If hyponatremia is mild, and if renal function is adequate, hypotonic contraction can be corrected by infusing isotonic sodium chloride solution for injection. Administration should continue until plasma sodium concentration has been raised to about 130 mEq/L. Patients should be monitored for signs of fluid overload (distention of neck veins, peripheral or pulmonary edema). Volume Expansion Volume expansion is defined as an increase in the total volume of body fluid. As with volume contraction, volume expansion may be isotonic, hypertonic, or hypotonic. The principal drugs employed to correct volume expansion are diuretics and the agents used for heart failure. Acid-Base Disturbances Maintenance of acid-base balance is a complex process, the full discussion of which is beyond the scope of this text. The most important are (1) the bicarbonate–carbonic acid buffer system, (2) the respiratory system, and (3) the kidneys. Conversely, by increasing bicarbonate excretion, the kidneys can lower pH, and thereby compensate for alkalosis. There are four principal types of acid-base imbalance: (1) respiratory alkalosis, (2) respiratory acidosis, (3) metabolic alkalosis, and (4) metabolic acidosis. Respiratory Alkalosis Causes Respiratory alkalosis is produced by hyperventilation. Mild hyperventilation may result from a number of causes, including hypoxia, pulmonary disease, and drugs (especially aspirin and other salicylates). Treatment Management of respiratory alkalosis is dictated by the severity of pH elevation. Although this technique has been used for many years, there remains a lack of evidence regarding its efficacy in respiratory alkalosis. Primary causes of impaired ventilation are (1) depression of the medullary respiratory center and (2) pathologic changes in the lungs (e. Over time, the kidneys compensate for respiratory acidosis by excreting less bicarbonate. Treatment Primary treatment of respiratory acidosis is directed at correcting respiratory impairment. Metabolic Alkalosis Causes Metabolic alkalosis is characterized by increases in both the pH and bicarbonate content of plasma. Causes include excessive loss of gastric acid (through vomiting or suctioning) and administration of alkalinizing salts (e. Treatment In most cases, metabolic alkalosis can be corrected by targeting the specific cause of the acidosis (e. One may also consider infusing a solution of sodium chloride plus potassium chloride. This facilitates renal excretion of bicarbonate and thereby promotes normalization of plasma pH. Metabolic Acidosis Causes Principal causes of metabolic acidosis are chronic renal failure, loss of bicarbonate during severe diarrhea, and metabolic disorders that result in overproduction of lactic acid (lactic acidosis) or ketoacids (ketoacidosis). Metabolic acidosis may also result from poisoning by methanol and certain medications (e. Treatment Treatment consists of correcting the underlying cause of acidosis, and, if the acidosis is severe, administering an alkalinizing salt (e. When an alkalinizing salt is indicated, sodium bicarbonate is generally preferred. When sodium bicarbonate is given intravenously to treat acute, severe acidosis, caution must be exercised to avoid excessive elevation of plasma pH because rapid conversion from acidosis to alkalosis can be hazardous. Also, because of the sodium content of sodium bicarbonate, care should be taken to avoid hypernatremia. Potassium Imbalances Potassium is the most abundant intracellular cation, having a concentration within cells of about 150 mEq/L.

