Kwesi Hankins, RN

• Department of Emergency Medicine
• Methodist Hospital
• Peoria, IL

The choice to continue or reenter treatment should balance the impact on survival with the effects on quality of life impotence synonym cheap 160 mg super viagra with mastercard. Prognosis the most reliable predictor for survival is the stage of breast cancer at the time of diagnosis (Table 32-5) erectile dysfunction uti 160 mg super viagra with visa. Other prognostic indicators include lymph node status erectile dysfunction medication names discount super viagra 160mg on-line, hormone receptor status causes of erectile dysfunction in 20s order super viagra 160mg free shipping, tumor size erectile dysfunction drugs over the counter canada buy 160 mg super viagra mastercard, nuclear grade relative impotence judiciary buy genuine super viagra on-line, histologic type, proliferative rate, and oncogene expression. The current overall 5-year survival rate for stage 0 breast cancer has increased to 93%. Positive estrogen and progesterone receptor status carries a more favorable prognosis as does negative lymph node status. Women taking tamoxifen should be followed for irregular bleeding given the possibility of increased endometrial cancer with tamoxifen use. Hormone Use after Breast Cancer Treatment Some premenopausal patients may wish to become pregnant after breast cancer treatment. Traditionally, this has been discouraged for fear that pregnancy-related estrogens may stimulate dormant cancer cells. Studies now suggest that there is no difference in survival rates in women who become pregnant after breast cancer treatment. For women who wish to avoid fertility after cancer treatment, there has been no adverse effect shown with the use of oral contraceptives containing estrogen. Follow-Up Follow-up after breast cancer treatment should include a physical examination every 3 to 6 months for 3 years, every 6 to 12 months for years 4 and 5, and annually thereafter. In women who receive breast-conserving surgery, the first followup mammogram is usually performed 6 months after completion of lumpectomy and radiation treatment and annually after that. Women who had a mastectomy should continue to have yearly mammograms on the remaining breast. Clinical breast examination every 1 to 3 years is recommended for all women over age 20. Current routine mammogram recommendations include a mammogram every 1 to 2 years from age 40 to age 50, and yearly after age 50. Women with a strong family history of breast cancer should begin screening mammograms 5 years earlier than the age of diagnosis of the youngest family member with breast cancer; 10 years earlier in the case of premenopausal breast cancer. Evaluation of breast masses includes careful physical examination, evaluation with mammography and ultrasound of any abnormal findings, and biopsy of suspicious findings to rule out malignancy. Benign breast symptoms and findings are common and occur in approximately 50% of women, with a higher incidence in younger women. Patients with fibrocystic change often have cyclic breast pain and masses due to an exaggerated stromal response to hormones and growth factors. Reduction in caffeine, tea, and chocolate, and treatment with progestins, danazol, and tamoxifen, have been found to help symptoms. Invasive breast disease-including infiltrating ductal carcinoma (76%) and infiltrating lobular carcinoma (8%)-is treated with lumpectomy and radiation or with modified mastectomy with equal risk of recurrence and survival in properly selected patients. The standard adjuvant treatment for women with positive lymph nodes is combination chemotherapy. All hormone receptor positive patients should receive hormone therapy aimed at suppressing estrogen, and thereby suppressing stimulation of cancer cells. This is most commonly achieved with tamoxifen (an estrogen agonist/antagonist) or aromatase inhibitors. Follow-up for patients with invasive breast cancer includes annual bilateral mammography in women who underwent lumpetomy and radiation and annual mammography of the contralateral breast in women who underwent mastectomy. Frequent physical examination to evaluate for recurrent metastatic disease is also indicated. Other routine blood and imaging studies are not indicated in the asymptomatic patient. She undergoes the recommended diagnostic tests for a palpable breast mass in her age group. You are surprised that on biopsy the pathologist finds epithelial and stromal proliferation consistent with a fibroadenoma, but with few scattered malignant cells. Bilateral modified radical mastectomy A 38-year-old female G0 presents to your office for her annual gynecologic examination. Her mother was diagnosed with breast cancer at age 48, and her paternal aunt was diagnosed with breast cancer at age 67. Her previous gynecologist diagnosed her with fibrocystic breast change, and this worries her. She notices pain in both breasts often, and she has a clear discharge from both nipples around the time of her menses. Her breast examination shows Tanner stage 5 breasts that are symmetric and without palpable mass or abnormal skin changes. Which element of her history and examination is most associated with an increased risk of breast cancer over the general population Which element of her history