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Cross References Ataxia; Flaccidity; Hemiballismus; Hypertonia Hypotropia Hypotropia is a variety of heterotropia in which there is manifest downward ver tical deviation of the visual axis of one eye treatment diabetes urdu trusted diabecon 60caps. Improvement of ptosis is said to be spe ci c for myasthenia gravis gestational diabetes type 1 or 2 cheap diabecon 60caps visa, perhaps because cold improves transmission at the neuromuscular junction (myasthenic patients often improve in cold as opposed to hot weather) blood glucose watch meter order diabecon 60caps with mastercard. This phenomenon is generally not observed in other causes of ptosis blood sugar conversion chart 60 caps diabecon for sale, although it has been reported in Miller Fisher syndrome diabetes mellitus krankheitsbild purchase diabecon 60 caps line. A pooled anal ysis of several studies gave a test sensitivity of 89% and speci city of 100% with correspondingly high positive and negative likelihood ratios managing your diabetes patient education program cheap diabecon 60 caps without prescription. Whether the ice pack test is also applicable to myasthenic diplopia has yet to be determined: false positives have been documented. Illusions occur in normal people when they are tired, inattentive, in conditions of poor illumination, or if there is sensory impairment. They also occur in disease states, such as delirium, and psychiatric disorders (affective disorders, schizophrenia). They are consistent and have a compulsive quality to them, perhaps triggered by the equivocal nature of the situation. There may be accompany ing primitive re exes, particularly the grasp re ex, and sometimes utilization behaviour. Imitation behaviour occurs with frontal lobe damage; originally mediobasal disease was thought the anatomical correlate, but more recent studies suggest upper medial and lateral frontal cortex. Part I: imitation and utilization behaviour: a neuropsychological study of 75 patients. It is most commonly seen with lesions affecting the right hemisphere, especially central and frontal mesial regions, and may occur in association with left hemiplegia, neglect, anosognosia, hemianopia, and sensory loss. Neuropsychologically, impersistence may be related to mechanisms of directed attention which are needed to sustain motor activity. Thus, the anatomical differen tial diagnosis of neurological incontinence is broad. Moreover, incontinence may be due to inappropriate bladder emptying or a consequence of loss of aware ness of bladder fullness with secondary over ow. Other features of the history and/or examination may give useful pointers as to localization. Incontinence of neurological origin is often accompanied by other neurological signs, especially if associated with spinal cord pathology (see Myelopathy). The pontine mic turition centre lies close to the medial longitudinal fasciculus and local disease may cause an internuclear ophthalmoplegia. However, other signs may be absent in disease of the frontal lobe or cauda equina. Approach to the patient with bladder, bowel, or sexual dysfunction and other autonomic disorders. Intermanual con ict is more characteristic of the callosal, rather than the frontal, subtype of anterior or motor alien hand. It is most often seen in patients with corticobasal degeneration, but may also occur in association with callosal infarcts or tumours or following callosotomy. Intrusions are thought to re ect inattention and may be seen in dementing disorders or delirium. The term intrusion is also used to describe inappropriate saccadic eye movements which interfere with macular xation during pursuit eye movements. Intrusions as a sign of Alzheimer dementia: chemical and pathological veri cation. The nding of inverted re exes may re ect dual pathology, but more usually re ects a single lesion which simultaneously affects a root or roots, interrupting the local re ex arc, and the spinal cord, damaging corticospinal (pyramidal tract) pathways which supply segments below the re ex arc. Hence, an inverted supina tor jerk is indicative of a lesion at C5/6, paradoxical triceps re ex occurs with C7 lesions; and an inverted knee jerk indicates interruption of the L2/3/4 re ex arcs, with concurrent damage to pathways descending to levels below these segments. The pathophysiological implication is of electrical disturbance spreading through the homunculus of the motor cortex. It may also be used to refer to the restlessness seen in acute illness, high fever, and exhaustion, though differing from the restlessness implied by akathisia. Cross References Akathisia; Myoclonus; Seizures Jamais Entendu A sensation of unfamiliarity akin to jamais vu but referring to auditory experi ences. This is suggestive of seizure onset in the limbic system, but is not lateralizing (cf. There is debate as to whether jargon aphasia is simply a primary Wernicke/posterior/sensory