By B. Owen. Oral Roberts University. 2019.
This is true for elective as well as emergency interventions cheap microzide 25mg on line, but especially so for trauma (the subject of senior wanted to do as much operating as he could volume 2) proven 25 mg microzide. All your seniors have now left and have gone into Surgically treatable diseases may not be as numerous as the private practice cheap 25 mg microzide mastercard, so there is nobody to help you discount microzide 25mg online. Low & Medium Income Countries, 8% of all deaths, and almost 20% of deaths in young adults are the result of conditions that would be amenable to surgery in the industrial world. If even very simple surgical services were available two-thirds or more of these deaths would not have occurred. What is more, for every person who dies of an accident, there are at least eight who were permanently disabled. Only 1 in 10 who need an inguinal hernia repair get it done, and since a strangulated hernia is almost always fatal unless it is treated, this is a mortality of nearly 90%. For emergency laparotomies the situation is worse: of 50 who need such an intervention to save their life, only one gets it done! They illustrate the fact that hospitals are only coping with a fraction of the burden of surgical disease in the communities around them. Too many people still die from obstructed labour or obstructed bowel, or are disabled by untreated osteomyelitis, or burns contractures, much as they were in the industrial world a hundred years ago. The countries of the third world and the surgical scene They can do much to improve the quality of life of the poor. Ethiopia and Paraguay, for example, are about as different as two countries could be. Gambia, Ghana, Liberia, Nigeria) have >50% of their Meanwhile its per capita food production and its already population living in towns. There were no such countries in meagre gross national product even if increasing remains Africa in 1950. Practically all South American and Far hugely unevenly distributed, whilst costs on the military and Eastern nations have a majority of people urbanized. It is obscene that the There is therefore an urgent need for district hospitals in richest 1% own half the worlds wealth. One feature developing countries do have in common is that Furthermore trauma presents an increasing burden of much of the surgery should be done in district hospitals. Each hospital typically serves about 150-250,000 people living in an area which may be as Surgery has an importance in the public mind that medicine large as 3,000 square miles. It is also the most technically demanding of the tasks of a district hospital doctor or clinical officer, Over the world as a whole these hospitals range from the and is thus a good measure of the quality of his medical excellent to the indescribable. This is why many rural focus of health care in the community and have an important hospitals, and several district hospitals in some countries do place as such, as well as being a major employer of labour. When this happens, patients soon realize that it How much your hospital is valued by the Government can be is no use going to such hospitals, with the result that they measured by whether the Minister of Health or his accolades soon have empty beds. So if you see a hospital with empty would be willing to be treated at your institution, or whether beds, one of the first questions to ask yourself is: What is they will use scarce resources for treatment in a richer the quality of the surgery here? If you work in a hospital in the middle or at the lower end of this spectrum, expect to find your wards overcrowded, with The constraints on the provision of surgical care are more than one patient in a bed. Your maternity ward is likely to be particularly overcrowded, and resist all your attempts to decongest it. Cultural reasons may make it impossible to restrict the number of visitors to the wards. If your hospital is at sea level on the equator, expect to 0 operate at 30 C in 95% humidity, your clothes wet, and everything which can go rusty or mouldy doing so. When you need to prepare for a laparotomy expect that no instruments have been prepared beforehand. When you go into the maternity ward late one night, be prepared for the last sphygmomanometer to be missing. Try not to blame your staff too harshly, they may not be responsible; and even if they are, their families may be starving. Try to examine where things need to be changed and call meetings to get these things done. If you do have electricity, be prepared for it to fail at 3am, just when you are in the middle of a Caesarean section. This is somewhat better than the average conditions for Sub- Saharan Africa at the time of writing. You may be in a health service which is primary education who have not had training relating to the steadily improving, or in one which seems to be getting idea of sterility. Their ability to