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Premature rupture of membranes is a complication in approximately one third of preterm births. It typically is associated with brief latency between membrane rupture and delivery, increased potential for perinatal infection, and in utero umbilical cord compression. Management may be dictated by the presence of overt intrauterine infection, advanced labor, or fetal compromise. Examination should be performed in a manner that minimizes the risk of introducing infection, particularly before term. Digital examinations should be avoided unless the patient is in active labor or immi nent delivery is planned. The diagnosis of membrane rupture is confirmed by the visualization of fluid passing from the cervical canal. When the clinical history or physical examination is unclear, membrane rupture can be diagnosed unequivocally with an ultrasonographically guided transabdominal instillation of indigo carmine dye (1 mL in 9 mL of sterile normal saline), followed by observation for passage of blue fluid from the vagina. At any gestational age, a patient with evident chorio 260 Guidelines for Perinatal Care amnionitis, abruptio placentae, or evidence of fetal compromise is best cared for by expeditious delivery. If chorioamnionitis is diagnosed, appropriate antibiotic treatment also is indicated. In the absence of an indication for immediate deliv ery, swabs for diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae may be obtained from the cervix, if appropriate. When the decision to deliver is made, group B strepto cocci prophylaxis should be given based on prior culture results or risk factors if cultures have not been previously performed. The efficacy of corticosteroid use at 32?33 completed weeks is unclear based on available evidence, but treatment may be beneficial particularly if pulmonary immaturity is documented. Stillbirth Fetal death, or stillbirth (the term preferred among parent groups), is one of the most common adverse pregnancy outcomes, complicating 1 in 160 deliveries in the United States. Approximately 25,000 stillbirths at 20 weeks of gestation or greater are reported annually. In any specific case, it may be difficult to assign Obstetric and Medical Complications 261 a definite cause to a stillbirth. A significant proportion of stillbirths remain unexplained even after a thorough evaluation. Risk Factors and Comorbidities In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, and obesity. From a public health perspective, obesity, smoking, and drug and alcohol use are common potentially modifiable risk factors for adverse pregnancy outcome. Hypertension and diabetes are two of the most common medical comorbid pregnancy conditions. Methods of Delivery the method and timing of delivery after a fetal death depends on the gesta tional age at which the death occurred, on the maternal history of a previ ous uterine scar, and maternal preference. Although most patients will desire prompt delivery, the timing of delivery is not critical. In the second trimester, dilation and evacuation can be offered if an experienced health care provider is available, although patients should be counseled that dilation and evacuation may limit efficacy of autopsy for the detection of macroscopic fetal abnormali ties. Labor induction is appropriate at later gestational ages, if second trimester dilation and evacuation is unavailable, or based on patient preference. Induction of labor with vaginal misoprostol is safe and effective before 28 weeks of gesta tion in patients with a prior cesarean delivery with a low transverse uterine scar. Evaluation of Stillbirth After a stillbirth or neonatal death, proper management includes obtaining a complete perinatal and family history, performing a physical examination of the fetus (with documentation by description and photography, if possible), and obtaining laboratory studies. The most important tests in the evalua tion of a stillbirth are fetal autopsy; examination of the placenta, cord, and membranes; and karyotype evaluation. The results of the autopsy, placental examination, laboratory tests, and cytogenetic studies should be communicated to the involved physicians and to the family of the deceased infant in a timely manner. Sensitivity is needed when discussing evaluation of a stillborn fetus with the family. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, religious leader, peer support group, or mental health professional may be advisable for management of grief and depression. In low-risk women with unexplained stillbirth the risk of stillbirth recurrence after 20 weeks of gestation is estimated at 7.

