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By E. Frillock. Auburn University, Montgomery.

Inactivation: The effect that the application of a disinfectant has in destroying the cellular structure of pathogenic micro-organisms or in disrupting their metabolism buy vermox 100mg visa antiviral paint, biosynthesis or ability to grow/reproduce cheap 100 mg vermox otc antiviral plants, thereby inhibiting their ability to infect a host and cause human illness or disease discount vermox 100mg on-line hiv infection vdrl. Inorganic Materials: Chemical substances of mineral origin cheap 100mg vermox mastercard hiv infection first week symptoms, such as sand, salt, iron. Such persons are more prone to more serious infections and/or complications than healthy people. Log inactivation: A mathematical measure of microorganisms inactivation consequent to the application of a particular dosage by a given disinfection process, expressed as the log of the relative number of live organisms to unviable organisms remaining after exposure to the disinfection process Percentage reduction of viable organisms is expressed as (2-x) [100-10 ]% where x is the log inactivation value One log activation means that 90% of the microorganisms are no longer viable. Log removal: The percentage of microorganisms physically removed by a given process. L: The Occupational Exposure Limit means the maximum permissible concentration, of a chemical agent in the air at the workplace to which workers may be exposed Oxidant: A substance that readily oxidizes (removes electrons from) something chemically. Common drinking water oxidants are chlorine, chlorine dioxide, ozone, and potassium permanganate. Pathogens: Microorganisms that can cause disease in humans, other organisms or animals and plants. They may be bacteria, viruses, or protozoa and are found in sewage, in runoff from animals, farms or rural areas populated with domestic and/or wild animals, and in water. Water Treatment Manual: Disinfection There are many types of microorganisms which do not cause disease. Mathematically, pH is the negative logarithm (base 10) of the hydrogen ion concentration, [H+]. The pH may range from 0 to 14, where 0 is most acidic, 14 most basic, and 7 neutral. Plug flow: The travel of water through a tank, pipe, or treatment process unit in such a fashion that the entire mass or volume is discharged at exactly the theoretical detention time of the unit. For chlorination byproducts) systems, precursors are constituents of natural organic matter, comprising suspended solids, turbidity, colour and dissolved organic carbon. In addition, for ozonation systems, the bromide ion (Br-) is a precursor material. Secondary The application of a chemical disinfectant at the end of a treatment Disinfection: system or at some appropriate point along the distribution network to maintain the disinfection residual throughout the system to consumers. Slow Sand A filter that consists of a bed of fine sand and relies on a biologically Filtration: active layer on top of the sand, called Schmutzdecke, to filter out particles. Surface water can be running (as in streams and rivers) or quiescent (as in lakes, reservoirs, impoundments and ponds). Tracer: A foreign substance (such a dye) mixed with or attached to a given substance for subsequent determination of the location or distribution of the foreign substance. Tracer study: A study using a substance that can readily be identified in water (such as a dye) to determine the distribution and rate of flow in a tank, pipe, ground water, or stream channel. Turbidimeter: An instrument for measuring and comparing the turbidity of liquids by passing light through them and determining how much light is reflected by the suspended particulate matter in the liquid. Water The phenomenon of oscillations in the pressure of water in a closed Hammer: conduit flowing full, which results from a too rapid acceleration or retardation of flow. Momentary pressures greatly in excess of the normal static or pumping pressure may be produced in a closed pipe from this phenomenon. Absence of characterisation of the raw water source Conduct catchment risk assessment and/or establish