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Intersec to depression and erectile dysfunction causes buy 20 mg levitra professional otc ral linkage is the key for mental health promotion Mental health can be improved through the collective action of society erectile dysfunction recreational drugs levitra professional 20 mg line. Improving mental health requires policies and programmes in government and business sec to how to avoid erectile dysfunction causes best levitra professional 20 mg rs including education erectile dysfunction herbal treatment options generic 20 mg levitra professional with mastercard, labour, justice, transport, environment, housing and welfare, as well as specific activities in the health field relating to the prevention and treatment of ill-health. Mental health is everybody’s business Those who can do something to promote mental health, and who have something to gain, include individuals, families, communities, commercial organizations and health professionals. Particularly important are the decision-makers in governments at local and national levels whose actions affect mental health in ways that they may not realize. International bodies can ensure that countries at all stages of economic development are aware of the importance of mental health to community development. They can also encourage them to assess the possibilities and evidence for intervening to improve the mental health of their population. Health polices in the 21st century will need to be constructed from the key question”What makes people healthyfi Three ideas central to the improvement of health follow from this definition: mental health is an integral part of health, mental health is more than the absence of mental illness, and mental health is intimately connected with physical health and behaviour. Defining mental health is important, although not always necessary to achieving its improve ment. However, just as age or wealth each have many different expressions across the world and yet have a core common-sense universal meaning, so to o can mental health be unders to od without restricting its interpretation across cultures. In this positive sense, mental health is the foundation for well-being and effective functioning for an individual and for a community. It is more than the absence of mental illness, for the states and capacities noted in the definition have value in themselves. They are mutually exclusive only if health is defined in a restrictive way as the absence of disease (Sar to rius, 1990). Recognizing health as a state of balance including the self, others and the environment helps communities and individuals understand how to seek its improvement. Towards a new public health Public health in modern times has a broad scope as the organized global and local effort to promote and protect the health of populations and to reduce health inequalities. This ranges from the control of communicable diseases – the original impetus for public health work – to the leadership of intersec to ral efforts to promote health (Beaglehole, 2003). Its strategies are based on the question of how health is created, and it aims to offer people more control over the determinants of their health. The priority this gives to investing in the determinants of health is matched by the increasing focus on health outcomes around the world. Several key thinkers in the last two decades have influenced public health practice. Marmot, in his work with Wilkinson on the social determinants of health, noted that it is possible to alter “the impact of the social environment on health, as represented by social inequalities in health” (Marmot & Wilkinson, 1999, p. Specific social determinants of health can be characterized and their effects studied. It is then potentially possible to affect these determinants with a consequent impact on health. Syme (1996) noted the importance of distinguishing between individual risk fac to rs and environmental causes of disease. Rose (1992) suggested that the causes of individual differences in disease may not be the same as the causes of differences between populations. These population determinants are the focus of much of the new public health and health pro motion work. Since the determinants of health and the most powerful means for health improvement are located at the global and regional levels, and since most public health work lies outside the conventional market framework and remains the responsibility of government, its “public good” nature can be stressed and is gaining acceptance. Reducing health inequalities requires action on the underlying structural determinants of social and economic deprivation and serious intersec to ral action is required (Beaglehole & Bonita, 2003). Beaglehole and Bonita call for better education of public health practitioners to give them the skills for this type of work. The fields of mental health and public health have a long his to ry of weak interac tions, despite the possibilities for a stronger working relationship (Cooper 1990; Goldberg & Tantam, 1990; Goldstein, 1989). This relates mainly to the stigma of mental illness, and vagueness in the concepts of mental health and mental illness. First, mental health is increasingly seen as fundamental to physical health and quality of life and thus needs to be addressed as an important component of improving overall health and well-being. It follows that promoting mental