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The use of powder-free latex gloves is and chestnut have been found to medications quinapril purchase ondansetron with american express be antigenically similar to treatment authorization request order ondansetron no prescription an important control measure for airborne latex allergen medications for migraines purchase genuine ondansetron line. Insulin Complications may be similar to medications derived from plants ondansetron 8 mg with amex those caused by other Approximately 50% of patients receiving insulin have posi allergens. Prolonged exposure to aerosolized latex may lead tive skin tests, but IgE-mediated reactions occur rarely. If less than 24 hours has especially on the hands, can lead to functional disability. Skin testing and desensi Avoidance remains the corners to ne of treatment for latex tization are necessary if the interval between the allergic allergy. Prevention and supportive therapy are the most reaction and subsequent dose is greater than 24 hours. Local Anesthetics supply of vinyl or latex-free gloves for use when visiting a Less than 1% of reactions to local anesthetics are IgE physician or dentist. Management involves selecting a local anesthetic classified with respect to their ability to induce IgE-mediated from another class. Gloves made from synthetic materials include pected agent, followed by a provocative challenge. To rule Neolon (Bec to n-Dickinson), Tactyl 1 (Smart Practice), and out paraben sensitivity, skin testing can be done with 1% Elastyren (Hermal). Aspirin & Other Nonsteroidal Prophylactic premedication of latex-allergic individuals has been used in some surgical patients at high risk for latex Anti-Inflamma to ry Drugs allergy. This approach should not a systemic reaction, a refrac to ry period of 2–7 days occurs. Cross-reactivity between aspirin and tartrazine (yel Owing to the ubiqui to us nature of natural rubber, the low dye No. No skin test or in-vitro test is available to diagnose aspirin Chronic exposure to airborne latex particles may lead to sensitivity. Biological Agents (Note: Some patients who to lerate cooked egg, that is, In recent years, a growing number of biological agents have denatured protein, may still react to the vaccine. Their use may be associated with a variety of adverse reactions including hypersensitivity reactions. Radiocontrast Media warning regarding risk of anaphylaxis and need for patient Non–IgE-mediated anaphylac to id reactions may occur with moni to ring with use of omalizumab (see pharmacologic ther radiocontrast media with up to a 30% reaction rate on apy section under Treatment, Chronic Asthma, earlier). Management involves using a low-molarity agent and premedication with prednisone, diphenhydra Bohlke K et al: Risk of anaphylaxis after vaccination of children mine, and possibly an H2-blocker. Symp to ms and Signs Academy of Pediatrics recommendation for prescribing cepha Most reactions to foods occur minutes to 2 hours after losporin antibiotics for penicillin-allergic patients. A symp to m diary kept for 7–14 days may be helpful in establishing an association between inges Temporal relationship between ingestion of a sus tion of foods and symp to ms and also provides a baseline pected food and onset of allergic symp to ms. It is For IgE-mediated reactions, positive prick skin test or important to record both the form in which the food was in-vitro test to a suspected food allergen confirmed by ingested and the foods ingested concurrently. In severe cases, angioedema of the to ngue, uvula, pharynx, or upper airway can occur. Gastrointestinal symp to ms include abdominal discom General Considerations fort or pain, nausea, vomiting, and diarrhea. Children with Food allergy, defined as an adverse immune response to food food allergy may occasionally have isolated rhinoconjunctivi proteins, affects 6% of young children and 3–4% of adults. Rarely, anaphylaxis to food may involve only the most common IgE-associated food allergens in children cardiovascular collapse (see section on Anaphylaxis). The highest confirmed by blinded challenge (although this percentage is prevalence of food allergy is found in children with moder much higher in food-induced anaphylaxis). Prick skin test ate- to -severe a to pic dermatitis, with approximately 35% ing is useful to rule out a suspected food allergen, because the affected, whereas chronic conditions such as urticaria and predictive value is high for a properly performed negative asthma are much less likely due solely to food allergy. Of test with an extract of good quality (negative predictive note, food allergy can be caused by non-IgE (cell)–mediated accuracy of greater than 95%). In contrast, the predictive mechanisms, in conditions such as food-protein–induced value for a positive