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The pre treatment assessment can be improved by incorporating other risk predic to muscle relaxant addiction order azathioprine 50 mg mastercard rs xanax muscle relaxant dosage generic azathioprine 50mg without a prescription, such as age spasms jaw discount 50 mg azathioprine free shipping, body mass index spasms sphincter of oddi order 50mg azathioprine overnight delivery, family his to ry and ethnicity/race. Pre-treatment prostate ultrasound examinations or biopsies are not recommended as routine requirements. The diagnosis of hypogonadism should be confirmed before any androgen therapy is initiated. In the presence of a clinical picture of tes to sterone deficiency and borderline serum tes to sterone levels, a short therapeutic trial. The aim of therapy should be a to tal tes to sterone level of at least 15 nmol/l to ensure symp to matic improvement. A satisfac to ry response may be generated by placebo, and so continued assessment is advisable before long-term treatment is recommended. The situation is clearer in younger men, where hypogonadism is usually associated with specific clinical diagnoses. Men successfully treated for localised prostate cancer but suffering from confirmed symp to matic hypogonadism are potential candidates for tes to sterone substitution, after a prudent interval (at least two years), if there is no clinical or labora to ry evidence of residual cancer. Intramuscular, subdermal, transdermal, oral and buccal preparations are safe and effective. The treating physician should have sufficient knowledge and adequate understanding of the pharmacokinetics as well as of the advantages and drawbacks of each preparation. The selection of the preparation should be a joint decision of an informed patient and physician. Anti estrogens and aromatase inhibi to rs have been shown to increase endogenous tes to sterone levels but there is inadequate evidence to recommend their use. Selective androgen recep to r modula to rs are in clinical development but not yet available; many of these compounds are non-aromatisable and the risks of long-term use are unclear. Hypogonadal older men should be counselled on the potential risks and benefits of tes to sterone replacement before treatment and be carefully moni to red for prostate safety during treatment. Haema to logical assessment is indicated before treatment, then at 34 months and 12 months, and annually thereafter. To keep the haema to crit below 5255%, dose adjustments and/or periodic venesection may be necessary. Failure to benefit within a reasonable time interval (up to six months is adequate for libido and sexual function, muscle function and improved body fat) should result in discontinuation of treatment. Man presenting with erectile Candidate for tes to sterone dysfunction and/or diminished libido. Are there symp to ms and signs Establish a diagnosis of suggestive of tes to sterone deficiency: hypogonadism by the low libido, erectile dysfunction, delayed documentation of low serum to tal ejaculationfi Is the to tal tes to sterone level above 12 Does not require replacement Patients with serum to tal nmol/l (350 ng/dl)fi Is there a co-morbidity such as Do not start treatment with diabetes mellitus, hyperprolactinaemia, tes to sterone without appropriate metabolic syndrome, bladder outlet treatment of the co-morbid obstruction and peripheral vascular condition. The use of tes to sterone disease, significant erythrocy to sis in patients with locally advanced or (haema to crit >50%), untreated metastatic prostate cancer is obstructive sleep apnoea or untreated absolutely contraindicated. Severe severe congestive heart failure, breast or symp to ms of lower urinary tract prostate cancerfi Is the patient taking any medication Consider if there are alternative that could cause the complaintfi Determine the serum level of luteinising hormone, to differentiate between primary and secondary hypogonadism. Once patients are on therapy, tes to sterone levels should be moni to red to ensure normal concentrations are being achieved. Erythrocy to sis can develop during tes to sterone treatment, especially in older men treated with injectable tes to sterone preparations. To keep the haema to crit below 53% (48% if his to ry of thrombosis), dose adjustments and/or periodic venesection may be necessary. Failure to benefit within 6 months Has there been an adequate response to should result in discontinuation of tes to sterone treatmentfi Hypogonadal older men should be carefully moni to red for prostate safety during treatment, at 36 months, 12 months, and at least annually thereafter. He has been awarded research grants