Mark Corson

By L. Ilja. Malone College. 2018.

Pregnancy Care Basics Despite all the best efforts made to prevent pregnancy buy tamoxifen 20 mg mastercard, the best laid plans of mice and men sometimes go awry order tamoxifen 20 mg on line. Whether by accident or on purpose tamoxifen 20 mg on-line, you may find yourself responsible for the care of a pregnant woman. It will be important to know how to support that pregnancy and, eventually, deliver that baby. In a survival situation, you won’t have access to ultrasound technology to take a look at the fetus; whether it’s a boy or a girl will once again become a mystery. It’s less traumatic for the mother to deliver a 6 or 7 pound baby than a 10 pounder. Despite all the possible complications that I mentioned in the previous section, pregnancy is still a natural process. It usually proceeds without major complications and ends in the delivery of a normal baby. Although your pregnant patient will not be as productive for the survival group as she would ordinarily be, she will probably still be able to contribute to help make your efforts a success. To make a pregnancy a success, the medic will need to have a little knowledge of the subject and an idea of how to deliver the fetus. We are, of course, fortunate to have simple tests that can identify pregnancy almost before your miss a period. You will have to rely on the following tried and true signs and symptoms to identify the condition: Absent menstruation Tender Breasts Nausea and Vomiting Darkening of the Nipples/Areola Fatigue Frequent Urination Backache These symptoms, in combination, are indicative of pregnancy. It should be noted that this investigation will likely be necessary only in those women experiencing their first pregnancy. Of course, as time goes on, the abdominal swelling associated with uterine and fetal growth will be undeniable. Stretch marks come later, as do hemorrhoids, backache, and varicose veins (all very common but not universal). Most of the above will improve after the pregnancy is over, but may not disappear completely. A human pregnancy lasts 280 days or 40 weeks from the first day of the last menstrual period to the estimated date of delivery. This used to be called the “estimated date of confinement” because, yes, they confined women to their beds as they approached it. To get the due date, subtract 3 months and add 7 days to the first day of the last period. If the woman does not know when her last cycle started, you can still estimate the age of the pregnancy by physical signs. When you gently press on the woman’s abdomen, you will notice a firm area (the uterus) and a soft area (the intestines). Identify the uppermost level of firmness, and you will able to estimate the approximate age of the pregnancy. Each centimeter above the belly button adds a week, so have a measuring tape handy. A term pregnancy will measure 36-40 centimeters from the pubic bone to the top of the uterus. Don’t worry about triplets: They occur in only 1 in 7,000 births, unless you use fertility drugs. Once you have identified the pregnancy, you should make every effort to assure that your patient is getting proper nutrition. Deficiencies can affect the development of the fetus, so obtaining essential vitamins and iron through the diet will give the best chance to avoid complications. Common early pregnancy issues will include hyperemesis, as described in the last section. Be sure to ask your physician for prescriptions for Zofran (ondansetron) and/or other anti- nausea medications to add to your stockpile. Dry bland foods, like crackers, are helpful in getting a woman through this stage. This will be characterized by bleeding or spotting from the vagina, along with pain that simulates menstrual cramps. As 10% of pregnancies end in miscarriage and a higher percentage threaten to, this will be an issue that you must know how to deal with. Other than placing your patient on bed rest, there will not be much you’ll be able to do in this circumstance. Some of these pregnancies don’t continue because the fetus is abnormal, and no amount of rest will stop many of these pregnancies from ending very early. The good thing is that a single miscarriage generally does not mean that future pregnancies will be unsuccessful. Keep a close eye out for evidence of infection, such as fever or a foul discharge from the vagina. Pregnant women should be evaluated periodically to see how the fetus is progressing. Besides verifying progressive growth in the size of the uterus, the fetal heartbeat should be audible via stethoscope at around 16-18 weeks, or much earlier if you have a functioning battery-powered fetal heart monitor (also called a Doppler ultrasound). Weight gain is desirable during pregnancy; you should shoot for 25 pounds or so, total. Blood pressure should be taken regularly to rule out pregnancy-induced hypertension. Check for evidence of edema (swelling of the feet, legs and face) as well as excessive weight gain). The patient’s abdomen may look different, or the top of the uterus (the “fundus”) may appear lower.

