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Cadaveric fbula discount 40/60 mg levitra with dapoxetine with amex, locking pla buy levitra with dapoxetine 40/60mg with visa, and allogeneic bone matrix for an- References rior cervical fusions afr cervical discectomy for radicu- 1 buy line levitra with dapoxetine. Jul 2001;95(1 Sup- rior discectomy withoufusion for treatmenof cervical pl):43-50. Microsurgical cervical rior cervical discectomy and fusion with titanium cylin- nerve roodecompression via an anrolaral approach: drical cages. Apr 2009;151(4):303- Clinical outcome of patients tread for spondylotic radic- 309. May 2003;43(5):228- fbula, locking pla, and allogeneic bone matrix for an- 240; discussion 241. May 15 2006;31(11):1207-1214; discussion 1215- rior cervical discectomy and fusion with titanium cylin- 1206. Patients tread one way with no comparison group of pa- compared with a group of patients tread in another way tients tread in another way. I: Insufcienor conficting evidence noallowing a recommendation for or againsinrvention. Should duplicas be eliminad between the analysis of thapiloprocess, the same lirature searches? Should human studies, animal studies or ca- perimenand the diferenstragies employed for daver studies be included? Search results with abstracts will be compiled cur outside the Research and Clinical Care Councils, by Galr in Endno software. Follow- librarian the second level searching to identify rel- ing #3, depending on the time frame allowed, deeper evan�relad articles. Use of the expedid protocol or any devia- tion from the full protocol should be documend 6. Research staf will maintain a search history in to obtain the 2nd relad articles search results and EndNo for future use or reference. Whais the besworking defnition of cervical radiculopathy from degenerative disorders? Whaare the mosappropria historical and physical exam fndings consisnwith the diagnosis of cervical radiculopathy from degenerative disorders? Whaare the mosappropria diagnostic sts for cervical radiculopathy from degenerative disorders? Whaare the appropria outcome measures for the treatmenof cervical radiculopathy from degen- erative disorders? Whais the role of pharmacological treatmenin the managemenof cervical radiculopathy from de- generative disorders? Whais the role of physical therapy/exercise in the treatmenof cervical radiculopathy from degenera- tive disorders? Whais the role of manipulation/chiropractics in the treatmenof cervical radiculopathy from degen- erative disorders? Whais the role of epidural sroid injections for the treatmenof cervical radiculopathy from degenera- tive disorders? Does surgical treatmen(with or withoupreoperative medical/inrventional treatment) resulin bet- r outcomes than medical/inrventional treatmenfor cervical radiculopathy from degenerative dis- orders? Does anrior cervical decompression with fusion resulin betr outcomes (clinical or radiographic) than anrior cervical decompression alone? Does anrior cervical decompression and fusion with instrumentation resulin betr outcomes (clini- cal or radiographic) than anrior cervical decompression and fusion withouinstrumentation? Does anrior surgery resulin betr outcomes (clinical or radiographic) than posrior surgery in the treatmenof cervical radiculopathy from degenerative disorders? Does posrior decompression with fusion resulin betr outcomes (clinical or radiographic) than pos- rior decompression alone in the treatmenof cervical radiculopathy from degenerative disorders? Does anrior cervical decompression and reconstruction with total disc replacemenresulin betr outcomes (clinical or radiographic) than anrior cervical decompression and fusion in the treatmenof cervical radiculopathy from degenerative disorders? Whais the long-rm resul(four+ years) of surgical managemenof cervical radiculopathy from de- generative disorders? How do long-rm results of single-level compare with multilevel surgical decompression for cervical radiculopathy from degenerative disorders? Type of Study design: case series poinin their disease Reliability of evidence: <80% follow-up clinical sts in diagnostic Stad objective of study: To analyze the reliability No Validad outcome the assessmenof clinical sts in the assessmenof neck and arm measures used: of patients with pain in primary care patients. Physical examination/diagnostic sdescription: Other: only two reviewers Oc1 66 clinical sts divided into nine cagories 2003;28(19):222 Work group conclusions: 2-2231. Results/subgroup analysis (relevanto question): Pontial level: I Reliability of clinical sts was poor to fair. With known clinical history, the prevalence of Conclusions relative to