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These drugs decrease latency time to falling asleep best order provera menstruation occurs when there is a decrease in, reduce awakenings provera 2.5mg generic women's health center keokuk iowa, and increase total sleeping time order provera once a day menstrual exercises. Seizure Disorders Four benzodiazepines—diazepam, clonazepam, lorazepam, and clorazepate—are employed for seizure disorders. Muscle Spasm One benzodiazepine—diazepam—is used to relieve muscle spasm and spasticity (see Chapter 20). Alcohol Withdrawal Diazepam and other benzodiazepines may be administered to ease withdrawal from alcohol (see Chapter 31). Benefits derive from cross-dependence with alcohol, which enables benzodiazepines to suppress symptoms brought on by alcohol abstinence. Adverse Effects Benzodiazepines are generally well tolerated, and serious adverse reactions are rare. Central Nervous System Depression When taken to promote sleep, benzodiazepines cause drowsiness, lightheadedness, incoordination, and difficulty concentrating. Anterograde Amnesia Benzodiazepines can cause anterograde amnesia (impaired recall of events that take place after dosing). If patients complain of forgetfulness, the possibility of drug-induced amnesia should be evaluated. Sleep Driving and Other Complex Sleep-Related Behaviors Patients taking benzodiazepines in sleep-inducing doses may carry out complex behaviors and then have no memory of their actions. Reported behaviors include sleep driving, preparing and eating meals, and making phone calls. Because of the potential for harm, benzodiazepines should be withdrawn if sleep driving is reported. To minimize withdrawal symptoms, dosing should be tapered slowly, rather than discontinued abruptly. Paradoxical Effects When employed to treat anxiety, benzodiazepines sometimes cause paradoxical responses, including insomnia, excitation, euphoria, heightened anxiety, and rage. Hence, in contrast to the barbiturates, benzodiazepines present little risk as vehicles for suicide. It must be emphasized, however, that although respiratory depression with oral therapy is rare, benzodiazepines can cause severe respiratory depression when administered intravenously. The behavior pattern that constitutes “addiction” is uncommon among people who take benzodiazepines for therapeutic purposes. When asked about their drug use, individuals who regularly abuse drugs rarely express a preference for benzodiazepines over barbiturates. Use in Pregnancy and Lactation Benzodiazepines are highly lipid soluble and can readily cross the placental barrier. Use of benzodiazepines during the first trimester of pregnancy is associated with an increased risk for congenital malformations, such as cleft lip, inguinal hernia, and cardiac anomalies. Because they may represent a risk to the fetus, most benzodiazepines are classified in U. Four of these drugs—estazolam, flurazepam, temazepam, and triazolam—are in Category X. Women of childbearing age should be warned about the potential for fetal harm and instructed to discontinue benzodiazepines if pregnancy occurs. Benzodiazepines enter breast milk with ease and may accumulate to toxic levels in the breastfed infant. Other Adverse Effects Occasional reactions include weakness, headache, blurred vision, vertigo, nausea, vomiting, epigastric distress, and diarrhea. Rarely, benzodiazepines may cause severe allergic reactions, including angioedema and anaphylaxis. Drug Interactions Benzodiazepines undergo very few important interactions with other drugs. Unlike barbiturates, benzodiazepines do not induce hepatic drug-metabolizing enzymes. Hence, although benzodiazepines are very safe when used alone, they can be extremely hazardous in combination with other depressants. Tolerance and Physical Dependence Tolerance With prolonged use of benzodiazepines, tolerance develops to some effects but not to others. No tolerance develops to anxiolytic effects, and tolerance to hypnotic effects is generally low. Physical Dependence Benzodiazepines can cause physical dependence—but the incidence of substantial dependence is low. When benzodiazepines are discontinued after short-term use at therapeutic doses, the resulting withdrawal syndrome is generally mild and often goes unrecognized. Withdrawal from long-term, high- dose therapy can cause more serious reactions, such as panic, paranoia, delirium, hypertension, muscle twitches, and seizures. Symptoms of withdrawal are usually more intense with benzodiazepines that have a short duration of action. Because the benzodiazepine withdrawal syndrome can resemble an anxiety disorder, it is important to differentiate withdrawal symptoms from the return of the original symptoms of anxiety. The intensity of withdrawal symptoms can be minimized by discontinuing treatment gradually. Substituting a benzodiazepine with a long half-life for one with a short half-life is also helpful. After discontinuation of treatment, patients should be monitored for 3 weeks for indications of withdrawal or recurrence of original symptoms. Acute Toxicity Oral Overdose When administered in excessive dosage by mouth, benzodiazepines rarely cause serious toxicity. If