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The neck may break immediately beneath the head (subcapi tal) arthritis between fingers order celecoxib 100mg on line, near its midpoint (cervical) or adjacent to the trochanters (basal) arthritis neck shoulder 100mg celecoxib free shipping, or the fracture line may pass between anti-arthritis diet for dogs order celecoxib 100mg fast delivery, along or just below the trochanters (Fig arthritis urica diet discount celecoxib 200 mg online. Fractures of the femoral neck will interrupt completely the blood supply from the diaphysis and psoriatic arthritis definition order 200mg celecoxib with amex, should the retinacula also be torn arthritis in the back muscles purchase discount celecoxib on line, avascular necrosis of the head will be inevitable. The nearer the frac ture to the femoral head, the more tenuous the retinacular blood supply and the more likely it is to be disrupted. There is a curious age pattern of hip injuries; children may sustain greenstick fractures of the femoral neck, schoolboys may displace the epiphysis of the femoral head, in adult life the hip dislocates and, in old age, fracture of the neck of the femur again becomes the usual lesion. The proximal segment is exed by iliacus and psoas and abducted by gluteus medius and minimus, whereas the distal segment is pulled medially by the adductor muscles. Reduction requires powerful trac tion, to overcome the shortening, and then manipulation of the distal fragment into line with the proximal segment; the limb must therefore be abducted and also pushed forwards by using a large pad behind the knee. Fractures of the lower end of the shaft, immediately above the condyles, are relatively rare; fortunately so, because they may be extremely dif cult to treat since the small distal fragment is tilted backwards by gastrocnemius, the only muscle which is attached to it. This may result from adduction fractures, slipped the femoral epiphysis or bone-softening diseases. Occasionally this same mechanism of sudden forcible quadriceps contraction tears the quadriceps expansion above the patella, rup tures the ligamentum patellae or avulses the tibial tubercle. It is interesting that following complete excision of the patella for a comminuted fracture, knee function and movement may return to 100% ef ciency; it is dif cult, then, to ascribe any particular function to this bone. The tuberosity of the tibia is at the upper end of the anterior border of the shaft and gives attachment to the ligamentum patellae. The anterior aspect of this tuberosity is subcutaneous, only excepting the infrapatellar bursa immediately in front of it. It is not surprising that the tibia is the commonest long bone to be fractured and to suffer compound injury. It is: 1 an origin for muscles; 2 a part of the ankle joint; 3 a pulley for the tendons of peroneus longus and brevis. The latter bears a medial roughened surface for the lower tibio bular joint, below which is the articular facet for the talus. A groove on the posterior aspect of the malleolus lodges the tendons of peroneus longus and brevis. A note on growing ends and nutrient foramina in the long bones the shaft of every long bone bears one or more nutrient foramina which are obliquely placed; this obliquity is due to unequal growth at the upper and lower epiphyses. The bones and joints of the lower limb 243 direction of more rapid growth and the direction of slope of entry of the nutrient foramen therefore points away from the more rapid growing end of the bone. The site of the growing end is of considerable practical signi cance; for example, if a child has to undergo and above-elbow ampu tation, the humeral upper epiphyseal line continues to grow and the elongating bone may well push its way through the stump end, requiring reamputation. Its articular sur faces are the femoral head and the horse-shoe shaped articular surface of the acetabulum, which is deepened by the brocartilaginous labrum acetabulare. The non-articular lower part of the acetabulum, the acetabular notch, is closed off below by the transverse acetabular ligament. From this notch is given off the ligamentum teres, passing to the fovea on the femoral head. Of these, the iliofemoral is by far the strongest and resists hyper extension strains on the hip. The synovium of the hip covers the non-articular surfaces of the joint and occasionally bulges out anteriorly to form a bursa beneath the psoas tendon where this crosses the front of the joint. Further access may be obtained by detaching the greater trochanter with the gluteal insertions. The anterior approach passes between gluteus medius and minimus laterally and sartorius medially, then dividing the re ected head of rectus femoris to expose the anterior aspect of the hip joint. The posterior approach is through an angled incision commenc ing at the posterior superior iliac spine, passing to the greater trochanter and then dropping vertically downwards from this point. Gluteus medius and minimus are detached from their insertions into the greater trochanter (or the trochanter is detached and subsequently wired back in place), and an excellent view of the hip joint is thus obtained. The hip is no exception and receives bres from the femoral, sciatic and obturator nerves. It is important to note that these