Sonia Ancoli-Israel, PhD

Uterine Factor Infertility Dysfunction in the uterus can prevent the establishment of a pregnancy pregnancy massage purchase kyliformon line. Uterine fibroids are a common finding and occur in approximately 15% to 20% of women over the age of 35 contemporary women's health issues for today and the future 4th edition pdf buy generic kyliformon 25 mg line. In the majority of cases menstrual symptoms vs pregnancy symptoms purchase 25 mg kyliformon otc, the fibroids do not produce symptoms or impact on fertility menstrual ablation buy genuine kyliformon on-line. Fibroids can be located and attached to the outside of the uterus (subserosal) menstrual unusual bleeding order 25 mg kyliformon visa, in the uterine wall (intramural), and in the cavity (submucosal). In the past, it was standard to recommend that asymptomatic fibroids 2 cm or larger be removed. However, the approach has changed since there is a great deal of controversy concerning the role of fibroids on fertility and complicating pregnancy (27,28). Unfortunately, most published studies looking at the effectiveness of a myomectomy are retrospective in design and prospective randomized studies are lacking. This test can be performed in the office if the clinician has access to a vaginal ultrasound. To perform the test, a small catheter is inserted in to the cavity and a syringe filled with saline is attached. Any structure seen within the cavity is considered abnormal and could represent a polyp or fibroid. This is a longitudinal image of the uterus taken at the time of a sonohysterogram. The black area (arrow) is the image of the saline that has been injected in to the uterine cavity. Note that the borders of the uterine cavity are sharp and no masses are noted to be entering in to the cavity. In this image, the injected fluid in the cavity (appearing black) outlines an intracavitary mass, which was later confirmed to be a uterine fibroid. Therefore, it is important that a complete evaluation is performed and the evaluation is not halted after a single abnormal test is encountered. After the evaluation is completed, the couple should be seen in consultation to discuss the results and formulate a treatment plan. Antral follicle count in the prediction of poor ovarian response and pregnancy after in vitro fertilization: a meta-analysis and comparison with basal folliclestimulating hormone level. Age-specific serum anti-Mullerian hormone values for 17,120 women presenting to fertility centers within the United States. Assessment of ovarian reserve with anti-Mullerian ¨ hormone: a comparison of the predictive value of anti-Mullerian hormone, follicle-stimulating ¨ hormone, inhibin B and age. Pulsatile cosecretion of estradiol and progesterone by the midluteal phase corpus luteum: temporal link to luteinizing hormone pulses. Histological dating of timed endometrial biopsy tissue is not related to fertility status. Correlation of endometrial maturation with four methods of estimating day of ovulation. How precise is histologic dating of endometrium using the standard dating criteria Should all infertile males undergo urologic evaluation before assisted reproductive technologies Prevention of acute pelvic inflammatory disease after hysterosalpingography: efficacy of doxycyline prophylaxis. Gadolinium radiologic contrast is a useful alternative for hysterosalpingography in patients with iodine allergy. Hysterosalpingography with oil contrast medium enhances fertility in patients with infertility of unknown etiology. The Practice Committee of the American Society for Reproductive Medicine Educational Bulletin. Preconceptional counseling is an assessment of the medical, social, genetic, environmental, and occupational factors that can impact on fertility and the health of a pregnancy. In this chapter, a comprehensive summary and framework for preconceptional care is presented. The use of tobacco, alcohol, and recreational drugs should be ascertained and the couples appropriately counseled. These habits may not only be harmful during pregnancy but could also impair conception. Smoking Smoking is one of the major public health care issues which continues to challenge the medical community. There are substantial data to support that smoking compromises reproductive health and is considered a reproductive toxin (2). Women who smoke are at greater risk of having infertility, a spontaneous abortion, and a tubal pregnancy. During pregnancy, maternal smoking increases the chances of abruptio placenta, premature rupture of the membranes, and impaired fetal growth. It is clear that any woman who smokes and is contemplating a pregnancy should be strongly encouraged to stop smoking. It is encouraging that 70% of active smokers would like to stop but nicotine is a strong addiction and simple counseling will not prove effective in most cases. Referring the patient back to her primary care physician is prudent for counseling and intervention. Strategies for smoking cessation include behavioral modification, over-the-counter nicotine replacement products, and pharmacologic agents including bupropion and varenicline tartrate. Alcohol Alcohol use during pregnancy increases the risk of several complications and the most concerning complication is "fetal alcohol syndrome," which is associated with altered fetal growth, dysmorphic features, and mental retardation. The risk of fetal alcohol syndrome is related to the degree and timing of alcohol intake but no level of alcohol intake is considered safe. Previous studies have demonstrated that maternal alcohol intake can decrease the chances of conception (5,6). Therefore, any woman who is trying for a pregnancy should limit alcohol intake and avoid it altogether once pregnancy is established. Finally, heavy alcohol intake may suggest an addiction and a history of other drug use should be ascertained. In some cases, referral for counseling may be indicated before the couple attempts a pregnancy. Recreational Drug Use the use of recreational drugs is absolutely contraindicated while a couple is attempting to conceive and during pregnancy. Other drugs used by the mother, such as cocaine and heroin, may lead to a severe neonatal withdrawal reaction. In addition, nutrition impacts on reproductive health can influence the establishment and maintenance of a pregnancy. There is evidence to suggest that we are in the midst of an epidemic of this problem. The rates of obesity in nonHispanic white women, non-Hispanic black women, and Mexican-American women were 33%, 50%, and 45%, respectively. While there may be a genetic or medical explanation for some, the majority of cases of obesity are preventable and simply the result of a