and examination is most associated with a low risk of breast cancer Expectant management Vignette 3 A 35-year-old G0 woman presents to your office with complaints of bloody nipple discharge. When asked about breast self-examination, she denies feeling a mass at home but states she is also not very consistent in examining herself. You perform a guaiac test and cytology of nipple discharge and breast examination. The cytology shows malignant cells, and you can palpate a breast mass just lateral to the nipple. Vignette 2 A 42-year-old female G4P3 presents to your office with complaint of a palpable breast mass that she noticed while performing her breast self-examination. After taking her history, you perform a clinical breast examination which reveals a solitary, 3-cm, mobile, nonpainful, rubbery mass. Breast cancer patients should never become pregnant in the future due to the increased risk of recurrence with a pregnancy (regardless of type of tumor) b. There is no difference in survival among premenopausal patients who become pregnant after treatment and those who do not c. If her tumor is estrogen and progesterone receptor positive, she is at increased risk of recurrence if she becomes pregnant c. During surgery, the tumor was found to be 4 cm in size, with negative sentinel node biopsy and negative margins after excision. The current overall 5-year survival rate is 94%; however, the most reliable predictor of survival is the stage of breast cancer at the time of diagnosis b. Because she received radiation anyway, her lymph node status is not a predictor of survival 3. Physical examination every month for 12 months, mammogram every 3 months for 1 year, then annually thereafter for both c. Physical examination every 3 to 6 months for 3 years, then every 6 to 12 months for years 4 and 5, with annual mammogram (beginning 6 months after radiation). Wide local excision with periodic surveillance with breast examination and annual mammogram CliniCal Vignettes A answers a small proportion of malignant cells found on biopsy. Fibrocystic breast change and fibroadenoma are not associated with malignant cells. Vignette 2 Question 3 Answer C: the most appropriate treatment of cystosarcoma phyllodes is wide local excision with 1-cm margins or simple mastectomy. Because it is considered a low-grade malignancy, expectant management is contraindicated. One-centimeter margins are necessary due to the high rate of local recurrence after simple excision. Lumpectomy with radiation and modified radical mastectomy are reserved for treatment of invasive breast cancers. Vignette 3 Question 1 Answer D: Intraductal papilloma is the most common cause of bloody nipple discharge. Fibrocystic breast change, fibroadenoma, and cystosarcoma phyllodes typically present as painful and nonpainful breast masses. Vignette 3 Question 2 Answer E: Invasive papillary carcinoma is the second most common cause of bloody nipple discharge, and it is a malignancy (unlike intraductal papilloma). Vignette 3 Question 3 Answer B: Studies have shown that there is no difference in survival rates in women who become pregnant after successful breast cancer treatment, regardless of tumor type or receptor status. However, it is generally recommended that pregnancy be delayed until 2 to 3 years after completion of treatment, not because of any influence of the pregnancy on the malignancy, but rather to defer childbearing until after the period of greatest risk of recurrence. Breast reconstruction should be considered when a large mass is removed from the breast as it carries significant psychosocial benefits. Estrogen/ Vignette 1 Question 1 Answer A: the risk for breast cancer with a first-degree relative (mother, sister, or daughter) diagnosed before menopause is 1. Only 5% of patients presenting with nipple discharge will have a malignancy, and this is more likely with unilateral or bloody discharge. Nulliparity is associated with a 3:1 risk of breast cancer compared to parous women. Regular menses are theoretically protective due to a constant monthly control of estrogen exposure, but are not as protective as young age. A normal breast examination is a reassuring clinical sign, but 30% to 50% of breast abnormalities are diagnosed by mammography because a lesion is not palpable. Having a seconddegree relative with breast cancer is a risk factor and is not protective against breast cancer. Vignette 1 Question 3 Answer E: With a normal exam and bilateral clear nipple discharge with expression only expectant management and reassurance are appropriate. Bloody nipple discharge should be evaluated by testing with a guaiac card and sent for cytology. Culture, especially without a foul odor or sign of infection, is not necessary in this case. Ultrasound, mammography, and biopsy are reserved for the evaluation of breast masses. Vignette 2 Question 1 Answer B: A solitary, mobile, nonpainful, rubbery mass is most likely a fibroadenoma. Fibrocystic breast change is typically multiple, painful, bilateral, and fluctuates throughout the menstrual cycle. Cystosarcoma phyllodes is a rare variant of fibroadenoma that is usually associated with overlying skin changes. Intraductal papilloma usually presents as bloody nipple discharge in the absence of a mass. Invasive breast cancer is not usually