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Predictors of a poorer prognosis include evidence of cardiopulmonary arrest buy generic atenolol 50mg on line blood pressure difference in arms, a spontaneous respiratory rate less than 4 per minute discount atenolol online mastercard arteria networks corp, need for intubation atenolol 100 mg with visa blood pressure chart normal, and neurogenic pulmonary edema [5] generic 50 mg atenolol with visa blood pressure chart 16 year old. In patients who have cardiopulmonary arrest survival rate is less than 50%, with only about 12% of survivors having good neurologic outcome [12]. Other neurologic sequelae can become manifest either in the immediate posthanging period or after a relatively asymptomatic latent period. The individual may show evidence of a confusional state; a circumscribed retrograde amnesia; Korsakoff’s syndrome; or even progressive dementia [7]. Transient hemiparesis; aphasia; abnormal movements; motor restlessness; and myoclonic jerks also can characterize this period [7]. Three more severe delayed outcomes have also been observed: (a) comatose state with minor neurologic improvement and death; (b) early neurologic recovery, followed by cerebral edema with uncontrollable uncal herniation and severe morbidity or mortality; and (c) complete neurologic recovery, followed by delayed encephalopathy and death [3]. Approximately 400 people per year are affected by lightning strikes, with one-third of victims dying owing to their exposure [15]. Pathophysiology Electrical and lightning injuries are exceedingly variable and dependent on a number of factors. Current flowing between two potentials, or amperage, is equal to the voltage divided by the resistance to current flow (I = V/R). Alternating current has a tendency to produce tetanic contractions that prevent voluntary release from the current source, thus prolonging the electrical contact time and increasing the potential for injury. Higher voltages, such as those that occur with lightning or with contact with high-voltage conductors, produce more severe injuries than those caused by lower voltages. Wet skin and tissues high in water content provide low resistance to current flow and are at a higher risk for injury, whereas tissues high in fat and air, such as hollow organs, provide high resistance. Nerves and blood vessels have lower than expected resistances, and thus are more sensitive to electrical injury than their water content would suggest [16]. Finally, “stride current” involves the spread of electricity from the lightning bolt to the ground and then through contact points in the patient. Stride current patients are more likely to experience spinal cord injuries, because the current crosses through the spinal cord from one limb to another. Neurologic Complications of Electrical and Lightning Injuries Neurologic sequelae of electrical injuries affect both the central and peripheral nervous systems, with both immediate and long-term difficulties. Immediate Effects Immediate neurologic effects of electrical injuries are noted throughout the neuraxis. Patients with electrical and lightning injuries to the head may also suffer subarachnoid or parenchymal hemorrhages, particularly in the basal ganglia and brainstem [19]. In patients who suffer cardiac or respiratory arrest, posthypoxic encephalopathy may develop in “watershed” areas of the cerebral cortex. Catecholamine release may result in autonomic dysfunction, as evidenced by transitory hypertension; tachycardia; diaphoresis; vasoconstriction of the extremities; and fixed and dilated pupils [20]. Thus, lightning-strike victims should receive full resuscitative efforts despite pupillary changes, because these may not indicate permanent brainstem dysfunction. Lightning-strike victims may also suffer “keraunoparalysis,” a self-limited paralysis more often involving the lower extremities, accompanied by a lack of peripheral pulses, pale and cold extremities, and variable paresthesias [19]. The spectrum of spinal cord injuries includes paralysis, spasticity, autonomic dysfunction, and, later, chronic pain and pressure ulcers [19]. Acute neuropathies are typically not seen with lightning strikes, but may be seen with electrical injuries in association with compartment syndromes, local burns, or vascular injury [21].

