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It occurs most frequently in children individuals’ preoccupations, influence dreams. About one-half of children with Down syndrome have heart defects, drug, anti-angiogenesis See anti-angiogene- most often holes between the two sides of the heart sis drug. With appropriate intervention, most children with Down syndrome live active, pro- drug, antihypertensive See antihypertensive. Most are mildly to moderately retarded, although some have drug, anti-infective See agent, anti-infective. Down syn- drug, over-the-counter A drug for which a pre- drome was also once called mongolism, a term now scription is not needed. If the ductus stays open, flow reverses, and of seizure disorder or brain disease. See also diph- blood from the aorta is shunted into the pulmonary theria; tetanus. Acellular dumping syndrome A group of symptoms, pertussis vaccine is also probably less likely than including cramps, nausea, diarrhea, and dizziness, regular pertussis vaccine to cause the more severe that occur when food or liquid enters the small reactions occasionally seen following pertussis vac- intestine too rapidly. See duodenal ulcer A crater (ulcer) in the lining of also diphtheria; pertussis; tetanus. Other factors predisposing a tussis (whooping cough) immunization, a vaccine person to ulcers include anti-inflammatory medica- that is given in a series of five shots at 2, 4, 6, and 18 tions and cigarette smoking. Treatment involves using antibi- viduals who are capable of carrying and passing otics to eradicate H. Tetanus bacteria are prevalent in natural sur- roundings, such as contaminated soil. Children with duodenitis Inflammation of the duodenum, the compromised immune systems or known neurologi- first part of the small intestine. Dupuytren’s contracture A localized formation duct A walled passageway, such as a lymph duct, of scar tissue in the palm of the hand within a tissue that carries fluid from one place to another. The precise cause of Dupuytren’s contracture dwarfism, rhizomelic Dwarfism with shorten- is not known. Most patients with Dupuytren’s contracture require only stretching exercises with dwarfism, Seckel-type See Seckel syndrome. When the palm is persistently sore with grasping, ultrasound treatments can be helpful. The bones fixed flexed posture (contracture) of the fingers of the arms and legs are very short. The ribs are also from Dupuytren’s contracture, surgical procedures extremely short, and the rib cage is small, leading to can remove the scarred tissue to free the fingers. A person with dysarthria may also have problems controlling power of attorney allows another person to make the pitch, loudness, rhythm, and voice qualities of bank transactions, sign Social Security checks, his or her speech. Dysarthria is caused by paralysis, apply for disability, or write checks to pay utility bills weakness, or inability to coordinate the muscles of while an individual is medically incapacitated. Dysarthria can occur as a developmen- documents are recommended for any patient who may be unable to make his or her wishes known tal disability. Treatment of dysarthria includes intensive speech therapy with a focus on oral-motor dwarfism Abnormally short stature, which may skill development. Mild cases can often be com- height of 148 cm (4 feet 10 inches) or shorter, pensated for with use of a calculator, but those with among both men and women. See also achondroplasia; dwarfism, dysentery Inflammation of the intestine, with pituitary; hypochondroplasia; Seckel syndrome. Children with growth hormone deficiency may grow normally for the first dysfunction, erectile See erectile dysfunction. Pituitary dwarfism can be include fine-motor-muscle control of the hands and/or processing difficulties. Sometimes occupational treated with injections of human growth hormone. Most suc- toward the underlying cause and vaginal lubricant cessful students with dysgraphia that does not respond jelly can be of help. A condition characterized by upper abdominal symptoms that may include dyskinesia the presence of involuntary move- pain or discomfort, bloating, feeling of fullness with ments, such as the choreaform movements seen in very little intake of food, feeling of unusual fullness some cases of rheumatic fever or the characteristic following meals, nausea, loss of appetite, heartburn, movements of tardive dyskinesia. The dyskinesia are side effects of certain medications, term dyspepsia is often used for these symptoms particularly L-dopa and, in the case of tardive dysk- when they are not typical of a well-described disease inesia, antipsychotic drugs. After a cause for the symptoms has been dyslexia A specific developmental disability that determined, the term dyspepsia is usually dropped alters the way the brain processes written material. Because dyslexia is due to a defect in the brain’s pro- cessing of graphic symbols, it is thought of primarily dysphagia Difficulty swallowing. Dysphagia can among people with dyslexia is that they read at levels compromise nutrition and hydration and may lead significantly lower than are typical for people of their to aspiration pneumonia and dehydration. Dyslexia is different from read- ing retardation which may, for example, reflect men- dysphonia An impairment of the voice. Hoarseness caused by a virus is a com- dyslexia should be directed to the specific learning mon form of dysphonia. The usual course is to modify teaching methods and the educational dysphonia, spasmodic A disorder that involves environment to meet the specific needs of the indi- the muscles of the throat that control speech. The progno- Spasmodic dysphonia causes strained and difficult sis is generally good, however, for