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• Clinical Professor, School of Pharmacy, Northeastern University, Boston, Massachusetts

Sudden death of the foetus may occur without preceding slowing of the foetal movement as in abruptio placentae or it may be preceded by increased flurry movements erectile dysfunction remedies fruits best order himcolin. If foetal movement did not occur the test is extended for another 20 minutes during which the foetus is stimulated mechanically by the 1st pelvic grip or by acoustic stimulation using an artificial larynx placed against the maternal abdomen to " awaken the foetus" erectile dysfunction treatment lloyds purchase himcolin with visa. Reactive test means that the foetus can survive for one week impotence is a horrifying thing buy discount himcolin 30 gm online, so the test should be repeated weekly erectile dysfunction medication for high blood pressure order himcolin 30gm without a prescription. It denotes that the foetus can survive safely for one week when it should be repeated erectile dysfunction treatment philippines purchase himcolin 30 gm visa. One or more amniotic fluid pockets measures 1 cm Largest pocket measures less than 1 cm in 2 Amniotic fluid volume or larger in 2 perpendicular planes erectile dysfunction medicine names discount himcolin. At about 35 weeks, the lecithin concentration rises so the ratio of L/S is 2/1 or more with this ratio the risk of respiratory distress is minimal. It is more reliable than L/S ratio as it is not detected in blood, meconium or vaginal discharge so the contamination of the sample with any of these does not confuse the interpretation. C Foam stability (shake) test: It is a rapid test for detection of foetal lung maturity. If 50% or more of the cells in the amniotic fluid are of these type the foetus is mature. Chromosomal study is indicated in the following conditions: file:///D|/Webs On David/gfmer/Books/El Mowafi/assessment of foetal maturity. Ultrasonographic markers of chromosomal anomalies as: cardiac defects, duodenal atresi, omphalocoele and hands or feet anomalies. Progressive fall in urinary oestriol by serial measurement indicates that the foetus is jeopardous. In good pregnancy : 95% of the cells in the smear are of the intermediate type (navicular cells) that have folded edges and present in clusters. At full term: 10% of the cells are of superficial type, clumping and folding of the intermediate cells become less evident due to decreasing progesterone level. Foetography: Injection of oil-soluble radiopaque material as Ethiodol into the amniotic fluid to outline the foetus as it has a strong affinity to vernix caseosa giving a clearer view in X-ray radiography. Radiological methods are abandoned since the development of sonography as these have the following hazards: 1. Internal: by an internal electrode applied to the foetal scalp after rupture of the membranes while the cervix should be one or more cm dilated. The intrauterine pressure is transmitted to the catheter then to a transducer giving electrical signals expressing the exact pressure in mmHg. El-Mowafi values inbetween denotes pre-acidotic range and repeated estimation is indicated. El-Mowafi the growth impairment involves the body but not the brain tissues " sparing effect", so the head is big in comparison to the body. The neonate shows signs of dysmaturity as: underweight, dry wrinkled skin, meconium stains the foetus, placenta umbilical cord as well as the amniotic fluid. Termination of pregnancy according to the balance between risk of intrauterine asphyxia against those of prematurity. El-Mowafi 1 Mode of delivery is influenced by : gestational age, result of the stress test, associated factors as malpresentations, antepartum haemorrhage, previous caesarean section. Hypothermia: due to relatively large surface area and lack of insulating fat layer 2. Asphyxia neonatorum: as an extension to the intrauterine asphyxia or due to meconium aspiration. Hypoglycaemia: due to increased metabolic demands, especially in presence of chilling and poor glycogen reserves. This may be the result of : file:///D|/Webs On David/gfmer/Books/El Mowafi/Placental Insufficiency Perinatal Mortality. Uterus is smaller than the period of amenorrhoea and does not enlarge with repeated examination. Maceration of the foetal skin starts 12 hours after death which can be detected after its birth. Ultrasound: the most accurate and rapid method which shows: i absent foetal movements, ii absent foetal heart movement, iii Spalding sign: overriding of the skull bones due to softening of the brain and absorption of C. Pregnancy test: becomes negative within 2 weeks but may remain positive as long as there is living chorionic tissues. Disseminated intravascular coagulation if the foetus is retained more than 4 weeks. Induction of labour by prostaglandins and/or oxytocin is indicated in : i No expulsion after 3 weeks. Surgical evacuation of the uterus abdominally: may be indicated in failure of prostaglandins. Foetal birth injuries as fracture dislocation of cervical spines and rupture spleen. Tetanus toxoid vaccination to the mother to protect the foetus from tetanus neonatorum. Diagnosis = Signs of Foetal Distress: (1) Foetal heart rate changes : in the form of; i) Tachycardia : > 160 beats / min. The fresh thick dark brown meconium that is seen on the examining fingers in breech presentation is not an indicator of foetal distress. Left lateral position of the mother : to relieve aorto -caval compression - improves venous return - improves cardiac output - improves uteroplacental blood flow. El-Mowafi is indicated if the foetal distress is not improved by the conservative methods. Vacuum extraction, forceps delivery or breech extraction: if the cervix is fully dilated and vaginal delivery is amenable. Sign 0 1 2 Heart rate Absent <100 >100 Respiratory effort Absent Slow, irregular Good, crying Muscle tone Flaccid Some limb flexion Active movement Reflex (Response to No response Grimace Cough or sneeze nasal catheter) Body pink, limbs Colour Blue or pale Completely pink blue the score at 1 minute determine the need for resuscitation: Score Condition Resuscitation 7-10 Good. Minimise the foetal exposure to anaesthesia during labour and ensure adequate oxygenation with it. El-Mowafi q is stimulated by slapping the soles of the foetus, flexion and extension of the legs and rubbing the back. Antibiotics: to guard against pneumonia which is liable to develop after prolonged resuscitation. Drugs : the most well documented are: Drug Effect I Antibiotics Streptomycin Nerve deafness. Diagnosis and Differential Diagnosis: Cephalhaematoma Caput Succedaneum Develops hours or days after birth. Sudden compression and decompression of the head as in breech and precipitate labour. Prematurity due to physiological hypoprothrombinaemia, fragile blood vessels and liability to trauma. Subdural : results from damage to the superficial veins where the vein of Galen and inferior sagittal sinus combine to form the straight sinus. Subarachnoid: the vein of Galen is damaged due to tear in the dura at the junction of the falx cerebri and tentorium cerebelli. In (1) and (2) it is usually due to birth trauma, in (3) and (4) the foetus is usually a premature exposed to hypoxia. Forceps delivery: carried out by an experienced obstetrician respecting the instructions for its use. Lumbar puncture: is diagnostic and therapeutic to relieve the intracranial tension if the anterior fontanelle is bulging. The pain is due to increased intrauterine pressure 10-12 1 with each contraction to 25 mmHg or more and due to cervical dilatation. The highest degree of pain felt during the transitional period between the first and second stage. Breathing and relaxation exercises: increases the oxygen supply to the contracting myometium so ischaemia is reduced and pain is minimised. Complications: it may cause neonatal hypothermia, hypotonia and respiratory depression. It should not be given 2 hours before delivery to avoid foetal respiratory depression. It has more potent analgesic effect but more depression to the foetal respiratory centre so it should not be given 4 hours before delivery. The antidote of narcotic analgesics is Naloxone 5 g/ kg body weight into the umbilical vein. It abolishes the perineal reflex leading to prolonged second stage and hence increased incidence of instrumental delivery. El-Mowafi It is the safest and simplest technique but time should be allowed to establish analgesia. Complications of General Anaesthesia: (I) Foetal : Depression of the respiratory centre and asphyxia. During induction: occlude the oesophagus by cricoid pressure and guard the trachea by cuffed endotracheal tube. During recovery: remove the tube in lateral position with the head lower down and only when the patient is conscious. Hypotension: because block of the sympathetic nerve supply to the lower part of the body leads to peripheral vasodilatation. Accidental dural puncture: There is a 50% possibility of a low pressure headache which lasts for few days from leakage of cerebrospinal fluid into the epidural space. These cause initiation and increase in frequency, strength and duration of uterine contractions. Before delivery of the foetus as it will cause foetal asphyxia and rupture uterus. Direct obstetric deaths: resulting from obstetric complications of pregnancy, labour or puerperium and from interventions, omissions and/or incorrect treatment. Indirect obstetric deaths: resulting from previously existing disease or a disease that developed during pregnancy, labour or puerperium. Accidental deaths: not related to pregnancy, labour or puerperium itself but happened during it. Maternal age: the golden age for fertility and childbearing is between 18 and 35 years, the risk is more both to the mother and foetus with more deviation below or above this range. Proper intranatal monitoring by clinical observation, cardiotocography and partogram. Indications: (I) Maternal: (1) Hypertensive disorders with pregnancy: i Severe pre-eclampsia. El-Mowafi Modified Bishop Score: this score is predicting for the succession of induction of labour. The total score is in the range of 0-13, a score of 9 or more is favourable for successful induction. In most of the cases with favourable bishope score labour is commenced within 24 hours. No side effects, complications or contraindications as regard the mother or the foetus. Spontaneous uterine contractions start without medication or surgical interference. The procedure can be repeated for unlimited times and caesarean section must not be the alternative if it fails. These can be administered via many routes (see ecbolics) but the commonest are: (A) In living foetus: q Prostaglandin E vaginal tablet 3 mg (Prostin) is applied deep in the 2 posterior fornix. A drip of normal saline is connected to it to pass extra-amniotic in a rate of 1 ml / minute. Hindwater (high) amniotomy: the Drew-Smythe catheter is introduced between the membranes and uterine wall to a point above the presenting part. Method of administration : the initial rate of administration is 6 m units/ minute, increased by 6 m units/ minute every 15 minutes up to a maximum of 36 m units/minute or until 3 contractions/ 10 minutes are achieved. Ultrasound is sound waves above this audible range and for diagnostic purposes it ranges between 2. The transducer of the ultrasound machine contains piezoelectric crystals previously were made of quartz but now these are synthetic crystals. These crystals have the property of changing the electric to sound waves and vice versa. The electric current supplied to the machine generates ultrasound waves from these crystals to be reflected from tissue interfaces at various depths and by different echoes according to the nature of the medium i. The reflected sound waves is re-transformed again into electric waves presented as dotes or lines on the ultrasound screen. The ultrasound waves can pass through fluid and solid media but not effectively through gases,so a gel should be applied between the transducer and skin. In abdominal ultrasonography, the full bladder is essential for effective transmission of the waves and delineation of the pelvic organs in gynaecological and first trimester obstetric diagnosis. El-Mowafi Modes: (I) A (Amplitude) mode: It is a unidimensional system used to measure the depth of structures not used in obstetrics. Real-time: 40 images or more are obtained per second so that the movement of the structures is shown. This can be achieved by 3 different techniques: i Linear : giving a rectangular image (more convenient for obstetric examination). Multiple pregnancy: may be detected in the early weeks but diagnosed reliably by 16 weeks. Different types of abortion including blighted ovum, threatened, inevitable, incomplete, complete and missed abortions. Hazards of Ultrasound: Up till now, there is no data about any deleterious effects on the foetus or the mother. Localisation of placental site (the old methods of head displacement from the symphysis pubis or placentography).

