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By C. Einar. Bridgewater College.

There is limited evidence that continuous glucose monitoring may be of benefit to women during pregnancy purchase zithromax 250 mg antibiotic resistance in dogs. Use of continuous glucose monitoring compared to conventional monitoring 1++ was associated with an improvement in birth weight and macrosomia in one study of women with type 1 and type 2 diabetes but not in another randomised control trial in women with gestational diabetes discount zithromax 100mg amex antibiotic 54 312. Diabetes specialist nurses and midwives have an important role in educating women on the need for home blood glucose monitoring and intensive insulin regimens generic 250 mg zithromax otc antibiotic 93 3196. Intensive basal bolus regimens are commonly used and insulin analogues are increasingly used zithromax 500mg with amex antimicrobial office supplies, although published research on their role and safety in pregnancy is limited. It has been demonstrated that rapid-acting analogue insulins to confer potential advantages during pregnancy. Lispro and aspart have been associated with an improved glycaemic profile in the short term compared to unmodified short acting human insulin. Several case control studies suggest no increase in adverse outcomes with glargine. B Rapid-acting insulin analogues (lispro and aspart) appear safe in pregnancy and may be considered in individual patients where hypoglycaemia is problematic. Diabetic ketoacidosis can develop more rapidly, at lower levels of blood glucose and in response to therapeutic glucocorticoids. Women and their partners need education on the management of hypoglycaemia, including the use of glucagon, avoiding hypoglycaemia during driving and on the recognition and prevention of ketoacidosis, which may result in fetal death. In one study, 43% of women with baseline retinopathy showed progression during pregnancy,346 although sight-threatening retinopathy is rare (around 2% of pregnancies). More frequent assessment may be required in those with poor glycaemic control, hypertension or pre-existing retinopathy. C Early referral of pregnant women with referable retinopathy to an ophthalmologist is recommended due to the potential for rapid development of neovascularisation. Parous women with type 1 diabetes have significantly lower levels of all retinopathy compared with nulliparous women. C Women should be reassured that tight glycaemic control during and immediately after pregnancy can effectively reduce the long term risk of retinopathy. Nephropathy There is an association between pre-existing nephropathy (microalbuminuria or albuminuria) and a poorer pregnancy outcome, though this is not due to any increase in congenital malformations. Proteinuria increases transiently during pregnancy, returning to a pre-pregnancy level within three months of delivery. The incidence of worsening chronic hypertension or pregnancy-induced hypertension/pre-eclampsia is high in women with both incipient and overt nephropathy, occurring in over 50% of women where overt nephropathy is present. Worsening nephropathy and superimposed pre-eclampsia are the most common causes of pre-term delivery in women with diabetes. There is evidence of an increased incidence of congenital malformations in women with pre- existing diabetes (type 1 and type 2). A detailed anomaly scan, including evaluation of the four chamber heart and outflow tracts, undertaken at around 20 weeks (18-22 weeks) enables detection of many major structural abnormalites. B;a detailed anomaly scan including four chamber cardiac view and outflow tracts between 20 and 22 weeks. Although regular fetal monitoring is common practice, no evidence has been identified on the effectiveness of any single or multiple techniques and therefore the clinical judgement of an obstetrician experienced in diabetic pregnancy is essential. The evidence for the accuracy of ultrasound scanning in predicting macrosomia (birth weight >4,000 g) is mixed. The accuracy of fetal weight estimation in women with diabetes is at least comparable to women who are not diabetic,353 but for prediction of macrosomia sensitivities ++ 2 have been found to vary from 36-76%, and positive predictive values from 51-85%. The trials reported either equivalent outcomes or improved outcomes (birthweight, macrosomia, large for gestational age) in women 1+ with gestational diabetes. Two randomised control trials have shown that intervention in women with gestational diabetes with dietary advice, monitoring and management of blood glucose is effective in reducing birth weight and the rate of large for gestational age infants,330, 331 as well as perinatal 330 1+ morbidity. Clinical suspicion that type 1 or type 2 diabetes is present or 4 developing in pregnancy may be raised by persistent heavy glycosuria in pregnancy (2+ on more than two occasions), random glucose >5. Strategies are likely to be simplified for women believed to be low risk based on risk factors (see Table 4). If, after nutritional advice, preprandial and postprandial glucose levels are normal and there is no evidence of excessive fetal growth, the pregnancy can be managed as for a normal pregnancy. Women who are at risk of pre-term delivery should receive antenatal corticosteroids. Women with diabetes have a higher rate of Caesarean section even after controlling for 2+ confounding factors. There is insufficient evidence on the preferred method of cotside blood glucose measurement 4 in neonates; however, whichever method is used, the glucose value should be confirmed by laboratory measurement. However, methods of glycaemic monitoring and interventions were not standardised in the study, so caution is required before extrapolating these findings to term infants. Glycaemic control at six weeks in women with type 1 diabetes, who exclusively breast fed, has 388 2++ been found to be significantly better than those who bottle fed. B Breast feeding is recommended for infants of mothers with diabetes, but mothers should be supported in the feeding method of their choice.

