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AAFP Journal Review Dec 15 2009. Ayesha Shaikh PGY3 Emory Family Medicine. We will review…. Intrapartum fetal monitoring: Review definitions and FHR tracings Evaluation of hematospermia: Most common causes and management NSAIDs prescribing precautions:

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aafp journal review dec 15 2009

AAFP Journal ReviewDec 15 2009

Ayesha Shaikh

PGY3

Emory Family Medicine

we will review
We will review…
  • Intrapartum fetal monitoring:

Review definitions and FHR tracings

  • Evaluation of hematospermia:

Most common causes and management

  • NSAIDs prescribing precautions:

System based risk assessment

intrapartum fetal monitoring1
Intrapartum Fetal Monitoring
  • Developed in 1960
  • External or internal transducers, became a part of routine maternity care during the 1970s.
  • Cesarean delivery and instrumental vaginal delivery
  • Neonatal mortality and cerebral palsy.
  • Neonatal seizures.
selection of fhr monitoring method
Selection of FHR Monitoring Method
  • Structured intermittent auscultation: The systematic use of a Doppler assessment of fetal heart rate (FHR) during labor at defined timed intervals. For low-risk patients, a nurse-to-patient ratio of 1:1
  • Continuous EFM: When abnormalities in structured intermittent auscultation, high-risk patients
maternal and fetal high risk factors that indicate use of continuous electronic fetal monitoring
Maternal and Fetal High-Risk Factors That Indicate Use of Continuous Electronic Fetal Monitoring

Antenatal

Fetal

  • Oligohydramnios
  • Breech presentation
  • Intrauterine growth restriction
  • Multiple pregnancies
  • Rh isoimmunization
  • Abnormal umbilical artery Doppler velocimetry

Maternal

  • Anemia
  • Antepartum hemorrhage
  • Cardiac disease
  • Diabetes
  • Hypertension (preeclampsia or eclampsia)
  • Hyperthyroidism
  • Maternal motor vehicle collision or trauma
  • Morbid obesity
  • Renal disease
  • Vascular disease

Intrapartum

Fetal

  • Abnormal fetal heart rate on auscultation or admission
  • tracing (20-minute strip)
  • Meconium-stained amniotic fluid

Maternal

  • Hypertonic uterus
  • Induced or augmented labor
  • Intrauterine infection or chorioamnionitis
  • Post-term pregnancy (> 42 weeks' gestation)
  • Preterm labor (< 32 weeks' gestation)
  • Previous cesarean delivery
  • Prolonged membrane rupture > 24 hours at term
  • Regional analgesia, particularly after initial bolus and after top-ups (continuous electronic fetal monitoring is not required with mobile or continuous-infusion epidurals)
  • Vaginal bleeding in labor
interpretation of fhr tracings
Interpretation of FHR tracings
  • National Institute of Child Health and Human Development (NICHD) 1997 definations
  • Adopted by
  • ACOG in 2002
  • The Society of Maternal-Fetal Medicine
fetal heart rate characteristics
Fetal Heart rate Characteristics

Accelerations

Visually apparent, abrupt (onset to peak < 30 seconds) increase in FHR from the most recently calculated baseline Peak ≥ 15 bpm above baseline, duration ≥ 15 seconds, but < 2 minutes from onset to return to baseline; before 32 weeks’ gestation: peak ≥ 10 bpm above baseline, duration ≥ 10 seconds

Baseline FHR

Approximate mean FHR rounded to increments of 5 bpm during a 10-minute segment, excluding periodic or episodic changes, periods of marked variability, and segments of baseline that differ by > 25 bpm In any 10-minute window, the minimum baseline duration must be ≥ 2 minutes, or the baseline for that period is indeterminate

Bradycardia

Baseline rate: < 110 bpm

fetal heart rate characteristics1
Fetal Heart rate characteristics
  • Decelerations

Early

The nadir of the deceleration occurs at the same time as the peak of the contraction

Late

The nadir of the deceleration occurs after the peak of the contraction

Variable

Abrupt decrease in FHR; if the nadir of the deceleration is ≥ 30 seconds, it cannot be considered a variable deceleration