monitoring programme. Urban Waste Water discharge upstream with potential to cause microbial Ensure appropriate treatment and robust disinfection system in place contamination with appropriate monitors and alarms on key equipment. Storm water overflow upstream with potential to cause microbial contamination Ensure appropriate treatment and robust disinfection system in place with appropriate monitors and alarms on key equipment. On site systems/ septic tanks upstream with potential to cause microbial Ensure appropriate treatment and robust disinfection system in place contamination with appropriate monitors and alarms on key equipment. Presence of Cryptosporidium in raw water Liaison with stakeholders to prevent contamination of surface waters. Appropriate treatment in place for Cryptosporidium removal/inactivation and consider additional treatment if needed. Contamination Ensure appropriate treatment and robust disinfection system in place with appropriate monitors and alarms on key equipment. Water Treatment Manual: Disinfection Hazard Control Abattoirs - Organic and Microbial Contamination Liaison with stakeholder to prevent contamination of surface waters. Ensure appropriate treatment and robust disinfection system in place with appropriate monitors and alarms on key equipment. Wildlife - Organic and Microbial Contamination Consider additional fencing/security to prevent wildlife if possible. Recreational use causing microbial contamination Regulate or influence recreational use to prevent or reduce contamination. Forestry felling causing increased sedimentation of the raw water and Turbidity monitor at intake, ability to shut off intake if raw water beyond challenging disinfection acceptable limits. Catchment: Ground Water Supply Hazard Control Geology - swallow holes (surface water ingress) associated with raw water Turbidity monitoring to identify deterioration in quality, appropriate source treatment to deal with source water. Consider closing intake or switching to other sources if raw water quality deteriorates. Well head casing incomplete or borehole unsealed causing intrusion of surface Secure and maintain well head to prevent contamination. Well head not secured against livestock access causing microbial Protect well-head with appropriate cover. Water Treatment Manual: Disinfection Hazard Control contamination Infiltration gallery influenced by surface water causing microbial contamination Monitor source water. Land drains causing preferential pathway for pollution of shallow well source Re-route land drains. Catchment: Surface Water or Groundwater Supply Hazard Control Vandalism – deliberate contamination of source and unauthorised access Appropriate security and alarm system for site. Raw Water Intake Hazard Control Direct surface water abstraction causing variability in water quality Change abstraction point to minimise variability in raw water. Intake not secured against livestock access causing microbial contamination Install and maintain fencing in the vicinity of the intake. Lake source intake point vulnerable to variation due to streams/ stratification/ Change abstraction point to minimise variability in raw water. Raw Water Storage Hazard Control Susceptible to flooding / contamination Consider flood defences. Unauthorised access resulting in deliberate contamination Appropriate security and alarm system for site. Lockable covers on all Water Treatment Manual: Disinfection access points to water supply. Wildlife access to raw water tank causing contamination Erect fencing or cover to prevent wildlife access. Sludge build up in raw water tank causing contamination Regular inspection and maintenance programme. Leaking impounding reservoir causing ingress of contamination Regular inspection and maintenance programme. Raw Water Line Hazard Control Pipe corroded or not watertight causing intrusion of Surface Water Regular inspection and maintenance programme. Raw water serving consumers without disinfection or other treatment Ensure asset records are kept up to date and authorised connections refer to these records. Treatment plant operating above design capacity Ensure treatment plant is operating within acceptable limits.

