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Unless managed properly it can lead to the following complications like: (i) Postpartum hemorrhage buy discount epivir-hbv 100 mg line symptoms 4 days post ovulation, (ii) Shock purchase epivir-hbv 100 mg online treatment 34690 diagnosis, (iii) uterine inversion discount epivir-hbv 100mg on line symptoms 7 weeks pregnancy, (iv) retention of placenta purchase epivir-hbv 150 mg visa symptoms 0f food poisoning, (v) pulmonary embolism and (vi) maternal death. Previous uneventful first and second stage may become abnor- mal in the third stage and may lead to maternal death. To prevent such complications active management of third stage of labor is helpful. The significant advantages of active management of third stage of labor are: (i) Third stage blood loss is reduced approximately to one-fifth (ii) Duration of third stage is reduced to its half. Active management therefore needs more trained nursing personnel in the labor ward to give the injection in time. These cases are women with heart disease, severe pre-eclampsia and in cases with twins until the 2nd baby is born. Considering all the benefits, active management should be done in almost all cases in the third stage of labor. In India life time risk of dying for a woman during pregnancy is 1 in 70 compared to one in 48,000 in developed countries. The direct causes of maternal deaths are due to hemorrhage (20–25%), infection (15–20%), hypertension during pregnancy (15–20%), unsafe abortion (10–13%), and obstructed labor (8%). The important indirect causes of deaths are anemia (15–20%), viral hepatitis and heart disease. The factors associated with high maternal mortality are advanced women’s age, high parity and poor antenatal care. The important social factors associated are illiteracy, ignorance, unregulated fertility, poor socioeconomic condition, under utilization of existing health care services and lack of communication and referral facilities. The important steps to reduce maternal mortality are: ■ Utilization of basic antenatal, intranatal and postnatal care. Infection (labor and puerperium): Clean delivery practices, skilled birth attendant, use of antibiotics—when infection is evident. Medical disorders in pregnancy (diabetes, chickenpox)—appropriate intervention or referral for optimum care. Combining all the above factors (health, social and policy actions) and by proper implementation of interventions against the major causes, maternal mortality can be avoided significantly in India. Prenatal counseling means evaluation and then counseling a woman about pregnancy, its course and the likely outcome well before the time of actual conception. The objective of prenatal counseling is that woman should enter the pregnancy in an optimal state of health which would be safe both to herself and the fetus. Otherwise many adverse factors begin to exert their effects by the time woman is seen in the antenatal clinic. Generally women are first seen in the antenatal clinic at around 14 weeks of gestation. At the same it helps to organize care to reduce or to eliminate risk factor so that pregnancy outcome is improved. Folic acid supplementation (4 mg a day) starting 4 weeks before conception and continued upto 12 weeks of pregnancy. Women with medical complications (hypertension and diabetes) in pregnancy, need education and treatment before conception. Many drugs used during the nonpregnant state should be avoided during pregnancy because of fetal hazards. Warfarin, oral antidiabetic drugs are replaced with other drugs like heparin and insulin respectively for the safety of the fetus. This can only be done once the woman is seen and counseled before pregnancy (prenatal counseling). External cephalic version is a maneuver done externally to change the fetal presentation and to bring the fetal head to the lower pole of uterus. These are fetal distress, placental abruption, premature rupture of membranes, etc. Considering all the benefits and the risks, it appears that each case should be selected carefully excluding the contraindications. Cardiotocography should be done before and after the procedure to assess fetal well-being. Facilities for cesarean delivery must be there, should any complications develop during procedure. Therefore it appears on critical evaluation that external cephalic version has got a place in the management of breech presentation in a well-selected case. High-risk pregnancy is defined as one which is complicated with factor (s) that adversely affects the pregnancy outcome—maternal or perinatal or both. The fetal hazards are miscarriage, vanishing twin, fetus papyraceus, preterm birth, fetal anomalies, discordant growth, intrauterine death of one fetus, twin