The mechanism is unclear order atenolol 50mg with amex arrhythmia list, but cholestatic jaun- dice and pruritus were occasional complications of higher dose oral con- traception cheap 100 mg atenolol fast delivery blood pressure medication ramipril, and are similar to the recurrent jaundice of pregnancy atenolol 100 mg line blood pressure medication gluten free, that is buy atenolol 50 mg low cost prehypertension icd 9 code, benign and reversible. The only absolute hepatic contraindication to steroid contraceptive use is acute or chronic cholestatic liver disease. Once recovered from the acute phase of liver disease (normal enzyme levels), a woman can use steroid contraception. Data from the Royal College of General Practitioners’ prospective study indicated that an increase in the incidence of gallstones occurred in the Oral Contraception frst years of oral contraceptive use, apparently due to an acceleration of gallbladder disease in women already susceptible. The mech- anism appears to be induced alterations in the composition of gallbladder bile, specifcally a rise in cholesterol saturation that is presumably an estro- gen efect. Indeed an Italian case-control study and a report from the Oxford Family Planning Association cohort found no increase in the risk of gallbladder disease in association with oral contraceptive use and no interaction with increasing age or body weight. Liver Adenomas Hepatocellular adenomas can be produced by steroids of both the estro- gen and the androgen families. Peliosis is character- ized by dilated vascular spaces without endothelial lining and may occur in the absence of adenomatous changes. Tere is some evidence that the tumors and focal nodular hyperplasia regress when oral contraception is stopped. The risk appears to be related to duration of oral contraceptive use and to the steroid dose in the pills. This is reinforced by the rarity of the condition ever since low-dose oral contraception became available. The ongoing pro- spective studies have accumulated many woman-years of use and have not identifed an increased incidence of such tumors. If an enlarged liver is found, oral contraception should be stopped, and regression should be evaluated and followed by imaging. Other Metabolic Effects Nausea and breast discomfort continue to be disturbing efects, but their incidence is signifcantly less with low-dose oral contraception. Fortunately, these efects are most intense in the frst few months of use and, in most cases, gradually disappear. In placebo-controlled trials with low-dose oral contraceptives, the incidence of “minor” side efects such as headache, nau- sea, dysmenorrhea, and breast discomfort actually occurred at the same rate in the treated group and the placebo group! This must be rare with low-dose oral contraception because data in published studies, especially in placebo-controlled trials, fail to indicate a diference in body weight between users and nonusers. Chloasma, a patchy increase in facial pigment, was, at one time, found to occur in approximately 10% of oral contraceptive users. Unfortunately, once chloasma appears, it fades only gradually following discontinuation of the pill and may never disappear completely. The use of oral contraceptives results in a decrease in iron defciency anemia because of a reduction in menstrual bleeding. Changes in vitamin metabolism have been noted: a small nonharmful increase in vitamin A and decreases in blood levels of pyridoxine (B6) and the other B vitamins, folic acid, and ascorbic acid. Despite these changes, routine vitamin supplements are not necessary for women eating adequate, normal diets. In studies with higher dose oral contraceptives, the efect was due to estro- gen interference with the synthesis of tryptophan that could be reversed Oral Contraception with pyridoxine treatment.

On the fetal side of the placenta order atenolol blood pressure pregnancy range, the amnion Cytotrophoblast covers the chorionic plate discount atenolol 100 mg without prescription hypertension nutrition. The amnion is assembled by Uterine epithelium Syncytiotrophoblast a single‐layered cuboidal epithelium fixed to an avascu- lar layer of mesenchymal tissue effective atenolol 100mg heart attack romance. Beneath the amnion best buy for atenolol blood pressure medication raises pulse, the chorionic mesenchymal tissue layer contains the chorionic plate vessels that are direct continuations of Uterine decidual stroma those within the umbilical cord. These chorionic plate vessels penetrate to supply the fetally derived vessels within the villous trees where the capillary system, between arteries and veins, is located within the so‐called Endometrial gland and capillaries gas‐exchanging terminal villi. Hence, the chorionic vessels connect the fetal circulation (via the umbilical. Only this multinucleated tissue is able the chorionic plate, floating within a vascular space to penetrate the uterine epithelium and to implant the developing embryo. The villous trees are con- nected via a major trunk (stem villus) to the chorionic attachment of the blastocyst to the endometrial epi- plate and display multiple sites of branching, finally thelium, further differentiation