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There is a pro- The engorgement and friability of the respiratory tract buy cheap cephalexin on-line antibiotic quinolone, mucosal gressive reduction in blood pressure in the first trimester discount cephalexin 250mg amex antibiotic 500g, followed oedema and capillary engorgement of nasal and oropharyngeal by a steady increase in the third trimester to pre-pregnancy val- mucosa and laryngeal tissues increase the possibility of iatro- ues 250mg cephalexin visa virus 50 nm microscope. Pregnancy-induced the pregnant patient at risk of postural hypotension during rapid weight gain and an increase in breast size may obstruct laryn- postural changes purchase 500 mg cephalexin amex antibiotic jaw pain. During the late second and third trimester the gravid uterus Unmounted blade insertion or a short-handled ‘stubby’ laryngo- compresses the inferior vena cava in the supine position (aorto- scope handle are useful alternatives. The bowels and omentum are displaced which can Supine Lateral make the diagnosis of appendicitis or disseminated infection, more Vena difficult. In advanced pregnancy assessment should be performed in the left lateral position to eliminateaortocavalcompression. Themanagementofcatastrophic obstetric haemorrhage involves immediate transfer to hospital with circulation management en route. In the shocked pregnant patient the uterus should be considered as a fifth source of concealed Figure 28. An assessment of the fundus and fetus forms the final part of the primary survey in the pregnant patient. Make a In the event of blood loss the maternal circulation is maintained brief assessment of the fundal height, noting any significant uterine by diverting blood away from the uterus with only minimal change tenderness. A fundal height below the umbilicus suggests that if the to the patient vital signs. The pregnant patient may tolerate a loss fetus is delivered it is unlikely to survive. The introitus should then of up to 20% of their circulating volume without showing clinical be inspected for foetal parts, cord prolapse and significant bleeding. With continued blood loss and reduced ability to compensate due to limited cardiorespiratory reserve there will Box 28. This hypercoagulable state increases the risk of B Breathing deep vein thrombosis and pulmonary embolism. C Circulation D Disability E Exposure Uterus F Fundus / Foetus Uterine growth is the most important anatomical change and will clearly affect the presentation of abdominal disease and trauma. The most anterior presenting organ and therefore the most susceptible patient will often have hand-held maternity notes which may assist you in identifying potential problems. Gestation in weeks Estimated date of delivery Which hospital she is booked into Midwife or obstetric consultant care Complications in this pregnancy Nature of bleeding/pain/fluid loss/discharge Subjective assessment of foetal movements. It usually presents after 20 weeks, but can occur the practitioner has the requisite skills. The uterus should be palpated for tenderness, rigidity, contractions, • Severe pre-eclampsia is characterized by greatly elevated blood foetalpartsandmovements. Iftherehasbeenaspontaneousrupture pressure (>170/110 mmHg), proteinuria and one or more of of membranes the colour of the liquor should also be assessed for the following symptoms: severe headache, visual disturbance, blood or meconium staining. It generally occurs in the third Antenatal emergencies trimester, with 60% of cases reported in the intrapartum period Antepartum haemorrhage or within 48 hours after parturition. The incidence is higher Antepartum haemorrhage is vaginal bleeding after 24 completed in developing countries. The common causes are placental abruption lasting 90 seconds or less, but may be severe and recurrent. The result is Managementofseverepre-eclampsiaandeclampsiarequiresurgent bleeding from the maternal sinuses into the space between the transfer to an obstetric unit. Blood may remain concealed or left lateral position for transfer and oxygen applied if SpO2 <94%. Abruption Monitor the blood pressure en route and pre-alert the obstetric unit usually presents with severe abdominal pain and a hard, tender so that they can prepare drugs and/or theatre. Delay in presentation (up to 48 hours) is not uncommon shouldbemanagedinitiallywithbasicairwayadjucts(e. Further seizures can be prevented • Placenta praevia is when the placenta implants either completely by giving magnesium sulphate 4 g intravenously/intraosseously or partially across the cervical os. If magnesium sulphate is not available and the pregnancy because of intercourse or contractions the tearing of patient has recurrent or prolonged seizures consider parental or maternal blood vessels close to the cervical canal leads to blood rectal benzodiazepines. Emergency prehospital delivery Management of antepartum haemorrhage involves urgent Less than 1% of booked hospital deliveries are born before arrival at transfer to an obstetric unit. Neonatal consequences include a slightly higher perinatal access should be made en route and fluid resuscitation mortality rate (relative risk 5. Pre-eclampsia is a multisystem disorder consisting chiefly of elevated blood pressure (>140/90 mmHg), proteinuria with or First stage of labour The first stage of labour