Biaxin

Dr Samuel Ajayi

• Consultant Nephrologist
• Department of Medicine
• University of Abuja Teaching Hospital
• Abuja, FCT
• Nigeria

In her forties gastritis diet ëàéô buy discount biaxin on-line, Lindzy gradually began to slow down chondrial genes differ from those for genes in the nucleus gastritis meaning buy biaxin cheap. She heard a buzzing in her ears and developed difRather than being transmitted equally from both parents gastritis otc order discount biaxin on line, ficulty talking and walking nhs direct gastritis diet order biaxin line. Her condition worsened gastritis diet çàêîí biaxin 250mg otc, and she which enters an oocyte at fertilization gastritis diet plan buy biaxin 500 mg low price, does not include mitodeveloped diabetes, seizures, and pneumonia and became deaf chondria, which instead are found in the sperm midsection, and demented. If mitochondria from a male (discussed in chapter 12), and the do enter, they are destroyed. However, mitochondrial diseases are rare, affecting about 1 in 6,500 people, apparently because No crossing over of a weeding-out process during egg formation. Inherited from the mother only Many copies per mitochondrion and per cell Heteroplasmy High exposure to oxygen free radicals the fact that a cell contains many mitochondria makes possible a condition called heteroplasmy (see A Glimpse of History). At each cell division, the mitochondria are distributed at random into daughter cells. Over time, the chromosomes within a mitochondrion tend to be all wild type or all mutant for any particular gene, but different mitochondria can Cell have different alleles predominating. As an oocyte matures, the number of mitochondria drops from about 100,000 to 100 or fewer. If the woman is heteroplasmic for a mutation, by chance, she can produce an oocyte that has mostly mitochondria that Mitochondria are wild type mostly mitochondria that have the mutation, or anything in between (figure 5. In this way, a woman who does not have a mitochondrial disorder, because the mitochondria bearing the mutation are either rare or not abundant in affected cell types, can nevertheless pass the associated condiMitochondrial tion to a child. Expressivity may vary widely among siblings, depending upon how many mutation-bearing mitochondria were in the oocyte that became each individual. Severity of symptoms reflects which tissues have cells whose mitochondria bear the mutation. More Theoretically, a woman with a mitochondrial disorder puzzling, retesting the remains showed that for this site can avoid transmitting it to her children if her mitochondria in the mitochondrial genome, the purported Tsar was in can be replaced with healthy mitochondria from a donor. If an oocyte is heteroplasmic, differing numbers of copies of a mitochondrial mutation may be transmitted. Two boys died of the severe In 1845, the boy was given a royal burial, but some people form of the disorder because the brain regions that control movethought the buried child was an imposter. Another sibling was blind and had stolen at the autopsy, and through a series of bizarre events, central nervous system degeneration. Several relatives, however, wound up, dried out, in the possession of the royal family. Genes linked closely to one another are usually inherited together when the chromosome is packaged into a gamete. The term is popularly used to mean any association L l between two events or observations. Linked genes do not assort independently and do Genes linked not produce Mendelian ratios for crosses tracking two or more genes. Understanding and using linkage as a mapping tool Self-cross helped to identify many disease-causing genes before genome sequencing became possible. Punnett first observed the unexMale gametes pected ratios indicating linkage in the early 1900s, again in pea pl PpLl ppll plants. The expected Bateson and Punnett noticed that two types of thirdphenotypic ratio of a dihybrid cross is 9:3:3:1. The phenotypic ratio is 3:1, the same as for a two progeny classes, ppL and P ll, were less common (the monohybrid cross. The two less common offspring classes could also be explained by a meiotic event, crossing over. Recall that crossing over is an exchange between homologs that mixes up maternal and paternal gene combinations without disturbing the sequence of genes on the chromosome (figure 5. P p P p Progeny that exhibit this mixing of maternal and paterL l I L nal alleles on a single chromosome are called recombinant. Whether alleles in a dihybrid are in cis or trans Linkage Maps is important in distinguishing recombinant from parental progeny classes in specific crosses. They assigned genes to relative positions on chromosomes and compared progeny class sizes to assess whether traits were linked. The traits fell into four groups because their genes are inherited together on the same chromosome. Second, the fly room investigators translated their data into actual maps depicting positions of genes on chromosomes. Morgan wondered why Homologs the sizes of the recombinant classes varied for different genes. In 1911 Morgan proposed that the farther apart two genes are on a chromosome, the more likely they are to cross over simply because more physical distance separates them (figure 5. Then undergraduate student Alfred Sturtevant devised a way to represent the correlation between crossover P p P p frequency and the distance between genes as a linkage map. L L l l these diagrams showed the order of genes on chromosomes and the relative distances between them. These units are still Meiotic products used today to estimate genetic distance along a chromosome. The linkage between two genes may be interrupted if the sequencing of the human genome. Crossing over packages genes is inferred