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By M. Leif. The Johns Hopkins University. 2018.

Mifepristone is a progesterone antagonist used to termi- Seizure Disorders nate pregnancy during the first trimester buy 25 mg hydroxyzine mastercard anxiety 5-htp. A prostaglandin is given approximately 48 hours after the mifepristone to Although antiepileptic drugs (AEDs) are known teratogens order hydroxyzine 10mg visa anxiety symptoms change, augment uterine contractions and ensure expulsion of the they must often be taken during pregnancy because seizures conceptus. Despite the usually good outcomes, the incidence of birth defects is 2 to TOCOLYTICS 3 times higher in fetuses exposed to AEDs than in those not exposed. If an AED is required, monotherapy with the low- Drugs given to inhibit labor and maintain the pregnancy are est dose that stops seizures should be used and plasma drug called tocolytics. Uterine contractions with cervical changes levels should be checked monthly. Women with epilepsy between 20 and 37 weeks of gestation are considered prema- should take a folic acid supplement (at least 400 mcg daily) ture labor. Nonpharmacologic treatment includes bed rest, all the time and 800 mcg or more during pregnancy. Drug therapy is most effective when plemental vitamin K is usually needed during the last the cervix is dilated less than 4 cm and membranes are intact. An Ritodrine, terbutaline, magnesium sulfate, and nifedipine injection of vitamin K is also given to the infant immedi- are used as tocolytics (see Drugs at a Glance: Abortifacients, ately after birth. Ritodrine and There has been controversy as to whether teratogenic terbutaline are beta-adrenergic agents that relax uterine smooth effects stemmed from epilepsy or AEDs. Moreover, the rate of taline is not FDA approved for use in premature labor, but is birth defects in infants exposed to one AED was significantly used widely for that purpose. Hypermagnesemia may occur took AEDs for bipolar disorder rather than epilepsy also had because tocolytic serum levels (4 to 7 mEq/L) are higher than higher rates of birth defects. Close monitoring of serum 974 SECTION 11 DRUGS USED IN SPECIAL CONDITIONS Drugs at a Glance: Abortifacients, Prostaglandins, Tocolytics, and Oxytocics Generic/Trade Name Routes and Dosage Ranges Progesterone Antagonist Mifepristone (Mifeprex) PO 600 mg as a single dose or smaller amounts for 4–7 d Prostaglandins Carboprost tromethamine (Hemabate) IM 250 mcg q1. Termination usually complete within 48 h Tocolytics Ritodrine (Yutopar) IV infusion 0. The infusion should be continued for 12 h after uterine contractions cease. PO 10 mg 30 min before discontinuing the IV infusion, then 10 mg q2h for 24 h, then 10–20 mg q4–6h as long as necessary to maintain the pregnancy. Maximal oral dose, 120 mg daily Terbutaline (Brethine) Magnesium sulfate IV infusion 10 mcg/min, titrated up to a maximum dose of 80 mcg/min until contractions cease PO 2. Maintenance dose 1–2 g/h, according to serum magnesium levels and deep tendon reflexes. Nifedipine (Procardia) PO 10 mg every 20 min for 2–3 doses; maximum dose 40 mg in 1 h Oxytocics Oxytocin (Pitocin) During labor and delivery, IV 2 milliunits/min, gradually increased to 20 milliunits/min, if necessary, to produce three or four contractions within 10-min periods. Methylergonovine maleate (Methergine) To prevent excessive postpartum bleeding, PO 0. Oxytocin stimulates uterine contractions to initiate labor and promotes letdown of breast milk to the nipples in lactation. Pitocin is a synthetic DRUGS USED DURING LABOR form used to induce labor at or near full-term gestation and AND DELIVERY AT TERM to augment labor when uterine contractions are weak and in- effective. It also can be used to prevent or control uterine At the end of gestation, labor usually begins spontaneously and bleeding after delivery or to complete an incomplete abor- proceeds through delivery of the neonate. It is contraindicated for antepartum use in the presence prostaglandin preparations (eg, Prepidil or Cervidil formula- of fetal distress, cephalopelvic disproportion, preterm labor, tions of dinoprostone) are administered intravaginally to pro- placenta previa, previous uterine surgery, and severe mote cervical ripening and induce labor. Methergine is used for management of post- during labor, delivery, and the immediate postpartum period partum hemorrhage related to uterine atony. Analgesics Oxytocics Parenteral opioid analgesics are used to control discomfort Oxytocic drugs include oxytocin (Pitocin) and methyler- and pain during labor and delivery. Oxytocin is a hor- and cause sedation and respiratory depression in the mother CHAPTER 67 DRUG USE DURING PREGNANCY AND LACTATION 975 and neonate. Meperidine may cause less neonatal depression than other opioid analgesics. If Nursing Process neonatal respiratory depression occurs, it can be reversed by naloxone (Narcan). Assessment Duramorph is a long-acting form of morphine that pro- Assess each female client of reproductive age for possible vides analgesia up to 24 hours after injection into the epidural pregnancy. If the client is known to be pregnant, assess sta- catheter at the completion of a cesarean section. Possible • Use of prescription, over-the-counter, herbal, nonthera- side effects include maternal urinary retention, but no signifi- peutic, and illegal drugs cant effects on the fetus.