individuals whose speaking or breathy and effortful speech. Also dyslexia is identified early, who have supportive fam- known as spastic dysphonia and laryngeal dystonia. Dyslipidemias may be manifested by tion of the retina during embryonic development. A malformed ear, for example, nevi are generally larger than ordinary moles, and is a dysmorphic feature. They are usually flat, but parts may be malformations (birth defects), particularly those raised above the skin surface. Focal dystonia due to blepharospasm is the second most dyspraxia, developmental See developmental common focal dystonia. Only one eye may be affected initially, but eventually both eyes are usually dyspraxia of speech A developmental disability involved. The spasms may leave the eyelids com- characterized by difficulty with muscle control, pletely closed, causing functional blindness even specifically with the muscles involved in producing though the eyes and vision are normal. Treatment involves Uncontrollable blinking may also be caused by tic intensive speech therapy that concentrates on oral- disorders, including Tourette syndrome. Early-onset torsion dystonia is not fatal, but it can be severely dystocia Difficult or abnormal labor or delivery. The jaw may be pulled either open or shut, and speech and dystocia, placental Dystocia characterized by swallowing can be difficult. These symptoms typically start in one part of the body, usu- movements may involve the entire body or only an ally in an arm or a leg, and eventually spread to the isolated area. A form that strikes in childhood is sporadically without any genetic pattern, may be known as idiopathic torsion dystonia, early-onset associated with medications (particularly antipsy- torsion dystonia, and generalized torsion dystonia. Myotonic dys- trophy is also characterized by the development of a dystonia, dopa-responsive See dopa-respon- mask-like, expressionless face, premature balding, sive dystonia. Common focal dystonias that affect dysuria Pain during urination, or difficulty uri- the muscles of the hand and sometimes the forearm nating. Dysuria is usually caused by inflammation of have been called typist’s cramp, pianist’s cramp, musi- the urethra, frequently as a result of infection. The larger of the two sacs, the utriculus, is the principal organ of the vestibular system, which is the system of bal- ance. The smaller of the two sacs, the sacculus, is also connected by a mem- branous tube to the cochlea that contains the organ Ee of Corti. The hair cells, which are the special sen- sory receptors for hearing, are in the organ of Corti. Technically, the mally present in the colon with no harmful ear is low-set when the helix of the ear meets the cra- consequences, it can cause disease when transmit- nium at a level below that of a horizontal plane ted from human to human via water, food, or feces. The presence of two or more minor anomalies compromised immune systems are especially at risk such as this one in a child increases the probability for E. If the styloid process is oversized ear, middle A part of the ear that consists of the or projects too far, the tissues in the throat can rub eardrum (tympanic membrane) and, beyond it, a on it causing pain during the act of swallowing and cavity (tympanum). Diagnosis of Eagle syn- pharynx (nasopharynx) via a canal known as the drome is made by an X-ray demonstrating an abnor- Eustachian tube. The outer, or municates with the pharynx, equilibrates with exter- external, ear helps concentrate the vibrations of air nal pressure, and transmits the eardrum vibrations created by sound onto the eardrum, causing the to the inner ear. These vibrations are transmitted by a chain of little bones in the middle ear to the ear, outer the part of the ear that is visible along inner ear, where they stimulate the fibers of the the side of the head. The presence of two or ear, inner A highly complex structure whose more minor anomalies such as this one in a child essential component for hearing is the membranous increases the probability that the child has a major labyrinth, where the fibers of the auditory nerve malformation. Both of these con- labyrinth is a system of communicating sacs and ditions also feature a very high rate of sensorineural ducts (tubes) filled with fluid (endolymph), and it is hearing loss and ear infections. See also fetal alcohol effect; fetal alco- some points the membranous labyrinth is attached hol syndrome. The bony labyrinth has three parts: a central cavity called the ear piercing the practice of using a needle or vestibule; semicircular canals, which open into the needle gun to make holes through the ear lobe or vestibule; and a spiraling tube called the cochlea. The membranous labyrinth also has a vestibule, Ear piercing can result in inflammation and/or. Infected ear piercings should be washed drum, usually due to bacteria such as streptococcus, and then treated with antibiotic cream. External ear treatment involves either allowing the piercing to infection is usually caused by excessive water expo- close or using only nonirritating jewelry (usually sure. The likelihood of trapped by wax), the skin will become soggy and inflammation and infection is greater for piercings serve as an inviting culture media for bacteria. The that go through hard cartilage, as found on the side first sign of an external ear infection is a feeling of and top of the outer ear, than for the soft bottom fullness and itching in the ear. With severe infection, the ear canal can swell completely shut ear pit A tiny pit in front of the ear, also called and the side of the face can become swollen. This minor anomaly is of no Moisture and irritation will prolong the course of consequence in and of itself. For this reason, the ear should be blacks than in whites, and in females than males. A hearing aid should be left or more minor anomalies such as this one in a child out. However, the presence of two or more puncture may be due to an accident, as when some- minor anomalies such as this one in a child increases thing is stuck into the ear, or due to fluid pressure the probability that the child has a major malforma- in the middle ear.