mobile and rubbery, but is a firm, fixed mass. Vignette 4 Question 2 Answer A: Currently, the overall 5-year survival rate is 94%, and the most reliable predictor of survival is the stage of breast cancer at the time of diagnosis. Positive estrogen and progesterone receptor status are favorable prognostic signs. Other prognostic indicators are lymph node status, tumor size, nuclear grade, histologic type, proliferative rate, and oncogene expression. Vignette 4 Question 3 Answer D: Follow-up after breast cancer treatment should include a physical examination every 3 to 6 months for 3 years, every 6 to 12 months for years 4 and 5, and annually thereafter. In women who receive breast-conserving surgery, the first follow-up mammogram is usually performed 6 months after completion of radiation treatment. She just found out that her paternal grandmother has breast cancer at age 75, and she is very concerned. Reassurance and counseling about risk factors, breast selfexamination overall breast awareness, and annual clinical breast examination d. Reassurance and counseling about risk factors with follow-up at age 40 for first mammogram 5. She does not want any additional intrauterine or vaginal inserts, and asks if she is a candidate for the birth control pill. She is a nonsmoker, and otherwise has had only uncomplicated vaginal deliveries and no surgeries. Which of the following is an absolute contraindication to starting combined oral contraceptive pills in this patient A 38-year-old woman presents to your emergency department with complaints of irregular vaginal bleeding for the past 1 year. Upon evaluation of her surgical history, she tells you she had a procedure outside of the country for an "abnormal pregnancy" about 1 year ago. On review of systems, she tells you she has been coughing up blood for the past 1 week. A 37-year-old woman presents to your office with a 3-month history of intermenstrual bleeding and intermittent pelvic pain. This is a desired pregnancy and she shares that she believes she had a miscarriage 6 months ago while traveling abroad. Bedside ultrasound demonstrates intrauterine pregnancy with fetal heartbeat of 154. The father of the baby is Rh-positive, making the fetus at risk for fetal hydrops. In addition to advanced maternal age, her antenatal issues include chronic hypertension and type 2 diabetes mellitus. Additionally, she reports that her last pregnancy was induced at 35 weeks for severe preeclampsia. Risk factors for the development of preeclampsia include all of the following, except: a. A 17-year-old woman presents to your office with her mother with no menses for 2 months. A 34-year-old G4P1112 presents at 40 weeks 3 days to labor and delivery with onset of painful contractions 3 hours ago. Her obstetric history is significant for a prior vaginal delivery at 41 weeks after induction for oligohydramnios.

Antiinflammatory response is associated with mortality and severity of infection in sepsis erectile dysfunction topical treatment cheap super viagra 160mg amex. What is the role of interleukin 10 in polymicrobial sepsis: anti-inflammatory agent or immunosuppressant Prediction of sepsis in the multitraumatic patient by assays of lymphocyte responsiveness erectile dysfunction treatment australia buy super viagra 160mg cheap. Neutrophil apoptosis: a marker of disease severity in sepsis and sepsis-induced acute respiratory distress syndrome erectile dysfunction underwear cheap generic super viagra canada. Innate immune functions of immature neutrophils in patients with sepsis and severe systemic inflammatory response syndrome erectile dysfunction cream cheap super viagra 160 mg overnight delivery. Impairment of polymorphonuclear neutrophil functions precedes nosocomial infections in critically ill patients how does an erectile dysfunction pump work buy super viagra 160mg online. Regulatory dendritic cells act as regulators of acute lethal systemic inflammatory response erectile dysfunction vacuum pumps reviews order 160mg super viagra otc. Phenotype changes and impaired function of dendritic cell subsets in patients with sepsis: a prospective observational analysis. Modulation of dendritic cell differentiation in the bone marrow mediates sustained immunosuppression after polymicrobial sepsis. Enhancement of dendritic cell production by fms-like tyrosine kinase-3 ligand increases the resistance of mice to a burn wound infection. Fms-like tyrosine kinase-3 ligand alters antigen-specific responses to infections after severe burn injury. Bench-to-bedside review: endotoxin tolerance as a model of leukocyte reprogramming in sepsis. Phenotype and functions of natural killer cells in critically-ill septic patients. Interferon-gamma production by natural killer cells and cytomegalovirus in critically ill patients. Association of gammadelta T cells with disease severity and mortality in septic patients. Pro-versus anti-inflammatory cytokine profile in patients with severe sepsis: a marker for prognosis and future therapeutic options. Early postoperative monocyte deactivation predicts systemic inflammation and prolonged stay in pediatric cardiac intensive care. The compensatory anti-inflammatory cytokine interleukin 10 response in pediatric sepsis-induced multiple organ failure. Restoration of the depressed immune