of the trophoblast ending in terminal villi. Exact knowledge of the underlying molecular placenta, the basal plate is located. It is an processes in the human is still lacking, but at this stage artificial surface generated by separation of the placenta the first event is the creation of an outer layer of fused from the uterine wall during delivery. The basal plate is trophoblast cells, termed the outer syncytiotropho- a colourful mixture of fetal trophoblasts and maternal blast. This outer syncytiotrophoblast generated by cells of the decidua, all of which are embedded in fused trophoblasts is in direct contact with maternal trophoblast‐secreted matrix‐type fibrinoid, decidual tissues and thus is the first layer from the conceptus to extracellular matrices, and blood‐derived fibrin‐type encounter and subsequently penetrate the uterine epi- fibrinoid. Prelacunar stage At day 7–8 post conception, the blastocyst has com- Summary box 2. The the layers of a delivered placenta from the fetal to the developing embryo is completely surrounded by the maternal side comprise: growing placenta, which at that stage consists of the two ● avascular amnion (epithelium and mesenchyme) fundamental subtypes of the trophoblast. The multinu- ● vascularized chorionic plate (mesenchyme with blood cleated syncytiotrophoblast is in direct contact with vessels) maternal tissues, while the mononucleated cytotropho- ● villous trees directly connected to the chorionic plate blast as the stem cell layer of the trophoblast is directed ● maternal blood in the intervillous space surrounding towards the embryo. Placental development Lacunar stage Trophoblast lineage At day 8–9 post conception, the syncytiotrophoblast At the transition between morula and blastocyst, the generates a number of fluid‐filled spaces within its trophoblast lineage is the first to differentiate from the mass (lacunar stage) [1]. Following forming larger lacunae, and finally embed parts of the the Placenta and Fetal Membranes 21 syncytiotrophoblast (trabeculae) that cross the syncytial Placental villi are organized in villous trees that cluster mass from the embryonic to the maternal side. The devel- chorionic plate by a thick villous trunk stemming from a oping embryo with its surrounding extraembryonic trabecula. Continuous branching of the main trunk tissues is completely embedded in the decidualized results in the formation of floating villi that branch and endometrium, and the syncytiotrophoblast surrounds end freely as terminal villi in the intervillous space. Mesenchymal cells derived from the embryo spread over the inner Trophoblastic cell columns surface of the trophoblast (extraembryonic meso- derm), thus generating an additional mesenchymal During penetration of the syncytial trabeculae, the cyto- layer on top of the inner surface of the trophoblast, trophoblasts reach the maternal decidual tissues while termed chorion. Only those cytotrophoblasts remain as pro- together with the extraembryonic mesoderm (cho- liferative stem cells that are in direct contact with the rion) will develop into the chorionic plate. The lacunae surrounding Subtypes of extravillous trophoblast the villi will turn into the intervillous space that will the formation of cell columns does not always result in a subsequently fill with maternal blood at the end of the complete layer of trophoblastic shell but rather may be first trimester. All these cells migrate as interstitial tropho- sues will develop into the basal plate. The interstitial troph- oblast invades the whole thickness of the decidua and Early villous stage penetrates the inner third of the myometrium. Here, Very early in pregnancy, specific types of villi develop as invasion normally stops and no extravillous trophoblast the forerunners of the placental villous tissues seen later can be seen in the outer third of the myometrium.

It may not be the basic components should be analysis of risks as well apparent to the woman that her kidney disease poses any as provision of health education and advice plus any issues for her or a baby 100mg atenolol overnight delivery blood pressure chart bottom number. Once prompted purchase atenolol 100mg with amex hypertension over the counter medication, aside from what interventions that might be considered helpful order atenolol pills in toronto basic arrhythmias 7th edition, all united the team wants to discuss and achieve for the woman under the banner of that much‐used word ‘counselling’ [1] cheap atenolol 50 mg online blood pressure upon waking up. Scr of 80 µmol/L and Surea of 6 mmol/L, which are accept- able in the non‐pregnant state, are suspect in pregnancy. At term, a 15–20% decrement in Ccr occurs, which affects What the patient needs to understand Scr minimally. Timed urine collections are no longer because many other factors influence her behaviour. The key is a Chronic kidney disease strong, unwaivering, positive and supportive relation- ship with the team that allows pre‐pregnancy advice to Renal impairment and the prospects be included in the overall care agenda as a goal‐orien- for pregnancy and afterwards tated process. Thus a planned pregnancy is one that is desired well before conception, occurs