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In patients with ulcerative colitis treatment wpw cheap lamictal 150 mg buy on-line, primary sclerosing cholangitis is an inde pendent risk factor for the development of colorectal dys plasia and cancer (especially in the right colon), and strict adherence to a colonoscopic surveillance program (yearly for those with ulcerative colitis and every 5 years for those without ulcerative colitis) is recommended. Whether treat ment with ursodeoxycholic acid reduces the risk of colorec tal dysplasia and carcinoma in patients with ulcerative colitis and primary sclerosing cholangitis is still uncertain. For patients with cirrhosis and clinical decompensation, liver transplantation is the procedure of choice; primary sclerosing cholangitis recurs in the graft in 30% of cases, with a possible reduction in the risk of recurrence when colectomy has been performed for ulcerative colitis before transplantation. Reduced quality of life is associated with older age, large-duct disease, and systemic symptoms. Although maternal primary sclerosing cholangitis is asso ciated with preterm birth and cesarean section delivery, the risk of congenital malformations is not increased. Interest ingly, patients with milder ulcerative colitis tend to have more severe primary cholangitis and a higher rate of liver transplantation. Actuarial survival rates with liver trans plantation are as high as 85% at 3 years, but rates are much lower once cholangiocarcinoma has developed. Following transplantation, patients have an increased risk of non anastomotic biliary strictures and-in those with ulcerative colitis-colon cancer. Those patients who are unable to undergo liver transplantation will ultimately require high quality palliative care (see Chapter 5). Prognosis Survival of patients with primary sclerosing cholangitis averages 9- 1 7 years, and up to 21 years in population based studies. Patients in whom serum alkaline phospha tase levels decline by 40% or more (spontaneously, with ursodeoxycholic acid therapy, or after treatment of a domi nant stricture) have longer transplant-free survival times than those in whom the alkaline phosphatase does not decline. Transplant-free survival can also be predicted by serum levels of markers of liver fibrosis-hyaluronic acid. General Considerations the annual incidence of acute pancreatitis ranges from 13 to 45 per 1 00,000 population and has increased since 1 990. Most cases of acute pancreatitis are related to biliary tract disease (a passed gallstone, usually 5 mm or less in diame ter) or heavy alcohol intake. Genetic mutations also predispose to chronic pancreatitis, particularly in persons younger than 30 years of age if no other cause is evident and a family history of pancreatic disease is present. Acute pancreatitis may also result from the anomalous union of the pancreaticobiliary duct. Rarely, acute pancreatitis may be the presenting manifestation of a pancreatic or ampullary neoplasm. Celiac disease appears to be associated with an increased risk of acute and chronic pancreatitis. Apparently "idiopathic" acute pancreatitis is often caused by occult biliary microlithiasis and may be caused by sphincter of Oddi dysfunction involving the pancreatic duct. Smoking, high dietary glycemic load, and abdominal adiposity increase the risk of pancreatitis, and older age and obesity increase the risk of a severe course; vegetable consumption and use of statins may reduce the risk of pancreatitis. Acute kidney injury (usually prerenal) may occur early in the course of acute pancreatitis. Laboratory Findings Serum amylase and lipase are elevated-usually more than three times the upper limit of normal-within 24 hours in 90% of cases; their return to normal is variable depending on the severity of disease. Lipase remains elevated longer than amylase and is slightly more accurate for the diagnosis of acute pancreatitis. Leukocytosis (1 0,000-30,000/mcL), proteinuria, granular casts, glycosuria (1 0-20% of cases), hyperglycemia, and elevated serum bilirubin may be pres ent. Blood urea nitrogen and serum alkaline phosphatase may be elevated and coagulation tests abnormal. A decrease in serum calcium may reflect saponification and correlates with severity of the disease. L) (when serum albumin is normal) are associated with tetany and an unfavorable prognosis. Patients with acute pancreatitis caused by hypertriglyceri demia generally have fasting triglyceride levels above 1 000 mg/dL (1 0 mmoi! L); in some cases, the serum amylase is not elevated substantially because of an inhibitor in the serum of patients with marked hypertriglyceridemia that interferes with measurement of serum amylase. An early rise in the hematocrit value above 44% suggests hemocon centration and predicts pancreatic necrosis.