Refer the patient to eye surgeon immediately Surgery: This is done by a well trained eye specialist within 48 hours of injury order vermox 100 mg without prescription hiv infection rates sydney. If there are signs of endophthalmitis (pus in the eye) give D: Vancomycin 1000µg in 0 vermox 100mg with mastercard anti viral hand sanitizer. Diagnosis  There may be pain and or poor vision  There may be blood behind the cornea (hyphaema)  Pupil may be normal or distorted  There may be raised intraocular pressure Guideline on Management Complicated blunt trauma is best managed by eye specialist as surgery may be required in the management purchase 100mg vermox otc antiviral juice recipe. Refer patients with blunt trauma to eye specialist as indicated below:- Table 3: Management of Complicated Trauma Findings Action to be taken No hyphema order vermox 100 mg otc antiviral classification, normal vision Observe Hyphema, no pain Refer No hyphema, normal vision, Paracetamol, Observe for 2 days, Refer if pain pain persist Poor vision and pain Paracetamol, refer urgently Hyphema, pain, poor vision Paracetamol, refer urgently Management by eye specialist A. Medical Treatment Steroid eye drops This treatment is given to all patients with blunt trauma and present with pain and or hyphema: C:Prednisolone 0. Surgical Treatment This is indicated in patients with hyphema and persistent high intraocular pressure despite treatment with antiglaucoma medicines (5 days), with or without corneal blood staining. Surgical procedure is washing of the blood clot from the anterior chamber and Observe intraocular pressure post operative. Foreign bodies This is a condition whereby something like piece of metal, vegetable or animal parts entering into any part of the eye. Diagnosis  There may be pain, redness, excessive tearing and photophobia if the foreign body is on the corneal or eye lids  If the foreign body is superficial, it can be seen  There may be loss of vision Treatment For superficial foreign body  Instill local anaesthetic agents like B: Amethocaine 0. For intraocular foreign body Apply antibiotic ointment and eye shield Refer to eye Specialist for surgical management. Burns and chemical injuries This is a condition that occurs when chemicals such as acid or alkali, snake spit, insect bite, traditional eye medicine, cement or lime enter the eye. Diagnosis  Diagnosis relies mostly with patients’ history  Patients may present with photophobia  Excessive tearing  Cloudiness of cornea  Loss of conjunctival blood vessels  Traces of chemical substance such as cement or herbs and blisters or loss of eyelid skin in open flame injuries. If a patient gives a history of being in contact with the above, the following should be done:  Irrigate the eye with clean water continually for a minimum of 20 – 30 minutes  Test the patients’ vision and examine the eye  Apply eye ointment (Chloramphenical or Tetracycline)  Refer to eye Specialist for more care. Treatment can be changed depending on corneal scrapping results  Give antiviral if Viral causes is suspected after the examination of the eye C: Acyclovir 3% eye ointment 4 hourly. Patient with corneal abrasion complains of pain, gritty sensation and excessive tearing. Majority of the cases are Idiopathic where by other cases are due to autoimmune diseases e. Diagnosis It has 3 main clinical presentations namely acute, chronic and acute on chronic. In acute type, patients present with painful red eye, Excessive tearing and severe photophobia. Visual Acuity is usually reduced and the pupil is small or it may be irregular due to syneachia. With Slitlamp biomicroscopic examination, cells and keratic precipitates and hypopyon may be seen in the anterior chamber. Treatment Treatment of uveitis may be multidisciplinary approach as various specialists may be involved. Before starting treatment, investigations such as blood tests and X-Rays should be done to establish the cause of uveitis. Acute uveitis is a serious problem and the patient should be referred urgently for Specialist treatment. Treatment for uveitis is mainly steroids and specific treatment according to the cause. Clinical features and treatment guideline depends on the type and cause of conjunctivitis as shown in the following sections. Allergy Conjunctivitis: In this conditionpatients presents with history of itching of eyes, sand sensation, and sometimes discharge. When examined, the eyes may be white or red, there may also be other pathognomonic signs such as limbal hyperpigmentatin