The peak incidence is in sexually active women between the ages of 18 and 24 years old generic tamoxifen 20 mg visa. In this population 75-90% of infections are related to sexual intercourse with the frequency of infection directly correlating to frequency of intercourse tamoxifen 20 mg without a prescription. The frequency of spermicide use has been shown to correlate with infection frequency independent of intercourse frequency tamoxifen 20mg cheap. Repeated epidemiologic studies have shown there is no evidence that any of the following behaviors create increased or decreased risk for development of acute cystitis. These include oral contraceptive use, condom use, post-coital voiding, type of underwear, personal hygiene after voiding or bowel movement, or bath vs. The natural history of uncomplicated urinary tract infections has been shown through multiple placebo controlled trials. Spontaneous clinical and microbiologic resolution occurs in about half of patients by 3 days – 6 weeks. However, they cause significant life disruption, therefore leading patients to seek medical care for faster resolution of the infection and relief of symptoms. The following elements in the history have been shown to have a 90% positive predictive value in diagnosing acute cystitis: dysuria, urinary frequency, urinary urgency, new onset, absence of vaginal diacharge. Other common findings in the history may include suprapubic pain, hematuria, new urinary incontinence. The patient may have some suprapubic tenderness to palpation in the abdominal exam. Laboratory Studies These studies should be used to reinforce a clinical diagnosis. Urinalysis dipstick – may have positive either nitrite, leukocyte esterase, or both; may have protein or blood present *The sensitivity and specificity of the urine dipstick varies somewhat with the setting and population, as does its recommended interpretation. In women with nonspecific urogenital symptoms, positive or negative dipstick results may require a backup urine culture depending on the University of South Alabama, Department of Family Medicine June 30, 2008 207 clinical situation. Culture is appropriate and recommended with initial treatment failure, early recurrence, pyelonephritis, or an atypical presentation. These plus other studies have led to recommendations and guidelines that empiric antibiotic therapy can and should be initiated in cases of acute uncomplicated cystitis. Symptom resolution occurs in 6 hours in over 50% of patients and by 48 hours in greater than 90% of patients. Empiric antibiotic choice should be guided by local resistance patterns and patient allergy, however general guidelines are published. For treatment of uncomplicated urinary tract infections in older women, B 25 consider short or longer (three to 10 days) courses of antibiotics. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. This can be based on age, gender, urinary tract abnormalities, of co-morbid disease states. Drug resistance is very common, and indwelling catheters significantly increase the risk of multi-organism infection, thus necessitating urine culture with sensitivities. Coli is still often the initiating infection, but involvement of other gram negative and (to a greater extent than uncomplicated infections) gram positive organisms are often seen. When Pseudomonas aeruginosa is involved it creates a biofilm that lends a survival advantage and high antibiotic resistance. As with adults, they are usually ascending infections, except in infants <12 weeks old hematogenous infection is more common. Two studies have shown an association with constipation, encopresis, bladder instability, and infrequent voiding, but this did not hold true for febrile children less than 2yo. In infants symptoms include fever, irritability, jaundice, vomiting, and failure to thrive. Ultrasonography Urinary tract ultrasonography consists of examination of the kidneys to identify hydronephrosis and examination of the bladder to identify dilatation of the distal ureters, hypertrophy of the bladder wall, and the presence of ureteroceles. Previously, excretory urography (commonly called intravenous pyelography) was used to reveal these abnormalities, but now ultrasonography shows them more safely, less invasively, and often less expensively. Ultrasonography may show signs of acute renal inflammation and established renal scars, but it is not as sensitive as other renal imaging techniques. Usually the timing of the ultrasound is not crucial, but when the rate of clinical improvement is slower than anticipated during treatment, ultrasonography should be performed promptly to look for a cause such as obstruction or abscess. If the predicted bladder capacity is not reached, the study may underestimate the presence or degree of reflux. There is no benefit in delaying performance of these studies as long as the child is free of infection and bladder irritability is absent. While waiting for reflux study results, the child should be receiving an antimicrobial, either as part of the initial treatment or as posttreatment prophylaxis. Adapted with permission from Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children [published corrections appear in Pediatrics 2000;105:141, 1999;103:1052, and 1999;104:118]. Consider that short courses of antibiotics (two to five days) may be as B 37-39 effective as longer courses (seven to 14 days). A = consistent, good quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. American Academy Of Pediatrics ―Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children. Page 216 Pharmacotherapy 1,2 Understanding Pregnancy Categories Category A: controlled studies in women fail to demonstrate a risk to fetus in the first trimester (and there is no evidence of a risk in later trimesters), and the possibility of fetal harm appears remote. Category B: either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women or animal-reproduction studies have shown an adverse event (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of risk in later trimesters) Category C: either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if potential benefit justifies the potential risk to the fetus.