monitor a patient entrepreneur, or you may be in a system ready to direct postoperatively on the wards may be so poor that you may blame if you do something wrong, and ignore the truth if you be forced to assume that, once a patient has left the theatre, do nothing! Expect that you may be cut off from the rest of he is on his own as far as recovery is concerned. If you are lucky Finally, your greatest blow may be that your predecessor, you will have 2 or 3 anaesthetic assistants, trained to do most who was promised that he would be posted to your hospital of the methods described in Primary Anaesthesia. You may have the services of well-trained surgical technicians, who without formal medical training, can carry But you have great blessings. In coping with all this, out most of the surgical procedures required very adequately. Your laboratory done something that your colleagues in the more comfortable facilities will usually be minimal. You may have whether you are a national from the urban elite or a expensive equipment given by charitable organizations: foreigner, and will greatly increase their trust in you. If your morale is high, affluent world, you may well miss the sense of purpose and so soon will be that of your staff also. Your patients will be achievement that you found when treating patients in low grateful for anything you can do for them, and it is likely resource settings. Your experience, and your practical they will not yet have learnt to litigate against you. You will be shocked by the wastage of resources, and the If you serve your hospital and the community round it for lack of a clinical acumen, that you have tuned carefully over >5yrs, you will earn a unique place in its affections. As a doctor in one of the hospitals we have just described, you are unlikely to find a fully qualified specialist surgeon with 6-8yrs of postgraduate training. But somehow you have to care for the sick in all of the 20 specialist fields shown in the frontispiece, into which surgery has fragmented in recent years. There may be no maxillofacial surgeon, or hand surgeon in the country, and if it is a small one, there may not even be a specialist anaesthetist. Nor, despite present training programs, is the situation in many countries likely to improve much in the near future. Even your nearest regional hospital may only have one or two general surgeons, or none at all! But surgery will be only part of your work; you may also have to be a physician, and a paediatrician, and manage the Fig. If they are away from their villages during the planting and This will be especially true if you are an emergency surgeon harvesting season, they will go hungry. Socio- flown in to help in a disaster situation, such as an economic factors affecting utilization of a rural Indian hospital. Tropical earthquake; the first operation you are likely to have to do is Doctor 1978;8(4):210-9 with kind permission. You worked for hours to put up a reliable drip and took great care to ring up for a bed in the referral hospital. As a leader, or even district medical superintendent, you may When you pass by the ward 2 hours later, you find that she has indeed been have to deal with everything and everybody. When you sent there by ambulance, but the drip is lying on the bed, and the vein is arrive, make note of what you see (you easily forget your thrombosed. Unfortunately, the the back-handers for unnecessary or sub-standard equipment, first hospital she went to had run out of anaesthetic gases and so could not operate. Her mother had to take her through three states stopping at four the requests for unsecured financial advancements from hospitals before she found one which could anaesthetize her. It is necessary to have a critique of your To help you we have collected from among the activity: this is audit.
For example discount 25 mg microzide with mastercard, during intubations discount 25 mg microzide amex, respiration may be restored in response to stimulation of the receptors of the superior laryngeal nerve purchase microzide 25mg with visa, the nucleus of which is located in the medulla oblongata near the respiratory center purchase microzide 25mg free shipping. It manifests with irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain, including brain stem. However, one should notice that there are internationally accepted criteria to diagnose biological death. S Israel; General Pathology, Churchill Livingston Edinburgh and th London, 4 edition, 1974 th 5. Define hyperplasia, hypertrophy, atrophy, & Metaplasia & list some of their causes. Which of these outcomes occur depends on both the injurious agent & on cellular factors. In other words, the result depends on the type, severity, & duration of the injury & on the type of the cell. This chapter covers the types of cellular adaptation, reversible cell injury, & cell death in that order. Types of cellular adaptation The types of cellular adaptation