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By: Z. Yespas, M.A.S., M.D.

Co-Director, Mercer University School of Medicine

These guidelines are an invaluable tool for health care works providing maternal health services muscle relaxant mechanism discount sumatriptan 25 mg overnight delivery. Hypothyroidism during pregnancy could result in abortion (especially in early pregnancy) muscle relaxant benzo generic sumatriptan 50mg without prescription, recurrent pregnancy losses spasms quadriceps order sumatriptan 25 mg online, anaemia, pre-eclampsia, gestational diabetes, abruptio placenta, postpartum hemorrhage, increased rate of caesarean sections due to fetal distress and in some cases myopathy and congestive heart failure. Hypothyroidism results in preterm births, intrauterine growth restriction, intrauterine fetal demise, respiratory distress and increased perinatal mortality in newborns. It could lead to cognitive, neurological and developmental impairment as the thyroid hormone is critical for fetal brain development. In view of the above, there was a acute need to have national guidelines for screening and treatment of hypothyroidism during pregnancy. The tireless efforts by the Maternal Health Division with support from technical experts from various institutes and development partners have enabled us in drafting of these guidelines for implementation across the country. Although access to routine ante-natal care has been steadily improving across the country, it is now time to expand the range of services being provided and screen for disorders like hypothyroidism and diabetes during pregnancy that are proven to adversely affect maternal, fetal and neonatal health. In India, there are no universally accepted guidelines for screening of hypothyroidism and much of the evidence is in piecemeal. The present set of guidelines are comprehensive in scope beginning with areas of concerns, target population, screening and treatment protocols as well as operational aspects of the programme. There is a judicious mix of technical, programmatic and service provider?s perspective while framing these guidelines. I would like to express that these guidelines would not have been possible without the constant encouragement from Mr. I would like to acknowledge the contribution of all members of the Expert Group in developing the content of these technical and operational guidelines. Annexures 21 Annexure 1: effect of Hypothyroidism on Pregnancy 23 Annexure 2: High risk Factors for Hypothyroidism 24 Annexure 3: reporting Format at State and District level 25 Annexure 4: reporting Format at Health Facility level 26 Annexure 5: Migration Form 27 11. The foetus is dependent on maternal trans-placental thyroid hormone supply in the frst trimester. This, along with other factors, leads to an increased thyroid hormone demand during pregnancy. India is known to be a relatively iodine suffcient belt, however, iodine defciency is still prevalent in certain pockets like the hilly regions and foothills. Moreover, iron defciency is common in India, and this also contributes to hypothyroidism. Autoimmune thyroiditis contributes signifcantly towards hypothyroidism in iodine suffcient regions and may be associated with other autoimmune disorders. It recommends repeating the screening in the second trimester if initial screening is normal. Till date, universal screening has not been demonstrated to result in improved population outcomes. Incidence of hypothyroidism in women with recurrent pregnancy loss up to 12 weeks is 4. For this purpose, an expert group was constituted drawing a panel of experts (obstetricians, endocrinologists and public health specialists) to formulate guidelines for the country. Levothyroxine is to be taken orally, in the morning empty stomach, the patient should be asked not to take anything orally for at least half an hour after intake of the medicine. It has to be supplied in moisture tight packages and should be stored as room temperature. Exposure to direct sun light or heat should be avoided at all times Levothyroxine Sodium belongs to category A for use during pregnancy and can be used safely during pregnancy and lactation without any adverse effect on mother or fetus. If dose is missed on one day, the patient may take the same as soon as she remembers and should not eat anything for the next half hour? If she misses the tablet altogether, she should take double the dose on the next morning? A complete bottle of Levothyroxine tablets to be provided to patients (25/50/75/100 mcg)? Side effects of treatment in the suggested/recommended doses, this drug does not have any side effect. Monthly hypothyroidism reporting format for State and District Programme Managers (Annexure 3) ii.