  • Tachycardia:Baseline rate: > 160 bpm

Variability

  • Absent :Amplitude range: undetectable
  • Minimal :Amplitude range: detectable, but ≤ 5 bpm
  • Moderate : Amplitude range: 6 to 25 bpm
  • Marked : Amplitude range: > 25 bpm
normal baseline fhr
Normal baseline FHR
  • Normal baseline fetal heart rate (FHR), shown at 135 beats per minute (bpm). Normal baseline rate ranges from 110 to 160 bpm for a 10-minute segment and duration ≥ 2 minutes. Excludes periodic and episodic changes, marked variability, and segments differing by ≥ 25 bpm.
tachycardia
Tachycardia
  • Tachycardia of fetal heart rate (FHR), shown at 170 beats per minute (bpm). Baseline rate with tachycardia is > 160 bpm.
slide13
Minimal variability of fetal heart rate (FHR). Amplitude range of FHR tracing is undetectable.
slide14
Minimal variability of fetal heart rate (FHR). Amplitude range of FHR tracing ≤ 5 beats per minute.
slide15
Moderate variability of fetal heart rate (FHR). Amplitude range of FHR tracing is 6 to 25 beats per minute.
slide16
Marked variability of fetal heart rate (FHR). Amplitude range of FHR tracing > 25 beats per minute.
slide17
Acceleration of fetal heart rate (FHR). Visually apparent, abrupt (onset to peak < 30 seconds) increase in FHR from the most recently calculated baseline. Peak ≥ 15 beats per minute (bpm) above the baseline, and duration ≥ 15 seconds, but < 2 minutes from onset of the acceleration to return to baseline. Before 32 weeks’ gestation, peak ≥ 10 bpm above baseline, duration ≥ 10 seconds.
slide18
Early deceleration of fetal heart rate (FHR). Gradual decrease and return of FHR is associated with a uterine contraction. In most cases, the onset of the deceleration, nadir, and recovery coincide with the beginning, peak, and ending of the contraction, respectively (FHR mirrors the contraction).
slide19
Variable deceleration of fetal heart rate (FHR). Abrupt decrease in FHR < 30 seconds from the beginning of the deceleration to the nadir. The decrease in FHR (measured at the nadir) is ≥ 15 beats per minute, with a duration ≥ 15 seconds, but < 2 minutes.
slide20
Repetitive late deceleration of fetal heart rate (FHR). National Institute of Child Health and Human Development Category II: repetitive late deceleration with minimal variability.
slide21
Prolonged deceleration of fetal heart rate (FHR) with slow recovery. National Institute of Child Health and Human Development Category II: prolonged deceleration ≥ 2 minutes and < 10 minutes.
slide22
Prolonged deceleration of fetal heart rate (FHR) without recovery. National Institute of Child Health and Human Development Category III: absent variability and bradycardia.
interpretation and management of continuous efm findings
Interpretation and Management of Continuous EFM Findings

Finding:

NICHD Category I: Normal

Moderate baseline FHR variability, late or variable decelerations absent, accelerations present or absent, and normal baseline FHR (110 to 160 bpm)

Significance:

Normal pH and fetal well-being

Management:

Continue current monitoring method (SIA or continuous EFM)

interpretation and management of continuous efm findings1
Interpretation and Management of Continuous EFM Findings
  • NICHD Category II: Indeterminate

Finding:Baseline FHR changes (bradycardia [< 110 bpm] not accompanied by

absent baseline variability, or tachycardia [> 160 bpm])

Significance: Bradycardia- expedite delivery if persists, Tachycardia- general measures

Finding: Change in FHR variability (absent and not accompanied by decelerations;

minimal; or marked)

Significance: Medication/sleep cycle- general measure, Change in monitoring technique,

fetal hypoxia/acidemia- consider expedite delivery

Finding: No FHR accelerations after fetal stimulation

Significance: fetal hypoxia/acidemia- general mesaures, stop pitocin, expedite delivery

Findings: FHR decelerations without absent variability

Significance:Variable: cord entrapment or prolapse- general measure, amnioinfusion

Late:possible uteroplacental insufficiency; epidural hypotension; tachysystole general measure, D/C oxytocin expedite delivery

interpretation and management of continuous efm findings2
Interpretation and Management of Continuous EFM Findings
  • NICHD Category III: Abnormal

Finding:Absent baseline FHR variability with recurrent decelerations (variable or late) and/or bradycardia sinusoidal FHR pattern