an individual known to have taken an overdose of benzodiazepines does exhibit signs of serious toxicity, it is probable that another drug was taken, too. Preparations, Dosage, and Administration Preparations and dosages for insomnia are presented later in the chapter. Preparations and dosages of benzodiazepines used for other disorders are presented in Chapters 19, 20, and 28. When used for sedation or induction of sleep, benzodiazepines are almost always administered by mouth. Oral Patients should be advised to take oral benzodiazepines with food if gastric upset occurs. Also, they should be instructed to swallow sustained-release formulations intact, without crushing or chewing. Patients should be warned not to increase the dosage or discontinue therapy without consulting the prescriber. For treatment of insomnia, benzodiazepines should be given on an intermittent schedule (e.
Scarring under the vestibular mucosa occurs created a laterally based chondrocutaneous flap consisting of rarely trusted 10 mg provera womens health jackson ms, after procedures such as lateral crural strut placement part of the medial crus purchase provera with american express menstruation 3 times a month, the dome discount 2.5mg provera visa women's health clinic minneapolis, and all of the lateral crus and lower lateral cartilage repositioning where the vestibular with the underlying mucosa and vestibular skin coverage. In skin has been dissected free from the undersurface of the lower repositioning the medial edge of the chondrocutaneous flap lateral cartilages. Guyuron found the The modern adaptation, also known as the “Lipsett maneu- distance between the footplates ranged from 7. This procedure will provide further strength to the Unilateral flaired footplates will detract from the overall medial crus due to the overlap. It is important to distinguish Prior to excision of the cartilages, the natural dome is identified caudal septal deflection from footplate flare, which can be and marked. When overlapping cartilages, precise amount of done easily by palpation on physical exam. The overlap takes place with footplate is often associated with a deflection of the caudal septum. The suture will reinforce the medial crus, providing strength to stabilize and sometimes increase projection. For medialization to last, the soft tissue from the footplate and the posterior septum is divided, creating a potential space into which the footplates can be sutured. Guyuron found that divergent footplates were often associated with retracted columellar base and spine and that approximation without resection of soft tissue led to narrowing of the columella base with caudal advancement. The divided footplate then may be reconfigured with a suture across the columella or completely removed. The horizontal mat- tress suture should be placed so that the overlapping cartilagi- nous segments act as a fortified singular unit of cartilage, free from any interfragmentary motion. The cartilage should be separated from the underlying vestibular mucosa and the knot should be tied away from the vestibular skin and cut without a tail to minimize the risk of suture extrusion. Identifying patients with specific var- iant anatomy (for example, “hooked nose” or flared footplate) will allow an appropriate surgical solution to take place. Cartilage-splitting techniques can be performed with either an open or endonasal technique. However, open techniques maximize visualization and allow easy exposure for these techniques. Division of the lower lateral cartilages requires precision and introduces another variability of healing in the patient’s surgi- cal outcome. However, in the patient with the overly long lat- eral, medial, or intermediate crura, it is a powerful technique that eﬀectively and reproducibly corrects aesthetic flaws. Cartilage-splitting techniques, maligned for many years, are now a necessary tool in the successful rhi- noplasty surgeon’s armamentarium. These The nasal tip refers to the paired lower lateral cartilages, mechanisms are described as major and minor. The caudal aspect of the nasal septum that is principally relevant to tip projection is the anterior septal angle. A firm articulation at this Mechanisms point is essential, as cephalic rotation of the posterior septal Major nasal tip support mechanisms include (1) fibrous attach- angle, as can occur after disruption and incomplete reattach- ment of the alar cartilages (cephalic border) to the upper lateral ment after septoplasty, will lead to loss of tip support and pro- cartilages (caudal cartilage); (2) size, shape, and resilience of jection. Each lateral crus makes up one Mechanisms lateral limb, with the paired medial limbs making the central Minor nasal tip support mechanisms include (1) cartilaginous limb. Conceptually it interdomal ligament; (5) sesamoid complexes of lower lateral helps to illustrate how lengthening the medial limb in isolation cartilages; and (6) attachment of lower lateral cartilages to will project the tip; shortening of all three limbs will retrodis- overlying skin and soft tissue envelope. Although crude, the tripod theory aids in conceptualizing the relationship between tip projection 