Unproven Uses: Wild Daisy is used as an expectorant and for easing diarrhea and gastrointestinal catarrh order 20mg tamoxifen visa. It is also used for treating wounds proven tamoxifen 20mg, skin diseases order tamoxifen 20mg without a prescription, coughs and bronchitis, disorders of the liver and kidneys, and inflammation. Wild Daisy Homeopathic Uses: Wild Daisy is used for bruises, bleeding, Bellis perennis muscular pain (after injuries), purulent skin diseases and rheumatism. No health hazards or side effects are known in conjunction with the proper administration of designated therapeutic Flower and Fruit: The flower heads are usually found singly dosages. The sepals of the epicalyx are more Mode of Administration: The drug is used topically—as an or less double-rowed. The receptacle is conical and glabrous extract, in teas and in poultices of pressed leaves—for the when bearing fruit. A decoction can be used for linguiform, white, pink, purple or bluish and distinctly longer wound poultices. The achenes are obovate, very flattened, Preparation: An infusion or cold extract is prepared by ribless, and have side veins. The flower has no pappus but adding 2 teaspoonfuls of drug to 2 cups of water, then may have short, brittle bristles. Leaves, Stem and Root: Wild Daisy is a 10- to 15-cm high perennial plant that has basal leaves in rosettes or alternate Daily Dosage: The daily dose of the infusion is 2 to 4 cups leaves at the lower part of the stem; its roots are short and per day. The rosette leaves are circular to spatulate or heart-shaped, dentate and occasionally entire-margined with Homeopathic Dosage: 5 to 10 drops, l tablet or 5 to 10 a single rib; they have vertical hairs on both sides. It is also found from Great Avato P, Vitali C, Tava A, New acetylenic compounds from Britain to Ireland and southern Scandinavia, and as far south Bellis perennis L. The drug acts as an astringent, reduces mucous production, and also has anti-inflammatory and fever-reducing effects, Willigmann I et al. The calyx is 4 to 5 mm long and glabrous but found to raise the leukocyte count and to improve the has a slight fringe. Wild Indigo has a mild circular with convoluted sides and is slightly shorter than the estrogenic effect. The ovary is ride and glycoprotein fraction contained in the drug demon- stemmed, elliptoid, drawn together at the style and stigma. The seeds cells; a significant, dose-dependent stimulation of lympho- are yellowish-brown, kidney-shaped and 2 mm long. The stem is 1 to 3 mm thick, round, slightly typhoid cases with prostration and fever, such as diphtheria, grooved and glabrous. The alternating leaves are trifoliate influenza, malaria, septic angina and typhus. The leaflets are 1 to 4 cm common head cold, tonsillitis, stomatitis, throat and mouth long, and 0. It is also warty due to root fibers sticking to the root to make a tea to treat fever, scarlet fever, typhoid and surface. Water in fracture shows a thick bark and whitish wood with concen- which the root has been soaked is used to clean open and tric rings. Canadian Indians used the plant for Characteristics: The taste is bitter and acrid; the odor is treating gonorrhea and disease of the kidneys and as an faint. Habitat: Wild Indigo is indigenous to southern Canada and Homeopathic Uses: Uses in homeopathy include severe the eastern and northeastern U. Wagner H, Proksch A, Riess-Mauer I, Vollmar A, Odenthal S, Suppositories Stuppner H, Jurcic K. Tablets Further information in: Preparation: To prepare an ointment, use 1 part liquid extract to 8 parts ointment base. Beuscher N, Kopanski L, Stimulation der Immunantwort durch Flower and Fruit: The flowers are in 2 to 3 dense false Inhaltsstoffe aus Baptisia tinctoria. The korpereigenen Immunabwehr durch polymere Substanzen aus calyx is tubular, with 13 ribs and glabrous inside. The stem is Immunologically Active Glycoproteins from Baptisia tinctoria branched in the upper half and terminates in spikes of blue Roots by Affinity Chromatography and Isoelectric Focussing. The Flower and Fruit: The flowers are bright yellow, sometimes plant is a result of many cross-breedings in gardens and white with violet veins. The pods are cylindrical with vertical grooves between which the seeds Habitat: The plant grows in Europe, northern Africa and are tied (like a string of pearls). Leaves, Stem and Root: The leaves are petiolate and lyrate, Production: Wild Mint is the aerial part of Mentha aquatica. Volatile oil: chief components - menthofurane, beta-caryo- Production: Wild Radish is the fresh plant of Raphanus phyllene, l,8-cineole. Administration of high dosages of the freshly Preparation: Add approximately 30 gm of the drug to 500 harvested plant can lead to mucous membrane irritation of ml of water. Mode of Administration: Wild Radish is administered ground and as an alcoholic extract. The 4 Medicinal Parts: The medicinal parts are the steamed seeds are oblong, deltoid, 7 mm long and dark red-brown. It is cracked Flower and Fruit: The inflorescence is globular to very into scaly plates to fairly high up. The older branches are elongated, often interrupted in false whorls, which are glabrous, gray-brown, glossy and angular with lighter separate from each other. The leaves have 5 cm long, thin, downy, loosely tomentose petioles, which are Leaves, Stem and Root: The plant is a slightly woody fresh green.

