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Fetal Scalp Stimulation

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141. Factor IX (Overview)

, hematologists, and neonatologists in the United States for the treatment of pregnant carriers and newborns with hemophilia and intracranial hemorrhage (ICH) showed that more than 94% of the major facilities reviewed had no written guidelines. Survey findings led to the following recommendations [ , ] : Vacuum devices and fetal scalp monitors should not be used during vaginal delivery of known carriers of hemophilia All infants with intracranial hemorrhage should be evaluated for a bleeding disorder, Women (...) express TF only when stimulated by serine proteases, such as thrombin, and by inflammatory cytokines. In vivo, under physiologic conditions, only a trace amount of FVII is present in the activated form (activated factor VII [FVIIa] of approximately 1%). When TF becomes available, it complexes with FVII or FVIIa, and current concepts support the view that activation of FIX to FIXa is more rapid with the TF-FVII complex than with activated factor XI (FXIa). [ ] The activation peptide for FIX

2014 eMedicine.com

142. Erythrocyte Alloimmunization and Pregnancy (Overview)

and at 28 weeks gestation. Pending fetal blood type, the patient should also receive Rhesus Immunoglobulin following delivery. [ ] Fetal hydrops. Ultrasound image of edema of the scalp and face in a hydropic fetus. Additionally, advancements in fetal surveillance and treatment have allowed for successful outcomes for most affected fetuses. This article reviews the pathophysiology, diagnosis, and management of erythrocyte Rh D alloimmunization and includes a discussion of rarer erythrocyte antigens. Next (...) from white individuals, and agglutination was observed in 85% of the samples (Rh D positive). The remaining 15% of the samples were Rh D negative; this finding corresponds remarkably to the currently known prevalence of Rh D–negative blood type in whites. Following this discovery, Levine determined that hemolytic disease of the fetus and newborn was usually caused by Rh incompatibility (ie, the fetal stimulation of Rh D antibody development in an Rh D–negative woman). In 1953, Chown verified

2014 eMedicine.com

143. Teratology and Drug Use During Pregnancy (Overview)

, have performed many studies in this area. Specific drugs should be investigated before they are used. Risk-benefit assessment and counseling should involve the patient in the setting of her current state of health. The physician must consider the effects of drug exposure on the developing fetus or embryo and acknowledge specific susceptibilities at each point in fetal development, as balanced against the risks of worsening maternal illness. The patient must consider her symptoms, quality of life (...) exposures may alter the size, shape, performance, and production of sperm. This observation suggests that drug exposure in the male may put the fetus at risk. Animal studies have shown that paternal teratogenic exposure may lead to pregnancy loss or failure of the embryo to develop. However, unlike teratogenic agents taken by pregnant woman, teratogenic agents affecting the father do not seem to directly interfere with normal fetal development. Animal studies show that paternal teratogenic exposure may

2014 eMedicine.com

144. Surgical Treatment of Tremor (Overview)

, dopaminergic) The target area is well defined (ie, striatum) Postsynaptic receptors are relatively intact The neurons provide tonic stimulation of the receptors and appear to serve a modulatory function In double-blind studies, neither transplantation of autologous adrenal medullary cells nor transplantation of fetal porcine cells has been found to be effective; both have been abandoned. Although open-label studies of fetal dopaminergic cell transplantation yielded promising results, 3 randomized, double (...) physiologically. Medtronics Activa Tremor control system consists of 3 components: (1) stimulating lead, which is implanted to desired target; (2) extension cable, which is tunneled under scalp and soft tissues of neck to anterior chest wall; and (3) pulse generator, which is programmable source of electrical impulses. Stereotactic headframe is applied at start of surgery. MRI-localizing box is attached to frame only during targeting MRI. Localizer defines working volume of frame and provides reference

2014 eMedicine.com

145. Abnormal Neonatal EEG (Treatment)

it difficult to interpret EEG results, which can discourage the use of EEG testing. Given the close relationships between certain morphological aspects of the developing brain and EEG results, gestational age can be reliably estimated (to ±1 wk) by EEG criteria. In fact, CNS development of the immature brain proceeds at about the same rate during fetal development as in the postnatal environment. The physiological substrate for these early EEG patterns is unknown, but is probably derived from cortical (...) generators that are strongly influenced by subcortical (primarily thalamic) afferent input. Rapid maturation of these structures (and not the corpus callosum) is most likely responsible for the interhemispheric synchrony that occurs close to full-term gestational age; in particular, rapid dendritic spine development and synaptogenesis are typical of the last month of fetal development. The complex development of cerebral sulci during this same period is probably responsible for the neonatal EEG results

