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Women who are symptomatic may present with a non-specifc illness such as rash (erythema infectiosum) buy generic super avana pills erectile dysfunction labs, fever super avana 160mg overnight delivery impotence and diabetes, fatigue, lymphadenopathy and arthralgia (afects 80% of adults and 10% of children). The risk of fetal loss is around 10% if the mother is positive for IgM and these mostly occur 4–6 weeks from the onset of maternal symptoms or infection. Interpretation of serology results • The presence of IgM antibodies indicates recent infection. Management of women infected with parvovirus infection • The mother can be treated symptomatically. If the primary infection occurs within 6 weeks of the expected date of delivery or at the time of labour, a caesarean section should be recommended. Tese include avoiding artifcial rupture of membranes, fetal blood sampling and fetal scalp electrode insertion. The risks versus benefts of the procedure should be discussed with the woman in conjunction with the fndings on ultrasound examination. The fetus may acquire the virus 105 but may not manifest until later in life afer birth as shingles. Tey should choose an alternative destination for travel unless unavoidable and also should seek advice from a specialist with current experience of malaria. The choice of drug chemoprophylaxis in pregnant women depends on the resistance of Plasmodium falciparum and Plasmodium vivax to chloroquine and trimester of pregnancy. The use of this drug in frst trimester should be considered only afer discussion with a specialist. Women should be advised about the symptoms (fu-like illness and raised temperature) and treated as emergency if malaria is suspected. If a dose is vomited within 30 minutes, the full dose should be repeated and if the dose is vomited afer 30–60 minutes, half the dose should be repeated. The treatment should be fnished and mefoquine should be commenced 1 week afer the last treatment dose. The treatment in such cases includes: • oral quinine 600 mg 8 hourly and oral clindamycin 450 mg 8 hourly for 7 days (can be given together); or • riamet 4 tablets/dose for weight >35 kg, twice daily for 3 days (with fat); or • atovaquone-proguanil (Malarone) 4 standard tablets daily for 3 days. It can afect bone growth and cause permanent discoloration of the teeth in fetus when given in the 3rd trimester. The symptoms include headache, fever with chills, nausea, vomiting, diarrhoea, coughing and general malaise. The signs of malaria can be raised temperature, splenomegaly, jaundice, pallor, sweating and respiratory distress. Microscopic diagnosis allows species identifcation and estimation of parasitaemia. Pregnant women with 2% or more parasitized red blood cells are at higher risk of developing severe malaria and should be treated with the severe malaria protocol. Malariae • Primaquine use avoided in pregnancy • Involving infectious disease specialists, especially for severe and recurrent cases • If vomiting persists, oral therapy should be stopped and intravenous therapy should be instituted • Treatment of the fever with antipyretics • Screening for anaemia and treat appropriately • Arranging follow up to ensure detection of relapse 18E: False – Vomiting is a known adverse efect of quinine and is associated with malarial treatment failure. If the vomiting is persistent even afer administration of antiemetics, then parenteral therapy is recommended. The requirement is 1 mg/day in frst trimester, 4–5 mg/day in second trimester and more than 6 mg in third trimester. This increase in stroke volume is responsible for increase in cardiac output by 10–20 weeks’ gestation. This is why cardiac output levels fall almost to near normal non-pregnant values at term. It is a common complication of pregnancy that is associated with signifcant maternal and perinatal morbidity and mortality. Mild disease can be treated conservatively (observation, regular blood tests and antihypertensives). Severe pre-eclampsia would need delivery afer stabilization of the woman (control of blood pressure, prevention of seizures and delivery of the fetus). Pre-eclampsia afects 3% of pregnant women and out of these only 10% will develop severe pre-eclampsia. If a woman has a history of pre-eclampsia, giving aspirin (75 mg daily) would reduce the risk of pre-eclampsia from 30 to 15% in the next pregnancy. Oxytocin should be used routinely in the second stage of labour in women with epidural. A delayed second stage of labour is when the active second stage has lasted more than 2 hours in nulliparous and more than 1 hour in multiparous women. She