By R. Sebastian. University of California, Riverside. 2019.

Most affected obstetricians as they occasionally present in pregnancy mothers are asymptomatic but due to unequal lyoni­ and if the diagnosis is made and treatment implemented cheap danazol 100 mg menstruation young age, zation may have low factor levels requiring haemo­ pregnancy outcomes are improved buy cheap danazol 200 mg on line pregnancy induced hypertension. Pregnancies in static support during invasive procedures purchase danazol 200 mg overnight delivery womens health horizons, delivery patients with a known myeloproliferative disorder are and the postpartum period generic 200mg danazol visa breast cancer headbands. Management should include pre‐conception Women should be offered prenatal diagnosis of hae­ optimization of the condition 50mg danazol free shipping womens health quizzes, including withdrawal of mophilia danazol 200 mg overnight delivery menstrual sponge. If a couple are likely to consider terminating an potentially teratogenic medications (hydroxycarbamide affected fetus, this should be in early pregnancy. Maternal and anagrelide), thrombotic risk assessment and plan to blood sampling is usually used to determine fetal sex by control haematocrit and platelet count during pregnancy. Women who do not wish to have invasive early testing should be encouraged to have their fetus sexed at the 20‐week scan and in some centres third‐trimester Haematological malignancy during amniocentesis is offered for male fetuses to determine if pregnancy they are affected and plan for delivery. It is often recommended to termi­ setting including haematologists, obstetricians and neo­ nate pregnancies in women presenting with a malignancy natologists and given plenty of support as they make their in the first trimester. Consideration should be given to gestation, it is often possible to deliver the baby before starting risks to the mother of waiting to treat the condition, and chemotherapy; for those between 24 and 32 weeks, the the risks to the fetus of maternal treatment needed. In risk of fetal exposure to chemotherapy drugs should be general, chemotherapy and radiotherapy in the first tri­ balanced against the risks of premature delivery at that mester are associated with significant risks of congenital stage of gestation. References 1 Pavord S, Myers B, Robinson S, Allard S, Strong J, 5 Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, Oppenheimer C. Guideline for blood Reducing the Risk of Venous Thromboembolism during grouping and red cell antibody testing in pregnancy. Effect of early 7 Pavord S, Rayment R, Madan B, Cumming T, Lester W, tranexamic acid administration on mortality, Chalmers E, Myers B, Maybury H, Tower C, Kadir R. Management of Inherited Bleeding randomised, double‐blind, placebo‐controlled trial. Such infections usually have no effect on sles, mumps, rubella) vaccination could protect future the developing fetus. Uncommonly, the hepatitis B as an integral part of their antenatal care fetus may be infected by extension of infection into adja­ during their first and all subsequent pregnancies cent maternal tissues and organs, including the perito­ regardless of immunization history. Before rupture of fetal membranes, 3) Pregnant women arriving in labour who have not organisms in the genital tract may invade the amniotic received antenatal care elsewhere are offered screen­ fluid and infect the fetus. Obstetric risk factors associated with increased risk of transmission include vaginal delivery, prolonged rupture of membranes, chorioamnionitis and Human immunodeficiency virus invasive obstetric procedures. However, by 2011, over 80% of women diagnosed before delivery were already Pathogenesis and transmission aware of their infection before they conceived, many of them diagnosed in a previous pregnancy. If screening has been declined at lentiviruses belonging to the Retroviridae family and booking, it should be offered again at 28 weeks’ gestation. Where the indication for caesarean load provides the clinician with a useful snapshot of the section is the prevention of vertical transmission, deliv­ patient’s status and medication needs when she is first ery should be planned at 38–39 weeks’ gestation. This would with ruptured membranes in whom the current viral involve advice about management of their infection and load is not known; and in women on zidovudine mono­ interventions to reduce the risk of vertical and sexual therapy undergoing elective caesarean section. Transmission obstetric contraindications, a planned vaginal delivery is mostly occurs through vaginal or anal intercourse, as a recommended. Most infants, chil­ virus persists in some patients who become chronically dren and adolescents have chronic infection (lasting infected. The risk of progression is related to the level of ing for hepatitis B infection during each pregnancy. Notification of hepatitis B is a legal greater than 90% in neonates, and observed in only 5% of requirement. Fortunately, since the introduction of the rubella vaccine, Deafness is the most common and sometimes the only the incidence of rubella and congenital rubella syndrome manifestation, especially when infection occurs after 16 has decreased substantially. The aim of this policy was to interrupt circulation phthalmia, pigmentary retinopathy and glaucoma. However, recent data from Health Infection from 8 to 10 weeks of pregnancy results in Protection Agency national surveillance systems in the damage in up to 90% of surviving infants. The risk of fetal damage is small when infection happens after 16 weeks of pregnancy: only deafness has been reported fol­ Pathogenesis and transmission lowing infections up to 20 weeks of pregnancy. Some