include hypertrophy, atrophy, hyperplasia, & metaplasia. Increased workload leads to increased protein synthesis & increased size & number of intracellular organelles which, in turn, leads to increased cell size. Examples: the enlargement of the left ventricle in hypertensive heart disease & the increase in skeletal muscle during sternous exercise. It can be physiological as in enlargement of the breast during pregnancy or it can pathological as in endometrial hyperplasia. The atrophic cell shows autophagic vacuoles which contain cellular debris from degraded organelles. Metaplasia Metaplasia is the replacement of one differentiated tissue by another differentiated tissue. Squamous metaplasia This is replacement of another type of epithelium by squamous epithelium. For example, the columnar epithelium of the bronchus can be replaced by squamous epithelium in cigarette smokers 2. Osseous metaplasia This replacement of a connective tissue by bone, for example at sites of injury. Reversible cellular changes & accumulations Even though there are many different kinds of reversible cellular changes & accumulations, here we will only mention fatty change & accumulation of pigments. These etiologies cause accumulation of fat in the hepatocytes by the following mechanisms: a. Melanin Melanin is a brownish-black pigment produced by the melanocytes found in the skin. Bilirubin Bilirubin is a yellowish pigment, mainly produced during the degradation of hemoglobin. Excess accumulation of bilirubin causes yellowish discoloration of the sclerae, mucosae, & internal organs. Hemolytic anemia Hemolytic anemia is characterized by increased destruction of red blood cells. Biliary obstruction This is obstruction of intrahepatic or extrahepatic bile ducts. Hepatocellular disease This is associated with failure of conjugation of bilirubin. It appears in tissues as golden brown amorphous aggregates & is identified by its staining reaction (blue 17 color) with the Prussian blue dye. Hemosiderin exists normally in small amounts within tissue macrophages of the bone marrow, liver, & spleen as physiologic iron stores. Hemosiderosis When accumulation of hemosiderin is primarily within tissue macrophages & is not associated with tissue damage, it is called hemosiderosis. Necrosis In necrosis, excess fluid enters the cell, swells it, & ruptures its membrane which kills it. After the cell has died, intracellular degradative reactions occur within a living organism. Ischemia can be caused by obstruction of arterial blood flow the most common cause, or by decreased perfusion of tissues by oxygen-carrying blood as occurs in cardiac failure, hypotension, & shock. The cell injury that results following hypoxia can be divided into early & late stages: 1. Failure of the cell membrane Na K pump, which leads to increased intracellular Na & water, which cause cellular & organelle swelling. Cellular swelling (hydropic change) is characterized by the presence of large vacuoles in the cytoplasm. It is caused by massive calcium influx & very low pH, which lead to activation of enzymes, which damage the cell membrane& organelle membranes. Free radical-induced injury Free radical is any molecule with a single unpaired electron in the outer orbital. Cell membrane damage Direct cell membrane damage as in extremes of temprature, toxins, or viruses, or indirect cell membrane damage as in the case of hypoxia can lead to cell death by disrupting the homeostasis of the cell. Increased intracellular calcium level Increased intracellular calcium level is a common pathway via which different causes of cell injury operate. For example, the cell membrane damage leads to increased intracellular calcium level. The increased cytosolic calcium, in turn, activates enzymes in the presence of low pH. Coagulative necrosis Cogulative necrosis most often results from sudden interruption of blood supply to an organ, especially to the heart. It is, in early stages, characterized by general preservation of tissue architecture. It is marked by the following nuclear changes: Pyknosis (which is chromatin clumping & shrinking with increased basophilia), karyorrhexis (fragmentation of chromatin), & karyolysis (fading of the chromatin material). Liquefactive necrosis Liquefactive necrosis is characterized by digestion of tissue. Fat necrosis Fat necrosis can be caused by trauma to tissue with high fat content, such as the breast or it can also be caused by acute hemorrhagic pancreatitis in which pancreatic enzymes diffuse into the inflamed pancreatic tissue & digest it. The fatty acids released from the digestion form calcium salts (soap formation or dystrophic calcification). In addition, the elastase enzyme digests the blood vessels & cause the hemorrhage inside the pancreas, hence the name hemorrhagic pancreatitis. Caseous necrosis Caseous necrosis has a cheese-like (caseous, white) appearance to the naked eye. Gangrenous necrosis This is due to