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However safe 25mg hydroxyzine anxiety symptoms keyed up, a side effect of using too much Ma Huang in clinical prac- tice is that it arouses the brain and causes insomnia cheap 10 mg hydroxyzine anxiety breathing problems. For this rea- son, this medicinal is added to the formula to arouse the brain and, therefore, treats the tip or branch of enuresis. Huang Qi, on the other hand, addresses the root of this condition by supplementing the qi and upbearing the clear. This medicinal also strengthens the constitution of the individual by strengthening their ability to resist disease. It is also said, Children easily become vacuous and easily become replete. With the addition of these medicinals, the formula is able to warm without drying, secure without obstructing, and simul- taneously constrict and scatter and warm and clear. Professor Yu also points out that 30% of enuresis sufferers have a history of recurrent upper respiratory tract infections and simul- taneously develop asthma. In clinical practice, he observes that, when the enuresis is cured, these individuals also experience an obvious reduction in respiratory tract infections. In the comparison group who took Western pharmaceuticals, one case developed hives and three cases had facial flushing as if they had been drink- ing. Other common side effects, such as dry mouth and difficulty urinating, were not noted in this study. The patients in the treatment group took Yi Niao Ting between 7- 28 days. If the patient did not improve after two weeks, they were considered difficult to treat. Yu believes that the way a child is toilet trained influences the rate of enuresis. He believes that these rates are higher in the West compared to China where only 5-6% of six year-olds have enuresis because we use diapers. He believes the main TCM pat- terns of enuresis are kidney vacuity and lung-spleen vacuity. He also said that, if there was occult spina bifida, this related to the governing vessel in TCM and medicinals must be added to the formula which specifically enter this vessel. Warm the kidneys with Sang Piao Xiao (Ootheca Mantidis), Wu Wei Zi (Fructus Schisandrae), Jiu Cai Zi (Bulbus Allii Fistulosi), Tu Si Zi (Semen Cuscutae), and Bu Gu Zhi (Fructus Psoralea). Supplement the lungs and spleen with Huang Qi (Radix Astragali) and Dang Shen (Radix Codonopsitis). Strengthen the du mai by adding either 20 grams of Lu Jiao Shuang (Cornu Degelatinum Cervi), 10 grams of Lu Jiao (Cornu Cervi), six grams of Lu Jiao Jiao (Gelatinum Cornu Cervi), or 0. Other medicinals which enter and strengthen the governing vessel include Du Chinese Research on the Treatment of Pediatric Enuresis 77 Zhong (Cortex Eucommiae), Gou Ji (Rhizoma Cibotii), Xiang Ling Pi (Herba Epimedii), Ba Ji Tian (Radix Morindae Officinalis), and Suo Yang (Herba Cynomorii). Arouse the brain with 4-6 grams each of mix-fried Ma Huang (Herba Ephedrae) and Shi Chang Pu (Rhizona Acori Tatarinowii). Prevent side effects from the use of warm medicinals by using cool- or cold-natured medicinals, such as Huang Qin (Radix Scutellariae), Dan Pi (Cortex Moutan), and/or Zhi Zi (Fructus Gardeniae). However, if there was obvious vacuity cold then it is not necessary to add these medicinals. From Using Lu Qi Zhi Yi Tang (Deer Horn & Astragalus Stop Night [Urination] Decoction) to Treat 38 Cases of Pediatric Enuresis by Huang Wu-guang, Guang Xi Zhong Yi Yao (Guangxi Chinese Medicine & Medicinals), 1993, #5, p. Eighteen of these cases were 2-3 years old, 12 were 6-10 years old, and eight were 11-14 years old. The course of disease in these children was as short as one half year and as long as six years. In most cases, this enuresis was accompanied by lassitude of essence spirit, emaciation, a bright white facial complexion, fatigue, lack of strength, a cold body and chilled limbs, torpid intake, a pale tongue with white fur, and a moderate (i. If there was torpid intake, 10-15 grams of Ji Nei Jin (Endothelium Corneum Gigeriae Galli) were added. If there were sloppy stools, 10-15 grams of Cang Zhu (Rhizoma Atractylodis) were added. One packet of these medici- nals were decocted in water and administered per day in two divided doses, and five days equaled one course of treatment.