test is approximately 50%. It can also be caused by mixed other in-vitro tests have lower specificity and positive predic IgE and cell-mediated mechanisms, as in allergic eosino tive values. In contrast, specific IgE levels to milk, egg, philic esophagitis and gastroenteritis. Foods containing foods is not clinically useful as IgG responses are a reflection significant amounts of vasoactive amines such as chocolate, of normal immune recognition of foreign food proteins. Approximately 2% of children will considered the gold standard for diagnosing food allergy have food allergy as adults. If there is high suspicion of patients include the Food Allergy and Anaphylaxis Network, possible allergic reactivity to a food with a negative skin test at: (800) 929-4040;. Elimination without controlled chal lenge is a less desirable but at times more practical approach for suspected food allergy. Local or systemic allergic signs and symp to ms after Differential Diagnosis insect sting. Repeated vomiting in infancy may be due to pyloric stenosis or gastroesophageal reflux. With chronic gastrointestinal Allergic reactions to insects include symp to ms of respira to ry symp to ms, enzyme deficiency (eg, lactase), cystic fibrosis, allergy as a result of inhalation of particulate matter of insect celiac disease, chronic intestinal infections, gastrointestinal origin, local cutaneous reactions to insect bites, and anaphy malformations, and irritable bowel syndrome should be lactic reactions to stings. The order Hymen optera includes honey bees, yellow jackets, yellow hornets, Treatment white-faced hornets, wasps, and fire ants. Africanized honey Treatment consists of eliminating and avoiding foods that bees, also known as killer bees, are a concern because of their have been documented to cause allergic reactions. This aggressive behavior and excessive swarming, not because involves educating the patient, parent, and caregivers their venom is more to xic. Rarely, patients sensitized to regarding hidden food allergens, the necessity for reading reduviid bugs (also known as kissing bugs) may have epi labels, and the signs and symp to ms of food allergy and its sodes of nocturnal anaphylaxis. New adverse effects secondary to contact with larval or adult food labeling laws went in to effect in January 2006 requir butterflies and moths. Salivary gland antigens are responsible ing simple terms to indicate the presence of the major food for immediate and delayed skin reactions in mosqui to allergens listed previously (eg, milk instead of casein). Consultation with a dietitian familiar with food allergy may be helpful, especially when common foods such as milk, Clinical Findings egg, peanut, soy, or wheat are involved All patients with a his to ry of IgE-mediated food allergy should carry self A. Symp to ms and Signs injectable epinephrine (see section on Anaphylaxis) and a Insect bites or stings can cause local or systemic reactions fast-acting antihistamine, and consider wearing medical ranging from mild to fatal responses in susceptible persons. Monoclonal anti-IgE, Chinese herbal the frequency increases in the summer months and with formula, oral and sublingual immunotherapy, and vaccines outdoor exposure. Local cutaneous reactions include urti have shown promise as possible future treatments of food caria as well as papulovesicular eruptions and lesions that allergy. Papular urti caria is almost always the result of insect bites, especially of Prognosis mosqui to es, fleas, and bedbugs. Toxic systemic reactions the prognosis is good if the offending food can be identified consisting of gastrointestinal symp to ms, headache, vertigo, and avoided. Unfortunately, accidental exposure to food syncope, convulsions, or fever can occur following multiple allergens in severely allergic patients can result in death. These reactions result from histamine-like sub Most children outgrow their food allergies to milk, egg, stances in the venom. In children with hypersensitivity to wheat, and soy but not to peanut or tree nuts (only 20% and fire ant venom, sterile pustules occur at sting sites on a 10% of children may outgrow peanut and tree nut allergy, nonimmunologic basis due to the inherent to xicity of pi respectively). Mild systemic reactions followed by measuring food-specific IgE levels by Immuno include itching, flushing, and urticaria. Delayed systemic reactions occur from 2 hours to matic therapy includes cold compresses, antipruritics 3 weeks following the sting and include serum sickness, (including antihistamines), and occasionally potent to pical peripheral neuritis, allergic vasculitis, and coagulation de corticosteroids. Topical application of monosodium glutamate, baking Skin testing is indicated for children with systemic reac soda, or vinegar compresses is of questionable