36. For many years, In its simplest form, the concept of nasal tip projection refers to the tripod theory of the nasal tip, as described by Anderson, the anteroposterior extent to which the nasal tip is separated has provided us with a basic model on which to visualize the from the facial surface at the level of the alar-facial groove. However, this model can be criticized for oversimplifying Furthermore, alteration, either through increasing, decreas- nasal tip surgery, which we know to be quite complex and ing, or preservation of nasal tip projection, will have eﬀects challenging. Perhaps it is fair to say that it does not acknowl- on nasal tip rotation, dorsal height, and nasofacial aesthetic edge the three-dimensional unit that is the nasal lobule and harmony. In several patients undergoing rhinoplasty, nasal tip therefore does not allow us to fully appreciate the secondary projection will be adequate, and it is essential to preserve or eﬀects on tip rotation associated with certain maneuvers, reconstruct the tip support mechanisms to prevent loss of tip nor the secondary changes on the columella, alar margin, or projection postoperatively. Another line perpendicular to this between the alar sulcus and nasal tip is drawn, with a final line connecting the nasion to nasal tip. Three points are utilized: A (projection of nasal tip from nasion-alar line), B (nasion), and C (nasal tip). Normal tip projec- tion has been defined as 2:1, giving a nasofacial angle of 42 degrees. A modification of Baum’s ratio was made by Powell and Humphries to extend the ratio to 8:1 with a Fig. However, it is not suffi- It must be remembered that all these methods apply to Cau- cient to simply just determine whether or not you need to casian patients. There is significant variation in these objective modify the degree of nasal projection without also considering measures of “normality” for diﬀerent cultures and ethnicities. So when structur- The majority of cosmetic rhinoplasties will involve either reduction of an overprojected nasal tip or maintenance of the intrinsic degree of projection. Most commonly, overprojection of the nasal tip is due to alar cartilage overdevelopment, either as an entire structure or of the individual lateral, intermediate, or medial components. When the whole alar complex is enlarged, it often creates the eﬀect of extremely large and dis- proportionate nostrils. Overdevelopment of the caudal septum may result in an overprojecting nose, and hypertrophy of the nasal spine may exacerbate this deformity. The well-described tension nose deformity usually results from involvement of the anterior and posterior septal angles and the caudal aspect of the septum. Interestingly, the lower lateral cartilages may be normal in size, hypertrophied, or even underdeveloped. The overdeveloped quadrangular cartilage creates a pedestal eﬀect spuriously pushing the lower lateral cartilages forward. The resultant tension nose deformity tents the tip away from the face, tethers the upper lip, and blunts the nasolabial angle Iatrogenic overprojection may occur from overaggressive attempts to increase tip projection. Often this is due to borrow- ing the lateral crura through an interrupted strip technique to Fig. It must be remembered, however, that tip projection is only one parame- ter, and one must allow for changes in tip rotation or shape of the alar cartilages. Surgical techniques for nasal projection have evolved from those often described as destructive to those favored for sparing the integrity of the alar cartilage. Several diﬀerent techniques involving cartilage prepositioning, cartilage cutting, and suturing, as well as tip grafting are described here. When we consider the tripod model, lengthening the central limb and thus raising this point requires changing the position of the medial crura.
On examination she is ﬂushed generic 10mg provera fast delivery breast cancer volunteer opportunities, has a tachycardia of 100 bpm generic 10 mg provera visa menstrual blood smell, and has a tem- perature of 38°C buy provera toronto breast cancer survival rate. Speculum examination reveals a ﬂorid ectropion with contact bleeding on taking swabs. On speculum examination there is a thick, white discharge adherent to the vaginal walls. Several children in her class have ‘slapped cheek syndrome’ at the start of term and when she comes to hospital for her routine anomaly scan her baby is found to be hydropic. Answer [ ] 46 03:11:03 06 47 Curriculum Module 4 Management of Labour and Delivery Syllabus You will be expected to have the knowledge, understanding, and judge- ment to be capable of initial management of intrapartum problems in a hospital and in a community setting. You will need to demonstrate appropriate knowledge of regional anaesthesia, analgesia, and operative delivery including caesarean section. This part of the exam will be much easier if you have worked on a labour ward since you were a medical student. In the last pregnancy she had a very slow ﬁrst stage of labour and got stuck at 9 cm dilatation. The baby was in the occipito-posterior position, but there was no evidence of cephalo-pelvic disproportion. Which of these factors increases the