from Organon bv, Bayer-Schering Pharma Phillip Kell Worked for Bayer/Prostrakan as an advisor and have done research trials Geoff Hackett No conflicts. Neither he nor any immediate family member has a current financial arrangement or affiliation with any organization(s) that may have a direct financial interest in the subject matter of the guideline st Issue date 1 December 2010. Tes to sterone cypionate is a white or creamy white crystalline powder, odorless or nearly so and stable in air. It is insoluble in water, freely soluble in alcohol, chloroform, dioxane, ether, and soluble in vegetable oils. The chemical name for tes to sterone cypionate is androst-4-en-3-one, 17-(3-cyclopentyl 1-oxopropoxy)-, (17fi)-. These effects include 1 growth and maturation of the prostate, seminal vesicles, penis, and scrotum; development of male hair distribution, such as beard, pubic, chest, and axillary hair; laryngeal enlargement, vocal cord thickening, and alterations in body musculature and fat distribution. Drugs in this class also cause retention of nitrogen, sodium, potassium, and phosphorous, and decreased urinary excretion of calcium. Androgens have been reported to increase protein anabolism and decrease protein catabolism. Nitrogen balance is improved only when there is sufficient intake of calories and protein. Androgens are responsible for the growth spurt of adolescence and for eventual termination of linear growth, brought about by fusion of the epiphyseal growth centers. In children, exogenous androgens accelerate linear growth rates, but may cause disproportionate advancement in bone maturation. Use over long periods may result in fusion of the epiphyseal growth centers and termination of the growth process. Androgens have been reported to stimulate production of red blood cells by enhancing production of erythropoietic stimulation fac to r. There is a lack of substantial evidence that androgens are effective in fractures, surgery, convalescence, and functional uterine bleeding. Tes to sterone esters in oil injected intramuscularly are absorbed slowly from the lipid phase; thus, tes to sterone cypionate can be given at intervals of two to four weeks. Tes to sterone in plasma is 98 percent bound to a specific tes to sterone-estradiol binding globulin, and about 2 percent is free. Generally, the amount of this sex-hormone binding globulin in the plasma will determine the distribution of tes to sterone between free and bound forms, and the free tes to sterone concentration will determine its half-life. About 90 percent of a dose of tes to sterone is excreted in the urine as glucuronic and sulfuric acid conjugates of tes to sterone and its metabolites; about 6 percent of a dose is excreted in the feces, mostly in the unconjugated form. Tes to sterone is metabolized to various 17-ke to steroids through two different pathways. The half-life of tes to sterone cypionate when injected intramuscularly is approximately eight days. In many tissues the activity of tes to sterone appears to depend on reduction to dihydrotes to sterone, which binds to cy to sol recep to r proteins. The steroid-recep to r 2 complex is transported to the nucleus where it initiates transcription events and cellular changes related to androgen action. Primary hypogonadism (congenital or acquired)-testicular failure due to cryp to rchidism, bilateral to rsion, orchitis, vanishing testis syndrome; or orchidec to my. Prolonged use of high doses of androgens (principally the 17-fi alkyl-androgens) has been associated with development of hepatic adenomas, hepa to cellular carcinoma, and peliosis hepatis all potentially life-threatening complications. If a venous thromboembolic event is suspected, discontinue treatment with tes to sterone cypionate and initiate appropriate workup and management. Tes to sterone has been subject to abuse, typically at doses higher than recommended for the approved indication and in combination with other anabolic androgenic steroids. If tes to sterone abuse is suspected, check serum tes to sterone concentrations to ensure they are within therapeutic range. However, tes to sterone levels may be in the normal or subnormal range in men abusing synthetic tes to sterone derivatives. Counsel patients concerning the serious adverse reactions associated with abuse of tes to sterone and anabolic androgenic steroids. Conversely, consider the possibility of tes to sterone and anabolic androgenic steroid abuse in suspected patients who present with serious cardiovascular or psychiatric adverse events. Edema, with or without congestive heart failure, may be a serious complication in patients with pre-existing cardiac, renal or hepatic disease.

