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Numerous myths and stereotypes regarding sexual vio- ● Excellent contemporaneous medical notes discount generic apcalis sx canada, with a sub- lence exist for many reasons discount apcalis sx 20 mg overnight delivery, some anthropological order apcalis sx 20mg mastercard, sequent well‐written report. Female genital mutilation ● Do not give opinions that are not evidence based or the World Health Organization classification of female which are unjustifiable. Clinicians should be aware immediate, such as death or injury to more medium of it, appreciating what it may look like and also the term and long‐term problems. It can have physical, possible short‐ and long‐term health consequences, reproductive and psychological consequences. It is con- Vicarious trauma sidered to be an abuse of human rights and a child pro- tection issue [9] and is outlawed in many countries. That said, dealing with vic- under the Female Genital Mutilation Act 2003, and in tims of sexual violence, hearing their accounts and the Scotland it is illegal under the Prohibition of Female Table 67. Most will not, and those injuries that do happen often heal quickly and fully leaving no scars Rape victims will disclose the abuse at the No. A significant number of those that do disclose will do so earliest opportunity well after the attack and may only give partial details Some rape victims must shoulder No. The rapist is responsible for his own actions responsibility for the abuse Men cannot be raped No. Global and Regional uploads/system/uploads/attachment_data/ Estimates of Violence Against Women: Prevalence and file/214970/sexual‐offending‐overview‐jan‐2013. Spotting the Signs: A national 2 Ministry for Justice, Home Office, Office for National proforma for identifying risk of child sexual exploitation Statistics. Prohibition of Female Genital practice for the management of intimate images that may Mutilation (Scotland) Act 2005. Nor does its age make a difference, so on this view, it involve the creation and destruction of new human termination at six weeks is morally equivalent to termi- lives, but also the doctor will sometimes be faced with nation at 36 weeks. If an abortion is necessary in order to two possible patients, the woman and the developing save the woman’s life, then, if the fetus has an equivalent embryo/fetus. At the outset, it is worth noting that the right to life, it is not self‐evident that its life must be only clinical practices to which healthcare professionals sacrificed in order to save hers. These rights exist as a some might argue that birth is simply a matter of geography, result of the recognition that there is profound disagree- and that a newborn baby is not an intrinsically different ment over when morally significant life begins. But in This chapter will provide a broad overview of three legal terms, geography is central. While a fetus is inside areas of practice in obstetrics and gynaecology: termina- the woman’s body, it cannot be considered a separate tion of pregnancy, the management of pregnancy and legal person. One view, associated particularly A third ‘middle ground’ position on the morality of with Roman Catholicism, is that personhood begins at abortion would permit abortion subject to restrictions, conception [3]. According to this view, a fetus may If the fetus is a person, it makes no difference to the not have legal personhood, but it is also ‘not nothing’ [6]. Most people also satisfy one of the four statutory ‘grounds’ for abortion; believe that the respect accorded to the fetus increases as that the abortion is carried out by a registered medical it matures towards birth. This is often described as the practitioner in an approved place; and that it is notified ‘gradualist approach’: many people believe that abortion within seven days to the relevant Chief Medical Officer. Statutory defences have existed in England, tion 1(1)(a) of the Abortion Act 1967. It requires two reg- Scotland and Wales for 50 years, but under sections 58 istered medical practitioners to be ‘of the opinion, and 59 of the Offences Against the Person Act 1861, the formed in good faith’: maximum sentence for a woman who intentionally and unlawfully procures her own miscarriage continues to be that the pregnancy has not exceeded its twenty life imprisonment, and anyone who assists her could be fourth week and that the continuation the preg- imprisoned for up to five years. In R v Bourne [8], a distinguished obstetric surgeon, Aleck In 2016, 97% of all abortions were authorized on the Bourne, was prosecuted for carrying out an abortion on a grounds that the pregnancy posed a risk to the pregnant 14‐year‐old girl, who was pregnant following a violent woman’s own health, and 99. His defence was that the operation was not unlaw- solely because of the risk to her mental health [1]. In his direction to the jury, Macnaghten J was want to be pregnant will generally be promoted by allowing clear that an abortion might be