Treat ment with two drugs may further reduce seizure frequency or severity but usually only at the cost of greater toxicity treatment 7th feb bournemouth cheap lamictal 100mg online. Treatment with more than two drugs is almost always unhelpful unless the patient is having seizures of different types. Other factors to consider in selecting an anticonvul sant drug include likely side effects, teratogenicity, interac tions with other drugs and oral contraceptives, and route of metabolism. All antiepileptics are potentially teratogenic, although the teratogenicity of the newer antiseizure medications is less clear. Nevertheless, antiepileptic medication must be given to pregnant women with epilepsy to prevent seizures, which can pose serious risk to the fetus from trauma, hypoxia, or other factors. Monitoring- Individual differences in drug metabo lism cause a given dose of a drug to produce different blood concentrations in different patients, and this will affect the therapeutic response. In general, the dose of an antiepileptic agent is increased depending on the clinical response regardless of the serum drug level. When a dose is achieved that either controls seizures or is the maximum tolerated, then a steady-state trough drug level may be obtained for future reference; rechecking this level may be appropriate during pregnancy, if a breakthrough seizure occurs, a dose change occurs, or another (potentially interacting) drug is added to the regimen. Viga batri n 3 ·4 2 2 days Somnolence, anorexia, nausea, vomiting, ag itation, hosti lity, confusion, suicidal ity, neutropenia, Stevens-Johnson syndrome, permanent visual field loss. The most common cause of a lower concentration of drug than expected for the prescribed dose is suboptimal patient adherence. Recurrent seizures or status epilep ticus may result if drugs are taken erratically, and in some circumstances nonadherent patients may be better off without any medication. All anticonvulsant drugs have side effects, and many require baseline and regular labora tory monitoring (Table 24-3). Dose reduction should be gradual (over weeks or months), and drugs should be withdrawn one at a time. If seizures recur, treatment is reinstituted with the previously effective drug regimen. Surgical treatment- Patients with seizures refractory to pharmacologic management may be candidates for opera tive treatment. Surgical resection is most efficacious when there is a single well-defined seizure focus, particularly in the temporal lobe. Among well-chosen patients, up to 70% remain seizure-free after extended follow-up. Bilateral deep brain stimulation of the anterior thalamus for medi cally refractory focal-onset seizures may be of benefit, and there is an evolving role for electrical stimulation of other cortical and subcortical targets. Status epilepticus may complicate alcohol withdrawal and is managed along con ventional lines. Tonic-clonic status epilepticus-Poor adherence to the anticonvulsant drug regimen is the most common cause; other causes include alcohol withdrawal, intracranial infec tion or neoplasms, metabolic disorders, and drug overdose. The mortality rate may be as high as 20%, and among survivors the incidence of neurologic and cognitive sequelae is high. The prognosis relates to the underlying cause as well as the length of time between onset of status epilepticus and the start of effective treatment. Initial man agement includes maintenance of the airway and 50% dextrose (25-50 mL) intravenously in case hypoglycemia is responsible. If seizures continue, an intravenous bolus of lorazepam, 4 mg, is given at a rate of 2 mg/min and repeated once after 10 minutes if necessary; alternatively, 1 0 mg of midazolam is given intramuscularly, and again after 10 minutes if necessary. Respiratory depression and hypotension may complicate the treatment and are treated as in other circumstances; this treatment may include intubation and mechanical ventilation and admission to an intensive care unit. Regardless of the response to lorazepam or midazolam, fosphenytoin or phenytoin should be administered intrave nously to initiate long-term seizure control. When fosphenytoin is not available, phenytoin (1 8-20 mg/kg) is given intravenously at a rate of 50 mg/min. Phenytoin is best injected directly but can also be given in saline; it precipitates, however, if inj ected into glucose- containing solutions. B ecause arrhythmias may develop during rapid administration of phenytoin or fosphenytoin, electrocardiographic monitor ing is prudent. If seizures continue, phenobarbital is then given in a loading dose of 1 0-20 mg/kg intravenously by slow or intermittent injection (50 mg/min). Vagal nerve stimulation- Treatment by chronic vagal nerve stimulation for adults and adolescents with medi cally refractory focal seizures is approved in the United States and provides an alternative approach for patients who are not optimal candidates for surgical treatment.