vascular occlusion & most often affects the lower extremities & the bowel. It is called wet gangrene if it is complicated by bacterial infection which leads to superimposed liquefactive necrosis. Whereas it is called dry gangrene if there is only coagulative necrosis without liquefactive necrosis. Apoptosis usually occurs as a physiologic process for removal of cells during embryogenesis, menstruation, etc It can also be seen in pathological conditions caused by mild injurious agents. Metastatic calcification This is caused by hypercalcemia, resulting from hyperparathyroidism, milk-alkali syndrome, sarcoidosis etc 2. Inflammation is fundamentally destined to localize and eliminate the causative agent and to limit tissue injury. Thus, inflammation is a physiologic (protective) response to injury, an observation made by Sir John Hunter in 1794 concluded: inflammation is itself not to be considered as a disease but as a salutary operation consequent either to some violence or to some diseases. Causes: Causes of inflammation are apparently causes of diseases such as physical agents - mechanical injuries, alteration in temperatures and pressure, radiation injuries. Thus, inflammation of the appendix is called appendicitis and that of meninges as meningitis, etc. Classification: Inflammation is classified crudely based on duration of the lesion and histologic appearances into acute and chronic inflammation. The five cardinal signs of acute inflammation are Redness (rubor) which is due to dilation of small blood vessels within damaged tissue as it occurs in cellulitis. Some chemicals of acute inflammation, including bradykinins, prostaglandins and serotonin are also known to induce pain.
Phone: 201-585-8114 order 25 mg microzide visa, website medications may be tried cheap 25 mg microzide mastercard, but are much less Hereditary myoclonic dystonia cheap microzide 25 mg free shipping, hereditary www order 25 mg microzide with amex. Clonazepam appears to be most torsion dystonia and hereditary essential effective for brainstem myoclonus. Long-term therapy of myoclonus and hydroxytryptophan and carbidopa has been Jerks other neurological disorders with I-5- found to be successful in the treatment of Lance- Lightning-fast movements hydroxytryptophan and carbidopa. Common congenital myopathies Malignant hyperthermia, especially with Occasionally, cardiomyopathy is seen in the are initially referred to as those with obvious central core disease and multicore disease patients with nemaline rod myopathy and structural ab normalities, including central core Skeletal ab normalities including congenital myotubular myopathy. Incidence of other congenital Exercise intolerance, especially with myopathic features. In and early childhood cases, but as autosomal- M itochondrial myopathy myotubular myopathy, central nuclei are dominant diseases in late childhood cases. In the Nemaline rod myopathy is inherited as Congenital peripheral polyneuropathy multicore disease, multiple sma ll fusiform lesions autosomal-dominant disease, linked to without mit ochondria are present. In the chromosome 1q, but also as sporadic Congenital myasthenic syndrome fingerprint myopathy, ovoid inclusions are seen. In congenital fiber type disproportion, type 1 Central core disease is usually inherited as fiber smallness and predominance and type 2 autosomal-dominant disease, linked to fiber hypertrophy are seen. Semin Pediatr Neurol may be necessary in respiratory failure or Myotubular myopathy may also run mild to gastroesophageal reflux. Muscular Dystrophy Association clinics for care, education, and support: Muscular Dystrophy Association, 3300 E. Contraindications Because malignant hyperthermia is associated with central core and multicore myopathies, these patients should avoid halothane or other halogenated anesthetic agents and succinylcholine, which may precipitate malignant hyperthermia. Precautions Patients should wear medical alert bracelet or necklace indicating their risk of malignant hyperthermia associated with anesthesia. Prevalence rates between 1:40,000 and Onset of symptoms with prolonged 1:1,000,000 for each individual disorder. Most diseases have a usual manner of (4-12 hours) exertion However, collectively they are not uncommon. They are listed below by their Episodes mimicking a Reye-like syndrome Race presenting signs and symptoms, e n e r g y or coma No known difference. Genetics Mitochondrial disorders Multiple Repetitive nerve stimulation excludes Inheritance patterns vary by disease. Most mitochondrial inheritance (Mito) neuromuscular junction disorders in cases disorders are autosomal recessive. Phone: 800-572-1717, -Histochemicaldiminished or absent staining in protein and fats benefits some patients with website www. Distinct patient for the enzyme on the muscle tissue sections carbohydrate metabolism disorders. The obverse is organizations exist for many of the individual in