had a previous emergency caesarean section 3 years ago for undiagnosed breech in labour. The risk of uterine rupture is 10 times higher if the labour is induced or augmented. Question 4 Reduced fetal movement is associated with the following risk factors except: A. Small for gestational age Question 5 With respect to the management of gestational hypertension in a G2 para 1 woman with a blood pressure of 145/96 mm Hg and no proteinuria at 35 weeks’ gestation, which one of the following is the correct next step of management? Induction of labour at 37 weeks’ gestation Question 6 A 35-year-old nulliparous woman at 36 weeks’ gestation was diagnosed with pre-eclampsia. Disseminated intravascular coagulation 112 Question 7 Which one of the following is true with regard to obstetric cholestasis? Typically presents in second trimester Question 8 Which one of the following statements regarding analgesia in labour is true? Intermittent auscultation of the fetal heart rate is acceptable for women using epidural analgesia. Oxytocin should be routinely used in the second stage of labour for women with epidural analgesia. Question 9 A 38-year-old woman presents to the maternity day assessment unit with a history of swollen feet, headache and blurring of vision at 30 weeks’ gestation. Severe pre-eclampsia Question 10 A 30-year-old woman presents to the labour ward with uterine contractions at 37 weeks’ gestation. Oxytocin can be used for labour augmentation in cases of poor progress of labour 113 Question 11 Which of the following statements regarding bladder care is false? Pregnant women should be encouraged to empty their bladder every 2–4 hours during labour to minimize the risk of retention of urine. If the woman is unable to pass urine afer 4 hours, an in-and-out catheter should be used to empty the bladder. If repeat catheterization is required during labour, then one should consider inserting a Foley catheter. If the woman has difculties in emptying her bladder during or afer labour, or requires a catheter, this is an indication for transfer from home to hospital for assessment.

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Some argue that the low meningitis incidence purchase 160mg super avana reflexology erectile dysfunction treatment, especially in early-onset disease buy genuine super avana on line impotence and depression, does not warrant routine cerebral spinal fluid testing; rather, the test should be reserved for documented (positive cultures) or presumed (patients so sick that a full antibiotic course is to be given regardless of culture results) sepsis. Urinary tract infection is uncommon in the first few days of life, and urinalysis or culture is usually not included in early-onset disease workup. Chest radiologic findings include segmental, lobar, or diffuse reticulogran- ular patterns, the latter easily confused with respiratory distress syndrome (lack of surfactant). Pathogens The organisms that commonly cause early-onset sepsis colonize in the mother’s genitourinary tract and are acquired transplacentally, from an ascending infection or as the infant passes through the birth canal. For the hos- pitalized infant, bacteria sources include vascular or urinary catheters or contact with health care workers. Group B Streptococcus is the most common cause of neonatal sepsis from birth to 3 months. Approximately 80% of cases occur as early-onset disease (septicemia, pneumonia, and meningitis) resulting from vertical transmission from mother to infant during labor and delivery. Respiratory signs (apnea, grunting respirations, tachypnea, or cyanosis) are the initial clinical findings in more than 80% of neo- nates, regardless of the site of involvement, whereas hypotension is an initial find- ing in approximately 25% of cases. Other signs are similar to those associated with other bacterial infections described earlier. The association of early antibiotic use with increased risk of late-onset serious bacterial infections remains under study. Symptoms often occur between 7 and 30 days of life but can occur up to 3 to 4 months of age. For infants presenting with convinc- ing signs and symptoms of sepsis, antibiotics may be continued even with negative cultures. For infants with positive cultures, therapy continues for 10 to 21 days depending on the organism and the infection site. One of the signs of infection in the newborn population is hyperbilirubinemia, along with other findings of temperature instability, poor feeding, lethargy, etc. Birth weight is 4000 g, and Apgar scores were 6 and 9 at 1 and 5 minutes, respectively. The mother noticed the baby has had decreased feeding over the pre- vious