2014 eMedicine.com

146. Anabolic Steroid Use and Abuse (Treatment)

present in females in small amounts. Due to the negative feedback system, the release of LH and FSH decline, leading to a decrease in estrogens and progesterone. AAS use by a pregnant woman can cause pseudohermaphroditism or virilization in the female fetus or may even cause fetal death. The American College of Obstetricians and Gynecologists (ACOG) includes anabolic steroids in the list for routine substance-abuse-disorder screening. Healthcare professionals are encouraged to address the use (...) negative feedback inhibition upon gonadotropin-releasing hormone (GnRH). Since GnRH stimulates follicle-stimulating hormone (FSH) and LH release in the pituitary, this negative feedback can be seen to inhibit subsequent testosterone production and effect spermatogenesis. Testosterone activity is mediated via an androgen receptor that is present in various tissues throughout the human body. Testosterone binds to an intracellular receptor found in the cytosol of cells, forming a receptor complex

2014 eMedicine.com

147. Dermatologic Manifestations of Hematologic Disease (Treatment)

criteria) for definite APS. The criteria, developed by consensus among international clinical and laboratory experts, were originally referred to in 1999 as the Sapporo criteria [ ] and then modified at a meeting in Sydney in 2006. [ ] The primary diagnostic criteria include arterial thrombosis, venous thrombosis, recurrent fetal loss, and thrombocytopenia. One of the listed primary criteria is required for diagnosis, combined with a sustained elevated titer of immunoglobulin G (IgG) anticardiolipin (...) . [ ] According to the Cooperative Study of Sickle Cell Disease, approximately 25% of patients with sickle cell disease in the United States have a history of active ulcers or developed ulcers during the 8 years of observation. The incidence is low in children younger than 10 years because of the protective effect of persistent fetal hemoglobin. Other risk factors for developing leg ulceration are anemia, male sex, combined HLA-B35 and HLA-Cw4, and antithrombin III deficiency. Based on clinical experience

2014 eMedicine.com

148. Dermatologic Manifestations of Cardiac Disease (Treatment)

Clubbing (Hypertrophic Osteoarthropathy) Definition represents a localized drumsticklike swelling of the distal segments of fingers and toes, particularly over the extensor surface. It is caused by connective tissue proliferation leading to increases in the sponginess of the soft tissue at the base of the nails due to stimulation by a humoral substance that causes dilation of the vessels of the fingertip or toe tip. [ ] Differential diagnosis Clubbing, as illustrated below, is seen in persons (...) is observed in some infants born to mothers with . This may be due to various factors, such as fetal myocarditis, idiopathic hemorrhage and necrosis involving conduction tissue, degeneration and fibrosis related in some instances to the transplacental passage of anti-Ro/ss-A antibody, and other immune complexes from mothers. Neonatal lupus erythematosus and its dermatologic manifestations were reviewed by Neiman et al. [ ] They studied 47 mothers (83% white) whose sera contained anti-SSA/Ro, anti-SSB/La

2014 eMedicine.com

149. Childhood HIV Disease (Treatment)

weeks old Unfortunately, antepartum treatment is not without risk to the fetus. In a study of HIV-negative infants born to HIV-positive mothers, Lipshultz et al concluded that fetal exposure to ART was associated with various cardiac effects, including reduced left ventricular (LV) dimension, LV mass, and septal wall thickness z-scores, as well as increased LV fractional shortening and contractility up to age 2 years. [ ] These effects are more pronounced in girls than in boys Exposure to ART (...) Flucytosine Amphotericin Sulfonamides Trimethoprim, trimethoprim-sulfamethoxazole Pyrimethamine Pentamidine Infectious agents such as parvovirus B19 can cause myelosuppression, as can invasive neoplastic processes of the marrow. Granulocyte-macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF) are used to treat neutropenia and to promote granulocyte production and function. GM-CSF has more adverse effects than G-CSF, and it promotes viral replication. However, GM

2014 eMedicine.com

150. Androgenetic Alopecia (Treatment)

. [ ] Finasteride Finasteride is given orally and is a 5-alpha reductase type 2 inhibitor. [ ] It is not an antiandrogen. The drug can be used only in men because it can produce ambiguous genitalia in a developing male fetus. Finasteride has been shown to diminish the progression of androgenetic alopecia in males who are treated, and, in many patients, it has stimulated new regrowth. Although it affects vertex balding more than frontal hair loss, the medication has been shown to increase regrowth in the frontal (...) minizones on the scalp. Measurements of the hair growth, density, diameter, pigmentation, and anagen/telogen ratio were performed throughout the study. At 24 weeks, an increase in hair density was noted at the latanoprost-treated site compared with baseline and the placebo site. They concluded that this medication could be useful for stimulating hair follicle activity and treating hair loss. [ ] Androgenetic alopecia is very common; therefore, not surprisingly, it may accompany other forms of hair loss

