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Postpartum Office Visit

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1401. Antenatal Examinations

[ , ] Test for asymptomatic bacteriuria early in pregnancy using dipstick testing; send midstream specimen of urine (MSU) if indirect test is positive. Test for proteinuria at each antenatal appointment (along with BP as part of regular surveillance for pre-eclampsia). Check for glycosuria at every visit; if there is glycosuria of more than 2+ on one occasion, or 1+ on two or more occasions, test further to exclude gestational diabetes. An oral two-hour glucose tolerance test is normally used. See (...) mothers, and those without social support. Problems associated with previous pregnancies: Recurrent miscarriage (>3 consecutive pregnancy losses or a mid-trimester loss). Preterm birth. Severe pre-eclampsia, HELLP syndrome ( H aemolysis, EL (elevated liver) enzymes, LP (low platelet) count), or eclampsia. Rhesus isoimmunisation or other significant blood group autoantibodies. Previous antepartum haemorrhage or postpartum haemorrhage on two occasions. Retained placenta on two occasions. Puerperal

2008 Mentor

1402. Antenatal Mental Health Problems

and severe depressive illness) but is not protective against relapses of pre-existing serious mental illness, especially where usual medication has been stopped at the outset of pregnancy. Women who have had a previous episode of a serious mental illness, either following childbirth or at other times, are at an increased risk of developing a postpartum onset illness even where they have been well during pregnancy and for many years previously. This risk is estimated as at least 50%. Pregnancy was thought (...) subsequent consultations. Develop a written care plan in collaboration with the patient, her family, carers and specialist mental health services, which should deal with the management of the condition in pregnancy, delivery and the postnatal period. This should be recorded in all copies of the patient's notes (ie those held in primary and secondary care, and hand-held obstetric notes). Clear discussion regarding risks of treatment . Lower thresholds for access to psychological treatments - ideally

2008 Mentor

1403. Antenatal Infections and their Consequences

with CMV. Consequences [ ] CMV is estimated to affect 1,800 births per year in England and Wales. There is a 30-40% risk of intrauterine transmission, and a 20-25% risk of postnatal sequelae if the fetus has been infected. Because there is a good chance the baby will be unharmed, termination is not usually advised. The diagnosis can be made antenatally by amniocentesis at least seven weeks after infection and after 21 weeks of gestation. If infection is confirmed, ultrasound is performed regularly (...) , particularly within six weeks of delivery. Neonatal infection contracted in labour or postnatally may cause eye, skin or mouth lesions, HSV encephalitis, or disseminated HSV with multisystem disease. 70% have disseminated HSV and/or encephalitis and 60% of these infants have no skin, mouth or eye infection. With antiviral treatment, mortality from disseminated disease is 30% and from encephalitis alone it is around 6%. Neurological morbidity is 17% and 70% respectively. Management [ ] Management depends

2008 Mentor

1404. Anaemia in Pregnancy

be offered screening for anaemia at booking and at 28 weeks of gestation. [ ] Anaemia is defined as an Hb level <110 g/L at booking; haemodilution will result in further drops during pregnancy and subsequent reduction in oxygen-carrying capacity. In the second and third trimesters the diagnostic level for anaemia is an Hb level of <105 g/L. Postpartum the diagnostic level is 100 g/L. [ ] Aetiology accounts for the majority of cases of anaemia that are identified and is characterised by low mean cell (...) bleeding. Parasitic diseases (eg, hookworm, schistosomiasis). Epidemiology Anaemia in pregnancy is a common problem. In the UK, prevalence is estimated to be 24.4% antenatally. [ ] Nearly a third of women are anaemic postpartum. Worldwide prevalence of anaemia in pregnancy is estimated to be around 38% (compared to 29% of non-pregnant women). [ ] Presentation Anaemia in pregnancy may be asymptomatic. However, the following symptoms are most common: Fatigue Dyspnoea Dizziness The patient may appear pale

2008 Mentor

1405. Amoebiasis

amoebic colitis, chest involvement or cerebral amoebiasis. More severe illness occurs in children (especially neonates), the immunosuppressed, malnourished, pregnancy and postpartum. Recurrence is common if amoebae are not completely eradicated. The bowel heals rapidly and completely; hepatic abscesses usually disappear within 8 months to 2 years. Prevention Successful control of amoebiasis depends on prevention of infection through adequate sanitation, safe food and water and good personal hygiene (...) with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; Host-Parasite interactions in Entamoeba histolytica and Entamoeba dispar: what have we learned from their genomes? Parasite Immunol. 2012 Feb-Mar34(2-3):90-9. doi: 10.1111/j.1365-3024.2011.01325.x