efficacy. Large local reactions, in which swell available, but an extract made from fire ant bodies appears ing extends beyond two joints or an extremity, may require a adequate to establish the presence of IgE antibodies to fire short course of oral corticosteroids. Of note, venom skin test results can be negative following Hymenoptera stings should be managed essentially in patients with systemic allergic reactions, especially in the the same as anaphylaxis (see section on Anaphylaxis). Chil first few weeks after a sting, and the tests may need to be dren who have had severe or anaphylactic reactions to repeated. The presence of a positive skin test denotes prior Hymenoptera stings—or their parents and caregivers— sensitization but does not predict whether a reaction will should be instructed in the use of epinephrine. Patients at occur with the patient’s next sting, nor does it differentiate risk for anaphylaxis from an insect sting should also wear a between local and systemic reactions. Children at risk children who have had an allergic reaction to have positive from insect stings should avoid wearing bright-colored cloth skin tests to more than one venom.

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Total serum calcium level of more than 12 mg/dL or ionized calcium level of more than 3 medications that cause pancreatitis buy ondansetron without a prescription. In 90% of cases the underlying cause is hyperparathyroidism or malignancy treatment hypercalcemia order 8mg ondansetron visa, with malignancy the most common cause of severe hypercalcemia ( to 5 medications cheap ondansetron online visa tal serum calcium level above 14 mg/dL or ionized calcium level above 3 medications given for adhd discount ondansetron 8mg without a prescription. In gynecologic oncology patients, the most common mechanism is increased osteoclastic bone resorption without direct bone involvement by tumor. Clinical findings are usually nonspecific and can appear when to tal serum calcium level is above 12 mg/dL or ionized calcium level is above 3. Neurologic findings include lethargy, confusion, depressed consciousness, and coma. Hydration with iso to nic saline to promote renal calcium excretion, because hypercalciuria can produce an osmotic diuresis leading to hypovolemia. Administration of iso to nic saline allows for natriuresis, which promotes renal calcium excretion. This output must be replaced with iso to nic saline or hypovolemia will result, which defeats the purpose of hydration and diuresis. Calci to nin (salmon calci to nin 4 U/kg subcutaneously or intramuscularly every 12 hours) inhibits bone resorption and thus addresses the underlying issue of bone resorption. The onset of action is a few hours and the effect is not profound: only a maximal drop in serum calcium of 0. This agent is not commonly used as it has a potential for bone marrow suppression and other adverse affects. Dialysis (hemodialysis or peri to neal dialysis) is effective in patients with renal failure. To assess acid-base disorders, values for interpretation are obtained from arterial blood gas measurements. In acute (uncompensated) respira to ry acidosis or alkalosis, the change in pH is 0. In chronic (fully compensated) respira to ry acidosis or alkalosis, the change in pH is 0. Calculation of the anion gap in metabolic acidosis permits distinguishing the cause of metabolic acidosis as an accumulation of hydrogen ions or a loss of bicarbonate ions. Of note, a 50% reduction in the level of plasma proteins can result in a 75% reduction in the anion gap. In most situations, treatment of the underlying cause is the only therapy necessary. This therapy should be approached carefully, as there is a theoretical risk of causing a transient worsening of the cerebrospinal fluid pH level or of inducing fluid overload and rebound metabolic alkalosis. Oliguria is the most frequently encountered acute renal problem in critical care medicine. Although low urine output is generally defined as less than 25–30 mL/hour, many clinicians do not take in to account the fact that urine output is dependent on body weight. Therefore, minimal adequate urine output should be calculated by the following formula: 2. In gynecology, the most common prerenal cause of oliguria is volume depletion from either inadequate fluid repletion or hemorrhage. Intrinsic renal disorders, as the name implies, result from injuries to and dysfunction of the renal parenchyma. Injured tubular epithelial cells that have been shed off block the proximal tubular lumen, which reduces the net glomerular filtration pressure and results in a decreased glomerular filtration rate. Postrenal disorders rarely give rise to oliguria unless only a single functioning kidney exists. Postrenal disorders result from obstruction of the urinary tract distal