You apply it like a lotion to spasms sleep buy cheap azathioprine 50mg the upper arms and shoulders each morning after a shower quinine spasms buy azathioprine visa. This is the least expensive treatment option muscle relaxant non prescription proven 50mg azathioprine, but typically requires a nurse or doc to spasms under rib cage cheap azathioprine 50 mg on line r to administer the injection about every 3 weeks. Tes to sterone Medications Generic name Trade name Generic name Trade name Intramuscular Injections Transdermal (Skin) Agents Tes to sterone Cypionate Depo-tes to sterone Tes to sterone Patch Androderm Tes to sterone Enanthate Delatestryl Tes to sterone Gel Androgel Tes to sterone Gel Testim Oral Medications Tes to sterone Gel Axiron Tes to sterone Undecanoate Andriol the Consumers Handbook of Urological Health 163 What are the side effects of tes to sterone replacement therapyfi Serious side effects are uncommon provided your doc to r regularly moni to rs your treatment. If you have known or suspected cancer of the prostate or breast, you should not be treated with tes to sterone. The most common side effects include: Skin rash or irritation Abnormal blood test Acne or oily skin Headache Breast development Hair loss Sleep disturbances these side effects are reported in 5% or less of patients receiving treatment. Potentially serious side effects include: Increased red blood cell production causing thickening of the blood Prostate disorders Liver problems High blood pressure Cholesterol abnormalities Decreased sperm production and fertility Fluid retention Worsening of sleep apnea or heart failure Often side effects can be minimized or eliminated al to gether with dose adjustment, switching to another form of therapy or s to pping it completely. We based this on the fact that most patients with advanced prostate cancer can be controlled by significantly reducing tes to sterone concentrations. Recently, weve learned that the risk of prostate cancer is not increased in otherwise healthy men receiving tes to sterone replacement. In terms of prostate size and voiding symp to ms, tes to sterone replacement therapy does not seem to cause any significant negative effects. Depending on the type of tes to sterone replacement, you doc to r may perform others tests. Once symp to ms and tes to sterone levels have normalized, further moni to ring can be scheduled at intervals of six to 12 months. Once established, tes to sterone replacement therapy is frequently lifelong and requires a commitment to follow-up from the patient and treating physician. Important points to remember Tes to sterone deficiency is common and can negatively affect your overall health, sexual function and quality of life. Tes to sterone deficiency tes to sterone levels in these individuals may help to syndrome: benefts, risks, and realities associated manage or delay progression of the associated morbidities. Can J Urol Furthermore, despite controversies in the literature and 2016;23(Suppl 1):20-30. It is nevertheless been termed age-related or late-onset hypogonadism, is a very important for clinicians to be aware of the possible syndrome characterized by both clinical manifestations risks and contraindications of treatment to ensure proper as well as a biochemical defciency of tes to sterone. While these signs classifed, based on the level of disturbance, as either and symp to ms are characteristic of hypogonadal men, primary (testicular failure: biochemically associated they are by no means specifc, and thus biochemical with high gonadotropins follicle-stimulating hormone parameters are necessary to establish a diagnosis. Jacob Hassan, Credit Valley 45 and above are tes to sterone defcient based on a Hospital, Trillium Health Partners, 2200 Eglin to n Avenue to tal tes to sterone cut off of 300 ng/dL. Populations at high risk for low serum tes to sterone levels are Physical signs of hypogonadism shown in Table 2. The prevalence of symp to matic Change in body composition with more central hypogonadism in these populations has been body fat 11 estimated to exceed 30%. Populations at high risk for low serum According to the study, this would translate in to $190 tes to sterone levels 525 billion dollars in health care costs. Of note, cessation of tes to sterone therapy been shown to improve several domains of sexual resulted in return of cardiovascular fac to rs to baseline function, including libido, erectile function, and sexual 24 weeks later, despite ongoing exercise and dietary performance. Two Osteoporosis is a source of considerable morbidity of these studies used supra-physiologic doses of and mortality in elderly men. This is particularly important involving 308 men 60 years or older with low or low in those who are at high risk, such as elderly men normal tes to sterone levels (100 ng/dL to 400 ng/dL; with atherosclerosis and vascular insuffciency. Coprimary outcomes included replacement in those men with a baseline hema to crit common carotid artery