nerves also supply the knee joint and, for this 246 the lower limb reason, it is not uncommon for a patient, particularly a child, to com plain bitterly of pain in the knee and for the cause of the mischief, the diseased hip, to be overlooked. When standing on one leg, the abductors of the hip on this side (gluteus medius and minimus and tensor fasciae latae) come into powerful action to maintain xation at the hip joint, so much so that the pelvis actually rises slightly on the opposite side. If, however, there is any defect in these muscles or lever mechanism of the hip joint, the weight of the body in these circumstances forces the pelvis to tilt downwards on the opposite side. If the hip is forced into posterior dislocation while adducted (a), there is no associated fracture of the posterior acetabular lip (b). Dislocation in the abducted position (c) can only occur with a concomitant acetabular fracture (d). The knee joint (Figs 169, 170) the knee is a hinge joint made up of the articulations between the femoral and tibial condyles and between the patella and the patellar surface of the femur. The capsule is attached to the margins of these articular surfaces but communicates above with the suprapatellar bursa (between the lower femoral shaft and the quadriceps), posteriorly with the bursa 248 the lower limb Fig. The capsule is also perforated posteriorly by popliteus, which emerges from it in much the same way that the long head of biceps bursts out of the shoulder joint. Posteriorly, the tough oblique ligament arises as an expansion from the insertion of semimembranosus and blends with the joint capsule. The cruciate ligaments are extremely strong connections between the tibia and femur. The anterior ligament resists forward displacement of the tibia on the femur and becomes taut in hyperextension of the knee, it also resists rotation, the posterior resists backward displacement of the tibia and becomes taut in hyper exion. Conversely, the most skilful surgi cal repair of torn ligaments is doomed to failure unless the muscles are functioning strongly; without their support, reconstructed ligaments will merely stretch once more. The collateral ligaments are taut in full extension of the knee and are, therefore, only liable to injury in this position. The medial liga ment may be partly or completely torn when a violent abduction strain is applied, whereas an adduction force may damage the lateral ligament. If one or other collateral ligament is completely torn, the extended knee can be rocked away from the affected side. The cruciate ligaments may both be torn (along with the collateral ligaments) in severe abduction or adduction injuries. The anterior cruciate, which is taut in extension, may be torn by violent hyperex tension of the knee or in anterior dislocation of the tibia on the femur. If both the cruciate ligaments are torn, unnatural anteroposterior mobility of the knee can be demonstrated. If the exed knee is forcibly abducted and externally rotated, the medial cartilage will be drawn between, and then split by, the grinding sur faces of the medial condyles of the femur and tibia. The capsule of the joint ts closely around its articular surfaces, and, as in every hinge joint, it is weak anteriorly and posteriorly but reinforced laterally and medially by collateral ligaments. If the ligament is completely disrupted the talus can be tilted in its mortice; this is dif cult to demonstrate clinically and is best con rmed by taking an anteroposterior radiograph of the ankle while forcibly inverting the foot. First there is a torsional spinal fracture of the lateral malleolus, then avulsion of the medial collateral ligament, with or without avulsion of a ake of the medial malleolus and, nally, as the tibia is carried forwards, the posterior margin of the lower end of the tibia shears off against the talus. The joints of the foot Inversion and eversion of the foot take place at the talocalcaneal articulations and at the mid-tarsal joints between the calcaneum and the cuboid and between the talus and the navicular. Inversion is brought about by tibialis anterior and posterior the bones and joints of the lower limb 253 assisted by the long extensor and exor tendons of the hallux; ever sion is the duty of the peronei. The arrangement of the metacarpophalangeal and interphalangeal joints is on the same basic plan as in the upper limb. The medial arch comprises calcaneus, talus, navicular, the three cuneiforms and the three medial metatarsals; the apex of this arch is the talus. The lateral arch, which is lower, comprises the calca neus, cuboid and the lateral two metatarsals. When one walks, the weight is released from the arches, which unlock and become a mobile lever system in the spring-like actions of locomotion. The bones and joints of the lower limb 255 these ligaments are reinforced in their action by the plantar aponeurosis which is the condensed deep fascia of the sole of the foot. This arises from the plantar aspect of the calcaneus and is attached to the deep transverse ligaments linking the heads of the metatarsals; it also continues forward into each toe to form the brous exor sheaths, in a similar arrangement to that of the palmar fascia of the hand. The principal muscles concerned in the mechanism of the arches of the foot are peroneus