This registered nurse should have experience and training in obstetric nursing erectile dysfunction treatment las vegas best purchase for sildigra, neonatal nursing erectile dysfunction protocol cheap sildigra 120mg on line, or both erectile dysfunction treatment duration 120 mg sildigra overnight delivery, as well as in the care of patients at high risk erectile dysfunction treatment drugs order genuine sildigra. For antepartum care erectile dysfunction weed order cheapest sildigra, a registered nurse should be responsible for the direc- tion and supervision of nursing care. All nurses working with antepartum patients at high risk should have evidence of continuing education in maternal– fetal nursing. An advanced practice registered nurse who has been educated and prepared at the master’s degree level should be on staff to coordinate education. For intrapartum care, a registered nurse should be in attendance within the labor and delivery unit at all times. This registered nurse should be skilled in the recognition and nursing management of complications of labor and delivery. This registered nurse should be skilled in the recognition and nursing manage- ment of complications in women and newborns. They also should be experienced in caring for unstable neonates with multiorgan system problems and in specialized care technology. The neona- tal nurse provides direct care for the premature or term infant who requires com- plex care, including neonates requiring intensive life-support techniques, such as mechanical ventilation. In these units, the nurse also should be able to provide care for infants requiring inhaled nitric oxide therapy and high-frequency venti- lation as well as care for the chronically technology-dependent infant. An advanced practice registered nurse should be available to the staff for consultation and support on nursing care issues. Additional nurses with special training are required to fulfill regional center responsibilities, such as outreach and transport (see also “Transport Procedure” and “Outreach Education” in Chapter 4). The obstetric and neonatal areas may be staffed by a mix of professional and technical personnel. Assessment and monitoring activities should remain the responsibility of a registered nurse or an advanced practice registered nurse in obstetric–neonatal nursing, even when personnel with a mixture of skills are used. Physician Assistants Trends in neonatal care also have resulted in an increased use of physician assis- tants in addition to advanced practice registered nurses. Physician assistants are health care professionals licensed to practice medicine with physician supervi- sion. Within the physician–physician assistant relationship, physician assistants exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services. A physician assistant’s responsibilities also may include education, research, and administrative services. Physician assistants are educated and trained in programs accredited by the Accreditation Review Commission on Education for the Physician Assistant. The length of physician assistant programs averages approximately 26 months, and students must complete more than 2,000 hours of supervised clinical practice before graduation. Graduation from an accredited physician assistant program and passage of the national certifying examination are required for state licensure. A number of postgraduate physician assistant programs also have been established to provide practicing physician assistants with advanced education or master’s level education in medical specialties. The responsibilities of a physician assistant depend on the practice setting, education, and experience of the physician assistant, and on state laws and 34 Guidelines for Perinatal Care regulations. Support Health Care Providers ^ All Facilities Personnel who are capable of determining blood type, crossmatching blood, and performing antibody testing should be available on a 24-hour basis. The hospital’s infection control personnel should be responsible for surveillance of infections in women and neonates as well as for the development of an appropriate environmental control program (see also Chapter 11, “Infection Control”). A radiologic technician should be available 24 hours per day to per- form portable X-rays. Availability of a postpartum care provider with expertise in lactation is essential. The need for other support personnel depends on the intensity and level of sophistication of the other support services provided. An organized plan of action that includes personnel and equipment should be established for identification and immediate resuscitation of neonates in need of intervention (see also Chapter 8 for information on neonatal resuscitation). Additional medical social workers are required when there is a high volume of medical or psychosocial activity. Education In-Service and Continuing Education the medical and nursing staff of any hospital providing perinatal care at any level should maintain knowledge about and competency in current maternal and neonatal care through joint in-service sessions. These sessions should cover the diagnosis and management of perinatal emergencies, as well as the management of routine problems and family-centered care. The staff of each unit should have