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Signs (in Weeks from Last Menstrual Period) Breast changes (enlargement medicine 6 times a day generic lamictal 150mg, vascular engorgement, colos trum) start to occur very early in pregnancy and continue until the postpartum period. Cyanosis of the vagina and cervical portio and softening of the cervix occur in about the seventh week. Softening of the cervicouterine junction takes place in the eighth week, and generalized enlargement and diffuse softening of the corpus occurs after the eighth week. The uterine fundus is palpable above the pubic symphy sis by 1 2- 1 5 weeks from the last menstrual period and reaches the umbilicus by 20-22 weeks. Differential Diagnosis the nonpregnant uterus enlarged by myomas can be confused with the gravid uterus, but it is usually very firm and irregular. Ultrasonography and a pregnancy test will provide accurate diagnosis in these circumstances. The onset of the last menstrual period and its normality, possible conception dates, bleeding after the last menstruation, medical history, all prior pregnan cies (duration, outcome, and complications), and symp toms of present pregnancy should be documented. Physical Examination Height, weight, and blood pressure should be measured, and a general physical examination should be done, including a breast examination. Prenatal Visits Prenatal care should begin early and maintain a schedule of regular prenatal visits: 4-28 weeks, every 4 weeks; 28-36 weeks, every 2 weeks; 36 weeks on, weekly. Diet the patient should be counseled to eat a balanced diet containing the major food groups. Supplements that are not specified for preg nant women should be avoided as they may contain dangerous amounts of certain vitamins. Caffeine intake should be decreased to 0- 1 cup of cof fee, tea, or caffeinated cola daily. The patient should be advised to avoid eating raw or rare meat as well as fish known to contain elevated lev els of mercury. Patients should be encouraged to eat fresh fruits and vegetables (washed before eating). Sometimes compounding the above effects on pregnancy outcome are the independent adverse effects of illicit drugs. Cocaine use in pregnancy is associated with an increased risk of premature rupture of membranes, preterm delivery, placental abruption, intrauterine growth restriction, neu robehavioral deficits, and sudden infant death syndrome. Similar adverse pregnancy effects are associated with amphetamine use, perhaps reflecting the vasoconstrictive potential of both amphetamines and cocaine. Adverse effects associated with opioid use include intrauterine growth restriction, prematurity, and fetal death. Radiographs and Noxious Exposures Radiographs should be avoided unless essential and approved by a clinician. The patient should be told to inform her other health care providers that she is pregnant. Chemical or radiation hazards should be avoided as should excessive heat in hot tubs or saunas. Patients should be told to avoid handling cat feces or cat litter and to wear gloves when gardening to avoid infection with toxoplasmosis. Rest and Activity the patient should be encouraged to obtain adequate rest each day. She should abstain from strenuous physical work or activities, particularly when heavy lifting or weight bear ing is required. Regular exercise can be continued at a mild to moderate level; however, exhausting or hazardous exer cises or new athletic training programs should be avoided during pregnancy. Medications Only medications prescribed or authorized by the obstetric provider should be taken. Alcohol and Other Drugs Patients should be encouraged to abstain from alcohol, tobacco, and all recreational ("street") drugs. Fetal effects are manifest in the fetal alcohol syndrome, which includes growth restriction; facial, skeletal, and cardiac abnormalities; and serious central nervous system dys function. These effects are thought to result from direct toxicity of ethanol as well as of its metabolites such as acetaldehyde. Cigarette smoking results in fetal exposure to carbon monoxide and nicotine, and this is thought to eventuate in a number of adverse pregnancy outcomes.