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For inhibition of node molecules upstream molecules that are responsible for activation of node molecule may be potential efficient target for drug therapy spasms to the right of belly button buy sumatriptan 50 mg without a prescription. Therefore chemopreventive agents are designed to block anti-apoptotic pathways and potentiate the effect of chemotherapeutic agents spasms rib cage buy generic sumatriptan 50mg on line. Investigation is aiming towards determination of difference between physiological and pathological phenotype spasms hiccups cheap sumatriptan. This technique documents expression of thousands of genes on single microscope glass. There is extensive work in bioinformatics field to analyze micro-array data so that information acquired is reliable for biomedical purposes. Cell signaling in carcinoma cells - differences between healthy cells and transformed cells 6. It is well known that distinct phenotypes can be accomplished by the same set of proteins. For this phenomenon cells use different signal transduction modules within the same multiprotein complexes. A large scale of different methodologies is applied in functional proteomics to analyze protein complexes. Functional proteomics offers strategies to employ all of these methodologies in order to elucidate signal transduction module responsible for specific phenotype. Advancement in cloning techniques contributed to more effective transfection assay. Variations of this assay are extensively used in screening for potential tumorigenesis initiators. These decisions can be made through various cell signaling pathways of which some are more or less ubiquitous while others are regarded as more specific for tumor type. Cell signaling in carcinoma cells - differences between healthy cells and transformed cells 6. It is governing transcription for genes implicated in some physiological events such as cell survival, cell adhesion, differentiation and cell growth. Also, it is also implicated in pathophysiological events like inflammation, autoimmune diseases and carcinogenesis (cancer promotion, progression and angiogenesis). Instead of undergoing cell death program, cancer cell is enabled to survive and establish a clone of neoplastic cells. Immunohistochemical staining using anti-p65 antibody was positive in papillary, follicular and anaplastic cancer tissue specimens. It shows rapid invasive growth and has a strong metastatic potential to distant organs. Chemotherapy and radiation in combination are standard therapy for anaplastic carcinoma. Outcome of this malignancy in spite of multimodal therapy is still unsatisfactory. Overactivation of this pathway is known mechanism of resistance to those therapies. Cell signaling in carcinoma cells - differences between healthy cells and transformed cells inhibitors allows reducing the dosage and alleviates side-effects. Therefore management of thyroid carcinoma is becoming more important public health problem. Eighty percent of all thyroid carcinomas are papillary carcinomas, 15% follicular, 4% medullary and 1% anaplastic. Cancers that are of follicular cell origin are: papillary, follicular, Hurthle cell cancer and anaplastic. Cell signaling in carcinoma cells - differences between healthy cells and transformed cells Figure 6. Receptor tyrosine kinases are cell-surface molecules that transduce signals for cell growth and differentiation. In an adult, it is expressed in several cell lines: spleen, thymus, lymph nodes, salivary glands, spermatogonia and thyroid tissue.

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Vascular disorders In vascular bleeding disorders muscle relaxant 10mg buy 50 mg sumatriptan visa, tests of hemostasis are 370 Hematology usually normal bladder spasms 5 year old order sumatriptan with a visa. Purpura Simplex (Easy Bruising) the most common vascular bleeding disorder muscle relaxant abuse discount sumatriptan 50 mg without prescription, manifested by increased bruising and representing increased vascular fragility. The platelet count and tests of platelet function, blood coagulation, and fibrinolysis are normal. No drug prevents the bruising; the patient is often advised to avoid aspirin and aspirin-containing drugs, but there is no evidence that bruising is related to their use. Senile Purpura A disorder affecting older patients, particularly those who have had excessive sun exposure, in whom dark purple ecchymoses, characteristically confined to the extensor surfaces of the hands and forearms, persist for a long time. Lesions slowly resolve over several days, leaving a brownish discoloration caused by deposits of hemosiderin; this discoloration may clear over weeks to months. The skin and subcutaneous tissue of the involved area often appear thinned and atrophic. Hereditary Hemorrhagic Telangiectasia (Rendu- Osler-Weber Disease) A hereditary disease of vascular malformation transmitted as an autosomal dominant trait affecting men and women. Diagnosis is made on physical examination by the discovery of characteristic small, red-to-violet telangiectatic lesions on the face, lips, oral and nasal mucosa, and tips of the fingers and toes. These fistulas may produce significant right-to-left shunts, which can result in dyspnea, fatigue, cyanosis, or polycythemia. However, the first sign of their presence may be a brain abscess, transient ischemic attack, or stroke, as a result of infected or noninfected emboli. Cerebral or spinal arteriovenous malformations occur in some families and may cause subarachnoid hemorrhage, seizures, or paraplegia. Laboratory studies are usually normal except for evidence of iron-deficiency anemia in most patients. The disease primarily affects young children but may affect older children and adults. An acute respiratory infection precedes purpura in a high proportion of affected young children. Less commonly, a drug may be the inciting agent, and a drug history should always be obtained. Biopsy of an acute skin lesion reveals an aseptic vasculitis with fibrinoid necrosis of vessel walls and perivascular cuffing of vessels with polymorphonuclear leukocytes. Granular deposits of immunoglobulin reactive for IgA and of complement components may be seen on immunofluorescent study. Therefore, deposition of IgA-containing immune complexes with consequent activation of complement is 374 Hematology thought to represent the pathogenetic mechanism for the vasculitis. The disease begins with the sudden appearance of a purpuric skin rash that typically involves the extensor surfaces of the feet, legs, and arms and a strip across the buttocks. The purpuric lesions may start as small areas of urticaria that become indurated and palpable. Most patients also have fever and polyarthralgia with associated periarticular tenderness and swelling of the ankles, knees, hips, wrists, and elbows. The disease usually remits after about 4 wk but often recurs at least once after a disease-free interval of several weeks. In most patients, the disorder subsides without serious sequelae; however, some patients develop chronic renal failure. The presence of diffuse glomerular involvement or of crescentic changes in most glomeruli predicts progressive renal failure. Vascular Purpura Caused By Dysproteinemias Hypergammaglobulinemic purpura is a syndrome that primarily affects women. It is characterized by a polyclonal increase in IgG (broad-based or diffuse hypergammaglobulinemia on serum protein electrophoresis) and recurrent crops of small, palpable purpuric lesions on the lower legs. Cryoglobulinemia is characterized by the presence of immunoglobulins that precipitate when plasma is cooled (ie, cryoglobulins) while flowing through the skin and subcutaneous tissues of the extremities. Cryoglobulinemia can be recognized 376 Hematology after clotting blood at 37? C (98.

