Edward Anthony Evans, MD

https://medicine.duke.edu/faculty/edward-anthony-evans-md

Parasitic myoma after laparoscopic morcellation: A systematic review of the literature impotence brochures 25 mg veega purchase. Iatrogenic parasitic myoma and iatrogenic adenomyoma after laparoscopic morcellation: A mini-review erectile dysfunction causes and cures purchase 25 mg veega mastercard. Laparoscopic removal of a remaining myoma after vaginal hysterectomy: A case report impotence from alcohol discount veega 75 mg otc. Parasitic peritoneal leiomyomatosis diagnosed 6 years after laparoscopic myomectomy with electric tissue morcellation: Report of a case and review of the literature erectile dysfunction massage 75 mg veega mastercard. Familial clustering of Leiomyomatosis peritonealis disseminata: An unknown genetic syndrome A large uterine size has traditionally been considered a contraindication to laparoscopic and vaginal hysterectomy procedures erectile dysfunction doctors long island discount veega 50 mg on line. With the passage of time, surgical techniques have been refined and laparoscopic instruments have improved, making laparoscopic hysterectomy a safe and effective procedure for large uteri. Although the numbers of laparoscopic hysterectomies have been increasing, this surgical procedure is still under-used when it comes to the large uterus. Total laparoscopic hysterectomy in a uterus enlarged with multiple fibroids can pose several challenges that can result in increased operating time, increased blood loss, and a risk of injury to surrounding structures. These obstacles include limited visualization, less freedom to manipulate a larger uterus, distortion of normal anatomy, and greater vascularity. The challenges of laparoscopic hysterectomy warrant a modified approach tailored to addressing the distinctive pathology. In hysterectomy for large fibroid uterus, proper use of the manipulator and a 30° angle scope allow proper visualization of the uterine isthmus and the lateral and posterior fornices. These eliminate the visual impairment caused by the large fibroid uterus and create a familiar operative field that is very similar to that seen in a normal-sized uterus, thus inspiring confidence and safety. The availability of vessel sealing and ultrasonic devices plays a key role in tackling the varicosities and adhesions. Equipment used should be functional and there must be a backup plan in place to cover any unanticipated malfunction. Patient Position these procedures are performed under general anesthesia with endotracheal intubation. The legs are placed in a low lithotomy position with the hips extended to around 140° to 150°. Allen stirrups or knee braces that are adjustable to each patient are recommended. Once the primary trocar is in place and the pneumoperitoneum is created, the patient is placed in a steep Trendelenburg position. A tilt of 30° or more can provide a better view into the deep pelvis, which is very important while ligating lower pedicles and opening the vaginal vault. A shoulder support can help prevent the patient from sliding on a tilted operating table and avoid injuries. Generally, the higher the primary trocar is, the better the visualisation of the operative field. The distance between the primary trocar and the uterine fundus should be at least 5 to 8 cm to allow an adequate view and space for operation during uterine manipulation, without interference by masses. As for ancillary trocars, the numbers and positions vary, depending on the uterine size, location of fibroids, and complexity of the surgery. They should be placed at the level of the umbilicus or above the level of cornual structures to easily approach the opposite side of the utero-ovarian ligament and the broad ligament without obstruction by the fundus during uterine manipulation. Routine use of nasogastric tube decreases small bowel distension and diminishes the chance of trocar injury to the stomach. Therefore, reducing intraoperative blood loss, decreasing the need for blood transfusion, and the related morbidities are important issues. Vasopressin injection into the lower uterine segment helps in decreasing blood loss without increasing morbidity [11]. Injection of vasopressin 10 units diluted in 100 mL normal saline helps to reduce bleeding especially while using a myoma screw to manipulate the uterus. Intraoperative Devascularization of the uterus by clipping or coagulating the uterine artery can decrease the uterine perfusion; hence, a reduction in intraoperative blood loss can be achieved. Uterine vessels may be ligated at their origin, at the site where they cross the ureter, or where they enter the uterus. Blocking uterine arteries requires the opening of the pararectal space, tracing the lateral umbilical ligaments till their connection with the internal iliac arteries [12], and identification of the ureters [13] to enable safe coagulation or clipping of uterine arteries. The method of clipping the uterine artery with identification of the ureter in addition to reducing the intraoperative bleeding helps to prevent ureteric injury in cervical and broad ligament fibroid. Selective ligation of the uterine artery without adjacent vein gives the uterus a chance to return its blood supply to the general circulation. Complete devascularization includes coagulation of uterine arteries, uteroovarian ligaments if adnexa are preserved, or infundibulo-pelvic ligaments if adnexectomies are performed. The uterine manipulator is used to get a good retraction of the uterus, surgical exposure, tissue tension, and identification of essential anatomy. Lateralization of the ureter by manipulating the uterus also minimizes the risk of injury to vital structures and promotes case efficiency. Uterine manipulation can be achieved by using a vaginal uterine manipulator or a myoma screw or both. Vaginal Uterine Manipulator A variety of vaginal manipulators are available on the market, and the surgeon should choose the one that gives good uterine manipulation for his or her dexterity and comfort. Hysterectomies appeared to be easier with shortening of operation time and decreasing the blood loss. Perioperative Methods Misoprostol has been shown to reduce blood loss and the post operative drop in hemoglobin in a large number of well-designed but small randomized controlled trials [3­5]. Intravenous infusion of oxytocin during surgery causes uterine contractions and decreased uterine perfusion, resulting in less blood loss intraoperatively. Oxytocin 20 U was added to 1000 mL of saline solution running at the rate of 40 mU/min during the course of surgery [6]. Myoma Screw as Manipulator A 5-mm myoma screw can be used as an excellent uterine manipulator, especially in the very large uterus that is irregularly enlarged with multiple fibroids and impacted in the pelvis. It can be used through the right port so that the other two accessory ports are available for insertion of the energy source and other instruments. With a vaginal manipulator, it may not be possible to lift a very large uterus adequately to reveal the posterior fornix. In these cases, the myoma screw helps to dislodge and lift up the uterus from the pelvis and gives adequate traction and makes it easier to access the pelvic spaces around the uterovaginal junction. For the larger uterus, the position of the myoma screw on the uterus often needs to be changed midway through the procedure to a more suitable site to get adequate traction. While the position of the myoma screw is being changed, there can be bleeding from the initial site and this can make the surgery field bloody. A good way to avoid excessive bleeding here is to inject diluted vasopressin to the fundus and the anterior wall of the uterus. Also, while pushing the uterus with a myoma screw to get traction, one should be careful not to perforate through the uterus and hit on bowel or major vessels, which can happen very rarely, especially while taking the right-side pedicles. Usage of a vaginal colpotomizer allows the vaginal fornices to be pushed up so that a distinct endpoint for dissection is created. Use of a 30° scope is essential for proper visualization, especially in the uterus with fibroids in the lower segment. After the uterine vessels and cardinal ligaments are secured on either side, the vaginal vault can be opened anteriorly or posteriorly near the cervicovaginal junction, over the colpotomizer cup with a monopolar hook or other energy source. Excessive coagulation of the vaginal vault should be avoided as it can cause poor healing and increases the risk of vault dehiscence. When the myoma screw is used as a manipulator, the vaginal vault can be opened in any of the following ways: 1. To open the vault, the uterosacral ligament should be incised exactly at the point of insertion at the cervicovaginal junction and the vault is opened laterally. In that case, it is useful to place a sponge on a holder in the vagina and push the lateral vaginal fornix. Incising laparoscopically from inside the abdomen over the resulting bulge helps to easily open the vaginal vault. The third option is to place a reusable vaginal delineator tube, which helps to outline the cervicovaginal junction circumferentially. Unlike the cuffed uterine manipulators that prevent the loss of gas from the abdomen when the vagina is incised, using the myoma screw as the manipulator has the drawback of not maintaining the pneumoperitoneum once the vagina has been opened, and allowing a route for the gas to escape. To overcome this difficulty, a wet pack or a pack inside a surgical glove can be placed in the vagina. Alternatively, the assistant standing in between the legs of the patient to hold the myoma screw can close the vagina with the other gloved hand. The specimen can be removed more efficiently by many techniques for volume reduction, including transvaginal volume reduction, laparoscopic morcellation, a combination of vaginal and laparoscopic procedures, and minilaparotomy [14]. Vaginal Morcellation