type of aphasia with failure to self monitor speech output, or whether additional de cits. Others suggest that jargon aphasia represents aphasia and anosognosia, leading to confabulation and reduplicative paramnesia. Both the afferent and efferent limbs of the arc run in the mandibular division of the trigeminal (V) nerve, connecting centrally with the mesencephalic (motor) nucleus of the trigeminal nerve. The re ex is highly reproducible; there is a linear correlation between age and re ex latency and a negative correlation between age and re ex amplitude. Interruption of the re ex arc leads to a diminished or absent jaw jerk as in bulbar palsy (although an absent jaw jerk may be a normal nding, particu larly in the elderly). Bilateral supranuclear lesions cause a brisk jaw jerk, as in pseudobulbar palsy. Cross References Age-related signs; Bulbar palsy; Pseudobulbar palsy; Re exes Jaw Winking Jaw winking, also known as the Marcus Gunn phenomenon, is widening of a congenital ptosis when a patient is chewing, swallowing, or opening the jaw. It is believed to result from aberrant innervation of the pterygoid muscles and levator palpebrae superioris. Cocontraction increases the gain in the monosynaptic re ex arc, as distinct from facilitation or posttetanic potentiation which is seen in Lambert Eaton myasthenic syndrome following tetanic contraction of muscles involved in the re ex. Facilitation of monosynaptic re exes by voluntary con tractions of muscle in remote parts of the body. This may be confused in neonates with clonic seizures, but in the former there is stimulus sensitivity and an absence of associated ocular movements. However, both may occur in hypoxic ischaemic or metabolic encephalopathies or with drug withdrawal. Although often visible to the naked eye (dif cult in people with a brown iris), they are best seen with slit-lamp examination. There may also be an oculomo tor nerve palsy ipsilateral to the lesion, which may be partial (unilateral pupil dilatation). This observation helped to promote the idea that tics were due to neurological disease rather than being psychogenic, for example, in Tourette syndrome. It is due to rapid rhythmic contractions of the leg muscles on standing, which dampen or subside on walking, leaning against a wall, or being lifted off the ground, with disappearance of the knee tremor; hence this is a task-speci c tremor. Auscultation with the diaphragm of a stethoscope over the lower limb muscles reveals a regular thumping sound, likened to the sound of a distant helicopter. Although such deformity is often pri mary or idiopathic, thus falling within the orthopaedic eld of expertise, it may also be a consequence of neurological disease which causes weakness of paraspinal muscles. Duchenne muscular dystrophy Stiff person syndrome may produce a characteristic hyperlordotic spine. Some degree of scoliosis occurs in virtually all patients who suffer from paralytic poliomyelitis before the pubertal growth spurt. The test may be positive with disc protrusion, intraspinal tumour, or in ammatory radiculopathy. A positive straight leg raising test is reported to be a sensitive indicator of nerve root irritation, proving positive in 95% of those with surgically proven disc herniation. Crossed straight leg raising, when the complaint of pain on the affected side occurs with raising of the contralateral leg, is said to be less sensitive but highly speci c.

Finally signs diabetes 4 year old diabecon 60caps visa, irrigation runo ows back to surface streams and rivers diabetes definition mayo clinic purchase diabecon 60caps on line, percolates into the aquifer metabolic disease uk discount diabecon 60caps free shipping, or evaporates definition of diabetes type 1 order 60 caps diabecon with mastercard. First diabetes test home kit buy diabecon overnight, many aquifers underlie several countries diabetic pasta cheap diabecon master card, management districts, and/or property owners. Second, the use of aquifers is decentralized and therefore di cult to monitor and control. Finally, although aquifers are a common resource, the bene t of aquifer use accrues to the individual or group that pumps the water, whereas the costs of use are imposed upon all other users. Tese aquifers underlie Palestinian and Israeli territory, necessitating cooperation to successfully manage the resource. Water is pumped from hundreds of wells owned by individual property owners and municipalities. Finally, aquifer over-pumping has led to the extraction of more groundwater than is replenished. Depending on geologic fea tures, the aquifer may also become completely exhausted. As aquifers are depleted they can subside, leading to permanent loss of aquifer storage capacity. In the case of the Coastal Aquifer, seawater may enter an aquifer as the water table drops, decreasing its quality. Surface water is contaminated through the release of untreated sewage, industrial e uence, and