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There may be considerations that Offer or provide the service support providing the service in an indi- only if there are other vidual patient buy ethambutol 800mg overnight delivery bacterial infection in stomach. There is moderate or high considerations that support certainty that there is no net benefit or ofering or providing fr the harm purchase ethambutol 600mg on-line virus structure. I There is insufcient evidence 400 mg ethambutol with amex antibiotic resistance quizlet, or the If service is offered, patients available evidence is of such poor should understand the uncer- quality, that the balance of benefits and tainty about the balance of harms cannot be weighed and recom- benefits and harms. There is insuf­ fcient evidence to recommend fr or against these modalities (Level I) in adults at higher risk of coronary events. There is evidence to suggest against screening asymptomatic individuals among the general adult population fr carotid artery stenosis. Cancer Adults (men and women) older than 50 years are strongly advised (Level A) to have screening fr colorectal cancer. Screening fr testcular and pancreatc cancer in asymptomatic adults is not rec­ ommended (Level D). There is insufcient evidence to recommend screening fr bladder cancer in asymptomatic individuals (Level I). There is insufcient evidence to recommend screening of asymptomatic adults fr type 2 diabetes mellitus (Level I), although screening is recommended (Level B) fr adults with hyertension (135/89 or more sustained or untreated) or hyperlipidemia. Deression screening is recommended (Level B) if there are mechanisms in place fr ensuring accurate diag­ nosis, treatment, and fllow-up. Screening and counseling to identif and promote cessation of tobacco use is strongly recommended (Level A). Screening and counsel­ ing to identif and prevent the misuse of alcohol is also recommended (Level B). Recommendations fr immunizations change fom time to time and the most up-to-date source ofvaccine recommendations is the Advisory Committee on Immunization Practices. Adults who have not had a Td booster in 10 years or more and who have never had a dose ofTdap as an adult should receive a booster vaccina­ tion with Tdap. Persons who may need an increase in protection against pertussis, including health-care workers, childcare providers, or those who anticipate having close contact with infnts younger than 1 year, should also receive a Tdap booster. Other vaccinations may be recommended fr specifc populations, although not fr all adults. Hepatts B vaccination should be recommended fr those at high risk of exposure, including health-care workers, those exposed to blood or blood products, dialysis patients, intravenous drug users, persons with multiple sexual partners or recent sexually transmitted diseases, and men who engage in sexual relations with other men. A new recommendation also suggests routine vaccina­ tion against hepatitis B fr all patients with diabetes who have not previously been immunized. Varicella vaccination is recommended fr those with no reliable history of immunization or disease, who are seronegative on testing fr varicella immunity, and who are at risk fr exposure to varicella virus. Meningo­ coccal vaccine is recommended fr persons in high-risk groups, college dormitory residents and military recruits, with certain complement defciencies, fnctional or anatomic asplenia, or who travel to countries where the disease is endemic. Exercise has been consistently shown to reduce the risk of cardio­ vascular disease, diabetes, obesity, and overall mortality. Even exercise of moderate amounts, such as walking fr 30 minutes on most days of the week, has a posi­ tive efect on health. Studies perfrmed on counseling physically inactive persons to exercise have shown inconsistent results. Counseling to promote a healthy diet in persons with hyper­ lipidemia, other risk fctors fr cardiovascular disease, or other conditions related to diet is benefcial. Intensive counseling by physicians or, when appropriate, refr­ ral to dietary counselors or nutritionists, can improve health outcomes. In selected patients, recommendations regarding safer sexal practces, including the use of condoms, may be appropriate to reduce the risk or recurrence of sexually transmit­ ted diseases. Finally, all patients should be encouraged to use seat belts and avoid driving while under the influence of alcohol or drugs, as motor vehicle accidents remain a leading cause of morbidity and mortality in adults. In counseling him, which of the fllowing statements regarding exercise is most accurate? Counseling patients to exercise has not been shown consistently to increase the number of patients who exercise.