Generally, the transvaginal technique is preferred, except in women with morbid obesity, narrow vaginal cavity, or round and firm uteri prohibiting downward extraction. During the transvaginal procedure, bisection, morcellation, myometrial coring, vaginal myomectomy, and wedge resection are used to facilitate the process of removing the specimen. A curved clockwise or counterclockwise incision with a #10 blade on a long knife handle under direct vision can be made along the deepest uterine wall simultaneously with rotation and traction of the uterus. The myometrium is incised circumferentially parallel to the axis of the uterine cavity with the scalpel tip always inside the myomatous tissue and pointed centrally, away from the surrounding vagina. If the remaining specimen was stuck in the pelvis because of the large mass or irregular configuration of the uterus, the uterus should be pushed inward a little followed by traction again to keep the largest portion presenting in the vagina. The incision procedure should be repeated until the whole uterus is extracted completely. Different types of morcellation bags are available in different sizes varying from 1500 to 5000 mL, which can accommodate a uterine size up to 15 cm. In case in-bag morcellation or vaginal morcellation is not possible, the option is to perform a minilaparotomy to remove the specimen [15]. Minilaparotomy A minilaparotomy can be performed by enlarging one of the existing abdominal ports or creating a new incision, typically at either the umbilical or the suprapubic location. Manual morcellation of the uterine specimen can be carried out if needed, preferably in a bag. The specimen is grasped, pulled upward, and morcellated by hand with a scalpel in smaller pieces or strips. Adequate uterine manipulation with good tissue stretch makes the procedure simpler. The uterine artery should be coagulated and cut only after opening the uterovesical fold of the peritoneum and pushing the bladder down. The pedicles from the uterine artery and below should be taken very close to the uterus. The cervix is grasped with two tenaculum forceps on both sides and a scalpel is used to make successive cuts on the uterus in an anterior­posterior direction. After each cut on the uterus, the tenaculum forceps are repositioned closer to the upper part of the incision and, with the rotation of the proximal part toward the pubic arch, help the incision to progress to eventually reach the fundus. When the fundus has been reached or when posterior bisection is difficult, the uterus is repositioned in the correct orientation and bivalving continues anteriorly in a similar way. After bisection, one half of uterus is delivered through the vagina, followed by the other half. To avoid a sudden re-ascending of the uterus, a tenaculum should always be holding the residual uterine bulk. Otherwise, with re-ascending, there is the risk that the surgeon may to blindly grasp the uterus inside the abdomen and this can be dangerous for other abdominal structures. Laparoscopic Morcellation Morcellation with electromechanical power morcellation increases the risk of tissue dissemination during morcellation. In benign diseases, it can cause iatrogenic parasitic leiomyomas, inoculated endometriomas, upstaging, and metastasis in possible unknown malignancy. In case of cervical and broad ligament fibroids, opening the pelvic side wall to identify the ureter and clipping the uterine artery at the origin make the procedure safer by helping to avoid injury to the ureter. When the vault is being sutured, it is preferred to take thick bites to prevent vault dehiscence and secondary vault bleeding. Including uterosacral ligaments and pubocervical facia in the suture bites helps to prevent vault prolapse to some extent. While the specimen is being removed, contained in-bag morcellation should be considered wherever feasible, whether the morcellation be abdominal or vaginal. Pushing the myoma screw to left gives an adequate stretch to visualize the right pedicles. Efficacy of pre-operative gonadotrophin hormone releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy: A systematic review. Effect of sublingual miso- prostol on intraoperative blood loss during abdominal hysterectomy: Randomized controlled trial. Preoperative sublingual misoprostol and intraoperative blood loss during total abdominal hys- terectomy: A randomized single-blinded controlled clinical trial. Tabatabai A, Karimi-Zarchi M, Meibodi B, Vaghefi M, Yazdian P, Zeidabadi M, et al. Effects of a single rectal dose of misoprostol prior to abdominal hysterectomy in women with symptomatic leiomyoma: A randomized double-blind clinical trial. Expression of the oxytocin and V1a vasopressin receptors in human myometrium in differing physiologic states and following misoprostol administration. Gene expression studies provide clues to the pathogenesis of uterine leiomyoma: New evidence and a systematic review. Oxytocin-induced cell growth proliferation in human myometrial cells and leiomyomas. Expression of sex hormonebinding globulin, oxytocin receptor, caveolin-1 and p21 in leiomyoma. Laparoscopic-assisted vaginal hysterectomy with uterine artery ligation through retrograde umbilical ligament tracking. Laparoscopic hysterectomy of large uteri with uterine artery coagulation at its origin.

If the phrenic nerve was not bilaterally innervated erectile dysfunction at 20 purchase 100 mg veega overnight delivery, then damage to one cerebral hemisphere would incapacitate the entire contralateral half of the diaphragm gonorrhea causes erectile dysfunction cheap 25 mg veega otc. However erectile dysfunction treatment doctors in bangalore order veega overnight delivery, because of the protective redundancy of bilateral innervation impotence quiz purchase veega online, an individual can suffer damage to a cerebral hemisphere and still retain some function in the contralateral portion of the diaphragm erectile dysfunction medication options purchase generic veega. Because moving the diaphragm is important to sustaining life, the significance of bilateral innervation becomes evident. The primary sensory function of the glossopharyngeal is transmitting taste from the posterior one-third of the tongue and from a portion of the soft palate. The motor function of the glossopharyngeal nerve is to deliver efferent signals to the superior muscles of the pharynx, which are involved in swallowing, and to the parotid gland, which produces saliva (Gertz, 2007). Cranial Nerve X: the Vagus the 10th and largest cranial nerve, the vagus, is perhaps the most important cranial nerve for the speech-language pathologist. The vagus exits the medulla and travels inferiorly to innervate the muscles of the soft palate, pharynx, and larynx. Upon leaving the medulla, the first branch of the vagus innervating a structure important for speech is the pharyngeal plexus. This branch of the vagus innervates most of the muscles of the inferior pharynx and most of the muscles of the velum. The muscles of the inferior pharynx are responsible for pharyngeal constriction, which is used during swallowing; the muscles of the velum are important for sealing off the nasal cavity for production of nonnasal phonemes and for avoiding nasal regurgitation during swallowing. The right vagus nerve passes under the right subclavian artery within the right side of the thorax. The left vagus passes under the arch of aorta of the heart within the left side of the thorax. Both of these branches then immediately change course and pass superiorly back, recurring, into the neck and to the larynx to innervate all the remaining intrinsic muscles of the larynx (those muscles constituting the vocal folds and those responsible for adduction and abduction of the vocal folds). The accessory nerve has a spinal component responsible for innervating muscles of the shoulders, such as the trapezius, but also has a cranial component. The cranial component of the accessory nerve and the functional differences between it and the vagus nerve are poorly understood. The cranial component of the accessory nerve works alongside the vagus (as an accessory to the vagus) and often shares functions with the vagus. The hypoglossal nerve exits the brain stem at a more inferior location on the medulla than any other cranial nerve. The primary role of the hypoglossal nerve is to innervate all the intrinsic muscles of the tongue and most of the extrinsic muscles of the tongue. The intrinsic muscles of the tongue are the muscles that comprise the actual body of the tongue and are responsible for the finer motor movements of the tongue involved in articulation. The extrinsic muscles of the tongue are those muscles responsible for gross movements of the tongue, such as the protrusion and retraction of the tongue. These gross motor movements of the tongue are more likely to be used during mastication and swallowing than during speech. These are the cells in which cognition, speech, and language originate, and they transmit motor impulses from the brain to the body and sensory impulses from the body to the brain. Neuroglia, or glial cells, are cells that provide structural support to neurons and perform other important background functions. Sensory neurons transmit sensory information from sensory receptor cells of the body to the spinal cord or brain for processing. Sensory and motor neurons are concerned with the transmission of information across parts of the body. Interneurons connect to one another within the brain and are involved in processing information rather than transmitting information. Extending from the soma are projections known as dendrites that synapse, or connect, with other neurons. Myelin is a white sheath of protein and fat that insulates the axons of neurons and allows electrical chemical impulses of the nervous system to be conducted much faster than along unmyelinated neurons. Astrocytes are glial cells with multiple essential functions in the central nervous system. They provide structural support