involves cervical effacement and dilatation to 10 cm. There will be an increase in frequency and intensity of Placental abruption Placenta previa contractions during this stage. Second stage of labour The second stage begins when the cervix is fully dilated and is completed with delivery of the baby. In the absence of a midwife able to perform a vaginal examination, the second stage will usually be recognized when the head becomes visible at the introitus (crowning). At this stage delivery is imminent and an emergency prehospital delivery should be prepared for. Allow the head to deliver with gentle support to the perineum Care of Special Groups: The Obstetric Patient 153 (a) (b) (c) Figure 28. Encouraging the mother to pant or breathe through her contractions at this stage will also help control the delivery of the head. If cord is seen around the neck it can be left alone as the body will usually deliver through the loops. The exaggerated Sim’s position should be used to transfer the patient with cord prolapse. The mother is laid on her left side with her head Third stage of labour flat and her buttocks elevated by pillows (Figure 28. The addition The third stage of labour begins with delivery of the baby and of head-down tilt may assist in relieving the pressure of the foetal ends once the placenta has been delivered. Use your fingertips to gently push the presenting of the baby the cord may be cut after it has finished pulsating part upwards and off the cord – this must be maintained during (or immediately if resuscitation is required). Alternatively, pass a urinary catheter and fill the bladder at 3 cm and 6 cm from the baby and divided between the clamps. The increase in bladder In most cases the third stage will be physiological unless Syn- size will elevate the presenting part. Any protruding cord should be tometrine (1-mL vial intramuscularly/intravenously) is available. Owing to the risk of cord rupture and uterine inversion, prehospital application of cord traction is discouraged unless the practitioner is experienced in this technique. Once deliv- Breech presentation ered the placenta should be kept for inspection by the midwife or This is where the presenting part is the feet or buttocks and occurs in obstetrician.

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Once the FcεR1s are aggregated by the cross-linking process buy cephalexin 250 mg on line antibiotic induced c diff, phosphoryla- tion of motifs in both the β-andγ -chains initiates a cell-signalling cascade purchase cheap cephalexin online antibiotic guidelines 2014, acting on scaffold proteins of the cytoskeleton to promote degranulation (exocytosis) of the mast cell buy 500mg cephalexin with amex antibiotic resistance nursing implications. Anaphylactic shock cheap 750 mg cephalexin amex antibiotic resistance documentary, the most severe type of anaphylaxis, occurs when an allergic response triggers a quick release from mast cells of large quantities of immunological medi- ators (histamines, prostaglandins, leukotrienes), leading to systemic vasodilation (associated with a sudden drop in blood pressure) and bronchoconstriction (difficulty in breathing). An estimated 1–17% of the population of the United States is considered ‘at risk’ for having an anaphylactic reaction if exposed to one or more allergens, especially penicillin and insect stings. Most affected individuals successfully avoid such allergens and will never experience anaphylaxis. The most common presentation includes sudden cardiovascular collapse (88% of reported cases of severe anaphylaxis). After an initial exposure (‘sensitising dose’) to a substance such as bee sting toxin, the immune system becomes sensitised to that allergen. Common causes include insect bites, food allergies (peanuts, brazil and hazelnuts are the most common) and drug allergies. Symptoms of anaphylaxis are related to the action of IgE and other anaphylatox- ins, which act to release histamine and other mediators from mast cells (degranulation; Figure 15. In addition to other effects, histamine induces vasodilation of arterioles and constriction of bronchioles in the lungs (a bronchospasm). Constriction of the airways results in wheezing and difficulty in breathing; gastrointestinal symptoms include abdom- inal pain, cramps, vomiting and diarrhoea. Histamine causes the blood vessels to dilate (lowering blood pressure) and fluid to leak from the bloodstream into the tissues (lowering blood volume). Primary (emergency) treatment for anaphylaxis is administration of adrenaline (epinephrine). Adrenaline prevents worsening of the airway constriction, and stimulates the heart to continue beating. Adrenaline (epinephrine) acts on β-2 adrenergic receptors in the lung as a powerful bronchodilator (opening the airways), relieving allergic or histamine-induced acute asthmatic attack or anaphylaxis. Acute-phase proteins are a class of proteins whose plasma concentrations increase (positive acute-phase proteins) or decrease (negative acute-phase proteins) in response to inflammation. The liver responds by producing a large number of acute-phase reactants or reducing the production of others. Cachexia is loss of weight, muscle atrophy, fatigue, weakness and significant loss of appetite. Related syndromes are kwashiorkor and marasmus, although these are most often symptomatic of severe