However generic tamoxifen 20mg with amex, only some classes of compounds have shown to be completely safe in regards to other pregnancy outcomes [31] discount tamoxifen 20 mg without prescription. In addition order 20 mg tamoxifen with mastercard, most clinicians felt that current resources and information about these medications are not adequate, and that their training on this topic at the undergraduate and postgraduate level is insufficient [117]. The following sections summarize the available evidence on the risk of there relevant adverse outcomes after gestational exposure to anti-infectives: congenital malformations, preterm birth and small for gestational age newborns. Anti-infective drugs and the risk of congenital malformations Several observational studies have been conducted to evaluate the association between anti-infective drugs during pregnancy and the risk of congenital malformations. Considering the low prevalence of this adverse outcome in the general population (1 to 3%) [118, 119], the majority of these studies had small sample sizes, and hence, lack statistical power to assess risk of specific malformations groups (see Table 3 for sample size information). Penicillins and other beta-lactams have not shown to be teratogenic in humans [56]. A prospective multicentre study on the use of clarithromycin during pregnancy, conducted by Einarson et al. There were no significant differences between the two groups in the rates of major and minor malformations; 2. Congenital malformations after exposure to azithromycin was also evaluated in a more recent cohort study [127]. The results showed no statistically significant rates of major malformations, suggesting that gestational exposure to azithromycin is not associated with an increase rate of birth defects (p value= 0. Exposure to azithromycin, clarithromycin and roxithromycin during the first trimester of pregnancy was not associated with an increased risk of birth defects in another cohort study conducted in Israel by Bar-Oz et al. Exposure to roxithromycin alone had been previous evaluated in a smaller cohort study conducted by Chun et al. The authors did not observe any 26 major malformation in the exposed group whereas three cases were detected (1. More recent evidence corroborates previous data, and current consensus is that nitrofurantoin is safe in what concerns congenital malformations [133]. Furtheremore, this agent can induce hemolytic anemia in the fetus or newborn, particularly in those with glucose-6-phosphate dehydrogenase deficiency [134]. Sulfonamides as a group do not appear to pose a serious teratogenic threat; a study conducted by Ratanajamit et al. Trimethoprim is a folic acid antagonist and its use during the first trimester has been associated with structural defects, such as neural tube and cardiovascular defects [35]. The association between fluoroquinolones and arthropathy, although observed in animals models and rarely reported in humans, has resulted in the restricted use of these drugs during pregnancy [33]. As a consequence, the safety of these drugs has been explored in a number of studies. Data from a prospective follow-up study conducted on the European Network of Teratology Information Services, showed no specific patterns of congenital abnormalities after exposure to quinolones [136]. A comparison of ciprofloxacin, norfloxacin, and ofloxacin, was examined by a observational cohort study conducted by Wilton et al. There were no clinically significant musculoskeletal dysfunctions in children exposed to fluoroquinolones in utero [138]. Therefore, most of the available evidence seems to indicate absence of teratogen properties for these drugs. Aminoglycoisdes antibiotics (streptomycin, gentamicin, neomycin, amikacin, tobramycin, kanamycin) have been classically associated to congenital nerve deafness in animal models. Both vestibular and auditory irreversible dysfunction can follow administration of these agents [141]. Some case series and case reports associated deafness in children born to women who received streptomycin during pregnancy [142, 143]. However, most of the evidence issued from observational data in humans did not show a clear increase in the risk [33, 144]. Tetracyclines are able to cross the placenta and to cause straining of the deciduous teeth [146]. Consequently, the risk is apparent only after 4 to 5 months gestation when the deciduous teeth begin to calcify. A statistical association was found for minor malformations after exposure to tetracycline in the first trimester of gestation [148]. A report from the Hungarian surveillance group identified 56 malformed infants whose mothers had used doxycycline during pregnancy [149]. However, when each group of malformation was evaluated separetelly, no risk was detected [149]. These case-control analyses did not show any human teratogenic potential of the use of these drugs during the first trimester of pregnancy in the different groups of congenital abnormalities. Exposure to metronidazole was also evaluated with data from the Israeli Teratogen Information Service and no evidence of increased risk of birth defects was found [153]. Two recent studies analyzed the risk of major congenital malformation for several types of anti-infective drugs at the same time. A retrospective cohort study using data from the Tennessee Medicaid program conducted by Cooper et al. No increased risk was present in multivariable analyses for any malformations and for malformations of specific organs. Low statistical power and residual confounding was probable responsible for their results, and current consensus is that this drug should be used as a last alternative when no other choices are available.