from the proportion of offspring from a cross recombinant groupings of the genes into gametes. Frequency of recombination is based 102 Part 2 Transmission Genetics In 1968, researcher R. Donohue was looking at chromosomes in his own white blood cells when he noticed a dark area consistently located near the centromere of one member of his A a largest chromosome pair (chromosome 1). He examined chromosomes from several family members for the dark area, noting Genes A and B far apart; crossing over more likely also whether each family member had a blood type called Duffy. B b (Recall that blood types refer to the patterns of sugars on red blood Genes B and C close together; C c cell surfaces. Crossing over is more blood type by whether or not the chromosome had the dark area. Genes at human parents do not have hundreds of offspring, nor do they opposite ends of the same chromosome cross over often, genproduce a new generation every 10 days, getting enough inforerating a large recombinant class. Genes lying very close on mation to establish linkage relationships for us requires observthe chromosome would only rarely be separated by a crossing the same traits in many families and pooling the results. The probability that genes on opposite ends of a chromoToday, even though we can sequence human genomes, linkage some cross over approaches the probability that, if on different remains a powerful tool to track disease-associated genes. A A a a A a A a the situation with linked genes is like a street lined with stores on both Crossing over + sides. There are more places to cross the street between stores at opposite ends on Meiosis B B b bb B b b B opposite sides than between two stores in the middle of the block on opposite sides of the street. Similarly, more crossovers, Parental Recombinant allele allele or progeny with recombinant genotypes, configuration configuration are seen when two genes are farther apart (may approach 50%) on the same chromosome. Localizing B B genes on the X chromosome was easier Independent assortment + than doing so on the autosomes, because Meiosis a b a B X-linked traits follow an inheritance pattern that is distinct from the one all autosomal genes follow. In human males, with their single X chromosome, a a recessive alleles on the X are expressed b b and observable. Parental Recombinant By 1950, geneticists began to think allele allele about mapping genes on the 22 human configuration configuration autosomes. These two genes are 10 map units apart, which geneticists Calculating other genotypes for their offspring is more determined by pooling information from many families. It is complicated, because more combinations of sperm and oocytes the first example of linked autosomal genes in humans. A B that include I and I as well as at least one N allele (assuming Greg and Susan each have nail-patella syndrome. Consider genes x, y, and nail-patella syndrome, nail-patella syndrome, z (figure 5. It is a little like deriving a geoGametes: sperm frequency oocytes graphical map from distances between cities. Genetic maps derived from percent Parental N I A 45% N i recombination between linked genes accuB rately reflect the order on the chromosome, n i 45% n I but the distances are estimates because Recombinants N i 5% B crossing over is not equally likely across N I the genome. Note that in this figure, map blocks, called haplotypes, to track genes in distances are known and are used to predict outcomes. If we know the 22 22 22 21 21 percent recombination between all possible pairs of three 23 23 33 31 21 genes, we can determine their relative positions on the 23 23 13 12 22 chromosome. The numbers in bars beneath pedigree symbols enable researchers to track From Linkage to Genome-Wide Associations specific chromosome segments with markers. The first human genes mapped to their chromosomes encoded blood proteins, because these were easy to study. Such tests are no longer necessary, because interest as landmarks called g e n e t i c m a r k e r s. In the family with cystic fibrosis depicted in sites where the base varies among individuals. But researchers are still filling in the orders of genes on two alleles by chance. It means that the observed data are 1,000 (103) times more likely to have Key Concepts Questions 5. Why are linked genes inherited in different patterns mosomes and just happen to often be inherited together by than unlinked genesfi What is the relationship between crossover frequency together 1,000 times always come up both heads or both tails by and relative positions of genes on chromosomesfi Only females transmit mitochondrial genes; males can Mendelian Ratios inherit such a trait but cannot pass it on. A gene can have multiple alleles because its sequence proteins involved in protein synthesis or energy can deviate in many ways. Heterozygotes of incompletely dominant alleles have mitochondria in a single cell harboring different alleles. An incompletely penetrant genotype is not expressed unlike genes that independently assort, produce many in all individuals who inherit it. Phenotypes that vary in individuals with parental genotypes and a few with intensity among individuals are variably expressive. We can predict the probabilities that certain genotypes will appear in progeny if we know crossover frequencies 8. A phenocopy is a characteristic that appears to be from pooled data and whether linked alleles are in cis inherited but is environmentally caused. Do the parents contribute equally as they can study pairs of genes in fruit flies, how many in a genetic sensefi The popular media often use words that have precise from one for an autosomal dominant traitfi For each of the diseases described in situations a through penetrance or lethal alleles.