These guidelines are not intended to be a comprehensive list of all potential drug interactions and normal precautions should be taken when prescribing any combination therapy low testosterone causes erectile dysfunction generic 30gm himcolin. Significantly increased clearances of methotrexate and teniposide in patients receiving anti-convulsant therapy erectile dysfunction treatment injection cost discount generic himcolin uk. Combined Increased risk of thrombo Patients using combined contraceptives Contraceptives embolic event should stop and switch to a low dose erectile dysfunction kya hota hai order himcolin online. Cytarabine Flucytosine Uptake of flucytosine by fungi may be inhibited by cytarabine Cyclophosphamide Suxamethonium Duration and effect of neuromuscular blockade may be increased erectile dysfunction diet order himcolin 30gm visa. Failure to rescue a patient appropriately can lead to severe irreversible toxicity erectile dysfunction medication with high blood pressure cheap himcolin 30gm. Adjust the sodium bicarbonate concentration to maintain the urinary pH between 7 and 8 impotence 24 purchase himcolin online. Note, even if the infusion is not complete at this time point, it must be stopped. Hydration during methotrexate infusion Fluid: Dextrose/saline infusion fluid, bearing in mind the total sodium content. Infusion rate: Hydration needs to continue during 24 hours of methotrexate infusion to maintain a 2 combined infusion rate of 125ml/m /hr. This may be achieved either by using a Y extension set or using both lumens of the central venous line. Therefore the folinic acid should be administered intravenously, so that the rescue is optimal. Methotrexate plasma concentrations are measured at hours 24, (36*), 42, 48, (54*) hours from start of the methotrexate infusion. Time from start of Serum creatinine Methotrexate Methotrexate Folinic acid dose methotrexate measurement level plasma measurement concentration expected 24 hours Yes Yes <150?mol/L 36 hours (yes)* (yes)* <3?mol/L 2 42 hours Yes? Take care in interpreting results which are taken at different time points and processed by the lab at the same time. If the 36 hour level exceeds 10?mol/L then consider Glucarpidase regardless of urine output 2 3. If the 36 hour level is <10?mol/L then continue hydration to 200ml/m per hour: keep urine pH >7. Estimate urine output 4 hourly and if urine output less than 80% of fluid intake consider Glucarpidase. If the plasma methotrexate concentration at hours 42, 48 from the start of methotrexate exceeds the normal range for time, increase the folinic acid rescue according to the schedule below. If the plasma methotrexate concentration at hour 36 or 42 was high but then the patient ?catches up, and the level falls to? Consider using it >10?mol/L at T=48hr (or according to established local practice). Stop folinic acid 4 hours prior to administration of glucarpidase and reintroduce 4 hours after treatment to replenish intracellular folate. Repeat doses of glucarpidase carry a high risk of allergy or lack of efficacy due to tolerance. Full recovery was seen in 197 cases and in most cases this occurred within 48 hrs of the episode. Although episodes have occurred in all courses, just over half have been during the consolidation phase of Regimens B/C or part 2 of the Delayed Intensifications. These patients should be re-exposed, and in the absence of recurrence, administer missed doses during interim maintenance or maintenance. In the event of recurrence, change to intrathecal cytarabine + hydrocortisone in the doses given below. Encephalopathy during Protocol M Discuss with the trial coordinators Encephalopathy during other courses. The true prevalence in this patient population is unknown and varies with the method of assessment. However, the need to collect such information to judge the appropriateness of prophylaxis is recognised. Asparaginase therapy and the presence of a central venous catheter are accepted as the main predisposing factors. The procedures described below are recommendations, however sites may continue to use local established practices. The literature is inconclusive for risk conferred by other inherited thrombophilias. In the presence of persistent line dysfunction despite a normal linogram, further imaging is indicated. Discussion regarding the most appropriate product and dosing with a local expert in paediatric haemostasis is recommended. There is no excess drug cost associated with the induction dexamethasone randomisation. It is estimated that 80% of patients will be eligible for the methotrexate and pulses randomisations. The excess in patient days associated with administration of Protocol M are offset by the reduction in day case admissions for intrathecal chemotherapy and will likely be further offset by reduced admission for central line associated infection in the no pulses arm. There are now data to suggest that these two drugs are best used in conjunction, exhibiting a synergistic interaction. Side effects like sepsis, psychosis, encephalopathy and pancreatitis are potentially fatal, while others including avascular necrosis, thrombosis and diabetes lead to long-term disability. We will take advantage of its design to investigate individual variations in pharmacokinetics, explore synergy and correlate this with early response to therapy, toxicity and outcome. Results generated will lead to future individualisation of therapy to decrease toxicity and further improve outcome. Methodology For the pharmacokinetic studies, blood samples will be collected on the study days shown in Figure 1. Blood samples (3ml) will be obtained pre-treatment and at 1, 2, 4 and 8h after the first dose of dexamethasone on days 1 and 14 (short arm) or 28 (standard arm) of treatment. Plasma samples will be obtained immediately following sample collection and stored at -20?C prior to transport to Newcastle for analysis. With a study population of 250 patients, the study would have >90% power to detect a 40% relative difference in dexamethasone clearance between the defined groups. Laboratory Assays Asparaginase Activity: the diagnostic sample will serve as baseline, and subsequent samples are to be taken 7-14 days after the last pegaspargase and 1-1. The quantification of enzymatic activity of all forms of asparaginase is based on the measurement of substrate turnover at a maximum rate. One unit of activity is defined as the amount of enzyme which o releases 1mmol of ammonia and aspartate from 1mmol asparagine per minute at 37 C. The liberated ammonia can be measured spectrophotometrically either after nesslerization or by an enzyme coupled reaction. This method requires 20ul of plasma and has a sensitivity of 30U of Asparaginase/L of plasma. Asparaginase Antibody Assay: Briefly, microtitre plates are coated with purified (and recombinant) E