longus, tibialis anterior and posterior, exor hallucis longus and the intrinsic muscles of the foot. Peroneus longus tendon passes obliquely across the sole in a groove on the cuboid bone and is inserted into the lateral side of the base of the 1st metatarsal and the medial cuneiform. Into the medial aspect of these two bones is inserted the tendon of tibialis anterior so that these muscles form, in effect, a stirrup between them which sup ports the arches of the foot. Paraplegics can be taught to walk purely by this pelvic swing action, even though paralysed from the waist downwards. The contents of the triangle are the femoral vein, artery and nerve together with the deep inguinal nodes. Three important zones 257 ensheath the whole lower limb except over the subcutaneous surface of the tibia (to whose margins it adheres), and at the saphenous opening. The iliotibial tract, when tensed by its attached muscles, assists in the stabilization of the hip and the extended knee. The tough lateral fascia of the thigh is an excellent source of this material for hernia and dural repairs. Femoral hernia the great importance of the femoral canal is, of course, that it is a potential point of weakness in the abdominal wall through which may develop a femoral hernia. Unlike the indirect inguinal hernia, this is never due to a congenital sac and, although cases do occur rarely in children, it is never found in the newborn. As the hernia sac enlarges, it emerges through the saphenous opening then turns upwards along the pathway presented by the super cial epigastric and super cial circum ex iliac vessels so that it may come to project above the inguinal ligament. There should not, however, be any dif culty in differentiating between an irreducible femoral and inguinal hernia; the neck of the former must always lie below and lateral to the pubic tubercle whereas the sac of the latter extends above and medial to this landmark (Fig. The neck of the femoral canal is narrow and bears a particular sharp medial border; for this reason, irreducibility and strangulation occur more commonly at this site than at any other. This involves removal of the super cial and deep fascial roof of the femoral triangle, the saphenous vein and its tributaries and the fatty and lymphatic contents of the triangle, leaving only the femoral artery, vein and nerve. John Hunter described the exposure and ligation of the femoral artery in this canal for aneurysm of the popliteal artery; this method has the advantage that the artery at this site is healthy and will not tear when tied, as may happen if ligation is attempted immediately above the aneurysm. The roof of the fossa is deep fascia which is pierced by the small saphenous vein as this enters the popliteal vein. The popliteal vein lies immediately super cial to the artery; the popliteal artery itself lies deepest of all in the fossa.

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Alcohol may interact directly with the gastric mucosa or it may act through a more general mechanism affecting the release of hormones and the regulation of nerve functions involved in acid secretion (Bode & Bode rheumatoid arthritis best treatment buy generic celecoxib pills, 1997; Chari et al rheumatoid arthritis first symptoms purchase celecoxib 100 mg fast delivery. Intragastric application of absolute ethanol has long been used as a reproducible method to induce gastric mucosa lesions in experimental animals (Szabo et al fast arthritis relief genuine health purchase 100mg celecoxib visa. The effects of acute administration of absolute ethanol to rats and mice on the gastric mucosa are dose-dependent and the damage appears as early as 30 minutes after ingestion and reaches a peak at about 60 minutes arthritis in back pain relief discount 100 mg celecoxib fast delivery. The ethanol-induced gastric musosal lesions and erosions are similar to those occurring in gastric ulcer (Stermer can arthritis pain wake you up order 200mg celecoxib, 2002; Repetto & Llesuy does heat help arthritis in dogs buy celecoxib 200 mg with mastercard, 2002). Thus, alcoholic gastritis leads to the impairment of the integrity of gastric mucosal barrier, contributing to acid reflux into the subluminal layers of the mucosa and submucosa (Oh et al. On the other hand, an alcohol concentration of higher than 5% has no effect on gastric acid secretion (Stermer, 2002). Also, oxidative stress and depletion of non-protein sulfhydryls concentration, modulation of nitric oxide system and reduction of gastric mucosal blood flow frequently underlie the development of gastric lesions (Arafa & Sayed-Ahmed, 2003). It is important emphasize that changes induced by short-term exposure to alcoholic beverages are rapidly reversible while prolonged alcohol exposure leads to progressive structural mucosal damage (Bode & Bode, 1997). Oxidative stress and depletion of anti-oxidants have been considered a crucial step in alcohol-induced mucosal damage and so they have been widely investigated in a number of studies (Hirokawa 1998; La Casa et al. Ethanol treatment induces intracellular oxidative stress and produces mitochondrial permeability transition and mitochondrial depolarization, which precede cell death in gastric mucosal cells. Thus, considering that ethanol is involved in the formation of oxidative stress