functions and improved survival following subsequent sepsis. Dehydroepiandrosterone: an inexpensive steroid hormone that decreases the mortality due to sepsis following traumainduced hemorrhage. Dehydroepiandrosterone restores immune function following trauma-haemorrhage by a direct effect on T lymphocytes. A partial deficiency of interleukin-7R alpha is sufficient to abrogate T-cell development and cause severe combined immunodeficiency. Programmed death-1 levels correlate with increased mortality, nosocomial infection and immune dysfunctions in septic shock patients. A randomized controlled trial of filgrastim as an adjunct to antibiotics for treatment of hospitalized patients with community-acquired pneumonia. Interferon gamma-1b in the treatment of compensatory anti-inflammatory response syndrome. Immunoparalysis in patients with severe trauma and the effect of inhaled interferon-gamma. Opal Introduction Defining potential molecular targets for sepsis therapeutics has proven to be a real challenge in translating laboratory findings into effective clinical treatments. A myriad of possible targets have been proposed from preclinical studies but they often have overlapping pathologic functions, can differ depending upon the causative microbial pathogen, site of infection, and status of the immune response of the host at the time of treatment is initiated. When attempting to modulate the host response in critically ill patients during an ongoing systemic infection, the capacity to do harm is substantial and the net effects of such interventions on host defenses and antimicrobial clearance mechanisms in individual patients are highly variable. Finding a final common pathway that drives sepsis pathophysiology has been elusive and has limited progress in developing new sepsis therapeutics. Current aims to improve outcomes in sepsis are now focused upon regulation of the coagulation system; maintenance and repair of endothelial surfaces and the blood compartment; epithelial membrane integrity; regulating the dysfunctional systemic immune response in sepsis; and bolstering host defenses against microbial toxins and virulence. Opal Molecular Targets for Sepsis Therapies Within the Endothelium and Coagulation System the hemostatic system is among the oldest human evolutionary tools for humans to defend themselves against invasions from microorganisms such as bacteria and fungi by isolating them through the formation of micro clots, triggering an inflammatory response, and then allowing the immune system to act more effectively within these locations [1]. However, the derangement of this hemostatic system may lead to serious coagulation disturbances, including disseminated intravascular coagulation, microvascular thrombosis, hypoperfusion, organ failure, and death; accordingly, correct modulation of this clotting system could reduce the development of organ failure and death in patients with severe sepsis [2]. Thrombin and other serine proteases of the clotting system are highly injurious when generated in the intravascular space and are pro-thrombotic and pro-inflammatory mediators. There are three main regulators of the coagulation system during sepsis: tissue factor pathway inhibitor, protein C, and antithrombin. These three coagulation inhibitors work simultaneously on limiting the excessive thrombin generation. When any of these molecules becomes qualitatively or quantitatively dysfunctional, a hypercoagulable state evolves during sepsis. Therefore, concentrates and recombinant forms of these molecules have been administered to humans with the intent to improve outcomes of patients with sepsis-induced hypercoagulable states. We discuss the evidence in favor of and against the use of these molecular targets as potential therapies system during sepsis and severe sepsis. Antithrombin becomes depleted in patients with sepsis and its function is further compromised by the reduction of glycosaminoglycans on the endothelial surface during sepsis. However, their analysis was based on the pooling of post-hoc subgroup data, which may have introduced both multiplicity (higher probability of false-positive) and selection bias since the randomization process for the subgroups was not followed as in the original studies. Many factors may have confounded the antithrombin trial results: baseline disease severity, baseline level of sepsis-induced coagulopathy, heparin interaction, and rate of antithrombin alpha-form in the concentrate formulations; thus, more evidence is needed to better define the role of antithrombin in patients with severe sepsis and coagulopathy. Opal Recombinant Human Activated Protein C Protein C is a vitamin K-dependent protein, which is activated by proteolysis on the thrombin-thrombomodulin complex and by the endothelial protein C receptor. A recombinant human form of activated protein C (drotrecogin alfa activated) has anticoagulant, anti-inflammatory, profibrinolytic, and cytoprotective effects. Two large meta-analyses have recently been performed; the study by Marti-Carvajal et al. Both meta-analyses showed significant increase in bleeding adverse events with activated protein C compared to controls. Thus, the final verdict on the efficacy of recombinant activated protein C in patients with severe sepsis is yet to be