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Bacterial Vag inosis this condition is considered to be a polymicrobial disease that is not sexually transmitted medications john frew buy lamictal 100 mg online. An overgrowth of Gardner ella and other anaerobes is often associated with increased malodorous discharge without obvious vulvitis or vaginitis. An amine-like ("fishy") odor is present if a drop of discharge is alkalinized with 1 0 % potassium hydroxide. Three-day regimens-Effective 3-day regimens include butoconazole (2% cream, 5 g vaginally once daily), clotrim azole (2% cream, 5 g vaginally once daily), terconazole (0. Seven-day regimens-The following regimens are given once daily: clotrimazole (1 % cream), miconazole (2% cream, 5 g, or 100 mg vaginal suppository), or tercon azole (0. Fourteen-day regimen-An effective 14-day regimen is nystatin (1 00,000-unit vaginal tablet once daily). Recurrent vulvovaginal candidiasis (maintenance therapy)-Clotrimazole (500 mg vaginal suppository once weekly or 200 mg cream twice weekly) or fluconazole (1 00, 1 50, or 200 mg orally once weekly) are effective regimens for maintenance therapy for up to 6 months. Vulvovaginal Candidiasis A variety of regimens are available to treat vulvovaginal candidiasis. Women with uncomplicated vulvovaginal can didiasis will usually respond to a 1- to 3-day regimen of a topical azole. Women with complicated infection (includ ing four or more episodes in 1 year [recurrent vulvovaginal candidiasis], severe signs and symptoms, non-albicans Treatment ofboth partners simultaneously is recommended; metronidazole or tinidazole, 2 g orally as a single dose or 500 mg orally twice a day for 7 days, is usually used. If treatment failure occurs again, give metronidazole or tinidazole, 2 g orally once daily for 5 days. Women infected with T vagina/is are at increased risk for concurrent infection with other sexually transmitted diseases. However, abnormal bleeding should not be ascribed to a cervical polyp without sampling the endocer vix and endometrium. Cervical polyps must be differentiated from polypoid neoplastic disease of the endometrium, small submucous pedunculated myomas, large nabothian cysts, and endo metrial polyps. Bacterial Vag inosis the recommended regimens are metronidazole (500 mg orally, twice daily for 7 days), clindamycin vaginal cream (2%, 5 g, once daily for 7 days), or metronidazole gel (0. Alternative regimens include clindamycin (300 mg orally twice daily for 7 days), clindamycin ovules (1 00 g intravaginally at bedtime for 3 days), tinidazole (2 g orally once daily for 3 days), or tinidazole (1 g orally once daily for 7 days). Vulvar lesions may be obviously wart-like or may be diagnosed only after applica tion of 4% acetic acid (vinegar) and colposcopy, when they appear whitish, with prominent papillae. Recommended treatments for vulvar warts include podophyllum resin 1 0-25% in tincture of benzoin (do not use during pregnancy or on bleeding lesions) or 80-90% trichloroacetic or bichloroacetic acid, carefully applied to avoid the surrounding skin. Surgical removal may be accomplished with tangential scissor excision, tangential shave excision, curettage, or electrotherapy. The pain of bichloroacetic or trichloroacetic acid application can be lessened by a sodium bicarbonate paste applied immedi ately after treatment. Freezing with liquid nitrogen or a cryoprobe and electrocautery are also effective. Patient applied regimens, useful when the entire lesion is accessi ble to the patient, include podofilox 0. Vaginal warts may be treated with cryotherapy with liquid nitrogen or trichloroacetic acid. Extensive warts may require treatment with C0 2 laser under local or general anesthesia. Treatment Cervical polyps can generally be removed in the office by avulsion with uterine packing forceps or ring forceps. The infection usually resolves and pain dis appears, but stenosis of the duct outlet with distention often persists. A fluctuant swelling 1 -4 em in diameter lateral to either labium minus is a sign of occlusion of Bartholin duct. Pus or secretions from the gland should be cultured for Chlamydia and other pathogens and treated accord ingly (see Chapter 3 3); frequent warm soaks may be helpful. If an abscess develops, aspiration or incision and drainage are the simplest forms of therapy, but the prob lem may recur. Marsupialization (in the absence of an abscess), incision, and drainage with the insertion of an indwelling Word catheter, or laser treatment will estab lish a new duct opening.