2008 Mentor

1406. Amniotic Fluid Embolism

. Analysis of UK data has shown an increased risk in older, ethnic-minority women and an association between postnatal AFE and caesarean delivery. [ ] A prospective, national study of AFE is being undertaken by the United Kingdom Obstetric Surveillance System (UKOSS) and has currently found an estimated incidence in the UK of 1.7 cases per 100,000 maternities. [ ] Presentation Initial pulmonary symptoms may be minor. Amniotic fluid embolises to the pulmonary circulation and the patient responds (...) very abnormal, even before any observable haemorrhage, and will then exclude many other diagnoses. CXR may show pulmonary oedema, acute respiratory distress syndrome (ARDS), right atrial enlargement and a prominent pulmonary artery. ECG may show right heart strain and arrhythmia. Arterial blood gases will determine degree of hypoxaemia. Post-mortem will reveal fetal squamous cells and hair (lanugo) in the maternal pulmonary circulation. In the future, the measurement of complement, which may

2008 Mentor

1407. Amenorrhoea

effect. The pituitary gland may be damaged by tumours, trauma, cranial irradiation, sarcoidosis or tuberculosis. Sheehan's syndrome is acute pituitary infarction due to postpartum haemorrhage. Thyroid disease : either or may affect menstruation. Iatrogenic : apart from medication discussed above (those which raise prolactin and hormonal medication), other iatrogenic causes include surgery (hysterectomy, endometrial ablation, ovarian surgery), irradiation and chemotherapy. 'Post-pill amenorrhoea (...) for over a year. Did you find this information useful? Thanks for your feedback! Why not subscribe to the newsletter? Email address * We'd love to send you our articles and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email

2008 Mentor

1408. Ambiguous Genitalia

[ ] Management and diagnosis of DSD require understanding of normal sexual determination and differentiation. Chromosomal sex prescribes gonadal sex which, in turn, prescribes the phenotypic sex. The gonad type determines whether the Müllerian or Wolffian ducts develop or regress. Gender identity is affected by prenatal and postnatal brain development and not just by phenotypic appearance. [ ] Male and female embryos develop in a similar manner until seven weeks of gestation. In the presence of a Y (...) not subscribe to the newsletter? Email address * We'd love to send you our articles and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; Role of the Critical Period in Sex

2008 Mentor

1409. Vestibular Neuritis

disease. Many factors can cause cochlear trauma, including vertebrobasilar ischaemia, meningitis, Ménière's disease and medication (eg, aminoglycoside) [ ] . It is worth noting that viral infections cause both congenital and acquired hearing loss (rubella and cytomegalovirus are viral causes of prenatal hearing loss). Postnatally, viral-induced hearing loss is usually due to mumps or measles. Viral infections are also implicated in idiopathic sudden sensorineural hearing loss (SNHL). Epidemiology (...) in the fourth decade with women outnumbering men by about 2:1. Bacterial labyrinthitis is rare in the post-antibiotic era: Meningogenic suppurative labyrinthitis is most often seen in young children (under the age of 2 years), when children are at most risk of meningitis. Otogenic suppurative labyrinthitis can be observed in all ages and is almost always associated with cholesteatoma. Presentation [ , , ] History Patients with vertigo may find it difficult to describe their symptoms but clarifying

2008 Mentor

1410. Venous Thromboembolism In Pregnancy

and the postpartum period a moderate risk factor. Often more than one risk factor is present and these should be actively identified when assessing the patient for VTE during and post-pregnancy: [ ] Inherited factors Factor V Leiden mutation (most common). Prothrombin gene G20210A mutation. Antithrombin III deficiency. Protein C deficiency. Protein S deficiency. Hyperhomocysteinaemia. Dysfibrinogenaemia. Disorders of plasminogen and plasminogen activation. Strong family history. Acquired factors Obesity - body (...) or warfarin postpartum. If she opts for warfarin, this needs to be avoided until at least day three postpartum with an INR check at day two of warfarin treatment: aim for an INR between 2 and 3. Continue heparin treatment until there have been two successive readings of an INR >2. Although these drugs are detectable in breast milk, all are safe for use during breast-feeding because warfarin metabolites are inactive and heparin is not absorbed through the gastrointestinal tract. [ ] Postnatal review