Singnificance: Uteroplacental insufficiency; fetal hypoxia or acidemia

General measures: Discontinue oxytocin, Expedite delivery

interventions for abnormal electronic fetal monitoring
Interventions for Abnormal Electronic Fetal Monitoring
  • 1. Change maternal position
  • 2. Assess maternal vital signs (temperature, blood pressure, pulse)
  • 3. Discontinue oxytocin (Pitocin) infusion, if in use
  • 4. Initiate oxygen at 6 to 10 L per minute
  • 5. Perform a vaginal examination (check for cord prolapse, rapid descent of the head, or vaginal bleeding suggestive of placental abruption)
  • 6. Give intravenous fluids if not already administered; consider bolus
  • 7. Assess fetal pH (fetal scalp stimulation, scalp pH, or acoustic stimulation)
  • 8. Give amnioinfusion for recurrent, moderate to severe variable decelerations
  • 9. Consider need for expedited delivery (operative vaginal delivery or cesarean delivery)
slide27
Tocolytic agents such as terbutaline (formerly Brethine) may be used to transiently stop contractions, with the understanding that administration of these agents improved FHR tracings compared with untreated control groups, but there were no improvements in neonatal outcomes.A recent study showed a significant effect of maternal oxygen on increasing fetal oxygen in abnormal FHR patterns
which one of the following is associated with fetal bradycardia check one
Which one of the following is associated with fetal bradycardia ( check one)

A: fetal myocardial conduction defects

B: maternal dehydration

C: maternal fever

D: maternal chorioamnionitis

which one of the following is associated with fetal bradycardia check one1
Which one of the following is associated with fetal bradycardia ( check one)

A: fetal myocardial conduction defects

B: maternal dehydration

C: maternal fever

D: maternal chorioamnionitis

slide31
Compared with structured intermittent auscultation, continuous EFM reduces the incidence of which one of the following? ( check one)

A: Perinatal deaths

B: Neonatal seizures

C: Cerebral Palsy

D: Cesarean Section

slide32
Compared with structured intermittent auscultation, continuous EFM reduces the incidence of which one of the following? ( check one