regular multidisciplinary conferences at which patient care problems are presented and discussed. The staff of regional centers should be capable of assisting with the in- service programs of other hospitals in their region on a regular basis. Such assistance may include periodic visits to those hospitals as well as periodic review of the quality of patient care provided by those hospitals. The medical and nursing staff of hospitals that provide higher level care (ie, beyond basic and level I) 36 Guidelines for Perinatal Care should participate in formal courses or conferences. Regularly scheduled confer- ences may include the following subjects: • Review of the major perinatal conditions, their medical treatment, and nursing care • Review of electronic fetal monitoring, including maternal–fetal out- comes, toward a goal of standardizing nomenclature and patient care • Review of perinatal statistics, the pathology related to all deaths, and significant surgical specimens • Review of current imaging studies • Review of perinatal complications and outcomes • Review of patient satisfaction data, complaints, and compliments Perinatal Outreach Education Design and coordination of a program for perinatal outreach education should be provided jointly by neonatal and obstetric physicians and advanced practice registered nurses. Responsibilities should include assessing educational needs; planning curricula; teaching, implementing, and evaluating the program; col- lecting and using perinatal data; providing patient follow-up information to referring community personnel; writing reports; and maintaining informative working relationships with community personnel and outreach team members. Ideally, a maternal–fetal medicine specialist, a certified nurse–midwife or certified midwife, an obstetric nurse, a neonatologist, and a neonatal nurse should be members of the perinatal outreach education team. Other profes- sionals (eg, a social worker, respiratory therapist, occupational and physical therapist, or nutritionist) also may be assigned to the team. Each member should be responsible for teaching, consulting with community professionals as needed, and maintaining communication with the program coordinator and other team members. Each subspecialty care center in a regionalized or integrated system may organize an education program that is tailored to meet the needs of the peri- natal health professionals and institutions within the network. The various educational strategies that have been found to be effective include seminars, audiovisual and media programs, self-instruction booklets, and clinical practice rotations. Perinatal outreach education meetings should be held at a routine time and place to promote standardization and continuity of communication among community professionals and regional center personnel. As mandated by the subspecialty boards and the Accreditation Council for Graduate Medical Inpatient Perinatal Care ServicesCare of the Newborn 3737 Education, a facility providing subspecialty care that has a fellowship training program must have an active research program. Support also should be available for at least one ongoing, active quality improvement initiative (see also Chapter 3, “Quality Improvement and Patient Safety”). Physical Facilities the physical facilities in which perinatal care is provided should be conducive to care that meets the unique physiologic and psychosocial needs of newborns and their families (see also “Patient-Centered and Family-Centered Health Care” in Chapter 1). Special facilities should be available when deviations from the norm require uninterrupted physiologic, biochemical, and clinical observa- tion of patients throughout the perinatal period. Labor, delivery, and newborn care facilities should be located in proximity to each other. When these facilities are distant from each other, provisions should be made for appropriate transi- tional areas. The following recommendations are intended as general guidelines and should be interpreted with consideration given to local needs. Individual limi- tations of physical facilities for perinatal care may impede strict adherence to these recommendations. Provisions for individual units should be consistent with a regionalized perinatal care system and state and local public health regu- lations. Obstetric Functional Units the patient’s personal needs, as well as those of her newborn and family, should be considered when obstetric service units are planned. The service should be consolidated in a designated area that is physically arranged to prohibit unre- lated traffic through the service units. The obstetric facility should incorporate the following components of maternity and newborn care: • Antepartum care for patient stabilization or hospitalization before labor • Fetal diagnostic testing (eg, nonstress and contraction stress testing, biophysical profile, amniocentesis, and ultrasound examinations) 38 Guidelines for Perinatal Care • Labor observation and evaluation for patients who are not yet in active labor or who must be observed to determine whether labor has actually begun; hospital obstetric services should develop a casual, comfortable area (“false-labor lounge”) for patients in prodromal labor • Labor • Delivery • Infant resuscitation and stabilization • Postpartum maternal and newborn care Where rooms are suitably sized, located, and equipped, some or all of the components of maternity care listed previously can be combined in one or more rooms. Combining functions into labor, delivery, and recovery rooms maximize economy and flexibility of staff and space. The traditional obstetric program model––with separate rooms for labor, delivery, recovery, and postpartum care––has