Rubella is caused by a togavirus and spread by droplet infected infants may appear normal at birth but percep­ transmission. Replication occurs in the Diagnosis nasopharynx and regional lymph nodes, and viraemia develops 5–7 days after exposure. Viraemia usually The diagnosis of rubella infection is usually based on sero­ results in placental and fetal infection. Detection of rubella IgM indicates recent period is 14–21 days, and in most cases a rash develops infection, although re‐exposure to rubella may induce a 14–17 days after exposure. Following a primary infectious from 1 week before symptoms appear to 4 rubella infection, IgM can be detected within 5–7 days days after the onset of the rash. Specific IgG develops by 2 weeks and persists for life; re‐exposure may increase IgG titres temporarily. A history of exposure to, or possible Clinical manifestations recent infection with, rubella in early pregnancy is actively Rubella is a mild disease. There may be a mild prodromal sought, particularly in recent immigrants, and the labora­ illness involving a low‐grade fever, malaise, coryza and tory is informed of a suspicious history so that the appro­ mild conjunctivitis. Lymphadenopathy may precede priate tests for primary rubella infection (IgM and IgG the rash and usually involves post‐auricular and sub‐ avidity) are performed [10]. The rash is usually transitory, erythema­ detectable antibody and was obtained within 7–10 days of tous and mostly located behind the ears and on the exposure, there is no risk of infection and further evalua­ face and neck. Diagnosis of subclinical infection is rash may be fleeting and is not specific to rubella. Compli­ straightforward if the woman is known to be susceptible, cations include thrombocytopenia and post‐infectious the exposure is recognized, and a serum sample is obtained 166 Maternal Medicine approximately 28 days after exposure. The diagnosis of Syphilis subclinical infection is more difficult if the immune status of the woman is unknown. It can be facilitated, however, if Despite the description of syphilitic infection for more the acute‐phase serum specimen is obtained as soon as than 500 years and availability of adequate therapy possible after a recognized exposure that did not occur for more than 50 years, syphilis in the adult and neo­ more than 5 weeks earlier. Testing is considered unneces­ nate still represents a relevant issue for public health sary if there is documented evidence of two tests on differ­ providers. Diagnoses should be counselled regarding prevention strategies and of infectious syphilis in reproductive‐age women be vaccinated post partum. Despite the high antenatal The management of the pregnant woman exposed to screening coverage, concerns have been raised about rubella needs to be individualized and depends on when the effectiveness of case management and control during gestation she was exposed and on her state of strategies [11]. Confirming the diagnosis, counselling about the risks of infection of and damage to the fetus, and dis­ cussing all the available options, including the use of Pathogenesis and transmission immunoglobulin and consideration of termination of Treponema pallidum, the causative agent of syphilis, is pregnancy, require an understanding of the natural his­ a Gram‐negative bacterium. In the horizontally from person to person through direct case of congenital infection, emphasis is on diagnosis contact, such as during sexual activity, resulting in and acute and long‐term management. Isolation may acquired syphilis, or vertically from mother to baby, also be important to reduce spread of infection. Because sexual contact no treatment for rubella and supportive care should be is the most common mode of transmission for acquired offered. Droplet precautions are recommended for 7 disease, the sites of inoculation are usually the genital days after the onset of the rash. Human immunoglobulin organs, but lips, tongue and abraded areas of the skin is not routinely used for post‐protection from rubella have been described as well. It is not rec­ identified as the site of the initial ulcerating sore, or ommended for the protection of pregnant women chancre. The cervical changes associated with preg­ exposed to rubella, and should only be considered when nancy, including ectropion, hyperaemia and friability, termination of pregnancy is unacceptable. Local replication There is no evidence that rubella‐containing vaccines then occurs and lymphatic dissemination leads to the are teratogenic. Termination of preg­ sion of syphilis to the fetus can occur throughout preg­ nancy following inadvertent immunization should not nancy, the likelihood of vertical transmission increases be recommended. Postnatal transmission from mother to child is breastfeeding mothers without any risk to their baby [8]. The likelihood of vertical transmission is directly related to the maternal stage of syphilis, with early pri­ mary syphilis resulting in significantly higher trans­ Summary box 13. Maternal Infection During Pregnancy 167 Clinical manifestations therapy, fetal demise or late‐term stillbirth occurs, but premature delivery or neonatal death may also occur. In Maternal syphilis infection is staged according to dura­ liveborn infants, infection can be clinically recognizable tion and clinical features. When symptoms are present, congenital syphi­ stage and its characteristic lesion is an erosion called a lis is characterized by the presence of hepatosplenomeg­ chancre. It is a typical, indolent, well‐circumscribed, flat aly, lymphadenopathy, rash, mucocutaneous lesions, ulcer with a yellow‐coated base and an indurated non‐ haemolytic anaemia or thrombocytopenia, osteochon­ undermined wall.