A: Perinatal deaths

B: Neonatal seizures

C: Cerebral Palsy

D: Cesarean Section

author and references
Author And References.
  • The Author
  • R. EUGENE BAILEY, MD, FAAFP, is an associate professor and the director of the Family Medicine Clerkship in the Department of Family Medicine, SUNY Upstate Medical University, Syracuse, NY. He is currently advisory faculty and instructor certified for the Advanced Life Support in Obstetrics (ALSO) course, and previously served on the ALSO National Advisory Board.
  • Address correspondence to R. Eugene Bailey, MD, FAAFP, SUNY Upstate Medical University, 475 Irving Ave., Ste. 200, Syracuse, NY 13210 (e-mail: [email protected]). Reprints are not available from the author.
  • Author disclosure: Nothing to disclose.
  • The author would like to thank Dr. Kim Hinshaw for his expert contributions in the preparation of this manuscript and his development of the DR C BRAVADO mnemonic, and Dr. Larry Leeman for his endless hours of assistance and editorial prowess.
  • This article is one in a series on “Advanced Life Support in Obstetrics (ALSO),” initially established by Mark Deutchman, MD, Denver, Colo. The series is now coordinated by Larry Leeman, MD, MPH, ALSO Managing Editor, Albuquerque, N.M.
  • REFERENCES
  • 1. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. Natl Vital Stat Rep. 2003;52(10):1–113.
  • 2. Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2006;(3):CD006066.
  • 3. National Institute for Health and Clinical Excellence. Intrapartum care: management and delivery of care to women in labour. September 2007. http://guidance.nice.org.uk/CG55. Accessed July 6, 2009.
slide34
5. ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol. 2009;114(1):192–202.
  • 6. Bix E, Reiner LM, Klovning A, Oian P. Prognostic value of the labour admission test and its effectiveness compared with auscultation only: a systematic review. BJOG. 2005;112(12):1595–1604.
  • 7. Hindley C, Hinsliff SW, Thomson AM. English midwives' views and experiences of intrapartum fetal heart rate monitoring in women at low obstetric risk: conflicts and compromises. J Midwifery Womens Health. 2006;51(5):354–360.
  • 8. Kripke CC. Why are we using electronic fetal monitoring? Am Fam Physician. 1999;59(9):2416, 2421–2422.
  • 9. Bailey RE. Intrapartum fetal surveillance. In: Leeman L, ed. Advanced Life Support in Obstetrics Program: Provider Course Syllabus. Leawood, Kan.: American Academy of Family Physicians; 2009.
  • 10. Parer JT, Ikeda T. A framework for standardized management of intrapartum fetal heart rate patterns. Am J Obstet Gynecol. 2007;197(1):26.e1–e6.
  • 11. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol. 2008;112(3):661–666.
  • 12. Todros T, Preve CU, Plazzotta C, Biolcati M, Lombardo P. Fetal heart rate tracings: observers versus computer assessment. Eur J ObstetGynecolReprod Biol. 1996;68(1–2):83–86.
  • 13. Bernardes J, Costa-Pereira A, Ayres-de-Campos D, van Geijn HP, Pereira-Leite L. Evaluation of interobserver agreement of cardiotocograms. Int J Gynaecol Obstet. 1997;57(1):33–37.
  • 14. Electronic fetal heart rate monitoring: research guidelines for interpretation. National Institute of Child Health and Human Development Research Planning Workshop. Am J Obstet Gynecol. 1997;177(6):1385–1390.
  • 15. Hinshaw K, Ullal A. Peripartum and intrapartum assessment of the fetus. Anaesth Intensive Care Med. 2007;8(8):331–336.
  • 16. The International Federation of Obstetrics and Gynecology (FIGO). Guidelines for the use of fetal monitoring. Int J Gynaecol Obstet. 1987;25(2):159–167.
  • 17. Low JA, Victory R, Derrick EJ. Predictive value of electronic fetal monitoring for intrapartum fetal asphyxia with metabolic acidosis. Obstet Gynecol. 1999;93(2):285–291.
  • 18. Feinstein N, Torgersen KL, Atterbury J, for the Association of Women's Health, Obstetric and Neonatal Nurses. Fetal Heart Monitoring: Principles and Practices. 3rd ed. Dubuque, Iowa: Kendall/Hunt Publishing Company; 2003.
  • 19. Skupski DW, Rosenberg CR, Eglinton GS. Intrapartum fetal stimulation tests: a meta-analysis. Obstet Gynecol. 2002;99(1):129–134.
  • 20. The American College of Obstetricians and Gynecologists, American Academy of Pediatrics. Neonatal Encephalopathy and Cerebral Palsy. Defining the Pathogenesis and Pathophysiology. Washington, DC: American College of Obstetricians and Gynecologists; 2003: 74.
  • 21. Chez BF. Electronic fetal monitoring then and now. J Perinat Neonatal Nurs. 1997;10(4):1–4.
  • 22. Hofmeyr GJ. Amnioinfusion for potential or suspected umbilical cord compression in labour. Cochrane Database Syst Rev. 1998;(1):CD000013.
  • 23. Kulier R, Hofmeyr GJ. Tocolytics for suspected intra-partum fetal distress. Cochrane Database Syst Rev. 2000;(2):CD000035.
  • 24. Haydon ML, Gorenberg DM, Nageotte MP, et al. The effect of maternal oxygen administration on fetal pulse oximetry during labor in fetuses with nonreassuring fetal heart rate patterns. Am J Obstet Gynecol. 2006;195(3):735–738.
  • 25. Neilson JP. Fetal electrocardiogram (ECG) for fetal monitoring during labour. Cochrane Database Syst Rev. 2006;(3):CD000116.
evaluation and treatment of hematospermia1
Evaluation and treatment of Hematospermia
  • Presence of blood in the semen, known as hematospermia or hemospermia.
  • Blood in fewer than 10 consecutive ejaculations or for less than 12 weeks.
  • The incidence of hematospermia is difficult to quantify because most men do not observe their semen.Prevalence in clinical settings is highest in men younger than 40 years.
  • Management:

younger than 40 years without risk factors and in men with no associated symptoms vs 40 years and older, and patients with persistent or recurrent hematospermia

etiologies of hematospermia and their typical presentations
Etiologies of Hematospermia and Their Typical Presentations
  • Behavioral - abstinence, masturbation or rigorus intercourse
  • Infectious - 40% of cases: STD,TB, Schistosoma, echinococcus
  • Inflammatory -prostitis, vasculitis
  • Neoplastic- bladder, urethra, prostate, seminal vesicles and so on
  • Structural - polyps, cysts, stones.
  • Systemic - amyloidosis, bleeding disorder, liver disease, uncontrolled hypertension
  • Trauma (iatrogenic)- injections, biopsies, instumentations
  • Vascular- AVM, varicies, hemangiomas
history
History
  • R/O pseudo-spermia
  • Age of patient
  • Duration of symptoms
  • Presence of associated symptoms or risk factors
evaluation
Evaluation
  • Isolated Hematospermia
  • Hematospermia with associated conditions or symptoms
isolated hematospermia
Isolated Hematospermia