2008 Mentor

1411. Vaginal Discharge

acidity of the vagina (pH 4.5 or above) and vulvovaginal candidiasis (pH <4.5). [ ] It cannot, however, be used to differentiate between BV and T. vaginalis . NB : a high vaginal swab (HVS) is only worthwhile where there are recurrent symptoms, treatment failure or in pregnancy, postpartum, post-abortion or post-instrumentation. [ ] Management Take history with particular care to elicit clues suggestive of the presence of an STI. If there are suggestions that there might be an STI or for recurrent (...) in those aged under 20, where it is found in almost 13%. [ ] Does not affect pregnancy outcome but mother-to-baby transmission can occur at delivery, causing ophthalmia neonatorum in 15-25% or pneumonitis in 5-15% of newborns. It may be associated with postpartum endometritis. [ ] T. vaginalis : Increasingly thought to be associated with preterm delivery and low birth weight. Vaginal discharge following miscarriage, abortion or delivery These patients should be fully investigated and empirically

2008 Mentor

1412. Uterine Inversion

such as magnesium sulfate (drugs promoting tocolysis). Structural anomaly of the uterus, such as unicornuate uterus. [ ] Connective tissue disorders such as Marfan's syndrome. [ ] Poor management of labour may be a cause in up to 75% of cases, especially when the rate is high. [ ] Active management of the third stage of labour may reduce the incidence. [ ] In the non-obstetric uterine inversion, a fundally placed tumour is usually the cause. Presentation It presents most often with symptoms of a postpartum (...) haemorrhage. The classic presentation is of: Postpartum haemorrhage, which occurs in 65-94% of cases and can be massive. [ , ] Haemorrhage occurs due to the invaginated fundus preventing uterine contraction following delivery and the stretching of the endometrium leading to increased blood loss from the mucosal surface of the placental bed. [ ] Lower abdominal pain. Sudden appearance of a vaginal mass. Cardiovascular collapse, which may be out of proportion to the apparent blood loss. The sudden

2008 Mentor

1413. Usher's Syndrome

research and gene mapping, [ ] gene testing and testing for the carrier state is not yet available. There is no ante-natal diagnosis. If a child is born with the condition the risk of an affected sibling is 1 in 4. History Charles Howard Usher was a Scottish ophthalmologist who was born in Edinburgh in 1865. He trained at Cambridge and St Thomas' Hospital. He described the syndrome in 1914 in a work called On the inheritance of retinitis pigmentosa, with notes of cases. [ ] In it he reviewed (...) the syndrome, describing the pathology and inheritance of 69 cases. He was appointed ophthalmic surgeon to the Aberdeen Hospital for Sick Children and also worked in the Aberdeen Royal Infirmary. Apart from military service in Salonika during the First World War, he remained in these posts until he retired in 1926. He died in 1942. Did you find this information useful? Thanks for your feedback! Why not subscribe to the newsletter? Email address * We'd love to send you our articles and latest news by email

2008 Mentor

1414. Uterine Cervix and Common Cervical Abnormalities Full Text available with Trip Pro

glandular follicles lining the mucous membrane of the endocervix are responsible for the production of mucus. This mucus changes consistency in response to the levels of oestrogen: it is profuse, watery and alkaline when levels are high but, as levels drop post-ovulation, it becomes thick, scant and acidic. During pregnancy, it becomes even thicker and more tenacious, forming a plug rich in leukocytes. Microglandular hyperplasia can occur during pregnancy and immediately postpartum as well as in women (...) with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references Edmonds D K (Ed); Dewhurst's Textbook of Obstetrics and Gynaecology, 8th Edition (2012). John Wiley & sons. ; British Association for Sexual Health (BASHH) and HIV and Medical Foundation for HIV & Sexual Health (MEDFASH) (January 2014) ; The challenging pelvic examination. J Gen Intern Med. 2011 Jun26(6):651-7. doi: 10.1007/s11606-010-1610-8. Epub 2011 Jan 12. ; Vaginal