sedentary lifestyle and an unhealthy diet. If the trend does not change, obesity may become one of the leading causes of death. A major concern about increased body weight is the increased incidence of complications that may occur during pregnancy including spontaneous abortion, gestational diabetes, hypertension, thromboembolism, congenital anomalies, and stillbirth (8,9). A cesarean section that is performed on a woman who is overweight is associated with a higher incidence of anesthetic and surgical complications. Obesity is responsible for 18% of maternal mortalities and 80% of anesthesiarelated mortalities (10). Guidelines have been published that provide a strategy for the clinician in dealing with obesity in the patient population (11,12). The major differences in the current recommendations include reduced consumption of carbohydrates and increased physical activity. As a general recommendation, women should be encouraged to maintain a balanced diet of grains, vegetables, fruits, meats, and dairy products. Foods with a high content of fats and oils and carbohydrates should be used sparingly. In addition to a wellbalanced diet, caloric intake should be limited to maintain a normal body weight. It is a calculation that takes in to account the weight and height (weight (kg)/height (m2)). Further, caffeine intake during pregnancy is associated with an increased chance of a spontaneous abortion and a low birth weight (13). Therefore, it is reasonable to suggest women who are attempting and during pregnancy to discontinue their caffeine intake altogether or at least limit their intake to one caffeinated beverage a day. The average amount in a cup of coffee, tea, and a can of soda is approximately 100, 50, and 50 mg, respectively. Interestingly, sperm exposed to caffeine-like drugs in the laboratory actually have been shown to enhance motility. Vitamin Supplementation Women who take folic acid prior to pregnancy reduce their chance of having a baby with a neural tube defect. In the United States, the occurrence of neural tube defects is 1 to 2 per 1000 deliveries. Previous studies have reported that women who supplemented their daily diet with 0. Some studies have suggested that folic acid may prevent the development of other birth defects including cardiac, renal, cleft lip/palate, and limb abnormalities (18,19). This can be accomplished either through dietary supplementation or by taking an over-the-counter multivitamin preparation, which contains 0. It is recommended that a woman who has had a previous pregnancy complicated by a neural tube defect or a family history of this defect should be treated with 4. To achieve this level of supplementation, more than one multivitamin (or prenatal vitamin) should not be taken on a daily basis. This will increase the intake of vitamin A over the safe level, which could increase the chances of birth defects. While vitamin supplementation is helpful, excessive vitamin intake can prove to be harmful to the developing fetus. Published data have confirmed that excessive intake of vitamin A increases the chance of congenital anomalies involving craniofacial, cardiac, thymus, and central nervous system organ systems (24). Isotretinoin (Accutane1), a derivative of vitamin A, is used to treat severe acne. Women who take this drug orally during pregnancy have a 25% chance of congenital anomalies (25). Excessive intake of animal liver, a food that is rich in vitamin A, should also be avoided. Supplementation with b-carotene, a precursor of vitamin A, is not associated with a toxic effect. Herbal Remedies Over the past several years, there has been an increase in the use of alternative medical therapies including herbal remedies. Herbal remedies are advertised as "natural" but many have strong medicinal qualities. However, one must exercise caution in their use since there are very few published studies analyzing the effectiveness and safety of these agents especially during pregnancy (26). It is important to ask patients about the use of all medications, including herbal remedies. Many patients do not view herbal or over-the-counter medications as "true" medications. Until published studies confirm the safety of herbal remedies, women should be encouraged to discontinue these agents before and after pregnancy is established. Women age 30 and older who have had three consecutive normal Pap smears should have a Pap smear every three years. In essence, the same tests that are routine for any pregnant woman should also be performed on the woman who is contemplating a pregnancy. A blood type and screen may uncover the presence of an antibody that could increase the chance of isoimmunization. Borderline hypothyroidism during the early stage of pregnancy has been reported to impact on fetal neuropsychological development (28,29). A previous study confirmed that 85% of patients receiving treatment for hypothyroidism required an increase in thyroid replacement during the first trimester of pregnancy, so close vigilance is indicated (30). During the postpartum period, thyroid antibodies can further alter thyroid function and place the woman at increased risk of postpartum depression. Certain infections during pregnancy can pose a health risk to the mother and/or fetus. During childhood, it is public policy to administer immunizations that provide protection against many of these infections. Despite these efforts, a segment of the population remains at risk because of failure to receive the vaccine or failure to convert to immunity following a vaccination. Screening for other infectious diseases may be indicated depending on the clinical circumstances. Rubella (German Measles) Rubella is a self-limited viral infection that is associated with a characteristic rash. A maternal infection during the first trimester of pregnancy can result in fetal death or cause severe damage to the fetal cardiac, neurological, ophthalmologic, and auditory organs. Since the introduction of the rubella vaccine in 1969, there has been a significant reduction in rubella infections and babies born with congenital rubella syndrome. Screening for rubella immune status should be routinely performed on any woman who is contemplating pregnancy. Varicella (Chicken Pox) Varicella is a highly contagious viral infection that is caused by a herpes virus. Most individuals experience a memorable varicella infection during their childhood, which confers lifelong immunity. A nonimmune individual can acquire the infection after exposure to an individual who has a primary varicella infection or herpes zoster (a latent form of varicella). Symptoms of an infection include malaise, fever, and the development of characteristic vesicular lesions.