intima-media thickness and > 50 for fear of worrisome erythrocy to sis. While was short, the sample size was small and the supraphysiologic doses of tes to sterone may have patients were not tes to sterone defcient at baseline. Larger long term to achieve the eugonadal range of tes to sterone does randomized controlled trials are therefore necessary not seem to affect lipid profles. It has also been recommended that ago, that suppression of tes to sterone levels leads to a these patients be referred to a specialist for expert regression of prostate cancer. When however, the incidence is rare with doses used to androgen recep to rs are saturated, further increases achieve the normal range of tes to sterone. Erythema Furthermore, androgen therapy, both with or without and pruritus are the usual reactions and are much an aromatase inhibi to r, has been suggested to have more prevalent with patches (66%) than with gel a protective effect against breast cancer. Due to the Sleep apnea increasing life expectancy of the population, the Tes to sterone levels play a role in sleep architecture, number of symp to matic, hypogonadal men presenting which is suggested to be related to centrally mediated to our clinics is also expected to increase. Given the available with treatment so that patients are appropriately evidence, it appears that while supra-physiologic selected and follow up is adequate. Jack Barkin is a speaker and investiga to r for Glaxo, Actavis, Pfzer, Astellas, Merus Labs, Allergan, Janssen, Hepatic effects Ferring, NeoTract and Merck. The risk of hepa to to xicity with tes to sterone supplementation is his to rical and limited to oral preparations that are metabolized by the liver. Diagnosis and management of tes to sterone defciency syndrome in men: and therefore routine use can be impractical. Validation of a Skin reactions screening questionnaire for androgen defciency in aging Acne and oily skin are infrequent with physiological males. Effect of androgen defciency syndromes: an Endocrine Society clinical tes to sterone treatment on bone mineral density in men over practice guideline. Effects of transdermal the risk of atherosclerosis in elderly men: the Rotterdam tes to sterone treatment on serum lipid and apolipoprotein levels study. Effects of Associations of to tal tes to sterone, sex hormone-binding tes to sterone on body composition, bone metabolism and globulin, calculated free tes to sterone, and luteinizing serum lipid profle in middle-aged men: a meta-analysis. Low serum of correlations between endogenous sex hormone levels and tes to sterone and estradiol predict mortality in elderly men. Part I: epidemiology of associated with the severity of coronary atherosclerosis in hypogonadism. Effects of tes to sterone on coronary vasomo to r regulation year public health impact and direct cost of tes to sterone in men with coronary heart disease. Effects of tes to sterone undecanoate replacement and men with low tes to sterone levels. J Clin Endocrinol Metab withdrawal on cardio-metabolic, hormonal and body 2012;97(6):2050-2058. De Pergola G, Pannacciulli N, Ciccone M, Tartagni M, of mortality and tes to sterone replacement improves survival Rizzon P, Giorgino R. Eur J Endocrinol 2013;169(6): negatively associated with the intima-media thickness 725-733. Int J Obes Relat Metab Low-dose transdermal tes to sterone therapy improves Disord 2003;27(7):803-807. Relationship between tes to sterone randomized, double-blind, placebo-controlled study. Association acute tes to sterone on myocardial ischemia in men with between serum tes to sterone concentration and carotid coronary artery disease. Increased carotid lower levels of androgens than men with normal coronary atherosclerosis in andropausal middle-aged men. Endogenous sex hormones and or tes to sterone with fnasteride increases bone mineral density progression of carotid atherosclerosis in elderly men. Effects tes to sterone and elevated carotid intima-media thickness: of tes to sterone on muscle strength, physical function, body importance of low-grade infammation in elderly men. J Intern Med tes to sterone (T) alone or with fnasteride increases physical 2006;259(6):576-582. J Clin Endocrinol Metab 2005;90(3): tes to sterone level is associated with carotid intima-media 1502-1510. Randomized placebo-controlled trial of androgen effects Endogenous tes to sterone and the prospective association on muscle and bone in men requiring long-term systemic with carotid atherosclerosis in men: the Tromso study. Frequent occurrence of muscle and decreases fat mass in healthy elderly males hypogonadotropic hypogonadism in type 2 diabetes. Tes to sterone replacement in older hypogonadal men: treatment with diet and exercise plus transdermal tes to sterone a 12 month randomized controlled trial. J Clin Endocrinol reverses the metabolic syndrome and improves glyce-mic Metab 1997;82(6):1661-1667. J Am Geratr Soc 2002;50(10): replacement therapy improves insulin resistance, glycaemic 1698-1701.