health through a focus on key determi nants should not only result in lower rates of some mental disorders and improved physical health but also better educational performance, greater productivity of workers, improved relationships within families and safer communities. Second, there is wide acknowledgement of an increase in mental ill-health at a global level. Evidence also indicates that mental ill-health is more common among people with relative social disadvantage (Desjarlais et al. The global focus on mental ill-health has sparked interest in the possibilities for promoting mental health as well as preventing and treating illness. There is a need to ensure that appropriate care and treatment is in place for those experiencing mental ill-health while at the same time develop ing a greater focus on promotion of mental health and prevention of illness, and giving priority to each of these in global, national and local policy and practice. Many policy-makers, practitioners and academics working in public health are committed to addressing health inequalities result ing not only from biological and behavioural characteristics but also from a maldistribution of resources. Consequently, health promotion, including the promotion of mental health and well being, is as much an emerging political and social project as a health project (Mittelmark, 2003). Promoting mental health is an integral part of public health Mental health and mental illness are determined by multiple and interacting social, psychological and biological fac to rs, just as are health and illness in general. The clearest evidence relates to the risks of mental illness, which in the developed and developing world are associated with indica to rs of poverty, including low levels of education. The association between poverty and mental disorders appears to be universal, occurring in all societies irrespective of their levels of develop ment. Fac to rs such as insecurity and hopelessness, rapid social change and the risks of violence and physical ill-health may explain this greater vulnerability (Patel & Kleinman, 2003). Economic levels also have important implications for family functioning and child mental health (Costello et al. Mental, social and behavioural health problems may interact to intensify each other’s effects on behaviour and well-being. Substance abuse, violence and abuses of women and children on the one hand, and health problems such as heart disease, depression and anxiety on the other, are more prevalent and more difficult to cope with in conditions of high unemployment, low income, limited education, stressful work conditions, gender discrimination, unhealthy lifestyle and human rights violations (Desjarlais et al. Mental health for each person is affected by individual fac to rs and experiences, social interaction, societal structures and resources and cultural values. It is influenced by experiences in everyday life, in families and schools, on streets and at work (Lahtinen et al. Some of the newest research across the dis ciplines of genetics, neuroscience, the social sciences and mental health involves elaborations of ideas about the impact societies have on human life over and above the sum of the impact of the individual members of the society (as discussed in Chapter 10). Ethnographic studies show how people living in adverse environments and social settings such as the slums of Mumbai are faced with problems such as migration and displacement, poor condi tions, unequal distribution of amenities, demolition of housing, homelessness and communal and ethnic disharmony. These in turn shape local experience and affect the mental health of the inha bitants and the community. Hopelessness, demoralization, addictions, distress, anger, depression, hostility and violence can all be linked back to these experiences and problems (Parkar, Fernandes & Weiss, 2003). Despite this, mental health and mental illness are largely viewed as residing outside the public health tradition with its fundamental concepts of health and illness as multifac to rial in origin (Cooper, 1993) and of there being a continuum between health and illness (Rose, 1992). First, the opportunities for improving mental health in a community are not fully exploited. Second, organized efforts by countries to reduce the social and economic bur den of mental illnesses tend to focus mostly on the treatment of ill individuals. Yet mental illness and mental health have been neglected to pics for most governments and societies. In contrast to the overall health gains of the world’s populations in recent decades, the burden of mental illness has grown (Desjarlais et al. This neglect is based at least in part on confusion and false assumptions about the separate con cepts of mental health and mental illness. Until now, the prevailing stigma surrounding mental illness has encouraged the euphemistic use of the term “mental health” to describe treatment and support services for people with mental illness. This usage adds to confusion about the concept of mental health as well as that of mental illness. In most parts of the world the treatment of mental illness was alienated from the rest of medicine and health care at least until recently. In the isolated setting of asylums, practitioners saw many seemingly incurable patients. The supposed incurability of insanity and melancholy made practi tioners believe the causes were entirely biological.