generated extracellularly and/or intracellylary, the cytoprotective role of anti-oxidants in the prevention and healing of gastric lesions has also been widely investigated (Santos & Rao, 2001; Silva et al. In this sense, various studies point to intracellular antioxidants, such as glutathione (an endogenous sulfhydryl compound, as described below), as significant protective agents against ethanol in gastric mucosal cells (Repetto & Llesuy, 2002). Intragastric administration of superoxide dismutase was also able to protect the gastric mucosa against the damaging effect of ethanol (Terano et al. In addition to ethanol-induced gastrointestinal tract alterations, alcohol consumption has been linked to increased risk of tumors in the pharynx, esophagus, stomach and colon (Stermer, 2002). During gastric oxidative stress, the imbalance of aggressive and defensive factors in the stomach plays a pivotal role in gastric hemorrhage and ulcer formation (Hung, 2005). On the other hand, a large body of research in both animal and human studies has examined the effect of psychological stress on the gastrointestinal tract. Thus, several terms have been used to describe stress-related mucosal damage in critically ill patients, including stress ulcers, stress gastritis, stress erosions, hemorrhagic gastritis, erosive gastritis, and stress-related mucosal disease (Ali & Harty, 2009). Stimulation of gastric acid secretion has historically been considered a mechanism by which physiological stress increases susceptibility to gastroduodenal ulceration. It is also known to modify gastric blood flow, which plays an important role in the gastric mucosal barrier, and to affect possible mediators such as cytokines, corticotropin-releasing hormone and thyrotropin releasing hormone. Furthermore, stress seems to have different effects on gastric motility including delayed gastric emptying, which could increase the risk of gastric ulcer, while accelerated emptying could increase the net acid load delivered to the duodenum, enhancing the risk of duodenal ulcer. Conclusion Despite continuous exposure to several noxious factors, under normal conditions the gastric mucosa is able to maintain structural integrity and function. However, gastric mucosal injuries may occur when harmful factors overcome an intact mucosal defense or when the mucosal defensive mechanisms are impaired. Thus, much importance is attached to interactions and relationships among various ulcer-related factors, as well as to the individuality of the patients, including infections by H. Therefore, the incidence of gastric ulcers has declined, possibly as a result of the increasing use of proton pump inhibitors and decreasing rates of Helicobacter pylori infection. However, although there are many studies on gastroprotective therapies, their clinical effectiveness remains unclear. Thus, because gastric ulcer is a multifactorial disease, its medical management should not be based on a simple cause-effect relationship, instead a bio-psychosocial approach adjusted for the individual patient should be applied, with careful consideration of the association of this disease with many personal factors. Gastroprotective effects of aqueous extract of Chamomilla recutita against ethanol-induced gastric ulcers. Gastric mucus and bicarbonate secretion and their possible role in mucosal protection. Structure of gastrointestinal mucus and the viscous and gel forming properties of mucus. Protective role of carnitine esters against alcohol-induced gastric lesions in rats. Regulation by epidermal growth factor of prostaglandin production and cyclooxygenase activity in sensitized rat endometrial stromal cells in vitro. Nitric oxide-an endogenous inhibitor of gastric acid secretion in isolated human gastric glands. Lansoprazole prevents experimental gastric injury induced by non-steroidal anti-inflammatory drugs through a reduction of mucosal oxidative damage. Prostaglandin E2 and prostaglandin F2 alpha biosynthesis in human gastric mucosa: Effect of chronic alcohol misuse. Proceedings of the National Academy of Sciences of the United States of America, Vol. The Role of Stress on Physiological Responses and Clinical Symptoms in Irritable Bowel Syndrome. Endogenous somatostatin inhibits histamine release from canine gastric mucosal cells in primary culture. The effects of aspirin on gastric mucosal integrity, surface hydrophobic, and prostaglandin metabolism in cyclooxygenase knockout mice. Drug drug interactions between antithrombotic medications and the risk of gastrointestinal bleeding. A nitric oxide-releasing nonsteroidal anti-inflammatory drug accelerates gastric ulcer healing in rats. Mechanisms of increased acid secretion after eradication of Helicobacter pylori infection. The disease spectrum of Helicobacter pylori: the immunopathogenesis of gastroduodenal ulcer and gastric cancer. Proton pump inhibitors: do differences in pharmacokinetics translate into differences in clinical outcomes Role of bicarbonate in blood flow-mediated protection and repair of damaged gastric mucosa in the cat. Oxidative stress and mitochondrial damage precedes gastric mucosal cell death induced by ethanol administration. Effect of lysozyme chloride on betel quid chewing aggravated gastric oxidative stress and hemorrhagic ulcer in diabetic rats. Importance of