In: Proceedings Ninth International Waste Management and Landfill Symposium gastritis symptoms tongue purchase generic biaxin from india, 6-10th October chronic gastritis meal plan generic 500mg biaxin fast delivery, 2003 gastritis diet plan discount 500 mg biaxin visa, S gastritis kas tai per liga buy cheap biaxin 500mg on-line. Study of Sticky Rice Lime Mortar Technology for the Restoration of Historical Masonry Construction gastritis vs heart attack buy biaxin online pills. Birdwell has over 27 years of experience in the management of environmental remediation and geotechnical construction projects gastritis healthy diet discount 250 mg biaxin overnight delivery. Birdwell has presented at 4 International conferences on environmental remediation technologies, including in-situ bioremediation, stabilization of ash products, and the remediation of chlorinated solvents in groundwater. Birdwell assists Program and Project Managers with project planning, resolution of technical operational issues, contract management, client management and strategic planning. Burke is an Executive Director with the Province of Nova Scotia with more than 20 years experience in administrative and project management in the government (both municipal & provincial) and private sector particularly in environmental remediation and civil construction. During his career he was involved in or responsible for schedule, budget, quality control, environmental management, regulatory compliance, stakeholder management and risk for large projects. Directly engaged in community engagement, health and safety, public relations and stakeholder management. Departments included Street Department, Traffic Department, Water Department and Sewer Department. Duties also include capital works management (design, contact management and construction oversight). Following a PhD evaluating the use of synthetic zeolites for the treatment of heavy metal contaminated effluents, Kate undertook a research fellowship investigating the use of novel cement stabilization methods for the remediation of contaminated soils and wastes at the University of Greenwich. Funded by Blue Circle Cement, the project included establishing field and bench-scale trials for a range of stabilization/solidification techniques, and supporting a Mobile Plant Licence application. Kate joined Arup in 2003, and has become an experienced environmental risk assessor and brownfield development specialist. Her involvement with contaminated land remediation crosses all aspects of the work, from contamination investigations, risk assessments, design of remediation works, gas protection measure design, waste classification and the development of sustainable earthworks strategies through to site supervision and validation of remediation works. Most recently, her work has included outline remediation design and abnormals costings for many complex regeneration projects. She 354 has worked on a diverse range of contaminated sites, ranging from infilled quarries and manufacturing facilities to gasworks sites. Subjects include: petrography, structural geology, metamorphic geology, waste management, contaminated land remediation, site investigation, and natural materials for the construction industry. Was co-director of the Centre for Contaminated Land Remediation at the University of Greenwich and carried out research in the durability and testing of construction materials and the use of accelerated carbonation in the treatment of waste and contaminated soils. From 2010 Dr Carey has been Managing Director of a research and development company commercialising the use of accelerated carbonation in waste management. Was a contributor to the Science Review of Solidification and Stabilization for the Environment Agency, accompanying national guidance on S/S, published by the Environment Agency. He has enjoyed continuing his professional development in fields related to marine, environmental, industrial, civil and structural engineering. In 2010, Colin was invited by Dalhousie University to join the Faculty of Engineering in an advisory basis as an Engineer-in-Residence to Civil and Resource Engineering Department and lecturing on Engineering Ethics. Since 2010 Colin has been maintaining the S/S technical information network through the establishment of the LinkedIn Group S/S-Tech. A remediation specialist providing risk assessment, regulatory response support, and other services, to public and private sector clients. Provided responsible party laboratory testing recommendations regarding Solidification/Stabilization. Conceived and directed bench-scale laboratory testing programs, to identify preferred S/S mixes for site-specific project conditions. Provided industry with recommendations of preferred jurisdictions for their next efforts at encouraging S/S applications. Prepared a paper and presented on the relative regulatory receptiveness among Canadian jurisdictions to potential S/S activities and applications. Garrett is an experienced professional in the assessment and remediation of environmental contamination. He has served as a consultant since 1972, beginning his career in aquatic environmental assessments of both estuarine and fresh water ecosystems. His interests led him into the hazardous waste field where he has provided site environmental assessments, laboratory analyses, and development and implementation of remedial alternatives. Most recently, he has been responsible for project management of hazardous waste remediation projects, including bioremediation, soil fixation/solidification and building decontamination. The site was initially investigated using geophysics and drilling to determine the extent of contamination. When the extent of the plume was determined, the site was cleared of trees and approximately 60 vacuum extraction wells were installed. Contaminated ground-water was recovered, treated biologically in aboveground pools, and discharged to the site through spray irrigation. Above362 ground and in situ biological treatment resulted in 98% reduction of contaminants within 3 months. This soil was innoculated with bacteria and nutrients, and treated on site until it met acceptable regulatory criteria. The initial phase of the project involved the addition of 30,000 gallons of concentrated sulfuric acid to lower the pH from 14 to 9. Next, the liquid fraction was drained and the sludge was solidified with ground rice hulls. After the material had biodegraded, it was replaced in the lagoon, graded, seeded and mulched. This eliminated the need for our client to conduct 30 years of post closure care and saved hundreds of thousands of dollars. Since his appointment, he has been responsible for laboratory research including product and process development on industrial waste recycling, treatment of contaminated materials, and mineral carbon capture. He has co-ordinated numerous pilot-scale proof-ofconcept trials including the design and construction of novel carbon capture and waste/soil treatment plants. Gunning has continued to contribute to research at the University of Greenwich, and has an active role in the supervision of the research team at the Centre for Contaminated Land Remediation. In 2011 he became a Visiting Lecturer at the University of Greenwich (Centre for Contaminated Land Remediation). He has published numerous journal papers and articles on waste management, soil remediation, mineral sequestration of carbon, and secondary aggregates and recycled