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Particular information 24 and 2/5 project to the parvicellular nucleus about any parameter is weighted more strongly of the red nucleus purchase hydroxyzine 10mg on-line anxiety leg pain, which sends most of its out- in one or several of the parallel inputs to the put to the olivary nucleus buy hydroxyzine 25mg low price anxiety x rays. Parallel and distributed nucleus apparently has only modest connec- processing acts at both a cellular and systems tions to its lower half, the somatotopically level and provides the fabric for use-depend- arranged magnocellular nucleus. The magno- ent plasticity, a major focus of rehabilitation cellular division of the red nucleus also receives interventions. Magnocellular neurons create the rubrospinal tract, which crosses and intermingles with corticospinal fibers. The INDIRECT CORTICOSPINAL rubrospinal fibers terminate on interneurons PROJECTIONS and directly on some motoneurons in the dor- Corticorubrospinal, corticoreticulospinal, and solateral intermediate zone of the ventral horn, corticovestibulospinal projections contribute to where they contribute to motor control of the limb and trunk muscle contractions, especially limbs. Such contractions of charges occur in M1 and in magnocellular cells, muscle are important for stabilizing the trunk as well as in the basal ganglia and cerebellum, and proximal muscles during actions. The retic- which points to their close functional relation- ular and vestibular descending pathways proj- ship. These cells respond to skin tromedial zone of the anterior horns to con- touch and joint movements. The red nuclei help tribute to postural and orienting movements of control the extremities and digits for skilled the head and body and synergistic movements steering and fractionated movements. Kuypers suggested that midbrain neurons, which also receive cerebel- the interneurons of the ventromedial interme- lar projections, may independently subserve diate zone of spinal gray matter represent a sys- some aspects of the motor control for the dis- tem of widespread connections among a vari- tal arm after a hemispheric injury. Other corticomotoneurons project directly THE BASAL GANGLIA and by collaterals to the upper medullary me- dial reticular formation. Their spinal projec- Distributed, parallel loops characterize the tions overlap the descending reticulospinal subcortical volitional movement circuits that pathway to the same spinal cord gray matter in involve the basal ganglia and cerebellum. Some reticulospinal These circuits are critical for the procedural fibers run from the ventrolateral pons and ac- learning of motor skills and for cognition. Within these pathways, then, ternal segment of the globus pallidus and pars potential redundancy exists that could, after an reticulata region of the substantia nigra, proj- injury, allow partial sparing or reorganization, ect to motor and prefrontal areas and to brain especially for axial and proximal movements. The input nuclei include the Indeed, a patient with severe hemiparesis who caudate, putamen, and ventral striatum. The cajoles minimal voluntary flexion in the af- subthalamic nucleus, globus pallidus externa, fected leg or extension of the elbow, wrist, and and pars compacta of the substantia nigra mod- fingers may rely on corticorubrospinal and cor- ulate activity primarily within the basal ganglia ticoreticulospinal pathways for functional hip circuits. Many anatomical and physiological and knee flexion during walking or extension studies demonstrate the parallel and segre- for reaching to an object and on corti- gated arrangement, rather than convergent in- covestibulospinal projections for leg extension tegration, of the motor pathways in the circuit and postural control. M1-putamen-globus pallidus-thalamic ventro- Corticospinal fibers from M1, SMA, and BA lateral nucleus-M1. Plasticity in Sensorimotor and Cognitive Networks 25 The frontal lobe–basal ganglia–thalamocor- Dopamine and possibly cholinergic influences tical circuits include (1) a skeletomotor circuit mediate the response properties of these ton- from the precentral motor fields, (2) the ocu- ically active interneurons. This organization al- lomotor circuit from the frontal and supple- lows the basal ganglia to participate in concur- mentary eye fields, (3) the prefrontal circuit rently ongoing skeletomotor, oculomotor, from the dorsolateral prefrontal and lateral or- cognitive, and limbic drive activities. Together, bitofrontal cortex, (4) the limbic circuit from the circuits internally generate a movement, the anterior cingulate and medial orbitofrontal execute an automatic motor plan, and acquire cortex, and (5) a circuit with inferotemporal and retain a motor skill. For reha- rehabilitation strategies, activities of significance bilitation, the possibility holds that circuits for to a patient that motivate practice with rewards a particular domain of function or for a limited of success are most likely to activate