become obsolete in new construction guidelines, such as the 2010 Guidelines for Design and Construction of Health Care Facilities. The following facilities should be available to both the antepartum unit and the postpartum unit and, in appropriate circumstances, may be shared: • Unit director and head nurse’s office • Nurses’ station • Medical records area with a flat writing surface, computers with access to electronic medical records, or both • Conference room • Patient education area • Staff lounge, locker rooms, and on call sleep rooms • Examination and treatment room(s) • Secure area for storage of medications • Instrument cleanup area • Soiled workroom and holding room • Area and equipment for bedpan cleansing • Kitchen and pantry • Clean workroom or clean supply room • Equipment and supply storage area • Sibling visiting area Inpatient Perinatal Care ServicesCare of the Newborn 3939 the need for care of extremely obese patients is growing for all medical and surgical units in the United States, including maternity units. These patients require more space for antenatal, intrapartum, and postpartum care; staff; and equipment able to support heavier weights. The obstetric department, in conjunction with the hospital administration, should establish written policies according to state and local regulations indicating which nonobstetric patients may be admitted to the labor and delivery suite. Under all circumstances, however, labor and delivery patients must take precedence over nonobstetric patients in this area. Clean gynecologic operations may be performed in the delivery rooms if patients are adequately screened to eliminate infectious cases and if enough personnel are present to prevent any compromise in the quality of obstetric care. Combined Units Comprehensive obstetric and neonatal care is optimally provided for women at both low risk and high risk and their healthy newborns in a labor, delivery, and recovery unit that uses another room for mother–baby postpartum care. Alternatively, care can be provided in a conventional obstetric unit that uses dif- ferent rooms for labor, delivery, recovery, and newborn care. Registered nurses who are cross-trained in antepartum care, labor and delivery care, postpartum care, and neonatal care should staff this unit, increasing the continuity and quality of care. Each labor, delivery, and recovery room is a single-patient room containing a toilet and shower with optional bathtub. A sink should be located in each room for scrubbing, handwashing, and neonate bathing. A window with an outside view is desirable in the labor, delivery, and recovery room. Each room should contain a birthing bed that is comfortable during labor and can be read- ily converted to a delivery bed and transported to the cesarean delivery room when necessary. A des- ignated area within the room, distinct from the laboring woman’s area, should be provided for neonatal stabilization and resuscitation and contain a radiant warmer (see also “Neonatal Functional Units” later in this chapter). Separate oxygen, air, and suction facilities for the woman and the neonate should be provided in two separate locations. Gas outlets and wall-mounted equipment should be easily accessible but may be covered with a panel. Either a ceiling 40 Guidelines for Perinatal Care mount or a portable delivery light may be used, depending on the preference of the obstetric staff. Proper care of the woman in labor requires sufficient space for a sphyg- momanometer, stethoscope, fetal monitor, infusion pump, regional anesthesia administration, and resuscitation equipment at the head of the bed. The family area should be farthest from the entry to the room, and there should be a comfortable area for the support person. Equipment needed for labor, delivery, newborn resuscitation, and newborn care should be stored either in the room or in a nearby central storage or supply area and should be immediately available to the labor, delivery, and recovery room. For ease of movement, space below the foot of the bed should be ade- quate to accommodate staff and equipment brought into the room.
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Early ultrastructural reactions in various parts of the visual analyzer in guinea pigs after thermogenic microwave irradiation vacuum pump for erectile dysfunction in pakistan generic 120 mg sildigra with visa. Modelling the bioelectric behaviour of halo pin-patient structures during magnetic resonance imaging causes of erectile dysfunction young males generic 50mg sildigra visa. Proceedings of the Institution of Mechanical Engineers Part H erectile dysfunction treatment fruits order 50mg sildigra free shipping, Journal of engineering in medicine erectile dysfunction caused by nerve damage purchase sildigra 120 mg overnight delivery. Significance of blood lipid and electrolyte disturbances in the development of reactions to erectile dysfunction medicine name in india best order sildigra microwave exposure. Preterm birth among women living within 600 meters of high voltage overhead Power Lines: a case-control study. Effects of extremely low-frequency pulsed electromagnetic fields on morphological and biochemical properties of human breast carcinoma cells (T47D). Cellular phone use and risk of benign and malignant parotid gland tumors-a nationwide case-control study. A 12-week clinical and instrumental study evaluating the efficacy of a multisource radiofrequency home-use device for wrinkle reduction and improvement in skin tone, skin elasticity, and dermal collagen content. Interferences in the everyday life of the patient with a cardiac pacemaker or an implantable defibrillator. Thermal mapping on male genital and skin tissues of laptop thermal sources