carried out lawfully not her to end her pregnancy. Through what is sometimes only where the pregnant woman was in imminent danger called the ‘statistical argument’, it could be argued that, of death (as had always been the case), but also where the because pregnancy and childbirth will almost always effect of carrying the pregnancy to term might be to pose a greater risk to a woman’s physical health than ‘make the woman a physical or mental wreck’. Much more com- section(1)(1)(b) the termination is necessary to prevent monly, women with unwanted pregnancies relied on the grave permanent injury to the pregnant woman; under services of illegal abortionists It is thought that there section (1)(1)(c) continuing the pregnancy involves a risk were probably around 100 000 illegal abortions each year to her life; or under section (1)(1)(d) ‘there is a substan- before the Abortion Act came into force, and mortality tial risk that if the child were born it would suffer from rates were high. Abortion had become a public health such physical or mental abnormalities as to be seriously issue and by the mid‐1960s there was broad public sup- handicapped’. None of these three grounds is subject to a port for bringing it within the safety of medical control. In practice, however, terminations after 24 Ethical Dilemmas in Obstetrics and Gynaecology 989 weeks are rare (fewer than 0. The evidence While the legalization of abortion is sometimes shows that these two doctors did form this opin- assumed to be part of the pattern of liberal law reforms ion and formed it in good faith. Even if a woman’s pregnancy There are three ways in which the Abortion Act 1967 is a resulted from an act of rape or incest, she does not have poor fit with modern medical practice. First, to be lawful, the legal right to terminate it (of course, in practice doc- an abortion must be carried out by a registered medical tors will invariably find that the first statutory ground is practitioner. Notice, for example, clinical need for the pill to be provided by a doctor, and that the statute does not specify that the section 1(1) indeed nurse‐led abortion services are both clinically grounds have to actually be satisfied. In practice, the courts have inter- depends solely upon whether two doctors have formed preted this provision in a way that facilitates nurses’ the opinion, in good faith, that that woman’s circum- involvement in medical abortions, provided that the stances satisfy one of the statutory grounds. In Royal example, the legality of the 1% of abortions carried out College of Nursing v Department of Health and Social under s. In deciding nancy, provided that a registered medical practitioner is whether a fetus’s abnormality is sufficiently serious, the supervising the procedure. It might be argued that it would be tion, but they decided not to prosecute the doctors who preferable for women to be able to take the second drug, had signed the form. Ms Jepson sought and was granted misoprostol, at home, since this is what will usually trig- leave to apply for judicial review of this decision, on the ger her miscarriage. Instead, in addition to the inconven- grounds that the case raised an issue of public impor- ience of having to attend the clinic on two separate tance, but Jackson J admitted that she would face sub- occasions, which may be particularly difficult for women stantial evidential and legal hurdles at the full hearing. There is considerable evi- sufficiently thorough, and the case was reopened under a dence that home medical abortion would be safe, and different team of officers. It does not Supperstone J held that the ‘treatment’, which had to take contain a list of legitimate reasons for abortion. As we place in an approved place, was the taking of the drug, have seen, rape does not appear as a ground for abortion not its prescription. The irony of this is that a provision in section 1(1), but this does not mean that abortion on in the legislation which was intended to protect women’s the grounds of rape is unlawful. Instead, the Act gives safety – by ensuring that surgical abortions only take two doctors considerable discretion to determine place in properly equipped and staffed premises – in whether a woman’s health would be better served by ter- fact, in the case of early medical abortions, could make mination than by carrying the pregnancy to term. If Third, the provision of new birth control methods that passed, her amendment would have read: ‘Nothing in might involve a woman taking a contraceptive pill only section 1 of the Abortion Act 1967 is to be interpreted as once her period is late, or once a month, is blocked by the allowing a pregnancy to be terminated on the grounds of Abortion Act 1967. Anxieties were also expressed tion; the woman would have to take the pill in an about the use of the term ‘unborn child’ in legislation. This would make post‐implantation methods required research to be carried out into the incidence of of birth control both inconvenient and expensive.