for neurons, help to wall off the circulatory system from the neurons, and form glial scar around lesion sites in the central nervous system to restrict the spread of inflammatory processes. Astrocytosis is the protective process of astrocytes forming glial scars to restrict inflammation. Microglia are the immunological cells within the central nervous system that seek out and consume cellular waste products, neural tangles, and damaged neurons and respond instantaneously to invading pathogens. Schwann cells produce the myelin sheath around motor and sensory neurons in the peripheral nervous system. The surface of the cerebrum is the cerebral cortex and is composed of folded tissue that creates gyri and sulci. These folds of cortical tissue enable more neural tissue to be packed into a smaller space. The ventricular system of the brain has four ventricles that manufacture and contain cerebrospinal fluid. The ventricular system helps cushion the brain from trauma but also manufactures and circulates cerebrospinal fluid to deliver nutrients to the brain and to remove waste. The longitudinal fissure divides the cerebrum into right and left cerebral hemispheres. The right and left cerebral hemispheres are connected by a thick band of commissural fibers called the corpus callosum. The right cerebral hemisphere is responsible for interpreting nonlinguistic stimuli such as facial expressions, body language, gestures, prosody, melody, rhythm, and environmental sounds; understanding macrostructure; processing visuospatial information; and attention (sustained and selective). The left cerebral hemisphere is primarily responsible for expressive and receptive language abilities. The cerebrum is divided into four paired lobes: frontal, parietal, temporal, and occipital. The frontal and parietal lobes are divided by the central sulci, which run laterally down the side of each cerebral hemisphere in a vertical fashion. The frontal and parietal lobes are divided from the temporal lobes by the lateral sulci, which run anteriorly to posteriorly at an upward angle through each cerebral hemisphere. Some primary structures of the subcortex are the brain stem, cerebellum, thalamus, basal ganglia, and limbic system. The subcortex is responsible for less volitional and more automatic and visceral functions such as heartbeat, breathing, and sleep­ wake cycles. The brain stem is composed of (from superior to inferior) the midbrain, pons, and medulla. The cerebellum is attached to the pons by the inferior, medial, and superior peduncles. The cerebellum is an error control device and works to create smoothly coordinated and errorless body movements. The thalamus rests on top of the brain stem and is the relay station for afferent signals. The basal ganglia are made up of the caudate nucleus, putamen, and globus pallidus and is responsible for regulation of motor movement, muscle tone, and inhibition of extraneous movements. The limbic system is responsible for sense of pleasure, mating and feeding behaviors, fight-orflight response, as well as emotions, emotional memory, and sense of motivation. The spinal cord, which begins at the medulla, narrows and terminates at the conus medullaris and divides into loose strands of nerves. The internal carotid arteries and the basilar artery transmit blood from the thorax to the brain. The anterior cerebral arteries, middle cerebral arteries, and posterior cerebral arteries transmit blood out to certain portions of the brain. The anterior communicating artery and the posterior communicating arteries link up the internal carotid system with the vertebral/basilar system to form the circle of Willis. The circle of Willis acts as a safety valve to protect the brain from a lack of blood supply. The 31 paired spinal nerves connect the spinal cord to muscles, organs, and glands that usually do not play a direct role in speech production. However, the phrenic nerve is a spinal nerve that innervates the diaphragm, the muscle primarily responsible for inspiration of air into the lungs. It is divided into the temporal and zygomatic branches, which are bilaterally innervated, and the buccal and mandibular branches, which are unilaterally innervated. What are the ridges and valleys of the cerebral cortex called, and why are they there What major band of commissural fibers connects the right and left cerebral hemispheres Name the four lobes of the cerebral hemispheres, and describe the function and any important areas of each lobe that enable those functions to occur. Which sulci run superiorly to inferiorly and divide the frontal and parietal lobes List three structures of the subcortex and identify the main functions of those structures. Describe how a healthy stretch reflex occurs, and describe how a hyperactive stretch reflex contributes to spasticity. In your opinion, which cranial nerve is the most important for speech production and why What are the six most important cranial nerves that are central to the production of speech The mystery and magic of glia: A perspective on their roles in health and disease. Motor speech disorders: Substrates, differential diagnosis, and management (2nd ed. The glia/neuron ratio: How it varies uniformly across brain structures and species and what that means for brain physiology and evolution. The right cerebral hemisphere: Emotion, music visualspatial skills, body-image, dreams, and awareness. Clinicians use the term etiology to refer to the underlying cause of a symptom or deficit. The most common etiologies of neurogenic communication disorders in the general population are stroke, traumatic brain injury, surgical trauma, and degenerative diseases. However, infectious diseases and other conditions can also produce deficits in speech, cognition, and language. It is not uncommon for individuals with neurogenic communication disorders to have an unknown etiology of their deficits or symptoms. The etiologies mentioned in this chapter produce damage to the central or peripheral nervous system. How this damage to the nervous system manifests in deficits in communication, cognition, and behavior is determined by the site of the damage and the severity of the damage. Often, the site and severity of damage to the nervous system are intimately associated with the etiology. It is important for speech-language pathology students to secure a basic understanding of stroke. Strokes are an overwhelmingly common condition encountered in the adult and aging populations. Before tackling the communication disorders that a stroke can produce, students must understand the physiologic mechanisms behind this etiology and be able to recognize the early warning signs of stroke so that medical help can be acquired for the patient before permanent damage to the brain occurs. Stroke: Cerebrovascular Accident A stroke is the result of blood flow to a part of the brain being interrupted by a clot or a hemorrhage. Speech-language pathologists who work in hospitals and other medical settings inevitably work with many individuals who have had a stroke. Strokes can produce damage to any area of the brain or brain stem and therefore can create most any type of neurogenic communication disorder or cognitive deficit. Although the actual percentage of individuals experiencing communication difficulties following stroke is unknown, studies show that the presence of aphasia alone among individuals who have had strokes can be as high as 41. Specifically, a stroke is when brain tissue is either permanently destroyed or temporarily ceases to function as a result of decreased or absent blood supply to the affected area. When brain tissue is permanently destroyed, the body reabsorbs the dead cells, and an empty space is left on the cortex or within the brain where the tissue once was. During a stroke, a primary source of damage to brain tissue is from the loss of oxygen supply resulting from a lack of blood supply, which transports oxygen-rich blood to the brain. Typically, the brain can go 6 to 8 minutes without oxygen before anoxia begins to cause permanent cell death within the brain. It is therefore extremely important to be able to recognize quickly when an individual is experiencing a stroke so that appropriate medical care can be acquired. Typically, strokes can produce immediate deficits in cognition and language as well as weakness and difficulty seeing, hearing, and balancing. An occlusion in a blood vessel deprives brain tissue of the blood supply necessary for survival of the tissue. Atherosclerosis is a condition in which a person has a buildup of fatty materials such as cholesterol in the blood, and this material accumulates slowly over time on the walls of arteries, narrowing them and eventually restricting blood flow. A mass, such as a blood clot, that originates in the body and travels through the vascular system is known as an embolus. An embolic stroke occurs when an embolus, formed elsewhere in the body, travels to the brain and lodges in a blood vessel, restricting or cutting off blood circulation within the brain. A piece of a thrombus can become an embolus (a thromboembolus) if, for instance, a piece of thrombus breaks off an arterial wall and travels elsewhere within the brain to lodge and create an occlusion within a blood vessel. Transient ischemic attacks usually do not cause permanent deficits or life-threatening health issues. When an ischemic stroke occurs, the portion of brain tissue that is immediately deprived of the necessary level of blood flow to survive dies within an hour. The ischemic penumbra is the area of tissue that, although it has lost the appropriate level of blood supply to function, still receives enough collateral blood flow from other vessels to stay alive. The penumbra is important because, whereas the core has experienced permanent tissue damage, the tissue within the penumbra can often be salvaged with prompt and appropriate medical treatment. This means that with timely medical intervention the brain tissue within the penumbra can be saved.