and electromagnetic interaction. Epidemiological and laboratory studies of power frequency electric and magnetic fields. Electromagnetic Fields, Pulsed Radiofrequency Radiation, and Epigenetics: How Wireless Technologies May Affect Childhood Development. Cohort and nested case-control studies of hematopoietic cancers and brain cancer among electric utility workers. Viral contacts confound studies of childhood leukemia and high-voltage transmission lines. A simple solution for electrocardiographic artifacts during cardiopulmonary bypass and in the intensive care unit. Effects of 50 Hz magnetic field exposure on human heart rate variability with passive tilting. A study of heart rate and heart rate variability in human subjects exposed to occupational levels of 50 Hz circularly polarised magnetic fields. Initial clinical experiences with rescue unipolar radiofrequency thermal balloon angioplasty after abrupt or threatened vessel closure complicating elective conventional balloon coronary angioplasty. Power- frequency magnetic fields and childhood brain tumors: a case-control study in Japan. Concerns about sources of electromagnetic interference in patients with pacemakers. In vivo studies of the effect of magnetic field exposure on ontogeny of choline acetyltransferase in the rat brain. Intermediate frequency magnetic field at 23kHz does not modify gene expression in human fetus-derived astroglia cells. The influence of electromagnetic interference and ionizing radiation on cardiac pacemakers. Phase I clinical study of a static magnetic field combined with anti-neoplastic chemotherapy in the treatment of human malignancy: initial safety and toxicity data. A pilot study with very low-intensity, intermediate-frequency electric fields in patients with locally advanced and/or metastatic solid tumors. Altered operant behavior of adult rats after perinatal exposure to a 60-Hz electromagnetic field. Effect of extremely low frequency electromagnetic field on brain histopathology of Caspian Sea Cyprinus carpio. Treatment of refractory pain after brachial plexus avulsion with dorsal root entry zone lesions. Neurophysiological effects of flickering light in patients with perceived electrical hypersensitivity. International journal of psychophysiology: official journal of the International Organization of Psychophysiology. Comparison of symptoms experienced by users of analogue and digital mobile phones. Successful treatment of respiratory dyskinesia with picoTesla range magnetic fields. Application of weak electromagnetic fields facilitates sensory-motor integration in patients with multiple sclerosis. Paroxysmal itching in multiple sclerosis during treatment with external magnetic fields. The biological significance of yawning elicited by application of electromagnetic fields in multiple sclerosis. The Effects of Electromagnetic Field on the Endocrine System in Children and Adolescents. Adverse and beneficial effects in Chinese hamster lung fibroblast cells following radiofrequency exposure. Tidsskrift for den Norske laegeforening: tidsskrift for praktisk medicin, ny raekke. 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If carrier testing is to erectile dysfunction quality of life 100mg sildigra amex be done on the basis of ethnicity only erectile dysfunction how can a woman help buy cheap sildigra 100mg line, it is rea- sonable to erectile dysfunction icd 9 2014 order sildigra 100 mg fast delivery offer this to impotence low testosterone generic 25 mg sildigra overnight delivery the preconception or pregnant woman first and then test the father only if the mother is positive erectile dysfunction chicago buy sildigra 100 mg low price. If testing is being con- sidered on the basis of an affected relative, offer it to the family member of the affected individual first. Table 5-4 includes recommendations for genetic testing based solely on a patient’s ethnic identity. Fetuses with aneuploidy may have major anatomic mal- formations that often are discovered during an ultrasound examination that is performed for another indication. Abnormalities involving a major organ or structure, with a few notable exceptions, or the finding of two or more minor structural abnormalities in the same fetus indicate increased risk of fetal aneuploidy. Women should be counseled regarding the differences between screening and invasive diagnostic testing. Regardless of which screening tests your patients are offered, information about the detection and false-positive rates, advantages, disadvantages, and limita- tions, as well as the risks and benefits of diagnostic procedures, should be available to patients so that they can make informed decisions. In couples in which the male partner is 45 years or older, counseling also should address the increased risk of new onset autosomal dominant disorders (such as neurofibromatosis or Marfan syndrome) that are associated with increased paternal age. Some patients may benefit from a more extensive discussion with a genetics professional or a maternal–fetal medicine spe- cialist, especially if there is a family history of a chromosome abnormality, genetic disorder, or congenital malformation. Laboratories that report aneuploidy screening test results gener- ally provide the physician with numerical information regarding the patient’s revised risk of aneuploidy using maternal age, the serum ana- lyte levels, and nuchal translucency measurement if available as well as other factors, such as maternal weight, diabetes status, and ethnicity. Down syndrome screening in the first and/or second trimester: model predicted performance using meta-analysis parameters. It is often useful to contrast this risk with the general population risk and their age-related