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The assessment uses Gram stain and determines semiquantitatively Table 3 Scoring system (0–10) for Gram-stained vaginal smears* (b) Gardnerella and Lactobacillus Bacteroides spp generic toradol 10 mg with mastercard. Curved Gram- Score† morphotypes morphotypes variable rods 0 4+ 0+ 0 1 3+ 1+ 1+ or 2+ 2 2+ 2+ 3+ or 4+ 3 1+ 3+ 4 0+ 4+ *Morphotypes are scored as the average number seen per oil immersion field discount toradol 10 mg mastercard. Note that less weight is given to curved Gram-variable rods buy toradol 10mg line. The majority of women with • Treatment: see Table 4 cheap toradol 10 mg amex. Moreover they are not found as a infection might lead to a higher risk of VVC cheap toradol 10mg on-line. Nevertheless, studies have confirmed that the trans- Vulvovaginal candidiasis Vulvovaginal candidiasis mission of Candida organisms by vaginal sexual (VVC) has traditionally not been considered to be intercourse and other forms of sexual activity also a STI because it occurs in celibate women and occurs17. Table 4 Overview of common infections and treatment suggestions Infection Treatment Vaginitis Bacterial vaginosis Metronidazole 2 g orally (single dose) or Trichomoniasis Metronidazole 500 mg orally twice a day for 7 days Candidiasis (yeast) Miconazole 200 mg vaginal suppository, once a day for 3 days or Clotrimazole 100 mg vaginal tablets, 2 times a day for 3 days or Fluconazole 150 mg oral tablet (single dose) or Nystatin 100,000 units, vaginal tablets once a day for 14 days Cervicitis Gonorrhea Cefixime 400 mg orally (single dose) or Ceftriaxone 125 mg, by intramuscular injection or Spectinomycin 2 g by intramuscular injection Chlamydia Azithromycin 1 g orally (single dose) or Doxycycline 100 mg orally twice a day for 7 days (Pregnant women: azithromycin 1 g orally (single dose) or erythromycin 500 mg 4 times a day for 7 days) Pelvic inflammatory Treat for gonorrhea and chlamydia (see above) plus for anaerobic infections with disease (PID) Metronidazole 500 mg orally twice a day for 7 days or Ampicillin 2 g by intravenous or intramuscular injection, then 1 g every 6 h plus Gentamicin 80 mg by intramuscular injection every 8 h plus Metronidazole 500 mg or 100 ml by intravenous infusion every 8 h Genital ulcers Syphilis Benzathine penicillin G 2. A reliable and sensitive rapid test • Fungal elements can be confirmed by micros- is still under development. Gram staining of copy (simple saline preparation – wet mount). Among women, only culture on • Treatment: see Table 4. Most people contract the disease Chlamydia Chlamydial infection is cause by Chlamy- after a single exposure to an infected person. Symptoms are often unspecific trichomoniasis is accompanied by BV. The infec- and the infection presents with mild clinical tion may in particular cause premature rupture of manifestations. Differential diagnosis of vaginitis Where it is not poss- ible to confirm trichomoniasis, candidiasis or BV Pelvic inflammatory disease by microscopic diagnosis, the country-specific syn- dromic approach guidelines should be followed. PID is caused by microorganisms colonizing the endocervix and ascending to the endometrium and Cervicitis fallopian tubes. It is a clinical diagnosis implying that the patient has upper genital tract infection and Gonorrhea Gonorrhea is caused by Neisseria gonor- inflammation. The inflammation may be present at rhoeae a Gram-negative diplococcus. While the any point along a continuum that includes endo- clinical features of gonococcal urethritis in men are metritis, salpingitis and peritonitis. PID is normally a urethral discharge, often profuse, and dysuria, caused by sexually transmitted microorganisms such as N. A tubo- ovarian abscess is the end-stage of the disease. Many patients present with mild symptoms or no symptoms at all. Tubo-ovarian abscess Figure 4 Trichomnas vaginalis (wet mount). On ultrasound large masses in the ovaries can be seen and free fluid in Douglas’ pouch. If in doubt aspiration of this fluid will distinguish pus from blood (see Chapter 12 on ectopic pregnancy). Drainage with a Foley cath- eter and posterior culdotomy is explained in Chapter 18 (HIV-related gynecological prob- lems). If the symptoms persist a laparotomy with drainage might become necessary. Differential diagnosis of PID The diagnosis and therapy of PID is particularly difficult because often the PID progresses unnoticed and symptoms are minor Figure 5 Gonococcal ophthalmia neonatorum. Lower abdom- Dr Ron Ballard, US Centers for Disease Control and inal pain can also be caused by many other diseases Prevention such as endometriosis, benign and malign ovarian cysts, adnexal torsion or ectopic pregnancy. In addition patients suffering from infertility or marital problems might present with lower abdominal pain, and are often over-treated with antibiotics. Ophthalmia neonatorum Ophthalmia neonatorum might present with bi- or unilateral swollen eyelids with purulent discharge caused by N.