to the renal tissue: collecting system. Assessment usually involves bladder catheterization and urinary tract ultrasonography. Pos to bstructive diuresis is the significant increase in urinary flow after resolution of bilateral postrenal obstruction. This diuresis can result in electrolyte depletion and intravascular volume contraction. In an overdistended obstructed bladder, sudden emptying may cause capillary bleeding, hematuria, and even hemorrhage. This is not common but does occur, and one should be cautious and watch expectantly when decompressing a bladder containing more than 500 mL and certainly for one containing more than 1000 mL. False elevations in specific gravity can result from administration of manni to l, glucose, and radiocontrast dye. In postrenal cases involving collection system disorders, sloughed papilla from papillary necrosis can be seen. Urinary sodium level is best calculated by means of a 24-hour urine collection; however, a randomly obtained specimen of 10 mL may be used as well. In renal hypoperfusion, sodium reabsorption increases and sodium excretion decreases. UrineNahigher than 40 mEq/L suggests impaired sodium reabsorption and thus an intrinsic renal disorder. An elevated urine Na level can be seen in cases of coexisting prerenal and renal disorders as well as in the setting of diuretic therapy. In elderly patients, there is an obliga to ry sodium loss that can elevate the urine Na level in prerenal states. Fractional excretion of sodium is the fraction of sodium filtered at the glomerulus that is excreted in the urine. A 10-mL randomly collected urine specimen is taken for assay of sodium and creatinine (urine Cr) levels. A blood sample is also taken for assay of sodium (plasmaNa) and creatinine (plasmaCr) levels. Creatinine clearance (ClCr) is best measured from values obtained from a 24-hour urine collection, according to the following formula: A 24-hour urine collection is best accomplished by discarding the first void and then collecting the voids thereafter for 24 hours. ClCr reference range for women is 72–110 mL/minute (at the Johns Hopkins Central Labora to ries). Renal impairment is considered at a ClCr level of 50–70 mL/minute, renal insufficiency at a level of 20–50 mL/minute, and renal failure at a level of 4–20 mL/minute. In approaching the assessment of oliguria, the patient should always be evaluated first. Subjective symp to ms including those for hypovolemia (dizziness, chest pain, shortness of breath, palpitations), infection, and obstruction (pain, bloating) as well as signs (tachycardia, orthostatic hypotension, elevated temperature, hypertension) should be assessed, and to tal fluid input and output should be calculated. In the setting of oliguria, if the output exceeds the input (the patient is in negative fluid balance), hypovolemia should be considered. Serum and urine labora to ry tests should be performed before initiation of any fluid challenges or diuretic therapy. When testing is necessary in a low-risk patient with pos to perative oliguria, if the patient has a negative fluid balance, the most cost-effective test for hypovolemia is to measure urine specific gravity. In this setting, if the specific gravity is elevated (and in the absence of substances that falsely elevate specific gravity), the patient should be given a fluid challenge. The management of acute oliguria in a patient with invasive hemodynamic moni to ring involves optimizing central hemodynamics (cardiac filling pressures and cardiac output) and increasing glomerulotubular flow. If the cardiac output is still low after these measures, inotropic support should be initiated. If oliguria persists after these measures are taken, the probable cause of renal failure is an intrinsic disorder. Although low-dose dopamine (2 µg/kg/minute) and furosemide are common treatment attempts when arriving at this situation, neither therapy has been shown to be effective. In fact, administration of low-dose dopamine may increase the risk of bowel ischemia. Use of furosemide in this setting may convert an oliguric renal failure in to a nonoliguric renal failure and assist in fluid management. Conversion to a nonoliguric state does not influence the outcome of renal failure; however, it certainly makes the care of a critically ill patient easier.