2014 eMedicine.com

151. Common Pregnancy Complaints and Questions (Treatment)

fetal movement and delay maternal detection of fetal movements. As the fetus grows larger, the fetal movement feelings become stronger, regular, and easier to detect. While there is no absolute number that indicates fetal well-being, typical guidance may include that fetuses should move approximately 4 times an hour as they get larger, and some clinicians advise patients to count fetal movements to follow fetal well-being. What kind of breast changes are normal during pregnancy? Pregnancy-related (...) the fetal head and the maternal pelvis. Relaxin was also thought to loosen pelvic ligaments when secreted from the ovaries, contributing to enlargement of the pelvis, but this is not proven in human pregnancies. The symphysis pubis can enlarge from about 3-4 mm in nulliparas to about 4.5 mm (or as much as 8 mm) in multiparas, but during gestation itself the average separation is about 7-8 mm. When is fetal movement usually felt? Most women feel the beginnings of fetal movement before 20 weeks' gestation

2014 eMedicine.com

152. Benign Vulvar Lesions (Treatment)

is evidently a substantial predisposing factor because lesions occur in areas of the skin where sebaceous glands are most active, such as the face, scalp, body folds, and, less commonly, the genitalia. Seborrheic dermatitis is commonly observed in neonates during the early months of life (as a result of sebaceous gland activation by maternal androgens) or after puberty. An association with Pityrosporum yeasts has been noted. Neurologic factors have also been thought to play a role; emotional stress (...) , Parkinson disease, nerve injury, and syringomyelia have been related to onset or worsening of the disease. Seasonal factors, zinc deficiency, and HIV infection have been linked to this disorder. Psoriasis Psoriasis is a hereditary disorder of the skin that affects approximately 2% of the population in the Western world. The characteristic silver-white scales on erythematous plaques are caused by rapid cell turnover and primarily occur in sites of repetitive trauma, such as the scalp, elbows, forearms

2014 eMedicine.com

153. Autoimmune Thyroid Disease and Pregnancy (Treatment)

association exists between MMI and fetal scalp defects, aplasia cutis, and choanal and/or esophageal atresia. Some studies have reported a positive association between the two and others reported no association, which may be due to the fact that the studies showing no association were underpowered or did not assess outcomes at the optimal ages. [ ] Additionally, PTU has recently been shown to increase the risk of malformations, usually milder than those with MMI, but a change from one to the other has (...) before attempting pregnancy. For ablative therapy, TSI titers tend to increase and remain elevated for many months. A pregnancy test should be performed 48 hours before the iodine radiation ablation to avoid radiation exposure to the fetus. Conception should be delayed for 6 months postablation to allow time for the dose of T4 to be adjusted to obtain target values for pregnancy (serum TSH between 0.3 and 2.5 mIU/L). If the patient chooses thioamide drugs (ATD therapy), propylthiouracil (PTU) should

2014 eMedicine.com

154. Erythrocyte Alloimmunization and Pregnancy (Treatment)

and at 28 weeks gestation. Pending fetal blood type, the patient should also receive Rhesus Immunoglobulin following delivery. [ ] Fetal hydrops. Ultrasound image of edema of the scalp and face in a hydropic fetus. Additionally, advancements in fetal surveillance and treatment have allowed for successful outcomes for most affected fetuses. This article reviews the pathophysiology, diagnosis, and management of erythrocyte Rh D alloimmunization and includes a discussion of rarer erythrocyte antigens. Next (...) from white individuals, and agglutination was observed in 85% of the samples (Rh D positive). The remaining 15% of the samples were Rh D negative; this finding corresponds remarkably to the currently known prevalence of Rh D–negative blood type in whites. Following this discovery, Levine determined that hemolytic disease of the fetus and newborn was usually caused by Rh incompatibility (ie, the fetal stimulation of Rh D antibody development in an Rh D–negative woman). In 1953, Chown verified

2014 eMedicine.com

155. Paraneoplastic Diseases (Treatment)

have papillomatous thickening of the oral mucosa. Patients who have AN associated with malignancies also have skin changes involving the scalp, areolae, and eyelids. The appearance of paraneoplastic AN usually coincides with the presence of malignancy, but it can precede or follow the diagnosis of cancer and thus may signal a relapse in patients with a history of cancer. Diagnosis The diagnosis of AN is based on clinical findings alone and can be supported by the histopathologic changes (...) include symmetrical, scaly, violaceous plaques on the acral surfaces, with severe forms progressing to bullae. The lesions predominantly occur on the hands, feet, ear helices, nose tip, and scalp. Skin changes may spread to involve the knees, elbows, and malar surface of the face. [ ] Bazex syndrome occurs more commonly in men older than 40 years. [ ] Alopecia and nail changes are common and can be early findings. Subungual hyperkeratosis, onychodystrophy, and white flaking of the nail surface