when contracep- A woman may lose up to 50% of her renal function and tion is discontinued and where the woman attempts to still maintain Scr below 125µmol/L because of hyperfil- achieve optimal health beforehand. However, differentiated ‘healthy’ and ‘pathological’ levels of degrees of functional impairment that do not appear to assumed risk and which have tried to understand the disrupt homeostasis in non‐pregnant individuals can psychology of women who pursue parenthood despite jeopardize pregnancy. This multicentre Italian net- nancy Scr: 125µmol/L or less as descriptive of ‘mild’ work effort confirmed earlier observations that such insufficiency, 125–250µmol/L as ‘moderate’ insuffi- women have complicated pregnancies with poor perinatal ciency, and above these levels as severe insufficiency [23]. The main conclusion was encouraging because selling for over 25 years, consistently showing that nor- while the group as a whole lost function during pregnancy, motensive women with intact or only mildly decreased the rate of loss was not affected by pregnancy. Also, 95% of but stable renal function generally do very well, experi- the fetuses survived, albeit many were born preterm and/ encing more than 95% live births, about 75% of which or growth restricted. Although these women developed proteinuria, exceeding the nephrotic range (3g per 24 renal failure faster than other groups, it was not possible hours) in 50% of women in the second half of pregnancy. With moderate impairment, live ful outcome by ‘buying time’ for fetal maturation but it births still approach 90%, but the incidence of pre‐ does not arrest the inexorable decline in renal function, eclampsia, fetal growth restriction and/or preterm deliv- ultimately to end‐stage failure. With severe dysfunction, outlook is prematurity in this way, it has to be asked whether such more drastically curtailed. Although there is a paucity of life‐threatening effects on the mother’s renal prognosis data for analysis in both these categories, what has can be justified. Nevertheless, the awareness by some become obvious is that a cut‐off Scr of 250 µmol/L is too women of progress in antenatal care and neonatal provi- high for moderate impairment, with 180µmol/L more sion encourages them to anticipate good outcomes and appropriate, and thus there is a tendency to designate they will say that they are prepared to take a chance and these patient groups ‘moderate to severe’ (Tables 11. This literature is slowly increasing and the Of importance in all the current controversies is that the message could not be clearer: hypertension is common literature that forms the basis of our views is primarily by term (60%) as is significant proteinuria (50%) as well retrospective, with most patients only having mild dys- as deterioration in renal function (at times rapid and function and women with severe to moderate disease substantial) and although infant survival rates are good being limited in number. Confirmation of guidelines and (80–90%), rates of premature delivery (60%) and fetal prognoses therefore requires adequate prospective trials. Once Scr rises above 250 µmol/L there are Antenatal strategy and decision‐making even bigger risks of accelerated loss of renal function, and even terminating the pregnancy may not reverse the These women ideally will have had pre‐pregnancy coun- decline (Table 11. Thereafter assessments should usually be performed at Temporary or acute dialysis has been advocated during least every 4 weeks until 28 weeks’ gestation and then pregnancy in the face of overall deterioration in renal every 1–2 weeks depending on the clinical circumstances function (especially when Surea exceeds 20mmol/L and/ [8,45]. Dialysis may increase the chance of success- creatinine ratio ideally on a first morning void. Loss of >25% renal function Scr Fetal growth Preterm Pre‐eclampsia Perinatal Pregnancy Persists post End‐stage failure in (µmol/U) restriction (%) delivery (%) (%) deaths (%) (%) partum (%) 1 year (%) ≤125 25 30 22 1 2 – – 125–180 45 70 40 6 40 20 3 ≥180 70 >90 60 12 70 55 35 Estimates are based on literature from 1985 to 2009, with all pregnancies attaining at least 24 weeks’ gestation (Davison & Winfield, unpublished data). Ultrasound may reveal scarred kidneys, of hypertension (and assessment of its severity) and hydronephrosis and function may or may not be normal. If anaemia is persistent and resistant develop lupus nephritis, this is one of the commoner to iron, recombinant human erythropoietin can be forms of renal disease seen in pregnant women. Proteinuria increases the risk of women all of whom had prior or active lupus nephritis thrombosis and in the face of significant proteinuria and had undergone pre‐pregnancy counselling. The clinical watchpoints Importantly, the use of the antimalarial hydroxychloro- associated with specific renal diseases are summa- quine appeared to significantly reduce the probability of rized in Table 11. Furthermore, there is depletion or electrolyte imbalance (occasionally precipi- some disagreement about whether pregnancy adversely tated by inadvertent diuretic therapy), should be sought.

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