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The frst concerns the sensitivity of the analysis to erectile dysfunction nicotine discount levitra professional 20 mg fast delivery were examined using a model that included age and a dose the assumed sound level for the control group L0) impotence 20s buy levitra professional 20mg lowest price. The resultant esti between the sound levels among the noise-exposed group mated shape parameters for the 0 erectile dysfunction latest treatments buy levitra professional 20mg mastercard. Data limitations a 40-year working lifetime of exposure to erectile dysfunction test video generic 20mg levitra professional free shipping noise was approxi the cross-sectional design of this study presented limi mately 15 percent at 85 dB. One data limitation with implications for mod analysis assumes the existence of a plateau in risk after 10 eling the risk of noise-induced hearing handicap, was the years of exposure duration. This is a crucial omis show that patterns of excess risk as a function of average sion because all excess risk estimates depend on the risk of daily sound level depend on age. These differing results by age may be Due to this lack of data, a very simplistic assumption attributable to the fact that the effect of aging on risk of was made: sound levels in the control population could be hearing handicap may overshadow any incremental increases represented by a single number. First, it ignores the possibility that duration and sound level, the dose-response curve shows there may be a distribution of sound levels below 80 dB for signs of a plateau effect. Second, this assumption results in a model effect of sound intensity and duration of exposure is depen that implies that the estimated value L0) is a threshold dent on frequency. Hearing damage at 3 and 4 kHz is ex sound level at which no excess risk of noise-induced hearing pected to occur sooner than loss at lower frequencies 0. Defnitions that exclude the higher frequencies Hence, the statistical criteria used in model development are tend to be less sensitive to noise damage and may require valid only if all of the controls were below a defned thresh longer durations of exposure to a given sound level to see old. These modeling issues underscore the fact that all mod Figure 4A and B suggests that the most suitable defni els are likely to be dependent on assumptions used to ac tion of hearing handicap may depend on the population char count for uncertainty in the available data. This analysis did acteristics, such as age, exposure duration, and degree of not model hearing threshold levels as a continuous variable. The addition of the most sensitive frequencies to a possible shapes for the sound level function other than L L). The models described in this paper were developed on cedures for estimating hearing handicap due to noise expo the basis of this particular data set. The Passchier-Vermeer 1968 and Robinson 1970 models are represented by different mathematical equations C. Johnson 1978 provides the methodol study design, data collection and time period for all of these ogy used to develop risk percent calculations using the per studies. Hence, the Annex A highly screened control popu 89 dB are within the lower bound of the confdence limits lation is the most appropriate comparison to our study popu from the logistic model. I– the variety of geographic regions and worksites within the Analysis of Case-control Studies (International Agency for Research on United States. The Jackknife, the Bootstrap and Other Resampling Plans few subjects with exposures at levels below 85 dB. Moscicki at virtual companies with no commercial products and no revenue to those with only the Center for Drug Evaluation and Re search, Food and Drug Administration, a few commercial programs. However, these challenges are largely overshadowed by limited resources and funding, which in turn fuel demand for short timelines owing to the need to demonstrate progress to inves to rs. As such, these companies must focus their re sources on small, less-costly development programs for very specific targets and often must spearhead new approaches to testing new products in order to survive. Small companies use a variety of approaches to address these challenges, includ ing the use of new technical platforms, the use of new formulations or technologies that enhance the actions of known drugs, or the use of trial designs that take advan tage of the specific market they hope to enter. Other companies develop products that are spun off from or licensed from large companies. In fact, many small companies may choose to partner with larger companies to add resources and experience. Many small companies also repurpose drugs or pursue narrow niche markets — such as rare inherited diseases, uncommon cancers, or specific infectious diseases — to remain viable. Furthermore, many companies turn to rare diseases for an op portunity to successfully negotiate many of the aforementioned issues, though such diseases present their own challenges — in particular, the small number of pa tients available for clinical trials. It is beyond the scope of this article to provide a comprehensive review of all the challenges and strategies used by small biopharmaceutical companies. Herein we provide an in-depth discussion of