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Oral antihyperglycemic therapy for type 2 diabetes: scientific review order toradol 10mg with mastercard. Progress with thiazolidinediones in the management of type 2 diabetes mellitus purchase 10mg toradol free shipping. Type 2 diabetes generic toradol 10 mg with mastercard, cardiovascular risk buy cheap toradol 10mg, and the link to insulin resistance discount toradol 10 mg on line. Thiazolidinediones and blood lipids in type 2 diabetes. A systematic review of the clinical effectiveness of pioglitazone in the treatment of type 2 diabetes mellitus. Comparative clinical and budget evaluations of rosiglitazone and pioglitazone with other anti-diabetic agents. Ottawa Canadian Coordinating Office for Health Technology Assessment. A meta-analysis comparing the effect of thiazolidinediones on cardiovascular risk factors. Czoski-Murray C, Warren E, Chilcott J, Beverley C, Psyllaki MA, Cowan J. Clinical effectiveness and cost-effectiveness of pioglitazone and rosiglitazone in the treatment of type 2 diabetes: a systematic review and economic evaluation. Thiazolidinediones and the risk of edema: a meta- analysis. Benefits and harms of antidiabetic agents in patients with diabetes and heart failure: systematic review. Congestive heart failure and cardiovascular death in patients with prediabetes and type 2 diabetes given thiazolidinediones: a meta-analysis of randomised clinical trials. Factors associated with the effect-size of thiazolidinedione (TZD) therapy on HbA(1c): a meta-analysis of published randomized clinical trials. Thiazolidinediones and risk of repeat target vessel revascularization following percutaneous coronary intervention: a meta-analysis. Richter B, Bandeira-Echtler E, Bergerhoff K, Clar C, Ebrahim SH. Effect of thiazolidinedione therapy on restenosis after coronary stent implantation: a meta-analysis of randomized controlled trials. Thiazolidinediones Page 95 of 193 Final Report Update 1 Drug Effectiveness Review Project 53. Long-term risk of cardiovascular events with rosiglitazone: a meta-analysis. Thiazolidinediones and heart failure: a teleo-analysis. Dipeptidyl peptidase-4 (DPP-4) inhibitors for type 2 diabetes mellitus. A randomized, placebo-controlled trial assessing the effects of rosiglitazone on echocardiographic function and cardiac status in type 2 diabetic patients with New York Heart Association Functional Class I or II Heart Failure. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. Rosiglitazone evaluated for cardiovascular outcomes--an interim analysis. Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial. Efficacy of rosiglitazone and pioglitazone compared to other anti-diabetic agents: systematic review and budget impact analysis (Structured abstract). Pioglitazone and risk of cardiovascular events in patients with type 2 diabetes mellitus: a meta-analysis of randomized trials. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. Padwal R, Majumdar SR, Johnson JA, Varney J, McAlister FA.

It is Drug–drug interactions are defined as the effects of therefore important to know the most common ad- one drug changing the effects of another drug order 10mg toradol visa. In verse reactions possible and pay particular attention general it is a negative effect but there are cases to serious adverse reactions buy toradol 10mg with mastercard. Patients need to be where the interaction has a desirable effect discount toradol 10 mg without prescription. Inter- monitored not only for therapeutic effect but also actions may be pharmaceutical generic toradol 10mg, pharmacokinetic or for any other effects 10mg toradol otc. A typical example for this case would be the prophylactic prescription Pharmacokinetic and pharmacodynamic interactions of anti-emetic drugs for chemotherapy. Table 1 provides examples of relevant drug–drug Adverse reactions occurring above the normal dos- interactions but is not meant to be an exhaustive age range are called toxic reactions. Give drugs at least 2 h apart Coumarin derivatives (e. Antacid preparations containing aluminum, Decreased absorption and decreased efficacy doxycycline) magnesium or calcium salts, iron of tetracyclines. If combination necessary, preparations, milk give the products at least 2 h apart Oral contraceptives Decreased contraceptive efficacy Methotrexate Increased methotrexate toxicity Ciclosporin Increased ciclosporin toxicity Coumarin derivatives (e. Alcohol and drugs depressing the central Increasing depression of central nervous phenobarbital) nervous system system Coumarin derivatives Decreased anti-coagulation Contraceptives Decreased contraceptive efficacy Methotrexate Increased methotrexate toxicity Benzodiazepines (e. Alcohol and drugs depressing the central Increasing depression of central nervous diazepam) nervous system system Cimetidine Increased benzodiazepine effects Muscle relaxants Increased muscle relaxation Cont. Pharmaceutical interactions saline, administer the drug, rinse the connection again and reconnect the initial infusion. Physico-chemical reactions may occur between drugs in solution. These potential interactions are Examples: important to keep in mind for parenteral drug • Loss of potency of benzylpenicillin or ampicillin therapy. The stability and efficacy of a drug may be in dextrose solutions after 6–8 h. DRUGS IN PREGNANCY AND These incompatibilities are not necessarily LACTATION visible. To avoid problems, do not combine drugs in intravenous fluids. As an alternative, many drugs Drugs may have adverse effects on the pregnancy can be given through an infusion set with a two- or the fetus. Any drug therapy in pregnancy should way connector (Y-connector). To administer a be avoided if possible and should be given accord- second drug without the risk of an interaction, stop ingly only after establishing a strict indication