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The attitude towards the obstetrician is mollified by the fact that women realize that there are Chapter 2 the woman as a patient applies mostly in the big towns symptoms knee sprain order sustiva master card, for in rural areas there is usually only one District General Hospital medications ocd generic 600mg sustiva with visa. There again the woman may request to see (or not see) any given consultant for her own reasons. In the out-patients this can usually be arranged but not at an emergency level where consultants work to a rota. The presence of junior doctors or medical students at teaching hospitals is being highlighted at the moment. Naturally women want privacy, but when it is explained to them that these are the doctors of the future, they usually understand and allow them to be present. This raises the complication of the inclusion of events of a sensitive nature such as previous terminations of pregnancy or sexually transmitted diseases. If the woman wishes to keep confidential essential pieces of information which may affect the clinical management then marks such as an asterisk or euphemisms should be recorded in her notes that will alert your colleagues. If the woman attends an antenatal clinic where she is not known, one has to start from the beginning. The history, examination and investigation of the woman are taken at the booking clinic when she attends for the first time in pregnancy (see Chapter 9). Ideally, this should be at 810 weeks of gestation but more often in Britain it has slipped to 1214 weeks, hence invalidating all the help that can be offered to the woman in the first trimester and passing the time when teratogenesis might have been avoided. Ethics Ethics is the science of morals but probably is better interpreted as the rules of conduct recognized in certain departments of human life. Those in the medical profession owe an ethical duty to do their best for those who seek their care. In latter years the subject has moved more towards the science and people have tried to lay down guidelines. Generally speaking, the ethics of medicine are covered by the General Medical Council, the British Medical Association and the Ethical Committees of the various Colleges including the Royal College of Obstetricians and Gynaecologists. Details proliferate but a central principal remains that you should do unto others as you would they should do unto you. Always imagine your mother or your daughter as the patient and how you would like them to be treated. The gynaecological patient the pregnant woman When a woman becomes pregnant she usually consults her family doctor first. There may be records going back many years and the doctor may know the woman from previous medical encounters. While many of the items needed in the antenatal record for the history are already in the practice records, it is wise to keep a pro forma especially for each pregnancy with summaries of 20 Most women in their lives will consult a doctor about gynaecological symptoms. Be it specialist or general practitioner, the same logical processes must be used to make a diagnosis and direct management. History this is best considered under systematic headings so that no important symptoms are omitted. Any treatment of present complaint so far All drugs taken recently must be noted, especially tranquillizers, oral contraceptives, hormones and antibiotics. History of past major illness or operations · All admissions to hospital with approximate dates. Social history · Home conditions (including nature and state of relationships with other people in the residence). Vaginal discharge · Character of discharge: (a) mucoid; (b) purulent; 21 Chapter 2 the woman as a patient (c) colour; (d) quantity; (e) bloodstained. Palpation this is done lightly at first to test for any localized tenderness or rigidity. Deep palpation is used to confirm the presence of a tumour or enlargement, especially of uterus or ovaries. Percussion If there is a central tumour it will be dull to percussion with hollow sounds from the flanks. Auscultation Although this will rarely help, it may give reassurance about intestinal activity, and bowel sounds may be heard. Fetal heart sounds may help make a diagnosis of pregnancy using a handheld Dopplertone after 12 weeks. A systematic examination is made with special attention to the reproductive system.