these cir- region of the body may reorganize and substi- cuits. In ad- Within the topographically organized, closed dition, pharmacologic agents that affect the loops of the skeletomotor pallidothalamocorti- neurotransmitters of the striatum, including cal system, localized regions of the globus pal- dopamine, glutamate, acetylcholine, and - lidus organize into discrete channels. In CEREBELLUM addition to the SMA and ventral premotor area, at least 4 other premotor regions connect The cerebellum plays an important role in cre- to both the spinal cord and the basal ganglia, ating and selecting the internal models neces- including the dorsal premotor and the rostral sary for movements. Discrete regions of the ven- computationally efficient ways to generate an trolateral thalamus modulate these loops. Corticostriatal pyram- models can either predict the sensory conse- idal neurons in M1 are anatomically and func- quences of motor plans or control the motor tionally distinct from corticospinal neurons. The large Purkinje cells repre- The input and output architecture of the sent the sole output system to the cerebellar sensorimotor striatum has a modular design nuclei and they receive two main inputs. The strength of synaptic efficacy between parallel fibers and The cerebellum participates in the seamless Purkinje cells may set the force and timing of synthesis of complex, multijoint movements muscle contractions. Pure cere- sensorimotor skill in the rat leads to an increase bellar lesions, for example, cause upper ex- in the number of synapses between parallel tremity ataxia that decompose the coordination fibers and Purkinje cells, and these changes last for reaching between the elbow and shoulder. These actions may contribute activity in the contralateral anterior and bilat- more to modifying performance than to learn- eral paramedian cerebellar lobules.

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I did acknowledge to myself and in the way I phrased my response that we had arrived at a point of only one disease purchase 10 mg hydroxyzine mastercard anxiety 120 bpm. I ignored for the moment the fact that medical science did not recognize lice under the skin as even pos- sible buy 10mg hydroxyzine mastercard anxiety related to. She thought for several minutes and said, Treat me for lice and I will be satisfied. On the next visit, I wrote her the one and only prescription I had written for her in the nine months I had been seeing her. I suggested she apply the lotion to her whole body twice daily for ten days. I did not want her to miss a spot, so I spent some time tell- ing her exactly how she should apply the liquid. I put myself into whatever mental gear I thought might increase the potency of the placebo, if a placebo was going to work here. I did not make an- other appointment with her for a full month, the longest interval since I had been seeing her. I had very mixed feelings about having treated her with a drug for a disease I knew with some certainty did not exist. Doherty could save a dying man with a lizard and some apomorphine, then who was I to withhold a dilute solution of Qwell? She looked like an entirely different person—confident and very outgo- ing. A couple of years after her last visit, she had to come into the hospital for a kidney infection, which she actually had. I was almost certain it would trigger some relapse or a return of all her symptoms. When I last talked to her on the phone a few years ago, she had not seen a physician in many years. I had no idea how what I did helped or even if what I did had anything at all to do with her getting well. At times, I think I just followed someone while she went through the extraordinary course of some weird disease. At other times, I think she might have been called schizophrenic—and then I think not. I am sure many who read this will think I missed a depression with somati- zation. Besides, she had been on high-dose anti- depressants and under the care of a psychiatrist with no improve- ment. She lacked so many of the symptoms of depression, foremost being that she never felt depressed. I thought I was following her in the world in which she found herself, namely, a world filled with physical symptoms. She was the first patient with whom all I really did was listen and talk. If such a result could happen with someone as complex as Florence, it could also happen with a lot of other patients. Te experience encour- aged me to continue my exploration of patients who had symptoms but no definable medical disease. By then my belief that there is not a disease behind every symptom was absolute. Tere is just a series of connected thoughts, actions, conflicts, and stress. Any misplaced diagnosis will prevent discovery of the underlying causes. When I was able to find a medical disease to explain the symptoms of a patient in this group, I excluded that patient from further analysis. From 1973 to 1976, I saw 150 patients in whom I failed to find a medical disease to explain the symptoms.