Efficacy and safety considerations in women with uterine leiomyomas treated with gonadotropin-releasing hormone agonists: the estrogen threshold hypothesis erectile dysfunction and prostate cancer veega 100 mg order on-line. Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/ or multiple fibroids erectile dysfunction young order veega online now. Despite several medical and other non-medical management options for symptomatic fibroids impotence thesaurus veega 75 mg low price, myomectomy remains the most common approach in women desiring fertility or preservation of their uterus or both erectile dysfunction washington dc order 50 mg veega fast delivery. An outline of these risk factors is presented by critically appraising the current literature available on this subject drugs for erectile dysfunction order veega american express. It is reasonable to recommend that steps be taken to recognize an inadvertent entry into the uterine cavity. However, there was no significant difference for the risk of "secondary" cesarean section between the two groups (P = 0. The available evidence in the literature does not contraindicate a childbirth per viam naturalem with a previous myomectomy, regardless of the surgical technique [5]. However, this requires caution as there is a paucity of data to support this belief and therefore the evidence is graded as low. As the majority of the myomectomies are performed in the corporeal part of the uterus versus a lower uterine segment incision during a cesarean section, this could partly explain the aforementioned difference. Awareness to avoid a multiple pregnancy with a history of myomectomy especially should require more attention when assisted reproductive treatments are offered to this patient population, thereby preferring a single embryo transfer in in vitro fertilization and avoiding ovarian stimulation in intrauterine insemination [10]. The literature is scarce around the correct myometrial thickness post-myomectomy for vaginal delivery attempts, but recommendations on thickness of the lower uterine segment in gravid women who have a history of cesarean section have suggested a threshold of 2. However, the retrospective nature of study does imply that complete data were missing on specific surgical techniques, including the learning curve ­ both during the uptake of laparoscopy and the individual variation in skill set alongside this learning curve among the 20 surgeons involved U. Given the difficulty to achieve evidence from a randomized trial in assessing the outcomes after myomectomy because of obstetrical issues, the retrospective cohorts on a large scale can help tailor the clinical practice when used within the limits of the clinical characteristics of the individual patient. The residual strength of the myometrium after a myomectomy procedure is determined by a combination of factors consisting of the number of fibroids excised, their size and location, identification of a correct cleavage plane, entry into the uterine cavity, and completeness of the excision. In regard to adenomyomas, the depth and extent of the lesion, the time to local inflammation exposure, and the amount of extirpation play pivotal roles in weakening of the uterine muscle. As adenomyosis infiltrates the normal myometrium, its excision subtracts myometrial mass from the total uterine volume, therefore producing scars with reduced tensile strength [10, 14]. High-frequency electrosurgery is a commonly used surgical tool in the form of monopolar and bipolar devices and has the advantage of reduced blood loss when compared with cold knife/cold scissors. However, as cauterization heat leads to denaturation of proteins and clots, it causes high fibrin deposition and highly cohesive agglomerates affecting angiogenesis, adhesion formation, and tissue healing, whereas the discoloration makes the margins of the dissection planes of resection less clear, which also can lead to wound dehiscence. The presence of neuropeptide substance P and vasoactive intestinal peptide in the pseudocapsule of uterine myomas may affect wound healing and myometrial function in subsequent pregnancy. These can be preserved by avoiding excessive coagulation to protect the pseudocapsule neurovascular bundle and by using the intracapsular myomectomy technique proposed by Tinelli et al. A good hemostasis after fibroid enucleation is important to facilitate optimal healing. Severe postoperative pain following a myomectomy can indicate a hematoma of a hysterotomy wound, which can be diagnosed by ultrasound scan [4]. Diluted vasopressin can be used around the fibroid wall (extracapsular) to minimize the bleeding during dissection, whereas a selective diathermy of larger vessels only with a bipolar is preferable to monopolar. Excessive coagulation and carbonization, especially of the micro bleeders, should be avoided [9, 10, 18]. Furthermore, correct suturing technique is paramount to achieve good wound healing. Excessive tension sutures or incomplete approximation of edge-to-edge seromuscular planes can be a risk factor for tissue necrosis, increased scarring, and collagen deposition which can contribute to a weak myometrium exposed to the risk of rupture during pregnancy and labor. The literature reports that, depending on the depth of fibroid into the myometrium, single- or double-layer sutures can be used [19]. Intramural fibroid enucleation often requires a double-layer suture, especially when more than 50% of the myometrial thickness is involved [4, 10, 18]. The potential value of multiple-layer stitching was reflected by the multicenter, casecontrol study by Bujold et al. Nowadays, barbed sutures, such as Stratfix, are used by some for continuous suturing of the myometrial layers which not only can reduce operative time but also can increase the tensile strength of the defect. The suture pedicles should be inside the wound, and the serosal layer can be closed by performing mattress suturing, which can minimize the rough area left and thereby reduce the risk of adhesions [4]. Utilization of hemostatic oxidized regenerated cellulose or other physical anti-adhesive barriers has been documented by some but there is no conclusive evidence about their effectiveness at present. Furthermore, another causal relationship is a higher potential of the myometrium to produce leiomyomas as myometrial cells can undergo spontaneous chromosomal rearrangements to initiate proliferation of myoma cells in unicellular growth [30]. About 50% of the patients with incomplete resections required surgery within 2 years. Pregnancy after myomectomy was shown by the same authors to increase the risk of recurrence by 2. A combined effect of increased growth factors and estrogen and progesterone during pregnancy is potentially the attributing factor [35]. However, some authors have also reported a reduced risk for reoperation among patients who achieved subsequent parity [32, 33, 36]. The mechanism for the latter relationship remains unclear, but postpartum uterine remodeling has been suggested to lead to selective apoptosis of the residual small lesions [37]. A similar correlation with regard to preoperative use of the selective progesterone receptor modulator, ulipristal acetate, was proposed recently [41]. However, there remains a paucity of data on this potential correlation with mixed results, which does not allow us to ascertain these risks [42]. In addition, a significantly higher recurrence rate was found in this subgroup of patients who had coexistent endometriosis. Their results also suggested a superiority of an open adeno-myomectomy as surgical approach when more than 5 cm adenomyoma is involved to facilitate a complete excision [43]. These results need to be interpreted with caution as further studies with a larger subset of patients are required to confirm these findings. Furthermore, no statistical difference was noted in antiMüllerian hormone between the groups preoperatively or at 3, 6, and 12 months postoperatively [44]. However, there is currently no convincing biological rationale for reduction in recurrence rate associated with uterine artery occlusion at the index surgery. However, these results should be interpreted with caution as fibroid recurrence was evaluated as a secondary outcome whereas only a small number of the included studies reported data on recurrence rates and the follow-up time was relatively short. Whereas some report a lower recurrence rate when index surgery was performed at an age of less than 35 years, others have reported a decreased recurrence rate in patients operated after the age of 35 years and some have found no relationship [29, 30, 32]. Certain histopathological characteristics have been suggested to be linked to a higher risk of recurrence. Therefore, a long duration of follow-up is important because of their potential of recurrence, although a hysterectomy should be performed as first-line treatment if fertility preservation is not an issue. The hormonal imbalance caused by increased peripheral aromatase activity is potentially an attributing factor. Although there is a lack of evidence regarding entry into the cavity, many obstetricians seem to be influenced by this when deciding for mode of delivery. In addition, a complete excision, identification of a correct cleavage plane, and avoidance of excessive cauterization with high-frequency electrosurgery are the other main factors to prevent the undermining of residual myometrium during a myomectomy. The literature classically demonstrates a publication bias due to systematic under-reporting of iatrogenic complications, which calls for more solid scientific evidence by means of randomized controlled trials. In addition to this, this chapter contains information appearing in English publications only and mostly consisting of observational studies, which therefore can represent a selection bias. The risk of uterine rupture after myomectomy: a systematic review of the literature and meta-analysis. Optimal timing and mode of delivery after cesarean with previous classical incision or myomectomy: a review of the data. Risk of uterine rupture and placenta accreta with prior uterine surgery outside of the lower segment. Report of 7 uterine rupture cases after laparoscopic myomectomy: update of the literature. Prediction of complete uterine rupture by sonographic evaluation of the lower uterine segment. Prospective comparison of delivery outcomes of vaginal vagina births after cesarean section versus laparoscopic myomectomy. Prospective evaluation for the feasibility and safety of vaginal birth after laparoscopic myomectomy. Pregnancy outcomes and risk factors for uterine rupture after laparoscopic myomectomy: A single-center experience and literature review. Laparoscopic myomectomy focusing on the myoma pseudocapsule: technical and outcome reports. Uterine rupture, perioperative and perinatal morbidity after single-layer and double-layer closure at cesarean delivery. Pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure. Effect of pregnancy on recurrence of symptomatic uterine myomas in women who underwent myomectomy. Risk of recurrence of uterine leiomyomas following laparoscopic myomectomy compared with open myomectomy. Clinical and histopathologic predictors of reoperation due to recurrence of leiomyoma after laparotomic myomectomy. Recurrence of uterine myoma after myomectomy: Open myomectomy versus laparoscopic myomectomy. Recurrence factors and reproductive outcomes of laparoscopic myomectomy and minilaparotomic myomectomy for uterine leiomyomas. The use of ulipristal acetate (Esmya) prior to laparoscopic myomectomy: help or hindrance Comparisons of the efficacy and recurrence of adenomyomectomy for severe uterine diffuse adenomyosis via laparotomy versus laparoscopy: a long-term result in a single institution. Laparoscopic myomectomy with temporary bilateral uterine artery and utero-ovarian vessels occlusion compared with traditional surgery for uterine fibroids: blood loss and recurrence. Surgical outcomes after uterine artery occlusion at the time of myomectomy: systematic review and meta-analysis. Uterine smooth muscle tumor of uncertain malignant potential: fertility and clinical outcomes. Uterine smooth muscle tumor of uncertain malignant potential: a retrospective analysis. Immediate complications include intraoperative hemorrhage, requirement for blood transfusion [1], risk of hysterectomy due to uncontrollable bleeding, and conversion from a minimally invasive route to laparotomy. Short-term complications include febrile morbidity, bleeding, infection, and thromboembolism [2]. Long-term complications include pelvic adhesions [3], post-myomectomy intrauterine adhesions, recurrent fibroids [4], and associated risk of uterine rupture in subsequent pregnancies [5, 6]. Intraoperative blood loss is deemed one of the most significant of the lot; thus, principles of myomectomy and measures (both preoperative and intraoperative) to decrease intraoperative blood loss [7] have been extensively described in the literature. Evidence regarding secondary hemorrhage after myomectomy and its etiology and management is sparse; the evidence is limited to a few case reports and case series and its incidence has yet not been documented in the literature. Secondary hemorrhage after any surgical procedure usually happens after 7­10 days of surgery and is most often linked to local infection. It may be of varying intensity from minimal spotting to life-threatening exsanguination. However, most evidence related to secondary hemorrhage following myomectomy is related to the development of pseudoaneurysms of the uterine artery. These have been reported as early as 7 days [8] to as late as 97 days [9] after surgery. Pseudoaneurysm is a complication of vascular injury secondary to trauma or inflammation. It is a blood-filled cavity that communicates with lumen of the artery because of a focal deficiency in all three layers of the arterial wall [10, 11]. Pseudoaneurysms have been reported after uterine curettage, abortion, normal vaginal delivery, and cesarean section [10, 12­14]. Removal of the myoma or postmyomectomy local site infection can very rarely lead to disruption of a small part of the three-layered wall of the uterine artery with extravasation of blood and formation of a pseudosac in the myometrium. As more blood dissects into the myometrium, the pseudosac enlarges and can communicate with the uterine cavity and its rupture can lead to torrential bleeding per vaginum [15]. The exact incidence of uterine artery aneurysm after myomectomy is unknown [15] and these may be largely underreported as their presence may be realized only when they lead to hemorrhage. If bleeding does not respond to conservative approaches, conventional surgery and pelvic angioembolization must be kept in mind. As evidence suggests, for any patient with secondary hemorrhage after myomectomy (hysteroscopic, laparotomy, or laparoscopic), a high index of suspicion for a pseudoaneurysm must be kept in mind. On ultrasonography, a pseudoaneurysm appears like a well-defined hypoechoic/anechoic cystic structure which may be associated with a hematoma at the previous myomectomy site [16] with turbulent blood flow on color Doppler. Even in the absence of a pseudoaneurysm, if there is an obvious bleeder on angiography, embolization of the uterine artery has been shown to be a safe and effective method in stopping hemorrhage from its pseudoaneurysm/bleeding branch, as shown in various past studies. At the time of embolization, it is important that along with all the major feeding vessels, collateral supply from the opposite uterine artery is also taken care of to prevent a recurrence and rebleed. The first report of transarterial embolization for secondary hemorrhage after myomectomy was made by Zorlu et al. On angiography, the authors found bilaterally dilated uterine arteries with complex dispersion of distal parts of the artery on the side of removal of myoma.