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Over the ensuing 3648 hours generic zithromax 250mg with visa infection 2010, most of the volume deficit will be repaired by the movement of fluid from the extravascular into the intravascular space buy zithromax 100 mg with visa bacteria mod minecraft 152. Only at these later times will the Hb and Hct reflect the true degree of blood loss zithromax 500 mg low cost 51 antimicrobial agents 1. In a predisposed individual buy generic zithromax 500mg antibiotics for sinus infection webmd, anemia can lead to congestive heart failure or angina. Other important data includes a prior history of peptic ulcer disease, history of abdominal surgery (e. The hemodynamic status should be interpreted in light of the patients abilities to compensate for hypovolemia. In a young and fit adult, the presence of a resting or orthostatic tachycardia should be interpreted as a sign of significant volume loss, while the loss of an equivalent blood volume in an elderly or debilitated subject would more likely be manifested by hypotension or shock. Once supportive measures have been undertaken, the patient should be assessed with a view towards identifying the source of bleeding (ie. The pigmentation of the stool will depend on the length of time in transit along the bowel. In determining the likely source of bleeding, the clinician needs to interpret the patients manifestations of bleeding in conjunction with the hemodynamic status. In the absence of spontaneous passage of stools, a digital rectal examination to determine the stool color will be most informative. If the bleed is due to a peptic ulcer, upper endoscopy allows stratification of rebleed risk based on the appearance of the ulcer. Early upper endoscopy is done if there are signs of a brisk bleed, a variceal bleed is suspected, the patient is older or has numerous comorbidities. Wireless capsule endoscopy involves ingestion of a pill sized camera to take pictures of the small bowel. Enteroscopy involves a long scope inserted from the mouth to examine the proximal small bowel. Balloon enteroscopy is a newer endoscopic technique in which total endoscopic examination of the small bowel is possible. Description When an abdominal mass is discovered on physical examination, one must define its nature. Using a systematic approach often permits the identification of the mass before the use of sophisticated tests. Important Points in History and Physical Examination Important clues in the history and general physical examination may help to identify the enlarged viscus. For example, in a young patient presenting with diarrhea, weight loss and abdominal pain, finding a right lower quadrant mass would suggest inflammatory bowel disease. However, an abdominal mass may be discovered during physical examination of an asymptomatic individual. Certain observations made during the abdominal examination may be helpful (See also Section 20). A practical approach is to divide the abdomen into four quadrants (See Section 20. Starting from the principle that an abdominal mass originates from an organ, surface anatomy may suggest which one is enlarged. In the upper abdomen a mobile intraabdominal mass will move downward with inspiration, while a more fixed organ (e. Auscultation Careful auscultation for bowel sounds, bruit or rub over an abdominal mass is part of the systematic approach. Defining the Contour and Surface of the Mass This is achieved by inspection, percussion and palpation. In the absence of ascites, ballottement of an organ situated in either upper quadrant more likely identifies an enlarged kidney (more posterior structure) than hepatomegaly or splenomegaly. Differential Diagnosis The following suggests an approach to the differential diagnosis of an abdominal mass located in each quadrant: 18. This anterior organ has an easily palpable lower border, which permits assessment of its consistency. Right kidney: The kidney may protrude anteriorly when enlarged and be difficult to differentiate from a Riedels lobe of the liver. Gallbladder: This oval-shaped organ moves downward with inspiration and is usually smooth and regular. Left Upper Quadrant Location in the left upper quadrant suggests spleen or left kidney. Since it has an oblique longitudinal axis, it extends toward the right lower quadrant when enlarged. Shaffer 29 Left kidney: Its more posterior position and the presence of ballottement helps distinguish the left kidney from the spleen. Colon, pancreas, stomach: It is practically impossible to differentiate masses in these organs by physical examination.