agricultural runo. This polluted surface water then perco lates into the aquifers, leading to groundwater contamination. In water-scarce regions without proper water treatment facilities, consumption of polluted water leads to sig ni cant heath complications. All natural systems can accommodate some contamination, but as industrial, household, and agricultural uses of water grow, pollution loads in surface waters in crease as the remaining ows diminish in response to increased withdrawals. As a re sult, increasingly large levels of pollutants are discharged into ever-smaller quantities of water. Tese problems become particularly serious when urban water supplies and waste grow faster than sanitation infrastructures. As surface water quality and quantity decrease, groundwater extractions increase, further exacerbating groundwater overuse. Although no water quality database exists, individual studies and monitoring projects indicate severe contamination and water quality problems in all major aquifers. Although much has been accomplished in pro viding access to improved water supply and sanitation facilities, many people still lack adequate access to safe drinking water and sanitation. Many people in the Middle East without access to water supplies live in rural areas; however, many residents of poor urban neighborhoods in the West Bank and Gaza also lack access to adequate water 3 Chloride levels exceed 1,000 milligrams per liter (mg/l), and nitrate levels exceed 290 mg/l. Water supply in many cities is inter mittent, with lengthy intervals of no water service. As in many other developing countries, sanitation tends to receive less atten tion and fewer nancial resources than water supply. The intrusion of raw sewage into ground and surface waters and agricultural reuse of insu ciently treated wastewater have negative environmental and health impacts. Wastewater needs to be adequately treated, regardless of whether it is reused, to avoid degradation of water sources and adverse health e ects. Practically all countries of the region reuse at least some of their wastewater (al though reuse in the West Bank and Gaza is limited). The agricultural sector is both the leading consumer of water and a major source of water pollution in the Middle East. Irrigated agriculture accounts for 60 to over 80 percent of water use (Saghir, Schi er, and Woldu, 2000). In nearly all coun tries in the region, public irrigation agencies provide farmers with water at subsidized tari s. The economic value of water in municipal and industrial uses is many times higher than in agriculture. Due to heavy reliance on fertilizers and pesticides, agricultural runo is a signi cant source of water pollution. Agricultural runo can lead to nutrient overload and increased salinity in irrigated areas. Salinization reduces yields, decreases soil moisture, and increases susceptibility to erosion. As with water resources, the countries of the Middle East vary in terms of their domestic energy resources. Energy is expensive in countries such as Jordan, Syria, Israel, Egypt, and other North African countries. The recent discovery of natural gas reserves o shore in the Mediterranean Sea, however, could reduce this energy limitation for Israel and Palestine. Tese reserves could signi cantly reduce the cost of desalination by lowering energy prices in the region. Although most long-distance water conveyance systems rely on gravity, the water often must be pumped up and over mountain ranges or out of valleys, using much energy. The water also must be treated prior to delivery to end users if the water source is degraded. Tertiary treatments, such as ultraviolet radiation and ozonization, are very energy intensive. Finally, almost all water delivered for domestic and industrial use becomes sewage and must be treated prior to reuse or disposal. Finally, a portion of industrial, commercial, and household electricity consumption is used for groundwater pumping. Currently, the water system in the West Bank and Gaza is not very energy in tensive. Leading proposals for increasing the water supply, such as desalination and wastewater treatment and reuse, however, are highly energy intensive. Ensuring ad equate water supplies in the region will require investments not only in new water sources, but also in an expanded electric power infrastructure. Since the vast majority of energy consumed by Palestinians is imported, increases in energy consumption by the water sector will directly a ect energy imports, the cost of energy, and ultimately the economy. Water Issues in Israel and Palestine: the Past and Present Water issues in the region have been frequently studied, and many such studies have highlighted the vital role that water supply solutions may play in the peace process. Creating a viable Palestinian state will require settling water disputes and ensuring ac cess to adequate amounts of clean water for both Israelis and Palestinians. Historical