question: positive findings increased in all scagories. History had no impacon reliability, however, ihad an impacon the incidence of positive findings. Clinical Type of Study design: case series poinin their disease analysis of evidence: <80% follow-up cervical prognostic Stad objective of study: To investiga the No Validad outcome radiculopathy characristics of cervical radiculopathy causing measures used: Tis clinical guideline should nobe construed as including all proper methods of care or excluding other acceptable methods of care reasonably direcd to obtaining the same results. Author conclusions (relative to question): A painful cervical radiculopathy with deltoid paralysis emanas from the C4-5, C5-6 and C3-4 levels: 50%, 43% and 7% of the time respectively. Type of Study design: case series poinin their disease The shoulder evidence: <80% follow-up abduction sin diagnostic Stad objective of study: To reporobservations No Validad outcome the diagnosis of on a series of patients with cervical measures used: radicular pain in monoradiculopathy due to compressive disease in sts nouniformly applied cervical whom clinical signs included relief of pain with across patients extradural abduction of the shoulder. Small sample size compressive Lacked subgroup analysis monoradiculopaNumber of patients: 22 Other: hies. Motor weakness was presenin 15, that:relief from arm pain with Tis clinical guideline should nobe construed as including all proper methods of care or excluding other acceptable methods of care reasonably direcd to obtaining the same results. Results/subgroup analysis (relevanto question): Of the 15 patients with a positive shoulder abduction sign, 13 required surgery and all achieved good results. Of the seven patients with negative shoulder abduction signs, five required surgery and two were successfully tread with traction. Of the five surgical patients, three had surgery for a central lesion and improved afr surgery, two had surgery for a laral disc fragmenand only one had good results. Author conclusions (relative to question): The shoulder abduction sis a reliable indicator of significancervical extradural compressive radicular disease. Other: review of 846 consecutively Physical examination/diagnostic sdescription: Work group conclusions: operad cases. Results/subgroup analysis (relevanto question): One level was thoughto be primary 87. Author conclusions (relative to question): In a large group of patients with cervical radiculopathy, the study elucidas the common clinical findings of pain, paresthesia, motor deficit, and decreased deep ndon reflexes, along with their respective frequencies. Ipresents evidence thathe operative si can be accuraly predicd on the basis of clinical findings 71. Neck pain Patients nonrolled asame secondary to Type of Study design: case series poinin their disease radiculopathy of evidence: <80% follow-up the fourth prognostic Stad objective of study: To reporthe results of No Validad outcome cervical root: an surgical inrvention in a series of patients with measures used: analysis of 12 neck pain from C4 radiculopathy.

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The iodine is retained in the body tissues for a long period of time (three to five years) 40/60 mg levitra with dapoxetine, maintaining the thyroid hormones at normal levels  Iodinated oil capsules: 400 mg iodine administered orally purchase levitra with dapoxetine 40/60 mg on-line, repeated after one to two years  Lugol’s solution: 3 drop (21 mg) once a month purchase levitra with dapoxetine 40/60 mg on line, up to one year 4. It plays important roles in the body, including role in vision, maintenance of epithelial tissue, synthesis of mucous secretion, growth, reproduction and immunity. It, contributes to body’s supply of niacin (another B vitamin) by facilitating in the conversion of tryptophan (an amino acid) to niacin. Deficiency is commonly caused by consumption of highly polished cereals or foods containing thiaminase (anti-thiamine factor). Signs and symptoms of deficiency  Characterized by enlargement of nerves, weight loss (due to loss of appetite), oedema and disturbance in heart function  Lack of energy  Lesions in nervous tissues. Also it plays part in synthesis of corticosteroids and production of red blood cells. Signs and symptoms of deficiency  It characterized by sore throat, pharyngeal and oral mucous membrane hyperaemia, angular stomatitis, cheilosis, glossitis and anemia  Riboflavin deficiency almost invariably occurs in combination with other vitamin deficiencies. Dietary measures  Animal products (milk, meat liver, fish, eggs, cheese)  Vegetable products (green leafy vegetables)  Cereal