Urine output is monitored along with central venous pressure and fluid resuscitation is guided accordingly pregnancy sex purchase kyliformon canada. Stroke volume and stroke volume variability are measured through the arterial line breast cancer history kyliformon 25 mg purchase with amex. The stroke volume the catheter is advanced from the right ventricle in to the pulmonary artery breast cancer logo download buy cheap kyliformon 100 mg online, which of the following pressures being recorded from the catheter changes the most As a rule of thumb womens health 5k kyliformon 50 mg order amex, the catheter tip should not require advancement of more than 20 cm beyond its current position before encountering the next vascular compartment breast cancer stages 25 mg kyliformon buy otc. Fluoroscopy can be a helpful adjunct in difficult cases and is especially worthwhile to consider before attempting an insertion from the femoral site. Pulmonary artery saturation, arterial saturation, cardiac output, oxygen consumption E. None of the above Tissues attempt to extract the amount of oxygen required to maintain aerobic metabolism, thus mixed-venous O2 tension falls when O2 delivery (the product of cardiac output and arterial O2 content) becomes insufficient for tissue needs. Depression of venous return may nullify any beneficial effect of improved pulmonary gas exchange on O2 tissue delivery. A rational goal of resuscitative therapy in severe sepsis and shock is to restore balance between O2 delivery and demand, and boosting cardiac output is fundamental to such an approach. Aggressive goal-oriented resuscitation in the earliest phase of management appears to improve mortality in septic patients, whereas the literature is inconclusive as to which patients in other clinical settings benefit from raising cardiac output to normal or supranormal values. Which of the following are needed to calculate oxygen delivery from the data obtained using a pulmonary artery catheter Stroke volume, hemoglobin, pulmonary artery pO2, arterial saturation 58 Surgical Critical Care and Emergency Surgery tional to the voltage drop across a circuit (E) and inversely proportional to the flow of current (I); R = E/I. Upon family arrival they inform you that the patient has had a previous right pneumonectomy for invasive lung cancer and an unknown abnormal heart rhythm. Trans-thoracic echocardiography Relative contraindications to placement of a pulmonary artery cathertization include: tricuspid or pulmonary stenosis, right atrial or ventricular mass, previous pnuemonectomy, cyanotic heart disease, 13. What is the systemic vascular resistance (dyne sec/cm5) of the patient in question This force is a combination of 2 forces: A force that opposes the rate of change in flow, compliance and a force that opposes mean or volumetric flow, resistance. Vascular resistance is derived by assuming that hydraulic resistance is analogous to electrical resistance. Measurement of stroke volume using esophageal doppler is derived from the well established principles of stroke volume measurement in the left ventricular outflow tract using transthoracic echo and doppler. In the control group, the treatment team had no knowledge of lactate levels (except for the admission value) during this period. Lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors. Answer: C Berton C, Cholley B (2002) Equipment review: new techniques for cardiac output measurement- oesophageal Doppler, Fick principle using carbon dioxide, and pulse contour analysis. Rivers E, Nguyen B, Havstad S (2001) Early goal directed therapy in the treatment of severe sepsis and septic shock. He undergoes successful resection and has a temporary abdominal dressing in place for a planned second look operation. The normalization of which of the following is most consistent with successful fluid resuscitation Serum creatinine Blood lactate levels help determine whether oxygen delivery is adequate for the needs of aerobic metabolism. Adding lactate determinations to oxygen transport monitoring provides a more complete assessment of tissue oxygen balance. Ambient light Sickle-cell anemia, causing deformation of hemoglobin and decreasing flow through the microcirculation, may cause an overestimation of readings. Acute bloodloss anemia, by itself, seems to have no affect on 60 Surgical Critical Care and Emergency Surgery the placement of arterial catheters permits reliable and continuous monitoring of arterial pressure and easy repeated blood sampling. Analysis of the arterial pulse pressure curve also may have other applications, including assessment of fluid responsiveness and estimation of cardiac output. The appearance of arterial pressure waves will vary according to the site at which the artery is cannulated. As the arterial pressure wave is conducted away from the heart multiple effects can be observed: (1) the wave appears narrower; (2) the dicrotic notch becomes smaller; (3) the perceived systolic and pulse pressure rise and the perceived diastolic pressure falls. The smaller the diameter of the artery, the more the systolic pressure is overestimated. Most peripheral sensors use two wavelengths of light: those associated with oxygenated and deoxygenated hemoglobin. The presence of carboxyhemoglobin and methemoglobin, which have differing specific wavelengths, cause an overestimation of oxygen saturation. Motion artifact has long been a reason for inaccuracy with peripheral sensors, and despite several attempts at correction, this remains a common cause for alarms that are not associated with actual patient decline. Other causes of pulse oximetry inaccuracy include methylene blue, indocyanine green, indigo carmine (low readings), and black, blue, or green nail polish. A guillotine amputation is performed below-the-knee with application of a negative pressure dressing. Multiple attempts at arterial line cannulation are unsuccessful and finally a left femoral artery catheter is successful placed. In relation to placement of an arterial line catheter, all of the following occur as the distance from the heart increases except: A. She suffers a grade 2 splenic laceration, a grade 1 liver laceration, multiple pelvic fractures, a right femur fracture, a small left occipital subdural hematoma without mass lesion effect and multiple right-sided nondisplaced rib fractures. An external fixation device is used on both the pelvis and femur fractures to provide stabilization. A right radial artery catheter is placed along with a right subclavian vein triple lumen catheter. The presence of a large y descent indicates restriction of right ventricular filling; this can be due to intrinsic stiffness of the ventricular wall or occur in a ventricle that is excessively volume loaded. Loss of the x and y descent argues strongly for tamponade, whereas the presence of a prominent y descent argues against tamponade. The x 61 and y descents are lost in tamponade because the pericardial fluid keeps the pressure inside the pericardium constant. Joynt G, Gomersall C, Buckley T, Oh T, Young R, Freebairn R (1996) Comparison of intra-thoracic and intraabdominal measurements of central venous pressure. Prior to medication administration to facilitate endotracheal intubation, what factors predict difficulty of bag-mask ventilation All of the above Effective oxygenation and ventilation may be difficult or impossible in some patients. Langeron and colleagues described several factors predictive of difficult or ineffective bag-mask ventilation: Age 55, body mass index 26 kg/m2, beard, lack of teeth, and a history of