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Pour le traitement curatif des patients porteurs de goitre et en prevention dans les zones de carence lorsque le sel nest pas enrichi en iode: huile iodee spasms upper back purchase azathioprine australia, se conformer au pro to muscle relaxant drugs purchase generic azathioprine cole national spasms of the bladder generic 50 mg azathioprine fast delivery. Les populations cibles sont les femmes enceintes spasms under belly button azathioprine 50mg sale, allaitantes, en age de procreer et les enfants. Il disparait plus lentement (voire jamais) chez ladulte malgre la normalisation de la fonction thyroidienne, obtenue en 2 semaines. Chapitre 12: Autres pathologies 318 Guide clinique et therapeutique Annexes Annexe 1a. Ce pro to cole ne sapplique pas aux patients brules ou chirurgicaux ou atteints de maladie renale ou cardiaque ou dacidoce to se diabetique. Pour faciliter la prescription et ladministration, les volumes journaliers et debits en gouttes par minute ont ete arrondis. Poids Volume Debit* /24 heures (perfuseur pediatrique 1 ml = 60 gouttes) 3 a < 4 kg 350 ml/24 h 16 gouttes/min 4 a < 5 kg 450 ml/24 h 18 gouttes/min 5 a < 6 kg 550 ml/24 h 22 gouttes/min 6 a < 7 kg 650 ml/24 h 26 gouttes/min 7 a < 8 kg 750 ml/24 h 30 gouttes/min 8 a < 9 kg 850 ml/24 h 36 gouttes/min 9 a < 11 kg 950 ml/24 h 40 gouttes/min 11 a < 14 kg 1100 ml/24 h 46 gouttes/min Annexes 319 Guide clinique et therapeutique 14 a < 16 kg 1200 ml/24 h 50 gouttes/min 16 a < 18 kg 1300 ml/24 h 54 gouttes/min 18 a < 20 kg 1400 ml/24 h 58 gouttes/min Poids Volume Debit* Debit /24 heures (perfuseur pediatrique 1 ml = (perfuseur standard 1 ml = 60 gouttes) 20 gouttes) 20 a < 22 kg 1500 ml/24 h 62 gouttes/min 20 gouttes/min 22 a < 26 kg 1600 ml/24 h 66 gouttes/min 22 gouttes/min 26 a < 30 kg 1700 ml/24 h 70 gouttes/min 24 gouttes/min 30 a < 35 kg 1800 ml/24 h 74 gouttes/min 26 gouttes/min fi 35 kg 2000 ml/24 h 82 gouttes/min 28 gouttes/min * Avec un perfuseur pediatrique, le nombre de gouttes par minute est egal au nombre de ml par heure. Par exemple: 15 gouttes/min = 15 ml/heure 1(see page 0) Lapport hydrique journalier est calcule selon la formule suivante: Enfant 0-10 kg: 100 ml/kg par jour Enfant 11-20 kg: 1000 ml + (50 ml/kg pour chaque kg au-dessus de 10 kg) par jour Enfant > 20 kg: 1500 ml + (20-25 ml/kg pour chaque kg au-dessus de 20 kg) par jour Adulte: 2 litres par jour Annexe 1b. Annexes 320 Guide clinique et therapeutique Liquide a administrer Le solute de choix chez lenfant est le Ringer lactate-Glucose 5%. Franca Krikor Boyaciyan Maria Melisande Diogenes Pires Rena to Passini Junior Ricardo Fescina Sergio Martins Costa Suzanne Serruya Colaboradores Anibal Faundes Dorival An to nio Vi to rello Iracema de Mat to s Paranhos Calderon Jose Geraldo Lopes Ramos Marcus Vasconcelus Marilza Vieira Cunha Rudge Mary Angela Parpanelli Regina Viola Ronaldo Seligman Rui Gilber to Ferreira Sergio Eduardo Costa Sampaio Ministerio da Saude 2000 E permitida a reproducao to tal, desde que citada a fonte. Ao nao se garantir o acesso seguro ao even to da maternidade, impoe-se as mulheres o mais serio limite ao exercicio dos direi to s reprodutivos e, portan to, a condicao de cidadania. Embora o risco de obi to tenha se reduzido no Brasil com a ampliacao do acesso ao pre-natal e ao par to institucional, ainda ha mui to a fazer. Para evitar a morte de muitas mulheres, e fundamental o pron to e adequado atendimen to as emergencias obstetricas. O Guia de Urgencias e Emergencias Maternas ira contribuir, com certeza, para garantir a gestante uma assistencia mais efetiva. Choque hemorragico Regras para reposicao de volume e correcao das coagulopatias. Tabela de Uso de Medicacoes Parenterais Usadas no Tratamen to de Crise Hipertensiva. No entan to, cerca de 98% desses obi to s seriam evitaveis caso fossem asseguradas condicoes dignas de vida e de saude a populacao. A comparacao entre as taxas de mortalidade materna em paises desenvolvidos da Regiao das Americas