coli asparaginase. The positive anti-asparaginase antibody controls, calibrators with defined anti asparaginase reactivities, normal human serum as negative control, and patient serum samples at certain dilutions are added and incubated for 1 h. After washing, a polyclonal goat anti-human IgG and IgM horseradish peroxidase conjugate is added and incubated for 1 h. Anti-asparaginase antibody levels are measured at 450 nm for the enzymatic product (subtracting the absorbance at about 630 nm for nonspecific absorbance) using a microplate reader. All samples (peripheral blood) are for asparaginase activity and antibody detection. For this we need to know the date the last dose of asparaginase was given and the date the sample was taken. Please ensure that the peripheral blood sample is taken at least 7 days and not more than 14 days after the last dose of pegaspargase. Please note this sample will also be used for epitope analyses and therefore requires an adequate number of 9 white cells. Analytical validation of a microplate reader-based method for the therapeutic drug monitoring of L-asparaginase in human serum. To describe changes in QoL throughout treatment and up to the completion of therapy. To assess the ?burden of therapy for the child and (where appropriate) their family throughout therapy. Reliance on any of these individual measures is limited as none alone will provide a comprehensive or sensitive indicator of QoL during treatment for leukaemia. For this reason, a number of specifically developed measures of QoL for children with cancer have been reported. Availability of parallel versions, enabling comparisons to be made between parent and child views about QoL. Varni et al reported that children who had completed treatment had a better QoL than those who were still on treatment. Comparisons with norms will be made to enable us to distinguish changes in QoL which are the result of treatment compared with any that might be attributable to normal age-related changes. This is seen in all domains, with a fall in QoL scores early in treatment followed by some improvement over time. Analysis of the randomised groups has not yet been undertaken however it is clear that the instrument used is sensitive to changes in QoL in this population over time. Time points t1 week 1; t2 week 4; t3 start of maintenance t4 18 months; t5 end of treatment. Family burden of care Practical issues that affect day to day life are not included in contemporary QoL measures. In the absence of any standardised measure, we previously devised a questionnaire based on clinical and research experience. This is particularly true during induction chemotherapy when the patient may be acutely unwell and is overcoming the shock of the diagnosis of a life threatening condition. QoL will be assessed at diagnosis and again at the end of induction allowing a comparison between the two different induction steroid regimens (short or standard dexamethasone dosing). During the maintenance phase of treatment, patients are in a more stable state and thus the trial provides a real opportunity to understand the impact of both the use intravenous methotrexate rather than continued intrathecal therapy and the impact of pulses of steroids and vincristine. Assessment of QoL in 16-25 year olds QoL questionnaires that are age-appropriate with established reliability and validity will be used. In addition separate questions to determine participation in daily activities will parallel those used in the child study. All patients entering the trial at <3 years of age will reach this age at some point during treatment and questionnaires can be given to parents of these children at the designated time point after their birthday. Those patients who reach the age of 8 years during treatment will be eligible to complete the questionnaires themselves from that time point, even though they have not previously done so. This questionnaire should ideally be completed after informed consent has been obtained and before the first randomisation/commencement of treatment. This questionnaire must be completed within 2 weeks of the end of interim maintenance. This allows comparison of the impact of therapy on patients who have previously received methotrexate and those who are receiving pulses of dexamethasone and vincristine. A final assessment at the completion of therapy, which will be at approximately 24 months for girls and 36 months for boys. Evaluation of the length of treatment on QoL and family burden of care with ongoing comparison between the groups randomised to pulses of vincristine and dexamethasone and those not receiving these. Questionnaires will be given by the treating clinician, a research nurse or nurse specialist within the unit, based on patient eligibility and age at the assessment time point. Parent questionnaires will be given to those with children aged 3 to 15 years inclusive. Most will be able to complete these with minimum explanation (time for completion approximately 10 minutes). Nurses will be given specific instructions about administration of questionnaires and ongoing support throughout the running of the study by the QoL leads. Should this improvement occur earlier in the no-pulses arm, measurement at around 18 months will show a difference of 0. Upton P, Eiser C, Cheung I, Hutchings H, Jenney M, Maddocks A, Russell I, Williams J. Most studies have shown good concordance between the two methodologies but there are also discordant measurements. Analysis at diagnosis to further assess if any particular immunophenotype is predictive of prognosis 2. Assessment during induction therapy at all time points will allow comparison of disease kinetics in the 2 randomised dexamethasone arms and may identify different risk groups according to the pattern of disease response 3. Analysis at day 8 and day 15 of induction therapy (i) To assess identification of high risk patients. Analysis at the end of induction and later time points to allow comparison with molecular results 6. To determine the relationship between dexamethasone clearance and serum albumin concentration. However, while the use of dexamethasone has undoubtedly led to improvements in outcome seen over the past 10 years, it also makes a major contribution to a variety of short and long-term side effects which may negate its antileukaemic benefit. In addition, approximately a quarter of patients suffer at least one non haematological serious adverse event. Based on findings from this and previously published studies, the current study provides an opportunity to investigate the potential impact of pharmacokinetic variation in drug scheduling, i. Despite its successful use in the treatment of several haematological malignancies and other tumour types, very limited information is available concerning dexamethasone pharmacokinetics in children.