snoring. Difficult bag-mask ventilation was also associated with difficult endotracheal intubation. Clinicians should be aware of these easily identifiable factors as they prepare personnel and equipment for airway management procedures, and should be familiar with failed airway alternatives. Concerning the Mallampati classification of upper airway assessment, which of the following is correct Mallampati first described four classifications of airway visualization to predict difficulty of direct laryngoscopy B. Modifications to the original Mallampati classification simplified its clinical application C. The classification method is accurately predictive of difficult airway management D. The Mallampati classification, while useful, carries a high false-positive rate and should be supplemented with a careful oral and neck examination E. The Mallampati classification has little utilization outside the operating room setting the Mallampati classification was first described in 1985 as a method to predict difficult endotracheal intubation using direct laryngoscopy. With the mouth open and tongue protruded, the visibility of the uvula and faucial pillars is assessed. Class I, or visualization of the entire pillars and uvula, correlates with full visualization of the larynx and vocal cords. Modifications of the original classification scheme added physical characteristics or degree of medical illness in an attempt to improve accuracy. Unfortunately, these complex algorithms appear to result in high false-positive rates of predicting difficulty (as high as 50% in some series). Other factors to consider beyond Answer: E Langeron O, Masso E, Huraux C (2000) Prediction of difficult mask ventilation. He is minimally responsive as paramedics prepare to intubate him for airway protection. No significant cardiovascular response is expected the upper airway contains significant innervation from both the sympathetic and parasympathetic systems. During laryngoscopy, proprioceptors at the tongue base stimulate catecholamine release, leading to hypertension and tachycardia. These physiologic changes may also lead to increased myocardial oxygen use and peripheral oxygen consumption; both detrimental effects that may increase morbidity or mortality in patients with post-traumatic shock or traumatic brain injury. A 47-year-old man with an unremarkable past medical history is referred to you for right groin pain. Electrolytes and evaluation of renal function Many surgeons, anesthesiologists, and certainly administrators believe perioperative testing is one way to avoid unnecessary complications during surgical procedures. In fact, nearly 50­60% of perioperative tests could be eliminated without additional risk to patients or providers. When a careful history and physical suggest no underlying medical conditions, no testing is indicated for patients younger than 40 years of age. This represents the most comprehensive, evidence-based guide to risk assessment for non-cardiac surgery. Beta-blocker therapy has been proven to reduce risk in patients of all ages undergoing non-cardiac surgery B. Beta-blocker therapy only benefits patients over 65, and is therefore not indicated C. While the evidence is not definitive, it strongly supports beta-blocker therapy as early as possible before an intermediate-risk operation D. This patient is high risk, the operation should be delayed until the patient completes at least five (5) days of perioperative beta-blockade therapy Recent randomized trials have failed to reproduce the initial favorable results supporting the use of beta-blocker therapy in noncardiac surgery. Many studies lack adequate power but, when taken as a whole, the recommendations continue to "strongly suggest" benefit. Therapy should be initiated days to weeks prior to planned operations, and long-acting betablockade agents may hold additional benefit over shorter acting alternatives. After intubating the patient in the previous question, a colorimetric carbon dioxide detection device is used to confirm tube placement. Situations which may render this method ineffective and unreliable include all of the following except: A. Ingestion of carbonated beverages Qualitative colorimetic carbon dioxide detection devices are often employed in the pre-hospital environment because of their low cost and durability. Assuming carbon dioxide is detected after ventilation of the airway, several things can alter accuracy of these devices. Antacids convert sodium bicarbonate to carbon dioxide in the stomach and may create a false-positive result. Acute pulmonary embolus, cardiopulmonary arrest, or profound shock with hypoperfusion may render the device useless. Large amounts of carbonated beverages contain high amounts of carbon dioxide and can also provide false assurance about a misplaced tube. The astute clinician employs several methods to confirm correct tube placement and will avoid potentially devastating consequences. Redelmeier D, Scales D, Kopp A (2005) Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study. A 58-year-old man suffers a distal tibia fracture in a motorcycle crash and is admitted to the orthopedic service. Three days later the orthopedic surgeon planning operative repair stops you in the lounge to ask if 7. While she has known coronary artery disease, she has not required stent placement or bypass surgery. Her home medication list, which was never restarted, consisted of aspirin, atorvastatin, warfarin, and lisinopril. Aspirin and warfarin By an incompletely understood mechanism, statin use in the perioperative or injury phase relays a protective effect (plaque stabilization is the most widely accepted theory). Hindler and colleagues, through a meta-analysis, demonstrated a 44% reduction in mortality. Other investigators demonstrated postoperative statin withdrawal was an independent predictor of myonecrosis. Complications began to manifest in patients as early as four (4) days after drug cessation, thus statins should be resumed as early as possible after operation or injury. In contrast, management of the other medications listed is often driven by surgeon or institutional practice, as little evidence exists to guide decision making. Controlled trials have shown equivocal results and the last citation showed potential harm. Answer: D American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization (2003) Practice guidelines for pulmonary artery catheterization: an updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. He is often short of breath after walking back from the mailbox, but improves with rest and is stable on his home antihypertensives and diuretics. Controlled trials show equivocal results 66 Surgical Critical Care and Emergency Surgery progesterone cause relaxation of bronchial smooth muscle and minute ventilation is increased. Despite these favorable changes, the pregnant patient is at high risk for developing hypoxemia during intubation. Functional residual capacity is decreased, because of the gravid uterus, and this effect progresses as the fetus grows. Progesterone also slows gastric motility and relaxes the upper esophageal sphincter, making the pregnant patient prone to aspiration. Early oxygenation, assurance of gastric decompression, proper patient positioning, and thorough preoperative assessment are necessary to minimize potential complications. Not indicated, regardless of functional assessment this clinical scenario describes a patient with stable heart failure. If studies were preformed within 12 months of the planned operative date, new testing may not be necessary.