histamine, glutathione and oxyradicals in modulating gastric hemorrhagic ulcer in septic rats. The roles of nitric oxide and prostaglandins in alterations of ulcerogenic and healing responses in adjuvant induced arthritic rat stomachs. Role of apoptosis induced by Helicobacter pylori infection in the development of duodenal ulcer. Good bugs and bad bugs: indications and therapies for Helicobacter pylori eradication. Evidence for protective and antioxidant properties of rutin, a natural flavone, against ethanol induced gastric lesions. Rapid epithelial restitution of the rat gastric mucosa after ethanol injury, Laboratory Investigation, Vol. Low-dose aspirin and upper gastrointestinal damage: epidemiology, prevention and treatment. Sociodemographic characteristics, life stressors, and peptic ulcer: a prospective study. Increases in guinea pig small intestinal transepithelial resistance induced by osmotic loads are accompanied by rapid alterations in absorptive-cell tightjunction structure. The relation of Helicobacter pylori to gastric adenocarcinoma and lymphoma: pathophysiology, epidemiology, screening, 24 Peptic Ulcer Disease clinical presentation, treatment, and prevention. Changing patterns of Helicobacter pylori gastritis in long-standing acid suppression. Gastroprotection of (-)-alpha-bisabolol on acute gastric mucosal lesions in mice: the possible involved pharmacological mechanisms. The key-role of vagal nerve and adrenals in the cytoprotection and general gastric mucosal integrity. Clostridium difficile toxins disrupt epithelial barrier function by altering membrane microdomain localization of tight junction proteins. Over expression of 70-kDa heat shock protein confers protection against Gastric Ulcer Etiology 25 monochloramine induced gastric mucosal cell injury. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Antioxidant properties of natural compounds used in popular medicine for gastric ulcers. Therapy with gastric acidity inhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children. Gastrointestinal safety of cyclooxygenase-2 inhibitors: a Cochrane Collaboration Systematic Review. Protection by gastrin in the rat stomach involves afferent neurons, calcitonin gene-related peptide, and nitric oxide. The effect of nimesulide on the indomethacin and ethanol-induced gastric ulcer in rats. Effects of Rumex patientia root extract on indomethacine and ethanol induced gastric damage in rats. Central vagal activation increases mucous gel thickness and surface cell intracellular pH in rat stomach. Role of superoxide and hydroxyl radicals in rat gastric mucosal injury induced by ethanol. The lesion may involve in mucosal layer, submucosal or even muscle and plasma layer in duodenum and stomach. It was characterized as not only easy to relapse but also hard to prevent (Wang et al. Its etiology and mechanism was very sophisticated due to the imbalance between offensive factors (gastric acid, pepsin, H. There were at least 3 defensive barriers in the gastric wall to resist gastric acid and pepsin: the mucus-bicarbonates barrier that includes mucus and the bicarbonates grade in the mucus, the mucosa barrier that is the tight conjunction structure among gastric epithelial cells, and the blood flow in mucosa that provides oxygen and nutrition to mucosa and support the turnover of gastric epithelium and mucus. Although they cause peptic ulcer by destroying the gastric barrier function, the mechanism was not clear. There were arguments for their simultaneous effects on peptic ulcer (Fendrick et al. Ammonia can decrease the content of mucin in mucus and destroy the integrity of the ion in mucus, and finally decline the function of mucus barrier that results in the diffusion of hydrogen ion back to the stomach wall and the erosion of mucosa layer (Hazell et al. It may result in cellular edema, degeneration and necrosis, and the barriers of mucus and mucosa are finally destroyed and the ulcer is formed (Marshall, 1994). The hydroxy created from ammonia and water has cytotoxic effect on gastric mucosa. A high concentration of ammonia can cause cellular vacuolar degeneration (Xu et al. This ion can further combine ammonia and form more toxic monochloramine that participates in the process of mucosa injury (Sarosiek et al. The urea may serve as leukocyte chemotactic factor to attract inflammatory cells, cause local inflammation in the stomach, and damage indirectly the gastric epithelium. The degraded mucus losses its viscosity and elasticity and thus, allows the diffusion of hydrogen ion back to the stomach wall and the erosion of mucosa layer. Lipase and phospholipase: the normal cell membrane is composed of double phospholipid layers. The lipid and phospholipid in the gastric mucus play an important role in the maintenance of mucous viscosity and hydrophobic characters and in the prevention of hydrogen ion from diffusion back to the stomach wall (Goggin et al. The lipase and phospholipase A can hydrolyze lipid and phospholipid in the mucus and thus obliterate the function of mucous barrier. Phospholipase A can also enhance the release of arachidonic acid and generate inflammatory media such as prostaglandin and thromboxane that induce inflammatory reaction. The metabolism of phospholipid, such as lysolecithin, also has cytotoxic effect (Lewis et al. Pepsin hydrolyses the protein in gastric epithelium, originates epithelial injury and causes ulceration (Young et al. These similar antigenic determinants also distribute in the surface of parietal cell and gastric gland. Therefore, the mucosa barrier will be injured by autoimmune reaction (Appelmelk et al. Neutrophils, monocytes, lymphocytes and macrophage may infiltrate into mucosa and release a big amount of free radicals. Lipids and proteins in epithelium are peroxidized, and the cellular structure and function were damaged, and finally the epithelial barrier was destroyed. Persistent gastrinemia causes the proliferation of parietal cell and the further production of gastric acid.