tais como Canada e Estados Unidos, cujos valores sao inferiores a nove obi to s por 100. Entretan to, paises em desenvolvimen to dessa regiao, como Cuba e Costa Rica, apresentam taxas de mortalidade materna substancialmente inferiores, demonstrando que a morte materna pode ser um indicador da determinacao politica de garantir a saude da populacao. No Brasil, assim como nos paises em desenvolvimen to, a mortalidade materna e subenumerada. As causas para tal estao vinculadas a existencia de cemiterios clandestinos, a ocorrencia de par to s domiciliares em areas rurais, a dificuldade de acesso aos car to rios, ao desconhecimen to da populacao quan to a importancia do atestado de obi to como instrumen to de cidadania e ao preenchimen to inadequado das declaracoes de obi to (D. Alem disso, a permanencia da desigualdade social entre homens e mulheres to rna a declaracao do obi to feminino um documen to sem importancia imediata do pon to de vista legal, pois as mulheres mais expostas ao risco de morrer sao as de baixa renda ou da zona rural, que nao tem heranca nem beneficios previdenciarios assegurados. Em 1997, a razao de morte materna no pais, obtida a partir de obi to s declarados, foi de 51,6 obi to s por 100. Infelizmente, nao e possivel estimar o numero de obi to s nao registrados e os mal declarados, pela ausencia de pesquisas recentes capazes de determinar a real magnitude da mortalidade materna em cada macrorregiao do pais. Quan to as causas de morte materna, predominam as obstetricas diretas2 (74%), e entre essas, a eclampsia, hemorragias, infeccao puerperal e abor to. A maioria desses obi to s e evitavel mediante uma boa assistencia no pre-natal, par to, puerperio e urgencias e emergencias maternas. Para uma grande parcela das mulheres brasileiras, o acesso ao planejamen to familiar e mais do que is to : e questao vital, pois na ausencia de condicoes materiais, conjugais e ate existenciais para arcar com uma gravidez, recorrem ao abor to ilegal, e portan to, inseguro. Estudos realizados em diferentes regioes do Brasil demonstram que a razao entre as internacoes por abor to e as internacoes por par to varia de 1/10 a 4/10. O abor to representa a quarta causa de morte materna no pais, mas em algumas capitais, e a mais frequente. A inducao do abor to mediante praticas inseguras e sem duvida a causa basica dessas mortes. No entan to, pesquisas tem demonstrado que mulheres nessa condicao recebem muitas vezes tratamen to desumano motivado pelo prejulgamen to de profissionais de saude, cuja demora em instituir o tratamen to necessario contribui para o obi to. Causa obstetrica indireta e aquela resultante de doenca preexistente ou que se desenvolve durante a gravidez, nao por causas diretas, mas agravada pelos efei to s fisiologicos da gravidez. A menor cobertura foi encontrada no Nordeste (75%) e a maior no Estado do Rio de Janeiro (96%). A pesquisa tambem mostrou que em 75% das gestacoes foram realizadas mais de quatro consultas, e que entre as mulheres que fizeram pre-natal, 50% realizaram seis ou mais consultas; is to e, o numero minimo de visitas necessario para um bom acompanhamen to. Quan to a epoca de inicio do pre-natal, o estudo mostra que 66% das gestantes brasileiras o fizeram adequadamente, is to e, no primeiro trimestre da gravidez, com diferencial de 73% na area urbana e 46% na area rural. Uma proporcao menor de mulheres inicia o pre-natal nos primeiros tres meses nas regioes Nordeste (52%) e Norte (56%). A analise dos tres parametros acima descri to s indica que o acesso ao pre-natal e problema significativo para a populacao rural e da localizada nas regioes Norte e Nordeste. Demonstra ainda que a qualidade da assistencia e deficiente em to do o pais, pois mesmo em regioes com alta cobertura e concentracao de consultas de pre-natal a mortalidade materna se mantem elevada. Existem pelo menos tres indicadores objetivos da ma qualidade do atendimen to pre-natal no pais. O segundo, e o fa to de a hipertensao especifica da gravidez ser nossa causa mais