These include the following: Performing a myomectomy through an abdominal incision (figure 18 medicine 4211 v purchase sustiva overnight. There are times medications given im buy 200 mg sustiva mastercard, when myomectomy is associated with uncontrollable bleeding and thus needs to be converted into an abdominal hysterectomy during the time of planned surgery. Therefore, if myomectomy is selected as the therapeutic option, the women should be counseled about small risk of reoperation and the risk of conversion to hysterectomy. Evidence level C (based on evidence from expert committee reports or opinions and/or clinical experience of respected authorities) Safety of laparoscopic myomectomy has yet not been established in women planning pregnancy. Hysteroscopic myomectomy is an effective option for women with submucous fibroids. Hysteroscopic myomectomy has been considered as an effective option for controlling menorrhagia in women with submucous fibroids. Myomectomy is a viable therapeutic alternative to hysterectomy in women with symptomatic myomas, who desire fertility. If the myoma (especially the submucosal or intramural type) is large in size (> 5 cm), most studies recommend that it must be removed. Large submucosal or intramural myomas not only may cause distortion of endometrial cavity, they may also result in menometrorrhagia. Large myomas may also result in complications for the future pregnancies (miscarriage, preterm delivery, etc). However, finding of a small asymptomatic leiomyoma in an infertile woman is not an indication for immediate myomectomy. Uncertainty regarding surgery exists mainly for asymptomatic women along with the presence of mostly large intramural or subserous myomas in the uterus. In order to reduce the risk of development of post-operative intestinal adhesions, incisions over the peritoneal aspect of the posterior uterine wall must be avoided during surgery. Recurrence of myomas post-operatively is another complication associated with myomectomy (more with laparoscopic as compared to the abdominal procedure). However, if the myoma does not distort the endometrial cavity, the indications for myomectomy are not so clear. Due to a high rate of myoma recurrence, a myomectomy is generally not recommended for women who have completed child bearing, yet continue to suffer from excessive heavy menstrual periods and from pelvic pressure and pain due to fibroids. Deciding the Type of Myomectomy to be Performed Myomectomy can be performed abdominally, laparoscopically or hysteroscopically. If myomectomy is being performed to regain fertility, the next question, which requires to be answered is, what type of myomectomy would be associated with best pregnancy outcome? These various options are discussed below: Risks Associated with Myomectomy Risks associated with myomectomy are enumerated in table 18. Since there are numerous risks associated with myomectomy, the expected benefits of myomectomy must be weighed against the risks associated with the procedure, before carrying out this surgery. The most important complication associated with myomectomy is intraoperative blood loss. Before performing myomectomy, it is important to counsel the patient regarding the possibility that intraoperative findings may contraindicate myomectomy and require that hysterectomy be performed instead. If pregnancy is desired, there is a risk of uterine rupture after myomectomy during delivery. This can occur irrespective of the route for myomectomy (abdominal, laparoscopic or hysteroscopic myomectomy) due to excessive dissection of myometrial muscles during the surgery. Development of post-operative adhesions following myomectomy is an important complication of myomectomy. The surgeon is able to feel the uterus, which is helpful in locating myomas that may be deep in the uterine wall or are very small in size. As a result, a woman who becomes pregnant after a myomectomy may require a cesarean delivery to prevent rupture of the uterus at the myomectomy site. Steps: After inspecting the uterus to determine the number and position of the fibroids, the uterine endometrium overlying the fibroid is cut, following which the fibroids are separated and removed from the normal uterine muscle. After the removal of the fibroids, normal uterine muscle can be sewn back together. Once the fibroids are removed, they are cut into pieces and removed with help of a morcellator. The advantage of laparoscopic myomectomy is that it this can be performed as an outpatient procedure and allows faster recovery in comparison 350 Chapter 18 Menorrhagia due to Leiomyomas A B C D E 18 F G H Figs 18. One of the disadvantage of the procedure is that extended time may be required for removing large fibroids from the abdomen.