few days and has been sleeping more. Which of the following is the most appropriate initial choice of antibiotics for this infant? Young maternal age, low birth weight, rupture of membranes greater than 18 hours, initial Apgar less than 5, and maternal fever are additional risk factors for sepsis. The best initial treatment in this age group is broad-spectrum antibiotics such as ampicillin and cefo- taxime. Health care providers have immediate difficulty in determining whether the infant is a boy or girl. There appear to be small scrotal sacs that resemble enlarged labia and no palpable testes, with either a microphallus and hypospadias or an enlarged clitoris. Describe factors that influence gender assignment in infants with ambiguous genitalia. Considerations This neonate with sexual ambiguity represents a psychosocial emergency. Upon proper gender assignment for rearing and appropriate medical management, indi- viduals born with ambiguous genitalia should be able to lead well-adjusted lives and satisfactory sex lives. Gen- der assignment in the neonate born with sexual ambiguity should be influenced by the possibility of achieving unambiguous and sexually useful genital structures. Clear and comprehensive discussions with the parents, focusing on their understanding, anxieties, and religious, social, and cultural beliefs, are critical for an appropriate gender assignment. Once gender is assigned, it should be reinforced by appropriate surgical, hormonal, and psychological measures. An endocrinologist, clinical geneticist, urologist, and psychiatrist are essential members of the intersex evaluation team. The goals of the evaluation are to determine the etiology of the intersex problem, assign gender, and intervene with surgical or other treatment as soon as possible. Assessment After obtaining a careful history, a family pedigree should be constructed to identify consanguinity and to document cases of genital ambiguity, infertility, unexpected pubertal changes, or inguinal hernias. A thorough physical examination is crucial in determining the diagnosis and making the most reasonable gender assignment. A critical physical finding is the presence or absence of a testis in a labioscrotal compartment. Karyotype analysis using activated lymphocytes is an important first step in the laboratory evaluation of infants with ambiguous genitalia. Results with a high degree of accuracy typically can be available in less than 48 hours. Laparoscopy usually is not necessary in the newborn because primary emphasis is placed on the external genitalia and the possibilities for adequate sexual function in assigning gender. Treatment The major treatment consideration for infants with ambiguous genitalia is the possibility of achieving functionally normal external genitalia by surgical and hor- monal means, with judicious emphasis on cosmetic appearance. Because the pres- ence of ambiguous external genitalia may reinforce doubt about the sexual identity of the infant, reconstructive surgery is performed as early as medically and surgi- cally feasible, usually before 6 months of age. Feminizing genitoplasty is the most common surgical procedure performed in female pseudohermaphrodites, in true hermaphrodites, and in male pseudohermaphrodites reared as females. The goal of this surgery is to reduce the size of the clitoris while maintaining vascularity and innervation, feminizing the labioscrotal folds, and ultimately creating a vagina. Because of the high incidence of gonadal tumors in individuals with certain forms of gonadal dysgenesis, gonadectomy performed concurrently with the initial repair of the external genitalia is mandatory. A male with hypospadias often requires mul- tiple procedures to create a phallic urethra. Circumcision is avoided in these individu- als because the foreskin tissue is commonly used for reconstruction. Hormone substitution therapy in hypogonadal patients is prescribed so that secondary sexual characteristics develop at the expected time of puberty. Oral estrogenic hormone substitution is initiated in females, and repository injec- tions of testosterone are given to males. With the exception of some female pseu- dohermaphrodites and true hermaphrodites reared as females, disorders that cause ambiguous genitalia usually lead to infertility. Which of the following is the most likely expla- nation for the child’s ambiguous genitalia? Physical examination reveals a lethargic infant who has lost 250 g since birth, with pulse of 110 beats/min, dry oral mucosa, and no skin tur- gor. Which of the following serum levels should be checked after hemodynamic stabilization and electrolyte measurement?