Grade b: Slow or sluggish progressive motility (sperms may be less linear in their progression) menopause rash discount kyliformon 100 mg buy on line. Coital frequency should be increased in order to improve the chances of conception Medical therapy: Some of these include clomiphene citrate breast cancer 5k columbia sc cheap 25 mg kyliformon with mastercard, tamoxifen womens health 5 oatmeal smoothie purchase kyliformon cheap, gonadotropins pregnancy 6 weeks 5 days best kyliformon 50 mg, antibiotics (for treatment of infection) menstrual after menopause discount 25 mg kyliformon with amex, steroids, etc. A perfectly normal semen analysis report generally precludes a significant male factor component. Abdominal examination: Masses felt in the hypogastrium could be arising from the pelvic region. Per speculum examination: this involves inspection of the following: the distribution of hair pattern on the external genitalia Inspection of the vaginal mucosa to detect abnormalities, such as deficiency of estrogen or the presence of infection Cervical abnormalities. Alcohol consumption must be limited to one or two units, once or twice a week for women. Women who smoke should be advised to quit smoking Treatment of cervical factors: Chronic cervicitis may be treated with antibiotics. This can be performed by depositing the sperms at the level of internal cervical os (cervical insemination) or inside the endometrial cavity Treatment of uterine factors: this involves lysis of uterine septae and uterine synechiae, surgical treatment of uterine anomalies. Treatment of fibroids has been described in Chapter 7 Treatment of tubal factors of infertility: this may include microsurgery and laparoscopy. Tubal obstruction due to elective sterilization is usually repaired using microsurgical techniques. Nowadays, laparoscopic surgical approach is widely being used for the treatment of multiple tuboperitoneal pathologies, especially endometriosis, using techniques, such as electrocautery, endocoagulation, lasers, etc. It consists of retrieving a preovulatory oocyte from the ovary; fertilizing it with sperm in the laboratory, and subsequently transferring the embryo within the endometrial cavity. Follicular aspirations are commonly performed under ultrasonographic guidance Sperm preparation and oocyte maturation: the procedure of sperm preparation involves the removal of certain components of the semen sample. The fertilized embryos are then transferred in to growth media and placed in the incubator. A 4-cell to 8-cell stage, pre-embryo is observed approximately 36­48 hours after insemination Embryo transfer: the procedure of embryo transfer is performed transcervically under guidance of transabdominal ultrasound within 72 hours following fertilization, when the embryo has become approximately 8­16 cells in size. Of all the ovarian neoplasms, most ovarian tumors (80­85%) are benign and occur in the women between 20 years and 44 years. Non-neoplastic cysts of ovary are extremely common and can occur at any age (early reproductive age until perimenopause). These cysts are also known as functional cysts and include follicular cysts, corpus luteum cysts and theca lutein cysts. Tubular androblastoma with lipid storage, Sertoli cell tumor with lipid storage (folliculome lipidique of Lecene) c. However, sometimes they can grow up to 3­4 cm in size Spontaneous rupture of these cysts can cause pelvic pain and bleeding Benign ovarian tumors may sometimes present as massive abdominal swellings (size of a football) Menstrual cycles are usually not affected Benign ovarian tumors may produce pressure symptoms, such as increased frequency of micturition, dyspnea, palpitations, etc. Usually there is no abdominal pain Massive tumors may cause abdominal discomfort and distension. Abdominal Examination the upper and lateral limits of the tumor are usually well-defined, but the lower limit of the tumor cannot be identified the tumor is not fixed either to the skin or underlying tissues Cystic tumors have a tense and cystic consistency. Fluid thrill can be elicited Presence of ascites is indicative of underlying malignancy. It also helps in differentiating between benign and malignant lesions of the ovary. In general, benign lesions are likely to be unilateral, unilocular and thin walled with no papillae or solid areas and thin septae. In contrast, malignant lesions are often multilocular with thick walls, thick septae and mixed echogenicity due to the presence of solid areas. Doppler flow studies of the ovarian artery may also help in differentiating between benign and malignant growths. Therefore, the first line of management involves close observation of the patient Ultrasound-guided cyst aspiration is another option, but is associated with a high recurrence rate If the cyst persists for longer than 2 months, possibility of malignancy must be kept in mind and the patient investigated for underlying neoplastic changes Laparotomy is required in cases of persistent cysts in order to obtain the specimen for histopathology and for its definitive treatment involving removal. Even a benign ovarian tumor may require removal because of the risk of development of malignancy in the long term At the time of laparotomy, various treatment options that can be considered in cases of benign diseases are abdominal hysterectomy with bilateral salpingo-oophorectomy, unilateral ovariotomy, ovarian cystectomy or laparoscopic cystectomy or ovariotomy. Torsion causes occlusion of veins in the pedicle resulting in congestion and hemorrhage. This may cause severe abdominal pain and signs of peritoneal irritation Rupture: this may be traumatic or spontaneous Pseudomyxoma of peritoneum: this commonly occurs with a mucinous cystadenoma. The peritoneal mesothelium is converted in to high columnar cells which secrete mucinous material in to the peritoneal cavity Infection. It is characterized by the presence of many minute cysts in the ovaries and excessive production of androgens. Morphologically there is bilateral enlargement, thickened ovarian capsule, multiple follicular cysts (usually ranging between 2 mm to 8 mm in diameter) and an increased amount of stroma. These endocrine disturbances interfere with ovarian folliculogenesis and result in anovulation. Moreover, these endocrine disturbances are likely to constitute towards an increased risk for development of cardiovascular diseases and diabetes. The levels of androgens and testosterone may also be raised Ultrasound examination: Features of polycystic ovarian morphology on ultrasound scan are as follows. Initially, as the fimbrial end of the tube is open, pus discharge pours out in to the pelvic cavity resulting in the formation of pelvic abscess. Eventually with the sealing of fimbrial end by fibrinous exudates, there is accumulation of pus in the tubal lumen, resulting in the formation of pyosalpinx. Other symptoms: Lower abdominal pain, vaginal discharge, irregular bleeding, urinary symptoms, vomiting, proctitis and marked tenderness on bimanual examination. In an ectopic pregnancy, the fertilized ovum gets implanted outside the uterus as a result of which the pregnancy occurs outside the uterine cavity. Other extrauterine locations where an ectopic pregnancy can get implanted include the ovary, abdomen or the cervix. Acute blood loss in some cases may result in the development of dizziness or fainting and hypotension Many women with ectopic pregnancy may remain asymptomatic. Abdominal Examination Abdominal pain and tenderness Signs of peritoneal irritation (abdominal rigidity, guarding, etc. Pelvic Examination Vaginal bleeding may be observed on per speculum examination Uterine or cervical motion tenderness on vaginal examination may suggest peritoneal inflammation the uterus may be slightly enlarged and soft An adnexal mass may be palpated (with or without tenderness). This usually appears as an intact, welldefined tubal ring (Doughnut or Bagel sign) An empty uterus or presence of a centrally placed pseudogestational sac Cystic or solid adnexal or tubal masses. Non-gynecological Diseases Appendicitis, urinary calculi, gastroentritis Intraperitoneal hemorrhage, perforated peptic ulcer. Surgical treatment in form of open surgery (laparotomy) or minimal invasive surgery (laparoscopy) is the most commonly used treatment option. Abdominal Examination There may be presence of an abdominal lump, which may appear to be arising from the pelvis. It may sometimes also spread to the perinephric regions, resulting in the