myophosphorylase, phosphofructokinase, true for disorders of lipid metabolism. These patients metabolic myopathies and may be found by or acid maltase deficiencies. Metabolic myopathies, disease-causing mutations None myopathies: a clinical approach; part I. Incidence/Prevalence Antimicrotubular myopathy: colchicine, Hyperthermia vincristine Incidence is unknown for most toxic myopathies, Malignant hyperthermia Toxic focal myopathies but appears to be common. For malignant Neuroleptic malignant syndrome Ethanol (acute) hyperthermia, the incidence is 1 in 15,000 children and 1 in 50,000 adults. Race, age, and Painful ToxicMyopathies Intramuscular injections sex are not factors. Deep tendon reflexes and Over 50% of families show linkage to the gene fascia is fasciitis, and is listed since symptoms of appreciation of primary sensory modalities are encoding the ryanodine receptor. Phone: 203-746-6518, corticosteroid myopathy and demonstrates Contraindications fax: 203-746-6481,toll free: 800-999-6673, normal insertional and None. The event should be reported when use of a medication or Steroid myopathy product ca uses d isability or death, or requires Malignant hyperthermia Management Neuroleptic malignant syndrome medical intervention or hospitalization. These episodes typically last only Obesity a few seconds to minutes and terminate Narcolepsy is a chronic and disabling neurologic Type 2 diabetes spontaneously or by stimulation to hasten full disorder characterized by excessive daytime Multiple sclerosis wakefulness. Insufficient sleep syndrome (shift work, jet lag) should be performed to rule out symptomatic Age Delayed sleep-phase syndrome sleep apnea or movement disorders as the cause Develops around adolescence. A strong association with Narcolepsy i s manifested as a classic tetrad of falling asleep. Hypocretins are neurotransmitters whose Excessive daytime somnolencethe most frequent especially significant if they take place late in the cell bodies are located in the hypothalamus. The hypocretin gene was found to be transient, simultaneous loss of muscle tone and None abnormal in narcoleptic dogs in 1999 and a murine muscle stretch reflexes in agonist/antagonist narcolepsy model has been produced by knocking muscles. Rarely, narcolepsy has been narcolepsy patients do not seem to exhibit reported after head trauma. Modafinil has been limited duration (2030 minutes), especially remission nor relentless progression is known to shown to stimulate the release of hypocretins in before activity requiring alertness, such as driving. Cataplexy can be or more often, zaleplon (Celexa) temporarily suppressed by imipramine 25 mg. Narcolepsy associated with the risk of acute hepatic failure and associated with other central nervous system manufacturers now recommend that serum disorders. Randomized trial of modafinil as a treatment for the excessive daytime somnolence of narcolepsy. Growth of neurofibromas has been nodules (iris hamartomas), (f) a distinctive osseous Neuropathic pain reported during pregnancy. Most complications Balance disorder lesion such as sphenoid wing dysplasia or thinning of occur from preexisting problems such as pelvic the cortex of the long bones (with or without Headaches neurofibromas or existing seizures. Because these tumors are highly aggressive, immediate referral should be made for surgical diagnosis. Neurologic exams and hearing evaluations should be performed at least annually and when new symptoms occur. Neurofibromatosishenotype; natural monitoring because of the rare p ossibility of surgically removed. Dumbbell tumors of and London: Johns Hopkins When optic pathway tumors occur, it is in spinal nerve roots are difficultto manage. Within families, require nonsteroidal antiinflammatory drugs ( there is a tendency to similar clinical course. Patients with vestibular tumors sh ould be instructed on problems they may develop with balance, including underwater disorientation. Neuroleptic malignant syndrome: epidemiology, clinical presentation, diagnosis, Medications Follow-Up and treatment options. Neuroleptic malignant syndrome: a review, weeks following resolution of the#yndrome Vital Dopamine agonist agents are the drugs of Psychiatr Sery 1998;49(9):1163-1172. Precautions If an antipsychotic agent is necessary, use the Complications include: lowest effective dose and increase the dose Rhabdomyolysis slowly. Although this abnormal lipopigment distinguish between the different forms of the funduscopic evaluation, and clinical course. It also is important to confirm the potentials, and somatosensory evoked symptoms are confined to the central nervous diagnosis to rule out other neurodegenerative potentials may add supportive evide nce, system. There is See Signs and Symptoms, prominent macular degeneration, optic Sex atrophy. The neuronal ceroid- Psychotropic drugs for treatment of behavior attend school until the late teens, although lipofuscinoses: recent