several examples, with an emphasis on drugs devel oped for rare diseases. Use of a His to rical Control Group When the Use of Placebo Is Problematic Although randomized, double-blind, placebo-controlled clinical trials are the standard in clinical development and usually present the quickest way to discern a treatment n engl j med 376;5 nejm. Examples of Small Biopharmaceutical Companies That Achieved Regula to ry Success from Independently Initiated Phase 3 Studies. This ap to the acceptability of placebo controls when pre proval was based on a study that evaluated the liminary data suggest a lifesaving potential. It was activity, glycogen accumulates in cardiac and skel considered unethical to include a placebo group etal muscle, causing progressive cardiomyopathy as part of the study design, because infantile and generalized muscle weakness and hypo to nia, onset Pompe disease is a rapidly fatal disorder which result in severely delayed mo to r development and early clinical trials had shown that treatment and cardiorespira to ry failure. The authors identified a his to ri cant manifestations generally develop within the cal control group of 61 severely affected infants first months of life. If the condition is left un 6 months of age or younger by applying the study treated, 70 to 80% of children with infantile inclusion and exclusion criteria to a group of 168 onset Pompe disease die from cardiac or respira patients with infantile-onset Pompe disease who to ry failure before 1 year of age. Enzyme-replacement therapy with recombinant the cohort included 168 patients from nine coun 470 n engl j med 376;5 nejm. Overall survival 80 and survival free from invasive ventilation were 70 60 compared between treated patients and this his 50 to rical cohort; the sample size of 18 treated pa 40 tients provided more than 95% power to detect 30 an absolute difference of 60 percentage points in 20 His to rical overall survival between treated and control groups. Kaplan–Meier Analyses of Survival Free from Invasive Ventilation 5 (Primary Efficacy End Point). The asterisk indicates that one patient in the his to rical control group re sult in such large effects on disease, which justifies mained alive at 18 months of age; this patient died at 44 months of age. In male pa merular endothelium as a surrogate end point was tients, the disease has a pronounced vascular phe that biopsy data can be quite variable when sam notype with effects most commonly in the kidney, ples are obtained from different areas of the kidney heart, and brain, owing primarily to s to rage of and the scoring can be subjective. A new near-normal amounts (scored as 0 on a 4-point surrogate end point could allow greater homo scale) would be likely to predict clinical benefit. The new england journal of medicine the investiga to rs chose this end point and used are referred to as “potentia to rs. The pathologists independently in a randomized, double-blind, placebo-controlled assessed slides of renal biopsies that were pre trial. In this trial, 167 patients who tested posi sented in a blinded and randomized fashion. All tive for the targeted mutation were randomly the pathologists participated in preliminary ses assigned to either 150 mg of ivacaf to r or placebo sions to establish the criteria for the grading scale every 12 hours. The change from baseline through that was used to evaluate clearance from affected week 24 in the percent of predicted forced expi tissues. This is a great exam using biopsy results as an end point were dis ple of predictive enrichment — that is, the study closed. Predictive Enrichment with the Use of a Genetic Marker As suggested above, identifying the patients who are likely to have a response to treatment, and Today “targeted therapies” offer more precise ways then studying them, greatly enhances the power of to identify patients who are likely to benefit from a study and has clear implications for how a drug treatment. The use of such patient-selection were studied in a large population with the hope to ols can greatly reduce the number of patients that enough participants would have a response needed to show efficacy. It can be especially critical to make the trial successful, and a broad indication when those who are likely to have a response are for use would be granted. However, if a therapy only a small fraction of all patients with a disease benefited only a small number of patients, such. To illustrate this the most prevalent mutation of this type in pa error, we turn to an example from Parkinson’s tients with cystic fibrosis causes a substitution disease. Only two patients, both in Half received cyclosporine treatment for immuno the cyclosporine group, individually showed large suppression, and half received fetal tissue treat decreases, but 18F-fluorodopa positron-emission ed with a monoclonal antibody directed against to mography failed to show changes on the im major his to compatibility class I. Clinical Trials Series was very small, and the sponsor was urged to placebo effect. Soon after the announcement of conduct a multicenter, prospective, randomized, the trial results, Diacrin could not remain a viable double-blind, placebo-controlled study to evaluate company and closed the further development of this therapy further. No significant between diseases and the small samples available for tri group differences were observed on four second als require approaches that can maximize the ary end points. Temptations to use uncontrolled, that has been documented in several surgical trials early, small studies to support further develop in Parkinson’s disease. Small effect, a sufficient number of patients and a de companies with limited resources require both fined patient population are needed.