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Medication nonadherence: finding solutions to a costly med Scientific Meeting erectile dysfunction drugs free sample cheap himcolin 30gm without a prescription, April 26 erectile dysfunction louisville ky buy himcolin mastercard, 2001 erectile dysfunction protocol free order himcolin online. Basic concepts in biomechanics and Anesthesiologists erectile dysfunction treatment without side effects buy discount himcolin 30gm, Task Force on Pain Management impotence treatment after prostate surgery order himcolin online from canada, Acute Pain Section erectile dysfunction hypertension medications buy 30gm himcolin free shipping. Lesions of primary afferent and sympathetic effer Lippincott Williams & Wilkins; 2001:780-787. Efficacy of multidisciplinary pain centres: an antidote Practice guidelines for chronic pain management. Prevention of postoperative pain Manual for and Interpretive Guidelines for Medical Rehabilitation. Acute Low Back Problems in Adults: management treatment on locus of control and pain beliefs in chronic Assessment and Treatment Quick Reference Guide No. Gabapentin for the sympto Rheumatology 1990 criteria for the classification of fibromyalgia. Opioid maintenance in chronic non-malignant pain [syl features of fibromyalgia syndrome. Recommendations for individ gesia, allodynia and myoclonus related to morphine metabolism during ual drugs. Progress in Pain Research and evidence-based guidelines for migraine headache (an evidence-based Management. Headache Consortium, American Rheumatology Ad Hoc Committee on Clinical Guidelines. The fibromyalgia syndrome: myofascial pain and the chron Practice guidelines for cancer pain management. Evidence-based guidelines for Agency for Health Care Policy and Research; February 1993. AnesthesiologistsTask Force on Sedation and Analgesia by Non Available at: Anesthesiologists. Practice parameter: Anesthesiologists Task Force on Pain Management, Chronic Pain Section. November 15, 2000;62(10):2359-2360, ment of osteoarthritis, part I: osteoarthritis of the hip. The Eastern Cooperative Oncology Group University of Wisconsin-Madison Board of Regents; 2000. Stratis Health-Medicare Health Care Quality Improvement guidelines for the treatment of acute pain and cancer pain. Monitor vital signs in the term neonate hourly for the first 4 hrs post-delivery followed by normal observations. The mean elimination half-life for morphine is 2 to 3 hours, but effects may extend up to 24hours. Alterations in mood can include euphoria, dysphoria, drowsiness and mental clouding. A double blinded randomised placebo controlled study of intramuscular pethidine for pain relief in the first stage of labour. If one antiemetic does not work proceed to alternative or page Anaesthetist advice. Anti-emetics should be ordered on the medication chart but administration should be recorded on both the medication chart and pain observation chart. Any patient requiring more than 2 doses of antiemetic will need a regular dose ordered on their medication chart. Therefore, as medical students we stand for a nondiscriminatory obstetric practice that takes into account the patient in all of its assets and fulfills not only technical evidence-based efficiency but humane health support as well. We are committed to re discuss and redefine medical philosophy because we recognize the necessity among young doctors and medical students to welcome other modalities of practice that are primary health based and multi professional, needing the open minds of youth leaders today. Promote for obstetric violence awareness and acknowledging the term of humanized childbirth as a superior priority to be reached and accomplished as a current and continuing goal. Update or create laws that condemn all obstetric violence practices that are committed by practitioners and health care personnel against pregnant patients in healthcare facilities and institutions. Encourage maternal health institutions to advocate for the rights of pregnant women. Declare policies that impel spreading awareness among health care individuals, institutions, and patients on the subject of humanized childbirth and the necessity of elimination of obstetric violence. Reclaim equipment, supplementary services, lack of health care personnel, and any deficient sanitary state requirements by providing equivalent and sufficient finances for all maternal care facilities regardless of the position (geographic site), the religious, social, or political orientations of the given population group. Include and promote sexual and reproductive health rights within school syllabi, especially among young girls exposed to higher risks of young age marriages. Advocate, encourage, and promote actions towards awareness within the society about the terms of obstetric violence and humanized childbirth. Initiate solidarity movements towards supporting and empowering women worldwide regarding their sexual and reproductive health rights as well as promoting discussions about pregnancy and obstetric healthcare. Consider reporting cases witnessed of obstetric violence inside any health care facilities supervised in any way by agency. Create a safe environment for pregnant women to express their needs, expectations, and fears related to the childbirth process. Demand that governments observe, detect, and punish acts of disrespect or lack of proper care practiced upon pregnant women in public health care institutions. Collaborate with medical students for the development of activities and campaigns against Obstetric Violence and Humanized Birth. Acknowledge the terms of Obstetric Violence and Humanized Childbirth as acts of violation against women, ignorance of their sexual and reproductive health rights, and infringement on their privacy. Conduct lectures, workshops, and activities targeting medical students aiming to address the reality of obstetric violence in their countries. Act upon obstetric violence according to the circumstances, taking into account local, cultural, religious and legal frameworks and empower other medical students to do likewise. Facilitate and encourage the activation of solidarity movements among medical students that aim for women empowerment and awareness about sexual and reproductive health rights, as well as pregnancy and childbirth. Elucidate faculties and colleges as well as decision makers within the healthcare panorama to promote curricula changes and reinforce evidence based approaches for education strategies within the field of obstetrics and sexual and reproductive health. Empower medical students to be more knowledgeable about Obstetric Violence and Humanized Childbirth within their academic and personal lives. Create and promote projects and campaigns referent to this issue that are community based and using social determinants of health as main targets of approach such as gender inequality. Problematize the political roots that systematically attach gender inequality to medical practice within our debates, discussions and capacity building spaces. Position Paper Introduction the term obstetric violence was first defined and legally adopted by Venezuela in 2007. The law defines obstetric violence as ?the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women [1]. Obstetric violence being an umbrella term for a variety for demeaning and derogatory actions directed towards a pregnant woman can be exactly traced to a particular country. Literature from across the world has substantial references of women subjected to physical torment during labor. The rapid increase in obstetric violence began due to industrialization of