There is a modest increase in the incidence of hepatic dysfunction when rifampin is coadministered with isoniazid and pyrazinamide purchase 20mg apcalis sx with amex. When rifampin is dosed intermittently 20 mg apcalis sx otc, especially with higher doses buy apcalis sx discount, a flu-like syndrome can occur, with fever, chills, and myalgia, sometimes extending to acute renal failure, hemolytic anemia, and shock. This may necessitate higher dosages for coadministered drugs, a switch to drugs less affected by rifampin, or replacement of rifampin with rifabutin. Rifabutin is a less potent inducer (approximately 40% less) of cytochrome P450 enzymes, thus lessening drug interactions. Rifabutin has adverse effects similar to those of rifampin but can also cause uveitis, skin hyperpigmentation, and neutropenia. Pyrazinamide must be enzymatically hydrolyzed by pyrazinamidase to pyrazinoic acid, which is the active form of the drug. Pyrazinamide is active against tuberculosis bacilli in acidic lesions and in macrophages. Ethambutol inhibits arabinosyl transferase—an enzyme important for the synthesis of the mycobacterial cell wall. Ethambutol is used in combination with pyrazinamide, isoniazid, and rifampin pending culture and susceptibility data. Both the parent drug and its hepatic metabolites are primarily excreted in the urine. The most important adverse effect is optic neuritis, which results in diminished visual acuity and loss of ability to discriminate between red and green. The risk of optic neuritis increases with higher doses and in patients with renal impairment. Visual acuity and color discrimination should be tested prior to initiating therapy and periodically thereafter. Uric acid excretion is decreased by ethambutol, and caution should be exercised in patients with gout. In general, these agents are less effective and more toxic than the first-line agents. Infections due to streptomycin-resistant organisms may be treated with kanamycin or amikacin, to which these bacilli usually remain susceptible. Capreomycin This is a parenterally administered polypeptide that inhibits protein synthesis similar to aminoglycosides. Careful monitoring of renal function and hearing is necessary to minimize nephrotoxicity and ototoxicity, respectively. Cycloserine Cycloserine is an orally effective, tuberculostatic drug that disrupts D-alanine incorporation into the bacterial cell wall. Ethionamide Ethionamide is a structural analog of isoniazid that also disrupts mycolic acid synthesis. The mechanism of action is not identical to isoniazid, but there is some overlap in the resistance patterns. Metabolism is extensive, most likely in the liver, to active and inactive metabolites. Fluoroquinolones the fluoroquinolones (see Chapter 31), specifically moxifloxacin and levofloxacin, have an important place in the treatment of multidrug-resistant tuberculosis. Azithromycin may be preferred for patients at greater risk for drug interactions, since clarithromycin is both a substrate and inhibitor of cytochrome P450 enzymes. Bedaquiline is administered orally, and it is active against many types of mycobacteria. Elevations in liver enzymes have also been reported and liver function should be monitored during therapy. Drugs for Leprosy Leprosy (or Hansen disease) is uncommon in the United States; however, worldwide, it is a much larger problem (ure 32. Dapsone also is used in the treatment of pneumonia caused by Pneumocystis jirovecii in immunosuppressed patients. The drug is well absorbed from the gastrointestinal tract and is distributed throughout the body, with high concentrations in the skin. Adverse reactions include hemolysis (especially in patients with glucose-6-phosphate dehydrogenase deficiency), methemoglobinemia, and peripheral neuropathy. Its redox properties may lead to the generation of cytotoxic oxygen radicals that are toxic to the bacteria. Patients typically develop a pink to brownish-black discoloration of the skin and should be informed of this in advance. Eosinophilic and other forms of enteritis, sometimes requiring surgery, have been reported. Thus, erythema nodosum leprosum may not develop in patients treated with this drug. The patient received self-administered isoniazid, rifampin, pyrazinamide, and ethambutol. Two weeks following initiation of therapy, the patient is concerned that her urine is a “funny-looking reddish color. Rifampin (as well as rifabutin and rifapentine) and its metabolites may color urine, feces, saliva, sputum, sweat, and tears a bright red-orange. Patients should be counseled that this is an adverse effect which is not harmful, but can stain clothes and contact lenses. At his regular clinic visit, he complains of a “pins and needles” sensation in his feet. Isoniazid can cause peripheral neuropathy with symptoms including paresthesias, such as “pins and needles” and numbness. Which vitamin should have been included in the regimen for this patient to reduce the risk of neuropathy? Concurrent administration of pyridoxine (vitamin B ) prevents the neuropathic actions of6 isoniazid. The relative deficiency of pyridoxine appears to be due to the interference of isoniazid with its activation and enhancement of the excretion of pyridoxine. He has had no seizures in 5 years; however, upon return to clinic at 1 month, he reports having two seizures since his last visit. Rifampin is a potent inducer of cytochrome P450–dependent drug-metabolizing enzymes and may reduce the concentration of carbamazepine. Ethambutol and especially pyrazinamide both may increase uric acid concentrations and have the potential to precipitate gouty attacks. Pyrazinamide- and ethambutol-induced hyperuricemia may be controlled by use of antigout medications, such as xanthine oxidase inhibitors. He states that he feels fine, but now is having difficulty reading and feels he may need to get glasses. Optic neuritis, exhibited as a decrease in visual acuity or loss of color discrimination, is the most important side effect associated with ethambutol. Visual disturbances generally are dose related and more common in patients with reduced renal function. Her physician recently noticed that she appears confused and anxious, and has a slight tremor.