and papillae and papillae of the upper tarsal conjunctiva. In very advanced stages, allergic conjunctivitis patients may present with corneal complications. All patients with moderate to severe allergic conjunctivitis should be referred to eye specialist for further specialized care. Viral conjunctivitis: It presents with painless watery eye discharge, there may be photophobia if the cornea is involved. If adenovirus is the cause, it appears in epidemics so there will be history of being in contact with patients with similar eye condition. Apply antibiotic eye ointment or eye drops if there is secondary infection with other organisms 198 | P a g e Note: Viral Conjunctivitis is very contagious so patients and members of the family should be alerted Bacterial conjunctivitis: Presents with acute onset of painless purulent discharge. Bacterial conjunctivitis patients who are not responding to treatment should have eye swabs for Gram stain and for culture and sensitivity to tailor down treatment. Ophthalmia Neonatorum/Neonatal Conjunctivitis; This is a special type of acute bacterial infection of the eyes that affect newborn baby during the first 28 days of life. Causative organisms are Neisseria gonorrhoea, Chlamydia trachomatis and Staphylococcus spp. Diagnosis: Patients present with massive oedema and redness of eyelids and with purulent and copious discharge from the eyes. There is usually rapid ulceration and perforation of corneal which eventually leads to blindness if treatment is delayed. There are many causes of squint but the most important and common ones in children are refractive errors, amblyopia (lazy eye), retinoblastoma, cataract and syndromic eye diseases that may be of neurologic origin or not. In additional to that, in adults squint may be complication of diabetes mellitus and orbital/head trauma. Thorough examination of the eyes by a pediatric eye specialist is needed to guide the management of the patients, so refer all children to Paediatric Eye Tertiary Centre. These affect the exposed area of conjunctiva as a response to chronic dryness and exposure to sunlight. Treatment Treatment for pterygium is surgical excision in advanced stage where the visual axis is involved. Surgery should be done by qualified eye care personnel and antibiotic steroid combination drops should be given postoperative. Diagnosis The tumour is seen as papillary or gelatinous mass associated with feeder vessels. Treatment If tumour is suspected,  Excise the mass with wider margin (2 mm)  Treat the margins with Mitomycin C, 5 Fluorouracil or cryotherapy  Send the specimen for histological examination  For advanced tumours where the globe has been infiltrated, removal of the eye is indicated (Enucleation or exenteration)  Send patients with confirmed diagnosis to Oncologist for radiotherapy 4. Diagnosis 200 | P a g e The most common initial sign is white pupil reflex (leokocoria), followed by squint, and rarelyvitreous haemorraghe, hyphema, ocular/periocular inflammation, glaucoma and in late stagesproptosis and hypopyon. It can be inherited so examine the child and sibs in hereditary for every 4 months until yr 4, then 6 monthly until yr 6 and yearly in over 8yrs. Management The goals of treatments are:-  To save the patients life  To savage the patients eye and vision if possible Choice of treatment depends on Size of tumor, Location and Extent of the tumour. It is acquired through wounds contaminated with spores of the bacteria and in the case of neonates, through the umbilical stump, resulting in neaonatal tetanus. Diagnosis  Generalized spasms and rigidity of skeletal muscles  Patients are usually fully conscious and aware. Postnatal age >7 days: 1200-2000 g: 15 mg/kg/day in divided doses every 12 hours >2000 g: 30 mg/kg/day in divided doses every 12 hours For anaerobic infections: 204 | P a g e A: Metronidazole Oral, I. The manifestations of brain abscess initially tend to be nonspecific, resulting in a delay in establishing the diagnosis. Diagnosis  Headache is the most common symptom, neck stiffness, lethargy progressing to coma, vomiting, and focal neurologic deficit. V) 2g every 6 hours(children 5 – 6weeks (Staph aureus) 100 mg/kg/day) Note: Where the patient is allergic to penicillin, chloramphenicol 500 mg every 6 hours can be used instead 1. Diagnosis  Headache, fever, intolerance to light and sound, neck stiffness, vomiting, seizures, deafness and blindness  In advanced stages it may present with confusion, altered consciousness and coma.