for the infusion, rinse the connection with normal the therapy. Adverse effects can be caused by a 460 Management of Low-cost Drugs and Equipment direct effect on the fetus after crossing the placental Prescribing drugs in pregnancy barrier or they can occur in relation to physio- • Establish the need for drug therapy: is there an logical changes in the mother’s body. The follow- urgent indication for the treatment of the ing distinctions are made: mother? Do the benefits for the mother out- • Genotoxic drugs: these drugs affect embryonic weigh a potential risk for the fetus? However, the drug therapy the second and third trimester. CYP450 is a group of may have to be adapted, for example if possible key enzymes for the elimination of many drugs. Overview of effects of drugs in pregnancy and lactation What to do in cases of suspected exposure to a teratogenic drug • Drugs affecting the female reproductive system. Second establish as clearly as possible the time of • Drugs affecting labor. For example, the drug may be acceptable if needed in a life-threatening situation or serious disease for which safer alternatives cannot be used or are ineffective X Adequate well-controlled or observational studies in animals or pregnant women have demonstrated a positive evidence of fetal abnormalities or risks. The use of the drug is contraindicated in women who are or may become pregnant. Do not use in 3rd products drugs trimester of pregnancy Analgesics Paracetamol Aminoglycoside Fetal toxicity Anti-histaminic Diphenhydramine, dimenhydrinate, antibiotics drugs clemastine Chloramphenicol Grey syndrome Antibiotics Penicillins, cephalosporins, clinda- Tetracyclines Affect bones and teeth mycin, erythromycin Carbamazepine Increased risk for spina bifida Anti-asthmatic Beta2-sympathomimetics drugs (e. If using a drug with known adverse effects on the infant is unavoidable, consider interrupting breastfeeding for the period of medication: show the mother risks for the fetus, i. Further action will depend on a thorough risk evaluation. The risk SAFE HANDLING OF CYTOTOXIC DRUGS level of drugs in pregnancy is commonly indicated using the system shown in Table 2.

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A OBSTETRIC FISTULAE small number of patients will have Sheehan’s syn- Despite much debate safe toradol 10 mg, there is no universally drome – anterior pituitary necrosis due to prolonged accepted system of classification purchase 10 mg toradol visa. The resultant decrease in follicle- standable trusted toradol 10 mg, because so much of the assessment is stimulating hormone (FSH) and luteinizing hormone subjective discount 10mg toradol overnight delivery. For a classification to be worthwhile trusted 10mg toradol, it (LH) leads to amenorrhea. Asherman’s syndrome – should enable surgeons to communicate with each scarring of the endometrium by either repeated in- other and even consider clinical trials. Most sur- fections or perhaps urine in the endometrial cavity geons base their classification on simple descriptive – is another cause. These women may have normal terms involving three factors: hormone levels, but the endometrium will be un- responsive to them. Finally, there may be crypto- • Site menorrhea, or hidden menses, if the cervical canal is • Size stenosed leading to hematometra. Fistula site Juxta-urethral Reproductive outcomes The female urethra is approximately 3. For the above reasons, the potential for successful The commonest site of damage is at the urethro- pregnancy in women with obstetric fistulae is quite vesical junction, about 3–4cm from the external low. Only about 20% of post-repair patients will meatus (Figures 2a–c). In this situation they are achieve a term pregnancy. If a patient does become often referred to as juxta-urethral fistulas. Mild pregnant, she has a high chance of a miscarriage or ischemia will produce just a simple hole, but pro- prematurity. This is because of an incompetent longed ischemia will cause circumferential tissue cervix. The anterior lip is frequently torn so badly loss with the urethra and bladder becoming sepa- that it will not be able to hold a pregnancy to term. Others have vaginal stenosis that is severe enough to preclude intercourse. Mid-vaginal Small defects 4cm or more from the external Other causes of urinary incontinence not directly urethral orifice are not very common, but are the related to obstructed labor simplest to repair. Larger defects may involve much In war-torn countries sexual violence is a tragic of the urethra and extend back as far as the cervix cause of genital tract injuries. In these cases the 237 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS (a) (e) (b) (f) (c) (g) (d) Figure 2 (a) Common sites of injury. The most common site is from the residual bladder which may be greatly re- mid-vagina. Scar is the big enemy – any fistula with duced in size. Bare bone is exposed at the back of significant scarring is not for a beginner. Classification systems Juxta-cervical There are two published systems that are com- These are fistulae in the region of the cervix that monly used, introduced by Judith Goh and Kees are more frequent in multiparous patients and Waaldijk. Both have some limitations and though in those delivered by cesarean section. Sometimes, attempting to be as simple as possible may still be the defect extends into the cervical canal where the confusing to beginners. They are described in anterior cervical canal is completely missing or torn Appendix 2. These fistulae may result from a vertical tear when assessing a fistula are described in the opera- in the lower segment and an associated bladder tive section. PROGNOSIS Intra-cervical The factors affecting the prognosis for closure and Intra-cervical fistulae, i. There may be a history of a live baby, suggesting an iatrogenic cause (Figure 2g).