labor [2]. A major factor that contributed to the industrialization of labor was the development of obstetrics. With increased interest of medical sciences into labor, better instruments and labor accelerants were developed. Increased industrialization of births made hospitals such an integral part of the birthing process that obstetric violence became acceptable as labor without professionals was believed to be impossible. With the advent of time, obstetric violence today stems from increased monetary gains and deficient skills of medical practitioners [3]. Additional factors that contributed to obstetric violence is religious and cultural practices. However the popular medical opinion suggested that a woman could only undergo three C sections in a lifetime before sterilization would become necessary. Thus in Catholic country as Ireland, women were forced to undergo symphysiotomy [4]. Obstetric Violence as a Worldwide Issue After Venezuela, Argentinian law defined obstetric violence. The statute defines it as: [violence exercised by health personnel on the body and reproductive processes of pregnant women, expressed through dehumanizing treatment, medicalization abuse, and the conversion of natural processes of reproduction into pathological ones [5]. Incidences of obstetric violence in Argentina range from dehumanization of care, over medicalization and conversion of physiological processes into pathological ones. While dehumanization of care refers to misconduct amounting to physical and psychological harm, over medicalization refers to unnecessary episiotomies, enemas etc. Women can also be subjected to obstetric violence during different phases of pregnancy, not just limited to labor [6]. In the United States of America, a largely accepted manifestation of obstetric violence is forced caesarian sections. Despite unwillingness of women to undergo the surgical procedure, women in labor are threatened and coerced into opting for it. Legal notices, complaints to child protection services are some of the methods used to distress pregnant women to submit to the will of the physicians. Despite several lawsuits filed against physicians, most rule in their favor keeping the fact that ?physicians know best as paramount [7]. Physical and verbal abuse, lack of previous consent and poor communication are seen in the region. Rates of maternal mortality are shown to be significantly high in Islamic countries, and some reasons include low average age of marriage, illiteracy, lack of prenatal care, and obstetric complications [8]. In Morocco, the result of a survey found women who reported physical abuse have a frequency of 12. Most of these women were uneducated, socio-economically disadvantaged and had a partner with toxic habits [9]. When Jordanian women were surveyed regarding their birthing experience to understand the situation, the women saw childbirth as a dehumanized experience, feeling that childbirth was processed technologically, experienced a lack of human support as they were not permitted birthing partners and were in an inappropriate childbirth environment [10]. In the African continent social inequalities and intersectionality are also susceptible to the changes of gender perception in childbirth. The women reported that the female paramedics made women deliver lying down, did not always use aseptic procedures and were too busy to give information, making birth a passive experience [14]. Similarly in India, an urban slum was surveyed to assess the quality of maternal healthcare. Women reported lack of essential drugs, being left unsupported and evidence of physical and verbal abuse 1. Afghanistan is one of the few countries constantly labelled at being ill-equipped in providing appropriate ante and perinatal care. Women reported dissatisfaction with childbirth services, particularly the poor attitudes and behavior of health workers, including discrimination, neglect, and verbal and physical abuse. Despite negative experiences with the health services, women appreciated having any access to health services. Health workers reported that low salaries, high stress and poor working conditions contributed to the poor quality of care [16]. Clinical Aspects of the Obstetric Violence Panorama Obstetric violences are not only simple consequences of obstetric procedures but actually develop a pathological state that harms both mother life and fetal development. In 2010 Browser and Hill identified initial verbal abuse, lack of privacy, lack of consent, and denial of care as factors that affected significantly maternal morbidity and mortality because of its links to the development of complications [17]. Besides these, the world has encountered other examples of mistreatment such as unnecessary episiotomy that leads to the loss of sphincter control, abuse of oxytocin levels for partum induction and also the denial to safe abortion by multiple barriers that lead to complications of unsafe abortion procedures such as sepsis and hemorrhage [18, 19, 20]. This is especially important seeing the current upscale in cesarean sections over natural birth procedures in maternal care settings. This survey showed that about one quarter of mothers who had induced their labors felt pressure to do so and that 63% of women who had a primary cesarean identified their doctor as the ?decision maker of the procedure [22]. Obstetric Violence are not only found in large or complex procedures but as well in the pre and post partum care. One example are routine enemas for the clearance of intestinal content previous to delivery. This practice aims to improve sanitary conditions of partum stances but there is still no evidence on its real benefit while it is very uncomfortable for the patient and generally done without consent [25]. Most of the prenatal factors that make a partum longer or the forcing of partum using kristeller maneuvers (which are contraindicated currently) show a high risk potential of complications such as obstetric fistula that affects over 2 million women in Africa and Asia and that has a low resolution rate depending on the deficient comprehensive care systems that systematically allow obstetric violence to occur without legal consequences [26]. From the legal perspective many discussions are yet to be done for many countries in the world. Many healthcare providers attempt to justify obstetric violence by allocating goodwill to the fetus but then in this situation putting at risk the potential life of the mother which under a governmental law would be more evident. Some of this unethical behavior is likely related to the fact that the law has failed to directly rectify the lingering controversy among practitioners as to the appropriateness of overriding the decisions of pregnant patients in all jurisdictions. The Benefits of Humanized Birth Humanized birth is putting the woman giving birth in the center, giving her the control and authority to make all the decisions about what will happen not the doctors or anyone else [28]. Although humanized birth is contrary to obstetric violence, the simple eradication of obstetric violence does not completely evoke the concept of humanized birth. As per now, the medical academy has not reached to a full consensus about obstetric violence, but there are different perspectives in modern literature relevant for the knowledge and advocacy of medical students. The first aspect is that Humanized Birth is not only attributed to specific technical skills and the process of birth, but rather a whole unison of cultural, social and ethnicity aspects. As well, it is not simplified giving humanitarian care to a pregnant individual [29].