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Raloxifene acts in a manner similar to that of tamox- achieve effective blood levels buy 400 mg ethambutol with visa antibiotics to treat pneumonia. Methyltestosterone can be ifen by producing estrogen-like effects on bone and lipid given orally buy ethambutol 400mg free shipping antibiotic resistance results from, but it is seldom used because long-term use can metabolism while antagonizing the effects of estrogen on cause hepatic damage and liver failure 800mg ethambutol with amex antibiotics for acne australia. Unlike tamoxifen, however, raloxifene also acts Gels and skin patches are available for transdermal as an estrogen antagonist in uterine tissue. Raloxifene administration of testosterone, and long-acting esters of tes- increases the risk of stroke, pulmonary emboli, and deep vein tosterone (e. A buccal system (Striant) has been developed that adheres Aromatase Inhibitors to the gum or inner cheek and provides a sustained release Breast cancer is often hormonally responsive—including of testosterone for absorption through the buccal mucosa breast cancer classifed as estrogen and/or progesterone throughout the day. This type of breast cancer has responded treat hypogonadism caused by primary testicular failure or to a variety of efforts to decrease estrogen levels (e. In patients ectomy) or to inhibit estrogen effects, such as with estrogen with hypopituitarism, testosterone should be given in com- antagonists. These interventions lead to decreased tumor bination with growth hormone to obtain a maximal effect mass, delayed progression, and improved survival in many on skeletal growth. Testosterone therapy may also adrenal androgens, primarily testosterone and androstenedi- beneft older men with testosterone defciency by preventing one, that are converted to estrogens in peripheral tissues and osteoporosis and improving overall quality of life. Chapter 34 y Drugs Affecting Fertility and Reproduction 361 Anabolic Steroids baldness, and other conditions. The ratio of anabolic activity to androgenic activity for testosterone is 1 : 1, whereas Gonadotropin-Releasing Hormone Analogues the ratio for some synthetic androgens is as high as 3 : 1. Leuprolide has been successfully Anabolic steroids have been used by athletes to increase used in the treatment of inoperable prostate cancer. The large doses of ana- sometimes given in combination with an androgen recep- bolic steroids often used for this purpose can lead to a tor antagonist (e. In women, excessive use of androgens can Androgen Receptor Antagonists cause masculinization, hirsutism, deepening of the voice, and Flutamide, bicalutamide, and nilutamide are nonsteroidal menstrual irregularities. This issue of steroid abuse is further agents that compete with testosterone for the androgen discussed in Chapter 25. It is used in the treatment Adverse effects of these drugs include nausea, gynecomastia, of several gynecologic disorders because of its ability to cause impotence, hot fashes, and hepatitis. It is being strual bleeding, danazol treatment leads to endometrial used to treat hirsutism in women and to reduce excessive atrophy and reduced menstrual loss. Danazol has also been used in treating endometriosis, a 5α-Reductase Inhibitors condition characterized by the presence of endometrial Finasteride and dutasteride are synthetic testosterone tissue outside the endometrial cavity. The drugs are administered orally, undergo hepatic danazol does not improve fertility in subfertile women with metabolism, and are eliminated in the feces. Finasteride and dutasteride are used to treat symptomatic Danazol is also used to treat hereditary angioedema, a benign prostatic hyperplasia. The drugs reduce prostate disorder caused by defciency of an inhibitor of the activated volume and can retard the progression of benign prostatic frst component of complement (a cascade of plasma pro- hyperplasia. In men with benign prostatic hyperplasia, teins involved in immunity to pathogens). Danazol prevents they improve urinary fow and decrease the risk of urinary attacks of hereditary angioedema in both males and females retention. The reductase inhibitors are sometimes used in by increasing levels of frst-component esterase inhibitor. Common adverse effects of danazol include mild hirsut- Finasteride and dutasteride have been used off label to ism, oily skin, acne, and menstrual irregularities. However, studies show that the can also cause hypercholesterolemia, hepatotoxicity, and drugs lower the risk of less aggressive cancers but appear to thromboembolic events, including stroke. Danazol is tera- increase the risk of more aggressive and life-threatening togenic and should not be given to pregnant women. By reducing estrogen feedback inhibi- The adverse effects of fnasteride and dutasteride include tion of gonadotropin secretion, clomiphene increases erectile dysfunction, decreased libido, and gynecomastia, gonadotropin secretion and stimulates ovulation. The drug produces estrogen-like effects on bone metabolism and reduces the risk of osteoporosis. Recent clinical trials suggest estrogens may prevent cardiovas- cular disease in healthy, younger menopausal women Review Questions but may increase cardiovascular disease in older women. A woman is placed on a drug that has antiestrogen effects • Ethinyl derivatives of estradiol (ethinyl estradiol and on uterine and breast tissue.