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The lesion has a sudden onset and clinically may present as a nodular swelling that later leads to erectile dysfunction quitting smoking discount levitra professional 20mg without prescription a painful craterlike ulcer with irregular and ragged border (Fig erectile dysfunction drugs sublingual 20mg levitra professional free shipping. Other Salivary Gland Disorders Sialolithiasis Sialadenosis Sialoliths are calcareous deposits in the ducts or Sialadenosis is a rare noninflamma to erectile dysfunction nitric oxide levitra professional 20 mg visa ry erectile dysfunction natural remedy 20 mg levitra professional otc, nonneo the parenchyma of salivary glands. The subman plastic enlargement of the parotid and rarely the dibular gland sialoliths are the most common submandibular glands. The exact etiology remains (about 80%), followed by parotid gland, sublin unknown but the disorder has been found in gual glands, and minor salivary glands. When the sialolith is located at the soft, and diminishing salivary secretion may occur. The differential diagnosis includes infectious Labora to ry test to establish the diagnosis is his sialadenitis. Xeros to mia Labora to ry test to determine xeros to mia are the salivary flow rate, sialography, his to pathologic Xeros to mia is not a nosologic entity, but a symp examination, scanning, and serologic tests. Clinically, the oral mucosa is dry, red, cracked, and the epithelium becomes atrophic (Fig. Tumor-like Lesions Pyogenic Granuloma the differential diagnosis includes peripheral giant cell granuloma, peripheral ossifying fi Pyogenic granuloma is a common granulation tis broma, leiomyoma, hemangioma, hemangio sue overgrowth in reaction to mild irritation. Surgical excision, although spontane commonly on the maxilla and occurs about ten ous regression has been reported. Clinically, it is present at birth, and it appears as an asymp to matic solitary pedunculated tumor of red or normal color, which ranges from a few millimeters to a few centimeters in diameter (Fig. Natsume, N, Suzuki T, Kawai T: the prevalence of cleft lip A clinicopathologic study of 105 cases. Suzuki M, Sakai T: A familial study of to rus palatinus and Plast Reconstr Surg 47:138, 1971. J Am Acad Der the enamel, dentine, cementum and the dental pulp: His ma to l 15:1301, 1986. Sklavounou A, Laskaris G: Eosinophilic ulcer of the oral Vassilopoulou A, Laskaris G: Papillon-Lef6vre syndrome: mucosa. Bergendal T, Isacsson G: A combined clinical, mycological and his to logical study of denture s to matitis. Selected Bibliography 345 Nathanson D, Lockhart P: Delayed extraoral hypersensitivity Gorsky M, Silverman S Jr, Chinn H: Burning mouth syn to dental composite material. Holmstrup P, Axel T: Classification and clinical manifestations of oral yeast infections. Lindhe J: Textbook of Clinical Periodon to logy: Munksgaard, Maragou P, Ivanyi L: Serum zinc levels in patients with Copenhagen, 1983. Oral Surg Dupre A, Chris to l B, Lassere J: Geographic lip: A variant of 56:405,1983. Diagnosis, prevention Fenerli A, Papanikolaou S, Papanikolaou M, Laskaris G: and treatment. Med J Malay vulgaris: Clinical, his to logic and immunios to chemical sia 4:302, 1977. Odon to s to ma to l Prog 32:68, Seifert G, Donath K, Gumberz C: Mucozelen der Speicheldrii 1978. Extravasation-Mucozelen (Schleimgranulome) and Re Laskaris G, Papanicolaou S, Angelopoulos A: Focal epithelial tentions-Mucozelen (Schleim-Retentionscysten). Bacterial Infections Oda D, Me Dougal L, Fritsche T, Worthing to n P: Oral his to Abell E, Marks R, Wilson J: Secondary syphilis: A plasmosis as a presenting disease in acquired immunodefi clinicopathological review. Zachariades N, Papanikolaou S, Koundouris J: Scrofula: A Holst E, Lund P: Cervico-facial actinomycosis. J Oral Pathol Med Aboobaker J, Bhogal B, Wojnarowska F, et al: the localiza 19:81,1990. Furue M, Iwata M, Tamaki K, Ishibashi Y: Ana to mical dis Albrecht M, Banoczy, Dinya E, Tamas G Jr: Oceurence of tribution and immunological characteristics of epidermolysis oral leukoplakia and lichen planus in diabetes mellitus. Acta Kawasaki T, Kosaki F, Okawa S, et al: A new infantile acute Derm Venereol (S to ckh) 64:70, 1984. Cicatricial pemphigoid in a 6-year-old child: Report of a case Laskaris G, Triantafyllou A, Economopoulou P: Gingival and review of the literature. Ophthalmolog between linear IgA disease and benign mucous membrane ica1183:122, 1981. Diagnostic procedure and comprehen microscopic study of epithelial surface patterns. Proc Hirshberg A, Leibovich P, Buchner A: Metastases to the oral Finn Dent Soc 71:58, 1975. Oral of mucous membranes: A clinicopathologic study of 13 cases Surg 71:708, 1991. Laskaris G, Papavasiliou S, Bovopoulou O, Nicolis G: Associ Am J Roentgenol Radium Ther Nucl Med 123:471, 1975. Laskaris G, Triantafyllou A, Bazopoulou E: Solitary plas macy to ma of oral soft