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Patients with decompensated cirrhosis from hepatitis B should be treated with antiviral therapy order zithromax 250mg with amex virus that causes hives. Although bed rest will result in redistribution of body fluid generic 250 mg zithromax with amex treatment for k9 uti, salt and fluid restriction is required to mobilise the ascites purchase 100mg zithromax mastercard virus 56. The patient is usually prescribed a low salt diet containing 44-66 mmol sodium per day cheap 250mg zithromax with amex antibiotics for uti erythromycin, which is even lower than that contained in a no- added salt diet. Professional dietary advice is necessary, and patients require specific instructions regarding where to purchase low salt food. Salt substitutes are contraindicated, as they often contain potassium chloride, and therefore predispose the patients who are taking potassium- sparing diuretics to the development of hyperkalemia. Patients should be carefully monitored with daily weights and with frequent 24-hour urinary sodium excretion measurements. The rate at which ascitic patients gain or lose weight can be used to assess compliance with the low salt diet, and the efficacy of diuretic treatment (Table 4). The urinary creatinine is measured simultaneously with as the urinary sodium to assess completeness of the urine collection. Random urine sodium assessments are unreliable, as urine sodium excretion varies over the + + course of the day. However, a urine Na /K ratio of >1 predicts with 95% accuaracy a urinary + Na excretion of >78 mmol/day. Predicting weight change in patients compliant with low salt (44 mmol Na/day) Diet Scenario I o Urinary sodium excretion is 100 mmol/day o Na intake = 44 mmol/day o Na output = 100 mmol/day o Na balance = (44-100)mmol/day = -56 mmol o Ascitic [Na] = 130 mmol/L o Therefore fluid loss = -56 mmol / 130 mmol/L = -0. Spironolactone, a distal diuretic with anti-aldosterone activity, is the preferred first line diuretic. Furthermore, any sodium reabsorption that is blocked by loop diuretics at the Loop of Henle will be reabsorbed when the sodium is delivered to the distal tubule. Combination diuretic therapy, with both a distal potassium sparing and a loop diuretic, acting on two different sites of the nephron, is now the standard of care. The combination approach has been proven to be more effective than sequential use of different classes of diuretics in the elimination of ascites. Spironolactone has a slow onset and offset of action because its half-life in cirrhotic patients can be as long as 35 hours. Therefore, frequent dose adjustments are unnecessary, and patients should still be monitored even after spironolactone is discontinued. One of the unacceptable side effects of spironolactone is painful gynecomastia in men. Amiloride, another potassium-sparing diuretic, is a less potent but certainly acceptable alternative to spirolactone. Either potassium-sparing diuretic is usually combined with furosemide, starting at 40 mg/day. Shaffer 523 * Monitor: daily weights weekly postural symptoms/signs twice weekly electrolytes, renal function symptoms/signs of encephalopathy Increase diuretics if: weight loss < 1. Electrolyte abnormalities and renal dysfunction are common in cirrhotic patients on diuretics, and should be monitored regularly. Initial outpatient management may be attempted if the volume of ascites is small, and when the ascites occurs in the absence of complications such as concomitant gastrointestinal hemorrhage, encephalopathy, infection or renal failure. Hypokalemia and hypochloremic alkalosis can precipitate hepatic encephalopathy, and should be avoided by the use of juicial changes in the dose of diuretics. Patients with peripheral edema can have their fluid mobilized more rapidly, as the edema fluid can easily be absorbed to replenish the intravascular volume. The dose of diuretic should be reduced if there are symptoms of encephalopathy, a serum sodium 125mmol/L, or a serum creatinine of 130mmol/L. Initially, daily weights and at least twice weekly electrolytes and renal function should be monitored. Urine sodium excretion must be greater than the oral sodium intake in order for the patient to lose weight. This is because the amount of ascitic fluid that can be mobilized each day is 700 mL. Refractory ascites is defined as ascites unresponsive to 400 mg of spironolactone or 30 mg of amiloride plus up to 160 mg of furosemide daily for two weeks, in a patient who has been compliant with sodium restriction. Non-compliance with sodium restriction is a major and often overlooked cause of so-called refractory ascites. Refractory ascites without any underlying cause usually indicates a grave prognosis, with only 50% survival at 6 months. Large volume paracentesis is now recognized as a safe and effective therapy for the treatment of refractory ascites. In one large randomized controlled trial, large volume paracentesis was safer and more effective than was diuretic therapy for the management of ascites, with reduced length of hospitalization. There was, however, no survival advantage of paracentesis over diuretic therapy for the ascites. Removal of ascitic fluid volume of up to 5 litres without the simultaneous infusion of plasma expanders is safe, even in non-edematous patients.

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