These clubs act as medical cannabis dispensaries cheap 100 mg vermox visa antiviral roles of plant argonautes, supplying cannabis for therapeutic use upon a valid recommendation or confrmation of 184 diagnosis from a licensed health care practitioner 100mg vermox with amex antiviral antibiotic. Whilst the Senate 185 Special Committee on Illegal Drugs and other government bodies have recommended that these organisations be licensed and legally recogn- ised buy 100mg vermox visa hiv infection rates toronto, currently they are operating without legal sanction cheap vermox 100 mg line early stage hiv infection symptoms. They set clearly defned standards, including demands that a variety of strains be offered 181 Health Canada’s Medical Marihuana Access Division website: www. Report of the Senate Special Committee on Illegal Drugs’, Summary Report, September 2002, page 20. Cultivators must also protect the cannabis from yeasts, moulds, mildews and fungi. Whilst small scale cultivation for personal use is tolerated (as elsewhere in Europe), larger scale production or importation for supplying the coffee shops is not, and has been the subject of an increasing enforcement effort over the last few years. In previous decades Dutch criminal enterprises were more closely involved in European and international cannabis trafficking but an enforce- ment push in the late 1990s dismantled much of this activity and coincided with the expansion of domestic illicit production, both in the Netherlands and elsewhere. Domestic production of herbal cannabis now constitutes 75–80% of coffee shop sales, and whilst it is unregulated in terms of strength and contamination it is considered to be of generally good quality. There is no reliable data available, however, a substantial proportion of domestic Dutch production is still thought to be for export to neighbouring countries. The exported cannabis is rumoured to be of lower quality, and thus not acceptable in the coffee shops—it is supplied as vacuum sealed product more easily bulked up with non-cannabis materials. Most hash/resin form cannabis in the coffee shops is still imported from Morocco, through established illicit routes. It is associated with one of the main Hindu gods—Shiva—and is also used openly during tradi- tional annual festivals, most commonly the spring festival of Holi. Government bhang shops were, and in some cases still are, prevalent throughout large parts of India. Under the 1961 Single Convention they, like many other countries who had what was described as ‘traditional use’ of scheduled drugs, were obliged to end the use of such substances within 25 years. In a similar fashion to the traditional use of the coca leaf in the Andes this has, perhaps unsurprisingly, not happened (the 25 year window perhaps being a signal that it was never likely to either). There are still ‘official’ government bhang shops in some cities such as Varanasi and Puri (and others across Rajasthan), and it is still widely used during religious festivals, as well as on a more regular basis by a small number of holy men or Sadhus. Production of the bhang, which is relatively low potency and most commonly eaten or in a beverage, is essentially unregulated, operating much like production of herbs and spices. These cannot be legally restricted or controlled as they have a wide range of other legitimate uses. Given this reality, small scale domestic produc- tion has become increasingly popular and widespread, supported by a burgeoning industry in growing guides and literature, technology and paraphernalia. This development has been facilitated by the diffculty in legislating against the distribution of cannabis seeds, which do not 186 themselves contain the active drugs. Some countries have put in place regulations for domestic produc- tion for personal medical use. Under the Medical Marihuana Access Division regulations it allows the issuing of ‘personal use production licenses’, which allow small scale production (using a formula to determine a limited number of plants/yields) under strict licensing criteria. In Spain the policies of decriminalisation of personal possession and use of cannabis also cover the right for individuals to grow a limited number of plants for their own personal use. Discussion The licensed production of cannabis, on a medium to large scale, for medical use in a number of countries, demonstrates clearly how it is possible for such production to take place in a way that addresses both security concerns and quality control issues. Production for non- medical use would presumably not need to meet quite such exacting standards on either front. For example, going as far as growing in an underground mine would seem somewhat excessive. Clearly the economic incentive to divert to illegal markets would progressively diminish as legal production expanded and undermined the profts currently on offer to illegal suppliers. As with opium and coca products discussed above, the expansion of legal production would be incremental over a number of