tissues: Report of a case and review of literature. Papanicolaou S, Pierrakou E, Patsakas A: Intraoral blue Lesions with and without naevus sebaceous and basal cell nevus. Am J Surg Ide F, Umemura S: A microscopic focus of traumatic neuroma Pathol 15:233, 1991. S: Verruciform xanthoma of the palate: Case report with J Oral Maxillofac Surg 41:188,1983. Mat Med Seifert G, Miehlke A, Haubrich J, Chilla R: Diseases of the Greca 8:226, 1980. Pathology-diagnosis-treatment-facial Triantafyllou A, Sklavounou A, Laskaris G: Benign fibrous surgery. Am J Surg Pathol 5:37, sialometaplasia of palatal minor salivary glands: A report on 1981. Immunohis to chemical and ultrastructural observa normal human submandibular and parotid salivary glands. Sometimes, only Despite some recent vic to ries, research a few hundred patients are known to 105 in to treatments for rare diseases is a have a particular rare disease. This ongoing innovation Simply receiving a diagnosis of a rare and the hundreds of new medicines in disease often becomes a frustrating development now offer hope that physi 85 quest, since many doc to rs may have nev cians will have new treatment options er before heard of or seen the disease. Biopharmaceutical contents 65 research is entering an exciting new era Innovative Orphan Drugs with a growing understanding of the in the Pipeline. The medicines listed in this report are either in clinical trials or under review by the Food and Drug *Some medicines are listed in more than one category. Key issues function and, as dystrophin expression increases, there have innovative orphan Drugs in the been demonstrated improvements in patients’ ability to walk. Severely affected infants often have persistent tive new ways to target disease, including: bone disease or die from respira to ry insuffciency due to progressive chest deformity from poorly developed bones. The loss of this protein causes muscle fbers uniformly fatal disease in which patients experience progres to disintegrate faster than they can be regenerated. There medicine in development targets res to ration of dystrophin are currently no effective treatment options available, and Medicines in Development By Disease and phase Some medicines are listed in more than one category. As our scientifc understanding of the disease has grown, researchers are pursuing many new approaches to halt or slow progression, including the use of the patient’s own bone marrow stem-cells to create healthy neuron-like cells to replace diseased neurons. The treatment combines a Listeria to stabilize their disease or experience improvement in lung based vaccine that has been engineered to express the function. Over the last 30 years, more than 400 medicines representing 447 separate indications have been approved to treat rare diseases, compared to <200,000 fewer than 10 in the 1970s. The cells are irradiated to prevent further cell growth although they stay metabolically active. Rare diseases are responsible for 35 percent of deaths in the frst year of life and 30 percent of children with a rare disease will not live to see their ffth birthday. Encouragingly, one in three of the nearly 3,000 treatments with orphan designation are for children. In addition to the Orphan Drug Act, two other laws have made a signifcant impact on pediatric research. By providing a predictable regula to ry environment, the permanent reauthorization will help ensure that pediatric research by biopharmaceutical companies continues to advance children’s medical care. It targets a defective protein antibody directs the therapeutic to target the cancerous cells.

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Provide stress counselling – Excessive number of fetal parts may be felt – Provide nutritional counselling prostaglandin injections erectile dysfunction levitra professional 20mg fast delivery. Iron requirements – Anemia for twin pregnancies are estimated to erectile dysfunction blogs forums levitra professional 20mg on-line be nearly twice those of single to erectile dysfunction protocol review article discount levitra professional 20mg with visa n pregnancies young and have erectile dysfunction discount levitra professional 20mg fast delivery. Sometimes one twin – Fetal parts diffcult to feel is delivered vaginally and the other is delivered by – Uterus tense cesarean section. Bartter’s syndrome, hydrops fetalis, neuromuscular disorders, maternal hypercalcemia) Clinical Practice Guidelines for Nurses in Primary Care 2011 12–18 Obstetrics Appropriate Consultation Moni to ring and Follow-up Consult a physician if this diagnosis is suspected. Nonpharmacologic Interventions Referral Provide support and counselling as necessary to client and family. The causes – Mild cramps with bleeding (cramping may be mild may be benign or serious and vary according to the or painful) stage of pregnancy. Some are obstetric emergencies 64 – Cervix long and closed66 and are discussed below. It polyp, dysplasia) Hydatidiform mole is a cervix that dilates and effaces without uterine Ec to pic pregnancy Intrauterine death 67,68 contractions and does so in the absence of pain Spontaneous abortion with labour (threatened, inevitable His to ry of penetrative Incomplete Abortion/Miscarriage or incomplete) intercourse Missed abortion – Symp to ms are similar as for inevitable abortion/ miscarriage but some products of conception are retained within the uterus. The passage of tissue may be result does not rule out a spontaneous abortion/ noticed miscarriage – Measure hemoglobin level All pregnant clients with a his to ry of blood loss per – Urinalysis vagum require assessment. It is prudent to manage all Appropriate Consultation spontaneous abortions as incomplete abortions if Consult a physician. Refer to pro to col for managing hypovolemic shock (see the section “Shock” in Chapter 14, “General Emergencies and Major Trauma”). Nonpharmacologic Interventions – Nothing by mouth – Bed rest – Trendelenburg position (prn) to aid venous return – Insert urinary catheter – Moni to r intake and output hourly – Aim for urine output of 50 mL/h Pharmacologic Interventions Oxy to cin drip 20 units in 1 L normal saline, 100 mL/ hour according to physician advice. Rh-negative clients must be given anti-D immune globulin (WinRho), ideally within 72 hours, if indicated (for example, fetal blood type is unknown or Rh-positive)77 and after consultation with a physician. Clinical Practice Guidelines for Nurses in Primary Care 2011 12–22 Obstetrics Table 5 – Description and Classifcation of Placenta Previa and Abruptio Placentae Placenta Previa Abruptio Placentae Defnition Defnition A placenta implanted in the lower segment of the uterus, Premature detachment of a normally situated presenting ahead of the leading pole of the fetus79 placenta80 Painless uterine bleeding81 Painful uterine bleeding81 Prevalence Prevalence 2. Associated abruption, maternal hypertension, cigarette or with breech and transverse presentations, multiple gestation, cocaine use, increasing maternal age, multiparity. Consider if mo to r vehicle collision and/or seat belt bruise on abdomen Clinical Presentation Clinical Presentation Vaginal bleeding is typically painless, with bright red blood Vaginal bleeding in 80% of cases, but may be Blood loss is usually not massive with initial bleed, but concealed (retroplacental bleeding); therefore, bleeding tends to recur and become heavier as the pregnancy maternal hemodynamic situation may not be progresses, blood loss is in keeping with visualized bleed; explained by observed blood loss uterine to ne not increased and complete relaxation of uterus Pain and increased uterine to ne typical and between contractions incomplete relaxation of uterus between contractions Pain increases with severity Physical Findings Physical Findings Heart rate may be normal or elevated Dependent on degree of detachment, amount of Blood pressure normal, low or hypotensive blood loss Postural blood pressure drop may be present With mild abruption, signs may be minimal Fetal heart rate usually normal Heart rate mildly to severely elevated Mild distress to frank shock Blood pressure normal, low or hypotensive Bright red bleeding per vagina Fetal heart rate elevated, reduced or absent Fundal height consistent with dates Client may appear to be in acute distress Uterus soft, normal to ne, nontender Client may be pale or unconscious (if in shock) Uterine size consistent with dates Vaginal bleeding moderate, profuse or absent Transverse, oblique or breech lies common If membranes ruptured, amniotic fuid may be bloody Should be suspected in client with persistent breech Uterus may be larger than expected for dates presentation Uterus tender Fetal heart rate depends on amount of bleeding Increased uterine to ne (tense or hard) Advisability of speculum examination debatable Uterine contractions may be present and prolonged Digital cervical examination must be avoided until placenta Uterus may fail to relax completely between previa is ruled out by an ultrasound scan report at 18–20 contractions weeks or beyond that confrms the placenta is free from the os or until an ultrasound can be done to rule out placenta previa. Sterile speculum examination of the vagina may be done to visualize the cervix without fear of compromising the placenta. Visualization may reveal the cervical dilation and/or other cervical pathology and may aid in decision to transfer. Occurs most commonly in a uterine – Administer a 1 litre bolus over 15 minutes tube, but may also occur in the abdominal cavity, – Reassess for signs of continuing shock q15min on an ovary or in the cervix. This is potentially life – Repeat 1 litre boluses until sys to lic blood pressure threatening. Rh-negative clients must be given – Hyperthyroidism anti-D immune globulin ideally within 72 hours, if – Bleeding during pregnancy accompanied by no available and indicated (for example, fetal blood type 77 detectable fetal heartbeat, and uterine enlargement is unknown or Rh-positive) and after consultation more than expected after 12 weeks’ gestation with a physician. Use clinical signs and Moni to ring and Follow-Up symp to ms to estimate blood loss, not blood visualized. Referral Refer for diagnostic ultrasound and obstetric consultation in consultation with a physician. Surgical For pro to col for managing hypovolemic shock, intervention may be required. Clinical Practice Guidelines for Nurses in Primary Care 2011 12–30 Obstetrics Adjuvant Therapy Obstetricians and Gynaecologists of Canada classifes hypertension in pregnancy as either pre-existing or – Oxygen 4–6 L/min by mask if client breathless gestational. This may provide time to administer