Phenotypic identification of the insect-associated filamentous fungi the fungi were identified based on their macro- and microscopical features following the keys of Raper & Fennell (1965) symptoms zinc deficiency purchase sustiva american express, Pitt (1979) medicine 20th century buy discount sustiva 600mg online, Sivanesan (1987), Moubasher (1993), Zare & Gams (2004), Leslie & Summerell (2006) and Domsch et al. Physiological characterization of yeast strains Fermentation of sugars and oxidative utilization of carbon compounds were performed according to Barnett et al. Assimilation of nine nitrogen compounds (potassium nitrate, sodium nitrite, ethylamine, L-lysine, creatine, creatinine, D-glucosamine, imidazole, or Dtryptophan) was determined (Suh et al. Growth at high osmotic pressure, in the presence of cycloheximide and production of extracellular starch-like compounds were also tested (Suh et al. Confirmations of these identifications were carried out using the molecular technique. The samples were directly sent for extraction and sequencing or they were collected in a batch and stored at 70 °C before sending to Korea. Sequences obtained together with those 1299 retrieved from the GenBank database were subjected to the Clustal W analysis using MegAlign software version 5. Results Total fungi recovered from guts of the three insect species investigated the yeast isolates were characterized using phenotypic, physiological and molecular methods (Tables 1, 2), while filamentous fungi were identified using only phenotypic characteristics based on their macro- and microscopic features. From these, 48 species and two varieties assigned to 21 genera were filamentous fungi and 19 species + one variety belong to 15 genera were yeasts. The number of taxa recovered from honey bees (37 species and one variety belonged to 21 genera) and red-palm weevils (35 species and one variety related to 21 genera) was almost equal, while lower number was isolated from black beetles (20 species + one variety assigned to nine genera). However, higher number of yeast species (14 + one variety) was obtained from the gut of red-palm weevils than those obtained from honey bees (6 species) or black beetles (five species) (Table 3). Fungi recovered from guts of honey bees In the present investigation, thirty-eight species and one variety belonging to 21 genera were isolated from 28 gut samples of honey bees. Filamentous fungi were recovered from 21 samples and represented by 31 species, one variety and 16 genera while yeast fungi were isolated from 16 samples and represented by six species related to five genera. Aspergillus (11 species) was isolated in high frequency from bee samples (18 out of 28 samples analyzed). Aspergillus niger was the most common species recovered from 12 samples, followed by A. Both Cladosporium (4 species) and Penicillium (2 species) were recovered in low frequency (6 samples each) and C. On the other hand, Cochliobolus (3 species) and Mucor hiemalis were recovered each from two samples, and Bipolaris clavata, Fusarium verticillioides, Myceliophthora thermophila, Nigrospora oryzae, Papulaspora immerse, Pochonia suchlasporia var. From yeasts Lachancea thermotolerans was the most common in the gut of honey bees; it was isolated from ten samples. Wickerhamomyces subpelliculosus was isolated from 4 gut samples while Hanseniaspora opuntiae was recovered from one sample only. Fungi recovered from guts of black beetles Twenty species and one variety belonging to nine genera were isolated from eleven gut samples of black beetles. Filamentous fungi were recovered from all samples and represented by 15 species and one variety belonging to five genera, while yeast fungi represented by five species related to four genera were isolated from four gut samples. Cladosporium and Penicillium (3 species each) were recovered from six and five samples, respectively with C. Fungi recovered from guts of red-palm weevils Thirty-five species and one variety belonging to 21 genera were recovered from eleven gut samples of red-palm weevils. Filamentous fungi were recovered from nine samples and represented by 21 species assigned to ten genera, while yeast fungi were isolated from all samples and represented by 14 species and one variety related to eleven genera (Table 3). Cladosporium (3 species) and Fusarium (2 species) were isolated in moderate frequency (5 samples each). Cyberlindnera jadinii was the most common yeast fungus isolated from all gut samples of red-palm weevil investigated, followed by Prototheca zopfii var. Overview on the gut mycobiota of the three insect species the number of fungal taxa recovered from red-palm weevils and honey bees was almost equal, while lower number was isolated from black beetles. However, higher number of yeast species (14 + 1 variety) was obtained from the gut of red-palm weevils than those obtained from honey bees (6 species) or black beetles (5 species). Yeasts and filamentous fungi were isolated more frequently in guts of red palm weevil (100% and 81. Some filamentous species were recovered from guts of the 3 insect species (Aspergillus niger, A.