First Episode:

Excessive sex or masturbation/ prolonged sexual abstinence-> UA

STI -> Testing and treat as appropriate

UTI -> UA and Culture

BPH -> symptom index, post void residual

Prostatic cancer -> PSA, urology referral

Persistent, Recurrent or high volume hematospermia

Vascular- UA -> urology referral

Tumors- UA+cytology ->Urology referral

Bleeding Diathesis -> CBC, PT, PTT, treat as indicated

hematospermia with associated conditions or symptoms
Hematospermia with associated conditions or symptoms
  • Trauma: self inflicted or iatrogenic:

UA, U cx, consider Urology referral for endoscopy, penile doppler studies

  • Genitourinary infection or inflammation: UTI/STI, Prostitis, Epididmytis:

UA,urine culture, STI testing,sperm culture, scrotal doppler ultrasound treat as indicated, urology referral

  • Voiding symptoms:

UA, PSA, post void residual, AUA symptoms index, urology referral, alpha blocker +/- 5 alpha reductase inhibitor

  • Pain with ejaculation: Prostatitis, obstruction( polyp, strictures etc):

treat as indicated, urology referral

  • Systemic disorder: HTN, Bleeding disorder, malignancy , liver disease: investigate and treat underlying disorder.
  • Travel or exposure history: TB, Schistosomiasis:

evaluate and treat as indicated or ID referral.

physical exam
Physical Exam
  • Vitals: BP, Tachycardia, fever indicate systemic cause
  • Abdominal and urogenital exam for trauma, inflammation, discharge, lymphadenopathy
  • Full scrotal exam for inflammation, infection, testicular mass, epididymis, spermatic cord
  • Rectal exam for prostate
indications for hematospermia urology referral
Indications for Hematospermia Urology Referral

Based on symptoms:

  • Hematospermia associated with genitourinary pain
  • Hematospermia associated with unexplained voiding symptoms
  • Recurrent, persistent, high-volume hematospermia

Based on evaluation:

  • Abnormal examination findings suggestive of tumor or structural problems
  • Abnormal prostate-specific antigen findings
  • Abnormal urinalysis findings (hematuria, sterile pyuria)
  • Suspected foreign body, stent migration
  • Suspected vascular malformation
  • Based on lack of response to initial management
  • Symptoms or abnormal findings persist
treatment
Treatment
  • Directed at the diagnosed etiology
  • Suspected infection, empiric two-week treatment with an antibiotic that penetrates the prostate-blood barrier (e.g., fluoroquinolones, doxycycline, trimethoprim, trimethoprim/sulfamethoxazole [Bactrim, Septra])
  • Most men with an easily treatable cause of hematospermia do not need follow-up, otherwise within three to six months to reassess symptoms
slide47
Which one of the following factors suggest the need for a urology referral in the evaluation of hematospermia? (check one)

A: Prolonged sexual abstinence

B resolution with treatment of STI

C: younger age

D: Persistent, recurrent or heavy bleeding

slide48
Which one of the following factors suggest the need for a urology referral in the evaluation of hematospermia? (check one

A: Prolonged sexual abstinence

B resolution with treatment of STI

C: younger age

D: Persistent, recurrent or heavy bleeding

slide49
A 65 yo man presents with multiple episodes of hematospermia. On further questioning, he states that he has had some difficulty voiding. Which one of the following the most likely cause of his hematospermia? (check one)

A: BPH

B: Epididimitis

C: pseudo-hematospermia

D: Excessive masterbation

slide50
A 65 yo man presents with multiple episodes of hematospermia. On further questioning, he states that he has had some difficulty voiding. Which one of the following the most likely cause of his hematospermia? (check one)