2008 Mentor

1415. Wilms' Tumour

bilateral Wilms' tumour) or one after the other (metachronous bilateral Wilms' tumour) [ ] . Associations [ ] Wilms' tumours usually develop in otherwise healthy children but approximately 10% occur in children with recognised malformations; either: 'Overgrowth syndromes' (excessive prenatal and postnatal somatic growth resulting in macroglossia, nephromegaly and hemihypertrophy) - most commonly, or isolated hemihypertrophy. Others include Perlman syndrome, Sotos' syndrome, and Simpson-Golabi-Behmel (...) articles and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; Wilms' tumor: biology, diagnosis and treatment. Transl Pediatr. 2014 Jan3(1):12-24. doi: 10.3978/j.issn

2008 Mentor

1416. West's Syndrome

, microcephaly, Sturge-Weber syndrome, tuberous sclerosis); genetic syndromes (such as Aicardi's syndrome and Down's syndrome), hypoxic or ischaemic brain damage, congenital infections, and trauma. Perinatal disorders include hypoxia or ischaemia of the brain, meningitis, encephalitis, trauma and intracranial haemorrhage. Postnatal disorders include pyridoxine dependency, maple syrup urine disease, phenylketonuria, meningitis, degenerative diseases, biotinidase deficiency, and trauma. Idiopathic Idiopathic (...) content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics. Epilepsia. 2015 Aug56(8):1185-97. doi: 10.1111/epi.13057. Epub 2015 Jun 30. West WJ; Infantile spasm

2008 Mentor

1417. Who Benefits from Antidepressants

and in the postnatal period - see the separate and articles. (Men, however, have a higher risk of suicide.) Past history of depression. Significant physical illnesses, particularly those causing disability or chronic pain. Other mental health problems, such as schizophrenia or dementia. Psychosocial problems - eg, divorce, unemployment, poverty. Risk factors for depression in children and adolescents include family discord, bullying, physical, sexual or emotional abuse, comorbid disorders including drug (...) and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; Exploring thoughts of suicide. BMJ. 2017 Mar 30356:j1128. doi: 10.1136/bmj.j1128. ; NICE Interventional Procedure

2008 Mentor

1418. Vitamin A Deficiency

of carotenoids. A variety of foods, such as breakfast cereals, pastries, breads, crackers and cereal grain bars, are often fortified with vitamin A. In at-risk populations, vitamin A supplements are associated with a reduction of morbidity, mortality and blindness in young children aged 6 months to 5 years. [ , ] There is, however, no convincing evidence that either maternal postpartum or infant vitamin A supplementation results in a reduction in infant mortality or morbidity in low- and middle-income (...) countries. [ ] Did you find this information useful? Thanks for your feedback! Why not subscribe to the newsletter? Email address * We'd love to send you our articles and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm

2008 Mentor

1419. Urinary Tract Obstruction

imaging). Blood cultures if there are septic symptoms/signs. Imaging [ ] Ultrasound is the usual initial choice for imaging in suspected obstruction. It can reveal renal parenchymal masses, hydronephrosis, a distended bladder, enlarged prostate and renal calculi. Where there is abnormality, further imaging (CT scan or plain X-ray of the kidneys, ureters, and bladder (KUB)) is indicated. Transrectal ultrasound provides the best means of imaging the prostate and guiding biopsies. Post-void ultrasound (...) that antenatal bladder drainage for congenital lower urinary tract obstruction improves perinatal survival but a high risk of poor postnatal renal function persists despite intervention. [ ] Children with recurrent UTI or possible obstruction (eg, high blood pressure, poor growth, poor urine flow, antenatally diagnosed renal abnormality, a family history of vesico-ureteral reflux or renal disease, an enlarged bladder or abdominal mass or evidence of spinal lesion) should be assessed rapidly to prevent

2008 Mentor

1420. Hypernatraemia

' of referring infants that lose more than 10% of body weight in the first postnatal week are widely used, although some argue that the use of charts for relative weight change is a better screening strategy. [ ] Did you find this information useful? Thanks for your feedback! Why not subscribe to the newsletter? Email address * We'd love to send you our articles and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking (...) 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; Treatment of hypernatremia. UpToDate version 19.3, Jan 2012 ; Clinical review: practical approach to hyponatraemia and hypernatraemia in critically ill patients. Crit Care. 2013 Feb 2717(1):206. doi: 10.1186/cc11805. ; Understanding hypernatremia. Am J

2008 Mentor

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