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This can be the result of hip problems in childhood or changes to Drugs the shape of the hip as it develops muscle relaxant comparison chart order generic sumatriptan, but Non-steroidal anti-infammatory in most cases the cause is unknown muscle relaxant radiolab cheap sumatriptan 50 mg with visa. They may advise you about the best way to walk with your hip pain and may help you to use a stick or crutch spasms left upper abdomen purchase sumatriptan 50mg free shipping. You?ll need to use the stick in the opposite hand to your afected hip and make sure that it?s the correct height for you, so it?s important to see a physiotherapist before you start using one. They?ll be able to are other factors that may increase your advise on how to change your movements overall risk, such as high blood pressure to help prevent pain continuing or or cholesterol, diabetes, and heart or returning. They work by slowing Occupational therapy; Physiotherapy bone loss, which reduces the risk of hip and arthritis; Work and arthritis. Depending on the type of bisphosphonate, you may need to take them by mouth (but not with food), Steroid injections or they may be given by intravenous Steroid injections can help hip problems infusions, which is a slow injection into if they?re caused by infammatory joint a vein. The injections are often given with a local anaesthetic, Bisphosphonates are often used to treat and they?re usually very helpful in treating osteoporosis, and you can fnd out more trochanteric bursitis. A snapping iliopsoas tendon Physiotherapy may help you to maintain can be treated with steroid injections your hip movements with gentle range of which are done under videofuoroscopy movement exercises and activities. Ultrasound- treatment for arthritis-related hip pain, guided injections are also becoming and modern techniques make the more popular. Physiotherapists Not everybody with hip pain will need will help you become mobile when you?re surgery, but hip fractures almost always in hospital, and they?ll help you practise need fxation, which stabilises the bone getting in and out of bed, out of chairs and helps it to heal, or replacement of the and up and down stairs safely. Hip fractures often occur in elderly people, and they can take a long time to fully recover from. People can often be in hospital for a couple of weeks or more to get over the fall and the operation, and many often need extra help at home after discharge. Hip replacement surgery If your hip pain is caused by arthritis and it?s getting worse, your doctor may talk to you about hip replacement. If you?re being considered for hip Acetabular labrum surgery replacement, it?s important that you?re A torn acetabular labrum can be in good health before the operation. In some cases this procedure can be for an assessment before the operation performed through just a small incision and they?ll check your general health. This is also known the operation itself, and you?ll meet as keyhole surgery, and it can be done as the physiotherapists and occupational a day case or one-night stay in hospital. The outcomes of hip replacements are We don?t yet know what the long-term extremely good 90% or more of people efects of acetabular labrum surgery are, who have had a hip replacement fnd but you may get better hip movement as their pain is greatly reduced. Modern revision ceramic, metal or a combination of these) surgery techniques are developing to use. We also fund research into the best quickly and most failed hip replacements way to ft these joint replacements, the can be dealt with, which can restore preferred angle of the joint replacement function and activity. You?ll be in hospital longer than for your frst hip replacement, and it might take longer to recover. You?ll need physiotherapy after revision surgery to help you gain confdence in your new joint, and you?ll need someone to help you out for a couple of weeks or more when you go home. The Anaesthetic a drug that?s used during fow of blood increases, resulting in surgery to stop you feeling any pain. You heat and redness in the afected tissues, may be given a local, epidural, spinal or and fuid and cells leak into the tissue, general anaesthetic, depending on the causing swelling. Ligaments tough, fbrous bands Ankylosing spondylitis an anchoring the bones on either side of a infammatory arthritis afecting mainly joint and holding the joint together. In the the joints in the back, which can lead spine they?re attached to the vertebrae to stifening of the spine. It can be and restrict spinal movements, therefore associated with infammation in tendons giving stability to the back. It works by detecting high levels of calcium in the blood and by water molecules in the body?s tissue that slowing down bone turnover. These images are then specialist who helps people reach their transformed by a computer into cross- goals and maintain their independence sectional pictures.