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This circulates to medicine bow wyoming buy 4mg ondansetron amex the liver 278 Hema to treatment nausea ondansetron 8 mg without a prescription logy where it is conjugated to medicine klimt discount 4 mg ondansetron visa glucuronides which are excreted in to symptoms 7 days after conception order cheap ondansetron the gut via bile and converted to stercobilinogen and stercobilin (excreted in feces). Stercobilinogen and stercobilin are partly reabsorbed and excreted in urine as urobilinogen and urobilin. Globin chains are broken down to amino acids which are reutilized for general protein synthesis in the body. Intravascular hemolysis (breakdown of red cells within blood vessels) plays little or no part in normal red cell destruction. Extravascular Versus intravascular hemolysis There are two general sites in which hemolysis may take place (Table 17. In intravascular hemolysis, which is uncommon, red blood cells are destroyed directly within the circula to ry system. Extravascular hemolysis is more common than intravascular hemolysis and involves the destruction of red blood cells within mononuclear phagocytic cells, often in the spleen. They are usually inherited, and generally (but not always) the abnormality is observable in the peripheral blood smear. Extracorpuscular defects refer to problems in the environment of the red blood cell, not in the red blood cell itself (Table 17. Extracorpuscular hemolysis is usually acquired and is often but not always discernible in the form of morphologic abnormalities in the peripheral blood smear. Welchii *Intravascular hemolysis*Intravascular hemolysis Labora to ry findings • the major criteria for the labora to ry diagnosis of hemolytic anemia are reticulocy to sis and an increase in serum level of unconjugated bilirubin. For example, many spherocytes suggest hereditary spherocy to sis or immunohemolytic anemia and sickle cells suggest one of the sick cell syndromes. In the majority of cases hema to crit levels are normal or near normal with minimal hemolysis; greater than 25 percent (often 75%) of red cells are ellip to cytes. It should be noted that some elliptical cells also occur in thalassemia, iron deficiency, myelophthisic anemias, sickle cell disease, and megaloblastic anemia. These disorders, however, are accompanied by other characteristic morphologic changes as well. Erythrocyte enzyme deficiencies Hereditary hemolytic anemia has been associated with 284 Hema to logy at least ten red cell enzyme deficiencies. Because of the X-linkage, male patients are more severely affected than female patients. The deficiency is not limited to any particular racial or geographically defined population. Rather than producing acute hemolysis in association with drug ingestion, it causes a chronic congenital nonspherocytic hemolytic anemia. Pyrimidine-5’-nucleotidase deficiency A chronic hemolytic anemia inherited as an au to somal recessive and characterized by large numbers of erythrocytes with basophilic stippling is due to deficiency in an enzyme, Pyrimidine-5’-nucleotidase, which dephosphorylates the ribonucleotides of cytidine and uridine. Generally the term hemoglobinopathy is used to signify a structurally abnormal hemoglobin with at least one amino acid substitution. Structural abnormalities may cause premature red cell destruction; easily denatured hemoglobins; hemoglobins with abnormal oxygen affinity; altered hemoglobin solubility; and, in a few instances, reduced globin synthesis. In this to pic only the few clinically significant hemoglobinopathies are discussed. Hemoglobin S By far the most important hemoglobinopathies are those related to the presence of sickle hemoglobin (HbS). Sickle hemoglobin results form replacement 287 Hema to logy of the sixth amino acid form the N-terminal end of the fi chain, glutamic acid, by valine. Invariably sickle cells are typically seen on Wright-stained peripheral blood smears from patients. Hemoglobin C syndromes Hemoglobin C (HbC) is probably the second most common hemoglobinopathy (2-3% gene frequency in black populations). HbC is caused by substitution of lysine for glutamic acid in the sixth position form the N terminal end of the fi-hemoglobin chain (same location as the substitution in HbS). A variety of acquired clinical conditions result in shortened survival of previously normal red cells. These include immune-mediated destruction, red cell fragmentation disorders, acquired membrane defects, splenic effects, and the results of infections and environmental to xins. Immunohemolytic anemia 288 Hema to logy Immunohemolytic anemias are the result of the binding of antibody, complement, or antibody plus complement to red cells. Antibodies formed against erythrocyte antigens may be either warm (active at 37oC) or cold (active at room temperature and below). In some cases, these antibodies activate a series of proteins, referred to collectively as complement; in others, the red cells are coated with antibody alone. As a result of complement activation by hemolytic antibodies, intravascular red cell lysis and release of hemoglobin may occur. Immunohemolytic anemias fall in to one of three major categories: au to immune, in which the patient makes an au to antibody against his or her own red cells; alloimmune, where the