advances. Once axonal injury becomes Diagnosis well established, there are no known effective Basics interventions for reversing diabetic polyneuropathy. At the may be spared initially in compressive impairment of small-fiber sensory function. This time of diagnosis, 8% of diabetics have clinically lesions, The prognosis is favorable in these may present as tingling or burning overt peripheral neuropathy. Fifty percent have patients with functional recovery occurring paraesthesias in the toes and distal feet with overt peripheral neuropathic findings within 10 over 1-3 months. Proposed metabolic pain, which is generally unilateral, intense, Autonomic neuropathy may produce postural abnormalities include accumulation of and independent of position or inspiratory hypotension with an increased and invariant advanced glycosylationend products leading to movement. Oxidative stress with Lumbosacral radiculoplexus neuropathy: include bladder atony with difficulty excessive free radical production may lead to This syndrome of painful, asymmetric lower initiating micturition, incomplete bladder lipid peroxidation of nerve membranes. Most men Circulating nerve growth factors are also Garland syndrome or diabetic amyotrophy) is are aware of erectile impotence, although reduced, suggesting a role in pathogenesis. Patients may complain of gait glycemic control is the most important risk muscle weakness and atrophy affecting both unsteadiness, with difficulty walking in a dark factor for the development of diabetic proximal and distal muscles.
It is obvious that some patients will have a complete (2);Be gentle microzide 25 mg fast delivery, or you will perforate the fundus cheap microzide 25mg mastercard. Para 5 of age 40yrs cheap microzide 25mg visa, or Para 3 Your exploring finger will have shown you how deep it is microzide 25mg fast delivery. Some patients will be very grateful if you combine With your left hand on the abdomen, explore the uterus a uterine evacuation with a tubal ligation. If the logistics of your hospital make it possible, you should give women a If you still cannot empty the uterus fully, use a suction choice. Let it almost rest in your hand blood loss because the placenta has become stuck or is half as you use it. This is quite different from a If you do perforate the uterus with a suction curette, cervical gestation (20. If you see You will know that the uterus is empty by: products of conception in the cervix, remove them with (1) A characteristic grating feeling. Resistance to movement with a suction curette: be fooled into thinking a blood transfusion is necessary. An ultrasound performed during or directly after the misoprostol or oxytocin and at the same time evacuate the evacuation. Finally, with a large uterus that is still bleeding, perform a If bleeding does not stop after evacuation and you have bimanual compression (22-10) to encourage contraction and excluded a uterine perforation, it is probably due to poor expel clots from the uterus. Put two fingers into the anterior contraction of the uterus, or there may still be products of vaginal fornix, and your other hand on to the abdominal conception in the uterus. Sometimes uterine arteries at several locations in the area just after they packing the uterus helps; do not pack the vagina as that only enter the uterus (22-14). If this fails, a B-Lynch suture conceals the problem; it will not usually remove the cause of (22-13, 22. A torn cervix is occasionally the cause and If you have closed a uterine tear, warn that the uterus is in suturing might be a technical challenge. In that case packing danger of rupturing in later pregnancies and an elective the vagina near the cervix might solve the problem. If even this fails to control bleeding (very rare), tie both If you feel a fibroid in the uterus (uncommon), it may uterine arteries or perform a hysterectomy. Leave it for The younger the patient, the easier it is for her to cope with a 1month while treating with iron supplements. It is better to spend a few days extra in hospital closed, first use misoprostol 400g vaginally 2hrs prior to because of dizziness than to get a transfusion contaminated excision (23. In young anaemic, otherwise healthy women on oral iron, the Hb can increase 25g/dl/wk. If there are very few curettings, the miscarriage is Older women and those with sepsis, malaria, or heart disease probably complete. There is however a possibility that your cannot, however, so easily deal with very low Hb levels. This can be Material removed or spontaneously aborted from the uterus an extremely dangerous situation if missed. The high fever with an ectopic gestation has no connective tissue-like may then be diagnosed as sepsis as a result of the structure. The jaundice seen with severe malaria is also even the products of conception at 5wks have so much seen sometimes in sepsis. Legislation related to termination of pregnancy differs If there is no