Context Securing adequate water supplies has been an important issue in the region throughout both ancient and recent history. In the last 50 years, the enduring problems resulting 4 Personal communication with Alvin Newman, April 3, 2003. Tese issues continue to drive much of the dialogue sur rounding water in the region. Unilateral water development by every party in the region led to a crisis at the end of the 1960s. After creation of the Israeli state, Israel, Syria, Egypt, the United Nations, and the United States made many attempts to develop a multilateral water manage ment plan among the countries in the region. After its failure, unilateral water development and con icting attempts to divert the Jordan River were followed by military clashes in 1967 (Zahra, 2000). Israel then transferred water authority to the military and took control of the water resources in the area. Palestinian use was restricted to Israeli-established quotas, and Israel forbade unlicensed construc tion of new water infrastructure. Agreements made in the early 1990s established the basis for much of the current dialogue surrounding water issues in the region. In 1992, the second round of peace talks resulted in the creation of the water resources working group. This was a step forward; however, the parties were wary of entering into technical agreements in the absence of a political settlement of core issues. The Declaration of Principles recognized the need for cooperation in managing and developing water resources and allowed the Palestinians to drill new wells, subject to Israeli approval. However, in an important move forward, Is rael recognized Palestinian water rights in the West Bank for the rst time in 1995. Tese nal status negotiations never occurred, 174 Building a Successful Palestinian State and not all of the agreed-upon quantity has been released. Because these issues have not been resolved, Israel continues to consume according to historical use, and the West Bank and Gaza are unable to support their increasing needs. It is responsible for strategic planning, monitor ing and oversight, policy implementation, regulation, and water rights negotiations. Its main goal is to ensure the equitable utilization and sustainable management and development of Palestinian water resources. The main sources of water for the West Bank, Gaza, and Israel include groundwater from two main aquifers (Mountain and Coastal) and various springs, as well as surface water from the tributaries of the Jordan River and Lake Tibe rias (see Figure 6. The Mountain Aquifer is divided into three aquifer basins: West ern, Northeastern, and Eastern. Israel obtains water from several aquifers (Moun tain, Coastal, Galilee, and Negev) and the Jordan River. In addition, Israel recently signed an agreement to purchase water from a desalination plant to meet its expected water needs in the future. The expectation of the desalination plant developers is that a power plant, fueled by natural gas, would be built to power the desalination plant. The West Bank obtains most of its water from the Mountain Aquifers, some from Israel, and some from springs. There are disagreements and uncertainty about how much water is being pumped from the aquifers. Despite the high agricultural water use, only 13 percent of all cultivated land is irrigated. Fruit trees demand more than half of all water and require more than twice the water per hectare than do vegetables and eld crops. Meeting all current irrigation demand and accommodating growth of irrigated areas will dramatically in crease agricultural water demand. As more recent modeling estimates of the Gaza Aquifer do not exist, we use the Oslo recharge value as the sustainable yield. The Gaza and Western Aquifer problems are particularly severe, as use is twice as high as the sustain able yield. However, the drought of the past few years, together with increased groundwater exploitation, is likely to lead to a return to rapidly declining water levels. In the Gaza Aquifer, the groundwater level has remained relatively stable despite heavy overuse, likely due to saltwater intrusion. In ltration of untreated wastewater and intrusion of saltwater have reduced water quality in all of the aquifers in the region. The problems are most acute in the Gaza Aquifer as a result of the shallow depth of the groundwater and the almost complete lack of sanitation infrastructure in Gaza. Because the aquifer is close to the surface, polluted water percolates into the aquifer relatively quickly. Signi cant elevated nitrate concentrations have been found in most of the test wells, attributed mostly to agricul ture fertilizers, manure, and disposal of untreated sewage. Near the coast, an observa tion well showed a consistent 15 mg/l annual increase in chloride concentration from 1984 through 1998. Wells near agricultural areas have also shown chloride increases, perhaps due to in ltration of irrigation water.