chances of rupture of the uterine scar during labour? A primigravid woman whose baby is in the occipito-posterior position at the start of labour B. A woman with an otherwise uncomplicated pregnancy who has had a successful external cephalic version E. The woman refuses to give consent for the operation and the midwife looking after her thinks that she may be confused on account of her high temperature. Use the Mental Health Act to justify proceeding with caesarean delivery Answer [ ] 4. Halfway through the ﬁrst stage of labour the patient has become increasingly distressed and is complaining of severe abdominal pain. The pain continues between contractions, which are occurring every 3 minutes and the midwife has noticed that the uterus is tender and hard on palpation. The inexperienced student midwife hands you a selection of drugs to choose from to try and stop the uterine bleeding. Which of the following pregnant women does not need a cannula when she is admitted? A woman who had a forceps delivery for fetal distress in her previous pregnancy E. A woman who had an emergency caesarean for fetal distress in her last pregnancy Answer [ ] 4. The obstetric anaesthetist is keen for her to have an epidural inserted thereby avoiding a general anaesthetic if emergency delivery becomes necessary later. Which of the following procedures may help the birth attendants deliver the baby in this life-threatening situation? Postpartum haemorrhage Answer [ ] Extended Matching Questions A Amniotomy B Elective caesarean section C Electronic fetal monitoring D Emergency caesarean section E Intermittent auscultation F Request a clotting screen G Routine elective episiotomy H Titrated synthetic Oxytocin infusion I Vaginal examination in theatre with the operating team standing by J Ventouse delivery The following clinical scenarios apply to women delivering in a hospital obstet- ric unit. Her membranes have just ruptured spontaneously and fresh meconium is seen in the liquor. The uterus is nontender and the baby is well grown with a cephalic presentation, four-ﬁfths palpable. The condition of both mother and baby is stable but she is contracting strongly every 3 minutes and the blood continues to trickle from the vagina. She mobilises in her labour room using nitrous oxide for analgesia and 4 hours later the cervix is 7 cm dilated. The midwife is auscultating the baby’s heartbeat, which has been 70 bpm for 5 minutes. The mother’s pulse is 90, her blood pressure is stable, and the cervix is 8 cm dilated. She collapses in the waiting room, and when you attend to sort out the situation she appears confused and is asking where she is. Earlier, in antenatal clinic she was found to have a breech presentation conﬁrmed by scan and is await- ing a consultant outpatient appointment arranged for tomorrow. On admis- sion she experiences spontaneous rupture of membranes and the cervix is found to be 6 cm dilated. The placenta is still in situ and the midwife tells you that she has just noticed a large amount of blood in the bed. Both mother and baby are stable at the moment, but the haematology technician has just contacted you to say that the clotting screen you sent to the lab an hour ago is not normal. Her blood pressure has dropped to 70/40 and she has become unre- sponsive to questions. During the last 15 minutes the woman started bleeding heavily and so far has lost 3 litres of blood. The consultant obstetrician has been called and the 2 units of blood stored on the labour ward have already been transfused. In each scenario, choose the most appropriate immediate action that you think the obstetric team (not necessarily you personally) should take. You are asked to site an intravenous cannula whilst the midwife removes the pessary. Although the contractions lessen in frequency to 3 in 10 minutes, the baby becomes bradycardic and you can hear that the fetal heart rate has been running at 90 bpm for 4 minutes so far. The liquor is clear and intermittent auscultation of the fetal heart is reassuring. The cervix is now 8 cm dilated and the baby appears to be lying in the occipito-posterior position. On examination it is apparent that the second twin is lying transversely in the uterus. The midwife has noted meconium in the liquor and there are late decelerations on the cardiotocograph. The woman has asked for more analgesia and the midwife says that she is becoming more and more uncooperative. Answer [ ] A Abruption of the placenta B Cervical laceration C Disseminated intravascular coagulation D Placenta accreta E Placenta praevia F Retained succenturiate lobe of placenta G Rupture of the uterus H Uterine atony I Vasa praevia J Velamentous insertion of the cord Given the clinical information provided, select the most likely diagnosis for each of these obstetric patients experiencing vaginal bleeding. The mid- wife points out to you that there are blood vessels running through the membranes. Despite her epidural she seems to be in a great deal of pain and there are unmistakeable signs of severe fetal distress on the cardiotocograph. Her ﬁrst baby was delivered by caesarean section because of fetal distress related to chorioamnionitis at 6 cm dilatation in the ﬁrst stage.