A: BPH

B: Epididimitis

C: pseudo-hematospermia

D: Excessive masterbation

references
References
  • 1. Kumar P, Kapoor S, Nargund V. Haematospermia—a systematic review. Ann R Coll Surg Engl. 2006;88(4):339–342.
  • 2. Zhang XR, Gu BJ, Xu YM, Chen R, Zhang J, Qiao Y. Transrectal ultrasonography-guided transperineal bilateral seminal vesicle puncture and continuous irrigation for the treatment of intractable hematospermia. Chin Med J (Engl). 2008;121(11):1052–1054.
  • 3. Mulhall JP, Albertsen PC. Hemospermia: diagnosis and management. Urology. 1995;46(4):463–467.
  • 4. Ahmad I, Krishna NS. Hemospermia. J Urol. 2007;177(5):1613–1618.
  • 5. Sampalmieri G, Giancola FL, Cabras A. Hemospermia: cause, clinical significance and our experience [in Italian]. Riv Eur Sci Med Farmacol. 1992;14(2):135–137.
  • 6. Papp GK, Kopa Z, Szabó F, Erdei E. Aetiology of haemospermia. Andrologia. 2003;35(5):317–320.
  • 7. Han M, Brannigan RE, Antenor JA, Roehl KA, Catalona WJ. Association of hemospermia with prostate cancer. J Urol. 2004;172(6 pt 1):2189–2192.
  • 8. Leary FJ, Aguilo JJ. Clinical significance of hematospermia. Mayo Clin Proc. 1974;49(11):815–817.
  • 9. Manoharan M, Ayyathurai R, Nieder AM, Soloway MS. Hemospermia following transrectal ultrasound-guided prostate biopsy: a prospective study. Prostate Cancer Prostatic Dis. 2007;10(3):283–287.
  • 10. Andrade-Rocha FT. Ureaplasma urealyticum and Mycoplasma hominis in men attending for routine semen analysis. Prevalence, incidence by age and clinical settings, influence on sperm characteristics, relationship with the leukocyte count and clinical value. Urol Int. 2003;71(4):377–381.
  • 11. Golan S, Slomov E, Kra-Oz Z, et al. Detection of sexually transmitted pathogens in patients with hematospermia [in Hebrew] Harefuah. 2005;144(9):630–633676.
  • 12. Corachan M, Valls ME, Gascon J, Almeda J, Vilana R. Hematospermia: a new etiology of clinical interest. Am J Trop Med Hyg. 1994;50(5):580–584.
  • 13. Schwartz E, Pick N, Shazberg G, Potasman I. Hematospermia due to schistosome infection in travelers: diagnostic and treatment challenges. Clin Infect Dis. 2002;35(11):1420–1424.
  • 14. Maheshkumar P, Otite U, Gordon S, Berney DM, Nargund VH. Testicular tumor presenting as hematospermia. J Urol. 2001;165(1):188.
  • 15. Shen BY, Chang PL, Lee SH, Chen CL, Tsui KH. Complications following combined transrectal ultrasound-guided prostate needle biopsies and transurethral resection of the prostate. Arch Androl. 2006;52(2):123–127.
  • 16. Fuse H, Nishio R, Murakami K, Okumura A. Transurethral incision for hematospermia caused by ejaculatory duct obstruction. Arch Androl. 2003;49(6):433–438.
  • 17. Furuya S, Ogura H, Shimamura S, Itoh N, Tsukamoto T, Isomura H. Clinical manifestations of 25 patients with prostatic-type polyps in the prostatic urethra [in Japanese]. Hinyokika Kiyo. 2002;48(6):337–342.
  • 18. Meza-Vázquez HE, Martínez-Cornelio A, Espinoza-Guerrero X, Cárdenas-Rodríguez E, Maldonado-Alcaraz E, Serrano-Brambila E. Ejaculatory duct obstruction [in Spanish]. Cir Cir. 2008;76(4):349–353.
  • 19. Coppens L, Bonnet P, Andrianne R, de Leval J. Adult müllerian duct or utricle cyst: clinical significance and therapeutic management of 65 cases. J Urol. 2002;167(4):1740–1744.
  • 20. Furuya S, Masumori N, Furuya R, Tsukamoto T, Isomura H, Tamakawa M. Characterization of localized seminal vesicle amyloidosis causing hemospermia: an analysis using immunohistochemistry and magnetic resonance imaging. J Urol. 2005;173(4):1273–1277.
  • 21. Leifert S, Lurie A, Kellner J. Ectopic prostatic tissue in urethra. Urology. 1985;26(5):509–510.
  • 22. Close CF, Yeo WW, Ramsay LE. The association between haemospermia and severe hypertension. Postgrad Med J. 1991;67(784):157–158..
introduction
Introduction
  • NSAIDs to treat inflammation, fever and pain.
  • Difference in effectiveness for pain treatment
  • Aspirin for primary and secondary prevention of CAD, Stroke and colorectal cancers.
  • ASA for inhibiting platelet aggregation- 8-12 days duration of action ( COX1 and TXA2)