handed down. Thrombomodulin Thrombomodulin promotes the thrombin-mediated activation of protein C and during severe sepsis and septic shock this molecule is downregulated, which corroborates to a pro-coagulant and pro-inflammatory state. A clinical trial on the effect of heparin on the survival of patients with sepsis was completed in 2009 and no significant 28-day survival benefit was observed [20] (14% vs. Several other studies have been performed and a just published systematic review and meta-analysis by Zarychanski et al. The authors noticed poor reporting of bleeding side effects in most studies, but suggested up to twofold increase in bleeding events. Heparin has a number of other anti-inflammatory effects that might be of therapeutic value n sepsis independent of its anticoagulant properties by activating antithrombin. Heparin is among the strongest negatively charged molecules known in human biology and can avidly bind and inactivate histone signaling [26, 27]. Even non-anticoagulant forms of heparin bind to circulating histones and are highly protective in animal models of sepsis [23]. The degree to which this and other antiinflammatory effects of heparin account for its potential protective effects in septic patients is unknown at present. The Vascular Endothelium as a Target for Sepsis Therapeutics the endothelial surface regulates intravascular inflammation and to a lesser extent extravascular inflammatory responses during sepsis [28, 29]. The innate immune system and coagulation pathways coevolved to collaborate in protecting the host from the simultaneous risk of exsanguination and invasive microbial infection following any break in the integument. The interface between clotting and inflammation is particularly critical in sepsis [2]. Platelet adhesion to activated endothelial cells is increased in sepsis by alterations in von Willebrand factor. Large multimers of von Willebrand factor, occur in sepsis which avidly bind to platelet glycoprotein Ib under conditions of shear force [31]. Endothelial cell contraction disables extracellular membrane barrier function thereby increasing vascular permeability. Macromolecules such as large proteins and white cells can now exit the circulation into the extravascular space. This reverses the net effect of thrombin generation to an endothelial barrier protection effect. Endothelial barrier function prevents vascular leak, maintains an anticoagulant surface and prevents macromolecules from exiting the microcirculation. Intracellular actin filament networks maintain endothelial cell apposition and this is further supported by transmembrane Robo4-slit proteins [37, 38]. Several treatment options designed to retain endothelial barrier function are now under preclinical and clinical investigation (see Table 6. Mucosal ischemia and inflammatory changes are commonplace is septic shock patients and these events can perturb endothelial function and the resident microflora that inhabit these mucous membranes. Epithelial cells separate the parenchymal tissues from the external milieu and are polarized with an apical surface and a basolateral surface. The feature selective semipermeable membranes that determine the rate of water, solute, and macromolecule flow, and segregate the endogenous microbiota, now referred to as the resident microbiome, from host tissues [42]. The gut microbiome contains 100-fold more expressed genes that the entire complement of expressed human genes. The microbiome consists of over 1014 bacterial cells with is home to thousands of different species of bacteria, viruses, Archea, fungi, and commensal protozoan parasites. Changes in the microbiome certainly occur in critical illness and the relevance of these alterations on the human host is only beginning to be understood. This might be feasible by probiotics (the placement of favorable bacterial strains or fungi along the epithelium to reestablish a healthy microbiome) or prebiotics (the process of placing a nonabsorbable complex polysaccharides or other macromolecules to alter the substrates for metabolism on the microbiome population and alter its makeup of microorganisms). These efforts have already produced some limited success, particularly in preventing necrotizing enterocolitis in critically ill neonates and preventing recurrent respiratory infections in children [46]. Another therapeutic option is to repair damaged epithelial cells or reestablish the structure and functional junctions between adjacent epithelial cells. New epithelial barrier defensive strategies to prevent or to treat sepsis are presented in Table 6. Plasma levels of a ubiquitous human protein called gelsolin fall rapidly in severe sepsis and the loss of this protein impairs actin clearance, reduces phagocytosis, and promotes inflammatory cytokine generation [67]. Recombinant gelsolin is available and could be a potential novel therapy for severe sepsis. There are a number of innovative hemoperfusion devices that function as blood purification strategies. Another column adsorbs cytokines from the circulation and is available clinically in some European and Asian countries [69, 70]. Another uses the complement related pattern recognition receptor mannose binding lectin to bind endotoxin and bacterial, viral, and fungal pathogens [71]. Another