As with all chronic conditions erectile dysfunction cures veega 75 mg order without a prescription, preconception care should be available to ensure these women have their condition assessed protocol for erectile dysfunction buy veega overnight, medications reviewed and health optimised before becoming pregnant erectile dysfunction natural treatment reviews order generic veega from india. Tests in the preconception period also establish a baseline on which to compare developing trends in pregnancy6 erectile dysfunction treatment at home order veega overnight. Preconception planning allows time to improve health in conditions such as diabetes and hypertension impotence cures natural veega 100 mg order visa. Some women with a renal disease that has a genetic component will require genetic counselling1. During pregnancy the renal function should be closely monitored with regular blood and urine testing. Careful regular screening for, and treatment of, urinary tract infection will be carried out, and prophylactic antibiotics may also be used for those with recurrent renal system infections22. There is an increased risk of hypertension developing or worsening for all women with renal disease, and this must also be assessed regularly and treated as appropriate. Pregnancy is a hypercoagulable state, and this is exacerbated by heavy protein loss. The mechanism for the association between protein loss and increased coagulation is unclear but may be through renal loss of smaller anti-thrombotic proteins26. If the protein:creatinine ratio is greater than 100 mg/mmol, and there are any other risk factors for venous thromboembolism such as obesity, low molecular weight heparin prophylaxis throughout pregnancy and for six weeks postpartum may be indicated22. In addition to the routine scan to confirm gestation age, a detailed ultrasound scan at around 20 weeks, and regular growth scans (at least every four weeks), is advocated to review fetal well-being. A Doppler assessment of uterine artery blood flow at 20­24 weeks is recommended as a base to assess fetal growth restriction1. If renal function declines to the stage where dialysis is required, the woman may be offered the choice of terminating the pregnancy, but her renal function may continue to decline even after the pregnancy is stopped. Time of birth will be determined according to fetal complications and maternal renal function. Due to compromised renal function, fluid overload can occur at any time in the woman with renal disease. However, this is much more likely in labour, when intravenous fluids are commonly used. Observation for respiratory signs and symptoms (shortness of breath, rising respiratory rate, decreased oxygen saturation levels, frothy sputum and crackles heard during lung auscultation) is necessary. Strict fluid balance which will include hourly urine output measurement, must be observed and documented clearly. Arterial blood gas analysis may indicate metabolic acidosis, and this may also need urgent treatment. Renal assessment continues as necessary, and the midwife should ensure that appropriate follow-up is organised. Follow-up will aim to identify any post-pregnancy deterioration of renal function, particularly in the six months after birth28. Contraception and the need for preconception care before the next pregnancy should be discussed. Specific details concerning each particular organ is given in the relevant chapter. The usual advice to a woman following solid tissue transplant is to wait one to two years, using reliable contraception, before becoming pregnant29. This is to allow the graft function to stabilise and necessary immunosuppressant medication to be reduced to maintenance level. Many drugs can be altered to divided doses, to avoid peaks that may affect a fetus. Since many transplant procedures result in an underlying chronic hypertension, cardiac screening for baseline information may be undertaken prior to pregnancy. General health should be assessed, paying particular attention to nutrition, obesity, anaemia, proteinuria, smoking and alcohol intake, to ensure optimum well-being. Medication taken following a transplant may need regular monitoring of serum levels as the haemodilution effect of pregnancy may adversely affect them. As steroids are often used routinely by women following an organ transplant, particular care needs to be taken to avoid infection. Screening for gestational diabetes should be undertaken, although the literature is not in agreement as to an increase in occurrence5, 29. Fetal surveillance is vital, considering the large number of low birth-weight babies born to women following an organ transplant. Depending on individual situations, all women may be offered regular growth ultrasound assessment, and many will also have regular liquor volume estimation and Doppler tests. It is vital that an accurate assessment of where the donor organ is situated, and whether the original organ remains, is undertaken before any procedure is carried out. The midwife needs to ensure these records are available for every woman, as even planned vaginal deliveries may turn into a Caesarean section. Transplant surgeons often attend Caesarean sections to offer obstetricians specialist advice. Any medication dosage increase during pregnancy should be assessed and perhaps reduced as the haemodilution effect of pregnancy is lost. Breastfeeding needs to be assessed according to the drugs the woman is taking, but if they are safe, then breastfeeding should be encouraged. It is suggested that contraception advice is given to those waiting for transplants, as any reduced fertility is usually restored very soon after the transplant, and the advice is to wait to conceive until the graft is stable and medication optimised, usually one to two years. Pre-eclampsia is common (15­25%)30, but usual screening for pre-eclampsia may be problematic as many women may have degrees of hypertension and proteinuria, together with abnormal renal function tests, including raised uric acid. However, as symptoms of organ rejection may not be obvious, monitoring serum creatinine is usual, and since these levels normally decrease in pregnancy, any rise should trigger further investigations34. There are usually no general contraindications to a vaginal delivery in a woman with a kidney transplant29, but there is a high Caesarean section rate. The risk of damage to the transplanted organ during Caesarean section is estimated to be 1­2%35. Assessment of children born to mothers following a renal transplant has been made. Results have demonstrated that despite high rates of preterm births, and neonates that were small for gestational age, there was a good recovery of growth during the first year36. However, they face considerable challenges as they consider the uncertainty about their own long-term health and the risks to the baby38. In the past women were simply told by the specialist that they should not conceive, but nowadays an approach that emphasises the woman as a partner in care and not just a passive recipient of advice is valued. Understanding the concerns of women who do choose pregnancy will prompt midwives to give opportunities for women to voice their concerns and for midwives to provide care tailored to their needs. Continuity of care and timely access to specialist advice will enhance their experience. Many women report a sense of physiological breathlessness, and the challenge for midwifery care is to distinguish this normal breathlessness from that associated with deteriorating health and/or cardiac disease (see Chapter 2). There are a number of respiratory disorders the midwife may encounter in clinical practice (see Box 5. Women with cystic fibrosis are now more likely to consider having a baby due to advances in the management of this condition. Sarcoidosis is a condition that develops at different sites in the body but more usually affects the lungs and lymph nodes in the chest. Whilst it more commonly improves in pregnancy, midwives need to recognise features of sarcoidosis flare and other complications associated with this condition. Pulmonary embolism and pulmonary oedema are both life-threatening conditions that are more common due to the physiological changes in pregnancy. The recognition of deteriorating maternal illness including the recognition of a raised respiratory rate and falling oxygen saturations are key midwifery skills. Women with cystic fibrosis and other lung conditions should be screened for this prior to embarking on pregnancy. Both women who died from asthma were smokers, reminding us of the importance of support for smoking cessation, not just in relation to asthma but for a range of complications for mother and fetus/newborn. Nasal congestion that can make intubation diffcult Increased risk of infection Change to coagulation increases susceptibility to pulmonary embolism Need to deliver baby to ventilate the mother effectively 30% in oxygen consumption due to metabolic demand for oxygen by maternal body and fetoplacental unit Lower reserves of oxygen and a greater susceptibility to hypoxia Position of diaphragm rises as fetus grows, impeding ventilation transverse diameter of chest ­ this may make it more diffcult to clear secretions Mild respiratory alkalosis ­ facilitates fetal /maternal gradient gas exchange although subjective feelings of breathlessness are common. Women may experience nasal congestion and notice a change to the tone of their voice. These symptoms can be exacerbated by oedema and fluid overload associated with pre-eclampsia, making endotracheal intubation more difficult6. The inner lining of the trachea is a cilia-lined mucus membrane which wafts mucus and particles upwards. A cough reflex is generated via the vagus nerve to expel mucus and/or foreign material from the mouth. The diameter of the air passages is therefore altered by the contraction or relaxation