grains and pulses Drug treatment C: Vitamin B-complex 1 tablet 8 hourly for 1 month. In Tanzania deficiency occurs in communities whose main staple food is maize or sorghum and particularly during rainy season when food diversification is at its lowest. Signs and symptoms of deficiency It is a disease characterized by a triad, referred to as three Ds: o Dermatitis (darkened scaly skin on the parts exposed to the sun) o Diarrhea o Dementia (memory loss)  Some patients may present also with glossitis 372 | P a g e Dietary measures  Animal products (especially liver), pork, poultry  Groundnuts, beans, peas, other pulses, yeast  Cereal grains (but not maize or sorghum) Note  Treatment of maize with alkalis such as limewater makes the niacin much more available  Protein is good source as the amino acid tryptophan can be converted to niacin in the gut. Drug treatment C: Nicotinamide: Adult gives 100 mg every 6 hours for 7 days followed by multivitamin preparation containing 50 to 60 mg of nicotinamide daily for 1 month. Children: 10 to 25 mg every 8 hours for 7 days, followed by multivitamin preparation as above. It plays part in the metabolism of fatty acids, hence in the formation of myelin (the sheathing around the axons of nerve cells). The vitamin is involved also in the carbohydrate metabolism (stabilizes glutathione – a component of enzymes needed in carbohydrate metabolism). Signs and symptoms of deficiency  Macrocytic megaloblastic anaemia  Decreased white blood cells  Angular stomatitis, glossitis  Delusions, nerve problems, unsteady gait. Dietary measures Main source is animal foods – meat, liver, seafood, eggs, milk, and cheese. Note  Animals or plants do not synthesize the vitamin – it is synthesized by bacteria in animals. Intramuscular injection: Initially 1mg, repeated 10 times at intervals of 2 – 3 days. Signs and symptoms of deficiency  Macrocytic megaloblastic anaemia  Stomatitis, glossitis  Diarrhea  Neural tube defects (spina bifida, anencephaly, encephalocele) 374 | P a g e Dietary measures  Green leafy vegetables  Legumes  Liver, meat, fish, poultry Drug treatment Adults and children over one year A: Folic acid 5 mg (O) daily for 4 months, then maintenance dose of 5 mg every 1-7 days depending on underlying disease. Signs and symptoms of deficiency  Scurvy (bleeding gums, dry skin, dry mouth, impaired wound healing). Note: Substantial vitamin C can be lost during food processing, preservation and preparation. Signs and symptoms of deficiency  Rickets – a disease of bones in infants and children  Osteomalacia in adults 375 | P a g e Prevention  Exposure of the skin to sunshine (vitamin D is produced by the action of the sun on the skin)  Vitamin D rich foods: wheat germ, fish, liver, egg yolk, organ meats, cheese, milk (breast milk other milks), butter, margarine, mayonnaise. It plays role in reproductive health (enhances fertility) and also in haemoglobin synthesis. Signs and symptoms of deficiency  Leg cramps,  Muscle weakness,  Nerve problems and  Hearing problems. Dietary measures  Consumption of vegetable oils  Whole grain cereals Drug treatment Adult C: Alpha tocopherol acetate 50 - 100mg daily until recovery Below 1 yr: 50mg until recovery 14. Secondary deficiency may be associated with malabsorption syndrome, liver cirrhosis and the use of Coumarin derivatives such as dicumarol, warfarin and other analogues. Signs and symptoms of deficiency  Slow growth  Loss of smell and taste  Loss of appetite  Diarrhoea  Poor wound healing  Skin lesions Dietary measures Zinc is present in most foods of animal and plant origins. Also phytates found in whole grain products and vegetables reduces the bioavailability of zinc. Treatment A: Zinc tablets 50mg 2 to 3 times daily until recovery Zinc supplementation- Refer to National Guideline Micronutrient supplementation 16. Kwashiorkor children have shown improved weight gain with selenium supplementation. In China selenium deficiency has led to “Kesharis disease” – a serious condition affecting heart muscle. Meats, seafoods, egg yolk and milk are good sources of selenium  In cereals, selenium content depends on the concentration of the mineral in the soil  Mushrooms and asparagus are rich sources. But highest concentrations are in the liver, brain, heart, kidneys and in the blood. Copper in the form of ceruloplesmin (a copper-protein complex in the blood plasma) is involved in various stages of iron nutrition. Copper enhances iron absorption and stimulates mobilization of iron from stores (in the liver and other tissues). Plays part in the conversion of ferrous iron to ferric (important during various stages of iron metabolism). Copper deficiency has been linked to anaemia