promising blood purification strategy is heparin bound columns that avidly bind to many bacterial pathogens to clear bacteremic infections [72]. These devices might be particularly useful in clearance of blood stream infections with multidrugresistant bacteria no longer susceptible to standard antimicrobial agents. Oral administration of protease inhibitors to prevent increased gut permeability from pancreatic enzymes are in clinical trials at present [73]. Non-absorbed agents like transexamic acid and related protease inhibitors remain in the gut lumen and protect the intestinal epithelium from protease-mediated excess permeability during septic shock. Other novel sepsis therapies are designed as mitochondrial sparing agents to prevent intrinsic pathway activation of cellular apoptosis [74, 75]. Considerable interest has recently developed in readily available methods of regulating the host inflammatory status by immunometabolism approaches [76, 77]. Moreover, evidence now exists that recovery from sepsis and initiation of tissue repair is not a passive process of simply the lack of active inflammation. Resolution from sepsis is not a passive event but an active, organized process mediated by specific, lipooxygenase-derived, lipid signaling molecules such as resolvins or protectins [80]. Synthetic proresolving agonists might prove useful to prime the resolution phase of sepsis. Reduced T cell and B cell functions, reduced lymphocyte proliferative capacity excess apoptosis, T cell exhaustion and dysregulated innate immune responses are readily demonstrable and likely have important adverse clinical consequences [81]. Disseminated cytomegalovirus infection and herpes simplex infection occur regularly in severe sepsis patient. Opportunistic bacterial and fungal infections also occur at high frequency in septic patients [82]. A number of therapeutic strategies to limit immune dysfunction or reconstitute immune function following sepsis are now in early clinical development. Mesenchymal stem cells have remarkable immune regulation activities and might prove useful to manage selected patients with septic shock [89]. Immunostimulatory oligodeoxynucleotides appear capable of restoring immune competence in experimental models of sepsis and might find their way into clinical trials in the future [90, 91]. What is not clear at present is whether sepsis-induced immune suppression is primarily a physiologic, compensatory defense mechanism to control an overly exuberant systemic immune response in sepsis, or a pathological state of immune suppression increasing the risk of secondary infections [92]. When, if ever, does this compensatory anti-inflammatory state move from a necessary immune control mechanism of net benefit to patients to a state of immunosuppression that puts the patient at excess risk from opportunistic infection It seems likely that status of the dysregulated immune function in sepsis will vary between individual patients and over time in the same septic patient.

The major causes of abortion mortality are complications of hemorrhage and infection erectile dysfunction doctors rochester ny generic 160 mg super viagra, followed by thromboembolism and anesthetic complications erectile dysfunction in diabetes type 1 buy cheapest super viagra. Clinical xylometazoline erectile dysfunction discount super viagra 160mg line, laboratory erectile dysfunction doctor kolkata super viagra 160 mg otc, or imaging studies should be used as needed to confirm completion of the abortion erectile dysfunction treatment with exercise order super viagra 160mg line, and any complications should be treated causes juvenile erectile dysfunction purchase generic super viagra from india. Suction curettage (D&C), manual vacuum aspiration, and nonsurgical medical abortions are all methods of inducing abortion in the first trimester. Most first trimester terminations in the United States are achieved using the suction curettage (D&C) procedure. In general, the risk of complications after suction curettage is small and directly proportional to the gestational age. D&C typically involves mechanical dilation of the cervix and removal of the products of conception using a suction cannula. A sharp curettage may then be performed to ensure the uterus is completely evacuated. Antibiotic prophylaxis (doxycycline, ofloxacin, ceftriaxone, or metronidazole) is recommended to avoid the risk of postabortal upper genital Prior to termination, gestational age should be confirmed by last menstrual period, bimanual examination, and ultrasound evaluation. Women should be counseled on reliable forms of contraception with initiation of chosen method, if appropriate. Maternal complications are rare with suction curettage and the maternal mortality rate is 0. For early pregnancies up to 10 weeks of gestation, manual vacuum aspiration can be performed. The uterine contents are then manually extracted using a 50- or 60mL self-locking vacuum syringe instead of a suction machine. Evacuation is achieved by a gentle in and out motion while also rotating the unit to ensure clearance of all products of conception. Since that time, medication abortion has become increasingly utilized and now accounts for 25% of terminations prior to 9 weeks of gestation. Mifepristone thereby disrupts