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Intravenous infu sion of low-dose oxytocin can be initiated arthritis liquid medication buy celecoxib online from canada, usually at a rate of 0 arthritis in knee of dog order 100 mg celecoxib otc. If fetal heart rate decelerations occur in the presence of tachysystole arthritis pain vs bone cancer pain buy generic celecoxib on line, retesting is appropri ate to ensure a correct interpretation arthritis in back medications buy cheap celecoxib. The presence of variable decelerations may prompt examination of amniotic fluid volume arthritis in back legs of dog purchase celecoxib australia. Equivocal testing may be repeated in 24 hours or sooner unless an intervening indication for delivery arises or may prompt admission for closer observation arthritis nodules feet generic 200 mg celecoxib overnight delivery. Biophysical Profile A biophysical profile consists of assessment of five fetal variables. Before a 0 can be given for any of the ultrasound variables the fetus must be observed for 30 minutes. A score of 4 or less is nonreassuring and warrants further evaluation and consideration of deliv ery. Irrespective of the overall score, except in the setting of premature rupture of membranes, the finding of oligohydramnios may warrant consideration of delivery in term pregnancies or more frequent antepartum testing in the case of preterm gestations. Nonstress test changes are thought 150 Guidelines for Perinatal Care to be one of the early manifestations of fetal hypoxia, whereas amniotic fluid volume likely changes more slowly over time as the fetus preferentially shunts cardiac output to the heart and brain while decreasing renal perfusion and, thus, fetal urine output. The deepest vertical pocket of amniotic fluid is measured with the ultrasound probe directly at 90 degrees to the maternal abdomen (and with care not to include fetal parts or the umbilical cord). A value of less than or equal to five is considered indicative of oligohydramnios. Doppler Ultrasonography of Umbilical Artery the umbilical arteries arise from the common iliac arteries in the fetus and com prise the main outflow tract of fetal blood back to the placental bed. Normal placental physiology is such that vascular resistance decreases as gestational age progresses and, more specifically, high velocity forward diastolic flow in the umbilical arteries is maintained. Umbilical artery Doppler flow ultrasonography uses these hemodynamic characteristics to assess resistance to blood flow in the placenta, which may be altered in certain pathologic conditions, such as intra uterine growth restriction. Umbilical artery Doppler ultrasonography is not a screening test for detecting fetal compromise in the general population, but it can be used in conjunction with other biophysical tests in high-risk pregnan cies associated with suspected intrauterine growth restriction. The index most commonly used to quantify the flow velocity waveform is the systolic/diastolic ratio. As placental resistance increases, the systolic/diastolic ratio increases, the end diastolic flow decreases and may become absent or reversed. The find ing of abnormal umbilical artery Doppler studies also may be used to guide the administration of corticosteroids in anticipation of delivery. Special Populations and Considerations All pregnant women should receive the best appropriate care. However, each of the following groups is potentially more vulnerable to poor pregnancy Preconception and Antepartum Care 151 outcomes or barriers to health care and has unique circumstances that require additional attention. Adolescents Minors typically have legal rights protecting their privacy regarding the diag nosis and treatment of pregnancy. Once the gestational age is determined, she should be fully informed in a balanced manner about all options, including continuation of the pregnancy, either with the intent of raising the child herself or placing the child for adoption, or termination of the pregnancy. The patient should be encouraged to return for visits as needed and helped to understand the importance of a timely decision. She should be encouraged to include her parents or guardian and the father of the fetus in her decisions, if appropriate. Many states have laws regarding adolescent rights, and the physician should be aware of these state laws when making health care decisions. If the adolescent chooses to continue the pregnancy, she should be referred for psychosocial support. Incarcerated Women Generally, pregnant inmates, because of their disadvantaged background, are at a higher risk of poor pregnancy outcomes