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Bleeding episodes are epinephrine effective 10mg toradol, and arachidonic acid order toradol 10mg amex. The aggregation response to treated with platelet transfusions in patients with platelet-type high-dose ristocetin is usually normal buy toradol 10 mg lowest price, but may be reversible in VWD order toradol 10mg, whereas VWF concentrates are chosen for patients with type some cases toradol 10 mg with mastercard. IIb 3 Velocardiofacial syndrome (VCFS) is an inherited disorder charac- Platelet aggregation studies and genetic analysis are preferred for terized by abnormal pharyngeal arch development. Palatal abnormalities, craniofacial defects, cardiac Other platelet surface receptor deficiencies are very rare, and abnormalities, hypotonia, defective thymic development, and im- majority of these defects have no significant hemostasis in hu- mune deficiency are common features of the syndrome. GPVI (collagen receptor) deficiency is reported only 6 caused by a microdeletion located on chromosome 22q11. The patients with bleeding diathesis (2 with compound heterozygous platelet receptor GPIb gene is located in the same chromosome mutations, 4 with homozygous mutations). These patients may have macrothrombocytopenia and decreased aggregation with Miscellaneous ristocetin, as seen in heterozygous BSS carriers. The GATA-1 gene is VCFS may require major surgery for their anomalies and this carrier located on the X-chromosome and encodes GATA-1 protein, which state may increase the bleeding risk. GATA-1 plays an important role in the development erythroid and megakaryocytic Glanzmann thrombasthenia cells. Several mutations have been described in GATA-1, resulting GT is an autosomal-recessive bleeding disorder characterized by a in platelet abnormalities (dysmegakaryopoiesis, thrombocytopenia, defective platelet integrin IIb 3 receptor. The integrin IIb 3 (GP large or small platelets, -granule deficiency) and dyserythropoietic IIb-IIIa) receptor is abundantly expressed on platelets: 80 000 anemia with different clinical severity. Increased hemoglobin A2, copies are found on the surface of each platelet. The receptor is a persistence of hemoglobin F, and unbalanced production of - and heterodimer consisting of IIb and 3 subunits found in an inactive -globulin synthesis may cause a “beta-thalassemia-like pheno- state in resting platelets. After platelet activation, inside-out signal- type” in some patients. It has been shown to be associated with the development of 8. Recommendations for acute megakaryoblastic leukemia and transient myeloproliferative the standardization of light transmission aggregometry: a disorder in patients with Down syndrome. Published Familial platelet disorder with propensity to myeloid malig- online ahead of print April 10, 2013. Familial platelet disorder with propensity to myeloid 9. Glycoprotein analysis for the diagnostic evaluation malignancy is an autosomal-dominant disorder characterized by of platelet disorders. Hematopoietic stem cell transplantation using a with platelet traits and platelet disorders. Semin Thromb sibling known to be negative for RUNX1 mutations is the only Haemost. Watson SP, Lowe GC, Lordkipanidze M, Morgan NY; GAPP consortium. Genotyping and phenotyping of platelet function Wiskott-Aldrich syndrome. Inherited disorders of platelets: protein gene (WASp) mutations. WAS protein regulates actin membrane glycoprotein disorders. Hematol Oncol Clin North filament reorganization in hematopoietic cells and regulates lympho- Am. Leissinger C, Carcao M, Gill JC, Journeycake J, Singleton T, different phenotypes: WAS, X-linked thrombocytopenia, and X- Valentino L. Desmoppressin (DDAVP) in the management of linked neutropenia. The classic or severe WAS is characterized by patients with congenital bleeding disorders. In microthrombocytopenia, eczema, and susceptibilities to infections, press. Currently, the only curative therapy is the improves recruitment of activated platelets to collagen but allogeneic hematopoietic stem cell transplantation if a matched simultaneously increases platelet endothelial interactions in donor is available.

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