transfusion syndrome, cord prolapse, locked twins and increased perinatal mortality. Considering all these complications affecting the mother, fetus and the neonate, twin pregnancy is considered as a “high-risk pregnancy”. The importance of defining the high-risk situation is to anticipate the complications. Simultaneously we have to adopt the preventive measures to avoid or to minimize the complications. For example antenatal supplementation of increased amount of iron and folic acid can meet up the increased demand and thereby can prevent complications due to anemia. So twin pregnancy needs careful antenatal care and intrapartum care to prevent all these complications. All these are depicted in a single sheet of paper, against the duration of labor in hours. The components of a partograph are designed to assess the progress of labor and the well-being of the mother and the fetus. In a normal labor, the cervicograph (cervical dilatation) should be either on the alert line or to the left of it. Labor is said to be abnormal when cervicograph crosses the alert line and falls on zone 2. The main advantage is that it can detect deviation from normal course of labor early. First stage of labor is considered prolonged when the rate of cervical dilatation is < 1 cm/hour in primigravida and < 1. Similarly if the rate of descent of the fetal head is < 1 cm/hour in a primigravida and < 2 cm/hour in a multigravida it is called prolonged. Secondary arrest can be diagnosed when the active phase of labor commences normally but stops or slows down significantly for 2 hours or more prior to full dilatation of the cervix. Obstructed labor can be diagnosed when the progressive descent of the presenting part is arrested inspite of good uterine contraction.
They become hypoxic maintain cardiac output by increasing its stroke with increased work of breathing buy epivir-hbv 150mg on line treatment mrsa, which further volume and tends to rely on an increase in rate buy generic epivir-hbv 100 mg medicine 94. Chest auscultation This is inefficient in that diastole is short order 150 mg epivir-hbv otc treatment zinc deficiency, which reveals crepitations basally with some wheeze reduces the time available for diastolic filling (cardiac asthma) and 150 mg epivir-hbv otc medications you should not take before surgery, if very severe, pink, frothy (affecting preload) and for perfusion of the coronary sputum may be produced. You are asked to see her on the third postoperative day because she has become acutely short of breath following an episode of severe central chest pain which lasted about 10 min but has since settled. When you arrive on the ward, the patient is obviously dyspnoeic and is unable to speak in complete sentences. The staff nurse who is with her reports that her pulse rate is 110 bpm and her blood pressure is 170/95. You ask the nurse to give the patient high flow oxygen, using a mask with a reservoir bag. You examine the patient’s chest and find that she has a respiratory rate of 28 breaths/min and fine crepitations up to the mid zones on both sides. It is difficult to hear her heart easily but you do not think you can hear any murmurs, although you think she has a gallop rhythm. You ask the nurse to help you sit the patient up and establish intravenous access. An examination of the patient’s ward charts shows that she was progressing well until this episode. The case notes revealed that she is hypertensive, has occasional angina (about one attack every 2 weeks associated with exercise or cold weather) and usually takes bendrofluazide 2. Although she seems slightly better with the oxygen and re-positioning, you decide to give her a dose of frusemide 40 mg i. In the meantime, you arrange for routine blood tests and cardiac enzymes to be sent. If the afterload is high, reducing • give oxygen and monitor SaO2 it by using vasodilators may be beneficial but • stop i. It is very important to be aware of the risks of surgery in the patient with ischaemic heart disease Cardiogenic shock occurs when there is severe and, particularly, of the risk of re-infarction (Table impairment of cardiac function with hypotension 6. It should be evident that delaying surgery, of less than 90 mmHg or 30 mmHg less than the if at all possible, will have a marked effect on the patient’s ‘normal’ systolic pressure is present. The patient normally Decompensated Compensated has pulmonary oedema so increasing preload with heart failure heart failure i. It is vital to be aware The presence of cardiac failure pre-operatively that your patient has a pacemaker because the use indicates a significant anaesthetic risk. As place the pad on the back of the patient behind with almost all cardiac medication, it should be the pacemaker given on