years, allowing for a manageable transition and the evolution of an effective regulatory infrastructure in response to any emerging issues and challenges. It seems likely that—if a legal, retail supply was available—home growing for personal use would become an increasingly minority pursuit, rather like home brewing of wine or beer: the preserve of a small group of hobbyists and cannabis connoisseurs. In practical terms it would be near impossible to license non-commercial small scale production, even if some of the product was circulated amongst friends. Basic guidelines could be made publicly available and limits could be placed on how much production was allowed for any individual but experience with such schemes in Europe suggests they are hard to enforce and often ignored by police and growers alike. A licensing model might become appropriate for small to medium sized cannabis clubs or societies of growers who share supply/exchange on a non-proft basis, so that age and quality controls could be put in place, and some degree of accountability could be established. Drugs are commonly placed into categories according to their similarities in action and/or their physiologic effect when introduced into the system. The following two sections describe the basic categories of drugs commonly used in our laboratory. While these two chapters have some detailed descriptions of drugs that are important for our laboratory, they are still useful for the non‐specialist, as they explain the specific uses of these drugs in the laboratory, and their dosages for different procedures. Anticholinergics Anticholinergic agents may be indicated prior to the administration of a variety of anesthetic and related agents, including sedatives, narcotics, barbiturates, and inhalant anesthetic agents. Atropine sulfate, scopolamine, and glycopyrrolate are the three principle anticholinergics used in the laboratory. At the neuromuscular junction, where the receptors are principally or exclusively nicotinic, extremely high doses of atropine or related drugs are required to cause any degree of blockade. However, quaternary ammonium analogs of atropine and related drugs generally exhibit a greater degree of nicotinic blocking activity and, consequently, are likely to interfere with ganglionic or neuromuscular transmission in doses that more closely approximate those that produce muscarinic block. Autoradiographic studies have revealed a widespread distribution of muscarinic receptors throughout the human brain. More recent studies using muscarinic receptor subtype‐specific antibodies demonstrate discrete localization of these subtypes within brain regions. At high or toxic doses, the central effects of atropine and related drugs generally consist of stimulation followed by depression. Parasympathetic neuroeffector junctions in different organs are not equally sensitive to the muscarinic receptor antagonists. Small doses of muscarinic receptor antagonists depress salivary and bronchial secretion and sweating. With larger doses, the pupil dilates, accommodation of the lens to near vision is inhibited, and vagal effects on the heart are blocked so that the heart rate is increased. Larger doses inhibit the parasympathetic control of the urinary bladder and gastrointestinal tract, therein inhibiting micturition and decreasing the tone and motility of the gut. Thus, doses of atropine and most related muscarinic receptor antagonists that reduce gastrointestinal tone and depress gastric secretion also almost invariably affect salivary secretion, ocular accommodation, and micturition. This hierarchy of relative sensitivities probably is not a consequence of differences in the affinity of atropine for the muscarinic receptors at these sites, because atropine does not show selectivity toward different muscarinic receptor subtypes. More likely determinants include the degree to which the functions of various end organs are regulated by parasympathetic tone and the involvement of intramural neurons and reflexes. The muscarinic receptor antagonists block the responses of the sphincter muscle of the iris and the ciliary muscle of the lens to cholinergic stimulation. The wide pupillary dilatation results in photophobia; the lens is fixed for far vision, near objects are blurred, and objects may appear smaller than they are. The normal pupillary reflex constriction to light or upon convergence of the eyes is abolished. These effects can occur after either local or systemic administration of the alkaloids. Locally applied atropine or scopolamine produces ocular effects of considerable duration; accommodation and pupillary reflexes may not fully recover for 7 to 12 days. The muscarinic receptor antagonists used as mydriatics differ from the sympathomimetic agents in that the latter cause pupillary dilatation without loss of accommodation. Muscarinic receptor antagonists administered systemically have little effect on intraocular pressure except in patients with narrow‐angle glaucoma, where the pressure may occasionally rise dangerously.

