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Fetal Scalp pH

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121. 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 (...) may have clinical bleeding resulting from reduced levels of FIX include X-mosaicism, Turner syndrome, testicular feminization, or situations in which the father has hemophilia B and the mother is a carrier for the disorder. Carriers with basal levels of FIX of less than 30% can be expected to have a clinically evident bleeding disorder. Age Hemophilia B can be detected prenatally by measuring FIX activity in fetal blood samples obtained at 20 weeks of gestation by fetoscopy, but the presence

2014 eMedicine.com

122. Shock and Pregnancy (Overview)

results in respiratory alkalosis with compensatory renal excretion of bicarbonate. The arterial carbon dioxide pressure reaches a plasma level of 28-32 mm Hg, and bicarbonate is decreased to 18-21 mmol/L, maintaining an arterial pH in the range of 7.40-7.47. Mild hypoxemia might occur in the supine position. Oxygen consumption increases at the beginning of the first trimester and increases 20-33% by term because of fetal demands and increased maternal metabolic processes. [ ] In active labor (...) curve. The oxygen consumption of the fetus is 20 mL/min, and the oxygen reserve is approximately 42 mL. However, the fetus has the capability of surviving longer by redistributing blood flow to the vital organs. A 50% decrease in uterine blood flow may be tolerated for brief periods, and further reduction produces anaerobic metabolism, brain damage, and fetal death. [ ] Determinants of fetal oxygen delivery Oxygen delivery to fetal tissues can be affected at many levels (maternal oxygen delivery

2014 eMedicine.com

123. Blue Nevi (Overview)

, and the epitheliod blue nevus. [ ] Next: Pathophysiology Although definitive experimental evidence is lacking, blue nevi are believed to represent dermal arrest in embryonal migration of neural crest melanocytes that fail to reach the epidermis. Collections of melanocytes can be found in fetal dermis, but they involute during later gestation. Because of the variation of blue nevi in different populations, a genetic predisposition has been suggested. However, familial cases of blue nevi are exceedingly rare (...) . 49(2):310-2. . Di Cesare A, Sera F, Gulia A, Coletti G, Micantonio T, Fargnoli MC, et al. The spectrum of dermatoscopic patterns in blue nevi. J Am Acad Dermatol . 2011 Oct 24. . Dailey VL, Hameed O. Blue nevus of the prostate. Arch Pathol Lab Med . 2011 Jun. 135(6):799-802. . Cooper PH. Deep penetrating (plexiform spindle cell) nevus. A frequent participant in combined nevus. J Cutan Pathol . 1992 Jun. 19(3):172-80. . Munoz C, Quintero A, Sanchez JL, Ruiz-Santiago H. Persistent blue nevus

2014 eMedicine.com

124. 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 (...) affect or be affected by absorption kinetics. Didanosine contains an aluminum and magnesium buffer that may affect the absorption of other drugs (eg, ciprofloxacin). Delavirdine, atazanavir, and rilpivirine are poorly absorbed when the pH of the GI tract increases. Many ARD pharmacokinetic interactions alter the cytochrome P450 (CYP) metabolic enzyme system. Cytochromes are metabolic enzymes in the liver, and CYP denotes the specific enzyme. The CYP system is classified into families, 3 of which

2014 eMedicine.com

125. 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

126. Vacuum Extraction (Treatment)

position or station not resolved by examination or real-time ultrasound study Suspicion of fetopelvic disproportion (advanced cranial molding, bone overlap, caput) An inappropriate fetal presentation (eg, breech, face, brow) A known or suspected fetal bleeding diathesis or demineralizing bone disease Relative contraindications are as follows: Prior scalp sampling Prior failed forceps Gestational diabetes or pregestational diabetes Known or suspected fetal macrosomia Definitions The American Congress (...) of Obstetricians and Gynecologists (ACOG) has established standard definitions for instrumental delivery operations. These include outlet, low, and midpelvic operations. While the guidelines were originally written for forceps procedures, the same descriptions are easily applied to vacuum extraction operations with minor modifications. [ ] Outlet forceps/vacuum The leading point of the fetal skull has reached the pelvic floor, and at or on the perineum, the scalp is visible at the introitus without separating

2014 eMedicine.com

127. 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 (...) if the calculated activity of administered 131 I is less than 10 mCi. In children older than 10 years of age, radioactive iodine therapy is acceptable if the activity is greater than 150 µCi/g of thyroid tissue. Radioactive iodine should never be administered to pregnant women, because it can cross the placenta and ablate the fetus’s thyroid, resulting in hypothyroidism. Similarly, breastfeeding is a contraindication, in that the radioisotope is secreted in breast milk. Women will continue to receive increased