frequente de morte materna. O meio mais eficiente de reducao desse tipo de morte esta no adequado controle ao longo da gestacao. Alem disso, estudos mostram que as consultas sao mui to rapidas, fazendo com que possiveis anormalidades nao sejam percebidas e impedindo que as mulheres possam manifestar suas queixas, duvidas e medos intrinsecos a gravidez. Sao fa to res determinantes dessa situacao: a dificuldade para fixar recursos humanos em unidades basicas de saude, em funcao dos baixos salarios e da carente infra-estrutura; a retaguarda labora to rial insuficiente para realizar os exames minimos necessarios, a descontinuidade da oferta de medicamen to s basicos, como sulfa to ferroso e acido folico. Nenhum investimen to material na 9 assistencia pre-natal sera capaz de garantir a vida de mulheres e recem-nascidos se medicos e enfermeiras nao prestarem maior atencao a cada pessoa atendida. O pron to reconhecimen to desses casos associado a existencia de retaguarda de servicos com maior complexidade para o adequado acompanhamen to, sao decisivos para a manutencao da vida dessas mulheres. Entretan to, a grande maioria das mulheres recebe "alta" do pre-natal no seu momen to mais critico, ao redor do oitavo mes quando agravam-se pa to logias como a hipertensao, o diabetes deixando-as sem saber a que servico recorrer frente a uma intercorrencia ou no momen to do par to. Informar a gestante sobre qual o servico a ser procurado em situacoes de emergencia e no momen to do par to e obriga to rio, sem que is to signifique a desobrigacao da unidade basica de saude em atende-la ate o final da gestacao. Em varios centros urbanos ocorre uma verdadeira peregrinacao das mulheres no momen to do par to, como se fosse delas a responsabilidade pelo encontro de vagas. Essa demora no atendimen to obstetrico, alem de indigna, tem tragicas consequencias maternas e neonatais. Raramente o ges to r municipal e estadual conhece a relacao entre a oferta e a demanda por lei to s obstetricos, e planeja o sistema de atendimen to desde o pre-natal ate o par to. Frequentemente, o numero de lei to s e suficiente, sendo necessario apenas organizar a assistencia mediante a vinculacao de unidades basicas de saude a maternidades e a instituicao de centrais de regulacao de lei to s. A busca itinerante por uma vaga, o insuficiente acompanhamen to do trabalho de par to e do pos-par to imedia to acarretam o que se tem chamado de inoportunidade da assistencia. Is to e, a identificacao tardia de uma complicacao faz com que se perca a oportunidade de intervir quando ainda e possivel salvar a vida da mae. Contribui para essa "desassistencia" o fa to de a atencao ao par to nao ser vis to como obje to do trabalho de uma equipe. A enfermeira obstetra, profissional preferencialmente responsavel pelo acompanhamen to do trabalho de par to e pela realizacao do par to normal em inumeros paises, 10 e pouco encontrada nos nossos servicos de saude. Somente a atuacao compartilhada de medicos e enfermeiras sera capaz de garantir as mulheres brasileiras o acompanhamen to solidario e seguro ao longo do trabalho de par to, do par to e nascimen to. Agrava esse quadro, o recurso excessivo ao par to cirurgico, responsavel por conduzir gestacoes absolutamente normais a riscos materno-fetais desnecessarios. Estudos epidemiologicos tem demonstrado que o risco de morte materna e neonatal associado a cesariana e, respectivamente, sete e tres vezes maior do que o associado ao par to normal. Essa consulta e fundamental para a manutencao da amamentacao, a introducao da contracepcao necessaria para o devido intervalo entre as gestacoes, e a deteccao de intercorrencias proprias desse periodo, como anemia ou depressao puerperal. A maioria dos servicos, no momen to da alta hospitalar, nao faz a adequada orientacao sobre sinais precoces de infeccao puerperal ou de outras complicacoes frequentes.

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  • Sandrow Sullivan Steel syndrome

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