in premature infants and in people with severe protein- energy malnutrition. Menke’s disease (a rare congenital condition) is caused by failure of copper absorption. Dietary measures  Foods richest in copper are nuts, shellfish, liver, kidney, raisins and legumes. Many of the physiological functions of Mg are based on the mineral’s ability to interact with calcium, phosphate and carbonate salts. Magnesium catalyses many essential enzymatic reactions (glucose, fatty acid, amino acid metabolism), takes part in bone metabolism and protein synthesis. Signs and symptoms of deficiency  Muscle spasms, cramps  Tremors, seizures, coma Dietary measures  Most foods contain adequate amounts of magnesium  Animal foods: good source is dairy products, meats and poultry  Vegetables: green vegetables (okra, broccoli), cucumber skin  Fruits: especially avocado  Cereals (whole grain)  Legumes  Seafood Drug treatment D: Magnesium sulphate 0. Fluorine enhances iron absorption (protects against anaemia) and enhances wound healing. Chronic ingestion of high concentrations (from natural high content in the area or environmental pollution) can lead to bone and tooth malformations. Drug treatment: In areas where drinking water is fluoridated and the floride content is above 0. S: Fluorine tabs: Under 6 yrs 250 micrograms daily Over 6 years : 500 micrograms to 1mg daily 22. Deficiencies occur across all population groups but women and children are highly vulnerable because of rapid growth and inadequate dietary practices. Interventions to address micronutrient deficiencies include food based approaches whereby production and consumption of micronutrients rich foods are promoted. Micronutrient supplementation programs target most vulnerable groups such as pregnant and lactating women, and children aged below 5 years. Food fortification with micronutrients is another approach aimed to deliver micronutrients to the general population, most vulnerable groups included. Food fortification includes iodization of edible salt and fortification of staple foods such as cereal flours and cooking oil. Other interventions target children aged 6 to 23 months with a single dose of packets containing multiple vitamins and minerals in powder form that can be sprinkled onto any semi solid complementary food at the point of use.

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Modification of the clinical course of intestinal microsporidiosis in acquired immunodeficiency syndrome patients by immune status and anti-human immunodeficiency virus therapy cost of levitra with dapoxetine. Analysis of the beta-tubulin genes from Enterocytozoon bieneusi isolates from a human and rhesus macaque discount levitra with dapoxetine online mastercard. Analysis of the beta-tubulin gene from Vittaforma corneae suggests benzimidazole resistance purchase levitra with dapoxetine no prescription. Efficacy of ivermectin and albendazole alone and in combination for treatment of soil-transmitted helminths in pregnancy and adverse events: a randomized open label controlled intervention trial in Masindi district, western Uganda. Usually within 2 to 12 weeks after infection, the immune response limits multiplication of tubercle bacilli. A significant disadvantage of the 9-month regimen is that the majority of patients do not complete all 9 months of therapy. Increased clinical monitoring is not recommended, but should be based on clinical judgment. If the serum aminotransferase level increases greater than five times the upper limit of normal without symptoms or greater than three times the upper limit of normal with symptoms (or greater than two times the upper limit of normal among patients with baseline abnormal transaminases), chemoprophylaxis should be stopped. Factors that increase the risk of clinical hepatitis include daily alcohol consumption, underlying liver disease, and concurrent treatment with other hepatotoxic drugs. Patients should be reminded at each visit about potential adverse effects (unexplained anorexia, nausea, vomiting, dark urine, icterus, rash, persistent paresthesia of the hands and feet, persistent fatigue, weakness or fever lasting 3 or more days, abdominal tenderness, easy bruising or bleeding, and arthralgia) and told to immediately stop isoniazid and return to the clinic for an assessment should any of these occur. The majority of patients have disease limited to the lungs, and common chest radiographic manifestations are upper lobe infiltrates with or without cavitation. If a sensitive broth culture technique is used, the sensitivity of sputum culture is quite high. With progressive immunodeficiency, granulomas become poorly formed or can be completely