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Montravers P cheap 20 mg apcalis sx overnight delivery, Gauzit R purchase genuine apcalis sx, Muller C 20 mg apcalis sx amex, et al: Emergence of antibiotic- resistant bacteria in cases of peritonitis after intraabdominal surgery affects the efficacy of empirical antimicrobial therapy. Panhofer P, Izay B, Riedl M, et al: Age, microbiology and prognostic scores help to differentiate between secondary and tertiary peritonitis. Bassetti M, Right E, Ansaldi T, et al: A multicenter multinational study of abdominal candidiasis: epidemiology, outcomes and predictors of mortality. Sandven P, Qvist H, Skovlund E, et al: Significance of Candida recovered from intraoperative specimens in patients with intra- abdominal perforations. Augustin P, Kermarrec N, Muller-Serieys C, et al: Risk factors for multidrug resistant bacteria and optimization of empirical antibiotic therapy in postoperative peritonitis. In addition, administration of antibiotics alone does not cure this disease making it a true surgical emergency. Mortality increases significantly if wide surgical debridement is delayed, thereby placing high importance on accurate and rapid diagnosis of this devastating disease. It was not until the American Civil War when Joseph Jones, a confederate physician whose notes are one of the mainstays of medical documentation of this war, identified an organism, specifically a bacillus, as the cause of multiple cases of gangrene. Frank L Meleney discovered an association with the disease and β-hemolytic Streptococcus in the 1920s. This non-specificity can make early diagnosis difficult and delay lifesaving surgical intervention, emphasizing the importance of accurate and early diagnosis. The literature has repeatedly demonstrated that delayed surgical intervention, generally considered greater than 24 hours after diagnosis, is the main risk factor for mortality. The superficial fascial layer is termed dartos fascia in the genitalia, which is a continuance of the Colles fascia in the perineum, and the Scarpa fascia of the abdominal wall. The severity of infection is also determined by other factors including the size of the inoculum, virulence of the pathogen, blood flow to the tissue, presence of foreign bodies, as well as host response. Pathogens that are more virulent, if polymicrobial, work synergistically allowing for rapid reproduction in an anaerobic environment. Enzymes begin to necrose the hypodermis and cause vascular thrombosis of the nutrient vessels located in the hypodermis, leading to ischemia and edema. Ischemia of the nerves causes hypoesthesia, anesthesia, and hyperesthesia (pain out of proportion to physical examination). Crepitus on physical examination and subcutaneous air seen on imaging is caused by the gas-forming anaerobic pathogens. The hypodermis is more likely to develop necrosis leading to the expected later finding of overlying epidermal and dermal changes, once the cutaneous circulation has thrombosed. These classifications are also important for directing treatment which will be discussed in a later section. At least two pathogens are detected in the surgical specimen culture, with an average of over four species identified. Clostridium is commonly found in soil in endemic areas of the United States and the world with rates around 10%. Today’s definition is a little broader, and now includes the genitalia of both male and females, perineal, and perianal areas. This allows for the disease to spread easily from the groin superiorly to the anterior abdominal wall, making control of this disease more difficult [1–3,7–9,13–15]. This causes an extremely large inflammatory response, by releasing inflammatory cytokines including interleukin-1, interleukin-6, and tumor necrosis factor-α. Clostridium species are thought to produce two main toxins responsible for their virulence: α and θ toxins. These bacteria are observed in warmer marine water, hence an increase in incidence during the summer months. Attention to detail, especially with change or worsening conditions within a short time period, is extremely important. Symptoms Pain out of proportion to exam Nausea and vomiting Diarrhea Chills Signs Skin erythema, which is common in many skin conditions and is more sensitive than specific. Despite adequate treatment, a2 number of patients develop septic shock with multiorgan dysfunction syndrome. The aforementioned symptoms can be detected on examination but there are other tools to assist in making the diagnosis. The culture takes 24 to 72 hours to identify the pathogen, but if gram stain is positive for gram-positive cocci or bacilli, this will aid in making the diagnosis, especially in conjunction with other signs and symptoms exhibited by the patient. Surgical Biopsy This can be done at the bedside or in the operating room if clinical suspicion is high. Radiography tends to be more useful with Clostridium or gas-forming bacterium due to the subcutaneous emphysema. Magnetic Resonance Imaging This can also be useful in making the diagnosis, and is the most sensitive imaging. Laboratory