patient’s antibody is directed against foreign red cells; and drug-induced, where a drug-dependent or related antibody is responsible for hemolysis (Table 17. The red cells are usually coated with IgG alone, IgG and complement or complement alone, but a minority of cases show IgA or IgM coating alone or combined with IgG antibody. Part of the coated membrane is lost so the cell becomes 290 Hema to logy progressively more spherical to maintain the same volume and is ultimately prematurely destroyed, usually predominantly in the spleen. The disease may occur at any age in either sex and presents as a hemolytic anemia of varying severity. Labora to ry findings the hema to logical and biochemical finding are typical of a hemolytic anemia with spherocy to sis prominent in the peripheral blood. The hallmark of au to immune hemolytic anemia is the presence of antibody or complement, or both, on the patient’s own red cells. The antibodies both on the cell surface and free in serum are best detected at 37oC. In these syndromes the au to antibody, whether monoclonal (as in the idiopathic cold hemeagglutinin syndrome or associated with 291 Hema to logy lymphoprolifertative disorders) or polyclonal (as following infection. Hemolytic syndromes of varying severity may occur depending on the titer of the antibody in the serum, its affinity for red cells, its ability to bind complement, and its thermal amplitude (whether or not it bids to red cells at 37oC). Agglutination of red cells by the antibody often causes peripheral circulation abnormalities. Intravascular hemolysis occurs in some of the syndromes, in which the complement sequence is completed on the red cell surface. Low serum levels of complement in other case may help to protect the patient from a more sever clinical disease. Paroxysmal cold hemoglobinuria this rare disease, characterized by hemoglobinuria following cold exposure, is caused by an IgG au to antibody to the red cell antigen P. This Donath Landsteiner au to antibody is unique in that it binds to red cells at cold temperatures, in contrast to other IgG antibodies. Furthermore, it binds complement well, and brisk hemolysis results when the cells are warmed and the complement sequence proceeds to completion. Drug induced immune hemolytic anemias Four pathophysiologic mechanisms account for most cases of drug-induced red cell sensitization and positive 293 Hema to logy direct Coombs test. The drug-induced problem may result in serious hemolytic anemia on the one hand, or a labora to ry abnormality without clinical sequelae on the other. Penicillin: ‘Hapten’ (drug adsorption) mechanism Penicillin binds strongly to the red cell membrane, and can be detected on red cells in many patients who are receiving high doses of this drug. Although the drug coating by itself is not harmful, some patients develop high-titer antipenicillin IgG antibodies, which can react with the coated red cells. The coombs test is positive due to the presence of IgG; complement is not usually found. Quinidine: ‘Innocent bystander’ (immune complex) mechanism In some patients previously sensitized to quinidine, and taking it again, the drug reacts with a quinidine antibody, often IgM, to form an immune complex. This complex is then adsorbed on to the red cell membrane; the red cell is considered an “innocent stander’ because it is not the direct target of the antibody. The immune complexes often activate complement, and an abrupt and life threatening intravascular hemolytic anemia may 294 Hema to logy develop. The coombs test is positive for complement; the immune complexes themselves do not bind firmly to the cell. The direct Coombs test is usually strongly positive with IgG; complement is rarely found. Cephalosporins: Membrane modification these drugs cause a positive direct Coombs test through a non-immunologic mechanism. Cephalothin and other cephalosporins are capable of altering the red cell membrane so that proteins, including complement and an assortment of fi-globulins, are nonspecifically adsorbed. As a result of the presence of these proteins, the direct antiglboulin test is positive.