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Shoulder abduction Ask the patient to lift both his elbows out to the side (demonstrate) diabetes grapes diabecon 60 caps discount. Hold the middle of the little fingers and attempt to overcome the index finger (Fig diabetic diet for 7 days order diabecon 60caps free shipping. Fix the palm and diabetes diet malaysia buy diabecon now, pressing at the end of the proximal phalanx joint diabetes 72 blood sugar buy diabecon with mastercard, attempt to overcome the resistance (Fig diabetes symptoms children order diabecon mastercard. Ask him to push against the wall with his arms straight and his hands at shoulder level metabolic disease fever buy diabecon 60 caps lowest price. Attempt to extend the distal interphalangeal joint of the little and ring fingers. Note especially the quadriceps, the anterior compartment of the shin, the extensor digitorum and brevis, and the peroneal muscles. Look for the position and for contractures, especially at the ankle; look at the shape of the foot, a high arch or pes cavus. Pes cavus is demonstrated by holding a hard, flat surface against the sole of the foot; a gap can be seen between the foot and the surface. When the knee is at 90 degrees, ask him to pull it up as hard as he can; put your hand against his knee and try to overcome this (Fig. When it is flexed at 90 degrees, support the knee with one hand and place the other hand at his ankle and ask him to straighten his leg (Fig. Knee flexion Ask the patient to bend his knee and bring his heel towards his bot tom. Foot dorsiflexion Ask the patient to cock his ankle back and bring his toes to wards his head. Plantar flexion of the foot Ask the patient to point his toes with his leg straight. Additional tests Hip abductors Fix one ankle; ask the patient to push the other leg out at the side and resist this movement by holding the other ankle (Fig. Foot inversion With the ankle at 90 degrees, ask the patient to turn his foot inwards. Tendon reflexes are increased in upper motor neurone lesions and decreased in lower motor neurone lesions and muscle abnormalities. The root values for the reflexes can be recalled by counting from the ankle upwards (Fig. Place your index finger on the biceps tendon; swing the hammer on to your finger while watch ing the biceps muscle (Fig. Triceps Draw the arm across the chest, holding the wrist with the elbow at 90 degrees. Strike the triceps tendon directly with the patella hammer; watch the muscle (Fig. Finger reflex Hold the hand in the neutral position, place your hand opposite the fingers and strike the back of your fingers. Ask the patient to kneel on a chair so that his ankles are hanging loose over the edge. Reinforcement If any reflex is unobtainable directly, ask the patient to perform a rein forcement man uvre. For the legs, ask the patient either to make a fist, or to link hands across his chest and pull one against the other, as you swing the hammer (Fig. Ask diverting questions: where he comes from, how long he has lived there, and so on. Reflex spread indicates an upper motor neurone lesion occurring above the level of innervation of the muscle to which the reflex spread. This indicates a lower motor neurone lesion at the level of the absent reflex (in this case C5) with an upper motor neurone lesion below indicating spinal cord involvement at the level of the absent reflex. Gently draw an orange stick up a lateral border of the foot and across the foot pad. Syndromes limited to a single limb Upper motor neurone signs limited to a single limb can be caused by lesions in the spinal cord, brainstem or cerebral hemisphere. Upper limb Hand (i) Median nerve: weakness and wasting of thenar eminence abductor pollicis brevis. Arm (i) C5 root: weakness of shoulder abduction, external rotation and elbow flexion; loss of biceps reflex. Lower limb (i) Common peroneal palsy: weakness of foot dorsiflexion and eversion with preserved inversion. Variable weakness (i) Weakness seems to fatigue with effort then recovers: consider myasthenia gravis. The root compressed is from the lower of the levels; for example, an L5/S1 disc compresses the S1 root. It is distinct from other peripheral neuropathies because it produces a more proximal weakness. Vibration, joint position and temperature senses are often lost with out prominent symptoms. Sensory examination requires considerable concentration on the part of both patient and examiner. Vibration sense and joint position sense are usually quick and easy and require little concentration, so test these first. This also allows you to assess the reliability of the patient as a sensory witness. In all parts of sensory testing it is essential first to teach the patient about the test. In most patients you will be confident they have understood and that their responses are reliable. The relevant sensory loss is illustrated in the fingers for the median nerve, ulnar nerve, radial nerve and axillary nerve (Fig. The dermatomal representation in the arms can be remembered easily if you recall that the middle finger of the hand is supplied by C7. Demonstrate: ensure the patient understands that he is to feel a vibration, by striking the tuning fork and placing it on the sternum or chin. Place the tuning fork on the bony prominence and ask if he can feel the vibration. Place ini tially on the toe tips then, if this is not felt, on a metatarsal phalan geal joint, medial malleolus, tibial tuberosity, anterior superior iliac spine, in the arms, on the fingertips, each