  • COX 2 inhibitors have no antiplatelet effect.
nsaids side effects
NSAIDs side effects
  • Many Systems: GI, CV, Hepatic , renal , hematologic, CNS , resp.
  • Increased incidence of adverse effects with increased duration and dosing
  • Precautions based on patient’s risks
prescribing precautions gi
Prescribing Precautions: GI
  • Blockage of gastroprotective PG synthesis/ direct injury.
  • Dyspepsia and GI discomfort in 10-20 % of patients taking NSAIDs.
  • Only COX 2i in US is Celebrex
  • Use Misoprotol with NSAID
  • Use H2 blockers with NSAID
  • Inconclusive studies for COX 2 or non selective NSAID + GI prophylaxis.
prescribing precautions cardiovascular
Prescribing Precautions: Cardiovascular
  • Low dose Aspirin vs other NSAIDs.
  • Worsening CHF, increased BP, MI and ischemia.
  • Taking ASA with COX 2 inh: cardioprotective effect but negating GI benefits of COX 2
prescribing precaution hepatic
Prescribing precaution: Hepatic
  • NSAIDS do carry some risk in persons with impaired hepatic functions.
  • Sulindac and Diclofenac: increase in LFT x 3
  • Pre existing Hep C and NSAIDs use : LFT x10
  • Cirrhosis: coag impairment, increase bleeding risk with NSAIDs use
prescribing precaution
Prescribing precaution
  • Renal:
  • Vasodilatory effect of PG produced by COX-2.
  • Selective or nonselective NSAIDs cause volume dependant renal failure and interstitial nephritis, Nephritic syndrome
  • Unclear if monitoring of patients taking NSAIDs and at risk of renal failure does not improve morbidity and mortality
prescribing precautions hematologic
Prescribing Precautions: Hematologic
  • Combining NSAIDs with anticoagulants is associated with 3 to 5 fold increase in GI bleed.
  • Perioperative cessation of Aspirin therapy
  • The survival benefits in persons at high risk of cardiovascular or neurovascular events outweigh the risks
prescribing precautions cns
Prescribing Precautions:CNS
  • Psychosis and cognitive changes more common in elderly
  • Tinnitis is reversible
  • Aseptic meningitis occurs more often in persons with lupus who are taking ibuprofen or naproxen.
aspirin hypersensitivity and nsaids in persons with asthma
Aspirin Hypersensitivity and NSAIDs in Persons with Asthma
  • Not a true allergy which is IgE mediated
  • High cross-reactivity with other NSAIDs
  • Low cross-reactivity with COX-2 inhibitors and acetaminophen.
  • Higher index of suspicion in patients with asthma and nasal polyps.
  • Aspirin desensitization
nsaids in pregnancy and lactation
NSAIDs in Pregnancy and Lactation
  • Not teratogenic in humans, but may block blastocyst implantation.
  • safe in pregnancy , in low doses, intermittent and discontinue 6-8 wks before term.
  • Ibuprofen, indomethacin, and naproxen safe in breastfeeding women, contraindicated when breastfeeding a neonate with jaundice.
nsaids in children
NSAIDs in Children
  • Main risk is dosage error; leads to significant morbidity, even death.
  • Avoidance of combination cold medications that may contain NSAIDs
which one of the following statements about perioperative aspirin therapy is correct check one
Which one of the following statements about perioperative aspirin therapy is correct? ( check one)

A: It should be discontinued in all patients

B: It should be continued in high risk patients with recent MI or cardiac stent placement

C: If it is to be held preoperatively, aspirin should be discontinued one or two days before surgery

D: It should be initiated in persons at low risk of cardiovascular disease

which one of the following statements about perioperative aspirin therapy is correct check one1
Which one of the following statements about perioperative aspirin therapy is correct? ( check one)

A: It should be discontinued in all patients

B: It should be continued in high risk patients with recent MI or cardiac stent placement

C: If it is to be held preoperatively, aspirin should be discontinued one or two days before surgery

D: It should be initiated in persons at low risk of cardiovascular disease

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