2014 eMedicine.com

156. Hyperthyroidism (Treatment)

(albeit rarely) with cloacal and scalp (cutis aplasia) abnormalities when given during early gestation. [ , ] Generally, if a nonpregnant woman who is receiving methimazole desires pregnancy, she should be switched to propylthiouracil before conception. After 12 weeks of gestation, she can be switched back to methimazole, with frequent monitoring. Propylthiouracil remains the drug of choice in uncommon situations of life-threatening severe thyrotoxicosis (ie, thyroid storm) because of the additional (...) vasculitis. All of these adverse effects, except agranulocytosis, occur more frequently with propylthiouracil: agranulocytosis occurs in 0.2-0.5% of patients overall and is no more common with one drug than with the other. Patients with agranulocytosis usually present with fever and pharyngitis. After the drug is stopped, granulocyte counts usually start to rise within several days but may not normalize for 10-14 days. Granulocyte colony-stimulating factor (G-CSF) appears to accelerate recovery

2014 eMedicine.com

157. Platelet Disorders (Treatment)

the presence of petechiae and ecchymoses. The presence of lymphadenopathy or suggests other secondary causes of thrombocytopenia rather than ITP. The peripheral smear shows a decreased number of platelets. Often, the smear shows giant platelets, which is a reflection of increased thrombopoietin-induced stimulation of the bone marrow (see images below). Examination of the peripheral smears in immune thrombocytopenic purpura often shows giant platelets. These platelets reflect the increased megakaryocytic (...) mass in the marrow. Peripheral smear of a patient with Bernard-Soulier syndrome showing giant platelets. These platelets are not counted as platelets in most particle counters. At times, the smear may show eosinophilia and lymphocytosis, possibly reflecting hypersensitivity to the inciting viral antigens. The bone marrow shows an increase in the number of megakaryocytes and signs of thrombopoietin-induced megakaryocyte stimulation (increase in number and ploidy, decrease in cytoplasm), resulting

2014 eMedicine.com

158. Preoperative Evaluation and Management (Treatment)

, can cause bone growth retardation and staining of dental enamel in the fetus. Lidocaine also appears to be safe in low doses, although excessive amounts can cause fetal CNS and cardiac depression. Acetaminophen (Class B) is routinely used during pregnancy despite its ability to cross the placenta. [ ] Drugs should also be selected carefully during lactation. [ ] Snoring/sleep apnea Eighty percent of patients with breathing problems related to sleep disorders are male. Conscious sedation may (...) controlled, and the insulin doses should be adjusted as needed. Management of hypoglycemic agents and different types of insulin can be pivotal. [ ] Hypertension A history of hypertension should alert the physician to check the patient's blood pressure. Patients with elevated pressures may bleed profusely. This is especially true when working on larger areas of the body or in highly vascular regions, such as the scalp. Hypertension is an important cause of perioperative bleeding and hematoma formation

2014 eMedicine.com

159. Postterm Pregnancy (Treatment)

be reviewed. Finally, intrapartum fetal surveillance in an attempt to document fetal intolerance to labor before it leads to acidosis is critical. Whether continuous fetal monitoring or intermittent auscultation is used, interpretation of the results by a well-trained clinician is of paramount importance. If the fetal heart rate tracing is equivocal, fetal scalp stimulation and/or fetal scalp blood sampling may provide the reassurance necessary to justify continuing the induction of labor (...) of a positive human chorionic gonadotropin (+hCG) test finding, 20 weeks of fetal heart tones have been established by a fetoscope or 30 weeks by a Doppler examination, or 39 weeks' gestation have been established by a CRL or by an ultrasound performed before 20 weeks of gestation consistent with dates by the patient's LMP. Perinatal outcomes in postterm pregnancies Recent studies have shown that the risks to the fetus [ , , , , , , , , , , , , ] and to the mother [ , , , , , , , ] of continuing

2014 eMedicine.com

160. Nonneoplastic Epithelial Disorders of the Vulva (Treatment)

is evidently a substantial predisposing factor because lesions occur in areas of the skin where sebaceous glands are most active, such as the face, scalp, body folds, and, less commonly, the genitalia. Seborrheic dermatitis is commonly observed in neonates during the early months of life (as a result of sebaceous gland activation by maternal androgens) or after puberty. An association with Pityrosporum yeasts has been noted. Neurologic factors have also been thought to play a role; emotional stress (...) , Parkinson disease, nerve injury, and syringomyelia have been related to onset or worsening of the disease. Seasonal factors, zinc deficiency, and HIV infection have been linked to this disorder. Psoriasis Psoriasis is a hereditary disorder of the skin that affects approximately 2% of the population in the Western world. The characteristic silver-white scales on erythematous plaques are caused by rapid cell turnover and primarily occur in sites of repetitive trauma, such as the scalp, elbows, forearms

2014 eMedicine.com

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