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Prevalence, other hand, another study of 226 adult women severity and severity risk factors of acne in high (25?50 years old) reported comedonal postado school pupils: a community-based study. Suicidal ide References ation, mental health problems, and social impaire ment are increased in adolescents with acne: a 1. Medication and medical service utilization life in acne: a comparison with general medical condi for acne 1995?1998. Self-esteem and A community-based study of acne-related health body satisfaction among late adolescents with acne: 7 Acne Epidemiology and Socioeconomic Aspects 57 results from a population survey. The frequency of bidity: results of a school-based cohort study of common non-malignant skin conditions in adults in adolescents. The ences in the quality of life and choice of therapy Glasgow Alumni Cohort Study. The clinical fea lence of acne among a group of Portuguese medical stu tures of late onset acne compared with early onset dents. Dessinioti in acne initiation have been a matter of Department of Dermatology, debate. During adre In this chapter we will summarize what we narche (at the age of 6?7 years in girls and 7?8 have learned on acne pathogenesis over the years years in boys), the secretion of androgens by the until 2000. Human sebo a differential response of sebocytes to androgens cytes, however, could be maintained only for 3?6 in vitro depending on the anatomic localization subcultures with decreasing numbers of prolifer of their origin [25]. Facial sebocytes exhibit in ating and increasing numbers of differentiated vitro a stronger 5? This way, multiple donors were and their proliferation was stimulated by necessary in order to obtain adequate cell 5? The establishment of a human be critical for increased sebum production and immortalized sebaceous gland cell line termed acne development [24]. Moreover, the retain the morphologic, phenotypic, and func sebaceous glands of acne patients have increased tional characteristics of human sebocytes, includ number of such androgen receptors [29]. However, since acne is an Apart from androgens, other hormones includ exclusively human disease and the sebaceous ing insulin, hydrocortisone, and thyroid gland differentiation is species speci? Isotretinoin (13-cis model in vitro by Xia et al [36 ] revolutionized retinoic acid) demonstrates an independent regu research on sebocyte function. Thus, new insight lation of proliferation, lipid synthesis, and was provided on sebocyte differentiation and terminal differentiation of human sebocytes in sebocyte markers [37, 38]. The important role of androgens in acne has been Androgens have been proven to be one of the substantiated by both clinical and research evi main factors in acne pathogenesis as they enhance dence (Table 8. This data indicates patients with acne do not suffer from endocrino that adrenal androgens are a major determinant logic abnormalities. Also, the severity of acne has of sebaceous gland activity during the prepuber not been correlated with elevated androgen levels tal period [51 ]. This raises the question of whether there is Hyperplasia or carcinomas of the gonads or the an increased local production of androgen within adrenals, which result in elevated androgen levels, the sebaceous gland of patients with acne, which are often associated with the development of acne. Conversely, androgen excess has unit to androgens could explain the normal serum been found in women with persistent or severe levels of testosterone and other androgens usu acne without other clinical evidence of hyperan ally found in acne patients (Table 8. Also, not all sebaceous gland follicles are Additional evidence supporting the role of similarly affected by acne which predominates androgens in acne includes the? Also, anti-androgen therapy is sebocytes from the face show a dose-dependent highly successful in the management of female increase in proliferation [25]. As already mentioned, the increased sebum Although the role of androgens in the patho production in acne patients may be due to an genesis of acne cannot be refuted, an association 8 Acne Pathogenesis: What We Have Learned Over the Years 65 between acne severity and the degree of androgen comedogenic factor [79, 80]. It has hair, irregular menstrual bleeding, alopecia) and been reported that keratinocytes are capable of acne severity [73]. Infrainfundibular keratinocytes dem onstrate greater activity of this enzyme compared 8. This data is supported by the clinical to increased cohesion between keratinocytes [13, observation that anti-androgen therapy with 74, 75 ]. Also, cellular proliferation was to the clinical observation that many open and greater in normal follicles from acne-affected closed comedones resolve spontaneously [85 ]. There was no convincing evidence until Certain sebaceous lipids, such as squalene 2000 to support a role for Propionibacterium oxide and free fatty acids, are higher in acne acnes (P. This isolated in 1896, it was thought to be the direct data raises the question of whether in?

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Stop using Accutane and call your doctor right away if you develop conjunctivitis (red or inflamed eyes, lik pink eye?), a rash with a fever, blisters on legs, arms or face and/or sores in your mouth, throat, nose, eyes, or if your skin begins to peel. These organs include the liver, pancreas, bowel (intestines), and esophagus (connection between mouth and stomach). If your organs are damaged, they may not get better even after you stop taking Accutane. Accutane may affect bones, muscles, and ligaments and cause pain in your joints or muscles. Tell your doctor if you plan hard physical activity during treatment with Accutane. Stop using Accutane and call your doctor if your hearing gets worse or if you have ringing in your ears. This condition usually clears up after you stop taking Accutane, but it may be permanent. Stop taking Accutane and call your doctor right away if you have any problems with your vision or dryness of the eyes that is painful or constant. If you wear contact lenses, you may have trouble wearing them while taking Accutane and after treatment. Return to your doctor for blood tests to check your lipids and to get any needed treatment. Stop taking Accutane and get emergency care right away if you develop hives, a swollen face or mouth, or have trouble breathing. Stop taking Accutane and call your doctor if you get a fever, rash, or red patches or bruises on your legs. Call your doctor if you get any side effect that bothers you or that does not go away. General Information about Accutane Medicines are sometimes prescribed for conditions that are not mentioned in Medication Guides. Do not give Accutane to other people, even if they have the same symptoms that you have. You can ask your doctor or pharmacist for information about Accutane that is written for health care professionals. Active Ingredient: Isotretinoin Inactive Ingredients: beeswax, butylated hydroxyanisole, edetate disodium, hydrogenated soybean oil flakes, hydrogenated vegetable oil, and soybean oil. Teaching Chemistry Through the Jigsaw Strategy Example 1 Topic Thalidomide: A Controversial Chiral Drug Subtopics 1. Level Secondary 6-7 Curriculum Links Stereoisomerism Enantiomerism Chiral carbon compounds Medium of instruction English Copyright 2007 by Quality Education Fund, Hong Kong All rights reserved. Prepared by Professor Derek Cheung, the Department of Curriculum and Instruction, the Chinese University of Hong Kong. No part of this document may be reproduced in any manner whatsoever without written permission, except in the case of use as instructional material in a school by a teacher. Enantiomers are optical isomers which are nonsuperimposable mirror-image structures. When four nonidentical atoms or groups are attached to a tetravalent carbon, the tetrahedral arrangement of the bonds in space results in two enantiomers. Enantiomers can be distinguished by experiments because they have different ability to rotate a beam of plane-polarized light: to the clockwise direction as a dextrorotatory (+)-enantiomer and to the counterclockwise direction as a levorotatory (-)-enantiomer. A mixture of equal portions (50/50) of the (+) and (-) enantiomers is called a racemic mixture. In 1957, a pharmaceutical company in West Germany introduced a new drug to the market. The drug was made and marketed as a racemic mixture of the (+)(R)-thalidomide and (-)(S)-thalidomide. O O H H N * O O * N N N O H H O O O (-)(S)-thalidomide (+)(R)-thalidomide Tragically, thalidomide was found to have serious side-effects; thousands of babies were born with missing or abnormal arms, hands, legs, or feet.