development of swelling there. Pelvic Examination A rectovaginal examination should be performed to rule out the presence of clots in the vagina or the possibility of an expanding vaginal hematoma. Once the diagnosis of urine discharge is made, the clinician needs to identify its source. Approximately 50­100 mL of methylene blue dye is injected in to the bladder via the catheter. If none of the swabs get stained, but get wet from urine, leakage is from the ureter Ultrasonography: Sonography of the kidney, ureter and bladder must be performed Methylene blue dye test: the bladder can be filled with sterile milk or methylene blue in retrograde fashion using a small transurethral catheter to identify the site of leakage. The posterior vaginal wall becomes the posterior bladder wall and reepithelializes with transitional epithelium. Vitamin C in the dosage of 500 mg orally 3 times per day may be used to acidify urine Pelvic rest: Pelvic and speculum examinations of the vagina must be avoided during the first 4­6 weeks postoperatively because during this time, the tissue is fragile and delicate. Such a woman is often short statured with a contracted pelvis Prior to undertaking surgery, urine sample must be collected by catheterization and must be submitted for culture and sensitivity. Any infection must be treated prior to surgery At the time of surgery, routine excision of the fistula tract is not mandatory Successful fistula repair requires adequate dissection and mobilization of tissues, meticulous hemostasis and reapproximation under minimal tension. This may present as a social and/or hygienic problem the complaints may be minor and situational or severe, constant and debilitating There may be concomitant symptoms of fecal incontinence or pelvic organ prolapse General physical examination: the examination is tailored based on each specific case history. The following parameters must be recorded for each patient: height; weight; blood pressure and pulse. The grading system for urinary incontinence as devised by Stamey (1970) is described in Table 14. These include: Anatomic hypermobility of the urethra Intrinsic sphincter deficiency/weakness. Damage to the nerves, muscle and connective tissue of the pelvic floor is important in the genesis of stress incontinence. Investigations 490 Stress testing: Stress testing should be performed with a full bladder, with the patient in both lithotomy and standing positions. The patient then is asked to cough forcefully and repetitively or to perform a strong Valsalva maneuver. Loss of urine directly observed from the urethral meatus, coincident with the peak of increase in intra-abdominal pressure is strongly suggestive of stress incontinence. Pharmacotherapy: these may include alpha adrenergic drugs (imipramine, ephedrine, pseudoephedrine, etc. Use of weighted vaginal cones is likely to increase the strength of pelvic floor muscles. Biofeedback in form of visual or auditory signals may be an effective method of exercising the pelvic floor Behavioral approaches: Under this approach, the patient is asked to follow a timed, frequent voiding schedule, which helps to minimize incontinence. Various procedures for stress incontinence share the common goal of stabilizing the bladder neck and proximal urethra. Good nutrition helps to maximize tissue integrity and to support good healing Patient counseling: this must comprise of thorough discussion of risks, benefits, anticipated success rates and potential common complications related to the procedure. Nowadays, some of these procedures are performed through laparoscopic and robotic surgery. The other end of the suture passes through a small abdominal incision which is made transversely just above the pubic bone and is carried down to the rectus fascia. Suburethral Sling Procedures and Periurethral Injections these methods are used for stress incontinence resulting from intrinsic sphincteric damage or weakness. Both these methods work by compressing the urethral lumen at the level of bladder neck to compensate for a faulty urethral closure mechanism. Various materials have been used for making slings such as synthetic materials, cadaveric donor fascia, endogenous rectus fascia, fascia lata, etc. Sling operations can be performed using a combined vaginal and abdominal approach and involve midurethral placement of mesh. Various bulking agents have been used including collagen; carboncoated zirconium; ethylene vinyl alcohol; polydimethylsiloxane; polytetraflouroethylene and glutaraldehyde cross-linked bovine collagen (contigen). Most patients are able to void spontaneously in 3­7 days Measures must be taken to control chronic cough and to avoid or treat constipation the patient should avoid lifting anything heavier than 10 pounds for 12 weeks the patient must be instructed to avoid smoking and other activities that may repetitively stress the pelvic floor, resulting in long-term failure of the procedure. Needle suspension procedures may have higher rates of hemorrhage in comparison to the retropubic procedures (5­7% vs 2%) Urinary tract and visceral injury: Bladder injuries can commonly occur with the laparoscopic approach. Injury to the ureter can occur due to kinking or angulation during the retropubic procedures. Rates of rectocele formation also may be increased Other complications: these may include complications such as dyspareunia, chronic suprapubic pain, sinus tract formation, etc. The corresponding urodynamic term is detrusor overactivity, which is evident in form of involuntary detrusor contractions at the time of filling cystometry. The resultant clinical effect is bladder muscle relaxation and increased urethral sphincter tone Musculotropic relaxants: the main smooth muscle relaxant used in these cases is oxybutynin in the dosage of 5 mg, 2­4 times per day Behavior modification: Behavioral interventions help in establishing or reestablishing cortical control over a hyperactive micturition reflex Intermittent catheterization: this type of management is most appropriate for patients with detrusor hyperreflexia and functional obstruction Vaginal prosthetic devices: A disposable vaginal device made of polyurethane has been found moderately effective in patients with detrusor overactivity. Surgical Treatment Surgical therapy should be considered only in severe and refractory cases of urge incontinence and include bladder augmentation procedures; denervation procedures; urinary diversion; sacral neuromodulation, etc. This can best be done if the obstetrician provides them with a full range of safe and effective contraceptive methods and give them sufficient information to ensure they are able to make informed choices. Various contraceptive methods are based on three general strategies: prevention of ovulation; prevention of fertilization or prevention of implantation. Monophasic pills (each tablet containing a fixed amount of estrogen and progestogen) b. Biphasic pills (each tablet containing a fixed amount of estrogen, while the amount of progestogen increases in the luteal phase of the cycle) c. Triphasic pills (the amount of estrogen may be fixed or variable, while the amount of progestogen increases over three equally divided phases of the cycle) Progestogen only contraception: 1. She should be cautioned not to exceed the 7-day pill-free interval between packs If the woman forgets to take a tablet, she should take two tablets the following day Backup method of contraception. Follow-up Follow-up visit after 6 weeks is required to check patient compliance and well-being. Major risks: these include side effects such as venous thromboembolism, myocardial infarction, stroke, gallbladder disease, breast cancer, cervical cancer, etc. However, return of fertility may be slightly late due to delayed return of ovulation. A backup method should be used for 2 days if a woman is more than 3 hours late taking a dose. Backup contraception should be considered during the 1st month when the woman first starts taking minipills and then at midcycle every month thereafter (the time when ovulation is likely to occur). Depression, headache, migraine Weight gain and ectopic pregnancy Mastalgia (breast tenderness) Mood swings Abdominal cramps. Two types of injectable contraceptives are available: progestogen-only formulations and combined formulations (Table 15. The injection site should not be massaged afterwards, since this may accelerate absorption of the drug. It is long acting form of contraception, which is associated with minimal side effects.