of these involuntary muscles. Asthma is a condition whereby a range of factors cause inflammation, narrowing of the airways, and contraction of the smooth muscle of the airway walls (bronchospasm). Lung volumes will be affected by the elasticity and compliance of the lungs and by the resistance created by narrowing or distension of the airways. There are a number of changes to lung volumes in pregnancy in 144 DisorDers oF tHe resPirAtorY sYsteM response to an increased demand for oxygen and driven mainly by increased levels of progesterone the pregnant woman at rest increases her ventilation by breathing more deeply rather than more frequently7. This will help maintain normal oxygenation, but can contribute to a sense of breathlessness, which is experienced by up to 75% of women during pregnancy. These alterations in lung volumes are due largely to anatomical changes which allow greater lung expansion. The lower ribs flare, increasing the transverse diameter of the chest by 2 cm and the subcostal angle increases. Relaxation of the soft tissues of the rib cage is caused by increasing levels of the hormones, progesterone and relaxin, which contribute to increased rib cage elasticity5. As a consequence, there is a normal, mild, fully compensated respiratory alkalosis in pregnancy with arterial pH at around 7. As pregnancy progresses, the uterus displaces the diaphragm upwards by about 5 cm, decreasing functional residual capacity although the thoracic rib cage has splayed out to help compensate for this4. These changes may make it more difficult for pregnant women to clear secretions, which is one of the reasons they are more at risk of pneumonia. The presence of the fetus makes emergency artificial ventilation of the lungs more difficult and therefore in cases of maternal cardiorespiratory resuscitation it is recommended that urgent Caesarean section is performed to enable the best chance of recovery for the mother8. Changes in acid-base status due to this hyperventilation and increased oxygen consumption are potentially hazardous to both mother and fetus. Sometimes mothers experience tingling and dizziness as a result of hyperventilation. The woman should be encouraged to slow down her rate of breathing, relax, and breathe more deeply between contractions in order to promote oxygenation5. After delivery of the baby, blood gases return to pre-pregnant levels within 24 hours of delivery with anatomical and ventilatory changes taking one to three weeks9. The respiratory rate at rest is 12­15 breaths per minute, and breathing should seem relaxed. Women whose respiratory rate has increased at rest will begin to talk in short sentences, pausing to take a breath. When breathing becomes difficult, such as during an asthmatic event, inspiratory accessory muscles in the neck and abdomen may be used, raising the sternum and ribs. Wheezing characteristically occurs in asthma as air is forced through the narrowed bronchial airways10. When recording the oxygen saturation, it is important to note whether the measurement is taken in room air or with supplemental oxygen. Poor perfusion, movement, carbon monoxide (smoking) and dark nail polish may affect readings. The probe should be repositioned every four hours and the probe site observed for complications, ensuring good blood flow and avoiding pressure damage. This will provide an assessment of levels of oxygen, carbon dioxide and any acid-base disturbance. It is assessing the effectiveness of ventilation, gaseous exchange and blood supply. However, it is useful for midwives to have a basic knowledge of the normal ranges (see Table 5. When taking a chest X-ray the woman is asked to breathe in deeply and hold her breath while the X-ray is taken. When a woman requires a chest X-ray when she is pregnant, the uterus can be shielded with a lead apron. If the airways are narrowed, such DisorDers oF tHe resPirAtorY sYsteM 147 tAbLe 5. This reading therefore assesses the effectiveness of ventilation Bicarbonate is an alkali. Oxygen saturation is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry. It is measured by a spirometer and its normal values are also unaffected by pregnancy4. The inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough, and symptoms are more common at night or in the early morning (Box 5. There are 148 DisorDers oF tHe resPirAtorY sYsteM two mechanisms of airway obstruction: bronchial hyper-responsiveness and airway inflammation. Asthma involves an abnormal response of the airways, making them constrict easily in response to a wide range of possible stimuli (see Box 5. In addition, the bronchial mucosa of the airways is chronically thickened with inflammatory cells. When exposed to these stimuli, the airways become swollen, constricted and filled with mucus. This narrowing of the airway is usually reversible either spontaneously or with treatment.

Stroke volume is determined by the volume of blood in the ventricles before they contract erectile dysfunction drugs prostate cancer buy discount veega 75 mg on-line. Venous return is enhanced when lying flat statistics of erectile dysfunction in india proven veega 75 mg, although in a pregnant woman compression of the inferior vena cava in the supine position decreases venous return erectile dysfunction pumps cost buy veega visa. A reduced cardiac output caused by a decreased venous return will result in decreased blood flow to the uterus with reduced perfusion to the placenta and fetus erectile dysfunction bipolar medication purchase veega 50 mg overnight delivery. If the woman does have to lie flat guaranteed erectile dysfunction treatment discount veega 100 mg on line, efforts need to be made to rotate her pelvis so the uterus tips away from the inferior vena cava3. Muscle contraction around vessels, when walking for example, helps propel blood towards the heart. During inspiration of air the expansion of the chest creates a negative pressure within the thorax, drawing blood towards the heart. Heart rate and increased blood volume are the main factors in determining the increasing cardiac output of pregnancy7. Women with multi-fetal pregnancies have a greater increase in cardiac output than do those with singleton pregnancies5. Pregnant women often experience reduced exercise tolerance, tiredness and dyspnoea, and women with heart disease may not tolerate this dramatic increase in cardiac output. The gravid uterus creates a mechanical impedance to blood flow through the inferior vena cava. This increase in venous pressure causes leakage of fluid from the vascular bed into the interstitium, giving rise to oedema6. Reduced plasma colloid pressure due to physiological haemodilution contributes to this tendency to oedema. Pregnant women are particularly susceptible to pulmonary oedema (fluid in the lungs) when given too much intravenous fluid, especially when they have pre-eclampsia, which increases pulmonary capillary permeability (leaky vessels). It is a reflection of the ratio between the mean arterial pressure and cardiac output8. The blood vessel diameter is altered by the contraction of the smooth muscle in the tunica media of the blood vessel wall. The lesser the contraction, the larger the diameter and the least resistance to flow and vice versa. Factors contributing to reduction in systemic vascular resistance in pregnancy: Remodelling of spiral arteries. The walls of the spiral arteries of the uterus lose their muscular and elastic elements. They become almost completely dilated and are no longer responsive to circulating pressor agents or influences of the autonomic nervous system10. Heat production by the fetus results in vasodilatation of vessels in heat-losing areas such as the hands5. This relative vasodilatation of pregnancy increases not only uterine blood flow but also blood flow to other organs such as the breasts, skin and kidneys5. There is an increase in skin temperature, clammy hands and skin capillary dilation. Increased peripheral flow can also be seen in the mucous membranes of the nasal passages, leading to nasal congestion5. With the delivery of the baby and placenta and a degree of blood loss, the immediate postnatal period is a time of changing haemodynamics. Despite blood loss at delivery cardiac output remains significantly elevated above pregnancy levels for one-to-two hours post-partum with peak cardiac output occurring immediately after delivery5. Women with cardiac disease are most at risk of complications in the period just after delivery. This rise is due to4, 5: a decrease in gravid uterus pressure and improved venous return via the inferior vena cava transfusion of blood from the placental bed going back into the maternal circulation, which can cause volume overload reduced extent of the vascular bed due to the delivery of the placenta Post-partum haemorrhage, on the other hand, with potential for substantial loss of blood volume, can compromise cardiac function. Oxytocic drugs, including syntocinon and ergometrine, that promote uterine contraction also have major haemodynamic effects. Oxytocin can induce vasodilatation and arterial hypotension and ergometrine can cause arterial hypertension. Without this diuresis, pulmonary oedema can develop in women with pre-eclampsia or heart disease. However, knowledge and supportive therapy is growing rapidly, and all women should receive a skilled cardiology assessment from a team with up-to-date experience of pregnancy and heart disease. Nevertheless, the Confidential Enquiry into Maternal Deaths1 shows the very real risk many women may take in undergoing pregnancy. Specific individual information should be made available to all women before they become pregnant. Women with a history of heart disease should receive preconception advice before each pregnancy. Most congenital heart conditions, even following successful repairs in childhood, need full evaluation between each pregnancy, even