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Several media can be used as described under pulmonary It provides a rapid tissue diagnosis and confirms the tuberculosis buy danazol 100 mg with mastercard menopause menstrual cycle. Surgical techniques include aspiration buy 50 mg danazol with amex breast cancer causes, 281 incision and drainage safe 200 mg danazol menstrual kit for girls, and curettage 100 mg danazol amex breast cancer 25 years old, complete excision of (<5 years) in whom neurotuberculosis occurs is significantly the affected lymph nodes buy danazol 50mg without a prescription pregnancy weeks. Hence practicing When lymph nodes are fluctuant and ready to drain generic danazol 100mg otc womens health medical group, pediatricians have a greater responsibility in early diagnosis antigravity aspiration should be done. Infection usually occurs after inhalation of the bacilli in Paradoxical reaction can occur during antituberculous infected respiratory secretions. Affected nodes may enlarge or new nodes tuberculosis multiplies in alveolar macrophages. Within may appear representing an immune response to kill 2–4 weeks, through blood circulation, bacilli spread to mycobacteria. This can occur in 6–30% of patients extrapulmonary sites and produce small granulomas in within the first 2 months of tubercular lymphadenitis. These small lymphadenitis is best treated with antitubercular drugs and granulomas are known as ‘rich focus’. Decreased bibliography immunity is believed to play a role in the rupture of Rich foci. The bacilli enter the central nervous system by cytology as a diagnostic tool in pediatric lymphadenitis. Essentials of Tuberculosis in Children, 4th inflammation, dense basal exudates, vasculitis and hydro- edition. Diffuse tubercular encephalopathy is Introduction characterized by diffuse edema of the brain, perivascular In developing countries, tuberculous involvement of the myelin loss and hemorrhagic leukoencephalopathy. Even the latest guidelines – Radiculomyelitis/myelitis for diagnosis of neurotuberculosis laid down by Indian • Parenchymal: 282 Academy of Pediatrics (2010) fail to pick up any case of – Tuberculoma (tuberculous granuloma) neurotuberculosis. The other highlight is that the age group – Tuberculous abscess • secondary involvement of nervous system: based on clinical features, cerebrospinal fluid changes and – Spinal cord disease (compression) imaging characteristics. Bacteriological confirmation is not – Miliary tuberculosis of brain secondary to hemato- possible in all cases. It cannot discriminate between tuberculosis meningitis and partially • stage I (early): Conscious, nonspecific symptoms, with treated bacterial meningitis. The specificity of tuberculosis meningitis diagnosis can be The responsibility on practicing pediatricians is to send increased by molecular diagnostic tests. Because of its high specificity, a positive commercial • clinical entry criteria: Symptoms and signs of nuclear acid amplification test is regarded as a definite meningitis including one or more of the following: test in patients with suspected tuberculosis meningitis headache, irritability, vomiting, fever, neck stiffness, and offers particular value in patients who have previously convulsions, focal neurological deficits, altered consci- received tuberculous treatment. Hydrocephalus and • definite tuberculosis meningitis: Clinical entry criteria basal meningeal enhancements are the most common plus one or more of the laboratory criteria. Eighty percent of children have laboratory Investigations hydrocephalus and 75% basal meningeal enhancement. Tuberculosis meningitis is an important manifestation and Hydrocephalus is less common (45%) in adolescents and so is associated with high morbidity and mortality. Basal meningeal and gastric aspirate further increase the chance of a positive enhancement is most sensitive (89%). They have treatment higher frequency of infarcts, gyral enhancement and Appropriate chemotherapeutic regimens should be mass lesions compared with patients who do not have administered as early as possible. The patient’s clinical stage in other causes of meningitis, such as Cryptococcus, at presentation is the most important prognostic factor. Focal lesions, intracranial tuberculomas and Suggestive chest radiograph abnormalities are seen tuberculous abscess do not require surgical intervention in 33–60% of patients. The only way to reduce morbidity and mortality children with tuberculosis meningitis shows that they is by early diagnosis, timely recognition of complications significantly improve the survival rate and intellectual and institution of the appropriate treatment strategies. Corticosteroids do not affect the incidence of dual therapy with