construction materials. For the past 25 years he has been extensively concerned with S/S, has published over 100 journal papers, and has authored guidance on S/S for the Environment Agency (England and Wales). His work has attracted international recognition, has won national and regional awards and has led to innovative treatments for the management of difficult wastes. Ingraham is a senior project manager with substantial (30 years) experience in management of project quality, schedule, budget, and risk for large projects, specifically those involving heavy civil construction and environmental regulatory compliance or remediation. Remediation experience includes offsite removal activities, in-place closures, sludge stabilization, dredging, slurry walls and other types of groundwater cut-off walls, in-place soil mixing, soil vapor extraction, groundwater pump and treatment systems, and in-situ solidification/stabilization. Lear has over 25 years of experience in hazardous waste treatment, laboratory management, and chemical process development. His experience includes selecting and evaluating treatment alternatives, providing data for preliminary design activities and project equipment specifications, assisting project design teams, and implementing the final design. Lear has hands-on experience with full-scale remediation activities and specializes in process troubleshooting. He has provided technical operational support to bioremediation, dewatering, soil washing, stabilization, thermal, and wastewater treatment activities at toxic, hazardous, and radioactive waste remedial sites. MacNeil is a Senior Project Manager and Environmental Engineer with more than 17 years of experience. Over the course of his career he has developed specific expertise in the areas of contract management, environmental management and contaminated site remediation. MacNeil has managed in excess of 130 million dollars worth of environmental remediation and heavy civil projects. He has worked extensively on complex environmental remediation and geotechnical projects involving in-situ S/S, slurry walls, permeable reactive barriers and cap/containment construction. This includes cost estimates, proposal preparation, work planning, mix designs/treatability studies and the management of field operations, including resource allocations. Mr Naguib has been responsible for the execution of over 26 in-situ S/S projects employing auger mixing, and 37 slurry walls (including design and build) throughout the United States, and most significantly, has developed 374 extensive and specialized expertise in the area of in-situ S/S having successfully treated millions of tons of impacted materials. He is responsible for the scientific and process support for all environmental works at: site remediations, soil treatment, environmental dredging and sediment treatment. For about the last 10 years, he has been very active in innovative approaches for the stabilization/solidification applied on various sites in Europe. Has published over one hundred publications, case studies and technology appraisals with respect to soil remediation and environmental dredging. Plante has performed in-situ solidification at fly ash lagoons, fuel oil release areas, and coal tar sites. Plante has led solidification treatability studies for 11 sites and has been involved in the design, preparation of technical specifications and quality control/quality assurance plans, and implementation of in-situ solidification remedies at five sites, utilizing excavator buckets, large diameter augers, or in-situ rotary blenders. Plante has been a frequent presenter on solidification and other site investigation and remediation topics at environmental symposia. S/S specific experience includes: fi Manager of 7 field applications of S/S using in-situ soil mixing and/or jet grouting fi On-site project engineer for 4 field applications of S/S using in-situ soil mixing fi Manager of 16 Treatability (Bench-Scale) Studies for S/S 380 Daniel has delivered 7 Invited Lectures/symposia presentations, and has 10 publications on the theory and application of slurry trench cut-off walls and soil mixing. As President of Geo-Solutions, he oversees all company functions, operations, finance, administration, health and safety, quality assurance, marketing, and business development. Quantities of in-situ S/S treated materials exceed one million cubic yards, using a variety of application methods and reagents. He has actively participated in many cutting-edge projects, for example he managed the first permeable reactive barrier project installed using the Biopolymer trenching technique at the Oak Ridge National Laboratory in Oak Ridge, Tennessee. An addition to Geo-Solutions facilities in New Kensington was completed in November of 2013 and all facets of the companies were completely merged by December of 2013. Schindler has co-authored over 10 publications relating to specialty geoenvironmental construction. Wittenberg has over 27 years of experience performing project engineering and management, technical supervision, design engineering and analysis, construction oversight and regulatory interface. His project management and construction experience includes a number of site remedial restoration projects along major waterways. His environmental experience includes conducting remedial alternatives evaluations, and development of risk-based clean-up approaches. His technical experience includes environmental engineering for soil/sediment and groundwater treatment, benchand pilot-scale testing and civil engineering applications for site restoration and redevelopment. A significant portion of his professional project experience is associated with former manufactured gas plants using in-situ solidification/stabilization as a primary remediation technology. The data is presented as it was received from these sources and has not been independently verified by the editors. However each project listed in the following Table identifies the person that submitted data along with the name and E-mail contact (or in a few cases the relevant publication), should additional information be required. This extensive list of over 200 completed S/S projects illustrates the widespread successful application of S/S to a wide variety of contaminants and site types. Kitko (trade name of Industries cycy Excavator/ Solidification Slag Cement mkitko@geoGeo-Solutions) Superfund Site rotary blender Organophilic Clay solutions. Andromalos 2012 Columbus Wood Auger Activated Carbon kandromalos@ge Treaters o-solutions. Andromalos 2012 Municipal Solvents Auger Reduction kandromalos@ge Wastewater o-solutions. Lear 2012 Closure Project, sludge/sedi Excavator Redevelopment slag + 2% Ferrous plear@envirocon. Birdwell 2012 er Remediation, sediments mixing cap construction Construction steven. Andromalos 2011 Remediation Auger Permanganate/ kandromalos@ge East Rutherford, Cement o-solutions. Andromalos 2011 Remediation sediment Auger kandromalos@ge New Bedford, o-solutions. Birdwell 2010 Delaware City, fly ash and vanadium mixing closure Portland cement and Construction steven. Andromalos 2010 Remediation Auger cation Permanganate/ kandromalos@ge East Rutherford, Portland Cement o-solutions. Maitland (trade name of Force Base, vertical Solvents Auger Reactive Barrier gmaitland@geoGeo-Solutions) California wall square solutions. Maitland (trade name of North Carolina cycy Large diameter gmaitland@geoGeo-Solutions) auger solutions.