the morning of surgery and re-instituted • use short bursts of diathermy rather than long ones as quickly as possible afterwards. Pacemaker types are classified using a 3 or 4 letter Acute, life-threatening hypertension is rare. Classification is based on which chambers blood pressure is sustained at 220/120 or above are paced, the response of the pacemaker to a with signs of organ dysfunction, involve cardiology sensed beat and programmability. While certain viscera preserve flow • based on the history, clinical condition through autoregulation (e. Intestinal hypoperfusion may occur in the face of a normal pulse and blood pressure and, following a brief hypotensive episode, a This chapter aims to give a practical clinical prolonged period of intestinal hypoxia may occur, overview rather than a detailed account of the with generation of cytokines and the onset of pathophysiology of shock. Of course, the patient may have more than one factor contributing to Hypovolaemia Blood or fluid loss the shock state: for example, a patient with Cardiogenic Pump failure abdominal sepsis where the primary problem is vasodilation but where hypovolaemia due to ileus Septic Early vasodilation also contributes. Remember that the and insensible fluid losses during prolonged curve can be shifted up and to the left by inotropes operations and on going fluid loss from and sympathetic stimulation. Hypovolaemia Decreasing afterload Increasing contractility is the commonest cause of shock in the surgical 150 patient. It may result 100 from any of the following causes: • haemorrhage is a common cause of 50 hypovolaemia. Its effects vary with the duration and severity of blood loss, the patient’s age 0 0 10 20 30 and myocardial condition, and the speed and Ventricular filling pressure (mmHg) adequacy of resuscitation. It can be usefully classified, in terms of assessment and guiding treatment, by the degree of blood loss into Figure 7. The curve is shifted up and to the left by sympathetic stimulation 500–1000 ml; stage 3, 1000–2000 ml; and or inotropic agents. Prompt treatment myocardial depressant substances (particularly with oxygen, fluids, adrenaline, hydrocortisone in septic shock). The rapid increase in size of the circulating cortisol and aldosterone, the role of vascular bed, including venous capacitance vessels, the adrenal cortex in the production of shock by leads to reduced venous return and reduced cardiac other causes is debatable. An may occur in severe meningococcal sepsis analogous condition may be seen during epidural (Waterhouse–Friedrichsen syndrome). Adrenal analgesia, although in this case, the block is seldom insufficiency (often subacute) is also seen in high enough to cause a bradycardia. In septic shock, cells releases histamine and serotonin and, with the patient becomes hypotensive and the tissues systemic kinin activation, this leads to rapid are inadequately perfused as a result of organisms, vasodilation, a fall in systemic vascular resistance toxins or inflammatory mediators. The features are immediate assessment with simultaneous partly due to loss of circulating volume and tissue resuscitation, followed by a full patient assessment, perfusion, and partly to intense sympathetic including chart review, history, examination and stimulation. For a patient on a surgical ward, on recognition of the signs of decreased tissue it is also important to speak to the medical and perfusion, particularly of the skin, kidneys and brain. These are accompanied by varying degrees of tachycardia, hypotension and tachypnoea proportional to the severity of the shock. Confusion and coma are late signs patient suggest a possible myocardial of marked cerebral hypoperfusion, and blood component? Remember that trends in the – Poor filling of peripheral veins charted observations may be more important – Increased respiratory rate than absolute values and that patients with – Increased core–peripheral temperature hypovolaemic shock may have a normal gradient systolic blood pressure – Capillary refill time prolonged (> 2 s) • does the patient have a temperature, high – Poor signal on pulse oximeter white cell count or a history of an – Poor urine output (< 0. This usually reduces the presence of significant loss of circulating the left atrial and ventricular end diastolic volume. Although there response to hypovolaemia may be modified in the is no primary loss of circulating volume, cardiac elderly, in ischaemic heart disease, in patients on output falls and catecholamine-induced ß-blockers, trained athletes and young adults. The picture and magnitude of blood loss, the patient’s age and is modified, however, by elevation of cardiac cardiovascular status, and the speed and adequacy filling pressure leading to