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General Considerations Nausea and vomiting begin soon after the first missed period and cease by the fifth month of gestation medicine plies buy lamictal 200mg fast delivery. Up to three-fourths of women complain of nausea and vomiting during early pregnancy, with the vast majority noting nausea throughout the day. This problem exerts no adverse effects on the preg nancy and does not presage other complications. Persistent, s evere vomiting during pregnancy hyperemesis gravidarum-can be disabling and require hospitalization. Mild Nausea and Vomiting of Preg nancy In most instances, only reassurance and dietary advice are required. Because of possible teratogenicity, drugs used during the first half of pregnancy should be restricted to those of maj or importance to life and health. Antiemetics, antihistamines, and antispasmodics are generally unneces sary to treat nausea of pregnancy. Vitamin B (pyridoxine), 6 50- 1 00 mg/day orally, is nontoxic and may be helpful in some patients. Hyperemesis Gravidarum With more severe nausea and vomiting, it may become necessary to hospitalize the patient. General Considerations About three-fourths of spontaneous abortions occur before the 1 6th week; of these, three-fourths occur before the eighth week. Almost 20% of all clinically recognized preg nancies terminate in spontaneous abortion. More than 60% of spontaneous abortions result from chromosomal defects due to maternal or paternal factors; about 1 5 % appear to be associated with maternal trauma, infections, dietary deficiencies, diabetes mellitus, hypothy roidism, the lupus anticoagulant -anticardiolipin -antiphos pholipid antibody syndrome, or anatomic malformations. There is no reliable evidence that abortion may be induced by psychic stimuli such as severe fright, grief, anger, or anxiety. There is no evidence that video display terminals or associated electromagnetic fields are related to an increased risk of spontaneous abortion. It is important to distinguish women with a history of incompetent cervix from those with more typical early abortion. Characteristically, incompetent cervix presents as "silent" cervical dilation (ie, with minimal uterine contrac tions) in the second trimester. Women with incompetent cervix often present with significant cervical dilation (2 em or more) and minimal symptoms. When the cervix reaches 4 em or more, active uterine contractions or rupture of the membranes may occur secondary to the degree of cervical dilation. Prior to pregnancy or during the first trimester, there are no methods for determining whether the cervix will even tually be incompetent. After 14- 1 6 weeks, ultrasound may be used to evaluate the internal anatomy of the lower uter ine segment and cervix for the funneling and shortening abnormalities consistent with cervical incompetence. The cervix is semifirm and slightly patulous; the uterus becomes smaller and irregularly softened; the adnexa are normal. All tissue recovered should be assessed by a pathologist and may be sent for genetic analysis in selected cases. U ltrasonographic Findings the gestational sac can be identified at 5-6 weeks from the last menstruation, a fetal pole at 6 weeks, and fetal cardiac activity at 6-7 weeks by transvaginal ultrasound. Differential Diagnosis the bleeding that occurs in abortion of a uterine preg nancy must be differentiated from the abnormal bleeding of an ectopic pregnancy and anovulatory bleeding in a nonpregnant woman. The passage of hydropic villi in the bloody discharge is diagnostic of hydatidiform mole. Threatened abortion-Bed rest for 24-48 hours followed by gradual resumption of usual activities has been offered in the past. Data are lacking to support the administration of progestins to all women with a threatened abortion. Missed abortion-This calls for counseling regarding the fate of the pregnancy and planning for its elective termina tion at a time chosen by the patient and clinician. Medically induced first-trimester termination with prosta glandins (ie, misoprostol given vaginally or orally in a dose of 200-800 meg) is safe, effective, less invasive, and more private than surgical intervention; however, if it is unsuc cessful or if there is excessive bleeding, a surgical procedure (dilation and curettage) may still be needed. Incomplete or inevitable abortion-Prompt removal of any products of conception remaining within the uterus is. Inevitable a bortion- the cervix is dilated and the membranes may be ruptured, but passage of the products of conception has not yet occurred. Bleeding and cramping persist, and passage of the products of conception is con sidered inevitable.

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Bump RC, Mattiasson A, Bo K, et al: The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction, Am J Obstet Gynecol 175:10n17, 1996.
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