risk before screening. There are many strategies available to screen for chromosomal abnor- malities (Table 5-5). The choice of screening test depends on many factors, including gestational age at first prenatal visit, number of fetuses, previous obstetric history, family history, availability of nuchal translucency measurement, test sen- sitivity and limitations, risk of invasive diagnostic procedures, desire for early test results, and reproductive options. The goal is to offer screening tests with high detection rates and low false-positive rates that also pro- vide patients with the diagnostic options they might want to consider. Ideally, patients seen early in pregnancy can be offered first-trimester aneuploidy screening or integrated or sequential aneuploidy screening that combines first-trimester and second-trimester testing. The options for women who are first seen during the second trimester are limited to quadruple (or “quad”) screening and ultrasound examination. When a first-trimester screening test is performed and followed by a separate second-trimester screening test, the results are interpreted inde- pendently and there is a high Down syndrome detection rate (94–98%); however, the false-positive rates are additive, leading to many more unnecessary invasive procedures (11–17%). For this reason, women who have had first-trimester screening for aneuploidy should not undergo independent second-trimester serum screening in the same pregnancy. Instead, women who want a higher detection rate can have an integrated or a sequential screening test, which combines both first-trimester and second-trimester screening results. The integrated approach to screening uses both the first-trimester and second-trimester markers to adjust a woman’s age-related risk of having a child with Down syndrome. The results are reported only after both first-trimester and second-trimester screening tests are completed. Integrated screening best meets the goal of screening by providing the highest sensitivity with the lowest false-positive rate. The lower false- 124 Guidelines for Perinatal Care positive rate results in fewer invasive tests and, thus, fewer proce- dure-related losses of normal pregnancies. The possibility that patients might fail to complete the second-trimester portion of the screening test after per- forming the first-trimester component is another potential disadvantage because the patient would be left with no screening results. Sequential screening has a high detection rate of integrated screening but identifies very high-risk patients early in gestation, after the first- trimester component of the testing. In the stepwise sequential screening women determined to be at high risk (Down syndrome risk above a pre- determined cutoff) after the first-trimester screening are offered genetic counseling and the option of invasive diagnostic testing, and women below the cutoff are offered second-trimester screening. The sequen- tial approach takes advantage of the higher detection rate achieved by incorporating the first-trimester and second-trimester results with only a marginal increase in the false-positive rate. Neural tube defect screening may include second-trimester serum alpha-fetoprotein screen- ing, targeted second-trimester ultrasonography, or both. Patients with abnormal first-trimester serum markers or an increased nuchal translucency measurement also may be at increased risk of an adverse pregnancy outcome, such as spontaneous fetal loss before 24 weeks of gestation, fetal demise, low birth weight, or preterm birth. At the present time, there are no data indicating whether or not fetal surveil- lance in the third trimester will be helpful in the care of these patients. Amniocentesis may be recommended to confirm the presence of open defects or to obtain a fetal karyotype. Under ideal circumstances, second-trimester ultrasonography will detect approximately 100% of anencephaly and 95% of spina bifida anomalies. In the woman who chooses to have a diagnostic test for aneuploidy, rather than a screening, there are two primary options: 1) Chorionic villus sampling and 2) amniocentesis. It generally is performed between 10 weeks and 12 weeks of gestation, either by a transabdominal or a transcervical approach. This well-established, safe, and reliable procedure usually is offered between 15 weeks and 20 weeks of gestation. Many large, multicenter studies have confirmed the safety of genetic amniocentesis as well as its cytogenetic diagnostic accuracy (greater than 99%). Complications include transient vaginal spotting or amniotic fluid leakage in approximately 1–2% of all cases and chorio- amnionitis in less than 1 in 1,000 cases. Early amniocentesis performed from 11 weeks to 13 weeks of ges- tation has been widely studied, and the technique is similar to tradi- tional amniocentesis; however, performing early amniocentesis results in significantly higher rates of pregnancy loss and complications than performing traditional amniocentesis. For these reasons, early amnio- centesis (at less than 14 weeks of gestation) should not be performed. Chorionic villus sampling should not be performed in women who are red cell antibody sensitized because it may worsen the antibody response. Psychosocial Risk Screening and Counseling Psychosocial issues are nonbiomedical factors that affect mental and physical well-being. Screening for psychosocial risk factors may help predict a woman’s attentiveness to personal health matters, her use of prenatal services, and the health status of her offspring. Such screening should be done for all pregnant women and should be performed regardless of social status, educational level, race, and ethnicity. The reason for this is that past