2014 eMedicine.com

128. Platelet Disorders (Treatment)

. Hypertensive disorders of pregnancy These disorders of pregnancy (ie, / syndrome) are associated with increased platelet turnover, even when the platelet count is normal. Controlling hypertension and delivering the fetus lead to restoration of the platelet count. Occasionally, thrombocytopenia is associated with hemolysis and elevated liver enzymes (ie, hemolysis, elevated liver enzymes, and low platelet [HELLP] syndrome). This serious disorder often mimics TTP. Posttransfusion purpura Platelet GP IIb/IIIa (...) The prevalence of neonatal alloimmune thrombocytopenia is approximately one case in 200 term pregnancies; for clinically apparent disease, the prevalence is one case in 1500 term pregnancies. It is the most common cause of severe neonatal thrombocytopenia. [ ] This disorder occurs when maternal antibodies against fetal platelet antigens inherited from the father but absent in the mother cross the placenta and induce severe thrombocytopenia. Most cases of neonatal alloimmune thrombocytopenia are due

2014 eMedicine.com

129. Normal Labor and Delivery (Treatment)

be accomplished with blood sampling from fetal scalp capillaries. This procedure allows for a direct assessment of fetal oxygenation and blood pH. A pH of < 7.20 warrants further investigation for the fetus' well-being and for possible resuscitation or surgical intervention. Routine laboratory studies of the parturient, such as complete blood cell (CBC) count, blood typing and screening, and urinalysis, are usually performed. Intravenous (IV) access is established. Previous Next: Intrapartum Management (...) with the delivery of the fetus In nulliparous women, the second stage should be considered prolonged if it exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia In multiparous women, the second stage should be considered prolonged if it exceeds 2 hours with regional anesthesia or 1 hour without it [ ] Third stage of labor The period between the delivery of the fetus and the delivery of the placenta and fetal membranes Delivery of the placenta often takes less

2014 eMedicine.com

130. Paraneoplastic Diseases (Overview)

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

131. Platelet Disorders (Overview)

. Hypertensive disorders of pregnancy These disorders of pregnancy (ie, / syndrome) are associated with increased platelet turnover, even when the platelet count is normal. Controlling hypertension and delivering the fetus lead to restoration of the platelet count. Occasionally, thrombocytopenia is associated with hemolysis and elevated liver enzymes (ie, hemolysis, elevated liver enzymes, and low platelet [HELLP] syndrome). This serious disorder often mimics TTP. Posttransfusion purpura Platelet GP IIb/IIIa (...) The prevalence of neonatal alloimmune thrombocytopenia is approximately one case in 200 term pregnancies; for clinically apparent disease, the prevalence is one case in 1500 term pregnancies. It is the most common cause of severe neonatal thrombocytopenia. [ ] This disorder occurs when maternal antibodies against fetal platelet antigens inherited from the father but absent in the mother cross the placenta and induce severe thrombocytopenia. Most cases of neonatal alloimmune thrombocytopenia are due

2014 eMedicine.com

132. Shock and Pregnancy (Treatment)

results in respiratory alkalosis with compensatory renal excretion of bicarbonate. The arterial carbon dioxide pressure reaches a plasma level of 28-32 mm Hg, and bicarbonate is decreased to 18-21 mmol/L, maintaining an arterial pH in the range of 7.40-7.47. Mild hypoxemia might occur in the supine position. Oxygen consumption increases at the beginning of the first trimester and increases 20-33% by term because of fetal demands and increased maternal metabolic processes. [ ] In active labor (...) curve. The oxygen consumption of the fetus is 20 mL/min, and the oxygen reserve is approximately 42 mL. However, the fetus has the capability of surviving longer by redistributing blood flow to the vital organs. A 50% decrease in uterine blood flow may be tolerated for brief periods, and further reduction produces anaerobic metabolism, brain damage, and fetal death. [ ] Determinants of fetal oxygen delivery Oxygen delivery to fetal tissues can be affected at many levels (maternal oxygen delivery

2014 eMedicine.com

133. Local Anesthesia and Regional Nerve Block Anesthesia (Overview)

when the needle perforates the skin. Small-diameter needles also decrease the pain associated with injection. Fortunately, for most dermatologic procedures, a 30-gauge needle can be used to infiltrate tissue. Tissue irritation caused by local anesthetics is related to the acidity of the infiltrated solution; therefore, increasing the pH of the mixture can decrease associated discomfort. The addition of epinephrine to an anesthetic solution decreases the pH of the solution, making it more acidic (pH (...) 3.5-4.5) and leading to a more painful injection. The solution can be neutralized by the addition of sodium bicarbonate 8.4% to minimize discomfort. For example, sodium bicarbonate 8.4% can be added to lidocaine with epinephrine in a 1:10 ratio to achieve a solution pH similar to that of tissue fluid (pH 7.3-7.4). Discomfort associated with distension of the tissues during the injection of local anesthetics is caused by the rate of injection and the volume of fluid injected. To limit the pain