Excessive vitamin and mineral intake (ie muse erectile dysfunction wiki order himcolin, more than twice the recom mended dietary allowances) should be avoided during pregnancy erectile dysfunction treatment scams buy himcolin once a day. There also may be toxicity from excessive use of other fat-soluble vitamins (vitamin D erectile dysfunction even with cialis order himcolin with amex, vitamin E impotence by age 30 gm himcolin mastercard, and vitamin K; see Table 5-6) erectile dysfunction questions to ask order cheap himcolin. Fish provides a source of easily digestible protein with high biologic value in terms of vitamins erectile dysfunction treatment pumps buy cheap himcolin 30gm line, amino acids and minerals. Also many fish are a uniquely rich food source of long chain omega-3 fatty acids and long-chain polyunsaturated fatty acids. There is strong evidence to suggest that these fatty acids are impor tant in central nervous system development and that maternal consumption of these fatty acids benefits fetal development and provides good nutrition for the mother. Some large fish, such as shark, swordfish, king mackerel, and tilefish are known to contain high levels of methylmercury, which is known to be terato genic. As such, pregnant women and women in the preconceptional period and lactation period should avoid these fish. To gain the benefits of consuming fish, while avoiding the risks of methyl mercury consumption, pregnant women should be encouraged to enjoy a vari ety of other types of fish, including up to 12 ounces (2 average meals) a week of a variety of fish and shellfish that are lower in mercury. Five of the most com monly eaten fish that are low in mercury are shrimp, canned light tuna, salmon, pollock, and catfish. White (albacore) tuna has more mercury than canned light tuna and should be limited to no more than 6 ounces per week. Pregnant and nursing women also should check local advisories about the safety of fish caught in local lakes, rivers, and coastal areas. If no advice is avail able, they should consume no more than 6 ounces (one average meal) per week of fish caught in local waters and no other fish during that week. To prevent pregnancy-related listeria infections, pregnant women are advised not to eat hot dogs or luncheon meats unless they are steaming hot and to avoid Preconception and Antepartum Care 141 unpasteurized soft cheeses. Maternal infection has been associated with preterm delivery and other obstetric and neonatal complications. The possible occurrence of a major birth defect is a frequent cause of anxiety among pregnant women. Many patient inquiries concern the teratogenic potential of environmental exposures. There is little scientifically valid infor mation on which a risk estimate in human pregnancy can be based. Patients should be counseled that relatively few agents have been identified that are known to cause malformations in exposed pregnancies. Relatively few patients are exposed to agents that are known to be associated with increased risk of fetal malformations or mental retardation. The health care provider may wish to consult with or refer such patients to health care professionals with special knowledge or experience in teratology and birth defects. The Organization of Teratology Information Specialists provides information on teratology issues and exposures in pregnancy ( Prenatal lead exposure has known adverse effects on maternal health and infant outcomes across a wide range of maternal blood lead levels. Obstetric health care providers should consider the possibility of lead exposure in individual pregnant women by evaluating risk factors for exposure as part of a comprehensive health risk assessment and perform blood lead testing if a single risk factor is identified. Although most medications are not known to be teratogens, patients should consult with their health care providers before using prescription and nonprescription medications or herbal remedies (see also ?Medication Use earlier in this chapter). Importantly, patients and health care providers should be reminded that alcohol and hyperglycemia are more common teratogens than medications. Physician and patient information about known terato genic medications, as well as other teratogenic exposures, can be found on the Organization of Teratology Information Specialists web site. Many patients raise questions about the methods of detecting birth defects related to drug exposure. Although obstetric ultrasonography has been the mainstay of surveillance for teratogen induced congenital anomalies, its sensitivity varies with the experience and skill of the imager as well as the specific anatomic abnormality. However, even in expert hands, the overall sensitivity of ultrasonography in the detection of fetal anatomic anomalies is in the range of 50?70%. Concerns frequently are expressed over the teratogenic potential of diagnos tic imaging modalities used during pregnancy, including X-ray, nuclear imag ing, contrast agents, and magnetic resonance imaging. The imaging modality that causes the most anxiety for both the obstetrician and the patient is X-ray or ionizing radiation. Much of this anxiety is secondary to a general misperception that any radiation exposure is harmful and may result in injury to or anomaly of the fetus. In fact, most diagnostic X-ray procedures are associated with few, if any, risks to the fetus. Exposure to less than 5 rads has not been associated with an increase in fetal anomalies or pregnancy loss. Moreover, according to the American College of Radiology, no single diagnostic X-ray procedure results in radiation exposure to a degree that would threaten the well-being of a developing preembryo, embryo, or fetus. Concern about radiation exposure during pregnancy should not prevent medically indicated diagnostic X-ray studies when these are important for the care of the woman. Because magnetic resonance imaging does not use ion izing radiation, it may be the preferred test. Both spiral computed tomography and ventilation?perfusion scanning expose the fetus to only small amounts of radiation. However, most centers avoid the use of iodinated contrast agents in pregnancy because of the risk of neonatal hypothyroidism. Patients concerned about previously performed or planned diagnostic studies should have counsel ing to allay these concerns. Most diagnostic studies in which radioisotopes are used are not hazardous to the fetus and result in low levels of radiation exposure. Preconception and Antepartum Care 143 Therefore, women should be advised to drink plenty of fluids and to void fre quently after a radionuclide study. One important exception is the use of iodine 131 for the treatment of Graves disease. The fetal thyroid gland begins to incorporate iodine actively by the end of the first trimester. Administration of iodine 131 after this time can result in concentration of the radiation within, and destruction of, the fetal thy roid gland. By comparison, there are few reports on the safety of radioisotope imaging of the maternal thyroid during pregnancy, and such studies should be undertaken only after careful consideration of the risks and benefits of the procedure. Because significant elevation of core body temperature may be associated with fetal anomalies, pregnant women might reasonably be advised to remain in saunas for no more than 15 minutes and hot tubs for no more than 10 minutes. As an additional precaution, it is best for women to ensure their head, arms, shoulders and upper chest are not submerged in a hot tub so there will be less surface area to absorb heat and more surface area to radiate it. Recent cohort studies suggest no increase in adverse pregnancy outcomes for occasional air travelers. Some restrict pregnant women from international flights earlier in gestation and some require documentation of gestational age. For specific airline requirements, women should check with the individual carrier. Civilian and