improvement after evacuation, enormously throughout the world. She may have an ectopic gestation, America doctors do not dare to terminate a pregnancy even or be severely anaemic, or have a collection of pus. In others, abortions are allowed on find an abscess in the pouch of Douglas, drain it (10. The perforation will probably heal st 12-72hrs later by 800g vaginal misoprostol tablets easily, especially if she was in the 1 trimester. However, misoprostol (perhaps in repeated doses) without (b) before emptying the uterus, try a digital evacuation and mifepristone is also quite successful. The disadvantage of this so-called medical abortion is that it Observe carefully as before. In most countries induced If there is evidence of omental or bowel injury, abortions are performed with the help of suction curettes start resuscitation and perform an immediate laparotomy, only up to around 13wks. But, as long as a dead foetus remains experience, proper training and preferably guidance by inside the uterus, there is the remote but serious risk of a ultrasound. Rupturing the membranes to induce labour is dangerous, because the dead foetal tissues are easily infected by anaerobes and antibiotics will not reach the foetal tissues if there is no foetal circulation. Throughout pregnancy there is What you can do about it depends on whether death occurs sensitivity of the uterus to prostaglandins, although the before or after 20wks. Before this time this is termed a optimal dose varies according to gestation, but its sensitivity retained miscarriage, afterwards an intra-uterine death. Misoprostol is Before 20wks a dead foetus is usually expelled without easiest to administer (22. Monitor the growth of the uterus carefully: it will not miscarriage which stops bleeding spontaneously, grow, and may even become smaller. Pregnancy tests and is followed by a brown discharge and no further true become -ve after some weeks. The foetal heart movements are not visible (65-8wks) on proceed as follows: ultrasound or not heard (10-16wks) with a Doppler. Remember that using a foetal stethoscope is unreliable in If the uterus is smaller than 10wks, put 400g misoprostol obesity or polyhydramnios and enables you to hear the heart in the posterior vaginal fornix, or buccal cavity, and repeat only at 20-28wks. Instead, it either remains and then use a #6-10 Karman curette, depending on the stationary or falls. Continue until measure the height of the fundus above the symphysis pubis the uterus is empty, and you can feel the uterus tight round accurately with a tape measure. You can dilate the uterus to Hegar 10, and use a it is rare that there is a real indication for radiographs in this #10 Karman curette, which works up to 12wks but not setting. If drowsiness or convulsions ensue whilst on an oxytocin The mother notices that foetal movements stop, or do not infusion, suspect water intoxication. If the method you have used has not succeeded in 2days of Confirm the absence of the foetal heartbeat with ultrasound trying, try another method, or wait for 2-3days and try again. The patient may find this difficult to understand and her husband A dead foetus is usually easy to deliver when death is the may try to persuade you to act prematurely. Explain that, result of gestational hypertension or abruption, because the if you attempt induction by the method below, it may fail foetus is usually small and is often macerated. Caesarean Section might seem to be the If she is still undelivered 2wks after foetal movements obvious answer. Before you start this, in the pelvis, removing it from the uterus at Caesarean check the clotting time and platelet count, if the foetus might Section is difficult. Provided the head is well down in the pelvis, an low doses for grand multipara or where there is an uterine operative vaginal delivery, if necessary a destructive one scar. If this fails, repeat the infusion Otherwise, Caesarean Section is the only option, the next day with 25 units in 500ml. If necessary, wait and but even then a hydrocephalus is often so large that you need repeat it after 7days. If this does not work, wait 7days more to drain the head before you can extract it via a routine and try a 3rd time. You may have to use up to 100 units in uterine incision, or you have to make your incision higher, 500ml (the absolute maximum). Usually, much less is larger or maybe even vertical and any of these scars is in necessary. At Caesarean Section, the routine incision was, by a large margin, not large (1);You may have to use large doses. During abdominal closure, the baby who the volume you use, everybody had thought had died, started crying. The baby died 3months later probably from repeated urinary tract (d);keep a fluid balance chart; if there is a positive fluid infections. Mothers of (2) Oxytocin (and misoprostol) can rarely rupture the uterus malformed babies need counselling before delivery if at all possible.