The mother is healthy and has a normal platelet count gastritis diet øàíñîí discount 250mg biaxin, but produces antibodies that cross the placenta and destroy fetal/neonatal platelets diet for gastritis sufferers discount 500 mg biaxin otc. For severely low platelet counts gastritis diet óëûáêà buy biaxin australia, therapy can include prednisone gastritis symptoms and causes order biaxin without a prescription, intravenous immune globulin gastritis tylenol discount biaxin 500 mg overnight delivery, and splenectomy gastritis diet ÿíäêñ buy genuine biaxin. Intravenous steroids should be given if the exacerbation is severe, if the patient is currently taking oral steroids, or if the response to bronchodilator therapy is incomplete or poor. Antibiotics are used for patients with fever, leukocytosis, or evidence of infection. Venography is still the gold standard, but it is not commonly used because it is cumbersome to perform and expensive and has serious complications. Real-time ultrasonography or color Doppler ultrasound is the procedure of choice to detect proximal deep vein thrombosis. Maternal infection with varicella-zoster during the first half of pregnancy can cause malformations such as cutaneous and bony defects, chorioretinitis, cerebral cortical atrophy, and hydronephrosis. Adults with varicella infection fare much worse than children; about 10% will develop a pneumonitis, and some of these will require ventilatory support. Fetal manifestations of infection correlate with time of maternal infection and fetal organ development. If infection occurs in the first 12 weeks, 80% of fetuses manifest congenital rubella syndrome, while only 25% if occurs at the end of the second trimester. Rubeola (measles) virus does not appear to have any teratogenic effect on the fetus. Congenital infection includes low birth weight, microcephaly, intracranial calcifications, chorioretinitis, mental and motor retardation, sensorineural deficits, hepatosplenomegaly, jaundice, anemia, and thrombocytopenic purpura. Cytomegalovirus is common in day care centers and by age 2 or three children usually acquire the infection from one another and transmit it to their parents. Maternal immunity appears to protect against fetal infection, and up to one-third of American women are immune prior to pregnancy. Acute infection in the mother is often subclinical, but symptoms can include fatigue, lymphadenopathy, and myalgias. Fetal infection is more common when disease is acquired later in pregnancy (60% in third trimester vs 10% in first trimester). Congenital disease consists of low birth weight, hepatosplenomegaly, jaundice, anemia, neurological disease with seizures, intracranial calcifications, and mental retardation. Transplacental infection can occur with any stage of syphilis, but the highest incidence of congenital infection occurs in women with primary or secondary disease. The fetal and neonatal effects include hepatosplenomegaly, edema, ascites, hydrops, petechiae or purpuric skin lesions, osteochondritis, lymphadenopathy, rhinitis, pneumonia, myocarditis, and nephrosis. While parvovirus can cause stillbirth and fetal hydrops, it is not associated with skin lesions or placental hypertrophy. Acute infection in first trimester infects 10% of fetuses, and in third trimester 80% to 90% are affected. Perinatal transmission occurs by ingestion of infected material during delivery or exposure subsequent to birth in mothers who are chronic carriers. Some infected infants may be asymptomatic, and others develop fulminant Medical and Surgical Complications of Pregnancy Answers 131 hepatic disease. Administration of hepatitis B immune globulin after birth, followed by the vaccine, can prevent disease in infants born to mothers who are chronic carriers. If a pregnant woman has diagnosis confirmed with IgM antibodies, ultrasound is done for fetal surveillance. One-third of fetuses will have spontaneous resolution of hydrops, and 85% of fetuses who receive transfusion will survive. A 50% risk of neonatal infection occurs with primary maternal infection, but only 4% to 5% risk with recurrent outbreaks. Neonatal infection presentation is nonspecific, with signs and symptoms such as irritability, lethargy, fever, and poor feeding. Listeriosis during pregnancy can be asymptomatic or cause a febrile illness that is confused with influenza, pyelonephritis, or meningitis. Early onset neonatal sepsis is a common manifestation of listeriosis during pregnancy, and late onset listeriosis occurs after 3 to 4 weeks as meningitis, which is similar to group B streptococci. This page intentionally left blank Normal and Abnormal Labor and Delivery Q uestions 181. A 20-year-old G1 at 38 weeks gestation presents with regular painful contractions every 3 to 4 minutes lasting 60 seconds. On pelvic examination, she is 3 cm dilated and 90% effaced; an amniotomy is performed and clear fluid is noted. One hour later on repeat examination, her cervix is 5 cm dilated and 100% effaced. A 30-year-old G2P0 at 39 weeks is admitted in active labor with spontaneous rupture of membranes occurring 2 hours prior to admission. Two hours later on repeat examination her cervix is 5 cm dilated and the fetal head is at +1 station. Perform cesarean delivery of early decelerations 133 134 Obstetrics and Gynecology 183. A 32-year-old G3P2 at 39 weeks gestation with an epidural has been pushing for 30 minutes with good descent. The fetal heart rate has been in the 90s for the past 5 minutes and the delivery is expedited with forceps. A 27-year-old G2P1 at 38 weeks gestation was admitted in active labor