elevation of the central of resuscitation. Initially, the systemic blood or jugular venous pressure and pulmonary oedema, pressure is maintained, and may actually increase, but low arterial pressure. The pulse pressure A careful history and examination of the chest, may drop (difference between systolic and diastolic heart sounds (there may be a gallop rhythm or pressure) as a result of peripheral vasoconstriction associated murmur), neck veins together with but this is a subtle sign. Echocardiography vasoconstriction and, to a lesser extent, the shift may be valuable. A modest further loss (to 35–40% deficit) can precipitate calamitous collapse, perhaps with bradycardia rather than the expected tachycardia. Tamponade and tension pneumothorax need prompt intervention to relieve the pressure Tachypnoea Tachypnoea on the heart, but all can respond temporarily to Tachycardia Tachycardia intravenous fluids and oxygen. Clearly, haemodynamic or slightly decreased 80 mmHg instability and pyrexia 5–7 days after a colonic Oliguria Oliguria resection with anastomosis should be treated with suspicion but, in general, the early features of Metabolic acidosis, Metabolic acidosis, sepsis (Table 7. The Warm, dry, suffused Cold extremities patient may look remarkably well, largely due extremities to pink, well-perfused extremities. As already stressed, clues may be obtained from the history or the patient’s charts; in postoperative patients, In septic shock, an early effect of the mediators blood gas measurements can aid early diagnosis.
Root resection of the fused distal and palatal roots prior to ultrasonic preparation (c) discount epivir-hbv 150 mg with mastercard medications look up. Complete dehiscence of the root of tooth #28 and fenestration of tooth #29 was observed cheap epivir-hbv 150 mg mastercard medicine lyrics. Clinical picture of 18-month recall demonstrating normal color cheap epivir-hbv 100 mg with mastercard treatment of scabies, texture epivir-hbv 100 mg discount medicine during the civil war, and periodontal attachment (e) References 1. Agreement between periapical radiographs and cone-beam computed tomography for assessment of periapical status of root filled molar teeth. Esposito S, Huybrechts B, Slagmolen P, Cotti E, Coucke W, Pauwels R, Lambrechts P, Jacobs R. A novel method to estimate the volume of bone defects using Cone-Beam Computed Tomography: An In Vitro Study. Comparison of periapical radiography and lim- ited cone-beam computed tomography in mandibular molars for analysis of anatomical land- marks before apical surgery. Comparison of periapical radiography and lim- ited cone-beam tomography in posterior maxillary teeth referred for apical surgery. Accuracy of cone-beam computed tomography and periapical radiography in detecting small periapical lesions. Cone-beam diagnostic applications: caries, periodontal bone assess- ment, and endodontic applications. Detection of the apical lesion and the mandibular canal in conventional radiography and computed tomography. Characteristics and dimen- sions of the Schneiderian membrane and apical bone in maxillary molars referred for apical surgery: a comparative radiographic analysis using limited cone beam computed tomography. Relationship between root apices and the mandibular canal: a cone-beam computed tomographic analysis in a German population. Differential diagnosis of large periapical lesions using cone-beam computed tomography measurements and biopsy. Comparison between radiographic (2-dimensional and 3-dimensional) and histologic findings of periapical lesions treated with apical surgery. Cone-beam comput- erized tomographic, radiographic, and histologic evaluation of periapical repair in dogs’ post- endodontic treatment. Periradicular regenerative surgery in a maxillary central incisor: 7-year results including cone-beam computed tomography. Periapical radiography and cone beam computed tomography for assessment of the periapical bone defect 1 week and 12 months after root-end resection. Agreement between 2D and 3D radiographic outcome assessment one year after periapical surgery. Levin and George Jong Abstract Root resorption results in the loss of dentin, cementum, or bone by the action of clastic cells. Root resorption in permanent teeth is a pathologic process in response to inflammation that can be caused by numerous factors, such as infection, orthodontic treatment, traumatic injury, cysts, neoplasia, systemic disease, or chemical injury. Root resorption may be classified into external or internal root resorption, based on the location of the lesion. Accurate assess- ment is essential as the pathogenesis of external and internal root resorption is different and treatment protocols vary. Although periapical and panoramic