military aircrew members who become pregnant should check with their specific agencies for regulations or restrictions to their flying duties. Air travel is not recommended at any time during pregnancy for women who have medical or obstetric conditions that may be exacerbated by flight or that could require emergency care. Pregnant women should be informed that the most common obstetric emergencies occur in the first trimester and third trimester. In-craft environmental conditions, such as changes in cabin pressure and low humidity, coupled with the physiologic changes of pregnancy, do result in adaptations, including increased heart rate and blood pressure and a significant decrease in aerobic capacity. The risks associated with long hours of air travel immobilization and low cabin humidity, such as lower extremity edema and venous thrombotic events, have been the focus of attention for all air travelers. In pregnant women the seat belt should be belted low on the hipbones, between the protuberant abdomen and pelvis. For example, gas-producing foods or drinks should be avoided before scheduled flights because entrapped gases expand at altitude. Preventive antiemetic medication should be considered for women with increased nausea. Antepartum Tests of Fetal Well-Being ^ Fetal surveillance techniques, including fetal heart rate monitoring and ultra sonography, can identify the fetus that is either suboptimally oxygenated or, with increasing degrees of placental dysfunction, acidemic. Identification of suspected fetal compromise provides the opportunity to intervene before pro gressive metabolic acidosis can lead to fetal death. Although there have been no randomized clinical trials that clearly demonstrate improved perinatal outcome with the use of antepartum testing or that determine the optimal time to initiate testing, certain tests have become an integral part of the clinical care of preg nancies suspected to be at increased risk of fetal demise due to uteroplacental insufficiency. Indications for initiating antenatal testing can be thought of in categories of maternal conditions and pregnancy-related or fetal conditions and are listed below. Monochorionic diamniotic multiple gestation Antenatal Testing Strategy Devising the appropriate antenatal testing strategy?what test to use, when to start testing, and how frequently to re-test?requires balancing several consider ations. The prognosis for neonatal survival, the severity of maternal disease, the risk of fetal death, and the potential for iatrogenic prematurity as a complication from false-positive test results all must be taken into account when considering antenatal testing. There are risks of false-positive test results, including unneces sary delivery of a healthy baby. As with any screening test, false positive test results are more common in populations at low risk of the disease intended to be identified. In general, antepartum testing should not begin before a gestational age at which the health care provider is willing to intervene and should be targeted at the gestational age at which the increased risk of stillbirth is likely. Therefore, the College supports initiating antenatal testing at 32?34 weeks of gestation for most pregnancies with increased risk of stillbirth. However, for pregnancies with particularly high-risk conditions or multiple complicating factors, testing may begin earlier. However, in the presence of certain conditions, such as postterm pregnancy, intrauterine growth restriction, or pregnancy-induced hypertension, some investigators perform twice-weekly antenatal testing. In addition, any significant deterioration in maternal condition or new decrease in fetal activity requires fetal testing independent of time elapsed from previous testing. For the indication of decreased fetal movement, usually only one antenatal testing episode is indicated. The false-negative rate is defined as the incidence of a stillbirth occurring within 1 week of a normal test. Interpretation of abnormal test results must take into consideration the overall clinical picture and the possibility that the test result is falsely positive. Decisions regarding serial testing or proceeding with delivery should be made in the context of the gestational age, and the maternal and fetal condition. Certain maternal conditions, such as diabetic ketoacidosis, pneumonia with hypoxemia, or general anesthesia can result in abnormal test results. In these circumstances, stabilization of the maternal condition and retesting the fetus may be appropriate. If delivery is planned, in the absence of obstetric indications, an induction of labor with continuous fetal heart rate monitoring may be attempted, with a plan for cesarean delivery in the case of repetitive late decelerations. Assessment of Fetal Movement A decrease in the maternal perception of fetal movement may, but does not invariably, precede fetal death. This observation provides the rationale for fetal movement assessment by the mother (kick counts) as a means of antepartum fetal surveillance in all women, not just those at increased risk of stillbirth. Multiple studies have demonstrated that women who report decreased fetal movement are at increased risk of adverse perinatal outcome. Although fetal kick counting is an inexpensive test of fetal well being, the effectiveness in pre venting stillbirth is uncertain. Neither the ideal number of kicks nor the ideal Preconception and Antepartum Care 147 duration of daily movement count assessment has been defined. One strategy for fetal movement counts is the use of ?10 movements in 2 hours using focused counting. The perception of 10 distinct movements in a period of up to 2 hours is considered normal. After 10 movements have been perceived, the count can be discontinued for that day. In the absence of 10 movements in 2 hours, additional fetal evaluation is warranted. Nonstress Test A nonstress test uses fetal heart rate patterns and accelerations as an indicator of fetal well-being. Fetal heart rate accelerations occur via a link between fetal peripheral movements and a cardioregulatory center in the midbrain, which requires intact peripheral, central, and autonomic neural in-flow and out-flow pathways. These pathways mature as the fetus matures, such that criteria for accelerations differ based on gestational age. The testing can be continued for an additional 40 minutes or longer to take into account the typical fetal sleep?wake cycle. Fetal heart rate accelerations that peak at 15 beats per minute above the baseline and persist for 15 seconds are associated with an extremely low risk of fetal acidosis and, thus, are considered reassuring. Because fetal heart rate reactivity is a function of fetal maturity, if a nonstress test is performed at an early gestational age it is more likely to be nonreactive in the absence of fetal compromise. Before 32 weeks of gestation, accelerations that peak at 10 beats per minute and persist for 10 seconds (from baseline to baseline) are as reassuring as the 15 beat criteria for those fetuses beyond 32 weeks of gestation. A nonreactive tracing is one without sufficient fetal heart rate accelerations in a 40-minute period and requires further testing for confirmation of fetal reassurance. Stimulation is delivered for 1?2 seconds using a specially designed artificial larynx that is placed on the maternal abdomen. It can be repeated up to three times, each for a maximum duration of 2 seconds, to elicit fetal heart rate accelerations. If at least three contractions of 40 seconds or more are present in a 10-minute period, uterine stimulation is not necessary. If the contractions are not present, they are induced with either nipple stimulation or intravenously administered oxytocin. Intravenous infu sion of low-dose oxytocin can be initiated, usually at a rate of 0. If fetal heart rate decelerations occur in the presence of tachysystole, retesting is appropri ate to ensure a correct interpretation.