at 4 cm dilated; spontaneous rupture of membranes occurred prior to admission. She has had one prior uncomplicated vaginal delivery and denies any medical problems or past surgery. Currently, her vital signs are normal and the fetal heart rate tracing is reactive. A 38-year-old G6P4 is brought to the hospital by ambulance for vaginal bleeding at 34 weeks. She undergoes an emergency cesarean delivery for fetal bradycardia under general anesthesia. In the recovery room 4 hours after her surgery, the patient develops respiratory distress and tachycardia. Extubation with the patient in the lateral recumbent position with her head lowered. Extubation with the patient in the semierect position (semi-Fowler position) Normal and Abnormal Labor and Delivery 135 186. A 23-year-old G1 at 38 weeks gestation presents in active labor at 6 cm dilated with ruptured membranes. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. Perform forceps rotation in the second stage of labor to convert mentum posterior to mentum anterior and to allow vaginal delivery. Allow patient to labor spontaneously until complete cervical dilation is achieved and then perform an internal podalic version with breech extraction. A 32-year-old G3P2 at 39 weeks gestation presented to the hospital with ruptured membranes and 4 cm dilated. She has a history of two prior vaginal deliveries, with her largest child weighing 3800 g at birth. Compared with a midline episiotomy, which of the following is an advantage of mediolateral episiotomyfi She complains that, on bending down to pick up her 2-year-old child, she experienced sudden, severe back pain that now has persisted for 2 hours. By the time she arrives at the delivery floor, she is contracting strongly every 3 minutes; the uterus is quite firm even between contractions. Which of the following actions can most likely wait until the patient is stabilizedfi Preparing for cesarean section Questions 191 to 193 For each clinical description, select the most appropriate procedure. A 24-year-old primigravid woman, at term, has been in labor for 16 hours and has been dilated to 9 cm for 3 hours. The fetal vertex is in the right occiput posterior position, at +1 station, and molded. A second set of membranes is bulging through a fully dilated cervix, and you feel a small part presenting in the sac. Questions 194 to 196 Select the most appropriate treatment for each clinical situation. A multiparous woman has had painful uterine contractions every 2 to 4 minutes for the past 17 hours. The cervix is dilated to 2 to 3 cm and effaced 50%; it has not changed since admission. A nulliparous woman is in active labor (cervical dilation 5 cm with complete effacement, vertex at 0 station); the labor curve shows protracted progression without descent following the administration of an epidural block. A nulliparous woman has had arrest of descent for the past 2 hours and arrest of dilation for the past 3 hours. May be associated with increased need for augmentation of labor with oxytocin and for instrument-assisted delivery 201. A 23-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She states they are occurring every 4 to 8 minutes and each lasts approximately 1 minute. She reports good fetal movement and denies any leakage of fluid or vaginal bleeding. The nurse places an external tocometer and fetal monitor and reports that the patient is having contractions every 2 to 10 minutes. On examination the cervix is 2 cm dilated, 50% effaced, and the vertex is at fi1 station. A 19-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She reports good fetal movement and denies any leakage of fluid or vaginal bleeding. The nurse places an external tocometer and fetal monitor and reports that the patient is having contractions every 4 to 12 minutes. On examination the cervix is 1 cm dilated, 60% effaced, and the vertex is at fi1 station. A 38-year-old G3P2 at 40 weeks gestation presents to labor and delivery with gross rupture of membranes occurring 1 hour prior to arrival. The patient is having contraction every 3 to 4 minutes on the external tocometer, and each contraction lasts 60 seconds. The fetal heart rate tracing is 120 beats per minute with accelerations and no decelerations. The patient has a history of rapid vaginal deliveries, and her largest baby was 3200 g. On cervical examination she is 5 cm dilated and completely effaced, with the vertex at fi2 station. Which of the following is the most appropriate method of pain control for this patientfi The fetal heart rate tracing is 120 beats per minute with accelerations and early decelerations. Prepare for a cesarean section secondary to a diagnosis of secondary arrest of labor. After an additional 2 hours of labor, the patient is noted to still be 5 cm dilated. Perform an operative delivery with forceps Normal and Abnormal Labor and Delivery 141 206. She is on oxytocin to augment her labor and she has just received an epidural for pain management. The nurse calls you to the room because the fetal heart rate has been in the 70s for the past 3 minutes. The contraction pattern is noted to be every 3 minutes, each lasting 60 seconds, with return to normal tone in between contractions. On repeat cervical examination, the vertex is well applied to the cervix and the patient remains 5 cm dilated and at 0 station, and no vaginal bleeding is noted. She has a history of two previous uncomplicated vaginal deliveries and has had no complications this pregnancy. A 41-year-old G1P0 at 39 weeks, who has been completely dilated and pushing for 3 hours, has an epidural in place and remains undelivered.