imaging modalities may be helpful in identifying root resorption, early detec- tion with periapical radiography is not considered reliable because of the dif- ficulty in identifying lesions on the buccal or lingual/palatal surfaces. In the primary dentition, root resorption is a normal physiologic process that allows for the eruption of the secondary dentition, except when resorp- tion is premature. Root resorption in permanent teeth is a pathologic process in response to inflammation that can be caused by numerous factors, such as infection, orthodontic treatment, traumatic injury, cysts, neoplasia, systemic disease, or chem- ical injury [2]. The loss of tooth structure due to clastic activity may result from chronic inflammation and in some cases is a self-limiting process [3]. Root resorp- tion may be classified into external or internal root resorption, based on the location of the lesion [4]. External root resorption affects the outer surface of the root and internal resorption affects the walls of the root canal. Accurate assessment is essen- tial as the pathogenesis of external and internal root resorption is different and treat- ment protocols vary. Root resorption may be inconsequential or cause the premature loss of the teeth affected [5]. The successful management of root resorption requires early clinical and radiographic detection and accurate diagnosis [6]. Although periapical and pan- oramic imaging modalities may be helpful in identifying root resorption, early detection with periapical radiography is not considered reliable [7] because of the difficulty in identifying lesions on the buccal or lingual/palatal surfaces [8]. Conventional radiographic techniques are limited by the superimposition and misrepresentation of structures, geometric distortion, and magnification. According to the joint position statement of the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology on the use of cone beam computed tomography in endodontics, 2015 Update (Appendix A and available online at http://www. Laboratory studies of simulated resorp- tive lesions have demonstrated improved accuracy with the use of smaller voxel sizes [12, 13]. Although voxel size is important, processing algorithms and technique factors to improve contrast and spatial resolution may also affect probability of lesion detection. Radiation dose is an important consideration when selecting the appropriate imaging protocol for the task at hand. Additional consideration must be applied to the imaging of children because they are up to three times more susceptible to the effects of ionizing radiation than that of young adults aged 20–25 years and as much as an order of magnitude more than mature adults, aged 60 [16]. Local factors can promote extensive external resorption, such as impacted teeth, orthodontic treatment, apical periodontitis, tumors, cysts, and luxated or autotransplanted teeth. External resorp- tion can also be related to systemic diseases, such as thyroid disorders, calcinosis, and Gaucher’s and Paget’s disease. The excessive pressure from the impacted third molar may have caused the resorptive defect. It is usually associated with orthodontic treatment, occlusal trauma, pres- sure from cysts or apical granulomas, and ectopically erupting teeth (Fig. External inflammatory resorption after trauma is a well-known complication after intrusive luxation injuries and replantation of avulsed teeth, progresses quickly, and is radiographically distinguished by cavita- tion-like areas of low density along the root surface and surrounding alveolar bone. However, these ex vivo studies do not exactly replicate the clinical situation, where changes in the supporting structures such as the periodontal ligament and surround- ing bone may have influenced the result. In addition, the synthetic resorption cavi- ties in the teeth studied were created with round burs that may not have accurately replicated the irregular nature of some resorptive lesions, which may have influ- enced detection. The advantages of serial cross-sectional imaging have been well documented in the orthodontic and endodontic literature [23]. External apical root resorption in orthodontics is estimated to affecThat least one root in 94 % of patients investigated [25]. This type of resorption is characterized by a circular lesion that progresses in a coronal and api- cal direction (Fig. External cervical resorption may be distinguished from caries by a “non-sticky” feel upon exploration. A pink area may be noticed by the patient or clinician, a result of vas- cular granulation tissue visible through the resorbed dentin. Two-dimensional radiographs may not show the full extent of the lesion nor the portal of entry, com- plicating treatment.