Antepartum Hemorrhage: is bleeding from the vagina during pregnancy from the 24th week (sometimes defined as from the 20th week) gestational age to term medicine identification order sustiva line. Hemorrhage into the decidua basalis decidua splits decidural hematoma separation symptoms multiple myeloma sustiva 200mg mastercard, compression, destruction of the placenta adjacent to it. Types of placental abruption: external hemorrhage concealed hemorrhage Total Partial Risk factors: (see table) - - the most common presentation is pain which can vary from mild cramping to severe pain. Sometimes it is associated with bleeding and sometimes not concealed bleeding Examination: A firm, tender uterus and a possible sudden increase in fundal height on exam. The amount of external bleeding may not accurately reflect the amount of blood loss. Types of placenta previa: Total placenta previa: the internal cervical os is covered completely by placenta. Marginal placenta previa: the edge of the placenta is at the margin of the internal os. Low-lying placenta: the placenta is implanted in the lower uterine segment such that the placenta edge actually does not reach the internal os but is in close proximity to it. Bleeding in case of placenta previa results from small disruptions in the placental attachment during normal development and thinning of the lower uterine segment and it usually ceases spontaneously. Most presentation of placenta previa is painless bleeding or bleeding without contraction. This bleeding often starts mildly and may increase as the area of placental separation increases. Risk factors of placenta previa: (see table above) Placenta previa may be associated with placenta accreta, placenta increta or percreta. Vasa previa - - Vasa previa: "fetal vessels crossing or running in close proximity to the inner cervical os. The classic triad of the vasa previa is: membrane rupture, painless vaginal bleeding and fetal bradycardia. This is rarely confirmed before delivery the bleeding is from fetal circulation high fetal mortality rate ( 50 -95%) Causes: 1. Succenturiate (Accessory) lobe Risk factors: (see table above) Uterine rupture - - Uterine rupture: Separation of the muscular wall of the uterus. A uterine rupture typically occurs during early labor but may already develop during late pregnancy. S o Mode of Delivery is only by Caesarean section o Occasionally Caesarean hysterectomy necessary (in case of placenta accrete increta or percreta). S o Uterine Rupture following obstructed labor or trauma generally requires hysterectomy. Additional notes: o Apt test: clinician to determine whether the blood originates from the infant or from the mother. Invasive obstetric procedures as amniocentesis, Chorionic villous sampling or ectopic pregnancy 4. External cephalic version - Prevention: o All rhesus-negative unsensitized women who have any risk factor are given anti-D IgG. In case of women with rhesus- negative maternal Rh antibody titers negative repeat at 28 and 36 weeks 3. In case of positive antibody o Serial Ultrasound to detect hydrops fetalis (skin edema, ascites, pleural or pericardial effusions, cardiomegaly and an edematous placenta) o Serial Doppler examinations of middle cerebral artery and umbilical artery for detection increased blood flow velocities (sign of anemia) o Quantitative analysis of maternal anti-RhD antibodies - an increasing level is a sign of fetal Rh disease o amniocentesis for the level of bilirubin to assess the severity of hemolysis Amniotic fluid bilirubin concentration can be quantified by spectrophotometry by assessing the change in optical density at 450nm. Kleihauer-Betke test used When a high clinical suspicion of large fetomaternal hemorrhage for measurement of fetal red blood cells in maternal blood. Elevated serum bilirubin measurements, low hematocrit, and elevated reticulocyte count from the neonate can help determine if an early exchange transfusion is necessary. An emergent exchange transfusion, preferably performed is required in infants born with erythroblastosis fetalis, hydrops fetalis, or kernicterus 4. Phototherapy for neonatal jaundice in mild disease Complication of Hemolytic disease of the newborn: 1. Secondary postpartum hemorrhage: It is a blood loss of a volume greater than expected after 24 hours within the first 6 weeks of delivery [mainly due to trauma]. Hemorrhage is still one of the leading causes of maternal mortality all over the world.
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