absent. The yield of mycobacterial urine and blood cultures depends on the clinical setting; among patients with advanced immunodeficiency, the yield of culture from these two readily-available body fluids can be relatively high68,72 and may allow definitive diagnosis and be a source of an isolate for drug-susceptibility testing. In a 2014 meta-analysis, the sensitivity for detection of rifampin resistance was 95% (95% confidence interval 90%–97%) and specificity was 98% (95% confidence interval 97%–99%). Two recent analyses showed that treatment failure was more common among patients whose isolates had phenotypic susceptibility but mutations in the rpoB gene compared to patients whose isolates had normal rpoB gene sequences. Ethambutol can be discontinued when susceptibility to isoniazid and rifampin has been confirmed. Regimens that included once- or twice-weekly dosing during the continuation phase of therapy were also associated with increased risks of treatment failure or relapse with acquired rifamycin resistance. Although drug-drug interaction studies suggest that thrice-weekly and daily rifampin dosing is associated with similar levels of cytochrome P450 enzyme induction when dosed with raltegravir,120 whether there is a difference between daily and thrice- weekly dosing during the continuation phase of therapy has not been adequately studied in randomized trials. Every effort should be made to assure that patients receive daily therapy as previously described, allowing up to 28 weeks to complete at least 24 weeks (6 months) of treatment to accommodate brief interruptions of therapy for management of adverse drug reactions as described below. Addition of a fluoroquinolone may improve outcomes in patients with isoniazid-monoresistant tuberculous meningitis. The mortality was decreased from 13% in the 2-week arm to 8% in the 8-week arm,137 and viral suppression rates were very high among those who survived (>95%). Given the need for the initiation of five to seven new medications in a short time, adherence support should be offered. These drug-drug interactions are complex, but most result from the potent induction by the rifamycin of genes involved in the metabolism and transport of antiretroviral agents. Regular monitoring of transaminases is recommended when double dose lopinavir/ritonavir is used (e. Rifabutin has little effect on ritonavir-boosted lopinavir162 or atazanavir,163 and its co-administration results in moderate increases in darunavir164 and fosamprenavir concentrations. Therefore, the dose of rifabutin must be decreased to avoid dose-related toxicity, such as uveitis and neutropenia. However, given that the risk of adverse events related to high levels of rifabutin’s metabolite with this dosing strategy has not been firmly established, close monitoring for toxicity (especially neutropenia and uveitis) is required until larger studies provide adequate safety data. Raltegravir concentrations are significantly decreased when co-administered with rifampin. A pharmacokinetic study in healthy volunteers showed that increasing the dose of dolutegravir to 50 mg twice a day with rifampin resulted in similar exposure to dolutegravir dosed 50 mg daily without rifampin, and that rifabutin 300 mg daily did not significantly reduce the area under the concentration curve of dolutegravir. The breadth and magnitude of drug-drug interactions between the rifamycins and many antiretroviral drugs can be daunting. Management of Suspected Treatment Failure The causes of treatment failure include undetected primary drug resistance, inadequate adherence to therapy, incorrect or inadequate regimen prescribed, subtherapeutic drug levels due to malabsorption, super-infection with drug-resistant M. Patients with suspected treatment failure should be evaluated with a history, physical exam, and chest radiograph to determine whether the patient has clinically responded to therapy, even though his/her cultures have not converted. The initial culture results and drug-resistance tests, treatment regimen, and adherence should also be reviewed. Serologic testing for hepatitis A, B, and C should be performed, and the patient should be questioned regarding symptoms suggestive of biliary tract disease and exposures to alcohol and other hepatotoxins. Thereafter, if appropriate, relevant antiretroviral drugs and cotrimoxazole may be recommenced. Resistance to rifampin alone, or to rifampin and other drugs, substantially increases the complexity and duration of treatment. In general, such regimens will include a later-generation fluoroquinolone, a second-line injectable agent (i. Whenever possible, treatment should be individualized to the patient’s