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Adjustments should be made on His to medicine head purchase 4 mg ondansetron overnight delivery ry of thrombophlebitis medications erectile dysfunction ondansetron 8 mg free shipping, thromboembolic disorder medicine 93 5298 ondansetron 8 mg sale, cerebrovas cular disease symptoms 12 dpo order ondansetron 8mg without a prescription, or ischemic heart disease the basis of hormonal effects desired (Table 3–14). Changes Structural heart disease with endocarditis, atrial fibrillation, or are most often made for persistent breakthrough bleeding pulmonary hypertension not related to missed pills. It is given as a deep intramuscular injection of 150 mg First 3 wk postpartum due to increased risk of thromboembolism in to the gluteal or del to id muscle every 13 weeks. The first Lactation (6 wk–6 mo) injection should be given within the first 5 days of the men Active gallbladder disease strual cycle to ensure immediate contraceptive protection. Estrogenic Effects Proges to genic Effects Androgenic Effects Nausea Breast tenderness Decreased production of tes to sterone, improved acne, less oily skin, and improved hirsutism. Insertion and removal are reportedly significantly suppressing ovulation, but it also thickens cervical mucus and easier than with Norplant. With a failure do not lead to decreased bone density, likely due to lower rate of less than 0. Providers must complete formal training nature, reversibility, lack of interference with intercourse, and in order to be able to insert Implanon. Patients should be warned Contraceptive Vaginal Ring about unpredictable menstrual patterns, the possibility of weight gain or mood changes, and the potential for decreased the NuvaRing is a vaginal ring that releases 15 mcg of ethinyl bone density. The Food and Drug Administration has issued a estradiol and 120 mcg of e to nogestrel per day. The vaginal ring is easier to insert pregnancy, including deleterious effects on bone density with correctly than the diaphragm. Studies have shown no increased risk of liver menstrual period and may be difficult to predict. Diaphragms and cervical caps require professional Implantable Contraceptive Methods fitting and skill with insertion and are not popular among Implanon is a single implant, effective for 3 years. Management Westhoff C et al: Initiation of oral contraceptives using a quick start compared with a conventional start: A randomized con A. If she wants to be pregnant and the test is Approximately 750,000 adolescents younger than age 19 negative, further counseling about the implications of teen become pregnant every year. For those who do not wish to be pregnant, rate for younger teens, 15–17 years of age, fell to 21. Despite decreasing rates, the If the adolescent is pregnant, the physician must discuss United States still has the highest adolescent pregnancy rate of her support systems and her options with her (abortion, any developed country. If providers are not comfort lower maternal education are risk fac to rs for teen pregnancy able discussing the option of abortion, the adolescent should regardless of racial or ethnic group. It is important to be available for further assistance Adolescents report delayed or missed menses or may request a with decision making. Patients should be informed of the pregnancy test, but often they present with an unrelated con gestational age and time frames required for the different cern. If the patient knows what she wants to do, she inal pain, urinary frequency, dizziness, or other nonspecific should be referred to the appropriate resources. If a teenager symp to ms, and the adolescent may not have considered the is ambivalent about her plans, it is helpful to follow up in 1 possibility of pregnancy. A his to ry of weight gain, nausea, week to be certain that a decision has been made. Avoiding a painful or engorged breasts, an unusually light or mistimed decision reduces the adolescent’s options and may result in period, or urinary frequency may be present. Clinicians need to have a low the patient obtains prenatal care if she has chosen to con threshold for suspecting pregnancy. Fathers of Infants Born to Adolescent Mothers the his to ry and physical examination assists in making the diagnosis. Bluish coloring and softening of the cervix appear Statistics regarding the age of fathers of infants born to on speculum examination. The uterine fundus may be palpa adolescent mothers are limited due to fear of statu to ry rape ble on abdominal examination after about 14 weeks’ gestation. Data have shown that to dates, one must consider ec to pic pregnancy, incomplete or adult males impregnated 27–40% of 15–17-year-old adoles missed abortion, twin gestation, or inaccurate dates. These data vary by race and ethnicity, with Enzyme-linked immunosorbent assay test kits specific for larger age differences typical in Hispanic and Asian couples. Pregnancy Outcomes Mother Infant Young maternal age, low maternal prepregnancy weight, poor weight gain, delay in prenatal care, maternal depression, and Increased morbidity related to Greater health risks pregnancy Increased chance of low low socioeconomic status contribute to low birth weight and Greater risk of eclampsia, ane birth weight or prematurity poor fetal outcome. Increased chance of maternal Decreased academic Maternal risk fac to rs are linked to adverse neonatal mortality achievement Decreased educational Lower cognitive scores outcome, including higher rates of low birth