the pregnancy by making the endometrial lining unsuitable to sustain the pregnancy. Although it can be used alone, the success rate of completed pregnancy is greatly improved when used in combination with a prostaglandin analog such as misoprostol. Effectiveness When performed by a trained physician, the success rate for suction curettage is 98% to 99%. In these early pregnancies, an effort should also be made to identify villi after the procedure by floating the evacuated tissue in saline. Complications First trimester termination using suction curettage (D&C) is the safest of all surgical termination methods. Complications of suction curettage are rare and include infection (1% to 5%), excessive bleeding (2%), uterine perforation (1%), and incomplete abortion (1%). Limited data suggest that women who have three or more cervical dilation procedures (for termination, hysteroscopy, D&Cs, etc. Because methotrexate has been approved for use for a variety of medical conditions including ectopic pregnancy, it has been used by clinicians on an off-label basis as an abortifacient. When a second trimester termination is necessary, D&E is the most common and safest method of termination of pregnancy. D&E has a lower maternal mortality and morbidity compared to second trimester induction of labor. Methotrexate is contraindicated for patients with immunodeficiency and those with hepatic or renal disease. Effectiveness When used alone, the efficacy rate of mifepristone is approximately 65% to 85%. The efficacy rate of methotrexate with misoprostol for induced abortion is 94% to 96%. Methotrexate is also therapeutic for ectopic pregnancy in 90% to 95% of the cases. This method of termination is very similar to first trimester D&C except that wider cervical dilation is required. Typically, D&E involves the gradual dilation of the cervix to accommodate the larger volume of uterine contents. Cervical preparation can be achieved with careful manual dilation, multiple osmotic dilators, or prostaglandin agents. Osmotic dilators are generally preferred given that manual dilation for second trimester terminations may result in increased cervical lacerations and hemorrhage, and prostaglandin agents such as misoprostol can take some time to provide sufficient cervical dilatation. Osmotic dilators can be synthetic (Lamicel, Dilapan) or natural (seaweed-based laminaria). These dilators are placed into the cervix the day before the procedure and gradually dilate and soften the cervix as they absorb the cervical moisture. These osmotic dilators slowly expand over 12 to 18 hours to dilate the cervix prior to D&E. Once dilated, a large suction cannula (12 to 14 mm) can be introduced into the uterus to extract the fetal tissue and placenta. At more advanced gestational ages greater than 16 weeks, forceps designed to extract uterine contents are often needed in addition Uterus Side Effects the most common side effects of medical abortion are abdominal pain and cramps. Other side effects include nausea, vomiting, diarrhea, and excessive or prolonged uterine bleeding. The majority of women using misoprostal as a component of medical termination will start bleeding 2 hours after taking the prostaglandin analog. The rate of endometritis for medical abortion is lower than that after surgical abortion. Advantages/Disadvantages Nonsurgical abortion offers the advantages of being a highly effective noninvasive means of termination that can be achieved on an outpatient basis. However, in a nonsurgical abortion, a miscarriage is induced and the woman must go through the experience of miscarriage, which generally involves substantial uterine cramping and bleeding. Medication abortion typically requires two visits to a health provider: one to obtain the medication, and then a 2-week follow-up visit. Congenital fetal abnormalities are the primary reason for second trimester abortions. Multiple laminaria are placed inside the cervix through both the internal and external os. They slowly expand by absorbing moisture from the vagina, thereby dilating the cervix. Chapter 25 / Elective Termination of Pregnancy to suction curettage to remove fetal parts. Upon completion of the procedure, the clinician should verify extraction of the major fetal parts. Ultrasound can be used to guide the extraction and to rule out retained products of conception. Side Effects Complications from D&E are uncommon but may include cervical laceration, hemorrhage, uterine perforation, infection, and retained tissues. These can be lessened by visual inspection of the fetal parts to ensure complete evacuation of the products of conception. This may be emotionally important for some patients and also facilitates a more comprehensive postmortem evaluation of the fetus, particularly when fetal anomalies are involved and fetopsy is requested. Advantages/Disadvantages As a method of second trimester abortion, D&E offers the advantage of being performed on an outpatient basis, without the need to undergo induction of labor and delivery. Also, there is no risk of delivering a live-born fetus with extraction procedures. Complications from D&E occur at lower rates than those for intra-amniotic instillation or intravaginal prostaglandin abortions. Some patients may feel the decreased amount of time for this