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If no new risk factors are found, attention may be focused on the fol lowing historic factors: Use of any medication Serologic testing for hepatitis B virus surface antigen may be necessary, as described in Chapter 10. Women who have not received prenatal care, had Intrapartum and Postpartum Care of the Mother 173 episodic prenatal care, or who received care late in pregnancy are more likely to have sexually transmitted infections and substance abuse problems. Social problems, such as poverty and family conflict, also may affect patients? health. Because of these factors, a shortened obstetric hospital stay poses even greater problems for patients who have had no prenatal care. Routine obstetric screen ing tests (eg, hemoglobin level, blood type, and Rh factor), social intervention, and additional education may be needed within this limited period. Women with unidentified alcohol or drug dependence often opt for early postpartum discharge or leave the hospital against medical advice putting themselves and their infants in danger. If no complications are detected during initial assessment in the labor and delivery area and if contraindications have been ruled out, qualified nursing personnel may perform the initial pelvic examination. When the patient has been examined and instructions regarding her management have been given and noted on her medical record, all necessary consent forms should be signed and incorporated into the medical record. If electronic medical records are used, the electronic prenatal records should be accessible. Consideration should be given to providing periodic updates to the prenatal medical record on file. Blood typing and screening tests need not be repeated if they were performed during the antepartum period and no antibodies were present, provided that the report is in the hospital records. Policies should be developed to ensure expeditious preparation of blood products for transfusion if the patient is at increased risk of hemorrhage or if the need arises. At all times in the hospital labor and delivery area, the safety and well-being of the mother and the fetus are the primary concern and responsibility of the obstetric staff. This concern, however, should not unnecessarily restrict the activity of women with uncomplicated labor and delivery, or exclude people who are supportive of her. The woman should have the option to stay out of bed during the early stages of labor, to ambulate, and to rest in a comfortable chair as long as the fetal status is reassuring. Practices such as showers dur ing labor, placement of intravenous lines, use of fetal heart rate monitoring, and restrictions on ambulation should be reviewed in departmental policies. These policies should take into consideration physicians? preferences as well as patients? desires for comfort, privacy, and a sense of participation. Likewise, the use of drugs for relief of pain during labor and delivery should depend on the needs and desires of the woman. Obstetric department policies should include recommendations for transmitting to the nursery those maternal and fetal historical and laboratory data that may affect the care of the newborn. Information on conditions that may influence neonatal care should be communicated, as well. The lack of such data, perhaps because of a lack of Intrapartum and Postpartum Care of the Mother 175 prenatal care, also should be made known to the nursery personnel. The physi cian who will care for the newborn should be identified on the maternal medi cal record (see Appendix A). Health care professionals who provide anesthesia should be notified of women who may be at significant risk of complications from anesthetic procedures (eg, women with hypertension, morbid obesity, or receiving anticoagulation). This may require two or more cervical examinations that are separated by an adequate period of time to observe change. Even a well-prepared woman may arrive at the hospital labor and delivery area before true labor has begun. A policy that both allows for adequate evaluation of patients for the presence of labor and prevents unnecessary admissions to the labor and delivery unit is advisable (see also Appendix G). False Labor at Term Uterine contractions in the absence of cervical change are commonly referred to as false labor. Patients who are having uterine contractions and are not yet in active labor may be observed for evidence of cervical change in a casual, com fortable area. The patient may be discharged, after observation and evaluation by appropriate hospital-designated personnel and assurance of fetal well-being (see also Appendix G). Management may be dictated by the presence of overt intrauterine 176 Guidelines for Perinatal Care infection, advanced labor, or fetal compromise. Nevertheless, all patients reporting symptoms that suggest ruptured membranes should be examined with a sterile speculum as soon as possible to confirm this diagnosis.

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