It is associated with increased rate of miscarriage cheap vermox 100mg with mastercard oral antiviral, preterm delivery cheap 100 mg vermox overnight delivery hiv infection early stages, fetal growth restriction purchase vermox 100 mg on-line hiv infection and aids symptoms, fetal demise and increased perinatal loss vermox 100mg line hiv infection rates in poland. Pharmacological treatment (Evidence rating: C) • Ferrous sulphate, oral, 200 mg 8 hourly (This may be increased to 400 mg 8 hourly in severe cases if no gastric symptoms occur) • Folic acid, oral, 5 mg daily • Multivitamin, oral, One tablet 8 hourly • Parenteral Iron: For those with iron deficiency anaemia who are unable to tolerate oral iron, parenteral iron may be given. This should be given under careful observation and a small test dose should first be given (check product leaflet for test dose). Treatment for severe anaemia (Hb < 7g/dL) is best given in health facilities with blood transfusion capability 101. A fasting blood glucose test and 2-hour post-prandial blood glucose test must be done on all pregnant women at booking and also at 28-32 weeks (see section onAntenatal Care). The management of diabetes mellitus in pregnancy involves a multi- disciplinary approach comprising a team of obstetricians, midwives, nurses, dieticians, physicians, anaesthetists and paediatricians. For those who can afford a glucose meter, it would be prudent to do a glucose profile every 2-4 weeks. This involves the recording of fasting blood glucose, pre- breakfast, pre-lunch, post-lunch, pre-dinner and post-dinner levels. However, some patients would need to be admitted to hospital for short periods to ensure good glycaemic control. If complications exist then earlier delivery may be indicated • Indications for Caesarean section include severe pre-eclampsia, previous caesarean section, advanced maternal age, malpresentation or foetal macrosomia • If elective preterm delivery is necessary, confirm pulmonary maturity with amniocentesis (if facilities are available). There may be the need to mature the foetal lungs with corticosteroidsunder specialist care. For the convenience of patients shared care between specialist and medical officer may be appropriate. Cardiac disease may be present before the pregnancy or develop during the pregnancy or puerperium (peripartum cardiomyopathy). Examples are the increasing pulse rate, collapsing pulse and the presence of cardiac murmurs and a slight rise in the jugular venous pressure. Management involves a multi-disciplinary team including the obstetrician, neonatologist and physician. Pharmacological treatment Refer all patients needing treatment to a physician specialist or obstetrician. Primary post- partum haemorrhage refers to bleeding of more than 500 ml from the genital tract within the first twenty-four hours of delivery or any amount of blood loss that result in haemodynamic compromise of the patient. Secondary post-partum haemorrhage is defined as excessive vaginal bleeding occurring from twenty-four hours to six weeks after delivery. The bleeding may occur with the placenta retained or after its expulsion from the uterus. Provided the uterus is curetted gently and no damage is done the blood loss usually ceases soon afterwards and the patient may be discharged • If such a haemorrhage occurs in association with the placenta retained in the uterus, the following should be the course of action: • Rub up a contraction by manual pressure on the uterine fundus • Pass a urethral catheter to empty the bladder • Attempt removal of the placenta by controlled cord traction as soon as a contraction is felt. If not successful await the next contraction and repeat the procedure • If the placenta cannot be expelled in this fashion, manual removal under anaesthesia is indicated • If the facilities for manual removal under anaesthesia are not immediately available refer to hospital. Give at least 2000 ml in first hour • Aim to replace 2-3x the volume of estimated blood loss. Note Avoid dextrans; they interfere with grouping and cross matching as well as with coagulation of blood • If the uterus is poorly contracted (atonic) and the placenta is out and complete, • Misoprostol, oral/sublingual, 600 micrograms • Prostaglandin F2 alpha (if available) should be administered directly into the myometrium. In the first stage of labour the uterine contractions are painful and patients may therefore require analgesia. In the second stage of labour analgesia is required for instrumental delivery and when an episiotomy is given. It is therefore best not to give it when delivery is anticipated within 4 hours i. Inhalational • Nitrous Oxide 50% / Oxygen 50% This is used in the late first stage when delivery is expected within 1 hour. Epidural This procedure administered by an anaesthetist is a very effective way of reducing labour pains. When it is given in the first stage its use extends through the second stage of labour. During the second stage of labour Local Anaesthetics (for episiotomy and pudendal block anaesthesia to facilitate instrumental delivery). The immature foetus is at risk of cerebral haemorrhage because the fragile cranial bones provide insufficient protection for the brain and there is increased susceptibility to infection and impaired clotting mechanisms. The two types are pre-term (before 37 completed weeks) and term (before 37 weeks, but >1 hour before onset of labour). It may be primary or secondary indicating the absence or presence, respectively, of an identifiable underlying cause. It may be spontaneous (threatened, inevitable, incomplete, complete or missed) or induced (therapeutic, criminal or septic). After appropriate treatment and discharge from hospital, it is recommended that patients report back to hospital if there is lower abdominal pain, fever, vaginal bleeding and malodorous discharge. This helps to minimise the haemorrhage but it may be uncomfortable or painful to the patient. Do gentle digital curettage followed by the instrumental curettage under general anaesthesia within 6 hours of initiation of antibiotic therapy. Extreme care is needed in order not to perforate the uterus (if it has not been perforated already). Careful evacuation of the uterus must be done as risk of uterine perforation is high. The procedure must be covered adequately with oxytocics, as haemorrhage can be a problem • Hysterotomy may be indicated where induction fails or is contraindicated. Missed abortion 800 microgram vaginally 3 hourly Give 2 doses and leave to work (0-12 weeks) Or for 1-2 weeks (unless heavy 600 microgram sublingually bleeding or infection) 3 hourly Incomplete abortion 600 microgram orally stat Leave to work for 2 weeks (0-12 weeks) (unless heavy bleeding or infection). Induced abortion 400 microgram vaginally 3 hourly Use 200 microgram only in (13-24 weeks) (maximum 5 doses) women with caesarean scar. Intrauterine fetal 13-17 weeks: 200 microgram 6 with previous caesarean death (>24 weeks) hourly section 18-26 weeks: 100 microgram 6 hourly 27-43 weeks: 25-50 microgram 4 hourly Induction of 25 microgram vaginally 4 hourly Do not use if previous labour Or caesarean section. Note Oxytocin used together with misoprostol must be done with extreme caution as risk for uterine rupture is great. Termination of pregnancy is requested for and done for reasons permissible by law either through a surgical procedure or by pharmacological means. Under the current provisions for Ghana, an induced abortion may be carried out legally only under the following conditions: • In case of rape, defilement or incest • Threat to the physical and mental health of the mother • Presence of foetal abnormality • Mental retardation of the mother Patients given a pharmacological option for abortion will need to be monitored closely for completeness of the abortion process. They should be informed to report back immediately in cases of profuse or heavy vaginal bleeding, fever, offensive vaginal discharge. Abnormal menstrual patterns and bleeding are common in young adolescents and women within the ages of 45-50 years. No cause may be found on investigation as it is mostly due to immaturity of the ovaries and its pituitary controls. Postmenopausal bleeding is said to occur when a woman who has stopped having menstruation for 6-12 or more months begins to bleed per vaginam. Note If heavy menses return, the tablets can be continued for as long as necessary. Atrophic vaginitis responds to vaginal oestrogen cream treatment such as conjugated oestrogen cream. Note Patients taking clomifene (clomiphene) citrate need careful supervision best done by a specialist. A woman is considered to be menopausal if there is no menstruation for a period of at least 6-12 months in the absence of pregnancy. It is associated with physical, emotional and psychological upheaval of varying intensity in the affected individual. The flushes may be associated with • Palpitations • Faintness • Dizziness • Fatigue • Weakness • Emotional and psychological problems include: • Mood changes • Depression • Anxiety • Nervousness • Irritability • Loss of libido • Atrophic changes in the genital tract may give rise to the following: • Increased frequency of micturition and dysuria.

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