interphalangeal joint, the metacarpal phalangeal joint, the wrist, the elbow and the shoulder (Fig. Check: check the patient reports feeling the vibration and not just the contact of the tuning fork. Ensuring that your fingers are at 90 degrees to the intended direction of movement, move the digit, illustrating which is up and which is down. Start with large movements in either direction; gradually reduce the angle moved until errors are made. Test more proximal joints if proprioception is abnormal distally, mov ing to more proximal joints until joint position sense is appreciated. Touch an unaffected area with the pin and then touch an unaffected area with the opposite blunt end of the pin. Aim to stimulate points within each dermatome and each main nerve, though as a screening test this has a low yield. Check: intermittent use of a blunt stimulus that needs to be rec ognised correctly allows you to check that the patient understands the test. Temperature sensation Screening It is usually adequate to ask a patient if the tuning fork feels cold when applied to the feet and hands. If cold is not appreciated, move the tuning fork proximally until it does feel cold. Ideally these are con trolled temperatures, though normally the warm and cold taps are adequate. Other modalities Two-point discrimination this requires a two-point discriminator: a device like a blunted pair of compasses. Note the setting at which the patient fails to distinguish one prong from two prongs. If he is able to recognise each independently, then touch him on both sides at the same time. Single nerve: sensory loss within the distribution of a single nerve, most commonly median, ulnar, peroneal, lateral cutaneous nerve to the thigh. Brainstem: loss of pain and temperature on the face and on the opposite side of the body. Functional loss: this diagnosis is suggested by a non-anatomical distribution of sensory deficit frequently with inconstant findings. Common causes: diabetes mellitus, alcohol-related vitamin B1 deficiency, drugs. Common causes: trauma, spinal cord compression by tumour (usually bony secondaries in vertebra), cervical spondylitis, transverse myelitis, multiple sclerosis. Common causes: stroke (thrombosis, emboli or haemorrhage), cerebral tumour, multiple sclerosis, trauma. In the presence of weakness, tests for coordination must be interpreted with caution and are unlikely to be informative if there is significant weakness. Ask the patient to touch your finger with his index finger and then touch his nose (Fig. Repeated movements Ask the patient to pat one hand on the back of the other quickly and regularly (demonstrate). Ask the patient to tap the back of his right hand alternately with the palm, and then the back of his left hand. Ask him to lift his leg and place the point of his heel on his knee, and then run it down the sharp part of his shin (Fig.

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No study to date shows that tocolysis beyond 48 hr improves fetal or maternal outcomes diabetes 76 discount diabecon 60 caps with amex. Contraindications to tocolysis include the following: nonreassuring fetal status diabetes symptoms glucose in urine discount diabecon 60caps otc, chorioamnionitis diabetes type 1 video buy genuine diabecon, eclampsia or severe preeclampsia diabetes protocol program discount 60caps diabecon otc, fetal demise diabetes medications video purchase diabecon 60 caps fast delivery, fetal maturity diabetes symptoms tongue purchase diabecon canada, and maternal hemodynamic instability. Use of multiple tocolytics concurrently should be avoided given the risk of pulmonary edema (excluding indocin). On our inpatient unit, we check fetal doptones one to two times daily with vital signs and perform a fetal nonstress test one to three times per week. Discuss the risks and benefits of C-section for fetal distress given the increased maternal morbidity and poor neonatal prognosis. Document your discussion carefully in the chart, and revisit the issue as gestation progresses. Criteria for discharge include acontractile, stable cervical exam (without advanced cervical dilation [>4 cm], bulging membranes, or significant effacement), no vaginal bleeding, no suspicion of ruptured membranes, reasonable hospital access with appropriate level of neonatology support, ability to comply with activity recommendations (modified bed rest and complete pelvic rest), and reassuring fetal status (we typically do a nonstress test on the day of discharge). Nifedipine Calcium channel 10-20 mg Hypotension Hypotension First-line agent blocker > orally q6hr Congestive heart Flushing inhibits failure Lightheadedness myometrial Aortic stenosis Dizziness calcium entry Nausea Terbutaline 0. Digital examination decreases the latency period and increases the risk of neonatal sepsis. After some time, the tampon is examined to see whether blue stained fluid has leaked through the cervix. The goals are to screen for underlying chorioamnionitis or placental abruption and move toward delivery if these conditions are identified. If the fetal vertex is not well applied to the cervix, strict bed rest should be maintained to avoid cord accident. Once the patient and fetus are stable, monitor fetal heart tones every 8 hr and perform. Once the patient and fetus are stable, monitor fetal heart tones every 8 hr and perform daily fetal testing. At >34 weeks augment labor for delivery or proceed to cesarean section depending on the fetal presentation and obstetric indications. Evidence of chorioamnionitis or nonreassuring fetal status warrants prompt delivery. Antenatal magnesium sulfate and neurologic outcome in preterm infants: a systematic review. Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone caproate. Antibiotic therapy for reduction of infant morbidity after preterm premature rupture of the membranes. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Colon Guzman Cynthia Holcroft Argani Third-trimester bleeding, ranging from spotting to massive hemorrhage, occurs in 2% to 6% of all pregnancies. Etiology Bleeding does not correlate with abruption size and may vary from scant to massive. Blood in the basalis layer stimulates forceful, classically tetanic, uterine contractions leading to ischemic abdominal pain. Patients with chronic hypertension, superimposed preeclampsia, or severe pre-ec-lampsia have fivefold increased risk of severe abruption compared to normotensive women. Antihypertensive medications do not reduce the risk of abruption for chronic hypertension. Rapid changes in intrauterine volume can lead to abruption, such as in rupture of membranes or therapeutic amnioreduction with polyhydramnios or during delivery of multiple gestations. Abruption occurs more frequently when the placenta implants on abnormal uterine surfaces as with submucous myomas or uterine anomalies. Hyperhomocysteinemia, Factor V Leiden, and prothrombin 20210 mutations (thrombophilias) are associated with an increased risk of abruption. Fetal hypoxia may occur, leading to acute fetal distress, hypoxic-ischemic encephalopathy, premature delivery, and fetal death. Milder chronic abruption may lead to growth restriction, major malformations, or anemia. Diagnosis History and Physical Examination Classically presents late in pregnancy with vaginal bleeding and acute severe constant abdominal pain. Even slight clinical suspicion should prompt rapid investigation and close monitoring. Maternal vital signs, fetal heart rate assessment, and uterine tone should be evaluated immediately. Blood may be sequestered between the uterus and placenta when the placental margins remain adherent. Membranes or the fetus itself may obstruct the cervical os and prevent accurate assessment of blood loss. Perform a speculum exam to evaluate vaginal or cervical lacerations and the amount of bleeding. Laboratory Tests Complete blood cell count with hematocrit and platelets (<100,000 plts/mL suggests severe abruption) Blood type and screen (cross-match should be strongly considered) Prothrombin/activated partial thromboplastin time Fibrinogen (<200 mg/dL suggests severe abruption) Fibrin split-products Consider holding a whole blood specimen at the bedside while lab work is pending. The Apt test can be performed to evaluate whether vaginal blood is from the mother or the fetus. Fetal hemoglobin is resistant to the base and will remain pink, while maternal hemoglobin will oxidize and turn brown. Close monitoring of maternal vital signs and continuous fetal monitoring should be maintained. Further management depends on the gestational age and hemodynamic status of both mother and fetus. Term Gestation, Hemodynamically Stable Plan for vaginal delivery with cesarean section for usual indications and initiate induction of labor. Consider fetal scalp electrode for accurate and continuous fetal monitoring and intrauterine pressure catheter to assess resting uterine tone. Maintain fibrinogen level >150 mg/dL, hematocrit more than 25%, and platelets over 60,000/ L. Once the mother is stabilized, proceed to urgent cesarean section, unless vaginal delivery is imminent. If maternal instability or fetal distress arises, delivery should be performed as above. Magnesium is preferred over terbutaline or nifedipine as it may be less likely to obscure signs of shock. If maternal or fetal compromise arises, delivery should be performed after appropriate resuscitation. Preterm Gestation, Hemodynamic Instability Delivery should be performed after appropriate resuscitation. It can be classified into four types based on the location relative to the cervical os: complete or total previa, in which the placenta covers the entire cervical os; partial previa, in which the margin of the placenta covers part but not all of the internal os; P. Usually the placenta will migrate away from the cervical os as the uterus grows with gestational age and the upper third of the cervix develops into the lower uterine segment. The incidence after four or more cesarean sections increases to 10% and 40-fold increased risk compared with no cesarean section. Other risk factors include increasing maternal age (especially after age 40), multiparity, smoking, residing at higher elevations, male fetus, multiple gestation, and previous uterine curettage. Complications Bleeding occurs with the development of the lower uterine segment in the third trimester in preparation for labor. Cervical exams or intercourse may also cause separation of the placenta from the lower uterine segment. The placenta adheres directly to the uterus without the usual intervening decidua basalis. The incidence in patients with previa who have not had previous uterine surgery is approximately 4%, increasing to as many as 25% of patients who have had a previous cesarean section or uterine surgery. The placenta penetrates the entire uterine wall, potentially growing into bladder or bowel. About one third of patients develop bleeding before 30 weeks, while another third present after 36 weeks and 10% go to term. A thorough medical, obstetric, and surgical history should be obtained