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Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. Each question in this book has a corresponding answer, a reference to a text that provides background for the answer, and a short discussion of various issues raised by the question and its answer. For multiple-choice questions, the one best response to each question should be selected. For matching sets, a group of questions will be preceded by a list of lettered options. For each question in the matching set, select one lettered option that is most closely associated with the question. To simulate the time constraints imposed by the qualifying examinations for which this book is intended as a practice guide, the student or physician should allot about 1 minute for each question. After answering all questions in a chapter, as much time as necessary should be spent reviewing the explanations for each question at the end of the chapter. Attention should be given to all explanations, even if the examinee answered the question correctly. Those seeking more information on a subject should refer to the reference materials listed or to other standard texts in medicine. After an initial pregnancy resulted in a spontaneous loss in the first trimester, your patient is concerned about the possibility of this recurring. Which of the following is the most appropriate answer regarding the chance of recurrencefi Which of the following statements concerning chromosomal aberrations in abortions is truefi Approximately 20% of first-trimester spontaneous abortions have chromosomal abnormalities. Despite the relatively high frequency of Down syndrome at term, most Down fetuses abort spontaneously. She should be counseled that without evaluation and treatment her chance of having a live birth is which of the followingfi A 26-year-old G3P0030 has had three consecutive spontaneous abortions in the first trimester. As part of an evaluation for this problem, which of the following tests is most appropriate in the evaluation of this patientfi You should tell her that she has an increased risk of having a baby with Down syndrome in which of the following circumstancesfi Her pregnancy has been achieved by induction of ovulation by menotropins (eg, Follistin, Gonal-F). She has a history of acne, for which she takes minocycline and isotretinoin on a daily basis. She also takes a combined oral contraceptive birth control pill containing norethindrone acetate and ethinyl estradiol. She is concerned about the effectiveness of her birth control pill, given all the medications that she takes. She is particularly worried about the effects of her medications on a developing fetus in the event of an unintended pregnancy. A 24-year-old woman is in a car accident and is taken to an emergency room, where she receives a chest x-ray and a film of her lower spine. At 10 weeks, the fetus is particularly susceptible to derangements of the central nervous system. One of your patients, a 25-year-old G0, comes to your office for preconception counseling. She is a long-distance runner and wants to continue to train during her pregnancy. This patient wants to know whether there are any potential adverse effects to her fetus if she pursues a program of regular exercise throughout gestation. You advise her of which of the following true statements regarding exercise and pregnancyfi During pregnancy, women should stop exercising because such activity is commonly associated with intrauterine growth retardation in the fetus. Exercise is best performed in the supine position to maximize venous return and cardiac output. It is acceptable to continue to exercise throughout pregnancy as long as the maternal pulse does not exceed 160. Immediately following delivery, patients can continue to exercise at prepregnancy levels. She has a sonogram performed at 7 to 12 weeks gestational age that shows a quintuplet pregnancy. If the nuchal translucency resolves, the risk of a chromosome abnormality is comparable to that of other embryos. As part of her evaluation for recurrent abortion, she had karyotyping done on herself and her husband. A 31-year-old G1P0 presents to your office at 22 weeks gestation for a second opinion. A 40-year-old woman pregnant at 6 weeks gestation presents to your office for prenatal care. She read on the Internet that an ultrasound measurement of the neck of the fetus can be used in prenatal diagnosis. Which of the following is correct information to tell your patient regarding ultrasound measurement of the fetal nuchal translucency for prenatal diagnosisfi It is a screening test for Down syndrome performed between 10 and 13 weeks of pregnancy. She is anxious to know the chromosome status of her fetus in her current pregnancy. Which of the following tests will provide the most rapid diagnosis of Down syndromefi Second-trimester diagnosis allows for safer termination of pregnancy when termination is chosen by the patient. She was born outside the United States and has never had any routine vaccinations. During preconception counseling, a woman has a question for you regarding immunizations. Congenital rubella syndrome is common in fetuses born to mothers who were immunized early in pregnancy for rubella. The polio virus has the ability to spread from a vaccinated individual to susceptible persons in the immediate environment. An ultrasound is performed and shows the fetus to have multiple congenital anomalies, including microcephaly, cardiac anomalies, and growth retardation. You should question the patient if she has abused which of the following substances during her pregnancyfi You diagnose a 21-year-old woman at 