2014 eMedicine.com

134. Gonococcal Infections (Overview)

unprotected intercourse with new partners frequently enough to sustain the infection in a community are defined as core transmitters. Neonatal and pediatric gonococcal infection Neonatal gonococcal infection may follow conjunctival infection, which is obtained during passage through the birth canal. In addition, direct infection may occur through the scalp at the sites of fetal monitoring electrodes. In children, infection may occur from sexual abuse by an infected individual or possibly nonsexual contact (...) . Neisserial organisms disseminate to the blood due to a variety of predisposing factors, such as host physiologic changes, virulence factors of the organism itself, and failures of the host's immune defenses. [ ] For example, changes in the vaginal pH that occur during menses and pregnancy and the puerperium period make the vaginal environment more suitable for the growth of the organism and provide increased access to the bloodstream. (Three fourths of the cases of DGI occur in women; susceptibility

2014 eMedicine.com

135. Gonococcus (Overview)

partners frequently enough to sustain the infection in a community are defined as core transmitters. Neonatal and pediatric gonococcal infection Neonatal gonococcal infection may follow conjunctival infection, which is obtained during passage through the birth canal. In addition, direct infection may occur through the scalp at the sites of fetal monitoring electrodes. In children, infection may occur from sexual abuse by an infected individual or possibly nonsexual contact in the child's household (...) disseminate to the blood due to a variety of predisposing factors, such as host physiologic changes, virulence factors of the organism itself, and failures of the host's immune defenses. [ ] For example, changes in the vaginal pH that occur during menses and pregnancy and the puerperium period make the vaginal environment more suitable for the growth of the organism and provide increased access to the bloodstream. (Three fourths of the cases of DGI occur in women; susceptibility is increased

2014 eMedicine.com

136. Gonococcemia (Overview)

partners frequently enough to sustain the infection in a community are defined as core transmitters. Neonatal and pediatric gonococcal infection Neonatal gonococcal infection may follow conjunctival infection, which is obtained during passage through the birth canal. In addition, direct infection may occur through the scalp at the sites of fetal monitoring electrodes. In children, infection may occur from sexual abuse by an infected individual or possibly nonsexual contact in the child's household (...) organisms disseminate to the blood due to a variety of predisposing factors, such as host physiologic changes, virulence factors of the organism itself, and failures of the host's immune defenses. [ ] For example, changes in the vaginal pH that occur during menses and pregnancy and the puerperium period make the vaginal environment more suitable for the growth of the organism and provide increased access to the bloodstream. (Three fourths of the cases of DGI occur in women; susceptibility is increased

2014 eMedicine.com

137. Vacuum Extraction (Overview)

position or station not resolved by examination or real-time ultrasound study Suspicion of fetopelvic disproportion (advanced cranial molding, bone overlap, caput) An inappropriate fetal presentation (eg, breech, face, brow) A known or suspected fetal bleeding diathesis or demineralizing bone disease Relative contraindications are as follows: Prior scalp sampling Prior failed forceps Gestational diabetes or pregestational diabetes Known or suspected fetal macrosomia Definitions The American Congress (...) of Obstetricians and Gynecologists (ACOG) has established standard definitions for instrumental delivery operations. These include outlet, low, and midpelvic operations. While the guidelines were originally written for forceps procedures, the same descriptions are easily applied to vacuum extraction operations with minor modifications. [ ] Outlet forceps/vacuum The leading point of the fetal skull has reached the pelvic floor, and at or on the perineum, the scalp is visible at the introitus without separating

2014 eMedicine.com

138. Paraneoplastic Diseases (Follow-up)

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

139. Platelet Disorders (Follow-up)

. Hypertensive disorders of pregnancy These disorders of pregnancy (ie, / syndrome) are associated with increased platelet turnover, even when the platelet count is normal. Controlling hypertension and delivering the fetus lead to restoration of the platelet count. Occasionally, thrombocytopenia is associated with hemolysis and elevated liver enzymes (ie, hemolysis, elevated liver enzymes, and low platelet [HELLP] syndrome). This serious disorder often mimics TTP. Posttransfusion purpura Platelet GP IIb/IIIa (...) The prevalence of neonatal alloimmune thrombocytopenia is approximately one case in 200 term pregnancies; for clinically apparent disease, the prevalence is one case in 1500 term pregnancies. It is the most common cause of severe neonatal thrombocytopenia. [ ] This disorder occurs when maternal antibodies against fetal platelet antigens inherited from the father but absent in the mother cross the placenta and induce severe thrombocytopenia. Most cases of neonatal alloimmune thrombocytopenia are due

2014 eMedicine.com

140. Normal Labor and Delivery (Follow-up)

be accomplished with blood sampling from fetal scalp capillaries. This procedure allows for a direct assessment of fetal oxygenation and blood pH. A pH of < 7.20 warrants further investigation for the fetus' well-being and for possible resuscitation or surgical intervention. Routine laboratory studies of the parturient, such as complete blood cell (CBC) count, blood typing and screening, and urinalysis, are usually performed. Intravenous (IV) access is established. Previous Next: Intrapartum Management (...) with the delivery of the fetus In nulliparous women, the second stage should be considered prolonged if it exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia In multiparous women, the second stage should be considered prolonged if it exceeds 2 hours with regional anesthesia or 1 hour without it [ ] Third stage of labor The period between the delivery of the fetus and the delivery of the placenta and fetal membranes Delivery of the placenta often takes less

2014 eMedicine.com

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