A 64-year-old woman presents with ongoing bright red hemorrhage from her tracheostomy tube site 14 days after percutaneous tracheostomy womens health zinc 50 mg kyliformon purchase otc. The immediate goals in treating such patients involve airway protection and temporary control of active bleeding women's health worcester ma buy generic kyliformon on-line. Overinflation of the tracheostomy cuff is successful in temporarily arresting bleeding in 85% of cases breast cancer xenograft models generic 25 mg kyliformon fast delivery. If this is unsuccessful women's health issues in the news order kyliformon 50 mg with visa, the inominate artery may be digitally compressed against the sternum after tracheostomy removal and endotracheal intubation obama women's health issues discount kyliformon online visa. Flexible bronchoscopy prior to the use of these initial measures and transport to the operating room is not advised as it often fails to visualize the area of concern and may exacerbate bleeding by destabilizing clot. A 22-year-old man with multi-organ injury and paraplegia due to a high-speed motor vehicle accident underwent tracheostomy ten days ago. You are called to the bedside because of a report of bright red blood from the tracheostomy site and tube, but are unable to detect any bleeding on your assessment. The diagnostic procedure of choice is flexible and/or rigid bronchoscopy in the operating room, allowing immediate subsequent repair if needed. For the stable patient presented above, immediate invasive treatment is not indicated. Definitive repair after initial stabilization is approached via upper hemisternotomy or more often complete sternotomy. Cervical exploration is never indicated as it does not allow vascular control of the inominate artery prior to encountering the fistula site. Answer: C Ailawadi G (2009) Technique for managing tracheoinnominate arterial fistula. Patients may present with edema of the head, neck and arms, with cyanosis or plethora, respiratory symptoms, or in extreme cases with signs of cerebral edema. A 50-year-old man is transferred to the intensive care unit for new dyspnea and pleuritic right chest pain after an attempted right internal jugular venous catheter placement. The presence of tachycardia and hypotension in this setting is indicative of tension pneumothorax, a life-threatening condition requiring immediate treatment. Tension pneumothorax may be treated by needle thoracostomy with a needle or cannulae of at least 4. Intubation or vasoactive support would not be indicated unless the patient manifested persistent cardiopulmonary compromise after appropriate treatment of his mechanical complication. Mitral valve debridement only Approximately 50% of patients with bacterial endocarditis will require surgical treatment. Indications for surgery in endocarditis include refractory bacteremia or sepsis, recurrent embolic phenomena, congestive heart failure, and myocardial extension. Congestive heart failure from endocarditis that is severe and refractory to medical treatment is the most common indication for surgery for endocarditis, and early surgical intervention has the potential to substantially reduce mortality in this group of patients. The patient above has evidence of cardiogenic shock due to acute severe mitral valve regurgitation from his endocarditis. Mitral valve repair or replacement may be performed, although repair is preferred whenever this can be achieved in concert with the complete eradication of all infected tissues. The requirement for high-dose anticoagulation during cardiopulmonary bypass would present prohibitive risk and would likely be associated with a dismal neurological outcome. He should be treated with continued antibiotic therapy and respiratory/hemodynamic support. If he survives, surgical intervention could be contemplated after an interval of four weeks from his hemorrhagic event. A 54-year-old diabetic man without prior cardiac disease presented to the hospital four days ago with fevers and new left arm weakness. Echocardiography revealed multiple 3­5 mm vegetations on the mitral valve and severe mitral valve regurgitation. The patient has manifested a steady hemodynamic and respiratory decline since admission. Single-stage repair is performed after the patient is weaned from mechanical ventilation. For patients with a fistula in close proximity to the carina in whom effective distal ventilation cannot be achieved, cervical esophageal exclusion may be applied. A 68-year-old man developed a leak with sepsis and multi-organ dysfunction after sigmoid colectomy for diverticulitis. Over the past two days he has developed increasing pulmonary secretions, progressive abdominal distension, and loss of ventilatory volumes. Decompressing gastrostomy, feeding jejunostomy, placement of endotracheal tube cuff distal to fistula C. Several hours after the procedure the patient develops fever, tachycardia, and crepitance in the neck. Esophageal perforation can result from iatrogenesis, trauma, malignancy, inflammatory process, or infection. Iatrogenic injury is the most common cause of esophageal perforation, usually as a result of an upper endoscopy. The diagnosis of esophageal perforation is suspected with history of prior esophageal instrumentation or trauma, but the diagnosis is usually confirmed with a contrast swallow. If operative management is required the surgical approach depends on the location of perforation, and may require a cervical incision, left or right thoracotomy, or laparotomy. Answer: A Altorjay A, Kiss J, Bohak A (1997) Nonoperative management of esophageal perforations. A 17-year-old girl who ingests laundry bleach in a suicide attempt presents to the emergency department with oropharyngeal pain, difficulty swallowing, and excessive drooling. Neck x-rays to rule out perforation Caustic injuries of the esophagus usually result from an accidental ingestion in children or a suicide attempt in adults. The severity of injury to the esophagus depends on the type of agent ingested and the amount and concentration of the agent. Most common ingestions involve acid or alkaline substances, with an alkali ingestion leading to more extensive injury and associated mortality. Acids have a low viscosity leading to rapid transit time through the esophagus and cause a coagulation necrosis that causes a more superficial injury to the esophagus. In contrast, ingested alkalis cause a liquefactive necrosis and deep esophageal injury. Furthermore, alkali substances have higher viscosity, slowing transit time and prolonging exposure to the esophagus. General management of esophageal perforation includes broad-spectrum intravenous antibiotics and fluid resuscitation. Decision for operative versus nonoperative management depends on several factors including location of perforation, cause of perforation, time since perforation occurred, whether or not the leak is contained, and overall status of the patient. In general, patients with a localized perforation (particularly of the cervical 420 Surgical Critical Care and Emergency Surgery the same therapy as those with mild injury but the physician must maintain a high index of suspicion for progression of injury during the next 24­48 hours. Patients initially managed nonoperatively need a gastrograffin swallow or upper endoscopy several weeks after injury to evaluate for stricture formation. Patients with evidence of perforation require emergent surgery via thoracotomy, laparotomy, or both. Blind passage of nasogastric tubes or any attempt to neutralize or dilute the offending agent should be avoided. Clinical presentation after caustic ingestion typically includes oropharyngeal pain, dysphagia, salivation, and may include chest or abdominal pain. Essential in evaluation and treatment of a patient with a caustic ingestion includes early identification of the ingested agent and the amount ingested. Initial evaluation should focus on the airway by physical exam for direct visualization with laryngoscopy or fiber optic nasopharyngoscopy, and with any suspicion of airway compromise the patient should be endotracheally intubated. Further evaluation with chest or abdominal x-rays may indicate evidence of full thickness perforation. The mainstay of diagnosis and evaluation of extent of injury is early endoscopic evaluation within 12­24 hours. Treatment for mild injury seen by endoscopy includes antibiotics, acid suppression therapy, and nutritional support if needed. Which of the following is an important consideration when managing the airway of pediatric trauma patients The length of the trachea in children results in more left main stem intubations than in adults B. The vocal cords are the narrowest portion of the pediatric airway and are commonly the site of obstruction C. Children have an increased functional residual capacity as compared to adults, giving them increased reserve during respiratory compromise Management of the pediatric airway can represent a unique set of challenges. The airway diameter in younger children is typically smaller, the larynx is higher and more anterior, the tongue is proportionally larger, and the trachea is shorter than in adults. The narrowest portion of the airway is at the cricoid ring as opposed to the vocal cords in adults, making this a common location for obstruction. The shortened trachea predisposes to a right mainstem intubation that is poorly tolerated in these patients. Many of the same principles in airway management are similar in children, including supplemental oxygenation, suctioning, and use of oral and nasal airway adjuncts. Infants preferentially are nasal breathers and nasal suctioning can be of great benefit. Care must be exercised in using nasal airways due to the acute angle between the nasopharynx and oropharynx. Surgical airways are avoided in children less than 12 years of age due to collapsibility of the airway and high complication rate. Often, this is unknown and can be best estimated using the Breslow Pediatric Emergency Tape. In adults, massive transfusion can be defined by the loss of one or more circulating volume in 24 hrs, loss of half of the circulating volume in 3 h, or ongoing loss of greater than 150 mL/hr. It was first described in 1982 as a spinal cord injury in the absence of abnormality on plain x-ray and tomography. It is thought to occur through hyperextension, flexion, distraction, and spinal-cord ischemia. The hypermobility of the juvenile spinal column allows for the spinal cord to stretch beyond its ability to withstand injury. Although no radiographic spinal column injury instability is noted, recurrent injury has been documented up to ten weeks after initial injury prompting some to recommend three months of immobilization. Answer: B Pang D (2004) Spinal cord injury without radiographic abnormality in children, 2 decades later. Falls Extremes of Age Blunt injury is much more common than penetrating injury in pediatric patients, making up approximately 86% of all injuries. Motor-vehicle accidents are the leading cause of pediatric deaths, followed by drownings, house fires, homicides, and falls. Similar to adults, males comprise approximately 60% of all pediatric trauma admissions. Cooper A, Barlow B, DiScala C, String D (1994) Mortality and truncal injury: the pediatric perspective. His cranial nerves are intact and he has no peripheral weakness or sensory deficits. Of note, tachycardia is the most important early indicator of hypovolemic shock in the pediatric patient. Systolic blood pressure can give a false sense of security and may not be significantly low until almost 50% of the blood volume is lost. Observation An appreciation of the normal variation of cspine anatomy is important in caring for children. Reviews of normal, uninjured children reveal that this variation occurs in 22­46% of children 8 years old. If the line is more than 2 mm anterior to the anterior process of C2, then it suggests a true dislocation. Because the patient has no neurological symptoms or neck pain, further xrays or immobilization are not necessary. Magnetic resonance imaging would be recommended if neurological symptoms were present, x-rays were 424 Surgical Critical Care and Emergency Surgery present. Shaw M, Burnett H, Wilson A, Chan O (1999) Pseudosubluxation of C2 on C3 in polytraumatized children-prevalence and significance. A 6-year-old, 25 kg girl who was a back seat passenger involved in a motor vehicle crash is diagnosed with a severe splenic laceration. Nonoperative management avoids complications associated with laparotomy as well as overwhelming postsplenectomy infection. This is most important in children less than five years of age who have a serious infection rate of greater than 10%. Nonoperative management of blunt splenic injury is successful in greater than 90% of all children, and is influenced by the grade if injury. Hemodynamic instability is an absolute indication for splenectomy, but splenectomy is also indicated when blood transfusion of greater than half the blood volume (40 mL/kg) is anticipated or when other significant intra-abdominal injuries are 8. Notify child protection services only if the child has a history of prior visits for trauma E. Laws in all 50 states require the examining physician to report all suspicious cases of child abuse to the child protective services for review. Child protective services should be notified for all cases of suspected nonaccidental trauma. The above patient, greater than 28 × 15 mL/kg or 420 mL of blood would be significant enough to justify operative intervention. An 8-year-old, 28 kg boy was shot with a stray bullet in the right chest while riding his bike. Operative management would only be necessary if the child becomes hemodynamically unstable Penetrating thoracic trauma in the pediatric patient is a relatively infrequent occurrence. As with any penetrating trauma, low threshold for operative intervention should be maintained.

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