12 weeks gestation with gonorrhea cervicitis. Five years ago, this patient delivered a baby with anencephaly who died shortly after birth. She does not have a recurrence risk of a neural tube defect above that of the general population. She has an increased risk of having another baby with anencephaly because she is more than 35 years old. When she becomes pregnant, she should avoid hyperthermia in the first trimester because both maternal fevers and the use of hot tubs have been associated with an increased risk of neural tube defects. She has a recurrence risk of having another baby with a neural tube defect of less than 1%. This patient is extremely concerned and comes into your office to get additional counseling and recommendations. An ultrasound should be performed to confirm the gestational age of the fetus and to rule out any fetal anomalies. An obese, 25-year-old G1P0 comes to your office at 8 weeks gestational age for her first prenatal visit. She is delighted to be pregnant and wants to do whatever is necessary to ensure a healthy pregnancy. She is concerned because she is overweight and wants you to help her with a strict exercise and diet regimen so that she can be more healthy during the pregnancy. Which of the following is the best advice to give this patient regarding obesity and pregnancyfi Marked obesity in pregnancy decreases the risk of developing diabetes, hypertension, and fetal macrosomia. She should gain at least 25 lb during the pregnancy because nutritional deprivation can result in impaired fetal brain development and intrauterine fetal growth retardation. Obese women will still have adequate fetal growth in the absence of any weight gain during pregnancy. Being obese places her at a decreased risk of needing a cesarean section for delivery. A 26-year-old G1P1 comes to see you in your office for preconception counseling because she wants to get pregnant again. She denies a history of any illegal drug use but admits to smoking a few cigarettes each day and occasionally drinking some beer. When you advise her not to smoke or drink at all during this pregnancy, she gets defensive because she smokes and drinks very little, and she did the same during her previous pregnancy 2 years ago and her baby was just fine. Which of the following statements is true regarding the effects of tobacco and alcohol on pregnancyfi Small amounts of alcohol, such as a glass of wine or beer a day at dinnertime, are safe; only binge drinking of large amounts of alcohol has been associated with fetal alcohol syndrome. Fetal alcohol syndrome can be diagnosed prenatally via identifying fetal anomalies on sonogram done antenatally. In most studies, cigarette smoking has been associated with an increased risk of congenital anomalies. Tobacco use in pregnancy is a common cause of mental retardation and developmental delay in neonates. A 36-year-old G0 who has been epileptic for many years is contemplating pregnancy. She wants to go off her phenytoin because she is concerned about the adverse effects that this medication may have on her unborn fetus. Babies born to epileptic mothers have an increased risk of structural anomalies even in the absence of anticonvulsant medications. She should see her neurologist to change from phenytoin to valproic acid because valproic acid is not associated with fetal anomalies. She should discontinue her phenytoin because it is associated with a 1% to 2% risk of spina bifida. Vitamin C supplementation reduces the risk of congenital anomalies in fetuses of epileptic women taking anticonvulsants. The most frequently reported congenital anomalies in fetuses of epileptic women are limb defects. A patient who works as a nurse in the surgery intensive care unit at a local community hospital comes to see you for her annual gynecologic examination. She tells you that she plans to go off her oral contraceptives because she plans to attempt pregnancy in the next few months. This patient has many questions regarding updating her immunizations and whether or not she can do this when pregnant. The patient should be checked for immunity against the rubella (German measles) virus prior to conception because the rubella vaccine contains a live virus and should not be given during pregnancy. The patient should be given the tetanus toxoid vaccination prior to becoming pregnant because it is a live virus vaccine that has been associated with multiple fetal anomalies when administered during pregnancy. The Centers for Disease Control and Prevention recommends that all pregnant women should be vaccinated against the influenza virus during the first trimester. If she is exposed to chicken pox while she is pregnant she can be immunized at that time since the chicken pox vaccine is safe during pregnancy. Because of her occupation, the patient is at high risk for hepatitis B; she should complete the hepatitis B vaccination series before she conceives, since that vaccine has been associated with neonatal jaundice. A patient comes to see you in the office because she has just missed her period and a home urine pregnancy test reads positive. She is extremely worried because last week she had a barium enema test done as part of a workup for blood in her stools. She is also concerned because her job requires her to sit in front of a computer screen all day and she uses the microwave oven on a regular basis. The patient is concerned regarding the deleterious effects of radiation exposure on her fetus. Which of the following statements is true regarding the effects of exposure to radiation and electromagnetic fields during pregnancyfi

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