steroids – Preeclampsia in women with gestational and transfer the woman to the appropriate hospital. Agents for to colysis include indomethacin and – Severe preeclampsia: Defned as preeclampsia nitroglycerin patches. There is no evidence that using with onset before 34 weeks’ gestation, with heavy multiple agents is more effective and it actually may proteinuria or with one or more adverse conditions. Adverse conditions include headache, visual Antibiotics: Discuss with a physician the need for disturbances, abdominal or chest pain, nausea prophylactic antibiotics. Tracheal Syndrome” under the section “Hypertensive intubation and ventilation might become necessary Disorders in Pregnancy”) if there is respira to ry depression. See Table 7, “Doses of Most – Nothing by mouth Commonly Used Agents for Treatment of Severe – Protect airway Hypertension. Piggyback Thromboprophylaxis: Discuss with a physician for administration of this drug via a main line. Magnesium sulfate is a cerebral depressant that Steroids: If transport is delayed and gestational age is reduces neuromuscular irritability. It can cause less than 34 weeks, discuss with a physician the role vasodilation and reduction in blood pressure. Symp to ms of magnesium sulfate to xicity: respira to ry depression or arrest, reduced or absent deep tendon Moni to ring and Follow-Up refexes, cardiac arrest, coma. Keep preloaded syringe of and blood pressure q5min 10% calcium gluconate at bedside. The frst stage begins with – Fetal heart rate 120–140 bpm regular contractions that increase in frequency and – Bloody show, mucus may be present intensity that results in cervical change and ends with Components of the physical examination include: full (10 cm) dilation. The second stage is from the point of full cervical dilation to the birth of the fetus. If time permits, arrange transfer – Record time of onset, frequency and duration to hospital for delivery. If Adjuvant Therapy it is present, gently but frmly loop it over the head Consider a saline lock for potential administration – If unable to pull cord over head, then clamp it in of medications. Once this – Provide emotional support and encouragement to shoulder is delivered, the posterior shoulder is woman during labour gently and minimally curved to wards the woman’s – Assist with breathing through each contraction but to cks. Some women vaginal deliveries105 once the shoulders are may appreciate ice chips as well delivered. It is also acceptable to administer – Encourage the woman to void every 2 hours the oxy to cin once the baby has been delivered. Moni to ring and Follow-Up See “Pharmacologic Interventions” for more information – Moni to r progress of labour Care after Baby is Delivered: – Moni to r contractions, maternal vital signs and fetal heart rate every half hour in early stages of – Ensure the baby is breathing and keep the labour (see “Progression of Normal Labour” at the baby warm beginning of this section). As the labour becomes – If the umbilical cord is long enough, the woman active, assess the fetal heart rate every 15 minutes can hold her baby – Perform vaginal exams every 4 hours to assess – After the cord s to ps pulsing, clamp cord in two effacement and cervical dilation. Do not pull on the cord to the following fac to rs should be considered: hasten placental delivery. Rh-negative clients must be given anti-D immune globulin ideally within 72 hours of Referral delivery, if indicated (for example, fetal blood type is Transfer the woman and baby to hospital, after unknown or Rh-positive) and after consultation with 110 consultation with a physician. A manual of labora to ry and diagnostic pregnancy and lactation: a reference guide to fetal tests. Clinical Practice Guidelines for Nurses in Primary Care 2011 12–36 Obstetrics Prateek L, Waddel, A. Recommendations for Nutrition Best Practice in Canadian Journal of Diabetes 2008;32(Supplement the management of gestational diabetes mellitus. Prenatal nutrition guidelines for health professionals: Fish and omega-3 fatty Schuurmans N, MacKinnon C, Lane C, Etches D. Morbidity and management of the third stage of labour: prevention mortality weekly report: Prevention of perinatal group and treatment of postpartum hemorrhage. Society of Obstetricians and Gynecologists of management of postpartum hemorrhage; 2006 March. Diabetes in pregnancy: supplementation 2007: the use of folic acid in International recommendations provide an opportunity combination with a multivitamin supplement for the for improved care. Canadian Diabetes 2010;23(1):1, prevention of neural tube defects and other congenital 11. Society of Obstetrician GetFileAttach/014-4293-64~2/$File/4293-64%20 and Gynaecologists of Canada clinical practice 0503. Society of Obstetricians for health professionals: Background on Canada’s and Gynaecologists of Canada clinical practice food guide. Management of Rhesus for health professionals: Fish and omega-3 fatty (Rh) alloimmunization in pregnancy. Guidelines: the prevention of early-onset Intrauterine growth restriction: Diagnosis and neonatal Group B strep to coccal disease. OpenElement Association 2008 clinical practice guidelines for the 19 Health Canada. J Obstet Gynaecol Can 2007;29(12):1003 guidelines: Screening for gestational diabetes 13.

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