malnutrition. After the virus has infected the cell, two outcomes are possible; either the virus becomes latent and the infected cell continues to function, or the virus becomes active and replicates, and a large number of virus particles are liberated, which can then infect other cells. Over 25 million people are believed to have died of the infection since its recognition in 1981. A course of antiretroviral treat- ment administered immediately after exposure, referred to as post-exposure prophylaxis, is believed to reduce the risk of infection if begun as quickly as possible. Typically, these classes are two nucleoside analogue reverse transcriptase inhibitors, plus either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor. New classes of drugs, such as entry inhibitors, provide treatment options for patients who are infected with viruses already resistant to common therapies, although they are not widely available and not typically accessible in resource-limited settings. Other pathways and cycles (urea cycle, haem biosynthesis, cardiolipin synthesis, quinone and steroid biosynthesis) include steps both outside and inside the mitochondria. Paternal sperm mitochondria are marked with ubiquitin to select them for later destruction inside the embryo. Mitochondrial inheritance is therefore non-Mendelian (Mendelian inheritance presumes that half the genetic material of a fertilised egg derives from each parent). Some in vitro fertilisation techniques, such as the injection of a sperm into an oocyte, may interfere with this pattern. The severity of the defect may be great or small: some may cause ‘exercise intolerance’, with no serious illness or disability; other defects can have severe body-wide impacts. Mitochondrial disease begins to become apparent once the number of affected mitochondria reaches a certain level; this phenomenon is called ‘threshold expression’. It is not (ragged red fibre myopathy maternally inherited but rather occurs sporadically. An inherited disorder that usually affects infants encephalomyelopathy) between the age of three months and two years, but in rare cases teenagers and adults as well. Clinical ophthalmoplegia features include adult onset of weakness of the external eye muscles (ophthalmoplegia) and exercise intolerance. Leber’s hereditary optic Results in degeneration of retinal ganglion cells and their neuropathy (Leber optic axons, causing an acute or sub-acute loss of central vision; atrophy) affects predominantly young adult males. Pearson’s syndrome Characterised by sideroblastic anaemia and exocrine pancreas dysfunction. The few patients who survive into adulthood often develop symptoms of Kearns–Sayre syndrome. Symptoms of mitochondrial myopathies include: • muscle weakness or exercise intolerance • heart failure or rhythm disturbances • dementia • movement disorders • stroke-like episodes • deafness • blindness • droopy eyelids • limited mobility of the eyes • vomiting or seizures. Mitochondrial disease is difficult to identify; symptoms may be apparent at birth or appear later in adult life. Many diseases are suspected to be caused in part by dysfunction of mito- chondria, such as diabetes mellitus, forms of cancer and cardiovascular disease, lactic acidosis, specific forms of myopathy, osteoporosis, Alzheimer’s disease, Parkinson’s disease, stroke and many others. A number of changes occur to mitochondria during ageing: tissues from elderly patients show a decrease in enzymatic activity of the proteins of the respiratory chain; large deletions in the mitochondrial genome can lead to high levels of oxidative stress. Hypothesised links between aging and oxidative stress are not new, but there is much debate over whether mitochondrial changes are causes or merely characteristics of ageing. They are however relatively rare, having an incidence of approximately 2 in 10 000 births. Laboratory studies may include blood plasma or cerebral spinal fluid measurement for lactic acid, ketone bodies, plasma acylcarnitines and organic acids in the urine. They are the core components of the brain, the vertebrate spinal cord and the peripheral nerves. Neurons are ‘maintained’ by glial cells; glial cells provide support, nutrients and oxygen, electrical insulation in the form of myelin, and destroy pathogens and remove dead neurons. This charge difference is referred to as the resting potential and is measured in millivolts (=−65mV). A change in polarity of the membrane, an action potential, results in propagation of the nerve impulse along the membrane. An action potential is a temporary reversal of the electrical potential along the membrane that lasts for a few milliseconds. Sodium gates and potassium gates open in the membrane to allow their respective ions to cross. Sodium and potassium ions reverse positions by passing through membrane protein channel gates; sodium crosses first, to the outside, followed by potassium, to the inside. The changed ionic distributions are reset by the continuously running sodium–potassium pump, eventually restoring the original resting potential. Synapses are ‘terminals’ at which the action potential may be arrested, redirected or relayed; synapses at muscle fibres are called neuromuscular junctions (or myoneural junctions). Functional The somatic nervous system is responsible for coordinating voluntary body movements (i.