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Do you have a right to refuse to participate in an experience involving abortion as a student? If drug therapy is required purchase hydroxyzine 25mg amex anxiety symptoms mind racing, so cheap 10 mg hydroxyzine with mastercard anxiety symptoms like ms, how might you approach your instructor about this issue? Alternatives include labetalol and other beta blockers, cloni- dine, hydralazine, isradipine, nifedipine, and prazosin. With beta blockers, fetal and neonatal bradycardia, hypotension, hypoglycemia, and respiratory depression have been re- ABORTIFACIENTS ported. As a result, some authorities recommend avoiding the drugs during the first trimester and stopping them 2 to 3 days Abortion is the termination of pregnancy before 20 weeks. Medical Opinions seem divided on the use of angiotensin-converting abortion may be induced by prostaglandins and an antiproges- enzyme (ACE) inhibitors. Some sources say the drugs are tin (Drugs at a Glance: Abortifacients, Prostaglandins, To- contraindicated during pregnancy; others say they can be colytics, and Oxytocics). Prostaglandins may be used to used during the first trimester but should then be discontin- terminate pregnancy during the second trimester. The reproductive system, prostaglandins E and F are found in same effects would probably occur with angiotensin II the ovaries, myometrium, and menstrual fluid. They stimulate receptor blockers (ARBs), because they also act on the uterine contraction and are probably important in initiating and renin–angiotensin system. Drug preparations of Although diuretics are commonly used in the treatment of prostaglandins are capable of inducing labor at any time dur- hypertension, they should not be given during pregnancy. Misoprostol, a prostaglandin developed to They decrease blood volume, cardiac output, and blood pres- prevent nonsteroidal anti-inflammatory drug–induced gastric sure and may cause fluid and electrolyte imbalances, all of ulcers (see Chap. Mifepristone is a progesterone antagonist used to termi- Seizure Disorders nate pregnancy during the first trimester. A prostaglandin is given approximately 48 hours after the mifepristone to Although antiepileptic drugs (AEDs) are known teratogens, augment uterine contractions and ensure expulsion of the they must often be taken during pregnancy because seizures conceptus. Despite the usually good outcomes, the incidence of birth defects is 2 to TOCOLYTICS 3 times higher in fetuses exposed to AEDs than in those not exposed. If an AED is required, monotherapy with the low- Drugs given to inhibit labor and maintain the pregnancy are est dose that stops seizures should be used and plasma drug called tocolytics. Uterine contractions with cervical changes levels should be checked monthly. Women with epilepsy between 20 and 37 weeks of gestation are considered prema- should take a folic acid supplement (at least 400 mcg daily) ture labor. Nonpharmacologic treatment includes bed rest, all the time and 800 mcg or more during pregnancy. Drug therapy is most effective when plemental vitamin K is usually needed during the last the cervix is dilated less than 4 cm and membranes are intact. An Ritodrine, terbutaline, magnesium sulfate, and nifedipine injection of vitamin K is also given to the infant immedi- are used as tocolytics (see Drugs at a Glance: Abortifacients, ately after birth. Ritodrine and There has been controversy as to whether teratogenic terbutaline are beta-adrenergic agents that relax uterine smooth effects stemmed from epilepsy or AEDs. Moreover, the rate of taline is not FDA approved for use in premature labor, but is birth defects in infants exposed to one AED was significantly used widely for that purpose. Hypermagnesemia may occur took AEDs for bipolar disorder rather than epilepsy also had because tocolytic serum levels (4 to 7 mEq/L) are higher than higher rates of birth defects. Close monitoring of serum 974 SECTION 11 DRUGS USED IN SPECIAL CONDITIONS Drugs at a Glance: Abortifacients, Prostaglandins, Tocolytics, and Oxytocics Generic/Trade Name Routes and Dosage Ranges Progesterone Antagonist Mifepristone (Mifeprex) PO 600 mg as a single dose or smaller amounts for 4–7 d Prostaglandins Carboprost tromethamine (Hemabate) IM 250 mcg q1. Termination usually complete within 48 h Tocolytics Ritodrine (Yutopar) IV infusion 0. The infusion should be continued for 12 h after uterine contractions cease. PO 10 mg 30 min before discontinuing the IV infusion, then 10 mg q2h for 24 h, then 10–20 mg q4–6h as long as necessary to maintain the pregnancy. Maximal oral dose, 120 mg daily Terbutaline (Brethine) Magnesium sulfate IV infusion 10 mcg/min, titrated up to a maximum dose of 80 mcg/min until contractions cease PO 2. Maintenance dose 1–2 g/h, according to serum magnesium levels and deep tendon reflexes.

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