antibiotics and antitubercular therapy basal ganglia infarction significantly. Hepatotoxicity Antituberculosis Treatment Hepatotoxicity may be seen in malnourished and those A secured microbiological diagnosis is seldom, if ever, with disseminated disease. In case of overt toxicity there achieved in neurotuberculosis and the decision to is pain abdomen, vomiting and hepatic enlargement. This Mannitol (20%) is most frequently used in the emergency is because there is significant morbidity and mortality treatment of cerebral edema. The practicing pediatrician associated with late institution of therapy in advanced can safely give it in the dose of 5 mL/kg stat followed by 2 disease. Hyponatremia and raised intracranial pressure can cause drug regimens seizures in acute phase. Imaging Techniques Contrast enhanced computed tomography is utilized as the Surgical Management of Hydrocephalus initial imaging modality. Surgical wing three types of tuberculoma: intervention by shunt procedure depends upon the extent 1. Non-caseating granuloma of hydrocephalus and needs the attention of a pediatric 2. Usually respond to anti- Involvement of the spinal arachnoid lining secondary to tuberculosis treatment and resolves over 3–6 months. Prognosis Immature faintly enhancing tuberculomas have a more Parenchymal neurotuberculosis likely chance of resolution with antituberculous chemo- therapy and corticosteroids. In contrast, as well formed and tuberculoma or tuberculous Granuloma probably large-sized (>3 cm) granuloma may have a risk of Tuberculoma is a manifestation of tuberculosis which paradoxical enlargement. It usually occurs in an area of tuberculous cerebritis as a cluster of microgranuloma which spinal cord disease (compression) when coalesces forms a mature noncaseating granuloma. Pathogenesis Though Pott’s disease is the most common form of skeletal The center of the tuberculoma when becomes necrotic forms caseous debris, while the periphery tends to Table 5. Tuberculous abscess is due tuberculoma to the liquefaction of the caseous material. It is due to the Tuberculoma Neurocysticercosis presence of polymorphonuclear leukocytes. May present at any age Rare before the age of 3 years Progressive neurological deficit Generally no neurological deficit, clinical features post-ictal focal deficits of varying severity resolve with in a matter of The size and site of tuberculoma as well as the presence days to weeks of concurrent meningitis determines the clinical features. The common symptoms are seizures without associated Ring size is usually >20 mm, irregular Usually smaller, regular rounded meningeal signs or evidence of tuberculosis elsewhere in the outline with marked cerebral edema outline with less cerebral edema body. The other forms like resolution with antituberculosis chemotherapy and intramedullary tuberculoma, epidural abscess and spinal corticosteroids while a well formed and probably large arachnoiditis are rare in pediatric age group. Clinical manifestations, Constitutional symptoms precede the occurrence of specific diagnosis and management of neurotuberculosis. Essentials of Tuberculosis in Children, 4th Back pain (spinal or radicular) is the earliest and the most edition. Pathology, pathogenesis, compression of neural tissues like spinal cord and nerves, case studies of neurotuberculosis. Cord involvement indicates poor peritoneum, mesentery, abdominal lymph nodes, liver, prognosis. Mycobacterium tuberculosis is the Paradoxical Response to Chemotherapy in principle causative agent and rarely Mycobacterium bovis Neurotuberculosis and non-tuberculous Mycobacterium are responsible. Paradoxical responses to chemotherapy in neurotuber- culosis can occur at any time even up to 1 year during epidemiology chemotherapy despite a regular standard antituberculosis treatment. Intestinal involvement may be due Hypertrophic Retroperitoneal to swallowing of infected sputum. This gastrointestinal tract and relative stasis in ileocecal area type presents as abdominal distension and ascites. Fever and with alkaline pH in large and small intestine favors their night sweats may be present. The common site of involvement is small intestine This region is most commonly involved in older children. Contiguous extension from adjacent organs is commonly The former presents with chronic diarrhea and features reported in adolescent girls with tuberculous salpingitis of malabsorption. As a part of clinical features disseminated disease, spleen, pancreas and hepatobiliary Most of the symptoms are nonspecific and variable. The symptoms depend upon the site of Esophagus may be rarely involved due to extension of disease and the type of pathological involvement.

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