than the general population. Upon entry into a prison or jail, every woman of childbearing age should be assessed for pregnancy risk by inquiring about menstrual history, heterosexual activity, and contraceptive use and tested for pregnancy, as appropriate, to enable the provision of adequate perinatal care and abortion services. Incarcerated women who wish to continue their pregnancies should have access to readily avail 152 Guidelines for Perinatal Care able and regularly scheduled obstetric care, beginning in early pregnancy and continuing through the postpartum period, although many facilities do not offer it. Incarcerated pregnant women also should have access to unscheduled or emergency obstetric visits on a 24-hour basis. All pregnant women should be questioned about their past and present use of alcohol, tobacco, and other drugs, including the recreational use of prescrip tion and over-the-counter medication. Substance abuse can continue during incarceration despite efforts to prevent drugs from entering correctional facili ties. Incarcerated pregnant women also should be screened for depression or mental stress and for postpartum depression after delivery and be appropriately treated. Although maintaining adequate safety is critical, correctional officers do not need to routinely be present in the room while a pregnant woman is being examined or in the hospital room during labor and delivery unless requested by medical staff or the situation poses a danger to the safety of the medical staff or others. Delivery services for incarcerated pregnant women should be provided in a licensed hospital with facilities for high-risk pregnancies when available. Incarcerated pregnant women often have short jail or prison stays and may not give birth while incarcerated. Postpartum contraceptive options should be discussed and provided during incarceration to decrease the likelihood of an unintended pregnancy during and after release from incarceration. The use of physical restraints on pregnant incarcerated women may not only compromise health care, but is demeaning and rarely necessary. Shackling of pregnant and postpartum women (within 6 weeks postpartum) during transportation to medical care facilities and during the receipt of health services should occur only in exceptional circumstances after a strong consideration of the health effects of restraints by the physician providing care. If restraint is needed, it should be the least restrictive possible to ensure safety and should never include restraints that interfere with leg movement or the ability of the woman to break a fall. Pressure should not be applied either directly or indirectly to the Preconception and Antepartum Care 153 abdomen. Correctional officers should be available and required to remove the shackles immediately upon request of medical personnel. If restraint is used, a report should be filed by the Department of Corrections and reviewed by an indepen dent body. There should be consequences for individuals and institutions when use of restraints was unjustified. Homeless Women It has been estimated that as many as 14% of individuals living in the United States have been homeless at some time and as many as 3. Homeless women are far more likely to experience violence of all sorts com pared with women who are not homeless because of a lack of personal security when living outdoors or in shelters. Homeless women are less likely to receive prenatal care than women who are not homeless, and adverse birth outcomes are substantially higher in home less women compared with the general population. A Canadian study found that compared with women who are not homeless, homeless women were 2. In the United States, preterm birth rates and low birth weight rates in homeless women exceed national averages. It is important for physicians to identify patients within the practice who are (or are at risk of becoming) homeless by asking questions about living condi tions, nutrition, substance abuse, and intimate partner violence; provide health care, including preventive care, for homeless women without bias; and not with hold treatment based on concerns about lack of adherence. Health care profes sionals are advised to simplify medical regimens and address barriers, including transportation needs for follow-up health care visits. In addition, physicians should become familiar with and inform patients who are (or at risk of becom ing) homeless about appropriate community resources, including local substance abuse programs, intimate partner violence services, and social service agencies. With all disabilities, consideration of the history of the disability, the number and severity of limitations, and its expected progression is critical in meeting the health care needs and concerns of women. This information may be accessible through various means, such as consultation with rehabilitation physicians or other disability health care providers, further investigation of medical literature, disability organizations, and through discussion with the woman and her family. Many women are well informed about their disabilities and the resources available to them. Language and educational differences between women and their health care providers are barriers to effective care. Women with disabilities also may need extra