if the previous pregnancy was uneventful. The amount of stress a pregnancy puts on an abnormal heart condition is largely unknown, although there is evidence in certain specific conditions13. A full assessment of her condition, possible surgery pre-pregnancy and evaluation of current drug therapy, may improve pregnancy success rates. Undertaking cardiopulmonary exercise testing is suggested as impaired response during this has been found to correlate with poor pregnancy outcome14. Predictors of adverse outcomes include poor maternal functional status, myocardial dysfunctions, significant aortic or mitral valve stenosis and a history of arrhythmias or cardiac events. All members of the team should contribute to ensuring a plan of care is identified and modified as necessary for pregnancy, labour and the puerperium. Evaluation of drugs taken, and their dose will continue throughout the antenatal period, and is dealt with on an individual basis. Women may need expert help in managing their drug regime, and avoid being tempted to stop certain medications if they carry a fetal risk. The risk to the mother or fetus from the disease being treated by the drugs may be greater than the potential risk to the fetus from the drug. In addition, warfarin given around the time of delivery can cause fetal haemorrhage15. Ultrasound to identify nuchal translucency should be offered to all women17, as an increased measurement is not only associated with Down syndrome, but also with fetal cardiac anomalies18. A 22­24 week uterine artery Doppler (via transvaginal ultrasound) to screen for potential uteroplacental insufficiency20 may be used. Umbilical artery Doppler velocimetry is known to reflect placental function21, and this may be undertaken regularly throughout pregnancy to assess fetal well-being and underpin the timing of delivery20. Fetal echocardiography (transvaginal or transabdominal imaging studies from late in the first trimester to beyond the second trimester) by a fetal cardiologist is the normal diagnostic tool used. This may provide information for the mother (who may consider termination) or enable management plans to be made for the delivery to be at the best time and place and with relevant professionals available for a compromised baby. An early fetal echocardiography (14­16 weeks) is recommended, but many conditions may be missed at this early stage, and it is more commonly done ­ or repeated ­ at 18­22 weeks 18. A detailed anomaly scan by a fetal medicine specialist should also be carried out, as there is a high frequency of extracardiac abnormalities, as well as karyotype abnormalities associated with congenital heart disease. Ongoing assessment may be necessary as some cardiac anomalies progress during pregnancy18. The usual drugs used to stop premature labour (ritodrine or salbutamol) are contraindicated with cardiac disease. The use of steroids for fetal lung maturation is usual practice when possible before a preterm delivery, but care is needed as this is associated with fluid retention, which may lead to cardiac failure22. The ideal time of delivery would be following the spontaneous onset of labour, but most women with heart disease will have close monitoring during pregnancy, and the findings may indicate the need for induction of labour or a planned Caesarean section. In addition, for a woman who is receiving anticoagulants, the timing of delivery needs to be co-ordinated with doses of these drugs. Analgesia and anaesthesia An increase in cardiac output can be caused by pain or exertion in labour, and therefore regional analgesia is often recommended for women with cardiac disease. This may also allow for a controlled second stage with a minimum of exertion by the woman. The common side effects, however, need to be considered, and peripheral vasodilation can cause decreased preload and therefore a reduced cardiac output. Regional analgesia (or anaesthetic, if a Caesarean section is planned) needs to be undertaken by a skilled and experienced anaesthetist. The need for thromboprophylaxis will need to be weighed against the risk of bleeding in relation to spinal or epidural insertion and the timing of vaginal delivery or surgery. Caesarean section under general anaesthetic may be considered, as although there are increased risks (for example, an increased blood loss) there may also be benefits for a woman with cardiac disease, for instance, if she were to need cardiac interventions such as cardioversion during the operation or immediately after it22. It is essential that plans are made in consultation with the cardiologist and clearly documented in the notes. Position Aortocaval compression (when lying flat, or sometimes even semi-recumbent, on the back) must be avoided. If it is necessary to be supine, for example for an instrumental delivery or suturing, then a wedge is necessary and leg elevation should be avoided22. When fluid overload is a concern, the infusion is often made up in a smaller volume of fluid and the dosage altered appropriately. To this end, careful records need to be kept of input and output as precisely as possible. Maternal and fetal monitoring A woman with cardiac disease needs continuous observation, including regular blood pressure, pulse and saturation recordings, at a minimum. Arterial lines may be used to provide continuous blood pressure monitoring and when frequent arterial blood gas samples are necessary. All invasive monitoring needs to be undertaken by a midwife trained in using it to be safe and effective. Infection control is always important in these vulnerable women, but particular emphasis on this is necessary when using invasive monitoring as this is a high-risk situation for infection. Because of the potential danger of hypovolaemia in many conditions, volume preloading to allow for loss at delivery or surgery is sometimes recommended. Oxytocin affects the blood pressure and increases cardiac output, and also can cause decreased cardiac contractibility and heart rate22. Ergometrine is contraindicated in most women with heart disease, as it causes peripheral vascular constriction and coronary vasospasm. Careful observation therefore needs to be made of women who may be compromised by fluid swings that could lead to heart failure (see Box 2. Hypoxia increases pulmonary vascular resistance25, so oxygen administration may be required. It has been observed that at one to two hours postnatal, the cardiac output and stroke volume is still elevated, and there is evidence that changes in the haemodynamic status persist for some time into the puerperium25. Normal observations, such as pulse, respirations, blood pressure, oxygen saturation and fluid balance need to be done frequently. Adequate analgesia continues to be important, as pain may result in tachycardia and regional analgesia may continue from labour, but with opiates, which produce less systemic vasodilation. Position should be considered during the first few hours postnatal ­ left lateral, if the woman is vulnerable to changes in preload; sitting up, if she is at risk of pulmonary oedema25. The thromboembolic risk is highest at delivery and it is still high at three hours postnatal. Risks in the immediate postnatal period include pulmonary oedema, hypertension, alteration in the cardiac shunting of blood, arrhythmias, cyanosis, ventricular ischaemia, thromboembolism and infection25. Some drugs are contraindicated for breastfeeding and this should be investigated on an individual basis. Care in the later puerperium For many women, a close level of care is necessary well into the puerperium, as changes in the cardiac output and plasma volume continue for at least two weeks25. The midwife should ensure that there is follow-up care accessible for the woman after discharge from hospital, in particular if the diagnosis of a heart condition was made for the first time in pregnancy. It averages the pressure across the whole pulse cycle, and is considered to provide a more valuable assessment of perfusion. Therefore, saturation readings should always be interpreted in relation to haemoglobin levels26, as a woman may have normal saturations but still be hypoxic27. However, pulse oximetry can provide a useful continuous view of trends and responses to (or need for) oxygen therapy, and can act as an indicator of a deterioration in condition28. Normal is < 2 seconds30, and a delayed response (> 2 seconds) suggests poor peripheral perfusion. Variations can be significant and indicate diagnosis and/or treatment requirements. The advantage of an arterial line is the continuous visual display of both the arterial blood pressure and the arterial pressure waveform. An arterial line consists of a cannula that is inserted into an artery that is connected to a sterile system, which is primed with heparinised saline and fitted to a transducer. The pulsations produced will reverberate against the membrane in the transducer, and be displayed on a monitor in both a waveform and a digital reading32. Particular care of the site is necessary as dislodging the cannula can result in massive haemorrhage. It may indicate the blood volume as it reflects the pressure within the great veins (which hold 60% of total blood volume) and it may help to avoid either under-transfusion or fluid overload by assessing blood volume deficits34. In pregnancy, shielding of the uterus would be routinely carried out, and it is suggested that a chest X-ray should not be withheld if it is an investigation that is needed, as it only exposes the fetus to a very small fraction of the maximum recommended exposure in pregnancy3. Echocardiograms can measure cardiac function and structure, identifying regional wall abnormalities that occur in myocardial ischaemia and necrosis36. Serial echocardiograms can be used for assessment and/or surveillance of known pathologies35.

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