specific drug-susceptibility testing results or based upon his or her treatment history. An intensive phase of 8 months is then followed by a continuation phase without the injectable agent for an additional 12 to 18 months. Such screening should include serum chemistries, liver function tests, thyroid stimulating hormone, and audiometry. Sputum cultures should be sent monthly, even after culture-conversion, so that any relapse and amplified resistance are detected early. Specifically, efavirenz decreases bedaquiline levels and should not be used concurrently. The condition is thought to result from the recovering immune system driving inflammatory reactions directed at M. This manifests with nausea and vomiting, tender hepatic enlargement, cholestatic liver function derangement, and occasionally jaundice. Many patients require symptomatic therapy (analgesia, anti-emetics), and if symptoms are significant, anti-inflammatory therapy should be considered. No reduction in mortality was demonstrated, but immediately life-threatening cases (e. Repeated aspirations may be required as abscesses and effusions often re-accumulate. Post-treatment isoniazid (6–9 months of daily isoniazid therapy after the completion of standard multidrug therapy) has been shown to be effective in high-burden settings in which the risk of re-exposure is high,229,230 suggesting that this intervention decreases the risk of re-infection. However, post-treatment isoniazid is not recommended in low-burden settings such as the United States. The risk of isoniazid-associated hepatotoxicity may be increased in pregnancy and frequent monitoring is needed for women receiving therapy. Chest radiographs with abdominal shielding are recommended and result in minimal fetal radiation exposure.

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Case management Patient complains of genital sore or ulcer Take history and examine Look for another i genital disorder buy 40/60mg levitra with dapoxetine with mastercard. Donovanosis is endemic in South Africa buy levitra with dapoxetine online from canada, Papua New Guinea buy levitra with dapoxetine 40/60mg on line, India, Brazil and the Caribbean. Administer a single dose for early syphilis (less than 2 years); one injection per week for 3 weeks for late syphilis (more than 2 years) or if the duration of infection is unknown. Treatment of the partner The sexual partner receives the same treatment as the patient, whether or not symptoms are present, except in the case of genital herpes (the partner is treated only if symptomatic). Gynaecological examination should be routinely performed: – Inspection of the vulva, speculum examination: check for purulent discharge or inflammation, and – Abdominal exam and bimanual pelvic exam: check for pain on mobilising the cervix. If peritonitis or pelvic abscess is suspected, request a surgical opinion while initiating antibiotic therapy. Clinical features Sexually transmitted infections Diagnosis may be difficult, as clinical presentation is variable. Infections after childbirth or abortion – Most cases present with a typical clinical picture, developing within 2 to 10 days after delivery (caesarean section or vaginal delivery) or abortion (spontaneous or induced): • Fever, generally high • Abdominal or pelvic pain • Malodorous or purulent lochia • Enlarged, soft and/or tender uterus – Check for retained placenta. Treatment – Criteria for hospitalisation include: • Clinical suspicion of severe or complicated infection (e. They should be reassessed routinely on the third day of treatment to evaluate clinical improvement (decrease in pain, absence of fever). If it is difficult to organise routine follow-up, advise patients to return to clinic if there is no improvement after 48 hours of treatment, or sooner if their condition is worsening. Infections after childbirth or abortion – Antibiotic therapy: treatment must cover the most frequent causative organisms: anaerobes, Gram negatives and streptococci. Depending on the formulation of co- amoxiclav available: Ratio 8:1: 3000 mg/day = 2 tablets of 500/62. Stop antibiotic therapy 48 hours after resolution of fever and improvement in pain. In penicillin-allergic patients, use clindamycin (2700 mg/day in 3 divided doses or injections) + gentamicin (6 mg/kg once daily). Clinical features – Venereal warts are soft, raised, painless growths, sometimes clustered (cauliflower- like appearance) or macules (flat warts), which are more difficult to discern. Speculum exam may reveal a friable, fungating tumour on the cervix, suggestive of cancer associated with papilloma virus. Explain the procedure to the patient: apply the solution to the warts