obstetric events and infant outcomes, medical considerations in a current pregnancy, beliefs about and experience with breastfeeding, and family circumstances (among other factors) influence the experience of labor, delivery, and early neonatal and postpartum adjustment. Additionally, some women experience social, economic, and personal difficulties in pregnancy. Given the sensitive nature of psychosocial assessment, every effort should be made to screen patients in private. Even then, patients may not be comfortable discussing problems with physicians until a trusting relationship has been formed. Other clinical staff may be trained to provide this screening, with results communicated to the physician. Preconception and Antepartum Care 127 Addressing the broad range of psychosocial issues with which pregnant women are confronted is an essential step toward improving women’s health and birth outcomes. An effective system of referrals will be helpful in augmenting the screening and brief intervention that can be carried out in an office setting. Although some psychosocial issues are present before pregnancy, others arise during the course of pregnancy or may not be disclosed early on. To increase the likelihood of successful interventions, psychosocial screening should be performed on a regular basis and documented in the patient’s prenatal record. Screening should include assessment of patients’ desire for pregnancy, tobacco use, substance use, depression, safety, intimate partner violence, stress, barriers to care, unstable housing, communication barriers, and nutrition. When screening is completed, every effort should be made to identify areas of concern, validate major issues with the patient, provide information, and, if indicated, make suggestions for possible changes. Screening positive for a con- dition often necessitates a referral to resources outside the practice for further evaluation or intervention. Physicians should be aware of individuals and com- munity agencies to which patients can be referred for additional counseling and assistance when necessary. If the patient indicates that the pregnancy is unwanted, she should be fully informed in a balanced manner about all options, including raising the child herself, placing the child for adoption, and abortion. The health care professional should make every effort to avoid introducing personal bias. Some patients may feel more comfortable having a discussion of this type with someone who is not involved with their ongoing medical care. The physician should evaluate the patient’s available psychosocial support and refer her to appropriate counseling or other supportive services. Physicians often may best fulfill their obligations to patients through referral to other professionals who have the appropriate skills and expertise to address these difficult issues. All pregnant women should be screened at their first prenatal visit about their past and present use of tobacco, alcohol, and other drugs, including the recreational use of prescription and over-the- counter medications and herbal remedies. Use of validated screening question- naires, along with the assurance of confidentiality improves patient–physician communication and may increase the veracity of patient responses. If a woman 128 Guidelines for Perinatal Care acknowledges the use of tobacco, alcohol, cocaine, opioids, amphetamines, or other mood-altering drugs or if chemical dependence is suspected, she should be counseled about the perinatal implications of their use during pregnancy and offered referral to an appropriate treatment program. To reinforce and encourage continued abstinence, periodic health care provider follow-up is important. With the patient’s consent, drug or metabolite testing may be indicated for a pregnant woman who reports substance use before or during pregnancy. Testing of the mother, the neonate, or both also may be indicated in some clinical situations, including the presence of unexplained intrauterine growth restriction, third-trimester stillbirth, unexpected preterm birth, or abruptio placentae in a woman not known to have hypertensive dis- ease. Because positive test results have implications for patients that transcend their health, patients should give informed consent before testing. The require- ments for consent to test vary from state to state, and practitioners should be familiar with the testing and the reporting requirements in their states. Inquiry into tobacco use and smoke exposure should be a routine part of the prenatal visit. Multiple studies have demonstrated a clear associa- tion between maternal smoking and perinatal morbidity and mortality. This includes intrauterine growth restriction, placenta previa, abruptio placentae, preterm premature rupture of membranes, low birth weight, perinatal mortality, ectopic pregnancy, and sudden infant death syn- drome. Children born to mothers who smoke during pregnancy are at increased risk of asthma, infantile colic, and childhood obesity. Secondhand prenatal exposure to tobacco smoke also increases the risk of having an infant with low birth weight by as much as 20%. Preventive Services Task Force has concluded that the use of nicotine replacement products or other pharmaceuticals for smoking cessation aids during pregnancy and lactation have not been sufficiently evaluated to determine their efficacy or safety. Therefore, the use of nicotine replacement therapy should be undertaken with close supervi- sion and after careful consideration and discussion with the patient of the known risks of continued smoking and the possible risks of nicotine replacement therapy. If nicotine replacement is used, it should be with the clear resolve of the patient to quit smoking.