weight babies attainment Decreased development (< 2500 g) and neonatal mortality. Specific risk fac to rs Less likely to get high school Greater chance of being leading to adverse outcomes include poverty, maternal diploma, go to college, or behind grade or needing depression, exposure to domestic violence, and inadequate graduate remedial help support. Good family support, early prenatal care, and good Delayed education (average 2 y) Lower chance of advanced nutrition can make a difference with several of these prob Lower occupational attainment academics lems. The psychosocial consequences for the teenage mother and prestige Lower academic aptitude and her infant are listed in Table 3–15. Teenagers who are Less chance of stable employment as a teenager and perhaps (some resolution over time) a higher probability of pregnant require additional support from their caregivers. Lower job satisfaction dropping out of school Multidisciplinary clinics for young mothers, if available, may Lower income and wages Psychosocial consequences be the best providers for pregnant adolescents. Greater dependence on public Greater risk of behavior Adolescent mothers tend to be more negative and assistance problems authoritative when disciplining their children. They may Less stable marital relationships Poverty have inadequate knowledge of normal behavior and devel Higher rates of single parenthood Higher probability of living opment. Providers can help by educating the adolescent Earlier marriage (though less in a nonintact home while common than in the past) in high school mother during routine visits regarding appropriate disci Accelerated pace of marriage, sep Greater risk of adolescent pline and expectations of her child’s behavior. In untreated girls, the childbearing risk of a second unintended pregnancy within the next 2 High rate of repeat unintended years is approximately 30%. Providers should have nancy outcomes: Distinctions between neonatal and post-neo natal deathsfi Patients with recurrent episodes may be Vaginitis may be due to pathogens or to indigenous flora given prophylactic treatment whenever they take antibiotics. Candidal vulvovagini It may be helpful to simultaneously treat the partners of this and bacterial vaginosis (formerly called Gardnerella, Hae sexually active patients with recurrent candidal infections. Bacterial vaginosis may be caused by any of the indigenous In sexually active patients, Trichomonas infection or cervici vaginal flora, such as Gardnerella, Bacteroides, Pep to coccus, this due to sexually transmitted pathogens must be considered Mycoplasma hominis, lac to bacilli, or other anaerobes. On examination, a thin, homogeneous, grayish-white discharge is found adhering to the vaginal wall. Physiologic Leukorrhea which a drop of potassium hydroxide is added to a smear of Leukorrhea is the normal vaginal discharge that begins around the discharge on a slide, results in the release of amines, the time of menarche. Wet preparation reveals more than 20% and its consistency may vary according to cyclic hormonal influ of epithelial cells as clue cells and small pleomorphic rods. Girls in early adolescence may have concerns about such a discharge and need reassurance that Treatment it is normal. This may be a good time to tell girls that there is no Treatment for bacterial vaginosis should be reserved for symp need for douching. First-line treatment is with metronidazole squamous epithelial cells may be revealed, but there should be (500 mg orally twice daily for 7 days), which results in 95% fewer than five polymorphonuclear cells per high-power field. Candidal Vulvovaginitis that a disulfiram-type reaction of nausea and vomiting may Candidal vulvovaginitis is caused by yeast (Candida albicans occur when alcohol is consumed. Ampicillin (500 mg orally 4 following a course of antibiotics, after which the normal times daily for 7 days) is the alternative for pregnant patients. Chlamydia and gonorrhea testing should be done whenever a sexually active adolescent complains of Clinical Findings vaginal discharge even when the cervix appears normal. The patient usually complains of vulvar pruritus and a thick vaginal discharge, frequently beginning the week before B. Exami Foreign bodies (most commonly retained tampons or con nation of the vulva reveals erythema to us mucosa, sometimes doms) cause extremely malodorous vaginal discharges. The Treatment consists of removal, for which ring forceps may discharge may be adherent to the walls of the vagina. Allergic or Contact Vaginitis the vaginal preparations are often not helpful, and the patient should be treated on the basis of the clinical examination. Bubble baths, feminine hygiene sprays, or vaginal contracep tive foams or supposi to ries may cause chemical irritation of Treatment the vaginal mucosa.