time allotted for their appoint ment. When scheduling appointments, asking patients about the need for extra time or services in a nonjudgmental and nonstigmatizing fashion may be one way of accommodating such needs. Creativity and flexibility on the part of each staff member can go a long way in ameliorating these challenges and establish ing mutually rewarding and respectful services. Pregnancy and parenting for women with physical disabil ities may pose unique medical and social challenges but rarely are precluded by the disability itself. Health care professionals have the responsibility to provide appropriate reproductive health services to these women or arrange adequate consultation or referral. Nonbiased preconception counseling for couples in which one partner has a physical disability may decrease subsequent psychosocial and medical complications of pregnancy. Detailed pregnancy care plans should be developed in negotiation with managed care plans and other insurers to increase access to and use of pre Preconception and Antepartum Care 155 natal care services, ensure appropriate postpartum hospital length of stay, and arrange postpartum home care services, if necessary. Assessment of the need for additional assistance during pregnancy to ambulate, perform safe transfers, and maintain hygiene and household activities is recommended. Regular consulta tion or referral may be required to achieve the optimum outcome. In caring for pregnant women with intellectual and developmental disabilities, it is important to consider the following psychosocial factors: whether the individual lives at home or in a domiciliary care setting; whether there is a reliable caregiver present; previous history of sexual abuse; and cognitive factors, including her ability to relay a personal or family history of disease and symptoms. Genetic screening is par ticularly important for pregnant women with Down syndrome. Before examination, it should be determined who will give consent for the examination and any consequential treatment. It also is important at this time to ascertain if the patient is competent to understand findings and health rec ommendations or whether this information needs to be transmitted to an iden tified guardian or caregiver. For women with intellectual and developmental disabilities, making materials available in pictorial formats or in simple, straight forward language can facilitate communication greatly. This will help emergency room personnel, new health care providers, or consulting physicians when records are not available. Consent and Power of Attorney Obtaining informed consent for medical treatment is an ethical requirement that is partially reflected in legal doctrines and requirements. Communication is necessary if informed consent is to be realized, and physicians can and should help to find ways to facilitate communication not only in individual relations with patients but also in the structured context of medical care institutions. In emergency situations, medical professionals may have to act according to their perceptions of the best interests of the patient; in rare instances, they may have to forgo obtaining consent because of some other over riding ethical obligation, such as protecting the public health. An advance directive is the formal mechanism by which a patient may express her values regarding her future health status. Proxy directives, such as the durable power of attorney for health care, designate a surrogate to make medical decisions on behalf of the patient who is no longer competent to express her choices. Instructional directives, such as living wills, focus on the types of life-sustaining treatment that a patient would or would not choose in various clinical circumstances. Although courts at times have intervened to impose treatment on a pregnant woman, currently there is general agreement that a pregnant woman who has decision-making capacity has the same right to refuse treatment as a nonpreg nant woman. When a pregnant woman does not have decision-making capacity, however, legislation frequently limits her ability to refuse treatment through an advance directive. Statutes that prohibit pregnant women from exercising their right to determine or refuse current or future medical treatment are unethical. Second-Trimester and Third-Trimester Patient Education ^ Important topics to discuss with women before delivery include working, child birth education classes, choosing a newborn care provider, anticipating labor, preterm labor, breech presentation at term, trial of labor after cesarean delivery, elective delivery, cesarean delivery on maternal request, umbilical cord blood banking, breastfeeding, preparation for discharge, and neonatal interventions. Working A woman with an uncomplicated pregnancy usually can continue to work until the onset of labor. Women with medical or obstetric complications of pregnancy may need to make adjustments based on the nature of their activities, occupa Preconception and Antepartum Care 157 tions, and specific complications. It also has been reported that pregnant women whose occupations require standing or repetitive, strenuous, physical lifting have a tendency to give birth earlier and have small for gestational age infants.

Diseases

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