procedure is advantageous over an induction of labor; however, other patients may feel that the delivery of a nonintact fetus is unacceptable. Perceptions of advantages and disadvantages of these procedures depend greatly on patient preference. Ninety percent of all abortions in the United States are achieved using suction curettage. Complications are rare but can include infection, bleeding, and perforation of the uterus. Methotrexate is a chemotherapeutic agent that blocks dihydrofolate inhibitor that interrupts placental proliferation. During the second trimester, abortion may be achieved via D&E or induction of labor. D&E has lower maternal mortality and morbidity compared to induction of labor for second trimester abortions. D&E is similar to suction curettage (D&C) but requires wider cervical dilation and the use of special forceps and curets to assist with the extraction of the larger volume of fetal parts. Complications of D&E include cervical laceration, hemorrhage, infection, uterine perforation, and retained tissue. Induction of labor techniques most commonly include cervical ripening with a prostaglandin, and amniotomy along with induction of labor with high-dose oxytocin. Complications from induction of labor include retained placenta, hemorrhage, infection, and cervical laceration. Maternal morbidity is 4 in 100,000 for D&E and 8 in 100,000 for induction of labor compared to 7. In the past, installation of intrauterine abortifacient agents such as hypertonic saline, prostaglandin F2, or hyperosmolar urea was a common method of inducing labor for second trimester terminations. These methods have largely been abandoned for safer methods (D&E or induction of labor). Vaginal or oral prostaglandins (prostaglandin E2, misoprostol) can be used to ripen the cervix and augment labor in second trimester termination. Prostaglandins usually result in higher rates of fever and gastrointestinal side effects. Feticidal agents (intraamniotic saline or digoxin and intracardiac potassium chloride) can be used in conjunction with prostaglandins to circumvent the possibility of live birth. Oral and vaginal prostaglandins have a higher incidence of live births and significant gastrointestinal side effects (nausea, vomiting, diarrhea), whereas instillation agents have a higher rate of retained placenta (13% to 46%). The maternal mortality rate for second trimester induction of labor is 8 in 100,000, similar to that of term delivery (7. On physical examination, she seems well-appearing, and bimanual examination revealed a slightly enlarged uterus. Have your medical technician inform her the results so you can continue to see other patients c. Tell her that her pregnancy test is positive and ask her how she feels about that d. Hand her brochures on pregnancy and tell her you are available to answer any questions. You sit down across from the patient and tell her that her pregnancy test is positive. You ask her what her thoughts are regarding this pregnancy and she states that she is not ready to become a parent. Tell her you do not believe in abortion and that she would be making a mistake to terminate the pregnancy b. Present her with her options, which include carrying the pregnancy to term with parenting, adoption, and induced abortion c. Complete blood count A 36-year-old G3P2002 female presents to a family planning clinic for termination of pregnancy. She has no significant past medical history and has had two previous full-term vaginal deliveries. She currently smokes over a half a pack of cigarettes a day and has mild hypertension that is well controlled. At 7 weeks gestational age, what methods of termination can be offered to this patient She is counseled on signs of complications and instructed to call for an appointment if needed c. All of the above Vignette 4 A 30-year-old G2 P0010 female presents to a family planning clinic for termination of her current pregnancy. She complains of left lower quadrant pain and she has had vaginal spotting over the past few days. On physical examination, she has mild left lower quadrant tenderness and her uterus is approximately 5- to 6- weeks in size. Transvaginal ultrasound shows no gestational sac in the uterus and no adnexal masses. You counsel her that she probably has an early intrauterine pregnancy that is too small to be detected on ultrasound and that she should have a medication abortion if she desires b. You counsel her on warning signs such as severe abdominal pain and heavy vaginal bleeding for which she should call or go to the emergency room. She returns to the clinic in 72 hours for repeat serum testing and the level is 1,000. You schedule her to come back to the clinic in 72 hours for repeat serum testing and transvaginal ultrasound. Which termination method has the lowest maternal mortality rate at this gestational age The patient is counseled on the risks and benefits of both D&E and labor induction. Two weeks later she calls your nurse and says that she is passing large clots and having increased abdominal cramping. Answer C, serum pregnancy test would also help establish the diagnosis but it is more expensive and would take more time to get the results.

Discount super viagra online. Bhujangasan Yoga Pose l भुजंग आसन करने का तरीका लाभ सावधानी ले #yoga #yogaasan #bhujangasan.