values such as basic metabolic panel and complete blood count are routinely obtained in patients presenting to the emergency department. Patients usually require multiple returns to the operating room to evaluate the wound and to ensure all involved tissue is excised. Iodine, Dakin solution, as well as other chemicals can be added to the early wet to dry dressings to help decrease the bacterial load in the wound. Since the bacteria commonly found in this disease are gram-positive cocci, rods or anaerobes, broad-spectrum antibiotic coverage should be started initially. Other studies recommend use of meropenem plus clindamycin or ciprofloxacin, or clindamycin and metronidazole combination for broad-spectrum coverage. Clindamycin is also used frequently because it has been shown to decrease the release of Clostridium α-toxin as well as the Streptococcal M protein [9,13,20]. It is not a widely accepted option for treatment and requires more research to evaluate its efficacy [9,21]. Some retrospective studies have shown an additional benefit in patients treated primarily with surgical debridement and antibiotics. At the current time, there is no randomized prospective trial evaluating the benefit of hyperbaric oxygen in these patients. Lancerotto L, Tocco I, Salmaso R, et al: Necrotizing fasciitis: classification, diagnosis, and management. Khamnuan P, Chongruksut W, Jearwattanakanok K, et al: Necrotizing fasciitis: risk factors of mortality. Majeski J, Majeski E: Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment. However, high-risk, noncardiac populations, including those who are at high risk due to the presence of cancer, are a subgroup that requires special consideration. As morbidity and mortality after major oncologic surgery for cancer can be substantial, herein we focus on the complications specific to these operations, which can have significant implications on perioperative management and outcomes. While survival remains dismal with little improvement in recent decades, surgical resection currently offers the best option for long-term survival and cure. The type of resection is largely dependent upon tumor characteristics such as size, location, and vascular involvement. Total pancreatectomy for neoplastic purposes may be considered for selected cases, particularly in the setting of main duct intraductal papillary mucinous neoplasm. Early ambulation, pulmonary secretion clearance, and pain control (particularly with epidural analgesia) are paramount during the early postoperative period.

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Most cases of skeletal dysplasias are autosomal Fetal Anomalies 263 recessive cheap 20mg apcalis sx overnight delivery, for which genetic counselling is important generic 20 mg apcalis sx with visa. Management includes detailed assessment of the fetus Others may be due to a new dominant mutation discount 20 mg apcalis sx. Family for additional anomalies, karyotyping and fetal echocardi­ history of skeletal dysplasia, malformations and short ography. Parents an option for most cases of skeletal dysplasias as many should be counselled by a paediatric surgeon regarding have a poor outcome. Termination of pregnancy is an polyhydramnios in particular indicates a high chance of option if significant visceral herniation (particularly liver) lethal pulmonary hypoplasia. The mode of are known for some skeletal dysplasias – achondroplasia delivery is determined on standard obstetric criteria. There is evidence that Thoracic anomalies treatment in utero can increase postnatal survival for both Pulmonary development requires normal fetal breathing left‐ and right‐sided defects. However, prenatal treatment, movements, an adequate intrathoracic space, sufficient only available in select fetal therapy centres, is associated amniotic fluid, normal intra‐lung fluid volume and with significant risk of preterm premature rupture of pulmonary blood flow. It occurs more commonly on the excessive proliferation and cystic dilatation of terminal left side (75–80%) than on the right side (20–25%). They are usually unilat­ formations can result in high mortality for this condition. The degree of pulmonary hypoplasia depends entirely on Most (60%) are left‐sided lesions. The diagnosis is usually the length of time and extent the herniated organs have made on antenatal ultrasound by the detection of enlarged compressed the fetal lungs. Associated abnormalities hyperechogenic lungs sometimes containing cysts of may be present in 30–60% of cases and can involve varying sizes. Congenital diaphragmatic hernia should be can cause hydrops, pulmonary hypoplasia, cardiac dys­ suspected if the fetal stomach is not in its usual intra‐ function and perinatal death. Liver, mesentery and bowel and follow a characteristic growth pattern that is highly spleen may be present in the chest. There is usually an increase ses include congenital cystic adenomatoid malformations, in size between 17 and 26 weeks before possible regres­ bronchogenic cysts, pulmonary sequestration or tho­ sion after 30 weeks. Polyhydramnios and/or hydrops