using an applicator or cotton bud, sparing the surrounding healthy skin, allow to air dry. On vaginal warts, the solution should be allowed to dry before the speculum is withdrawn. Podophyllum preparations are contra-indicated in pregnantc or breastfeeding women. They should not be applied on cervical, intra-urethral, rectal, oral or extensive warts. Presence of genital warts in women is an indication to screen for pre- cancerous lesions of the cervix, if feasible in the context (visual inspection with acetic acid, or cervical smear, or other available techniques), and to treat any lesions identified (cryotherapy, conisation, etc. Protect the surrounding skin (vaseline or zinc oxide ointment) before applying the resin. Genital warts are not an indication for caesarean section: it is uncommon for warts to interfere with delivery, and the risk of mother-to-child transmission is very low. Recurrences in 1/3 of infections with shorter and • Recurrent infections: same dose for 5 days, given milder symptoms. Human Soft, raised, painless growths, sometimes clustered The diagnosis is based on clinical • External warts < 3 cm and vaginal warts: papillomavirus (acuminate condyloma) or macules (flat warts). It should not be administered to breast-feeding women if the treatment exceeds 7 days (use erythromycin). In women of childbearing age, always assess if the bleeding is related to a pregnancy. Bleeding unrelated to pregnancy – Clinical examination: • speculum examination: determine the origin of the bleeding [vagina, cervix, uterine cavity]; appearance of the cervix; estimation of blood loss; • bimanual pelvic examination: look for uterine motion tenderness, increased volume or abnormalities of the uterus. While waiting for surgery or if surgery is not indicated, treat as a functional uterine bleeding. Note: rule out other causes of vaginal bleeding before diagnosing functional uterine bleeding. Consider for example poorly tolerated contraceptive, endometrial cancer in postmenopausal women, genitourinary schistosomiasis in endemic areas (see Schistosomiasis, Chapter 6). Ectopic pregnancy Pregnancy that develops outside the uterus, very often in a fallopian tube. Ectopic pregnancy should be suspected in any woman of reproductive age with pelvic pain and/or metrorrhagia. There are many possible clinical presentations and these can mislead diagnosis towards appendicitis, intestinal obstruction, salpingitis or abortion. The major risk of ectopic pregnancy is rupture, leading to intra abdominal haemorrhage. Clinical features and diagnosis – Amenorrhoea (may be absent) or menstrual irregularity. If ultrasound shows an empty uterus together with intra peritoneal effusion, an ectopic pregnancy is likely, especially if the pregnancy test is positive. Management If in doubt (negative urinary pregnancy test, no sign of rupture and stable haemodynamic conditions), hospitalise the patient for surveillance, if possible in a surgical facility. Threatened abortion Clinical features In a context of amenorrhoea: slight, bright red bleeding; pelvic pain; closed cervix. Management 9 – Look for foreign bodies or vaginal wound consistent with induced abortion; remove foreign bodies, clean the wound; update tetanus immunization (see Tetanus, Chapter 7). Abortion Clinical features Slight or significant bright red bleeding; expulsion of the embryo, membranes or products; uterine contractions; open cervix. Management – Look for foreign bodies or vaginal wound consistent with induced abortion; remove foreign bodies, clean the wound; update tetanus immunization (see Tetanus, Chapter 7). Treatment success (that is, an empty uterus) must be verified in the days after the drug is taken. After 12/14 weeks of pregnancy: labour should be allowed to progress, do not rupture the membranes. If evacuation is incomplete or in the event of haemorrhage, perform manual removal immediately after the expulsion, before the uterus retracts or the cervix closes. If manual removal is delayed, curettage must be performed which carries a high risk of uterine perforation. Bleeding during the second half of pregnancy Three conditions –placenta praevia, abruptio placentae, and uterine rupture–can quickly become life-threatening to both mother and child. When no cause for the bleeding is found, consider the possibility of premature labour. Placenta praevia Placenta that covers either entirely or partially the internal os of the cervix. Placenta praevia may give rise to bleeding during the third trimester and carries a high risk of haemorrhage during delivery. Clinical features and diagnosis – Sudden, painless, slight or significant bright red bleeding.

B. Rhobar. Ferrum College. 2019.