along with documentation of previous ultrasound examinations. Other causes of vaginal bleeding must also be ruled out, such as placental abruption. Maternal vital signs, abdominal exam, uterine tone, and fetal heart rate monitoring should be assessed. The placenta must be within 2 cm of the cervical os to make the diagnosis and may be missed by a transabdominal scan, especially if the placenta lies in the posterior portion of the lower uterine segment where it is poorly visualized. A gentle speculum exam can be used to evaluate the presence and quantity of vaginal bleeding, but in most cases, this can be assessed adequately by inspecting the perineum and thereby avoid exacerbating the hemorrhage. Complete blood cell count Type and cross-match Prothrombin time and activated thromboplastin time Kleihauer-Betke test to assess for fetomaternal hemorrhage in Rh-negative unsensitized patients. They should receive advice about when to seek medical attention and be scheduled for fetal growth ultrasounds every 3 to 4 weeks. Steroids are administered to promote lung maturity for gestations between 24 and 34 weeks, and Rh D immunoglobulin should be administered to Rh negative mothers. In cases where uterine preservation is highly desired and no bladder invasion has occurred, bleeding might be successfully controlled with selective arterial embolization or packing of the lower uterine segment, with removal of the pack through the vagina in 24 hr. The Bakri balloon catheter has also been used to help control bleeding from the placental bed. Patients with partial or marginal previa at term may deliver vaginally, with thorough consent regarding risks for blood loss and need for transfusion. The staff and facilities for immediate emergent Cesarean section must be available. If maternal or fetal stability is compromised at any point in labor, urgent cesarean section is performed. Term Gestation, Hemodynamic Instability Stabilize the mother with fluid resuscitation and blood products Delivery via cesarean section is indicated for nonreassuring fetal heart monitoring, life threatening maternal hemorrhage, or bleeding after 34 weeks with documented fetal lung maturity. In general, once a patient has been hospitalized for three separate episodes of bleeding, she should remain in the hospital until delivery. For each bleeding episode, the following are recommended: Hospitalization until stabilized on bed rest with bathroom privileges. Periodic assessment of maternal hematocrit and maintenance of an active type and screen. Red blood cell transfusion as needed to maintain hematocrit above 30% for slight but continuous bleeding. Fetal testing and growth ultrasounds to assess for intrauterine growth restriction. Tocolysis is not warranted unless to administer a course of steroids in an otherwise stable patient. After initial hospital management, outpatient care may be considered if bleeding stops for >48 hr, no other complications exist, and the following criteria are met: the patient can maintain bed rest at home and is adherent to medical care. If the patient and fetus are stable, tocolysis may be considered with magnesium sulfate. Preterm Gestation, Hemodynamic Instability Appropriate stabilization and resuscitation are initiated with rapid delivery by cesarean section. Fetal mortality may be as high as 60% with intact membranes and 75% when membranes rupture. The initial cord insertion at the center of the placenta becomes more peripheral as one portion of the placenta actively grows and another portion does not. Complications Even small amounts of fetal hemorrhage can result in morbidity and possible death, due to the small total fetal blood volume. History the patient usually presents with acute onset vaginal bleeding after rupture of membranes. Typically, fetal tachycardia occurs, followed by bradycardia with intermittent accelerations. Diagnosis Transvaginal ultrasound, in combination with color Doppler ultrasonography, is the most effective tool in antenatal diagnosis. In one study, there was a 97% survival rate in cases diagnosed antenatally compared to a 44% survival rate in those without prenatal diagnosis. Antepartum bleeding of unknown origin in the second half of pregnancy and pregnancy outcomes. Transmission occurs through direct contact with infected saliva, semen, cervical and vaginal secretions, urine, breast milk, or blood products. Symptoms, however, can include fever, malaise, swollen glands, and rarely hepatitis. After the primary infection, the virus becomes dormant, with periodic episodes of reactivation and viral shedding. Most fetal infections are due to recurrent maternal infection and rarely lead to congenital abnormalities. Previously acquired maternal immunity confers protection from clinically apparent disease by maternal antibodies. Ten to fifteen percent of these may later develop symptoms including developmental delay, hearing loss, and visual and dental defects. Unlike recurrent infection, primary maternal infection during pregnancy can often lead to serious neonatal sequelae with neonatal mortality as high as 30%. Fetuses infected earlier in gestation have higher risk of sequelae than those infected in the third trimester. Fetal ultrasound may demonstrate microcephaly, ventriculomegaly, intracranial calcifications, oligohydramnios, and intrauterine growth restriction. The most common clinical findings at birth include the presence of petechiae, hepatosplenomegaly or jaundice, and chorioretinitis.

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