may hypoplasia, impairment of fetal swallowing and polyhy­ sometimes be present. Serial scans impaired swallowing and hydrops may occur if there is are essential to monitor the size of the lesion (particularly significant cardiac compression. These Sacrococcygeal teratomas are the most common neo­ interventions aim to alleviate the mass effect, prevent the plasm in the fetus and newborn, with an estimated progression of complications and improve the outcome prevalence of 1 in 30 000–40 000. The diagnosis is often made when a therapy (either aspiration of the cyst or insertion of a complex mass is detected at the base of the spine (sacro­ shunt to drain the cyst) may be an option. The mode and timing of vascularity, or mixed with equal amounts of solid and delivery is on standard obstetric criteria. Associated anomalies are present in baby will require careful monitoring and a chest X‐ray. Poor Pleural effusions [32,33] prognostic factors include large solid tumours (>10 cm), Fetal pleural effusions have an incidence of between 1 in hydrops and polyhydramnios. Complications include with malignancy more common in solid tumours and in mediastinal shift, cardiac compression, hydrops and pul­ males. Affected fetuses are at significant and polyhydramnios are more likely to experience a risk for respiratory distress at birth. The presence of other anomalies delivery are the main causes of perinatal morbidity and should be excluded. Additionally, polyhydramnios can precipitate performed as cardiac abnormalities are present in 5% of preterm delivery. Karyotyping should be offered as there is a signifi­ eclampsia (mirror syndrome) can occur if there is cant association (10%) with aneuploidy. Serial scans take place in a tertiary centre with facilities for imme­ should be arranged to assess the size of the effusion and diate surgery. Elective caesarean section should be the for the development of hydrops or polyhydramnios as mode of delivery, with particular care taken during these are poor prognostic features. Firstly, a period of expectant observa­ be available in the delivery room in case of tumour haem­ tion is reasonable if the fetus is not hydropic and the orrhage. Thoracocentesis or complications is relatively high and represents the lead­ pleuro‐amniotic shunting are other options. Survival after Fetal hydrops [37,38] pleuro‐amniotic shunting is approximately 80%. Hydrops is an end‐stage process for a number of fetal diseases resulting in tissue oedema and/or fluid collec­ Fetal tumours tion (ascites, pleural effusion, pericardial effusion) in various sites. Its aetiology may be either immune or non‐ Teratomas [34–36] immune depending on the presence or absence of red Teratomas are tumours that contain tissue from all three cell alloimmunization. Non‐immune causes now account germinal layers (ectodermal, mesodermal and endoder­ for more than 90% of all cases of hydrops. Most prenatally diagnosed teratomas are heart abnormalities, cardiac arrhythmias (supraven­ situated in the brain, oropharynx, sacrococcygeal tricular tachycardia, complete heart block), twin–twin region, mediastinum, abdomen and gonad. Teratomas transfusion syndrome, congenital anomalies, aneuploidy, are the most common perinatal tumour, comprising infections, congenital anaemia and congenital chylotho­ 37–52% of congenital neoplasms and having a yearly rax are all possible causes for hydrops. The aetiology, hydrops has a very poor outcome (>80% mor­ majority of teratomas occur in the sacrococcygeal region tality). Early development of hydrops has a particularly (60%), followed by the gonads (20%) and thoraco‐ poor prognosis. Counselling should to possible viral infections (maternal rash, arthralgia/ always be unbiased and respectful of the patient’s choice, myalgia) is especially important. The umbil­ evolution of the abnormality and to attempt to detect ical cord and placenta should be carefully examined to other anomalies not previously identified, as this may exclude vascular malformations. The fetal heart rate and influence counselling as well as the obstetric or neonatal rhythm should be examined to exclude fetal tachyar­ management. Fetal echocardiogra­ major and minor structural anomalies, whether isolated phy should be performed in all cases. If anaemia is or multiple, may sometimes be part of a genetic syn­ suspected the most likely cause is parvovirus infection. If hydrops is secondary to fetal function and that sometimes normal anatomy does not arrhythmia, maternal antiarrhythmic therapy may be of always correlate with normal function and vice versa. There is usually a delay in response because of Although fetal therapy is possible for some conditions, the slow transplacental transfer into the fetal circulation. If early or urgent postnatal man­ cases of fetal supraventricular tachycardia unresponsive agement is required, delivery at a centre that can provide to maternal treatment. If the hydrops is secondary to a the appropriate neonatal care should be considered.

By Y. Karrypto. Virginia State University.

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